SUBJECT_ID,AGGREGATED_TEXT,EXTRACTION_JSON
65417,admission date discharge date date of birth sex m service cardiothoracic allergies fentanyl lactose iron attending chief complaint chest tightness major surgical or invasive procedure cabgx lima lad svg om diag past medical history crohn s disease x yrs s p transverse colectomy ileocecectomy prostate cancer s p l nerve sparing radical prostatectomy basal cell carcinoma htn s p r shoulder arthroscopy cad s p mi most recent ef negative stress in sciatica osteopenia cis s p transverse colectomy social history sh lives w wife no children denies tobacco drugs but social alcohol family history fh father w cad and mother w als colorectal cancer in family physical exam pulse resp o sat b p right left height weight general aao x in nad skin dry x intact x heent perrla x eomi x neck supple x full rom x chest lungs clear bilaterally x heart rrr x brady irregular murmur abdomen soft x softly distended x non tender x bowel sounds x extremities warm x well perfused x edema lle edema trace rle 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 pt ptt inr pt am blood glucose urean creat na k cl hco angap r csurg fa a pm medical condition year old man with cabg reason for this examination f u lll atelect final report history cabg with left lower lobe atelectasis findings in comparison with the study of there is continued low lung volumes with bilateral atelectatic changes especially pronounced at the left base the possibility of supervening pneumonia cannot be excluded upper lung zones are clear and there is no definite vascular congestion incidental note is dilatation of gas filled loops of bowel consistent with an adynamic ileus dr approved mon pm echo conclusions prebypass the left atrium is normal in size no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage no spontaneous echo contrast is seen in the body of the right atrium no atrial septal defect is seen by d or color doppler left ventricular wall thicknesses are normal the left ventricular cavity size is normal overall left ventricular systolic function is normal lvef the right ventricular cavity is mildly dilated with mild global free wall hypokinesis the ascending aorta is mildly dilated the aortic valve leaflets are mildly thickened there is a focal calcification on one of the aortic valve leaflets either the non coronary or the left coronary leaflet there is no aortic valve stenosis trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened trivial mitral regurgitation is seen there is no pericardial effusion postbypass the patient is a paced on a phenylephrine infusion biventricular systolic function is preserved trace aortic regurgitation and trace mitral regurgitation persist the thoracic aorta is intact after aortic decannulation dr was notified in person of the results at the time of the study brief hospital course the patient was admitted on and underwent cabgx lima lad svg om diag the cross clamp time was minutes total bypass time was minutes he tolerated the procedure well and was transferred to the cvicu on propofol in stable condition he was extubated on the post op night and his chest tubes were discontinued on pod he was transferred to the floor on pod and his epicardial pacing wires were discontinued on pod he continued to progress and was discharged to home on pod in stable condition medications on admission adalimumab humira mg ml kit one time a week atenolol mg tablet tablet s by mouth once daily atorvastatin lipitor mg tablet once a day cyanocobalamin vitamin b mcg ml solution mcg im once monthly ferraheme dosage uncertain hydrochlorothiazide mg daily lisinopril mg once a day loperamide mg capsule capsule s by mouth mg capsules per day mesalamine pentasa mg takes x a day nitroglycerin pantoprazole mg once a day medications otc cholecalciferol vitamin d unit capsule once every evening cyanocobalamin vitamin b glucosamine chondroit mv min glucosamine sulfate kcl loratadine mg tablet daily multivitamin tx minerals natural calcium mg tablet tabs po take mg s a day 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 atorvastatin mg tablet sig tablet po daily daily disp tablet s refills pantoprazole 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 mesalamine mg capsule sustained release sig four capsule sustained release po qid times a day disp capsule sustained release s refills oxycodone acetaminophen mg tablet sig tablets po every hours as needed for pain disp tablet s refills metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet s refills lisinopril mg tablet sig one tablet po once a day disp tablet s refills discharge disposition home with service facility homecare discharge diagnosis coronary artery disease s p cabgx s p myocardial infarction htn elevated cholesterol gerd crohn s disease iron deficiency anemia discharge condition good ambulating well pain controlled with percocet 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 surgeon dr pm cardiologist dr 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 completed by,{}
21954,admission date discharge date date of birth sex m service micu reason for admission status post seizure with aspiration pneumonia intubated history of present illness this is a year old male with multiple medical problems found down in his assisted living facility seizing in bed of note the patient had just been discharged on the from after an unrevealing five day workup for abdominal pain upon returning to the nursing home he complained to his nurse of a headache when the nurse returned with pain medicine five minutes later the patient was found to be tonic clonic seizures unresponsive ems was called when they arrived he was found to have aspirated a good amount of food contents was intubated for airway protection and transferred to hospital of note the patient seized for approximately minutes and the seizures were broken by valium mg versed mg and ativan mg at the time of the seizure the patient s blood sugar was noted to be he was given amp of d and mg of glucagon and the fingerstick glucose rose to en route to the hospital he was given lidocaine for question of increased intracranial pressure at ed a ct of the head was performed which showed evidence of an old cva but no acute hemorrhage a lp was performed and was negative the patient was given grams of rocephin prior to the lp for meningitis prophylaxis he was also given aspirin and versed of note on the patient s admission ekg he did have lateral st depressions which were new compared with his prior ekgs from at as well as at the time the patient was unresponsive to deep painful stimuli but was minimally responsive to deep sternal rub in the emergency room he continued to have food suctioned from his et tube but he was able to maintain his oxygenation and ventilation on the ventilator he was transferred to the micu past medical history diabetes mellitus x years coronary artery disease status post cardiac catheterization with three vessel disease not intervened upon because there were no critical lesions at the time date of cardiac catheterization unknown history of peripheral vascular disease status post left below the knee amputation status post cva diffuse ischemic of unknown date gerd on protonix hypertension depression glaucoma right eye enucleation for phthisis bulbi legally blind in his left eye copd with some component of restrictive disease as well by pulmonary function tests performed in demonstrating fvc and fev of of predicted fev to fvc ratio of of predicted acute atypical psychosis osteomyelitis status post debridement procedure and amputation of several toes of the right leg in chronic pancreatitis with history of chronic alcohol abuse l l l l spinal stenosis status post laminectomy medications melatonin mg q h s protonix mg q d imdur mg q d effexor mg q d mom prn dulcolax prn fleet s enema prn aspirin q d albuterol and atrovent nebulizers q sublingual nitroglycerin prn nph units q a m artificial tears insulin sliding scale nph atropine drops o d pred forte drops o d lamictal mg q d creon mg t i d social history former heavy smoker former alcohol abuse lives at assisted living facility has a healthcare proxy designated by the court the state of family history noncontributory physical exam on admission temperature blood pressure heart rate respirations and on ac with a fio of and a peep of general intubated sedated and unresponsive to painful stimuli heent right sided enucleation left eye pupil fixed and dilated moist mucous membranes edentulous cardiovascular regular rate and rhythm no murmurs rubs clicks or gallops chest was clear to auscultation anteriorly abdomen positive bowel sounds no organomegaly nontender and nondistended extremities status post left below the knee amputation poor peripheral pulses distal extremities warm capillary refill less than two seconds data white blood cell count hematocrit platelets chem inr lactate ck troponin serum tox is positive for benzos negative for aspirin etoh tylenol barbiturates csf no white cells no red cells protein and glucose gram stain negative culture negative ct of the head no bleed multiple old infarcts sinus inflammation chest x ray clear et tube in correct position ekg shows normal sinus rhythm at beats per minute with t wave inversions in v through v with st depressions of mm in v and v t wave flattening in i and l new compared with prior brief summary of hospital course by issues seizures it was unclear exactly why the patient seized it is likely that he has underlying areas of ischemia secondary to massive cva he seems to have suffered anoxic brain injury as he had several episodes of myoclonic jerks which could be consistent with syndrome as well as some component of hypoglycemia an eeg was performed which shows diffuse slow wave pattern which ruled out status epilepticus and suggest some sort of encephalopathy perhaps due to sepsis the patient s psychotropic medications lamictal and effexor were discontinued his blood sugar was monitored q i d and kept euglycemic tsh calcium magnesium and phosphorus as well as a rpr were all unrevealing the patient did not receive any versed and was still unresponsive for hours on the ventilator we did consider getting a mri however due to the patient s penile prosthesis this was not possible neurology felt that most likely this was anoxic brain injury and the chance of recovery was very poor as the patient was unresponsive to deep painful stimuli cold calorics were unreactive dolls eyes were abnormal the patient did have not spontaneous respirations when he was extubated aspiration pneumonia originally the diagnosis of aspiration pneumonia was entertained given the food contents were suctioned from the et tube repeat chest films were negative however the patient was placed on levofloxacin and flagyl for hour period until the chest x ray was definitively clear respiratory failure patient was intubated for airway protection abg showed excellent oxygenation and ventilation however the patient had no spontaneous respirations when the ventilator was discontinued diabetes mellitus the nph was held the patient was kept euglycemic on insulin sliding scale coronary artery disease the patient did have mild elevation of the troponins but cks were negative although rising in the setting of lateral t wave changes and lateral st depressions it is likely that the patient did experience some sort of demand ischemia with whatever inciting events had occurred he was given aspirin and beta blocker however heparin was not initiated due to his allergy of unknown type renal failure he appeared to be at his baseline creatinine of gerd he was continued on his proton pump inhibitor ophthalmology he was continued on his eyedrops per outpatient regimen chronic pancreatitis he was repleted with creon zyprexa all psychotropic medications were discontinued fen the patient was kept npo access an a line was placed for arterial monitoring and pneumoboots were used for dvt prophylaxis code status discussion with the healthcare proxy it was felt that the patient would want to be do not resuscitate do not intubate comfort measures only given his prior poor functional status and new diagnosis with extremely poor prognosis therefore after discussion with five of the eight children and discussion with the healthcare proxy with documentation in the chart that she indeed is the healthcare proxy the patient was extubated on and had no spontaneous respirations went into an asystolic period and was pronounced dead at p m on at that time the family declined autopsy the attending was notified and admitting was notified per standard protocol m d dictated by medquist d t job cclist,"{
""Diagnoses"": [""seizure with aspiration pneumonia"", ""intubated"", ""status post seizure"", ""pneumonia"", ""headache"", ""abdominal pain""],
""Medications"": [""valium"", ""versed"", ""ativan"", ""d"", ""glucagon"", ""lidocaine""]
}"
70273,admission date discharge date date of birth sex f service neurology allergies tobramycin attending chief complaint unresponsive episodes major surgical or invasive procedure none history of present illness this is a yo w with a history of atrial fibrillation chronic obstructive pulmonary disease squamous cell carcinoma s p radiation and chemotherapy chronic trach dependent who developed acute unresponsiveness on she was recently discharged from the icu approximately one week or so ago where she was hospitalized for pneumonia pneumonitis during this hospitalization she was trach d d and transferred to for vent weaning the patient happened to be seen at on the afternoon of by the on call neurologist these are his first impressions this morning in rehab she had been fine alert and communicating with her husband through lip and writing suddenly at a m her head slumped to one side and eyes rolled upward she arrived in the emergency room at on arrival she was unresponsive a stroke burst page was activated noncontrast head ct was negative ct angiogram was negative because of multiple risks recent tracheostomy chest tube and placement inr yesterday and nih stroke score of greater than she was not felt to be a tpa candidate i examined her immediately after the head ct prior to mri at that time she had no response to voice or sternal rub there was no withdrawal of the limbs to nailbed pressure although if a limb was raised passively she could hold it in place there was no clear asymmetry of strength there was no meningismus the right pupil was mm left mm both sluggishly reactive corneal reflexes were present bilaterally oculocephalic responses were absent although there were occasional spontaneous eye movements to both the right and left there were some weak blinking movements of the eyelids but no other spontaneous motor activity the exam raised a concern for nonconvulsive seizure she was given lorazepam mg iv prior to the mri mri of the brain showed no acute infarction or other obvious structural lesion on arrival in the emergency room again she was given another milligram of lorazepam iv and i recommended a loading dose of iv phenytoin following her load of phenytoin the patient did not receive her complete gm dose of iv phenytoin because after the first mg she became hypotensive to the dilantin was stopped this also occurred in the setting of having received ativan as noted above she was aggressively fluid resuscitated and transferred to the intensive care unit at that time the neurologist once again had the pleasure of examining the patient these were his impressions at the time when i reexamined her at p m she could open eyes spontaneously and look to voice she followed a few simple commands including closing the mouth opening the eyes and sticking out the tongue she made weak attempts to grip with both the right and left hands she appropriately shook her head no when asked if her name was but weakly nodded to she could bend her knees to command pupils were mm on the right mm on the left each constricting by mm with light eye movements were full corneal reflexes were symmetric more detailed sensory testing was not possible there was no clear facial weakness the tongue was midline strength appeared symmetric without clear weakness reflexes were and symmetric in the biceps brachioradialis and patellar tendons at the achilles tendons plantar stimulation produced withdrawal bilaterally sensory exam was limited in the limbs although she appeared to feel nailbed pressure in all limbs later that day became more alert in the setting of initiating dilantin tid dosing overnight she did well this morning the patient was noted to be more drowsy and unresponsive the precise story is unclear the patient s family today report that she was more anxious but that in fact she did become more unresponsive she also did complain of some chest stomach discomfort that was initially thought to be cardiac in nature she received some nitroglycerin which dropped her blood pressures and ultimately required more fluid boluses her ekg and cardiac enzymes were normal later they thought that perhaps it might have been related to problems with tube feeds her feeds were stopped and she received a ct scan of her abdomen pelvis which only showed evidence of pancreatic ductal dilatation without free fluid or intraperitoneal air her responsiveness also subsequently improved throughout the course of this day since this osh was not able to check an eeg she was ultimately transferred to the for eeg monitoring and further work up for possible ncse review of systems as mentioned above in the hpi the patient s family reports that she has had some tremors in the past week which they recognize as possibly related to seizures these were mainly of her lower extremities otherwise they deny any fevers dysuria pain complaints difficulties with diplopia dizziness past medical history squamous cell lung carcinoma diagnosed in status post chemotherapy and radiation reportedly completed in course complicated by radiation pneumonitis which has required multiple steroid tapers copd on home oxygen for years atrial fibrillation on anticoagulation with coumadin also on amiodarone diltiazem for rate control recent pneumonia and pneumothorax with a most recent admission to from to during that admission she had placement of a chest tube tracheostomy on and tube placement hypothyroidism anemia of chronic disease hypertension herpes zoster reportedly involving the right eye and face early this year social history strong family support system married never smoker non alcoholic family history positive for grand mal seizures in her grandson physical exam admission physical exam physical exam vitals af general awake cooperative nad heent nc at no scleral icterus noted mmm no lesions noted in oropharynx tracheostomized neck supple no masses or lymphadenopathy pulmonary lungs cta bilaterally without r r w cardiac rrr nl s s no m r g noted abdomen thin in place soft nt nd no masses or organomegaly noted extremities warm and well perfused skin multiple erythematous purple bruises over bilateral upper and lower extremities neurologic mental status alert oriented to she speaks without a pmv and literally whispers her eyes tend to remain closed when she is not interactive but will quickly open her eyes when you call her name her language is fluent without naming errors or paraphasias cranial nerves i olfaction not tested ii perrl mm and brisk iii iv and vi eom are intact and full sustained nystagmus on right lateral gaze 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 no pronator drift bilaterally no adventitious movements such as tremor noted no asterixis noted in general she moves all extremities well symmetric proximal muscle weakness to prominently in deltoids triceps iliopsoas sensory no deficits to light touch throughout dtrs throughout plantar response mute coordination no intention tremor gait not tested discharge physical exam vitals on cpap general awake cooperative nad heent nc at no scleral icterus noted mmm no lesions noted in oropharynx tracheostomized neck supple no masses or lymphadenopathy pulmonary lungs cta bilaterally without r r w cardiac rrr nl s s no m r g noted abdomen thin in place soft nt nd no masses or organomegaly noted extremities warm and well perfused skin multiple erythematous purple bruises over bilateral upper and lower extremities neurologic mental status alert oriented to but not the date she intermittently thinks she is at a hospital she speaks without a pmv and whispers her eyes tend to remain closed when she is not interactive but will quickly open her eyes when you call her name her language is fluent without naming errors or paraphasias she is able to follow commands cranial nerves i olfaction not tested ii l pupil mm and r pupil mm both mildly sluggish iii iv and vi eom are intact and full sustained nystagmus on right lateral gaze 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 no pronator drift bilaterally no adventitious movements such as tremor noted no asterixis noted in general she moves all extremities well symmetric proximal muscle weakness to prominently in deltoids triceps iliopsoas sensory no deficits to light touch throughout dtrs throughout plantar response mute coordination no intention tremor gait not tested pertinent results admission labs 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 ck mb ctropnt am blood ck mb ctropnt pm blood albumin calcium phos mg pm blood phenyto discharge labs 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 pm blood calcium phos mg pm blood type mix po pco ph caltco base xs imaging cxr findings no previous images there is substantial scoliosis with degenerative change involving the thoracic spine convex to the right which makes it somewhat difficult to properly evaluate the heart and lungs the right lung and visualized portion of the left lung are clear without evidence of vascular congestion opacification at the left base most likely reflects atelectasis and effusion right subclavian catheter extends to the mid to lower portion of the svc tte conclusions the left atrium is normal in size 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 right ventricular chamber size and free wall motion are normal the ascending aorta is mildly dilated 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 mitral regurgitation is seen there is moderate pulmonary artery systolic hypertension there is no pericardial effusion kub impression no evidence of obstruction or ileus brief hospital course this is a yo w with a history of squamous cell carcinoma of the lung atrial fibrillation on coumadin history of radiation pneumonitis who was recently tracheostomized and gastrostomized and doing well in rehabilitation who had an acute episode of unresponsiveness concerning for seizure transferred here for eeg monitoring neuro while here on she had another episode of unresponsiveness after having been given haldol for icu delirium she was on continuous eeg monitoring which showed no seizure activity therefore her unresponsiveness episodes are more likely related to medications or metabolic issues and not seizure activity she should not receive haldol in the future we used seroquel as needed instead which did not cause pt to have unresponsiveness episodes she was put on aeds at the osh so it is possible that if she was having seizures before we aren t seeing them because they are now controlled when she arrived we stopped her dilantin and increased her keppra to mg her mri which was brought in by pt s son on cd was unremarkable given her lung cancer we consider leptomeningeal carcinomatosis as a possible cause of her unresponsiveness episodes however this is extremely unlikely to cause intermittent unresponsiveness we were unableto obtain an lp while she was here because her inr was persistently elevated likely in part because of interaction with dilantin and we felt it was too dangerous to reverse her anticoagulation at some point in the future if she becomes more persistently unresponsive while also being more medically stable it may be worth considering an lp cardiovascular we cotinued her home diltiazem and amiodarone for rate control she did have some episodes of atrial fibrillation while being monitored on telemtery with some second pauses which were asymptomatic this will need to be further monitored in the future we continued her on her home simvastatin for primary prevention when she got here her inr was supratherapeutic reaching a peak of her coumadin was held and when she left her inr was she will need her coumadin restarted once her inr drifts lower optho pt with hx of open angle glaucoma followed by dr s p iridotomies bilaterally not on any eye drops per pt and dr who on admission was noted to have bilaterally dilated and minimally reactive pupils new since last exam in we consulted optho for concern of open angle glaucoma crisis she was alert and conversant with no neurological reason for the eye findings but they found normal pressure in both eyes optho felt that her eye findings were secondary to ipratropium nebs given at the osh and surely enough the next day after not having gotten ipratropium at our institution her eyes were smaller and more reactive pulmonary she was able to be off of cpap through her trach for almost hours but became very tired and so we decided to keep her on cpap at night at least to prevent fatigue from wob she was continued on prn albuterol but not ipratropium as above her sputum culture grew gnrs but pt was asymptomatic and this was from a culture taken on arrival we decided not to treat but if she has any issues in the future she may need antibiotics code full confirmed with patient and family contact daughter pending results sputum culture speciation bcx x final read of eeg from however prelim reads by an attending epileptologist showed no seizure activity transitional care issues patient will need her inr followed and her coumadin restarted when her inr drifts down further her vent weaning will need to be continued while at rehab medications on admission nitroglycerin tablet sublingual mg p r n as needed for chest pain potassium chloride meq once citalopram p o mg daily atorvastatin p o mg at bedtime amiodarone p o mg daily quetiapine p o mg q hourly prn haloperidol tablet p o mg q hourly prn bactrim suspension p o ml every monday wednesday friday florastor p o mg b i d risperidone p o mg prn prednisone p o mg daily lansoprazole sublingual mg daily diltiazem p o mg q i d accuneb neb q hourly p r n duoneb neb q hourly p r n keppra mg iv q hourly dilantin iv mg t i d and discharge medications acetaminophen mg tablet tablets po q h every hours as needed for pain fever citalopram mg tablet tablet po daily daily atorvastatin mg tablet three tablet po daily daily amiodarone mg tablet one tablet po once a day risperidone mg ml solution mg po bid times a day as needed for agitation quetiapine mg tablet tablet po bid times a day as needed for agitation prednisone mg tablet three tablet po daily daily lansoprazole mg tablet rapid dissolve dr one tablet rapid dissolve dr daily daily diltiazem hcl mg tablet one tablet po qid times a day albuterol sulfate mg ml solution for nebulization one inhalation every four hours as needed for shortness of breath wheezing heparin porcine unit ml solution units injection tid times a day simethicone mg tablet chewable one tablet chewable po qid times a day as needed for gas bloating levetiracetam mg ml solution seven y mg po bid times a day nystatin unit ml suspension five ml po qid times a day as needed for thrush nitroglycerin mg tablet sublingual one sublingual twice a day as needed for chest pain albuterol sulfate mcg actuation hfa aerosol inhaler puffs inhalation q h every hours as needed for wheezing respiratory distress 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 florastor mg capsule one capsule po twice a day bactrim mg tablet one tablet po mon wed fri or can give ml suspension mon wed fri discharge disposition extended care facility discharge diagnosis medication side effect atrial fibrillation copd discharge condition mental status confused sometimes level of consciousness lethargic but arousable activity status out of bed with assistance to chair or wheelchair neuro exam aaox knows place year and month but not date r pupil reactive mm l pupil mm moves all extremities discharge instructions dear ms you were seen in the hospital for suspected seizures that caused you to become unresponsive while here you were monitored with continuous eeg monitoring which showed no seizures even when you had an episode of unresponsiveness while here therefore we think that your unresponsive episodes are related to medications or medical issues and are not seizure related we made the following changes to your medications the below changes are those made to your transfer meds not home meds we stopped your haloperidol we stopped yout duonebs because the ipratoprium was effecting your pupils we stopped your dilantin because it was interacting with your coumadin we decreased your seroquel to mg twice a day as needed for agitation we increased your keppra to mg twice a day this can likely be tapered then stopped once you are more medically stable we started you on tylenol mg every hours as needed for fever or pain we started you on subcutaneous heparin injections units three times a day to prevent dvts you can stop this medication once you are no longer chronically in bed or your inr is therapeutic we started you on simethicone mg four times a day as n eeded for gas pains we started you on nystatin suspension ml four times a day as needed for thrush we started you on albuterol inhaler puffs every hours as needed for wheezing respiratory distress when on cpap we started you on a heparin flush ml intravenously in your picc line as needed to flush the line this medication can stop once you no longer need your picc please continue to take your other medications as previously prescribed if you experience any of the below listed danger signs please contact your doctor or go to the nearest emergency room it was a pleasure taking care of you on this hospitalization followup instructions we recommend that you follow up with your neurologist within the next months if you would prefer to make an appointment with one of our neurologists you can call and be connected to our appointment line,"{
""Diagnoses"": [""atrial fibrillation"", ""chronic obstructive pulmonary disease"", ""squamous cell carcinoma"", ""pneumonia"", ""pneumonitis"", ""stroke""],
""Medications"": [""tobramycin"", ""radiation"", ""chemotherapy"", ""tracheostomy"", ""chest tube""]
}"
11498,admission date discharge date date of birth sex f service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint progressive dypnea on exertion major surgical or invasive procedure mv repair mm annuloplasty band history of present illness year old woman who has experienced progressive dyspnea on exertion an echocardiogram in revealed moderate mr with prolapse of the posterior mitral valve leaflet a cardiac catheterization revealed no significant coronary artery disease past medical history hypothyroid nephrolithiasis social history from lives alone and works in cleaning has a year old son family history non contributory physical exam heart rrr holosystolic murmur lungs clear abd benign pulses throughout skin no lesions or rashes pertinent results am blood hct 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 mg cxr the patient is status post median sternotomy the left chest tube and mediastinal drain remain in place the patient has been extubated and swan ganz catheter and nasogastric tube have been removed there is no evidence of pneumothorax the previously identified mild congestive heart failure has been markedly improving there is continued cardiomegaly ekg sinus rhythm normal ecg since previous tracing of no significant change ospital course ms was admitted to the on and taken directly to the operating room where she underwent a mitral valve repair utilizing a mm annuloplasty band postoperatively she was taken to the cardiac surgical intensive care unit for monitoring on postoperative day one she awoke neurologically intact and was extubated the pulmonology service was consulted for pulmonary hypertension however as her hemodynamics were significantly improved postoperatively no further intervention or treatment was recommended later on postoperative day one ms was transferred to the cardiac surgical step down unit for further recovery she was gently diuresed towards her preoperative weight the physical therapy service worked with her to increase her strength and mobility ms continued to make steady progress and was discharged home on postoperative day four she will follow up with dr her cardiologist and her primary care physician as an outpatient medications on admission aspirin synthroid discharge medications metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet s refills lasix mg tablet sig one tablet po twice a day for days disp tablet s refills potassium chloride meq packet sig one packet po q h every hours for days disp packet 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 levothyroxine sodium mcg 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 ferrous sulfate mg tablet sig one tablet po daily daily disp tablet s refills ascorbic acid mg tablet sig one tablet po bid times a day disp tablet s refills dilaudid mg tablet sig tablets po every hours disp tablet s refills discharge disposition home with service facility vna of discharge diagnosis mitral regurgitation discharge condition good discharge instructions follow medications on discharge instructions you may not drive for weeks you may not lift more than lbs for months you should shower let water flow over wounds pat dry with a towel do not use lotions creams or powders on wounds call our office for sternal drainage temp followup instructions make an appointment with dr for weeks make an appointment with dr for weeks make an appointment with dr for weeks completed by,"{
""Diagnoses"": [""cardiothoracic"", ""hypothyroid"", ""nephrolithiasis""],
""Medications"": [""none""]
}"
60897,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint hypotension major surgical or invasive procedure intubation central line placement axillary arterial line placement picc placement ng tube placement tips dilatation cardioversion paracentesis x egd history of present illness mr is a year old man with a history of chf cirrhosis s p tips and afib off coumadin was brought in the the by ambulance after his daughter found him to be short of breath confused and incontinent at the he was found to be febrile to hr bp rr spo ekg reveal afib with rvr and st depressions in v labs were notable for a wbc plt inr creatinine digoxin a femoral line was placed and he was given levaquin and zosyn for presumed urosepsis given a positive ua packed wbc bacteria ct abd pelvis without contrast showed no free air and no bowel wall thickening he received l ivf and was started on dopamine and levophed prior to transfer to for further evaluation on arrival to ed vs were l dopamine was discontinued due to tachycardia and levophed was titrated up he was given decadron mg iv and l ivf transplant surgery was consulted to evaluate for mesenteric ischemia given elevated lactate wbc and intermittent abdominal pain they recommended admission to micu of note records from osh mention admission on for sbp and recent klebsiella infection review of systems unable to assess due to confusion past medical history paroxysmal atrial fibrillation not on coumadin due to cirrhosis cirrhosis s p tips dilated cardiomyopathy cad obesity social history patient lives alone he is retired he reports smoking cigarettes per day he admits to a history of alcohol abuse but denies any recent alcohol use he denies use of herbal medications or illicit drugs including ivdu family history noncontributory denies family history of liver disease physical exam admission exam ga aaox nad heent perrla drymm poor dentition no lad no jvd neck supple cards tachycardic systolic murmur heard at lusb pulm moderately labored breathing crackles at bilateral bases abd soft nt decreased bowel sounds no rebound guarding extremities wwp no edema dps pts skin dry skin no rashes neuro psych awake alert but disoriented follows commands answers questions appropriately pertinent results i labs a admission 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 alt ast alkphos totbili pm blood ctropnt pm blood albumin am blood ammonia am blood tsh am blood cortsol pm blood lactate b discharge wbc hgb hct plt na k cl hco bun cr glc ca ph mg c other am blood vitb am blood caltibc hapto ferritn trf am blood digoxin d urine pm urine color yellow appear hazy sp pm urine blood mod nitrite neg protein glucose neg ketone tr bilirub neg urobiln ph leuks lg pm urine rbc wbc bacteri few yeast none epi am urine hours random urean creat na k cl pm urine bnzodzp pos barbitr neg opiates neg cocaine neg amphetm neg e ascites am ascites wbc rbc polys lymphs monos mesothe am ascites wbc rbc polys lymphs monos mesothe macroph am ascites albumin less than am ascites glucose ld ldh ii microbiology blood culture blood culture routine pending inpatient blood culture blood culture routine pending inpatient stool fecal culture final campylobacter culture final fecal culture r o e coli h final clostridium difficile toxin a b test final inpatient mrsa screen mrsa screen final inpatient urine urine culture final inpatient am blood culture final report blood culture routine final escherichia coli final sensitivities warning this isolate is an extended spectrum beta lactamase esbl producer and should be considered resistant to all penicillins cephalosporins and aztreonam consider infectious disease consultation for serious infections caused by esbl producing species bactrim septra sulfa x trimeth and tetracycline sensitivity testing per dr pager piperacillin tazobactam sensitivity testing confirmed by tetracycline sensitivity testing performed by sensitivities mic expressed in mcg ml escherichia coli ampicillin r ampicillin sulbactam i cefazolin r cefepime r ceftazidime r ceftriaxone r ciprofloxacin r gentamicin s meropenem s piperacillin tazo s tetracycline s tobramycin s trimethoprim sulfa s aerobic bottle gram stain final gram negative rod s reported by phone to icu anaerobic bottle gram stain final gram negative rod s time taken not noted log in date time pm peritoneal fluid peritoneal fluid final report gram stain final no polymorphonuclear leukocytes seen no microorganisms seen fluid culture final no growth anaerobic culture final no growth urine urine culture final inpatient fluid received in blood culture bottles fluid culture in bottles final inpatient blood culture blood culture routine pending inpatient blood culture blood culture routine pending inpatient stool clostridium difficile toxin a b test final inpatient stool clostridium difficile toxin a b test final inpatient stool clostridium difficile toxin a b test final inpatient blood culture blood culture routine pending inpatient serology blood rapid plasma reagin test final inpatient blood culture blood culture routine final inpatient blood culture blood culture routine final inpatient blood culture blood culture routine final inpatient blood culture blood culture routine final staphylococcus coagulase negative anaerobic bottle gram stain final inpatient blood culture blood culture routine final inpatient peritoneal fluid gram stain final fluid culture final anaerobic culture final inpatient stool clostridium difficile toxin a b test final inpatient blood culture blood culture routine final inpatient blood culture blood culture routine final inpatient peritoneal fluid gram stain final fluid culture final anaerobic culture final inpatient stool fecal culture final campylobacter culture final clostridium difficile toxin a b test final inpatient blood culture blood culture routine final inpatient blood culture blood culture routine final inpatient mrsa screen mrsa screen final inpatient urine urine culture final yeast inpatient blood culture blood culture routine final escherichia coli anaerobic bottle gram stain final aerobic bottle gram stain final inpatient sputum gram stain final respiratory culture final inpatient urine urine culture final inpatient blood culture blood culture routine final inpatient blood culture blood culture routine final inpatient blood culture blood culture routine final inpatient blood culture blood culture routine final inpatient urine urine culture final inpatient stool clostridium difficile toxin a b test final inpatient sputum gram stain final respiratory culture final inpatient blood culture blood culture routine final inpatient blood culture blood culture routine final inpatient blood culture blood culture routine final inpatient blood culture blood culture routine final escherichia coli anaerobic bottle gram stain final inpatient blood culture blood culture routine final inpatient blood culture blood culture routine final escherichia coli anaerobic bottle gram stain final inpatient catheter tip iv wound culture final inpatient stool clostridium difficile toxin a b test final inpatient urine urine culture final escherichia coli inpatient blood culture blood culture routine final escherichia coli aerobic bottle gram stain final anaerobic bottle gram stain final inpatient mrsa screen mrsa screen final inpatient blood culture blood culture routine final escherichia coli aerobic bottle gram stain final anaerobic bottle gram stain final emergency blood culture blood culture routine final escherichia coli aerobic bottle gram stain final anaerobic bottle gram stain final emergency iii radiology a redo tips b doppler lue impression no evidence of deep vein thrombosis in the left arm c liver us impression patent tips however the flow is not satisfactory on color doppler imaging due to lack of wall to wall appearance additionally flow in the left and right portal veins is noted to be away from the tips shunt the appearance may represent neointimal proliferation and a consult with interventional radiology is suggested gallstones splenomegaly ascites and left pleural effusion d bone scan conclusion normal bone scan no evidence of focal abnormality in the bone as described above gallium scan to follow e gallium scan impression normal gallium scan specifically no evidence of infection in the lumbar spine f tib fib two views of the tibia and fibula demonstrate edema within the soft tissues of the calf no abnormal findings in the fibula of note there is a faint region of lucency with indistinct cortex at the medial proximal tibial shaft this is best seen on the frontal view it is unclear if this area correlates to the wound further assessment with mri may be helpful to ascertain for osteomyelitis g mri spine history urosepsis with esbl e coli and now bacteremia with unknown source now with worsening lower extremity weakness concerning for cord compression rule out cord compression technique mri of the cervical thoracic and lumbar spine was performed utilizing sagittal t sagittal t sagittal stir without intravenous contrast due to patient s inability to cooperate axial t and t sequences were only obtained through l s after the administration of contrast sagittal and axial t weighted sequences were obtained comparison none findings cervical spine evaluation of the cervical spine is limited as only sagittal t and t weighted sequences could be performed due to patient s inability to cooperate the cervical alignment and vertebral body height are maintained the t signal of the vertebral bodies is mildly hypointense diffusely small disc protrusions are present at c c and c c without significant spinal canal narrowing no gross neural foraminal narrowing although this is limited without axial images the cervical cord is normal in signal and caliber no intradural or extradural fluid collections are noted the prevertebral soft tissues are normal thoracic spine the thoracic spine vertebral body heights and alignment are maintained diffuse t hypointensity of the vertebral body marrow signal is noted as seen in the cervical spine multilevel mild degenerative changes are noted with mild indentation on the adjacent end plates there is no spinal canal or neural foraminal narrowing the thoracic cord is normal in signal and caliber no epidural or soft tissue fluid collections are noted the prevertebral soft tissues are normal lumbar spine the lumbar spine vertebral body heights are maintained mild decrease in the t signal of the vertebral body marrow is noted similar to that seen in the cervical and thoracic spine approximately mm of grade retrolisthesis of l on l is present l l no gross spinal canal or neural foraminal narrowing l l a broad based disc bulge is present asymmetric to the right without significant spinal canal or neural foraminal narrowing l l minimal disc bulge is present without spinal canal narrowing moderate facet degenerative changes are noted with mild bilateral neural foraminal narrowing l l mm of retrolisthesis of l on l along with disc protrusion posterior osteophytes facet arthrosis and ligamentum flavum infolding produce moderate spinal canal narrowing mild to moderate right neural foraminal narrowing is present l s a broad based right paracentral disc protrusion is present superimposed upon a diffuse disc bulge resulting in mild spinal canal narrowing and moderate bilateral neural foraminal narrowing mild increase in the discs at l l s levels may be normal related to superimposed inflammation infection correlate with labs the lower cord and cauda equina are not well assessed due to suboptimal quality of the l spine study this may be due to technical factors although clumping of nerve roots cannot be excluded in this region no epidural or intradural fluid collection is identified the paravertebral soft tissues are grossly normal no obvious foci of enhancement are noted within the limitations of motion impression the study is significantly limited as the patient could not tolerate a complete exam and there is significant motion on multiple sequences no gross evidence for cord compression or gross evidence of spondylodiscitis mild increased t signal in the l and l s levels may be within normal limits or superimposed mild inflammtion infection correlate clinically and with labs and if necessary nuclear medicine studies the cauda equina is not readily discernable from the conus medullaris and is difficult to evaluate which may be technical due to the above limitations although abnormality of the cauda equina and conus cannot be excluded such as clumping of nerve roots and arachnoiditis a repeat examination when the patient is able to tolerate would be helpful for further evaluation diffuse diminished t signal of the vertebral body marrow signal is present suggesting such processes as myeloproliferative disorders chronic anemia and marrow replacement clinical correlation recommended multilevel multifactorial degenerative changes in the lumbar spine from l s can be assessed better on repeat study h ct abdomen indication year old male with congestive heart failure cirrhosis status post tips presents with bacteremia with failed antibiotics here for evaluation of source of infection comparison technique mdct images were acquired from the lung bases through the pubic symphysis following administration of oral contrast without iv contrast multiplanar reformations were generated g ct abdomen small bilateral pleural effusions are new since there is atelectasis and or scarring in the lung bases a mm subpleural nodularity is similar to the heart is top normal in size without pericardial effusion a large abdominal ascites is new since patient is status post tips which is in stable position the liver is small and nodular in contour there is splenomegaly to cm along the splenic hilum is an ovoid structure isoattenuating to the spleen most likely a large splenule although this may be confirmed by nuclear study if desired gallstones are redemonstrated there is no definite evidence to suggest cholecystitis the pancreas adrenal glands and bilateral kidneys appear within normal limits a small hiatal hernia is noted the stomach duodenum small and large bowel loops are normal in caliber the appendix is normal a duodenal diverticulum may be present there is no free air no mesenteric or retroperitoneal lymphadenopathy mild atherosclerotic disease is seen in the infrarenal aorta ct pelvis the bladder is partially collapsed containing air along the nondependent portion likely related to recent instrumentation a foley catheter is in place the rectum and sigmoid colon are unremarkable bone window multilevel degenerative disease is seen in the lumbar spine with spondylosis most pronounced at l l l and l s there is grade anterolisthesis of l with respect to l and s a sclerotic focus within l vertebral body is redemonstrated liekly a bone island impression no drainable collection bilateral small pleural effusions with atelectasis and or scarring cirrhosis status post tips new large abdominal ascites probable large splenule which could be confirmed by scintigraphy if desired mild anasarca new since i indication year old man with hypotension cirrhosis and diffuse abdominal pain to assess for colitis comparison no prior study is available for comparison technique outside hospital images done at have been uploaded to the pacs for a second opinion the visualized lung bases demonstrate linear atelectasis trace pleural effusions are seen bilaterally this study is limited without intravenous contrast for assessment of mesenteric ischemia the liver demonstrates a nodular contour a tips is in place multiple gallstones are present in a mildly distended gallbladder but no other evidence of acute cholecystitis is present both adrenal glands are normal both kidneys are unremarkable without evidence of nephrolithiasis or hydronephrosis the pancreas is unremarkable a large round lobulated soft tissue mass measuring x cm is seen in the left upper quadrant and is not well characterized in this non contrast study the adjacent presumed spleen is slightly abnormal in morphology and a well defined hilum is absent no stigmata of splenectomy noted the stomach and small bowel loops are unremarkable without evidence of bowel wall thickening or obstruction the study is limited for assessment of mesenteric ischemia without intravenous contrast within this limitation no pneumatosis or portal venous gas is identified the visualized large bowel is decompressed and unremarkable incidental note is made of a lipoma of the ileocecal valve a small focus of gas in the retroperitoneum adjacent to l l intervertebral disc space could represent extension of air from the disc degeneration a small amount of pelvic free fluid is present of unclear clinical significance the bladder is empty with a foley catheter in place the rectum and sigmoid colon are normal no significant pelvic lymphadenopathy is detected prostate is unremarkable osseous structures and soft tissues multilevel degenerative changes of the lumbar spine are noted with mild grade anterolisthesis of l on s a rounded sclerotic focus in l vertebral body likely represents a bone island impression limited study without intravenous contrast no portal venous gas or pneumatosis is detected to suggest bowel ischemia cholelithiasis without evidence of acute cholecystitis left upper quadrant soft tissue mass unclear etiology represent a splenule adjacent to large native spleen no history given or stigmata present of prior splenectomy nuclear spleen scan can help confrim splenic origin of mass to exclude neoplasm a trace amount of pelvic free fluid of unclear clinical significance small amount of gas in the retroperitoneum adjacent to the l l disc space could represent extension of the gas from the degenerating disc at that level ct chest with contrast chest ct on history pleural nodularity right apex and mediastinal adenopathy technique multidetector helical scanning of the chest was coordinated with intravenous infusion of cc optiray nonionic iodinated contrast reconstructed as contiguous and mm thick axial and mm thick coronal and paramedian sagittal images compared to torso ct findings the mediastinum is markedly widened with fat lymph node enlargement is greatest in the prevascular station where and mm wide nodes were previously and mm a mm right paraesophageal node was mm on and right lower paratracheal lymph nodes though numerous are neither pathologically enlarged nor changed the interval involution in node size probably reflects decreased edema since previous mediastinal edema and mild anasarca in the upper chest on the prior study have also cleared small nonhemorrhagic bilateral pleural effusions layer posteriorly slightly smaller today than on there is mild thickening of parietal pleura on both sides of the chest and the radiodensity of the effusions is higher than one would expect from serous fluid but since the patient has a history of chronic and recurrent pleural effusion this need not represent an active exudate such as infection there is no pericardial effusion all cardiac are chronically moderately enlarged atelectasis at the lung bases is probably due to chronic pleural abnormality there is no bronchial obstruction previous mass like atelectasis at the right apex has cleared a new region of mild peribronchial infiltration in the anterior segment of the right upper lobe is probably atelectasis relatively symmetric areas of discrete demineralization in the tips of both scapulae are most likely due to osteoporosis if patient has known malignancy a bone scan would be prudent to exclude lytic metastasis thoracic spine is unremarkable except for a focal sclerotic nodule in t a benign finding the thyroid gland is mildly enlarged diffusely particularly the right lobe and isthmus but there is no focal heterogeneity to suggest malignancy this study is not designed for subdiaphragmatic diagnosis except to note chronic calcified gallstone interval increase in moderate ascites and a portosystemic shunt in the right lobe of the liver impression decreasing reactive mediastinal lymph nodes probably a reflection of improved fluid status given concurrent resolution of previous mediastinal edema and mild anasarca and smaller chronic bilateral pleural effusions responsible for pleural thickening and basal atelectasis no focal pulmonary lesion of concern chronic cardiomegaly chronic calcific cholelithiasis left pic line ends in the upper svc mild thyromegaly no discrete mass increased moderate ascites focal lytic lesions in both scapulae most likely focal osteoporosis further attention would be indicated only if patient has known malignancy or other indication of osseous malignancy indication assess left basilic vein picc line placement comparison upright pa portable chest x ray from technique upright ap portable chest x ray findings the tip of the left basilic picc line is in the right atrium picc line nurse was called concerning this finding and we suggested that she withdraw the picc line cm to the distal superior vena cava interval mediastinal widening and cephalization of lung vasculature suggest of worsening heart failure bilateral pleural effusions are small but there is no pulmonary edema retrocardiac atelectasis appears unchanged impression picc line ends in the right atrium suggest withdrawing cm mild chf increased since indication left greater than right swelling rule out dvt comparison none findings grayscale and doppler evaluation of bilateral common femoral superficial femoral popliteal veins demonstrate normal compressibility flow response to augmentation the peroneal and posterior tibial veins were suboptimally visualized however demonstrated normal compressibility on real time evaluation impression no evidence of dvt in bilateral lower extremities iv cardiology a tee no spontaneous echo contrast or thrombus is seen in the body of the left atrium left atrial appendage or the body of the right atrium right atrial appendage no atrial septal defect is seen by d or color doppler overall left ventricular systolic function is normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened 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 no pericardial effusion impression no evidence of spontaneous echo contrast or intracardiac thrombus good left atrial appendage emptying velocities b ekg atrial fibrillation with a ventricular rate of st t wave changes in leads i ii iii avl avf and v v compared to the previous tracing of when the patient was also in atrial fibrillation there are no longer ventricular premature beats the rate is faster the non specific st t wave changes are unchanged the possible flutter waves seen previously in lead v are no longer seen on the current tracing otherwise no diagnostic interval change pending above blood cultures brief hospital course year old man with a history of secondary to tachycardia induced dilated cm alcoholic cirrhosis s p tips and paroxysmal atrial fibrillation off coumadin presented from osh with esbl e coli urosepsis and recurrent bacteremia with possible tips infection septic shock initially presented with altered mental status elevated creatinine decreased urine output and persistent hypotension after aggressive fluid resuscitation requiring three pressors lactate initially elevated to intubated for altered mental status acidosis and aggressive volume rescitation empirically started on vancomycin cipro and zosyn cultures ultimately grew esbl e coli in both urine and blood respiratory failure intubation pt required intubation on admission given respiratory distress he was ultimately extubated hd respiratory status has been stable over the last few weeks esbl e coli bacteremia presumed to be secondary to tips infection infectious work up included tte mri spine to r o osteo multiple paracentesis and multiple ct scans of abdomen and pelvis he was started on meropenem on given recurrent bacteremeia after an initial day course of meropenem another day course given which again resulted in positive blood cxs shortly after the abx was stopped given presumed tips he will likely need long term suppressive abx therapy plan is to dc him on meropenem g q until he follows up in clinic on his id physicians will determine whether he can be transitioned to an oral abx at time of discharge cxs had been negative since atrial fibrillation atrial flutter pt with long h o difficult to control afib aflutter while septic in micu developed svt with rates in the s he was started on an amiodarone drip with minimal decrease in his rates and without conversion to sinus rhythm electrophysiology was consulted and ultimately he was cardioverted and started on flecainide mg on he was cont on digoxin as well he had rhythm and rate control during the rest of his hospitalization with some limited episodes of atrial fibrillation with rvr to s given multiple procedures and recurrent hematocrit drops coumadin was deferred until outpatient colonoscopy could be performed risk of remaining off coumadin was discussed with pt and family volume overload pt was l positive following fluid resucitation from sepsis he required slow diuresis with lasix gtt currently he is near euvolemia and should restart home regimen of lasix and spironolactone altered mental status delirium during much of initial hospitalization likely related to illness and encephalopathy he was restarted home lactuose resolution of infection avoidance of narcotics all improved patient s mental status acute renal failure creatinine on presentation muddy brown casts shown demonstrated atn either secondary to hypoperfusion given inital low blood pressures vs direct effect of sepsis his renal function returned to after treatment of his infection and diuresis cirrhosis meld patient with history of cirrhosis s p tips for ascites per patient s hepatologist cirrhosis is likely secondary to alcohol abuse denies recent alcohol use hepatology followed the patient while in house should continue lactulose furosemide and spironolactone ascites the patient had interval development of abdominal swelling likely secondary to increased hydrostatic pressure from portal hypertension he had multiple ruq and two therapeutic and diagnostic paracenteses to rule out sbp given continuing ascites despite paracentesis his tips was explored with dopplers and found to have stenosis ir performed a tips venogram with successful dilitation on congestion heart failure diastolic chronic patient with history of dilated cardiomyopathy presumably secondary to alcohol abuse cardiology note from suggests ef of up from prior estimates of no known coronary disease echo performed during admission did not show any focal wall motion abnormalities and did show a normal ef it is of note his echo was performed with pressor support so his ejection fraction may be over estimated patient was total body positive in terms of fluid status given his aggressive fluid resuscitation initially no active signs or symptoms of heart failure at discharge thrombocytopenia unknown baseline likely chronic or chronic in setting of hepatic disease he had a platelet nadir at and was given one transfusion of a pack of platelets with improvement in numbers no episodes of bleeding dic labs negative he subsequent had platelets in s s diabetes the patient was placed on ssi in house and lantus due to persistent hypoglycemia in the morning he was discharged on lantus units he should also be on a humalog ss diarrhea the patient developed diarrhea on differential includes medication side effect secondary to lactulose excessive juice intake with sorbitol and c diff with the later being negative three times no longer having diarrhea at time of discharge hemoccult positive stool with anemia the patient has no gross blood per stool his stools were dark at times he had a post procedural hematocrit drop on to and was subsequently transfused hepatology was consulted and performed an egd on for upper tract causes with egd showing grade i varices portal gastropathy and erosions in the stomach cardia he was started on a ppi and his anemia gradually stabilized he had some variable fluctuations that on repeat were near baseline outpatient colonoscopy is advised loss of bilateral foot function resolved on patient reported loss of bilateral foot function with sensory lossin the lower extremities stat mri showed l signal abnormality no gross evidence for cord compression or gross evidence of spondylodiscitis following mri he was able to move both le again he denied any bowel bladder incontinence or saddle anesthesia rectal exam was performed with normal tone and enlarged prostate with any nodules or discrete masses he continues to have adequate extremity movement on discharge left ue swelling given concern for l r ue swelling ue dopper was performed to r o dvt doppler was negative for dvt on both and joint pain the patient endorses joint pains throughout the hospital there was a history of early joint pains per his daughter took prednisone at home which was held secondary to issues with infection given that his back pain was variably controlled bone and gallium scans as above were performed showing no osteomyelitis he was discharged with oral pain medication insomnia the patient was continued on home trazodone given habitus and snoring noted during rounds outpatient sleep study may be indicated given underlying heart disease would avoid ativan for insomnia given risk of confusion adjustment disorder given multiple medical problems the patient had a flat affected and endorses passive si that seemed to correlate with his medical condition and progress social work was consulted for coping in addition to psychiatry a family meeting was held with subsequent better spirits expansive affected and interval denial of si or hi the patient does have guns given his history as a police officer and an antique knife at home his daughter was notified that these items should be removed from his home after he returns and stabilizes nutrition the patient had poor po intake on the floor with excessive consumption of juice nutrition was consulted with suggestion for a feeding tube but the patient refused his appetite subsequently improved and he was given ensure supplementation as well would continue to monitor left upper tooth disease patient has severe dental disease with upper left tooth with severe decay advise outpatient dentist follow up incidentals on imaging large splenule noted on abdominal ct scan ct chest with contrast revealed focal lytic lesions in both scapulae most likely focal osteoporosis further attention would be indicated only if patient has known malignancy or other indication of osseous malignancy mri spine showing diffuse diminished t signal of the vertebral body marrow signal is present suggesting such processes as myeloproliferative disorders chronic anemia and marrow replacement code status full code contact information not preferred for contact access l picc placed pending blood cultures per lab section outpatient considerations patient will need outpatient id visit to manage meropenem therapy and plan for suppressive therapy consider outpatient colonoscopy given recurrent hematocrit drops atrial fibrillation he will need to follow up with dr to manage rhythm control medications flecainide and digoxin patient will need outpatient hepatology follow up given liver disease medications on admission digoxin mg po daily metoprolol mg po daily lasix mg po bid prednisone mg daily kcl meq po daily trazodone mg daily ativan unknown lactulose unknown discharge medications polyvinyl alcohol povidone dropperette sig drops ophthalmic prn as needed as needed for dry eyes lidocaine mg patch adhesive patch medicated sig one adhesive patch medicated topical daily daily as needed for back bottom lactulose gram ml syrup sig thirty ml po q h every hours titrate to two bowel movements per day digoxin mcg tablet sig one tablet po daily daily flecainide mg tablet sig tablets po q h every hours thiamine hcl mg tablet sig one tablet po daily daily folic acid mg tablet sig one tablet po daily daily multivitamin tablet sig one tablet po daily daily ferrous sulfate mg mg iron tablet sig one tablet po daily daily trazodone mg tablet sig one tablet po hs at bedtime as needed for insomnia oxycodone mg tablet sig one tablet po q h every hours as needed for pain disp tablet s refills insulin glargine unit ml solution sig twelve units subcutaneous at bedtime 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 sodium chloride flush ml iv prn line flush picc non heparin dependent flush with ml normal saline daily and prn per lumen omeprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day meropenem mg recon soln sig mg intravenous every eight hours please infuse over hours stop date lasix mg tablet sig one tablet po once a day spironolactone mg tablet sig one tablet po twice a day tylenol mg tablet sig tablets po every hours as needed for pain do not exceed greater than grams of apap daily discharge disposition extended care facility care and rehab woodmill in discharge diagnosis primary esbl e coli bacteremia septic shock acute renal failure atrial fibrillation with rapid ventricular response portal gastropathy secondary cirrhosis diabetes mellitus 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 dear mr you were treated at for a blood infection that required you to be admitted to the icu your infection has resolved though you will continue to need iv antibiotics and to follow up closely with your infectious disease physician medications stop toprol stop potassium supplement stop prednisone stop lorazepam stop tylenol with codeine start ferrous sulfate flecainide folic acid lidocaine patch meropenenm multivitamin oxycodone omeprazole thiamine spironolactone change lasix mg by mouth daily instead of mg by mouth twice daily followup instructions name location address phone appointment thursday pm department when wednesday at pm with md building sc clinical ctr campus east best parking garage department when wednesday at am with md building sc clinical ctr campus east best parking garage please make an appointment for pt to follow up with his cardiologist dr within weeks of leaving rehab,"{
""Diagnoses"": [""hypotension"", ""major surgical or invasive procedure"", ""intubation"", ""central line placement"", ""axillary arterial line placement"", ""picc placement"", ""ng tube placement"", ""dilatation"", ""cardioversion"", ""paracentesis"", ""EGD"", ""history of present illness"", ""MR is a year old man with a history of CHF, cirrhosis"", ""SP tips and AFib"", ""off Coumadin""],
""Medications"": [""Levaquin"", ""Zosyn"", ""Decadron"", ""LivF"", ""Dopamine"", ""Levophed""]
}"
14081,admission date discharge date date of birth sex m service csu history of present illness this year old white male had an abnormal ekg and a positive stress test prior to a hernia repair he denies having any chest pain or dyspnea he exercises on a treadmill on a daily basis with no symptoms he underwent cardiac catheterization at on which revealed an ejection fraction of percent normal right coronary artery a percent left main stenosis an percent mid left anterior descending stenosis and a percent intermedius stenosis he is now admitted for elective coronary artery bypass grafting past medical history significant for a history of non insulin dependent diabetes hypercholesterolemia and hypertension allergies he has no known allergies medications on admission lopressor mg p o twice daily univasc mg p o twice daily glyburide mg p o once daily metformin mg p o once daily lipitor mg p o once daily folate mg p o once daily and aspirin mg p o once daily family history significant for coronary artery disease social history he is married he does not smoke cigarettes and drinks alcohol occasionally review of systems as above physical examination on presentation he was a well developed and well nourished white male in no apparent distress vital signs were stable he was afebrile heent examination revealed normocephalic and atraumatic the extraocular movements were intact the oropharynx was benign neck was supple full range of motion no lymphadenopathy or thyromegaly the carotids were plus and equal bilaterally without bruits the lungs were clear to auscultation and percussion the abdomen was soft and nontender with positive bowel sounds no masses or hepatosplenomegaly with a positive hiatal hernia which was reducible the extremities were clubbing cyanosis or edema neurologic examination was nonfocal summary of hospital course he was admitted and on he underwent a coronary artery bypass graft times three with a lima to the lad a reversed saphenous vein graft to om and the ramus he tolerated the procedure well and was transferred to the csicu in stable condition on neo synephrine propofol and insulin he was extubated on postoperative night on postoperative day one he was transferred to the floor on postoperative day two his epicardial pacing wires and chest tubes were discontinued he continued to progress on postoperative day five he was discharged to home in stable condition his laboratories on discharge were a hematocrit of a white count of and platelets of sodium was potassium was chloride was bicarbonate was bun was creatinine was and blood sugar was medications on discharge aspirin mg p o once daily plavix mg p o once daily lipitor mg p o once daily colace mg p o twice daily lasix mg p o twice daily for seven days metformin mg p o twice daily glyburide mg p o once daily potassium meq p o twice daily for seven days lopressor mg p o twice daily percocet one to two tablets p o q h as needed for pain discharge diagnoses hypertension non insulin dependent diabetes hyperlipidemia coronary artery disease dictated by medquist d t job,"{
""Diagnoses"": [""Abnormal EKG"", ""Positive Stress Test"", ""Hernia Repair""],
""Medications"": [""Lopressor"", ""Univasc"", ""Glyburide"", ""Metformin"", ""Lipitor"", ""Folate"", ""Aspirin""]
}"
60968,admission date discharge date date of birth sex m service neurology allergies no known allergies adverse drug reactions attending chief complaint seizure major surgical or invasive procedure endotracheal intubation history of present illness the pt is a year old man who presents with first time seizure he was last seen well at pm on before going to bed early this morning at am his wife observed that he had full body shaking which lasted for about minutes she describes that his lips were blue and he was making strange noises there was no urinary incontinence ems was called when they arrived he was no longer seizing but was very agitated and combative requiring many men to hold him down he was taken to there upon arrival he appeared post ictal initially then he was able to accurately say his name his wife s name and address then he became increasingly combative and agitated and therefore he was intubated it was unsure whether his combativeness could be seizure he received mg of ativan mg of haldol and received etomidate and rocuronium he was placed on propofol and versed drips he was loaded with dilantin mg x head ct was done which reportedly did not show an acute intracranial process but this was not available at time of presentation to review he was afebrile blood cultures were obtained and he was empirically started on vancomycin ceftriaxone and acyclovir for meningitis coverage he received magnesium g iv or mildly prolonged qt interval of note a petecchial rash was noted to appear on both arms and chest which seemed to develop either at or during transport he was transferred to for further management lumbar puncture was done upon arrival on neuro his wife he does not have history of headaches yesterday he was interacting normally with normal speech and gait within the past year he had minor head trauma without loss of consciousness described as falling and hitting his head on a brick wall on general review of systems per his wife he has not had fever he has not had recent vomiting diarrhea or abdominal pain no recent change in bowel or bladder habits past medical history his wife describes an episode of waking up with confusion short term memory loss which occurred months ago his wife denies history of hypertension diabetes or high cholesterol he has never had a seizure before no history of febrile seizures or learning disabilities he has no prior hospitalizations or surgeries social history he is married with two children family history his wife is not aware of any family history of seizure or stroke his grandmother has physical exam on admission vitals t p r bp sao fio peep general intubated 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 petecchial rash on shoulders arms chest neurologic mental status intubated when examined off propofol he is not responsive to voice or noxious stimuli cranial nerves pupils and sluggishly reactive no blink to threat no horizonatal or vertical oculocephalics present no facial droop facial musculature symmetric no corneals bilaterally no gag reflex motor flexor posturing of both arms extensor posturing of both legs does not withdraw to noxious stimuli sensory does not withdraw to noxious stimuli dtrs unable to elicit reflexes throughout toes mute coordination unable to test gait unable to test on discharge gen red sclera on the right eye with some periorbital bruising ms intact minimal memory of the event cn intact strength full throughout reflexes symmetric b l with toes flexion coordination intact gait normal stride and gait pertinent results mri no acute infarction allowing for the pulsation artifacts no areas of altered signal intensity on the flair sequence however a few scattered t hyperintense foci may relate to pulsation artifacts slow flow in the venous structures these are not identifiable on the other sequences hence the significance of these findings is uncertain a followup study along with mrv can be considered for better assessment if there is continued concern in the coronal sequences the hippocampi are grossly symmetric in size slightly increased t signal in the left hippocampus which is equivocal significance to correlate with eeg and follwo up as clinically indicated paranasal sinus disease as described above cta no acute abnormality is seen subtle infarcts maybe occult on ct perfusion and if there is continued clinical concern mri would be more sensitive ck on discharge brief hospital course seizure was admitted after he had a witnessed gtc seizure at home he required multiple agents post ictally as he was combative and ended up being intubated there was initial concern for an infarct given absent cranial nerves on exam however it was later thought that this could be secondary to paralytics his mri showed flair abnormalities in the right temporal lobe consitent with a recent seizure his eeg was pending on discharge but showed no evidence of seizure activity he was started on keppra and discharged on this medication he was ordered for an mri with contrast one week after his discharge rhabdomyolisis his ck was climbing on hd to a max of renbal was consulted and he was put on bicarb drip his creatinine improved during the hospitalization he was told to get his ck and creatinine checked in days after his hospitalization medications on admission fish oil discharge medications levetiracetam mg tablet sig three tablet po bid times a day disp tablet s refills omega fatty acids capsule sig capsules po bid times a day oxycodone mg tablet sig one tablet po q h every hours as needed for pain disp tablet s refills outpatient lab work bun creatinine ck discharge disposition home discharge diagnosis seizure acute kidney injury rhabdomyolisis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to the neurology service after you had a seizure while waking up that was described as a generalized tonic clonic seizure your wife felt that it lasted at least minutes following the seizure you were confused and combative and were intubated a cta was done that showed no evidence of a stroke and an mri showed no evidence of stroke or mass you were transferred out of the icu but had elevations in your ck we kept you on fluids and renal was consulted and felt you would benefit from a bicarb drip you will need to stay on keppra and will need an mri with contrast of your head which was not done given the acute kidney injury an eeg was done which showed no evidence of seizure activity continue on keppra mg twice daily you will need an mri w contrast done in week this has been scheduled radiology will call you to make an appointment please come in to get your ck and creatinine checked in days followup instructions provider phone date time completed by,"{
""Diagnoses"": [""Seizure disorder""],
""Medications"": [""Ativan"", ""Haldol"", ""Etomidate"", ""Rocuronium"", ""Propofol"", ""Versed""]
}"
92649,admission date discharge date date of birth sex f service cardiothoracic allergies no known allergies adverse drug reactions attending chief complaint chest pain major surgical or invasive procedure four vessel coronary artery bypass grafting utilizing left internal mammary artery to left anterior descending with saphenous vein grafts to first obtuse marginal second obtuse marginal and pda history of present illness this is a year old female who presented to with exertional chest pain with radiation to both arms since summer patient denied rest pain and stated that her chest pain was relieved by rest she underwent cardiac catheterization which revealed severe three vessel coronary artery disease including a left main lesion with normal left ventricular function she was urgently transferred to the for surgical revascularization past medical history carotid artery disease hypertension history of abnormal mammogram hyperlipidemia stress incontinence peripheral vascular disease hypothyroidism asthamtic bronchitis s p cholecystectomy s p hysterectomy tubal pregnancy s p aorto bifem social history widowed lives alone occupation retired from lucent cigarettes smoked no yes x last cigarette etoh denies illicit drug use denies family history denies premature coronary artery disease physical exam admission exam t pulse bpm resp o sat b p right left height inches weight lbs general well nourished nad skin dry x intact x well healed aorta bifem incision heent perrla x eomi x mmm normal oropharynx neck supple x full rom x no jvd chest lungs clear bilaterally x heart rrr x no m r g abdomen soft x non distended x non tender x bs x extremities warm x no cce varicosities none x neuro grossly intact x pulses femoral right left dp right dopplerable left dopplerable pt dopplerable left dopplerable radial right left carotid bruit right w bruit left discharge ra gen nad neuro a o x cv rrr no murmur sternum stable incision cdi pulm cta bilat abdm soft nt nd bs ext warm well perfused pedal edema bilat pertinent results admit labs 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 ck cpk alkphos amylase totbili pm blood ck mb ctropnt discharge labs am blood hct 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 pnd ptt pnd inr pt pnd am blood pt inr pt am blood pt inr pt am blood pt ptt inr pt am 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 chest x ray pa and lat in comparison with the study of allowing for the pa versus ap projection there is probably little overall change continued enlargement of the cardiac silhouette with bilateral pleural effusions more prominent on the right and underlying compressive atelectasis there is persistent mild engorgement of the pulmonary vessels intraop tee pre cpb the left atrium is moderately dilated no thrombus 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 size is normal overall left ventricular systolic function is normal lvef hypokinesis is noted in the mid inferior and inferoseptal walls right ventricular chamber size and free wall motion are normal there are complex mm atheroma in the aortic arch there are complex mm atheroma in the descending thoracic aorta the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic stenosis no aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild to moderate mitral regurgitation is seen dr was notified in person of the results at time of study post cpb the patient is on a phenylephrine infusion the mid inferior and inferoseptal segments appear severely hypokinetic bordering on akinetic which is worse than pre bypass other wall segments are contracting well overall estimated systolic ef the right ventricular systolic function is preserved valve function remains unchanged there is no evidence of dissection brief hospital course mrs was admitted and underwent routine preoperative evaluation she remained pain free on medical therapy and was cleared for surgery on dr performed coronary artery bypass grafting surgery for surgical details please see operative note in summary she had urgent coronary artery bypass graft x left internal mammary artery to left anterior descending artery and saphenous vein grafts to obtuse marginal and posterior descending artery endoscopic harvesting of the long saphenous vein cardiopulmonary bypass time was minutes with a crossclamp time of minutes she tolerated the operation well and following the operation she was brought to the cvicu for invasive monitoring in the immediate post op period she remained hemodynamically stable woke neurologically intact and extubated later that day she continued to be hemodynamically stable throughout pod and transferred to the floor on pod for further recovery and post operative care chest tubes and pacing wires removed per cardiac surgery protocol the patient started on bblockers and was gently diuresed toward her preop weight on the stepdown floor she was noted to have bursts of atrial fibrillation and was started on amiodarone and coumadin for anticoagulation following which she converted to sinus rhythm the remainder of her hospital course was largely uneventful she worked with nursing and physical therapy however progress was slow and she was cleared for discharge to nevins nursing and rehab in on pod target inr for a fib first blood draw tomorrow all f u appts advised she is to follow up with dr in month medications on admission ditropan xl daily asa daily cartia xl daily fosamax qwk levothyroxine mcg daily losartan daily pravachol daily ntg sl prn discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily tablet delayed release e c s pravastatin mg tablet sig one tablet po once a day levothyroxine mcg tablet sig one tablet po daily daily docusate sodium mg capsule sig one capsule po bid times a day for months ranitidine hcl mg tablet sig one tablet po daily daily for weeks amiodarone mg tablet sig one tablet po once a day metoprolol tartrate mg tablet sig tablet po bid times a day hold hr and or sbp tramadol mg tablet sig one tablet po every hours as needed for pain acetaminophen mg tablet sig two tablet po every hours as needed for pain lasix mg tablet sig one tablet po once a day warfarin mg tablet sig daily dosing per rehab provider target inr for a fib tablets po daily daily dose today only is mg all further dosing per rehab provider potassium chloride meq tablet er particles crystals sig one tablet er particles crystals po once a day for weeks while on lasix hold for k ditropan xl mg tablet extended rel hr sig one tablet extended rel hr po once a day potassium chloride meq tablet extended release sig two tablet extended release po once a day bisacodyl mg suppository sig one suppository rectal every other day discharge disposition extended care facility nursing and rehab discharge diagnosis coronary artery disease s p cabg postop atrial fibrillation peripheral vascular disease prior aorto bifem in carotid disease hypertension dyslipidemia hypothyroidism discharge condition alert and oriented x nonfocal ambulating with steady gait incisional pain managed with tramadol and tylenol incisions sternal healing well no erythema or drainage leg right left healing well no erythema or drainage edema bilat 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 one month or while taking narcotics driving will be discussed at follow up appointment with surgeon no lifting more than pounds for weeks 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 p cardiologist dr at p wound check on at a please call to schedule appointments with your primary care dr miroslawa 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 atrial fibrillation goal inr to first draw please arrange followup with pcp prior to discharge from rehab office md completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex f service cardiothoracic allergies no known allergies adverse drug reactions attending addendum in a note entered on pod the anesthesia fellow documented post operative respiratory failure this was a routine post operative recovery the patient was intubated for surgery and recovered as expected there was no post operative respiratory failure discharge disposition extended care facility nursing and rehab md completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex f service cardiothoracic allergies no known allergies adverse drug reactions attending addendum on the patient had a cxr that showed continued enlargement of the cardiac silhouette with bilateral pleural effusions more prominent on the right and underlying compressive atelectasis there is persistent mild engorgement of the pulmonary vessels these changes are consistant with post operative volume overload she was also noted to have several episodes of post op atrial fibrillation which could cause some degree of congestive heart failure and pulmonary engorgement pertinent results on the patient had a cxr that showed continued enlargement of the cardiac silhouette with bilateral pleural effusions more prominent on the right and underlying compressive atelectasis there is persistent mild engorgement of the pulmonary vessels these changes are consistant with post operative volume overload she was also noted to have several episodes of post op atrial fibrillation which could cause some degree of congestive heart failure and pulmonary engorgement discharge disposition extended care facility nursing and rehab md completed by,{}
7065,admission date discharge date date of birth sex m service ccu history of present illness this is a year old male who presented to outside hospital after shoveling snow a few day prior to admission when he developed intermittent chest pain nausea vomiting diaphoresis and lightheadedness he described the pain as it was initially constant but then subsided and became intermittent on the day of admission he was driving and became very lightheaded he then went to and was found to have a systolic blood pressure of he was also found to be in atrial fibrillation with a heart rate in the s he also was noted to have mm to mm st elevations in leads v to v and large q waves his pressure responded to intravenous hydration he was also started on a low dose esmolol drip for rate control also on heparin and aggrastat he was transferred to for catheterization which revealed a totally occluded proximal to medial left anterior descending artery with no collaterals the left main was free of disease the right coronary artery was with medial stenosis and normal diastolic ventricular function when the patient was initially hypotensive when arriving to the laboratory the esmolol drip was discontinued his blood pressure remained in the low s systolically but later he required dopamine past medical history none allergies no known drug allergies medications on admission no medications on admission family history family history significant for father who died of a myocardial infarction social history social history is positive for tobacco of one pack per day for years positive for alcohol of approximately a few beers per week physical examination on presentation general physical examination revealed the patient was pleasant in no apparent distress head eyes ears nose and throat examination revealed pupils were equal round and reactive to light extraocular muscles were intact mucous membranes were dry heart examination revealed irregularly irregular tachycardic the lungs were clear the abdomen was benign extremity examination revealed no clubbing cyanosis or edema pertinent laboratory values on presentation hematocrit was and platelets were potassium was creatinine was creatine kinase was mb was and mb index was hospital course this is a year old gentleman with anterior st elevation myocardial infarction who was transferred to for emergent percutaneous coronary intervention now with atrial fibrillation with rapid ventricular rate he was initiated on aspirin plavix and started on statin at which time his liver function tests were sent to monitor baseline he was also initiated on a beta blocker an ace inhibitor was held while he was hypotensive he was continued on aggrastat for hours he was kept intra aortic balloon pump to maintain his blood pressure and to optimize perfusion he was also on a dopamine drip which was maintained for a goal mean arterial pressure of greater than he was also monitored for strict ins and outs and daily weights since the patient was found in atrial fibrillation it was unclear of the onset he was continued on heparin and coumadin once the intra aortic balloon pump was pulled before cardioversion a beta blocker was used for rate control the patient was full code the intra aortic balloon pump was pulled on without difficulties the patient had a bedside echocardiogram on with a preliminary report of left ventricular ejection fraction of approximately with global hypokinesis with more severe hypokinesis anteriorly there was no pericardial effusion noted the patient was scheduled for a transesophageal echocardiogram on in order to evaluate for clot prior to direct current cardioversion for the atrial fibrillation with a rapid ventricular rate by this point the patient was off dopamine and been initiated on a low dose ace inhibitor the transesophageal echocardiogram did not demonstrate any clot the patient was started on coumadin and the heparin was continued the patient received cardioversion on with joules with conversion to a sinus rhythm the patient was loaded on amiodarone given mg p o b i d times one week followed by mg p o q d for atrial fibrillation he was continued on aspirin plavix beta blocker and ace inhibitor he was then scheduled for risk stratification examination the patient also received a physical therapy consultation the patient had a signal average electrocardiogram as the first part of his risk stratification which was borderline positive at this point the patient was stable and called out to the floor and maintained on telemetry while on the floor his course was complicated by an episode of dyspnea with respiratory rates in the upper s to s a chest x ray demonstrated a right lower lobe infiltrate the patient was initiated on levaquin and flagyl p o for presumptive aspiration pneumonia therapy the patient responded well and was continued on levaquin and flagyl in addition due to some evidence of congestive heart failure based on the ejection fraction of approximately to the patient was diuresed with lasix mg intravenously times one with a good response he was also given atrovent nebulizers q h for the dyspnea and wheeze the patient continued to be cared for in house while awaiting for a therapeutic inr of between to for atrial fibrillation as well as monitoring oxygen saturations the patient did not require oxygen on admission and was not to go home with oxygen the patient s inr became therapeutic on in addition his ambulatory oxygen saturations on room air remained greater than to the patient was ambulating without difficulty and was cleared by physical therapy for discharge the patient was discharged to home discharge instructions followup the patient was to follow up with his new primary care physician cardiologist dr in on thursday at p m telephone number the patient was also scheduled for an inr check on the day status post discharge at the for coumadin maintenance the patient was also scheduled to follow up at the on for a t wave alternans test in addition to picking up a holter monitor medications on discharge lisinopril mg p o q d furosemide mg p o q d flagyl mg p o t i d times more days levofloxacin mg p o q d times days amiodarone mg p o b i d times one week followed by mg p o q d per week coumadin mg p o q h s to be titrated carvedilol mg p o b i d atorvastatin mg p o q d protonix mg p o q d plavix mg p o q d times months aspirin mg p o q d condition at discharge condition on discharge was improved discharge status discharge status was to home with followup discharge diagnoses anterior st elevation myocardial infarction ejection fraction of approximately to with evidence of heart failure atrial fibrillation with a rapid ventricular rate status post direct current cardioversion follow up plans as noted above dr dictated by medquist d t job,"{
""Diagnoses"": [""intermittent chest pain"", ""nausea"", ""vomiting"", ""diaphoresis"", ""lightheadedness"", ""atrial fibrillation"", ""systolic blood pressure"", ""heart rate"", ""mm to mm st elevations in leads v to v"", ""large q waves""],
""Medications"": [""esmolol"", ""heparin"", ""aggrastat""]
}"
81536,admission date discharge date date of birth sex f service medicine allergies penicillins sulfa sulfonamide antibiotics cephalosporins erythromycin base attending chief complaint questionable insulinoma major surgical or invasive procedure none history of present illness ms is a yo female with history of morbid obesity atrial fibrillation on chronic coumadin questionable dvt depression history of osa asthma hyopothyroidism presenting from medical center for workup of possible insulinoma per reports the patient is a resident at at rehabiliation facility she was found to have a fingerstick glucose of there and was transferred to mecial center for further evaluation she was transferred to the icu for recurrent hypoglycemia and cpeptide insulin levels were found to be elevated of note the patient has no history of diabetes a cosyntropin stimulation test was performed which was interpreted as mild suppression of hpa axis as cortisol went from with stim the patient was started on mg prednisone with glucose levels in the s afterwords endocrinology was consulted who was concerned for a possible insulinoma as patient is morbidly obese she did not fit in the ct scanner at the osh and was transferred to for imaging regarding her low blood sugars the patient had been expericening episodes of diaphresis and confusion assocaited with sweats and visual changes since her bg was checked and found to be hypoglycemic per above she was given juice and sugar cubes but her sugars would temporally respond then dip to the s s after an hours or so she denies any recent insulin use or oral hypoglcyemic use of note she has been trying to lose weight through diet and exercise losing a total of lbs in the last year with lbs in the last month regarding the endocrionlogy consult she had a cosyntropin test per above which suggested adrenal suppression possibly from chronic inhaled steroid use and increased levothyroxine dosing leading to hpa suppression this led to a recommendation of lifelong prednisone use which started at mg daily she was further evaluated on where insulin concentration was proinsulin was and c peptide was all c w insulin hypersecrtion from insulinoma or receiving a secreatgogue such as a sulfonylurea given that the patient did not have any further episodes of hypoglycemia endocrinology was under the impression that hypoglycemic episode related to sulfonylurea ingestion suggested ct abdomen as well as tapering of prednisone mg per week to goal of mg daily at the osh a left sided picc was placed given poor access a portable cxr performed that showed complete opacity of the left hemithorax with increasing infiltrate at the right lung base and gastric congestion in the right lung regarding placement the left picc line position was difficult to ascertain due to distorted anatomy from left lung collapse with concern for placement in the left innominate vein inr around that time was and the patient claism to continue to have oozing from the site since placement on at time of transfer the patient s t was pulse rr saturating on no documented o supplemnetation with bp of ros endorsed visual changes involving central clouding and peripheral acuity resolved after the hospital gave her some meds denies fever chills night sweats headache rhinorrhea congestion sore throat cough shortness of breath chest pain abdominal pain nausea vomiting diarrhea constipation brbpr melena hematochezia dysuria hematuria past medical history bronchtis questionable asthma history of pna morbid obesity hypothyroidsism atrial fibrillation on coumadin depression questionable history of venous thrmoboembolism osa per report social history former tax accountant nondrinker never smoker lives at rehab has an adopted daughter family history unknown per patient father died when she was mother died of complications related to obesity no siblings physical exam admission vs on l general nad obese heent nc at perrla eomi sclerae anicteric mmm op clear neck supple could not appreciate jvd or thyroid heart distant hs normal s s lungs distant bs otherwise ctabl ausculated anteriorly abdomen obese nbs nttp no organomegaly apprecaited extremities wwp no c c e peripheral pulses left power picc in place gu foley in place with cloudy urine neuro awake a ox cns ii xii grossly intact brief hospital course yo female with history of morbid obesity atrial fibrillation on chronic coumadin questionable dvt depression history of osa asthma hyopothyroidism presenting from osh for evaluation of possible insulinoma hypoxia lobar lung collapse patient is in chronic respiratory acidosis due to small airways collapse and air trapping she was found to have complete left upper lobe and partial lower lobe collapse on ct scan after admission echo performed to evaluate for pulmonary hypertension was suboptimal given patient s habitus most likely cause for o requirement is a mix of obstructive airway disease with pickwickian physiology she experienced respiratory decompensation with hypercarbia and was transferred to the micu where she was intubated for respiratory failure bronchoscopy showed collapse of left large airways due to extrinsic compression by right atrium and secretions in right lung serial cxrs showed an evolving right sided pneumonia she completed an day course of vancomycin and aztreonam for pneumonia due to the patient s body habitus and obstruction she required a large amount of peep on the ventilator she underwent a bronchoalveolar lavage which was unrevealing due to poor ability to wean from the ventilator the patient underwent tracheostomy she was weaned to intermittent trach mask with periods of rest on mmv and required cpap psv overnight for transient episodes of desaturation at night supratherapeutic inr persistently elevated inr after admission despite holding coumadin likely related to malnutrition malabsorption as opposed to liver dysfunction or medication effect in this patient she received a dose of po vitamin k prior to micu transfer in the micu inr improved it remained stable for the remained of admission hypoglycemic episodes at osh osh endocrine workup concerning for insulinoma vs adrenal insufficiency vs medication effect due to inappropriate insulin secretagogue other potential causes ruled out here she was followed by endocrine here and had no further episodes of hypoglycemia endocrine was not concerned for insulinoma the patient would benefit from endocrine follow up and was instructed to do so on discharge adrenal insufficiency abnormal cosyntropin stim test at osh although sub optimal study abd ct shows cm adrenal nodule left her repeat cortisol stimulation testing here off of steroids was normal suggesting that she does not actually have adrenal insufficiency proteus uti she had a positive ua with urine culture growing proteus given her allergies she was started on aztreonam for treatment uti proven aztreonam sensitive she completed an day course of antibiotics uti resolved asthma the patient was continued on nebs and inhalers throughout admission atrial fibrillation chronic patient s coumadin was held on admission for supratherapeutic inr coumadin was restarted and she remained therapeutic for the remained for admission hypothyroidism patient was continued on home dose levothyroxine mcg qday obesity morbidly obese has had pannus resection in past she was followed by wound care for pannus she was treated with nystatin and cream depression she was continued on celexa mg qday medications on admission albuterol neb soln neb ih q h prn wheezing shortness of breath miconazole powder appl tp apply to rash under pannus citalopram mg po ng daily ondansetron mg iv q h prn nausea docusate sodium mg po bid senna tab po ng prn constipation fluticasone salmeterol diskus inh ih tiotropium bromide cap ih daily levothyroxine sodium mcg po ng daily discharge medications levothyroxine mcg tablet sig one tablet po once a day fluticasone mcg actuation aerosol sig two puff inhalation times a day spiriva with handihaler mcg capsule w inhalation device sig one puff inhalation once a day serevent diskus mcg dose disk with device sig inhalation twice a day docusate sodium mg capsule sig two capsule po at bedtime albuterol sulfate mcg actuation hfa aerosol inhaler sig puffs inhalation q h every hours citalopram mg tablet sig one tablet po daily daily warfarin mg tablet sig one tablet po once daily at pm titrate to inr goal of oxycodone mg ml solution sig po every hours as needed for pain hold for sedation rr nystatin unit g powder sig one application topical twice a day as needed for rash under left breast pannus lasix mg tablet sig one tablet po once a day fleet enema gram ml enema sig one rectal twice a day as needed for constipation discharge disposition extended care facility northeast discharge diagnosis partial left lung collapse right sided pneumonia proteus urinary tract infection discharge condition mental status clear and coherent level of consciousness alert and interactive activity status bedbound discharge instructions you were admitted to the hospital for evaluation of a possible insulin secreting tumor insulinoma after further testing it was determined that you do not have an insulin secreting tumor insulinoma you were transferred to the intensive care unit for partial collapse of your left lung at hospital this was believed to be partially due to compression of your lungs by an enlarged heart you also developed a right lung pneumonia and received a full course of antibiotics to treat the infection you also underwent a bronchoalveolar lavage of your lungs which was unrevealing however it was difficult to take you off the ventilator and you underwent a tracheostomy so it would be possible to discharge you from the hospital while on a ventilator you were also found to have a urinary tract infection and you were treated with a course of antibiotics the following changes were made to your home medications furosemide mg daily was started prednisone mg daily was stopped percocet was switched to oxycodone as needed for pain followup instructions you should follow up with the interventionary pulmonologist as an outpatient for further evaluation and management of your lung function you should follow up with an endocrinologist as an outpatient within days after discharge from the hospital please follow up with your primary care physician z within days of discharge from the rehabilitation facility [NEW_RECORD] name unit no admission date discharge date date of birth sex f service medicine allergies penicillins sulfa sulfonamide antibiotics cephalosporins erythromycin base attending addendum cxr the dobhoff tube still is in the stomach and coiled left central catheter tip is in the left brachiocephalic vein mild pulmonary edema is unchanged right lower lobe consolidation is increased from prior could be atelectasis but superimposed infection cannot be excluded left lower lobe retrocardiac opacity consistent with atelectasis is unchanged if any there is a small left pleural effusion et tube tip is cm above the carina tte the left atrium is moderately dilated left ventricular wall thicknesses are normal the left ventricular cavity is moderately dilated overall left ventricular systolic function is mildly depressed lvef the number of aortic valve leaflets cannot be determined no aortic regurgitation is seen the mitral valve leaflets are structurally normal no mitral regurgitation is seen there is an anterior space which most likely represents a prominent fat pad impression poor technical quality due to patient s body habitus moderate lv dilatation global left ventricular function is probably mildly depressed a focal wall motion abnormality cannot be fully excluded the right ventricle is not well seen no pathologic valvular abnormality seen pulmonary artery systolic pressure could not be determined ct chest abdomen findings please note that evaluation is extremely limited given patient s body habitus ct chest there is complete collapse of the left upper lobe and partial collapse of the left lower lobe with leftward shift of mediastinal structures the obstructing cause is not seen on this study this is new when compared to the chest radiograph of there are patchy opacities in the right lung apex nonspecific but may be infectious or inflammatory in nature mosaic pattern of ground glass opacity within the right lung is consistent with air trapping and may represent underlying small airways disease there is a small right sided pleural effusion and adjacent compressive atelectasis there is cardiomegaly without pericardial effusion no definite mediastinal hilar or axillary lymphadenopathy is seen although again evaluation is extremely limited ct abdomen the spleen stomach and liver are within normal limits multiple small calcified gallstones are present within the gallbladder evaluation of the kidneys is limited although they do appear grossly normal there may be a left adrenal nodule measuring up to cm although it is unclear whether this is definitively part of the left adrenal gland unfortunately further assessment of this nodule cannot be made on this study the right adrenal gland appears normal the pancreas is markedly atrophic and extremely difficult to see on this study however no gross mass within the pancreas is identified bone windows no concerning osseous lesions are identified impression extremely limited evaluation given patient s body habitus complete collapse of the left upper lobe and partial collapse of the left lower lobe an obstructing cause is not seen leftward shift of midline structures small right sided pleural effusion patchy opacities in the right lung apex are nonspecific but may be infectious or inflammatory in nature mosaic ground glass pattern to the right lung is most consistent with air trapping and may reflect underlying small airways disease cardiomegaly the pancreas is not well seen given limitations of the examination and is also likely atrophic however no gross mass identified possible left adrenal nodule measuring up to cm however it is unclear whether this actually part of the left adrenal gland or adjacent to it and further characterization cannot be made on this study cholelithiasis microbiology bronchoalveolar lavage pm bronchoalveolar lavage bronchial lavage rll bal gram stain final per x field polymorphonuclear leukocytes no microorganisms seen smear reviewed results confirmed respiratory culture final commensal respiratory flora absent yeast ml isolates are considered potential pathogens in amounts cfu ml fungal culture preliminary yeast acid fast smear final no acid fast bacilli seen on direct smear no acid fast bacilli seen on concentrated smear acid fast culture preliminary urine culture pm urine source catheter final report urine culture final proteus mirabilis organisms ml presumptive identification piperacillin tazobactam sensitivity testing available on request aztreonam sensitivity requested per dr sensitive to aztreonam sensitivity testing performed by sensitivities mic expressed in mcg ml proteus mirabilis ampicillin r ampicillin sulbactam i cefazolin s cefepime s ceftazidime s ceftriaxone s ciprofloxacin r gentamicin i meropenem s tobramycin s trimethoprim sulfa r urine culture am urine site not specified hem l used final report urine culture final proteus mirabilis organisms ml presumptive identification piperacillin tazobactam sensitivity testing available on request aztreonam requested by dr on aztreonam sensitive sensitivity testing performed by sensitivities mic expressed in mcg ml proteus mirabilis ampicillin r ampicillin sulbactam i cefazolin s cefepime s ceftazidime s ceftriaxone s ciprofloxacin r gentamicin i meropenem s tobramycin s trimethoprim sulfa r urine culture pm urine source catheter final report urine culture final no growth admission laboratory values lactic acid mmol l abg o delivery device aerosol cool face tent spo pao fio wbc hb hct plt na k cl hco bun cr glucose discharge disposition extended care facility northeast md completed by,"{
""Diagnoses"": [""insulinoma"", ""morbid obesity"", ""atrial fibrillation"", ""hypothyroidism"", ""osA"", ""asthma"", ""depression""],
""Medications"": [""coumadin"", ""prednisone""]
}"
31231,unit no admission date discharge date date of birth sex female service neonatology history baby girl twin is a gram product of a weeks gestation born to a year old g p mother the maternal history was notable for a positive ppd on inh treatment which was stopped during pregnancy prenatal screens were blood type o negative antibody negative hepatitis b surface antigen negative rpr nonreactive rubella immune gbs unknown mom did receive rhogam the review of systems was otherwise negative the mother had a cerclage in place but developed preterm labor the infants were delivered via c section for a twin delivery rupture of membranes was at delivery twin a emerged vigorous with good cry apgars and physical examination weight g length cm hc cm vitals t hr s rr s bp heent anterior fontanelle open and flat palate intact resp clavicle intact clear breath sounds with moderate retractions cv regular rate and rhythm no murmur good femoral pulses abd soft nondistended no hepatosplenomegaly skin pink with moderate perfusion gu normal female genitalia patent anus neuro normal with good tone physical measurements at discharge weight g hc cm length cm summary of hospital course by systems respiratory the baby was admitted and placed on cpap and soon after admission she needed to be intubated and received two doses of surfactant she was extubated to room air on dol and remained on room air since that time she did have several apnea of prematurity which has since resolved she has been days without a spell cardiovascular the baby had normal blood pressures at birth and never received pressors or needed boluses she was found to have a murmur which was quite loud on echo it showed a structurally normal heart with a pfo and no treatment was ever given cardiology does not need to follow up fluids electrolytes and nutrition the baby was started npo on iv fluids she started on feeds on day of life one she increased as tolerated and is currently on breast milk with enfacare which she is taking all po gi the baby was found to have hyperbilirubinemia with a peak of she was on phototherapy for days and has had no further issues since that time hematology at birth the baby had a cbc which revealed a hematocrit of and a platelet count of she was started on iron which she continues at discharge no further issues infectious disease at birth the baby had a rule out sepsis workup she had a white blood cell count that was with polys and bands she received ampicillin and gentamicin for hours blood culture were negative and treatment was discontinued she has had no further issues neurology the baby had a normal neurologic exam at birth and continues to have a normal neurologic exam without any issues sensory a audiology hearing screen was performed with automated auditory brain stem responses which the baby passed b ophthalmology secondary to gestational age greater than weeks the baby did not have an ophthalmologic exam condition at discharge excellent discharge disposition home name of primary care of pediatrician dr at pediatrics phone care recommendations feeds at discharge please continue breast milk made with enfacare powder medications the baby is currently on iron sulfate mg per kilogram per day iron and vitamin d supplementation a iron supplementation is recommended for preterm and low birth weight infants until months corrected age b all infants feed predominately breast milk should receive vitamin d supplementation at international units may be provided as a multivitamin preparation daily until months corrected age car seat position screening test was done and passed state newborn screening status the baby had state newborn screens the first at birth which is normal and the second on which the results are pending immunizations received the baby received hepatitis b vaccination on immunizations recommended a synagis rsv prophylaxis should be considered from through for infant to meet any of the following 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 disease b influenzae 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 influenzae is recommended for household contact in that of home caregivers c this infant has not received 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 of age and less weeks of age follow up recommended the baby has a follow up appointment with her pediatrician discharge diagnoses prematurity twin gestation respiratory distress syndrome rule out sepsis evaluation reviewed by dictated by medquist d t job,"{
""Diagnoses"": [""Twin is a gram product of a weeks gestation born to a year old GP mother""],
""Medications"": [""Rhogam""]
}"
13978,admission date discharge date service cardiothoracic history of present illness the patient is an year old male with coronary artery disease he is status post catheterization at which time the results showed a severe greater then mid left anterior descending coronary artery stenosis left circumflex diffuse mild disease with obtuse marginal probably the graft target showed a total mid right coronary artery occlusion with bridging collaterals due to the extensive coronary artery disease the decision was made to proceed with coronary artery bypass graft the patient was admitted to the coronary care unit at time intraaortic balloon pump was placed in the patient as a bridge to the coronary artery bypass graft the patient was also placed on nitro and heparin drips on a coronary artery bypass graft times three vessels was completed with saphenous vein graft to distal left anterior descending coronary artery left internal mammary coronary artery to obtuse marginal saphenous vein graft to the right coronary artery the patient tolerated the procedure well and was taken to the cardiac surgical intensive care unit at which time the iabp was discontinued as well as the swan ganz catheter on postoperative day one the patient did quite well and was transferred to the surgical floor where he continued to do well and engage in physical therapy his epicardial wires and chest tubes were removed without incident and the patient s course was complicated by some early morning confusion which was unlike anything encountered at baseline urinalysis electrocardiogram and neurological examinations were without significant findings geratology consult was asked for by the family and they were kind enough to see the patient and give their recommendations but their diagnosis as well as ours was acute delirium on postoperative day five the patient was discharged to rehab in good condition condition on discharge good discharge status to rehab discharge diagnosis unstable angina secondary to coronary artery disease status post coronary artery bypass graft times three discharge medications sorbitol cc po q day lopressor mg po b i d finasteride mg po q day atorvastatin mg po q day aspirin mg po q day lasix mg po b i d times seven potassium chloride milliequivalents po b i d times seven dr dictated by medquist d t job [NEW_RECORD] admission date discharge date service acove chief complaint weakness history of present illness patient is an year old gentleman with a history of coronary artery disease status post coronary artery bypass graft on admitted to the intensive care unit with an upper gastrointestinal bleed on the day of admission the patient felt weak he denied any chest pain any shortness of breath or any palpitations he fell to the floor he denies any head trauma or loss of consciousness and he was brought to the emergency department by the family in the emergency department guaiac was found to be positive and hematocrit was from on nasogastric lavage was performed and had coffee ground which did not clear after liters of normal saline also in the emergency department the patient was initially transfused with unit of packed red blood cells and he was administered intravenous fluids he was then admitted to the intensive care unit for endoscopy and further care past medical history coronary artery disease status post coronary artery bypass graft in upper gastrointestinal bleed in with esophagitis and ulcer in the stomach and duodenum and h pylori positive benign prostatic hypertrophy prostate cancer treated with watchful waiting status post nephrectomy for renal cancer years ago ejection fraction is measured before coronary artery bypass graft medications metoprolol po bid finasteride mg po q day atorvastatin mg po q day aspirin mg po q day hydrochlorothiazide po q day allergies no known drug allergies social history he was born in he moved to the us on he is a retired rabbi smoked tobacco in the army and quit many years ago he denies any alcohol use physical examination on presentation blood pressure was pulse oxygen saturation is on room air general appearance elderly man pale in no acute distress heent no jugular venous distention dry mucous membranes lungs with decreased breath sounds in the right heart regular rate with normal s s no murmurs rubs or gallops and a well healing sternotomy abdomen is soft nontender nondistended with decreased bowel sounds extremities dorsalis pedis pulses bilaterally no edema neurologic is alert and oriented times three laboratories on admission white blood cells was hematocrit then dropped to mcv of coags ptt inr chem was unremarkable except for a potassium of chest x ray showed bilateral pleural effusions small on the left side and large on the right side electrocardiogram showed sinus rhythm at right axis right bundle branch block t wave depression in leads ii iii avf and v v biphasic similar to the electrocardiogram performed on brief hospital course mr is an year old gentleman with a history of coronary artery disease status post recent coronary artery bypass graft presented with an upper gastrointestinal bleed upper gastrointestinal bleed mr presented to the emergency department with a hematocrit of from on he was guaiac positive and nasogastric lavage showed coffee grounds which did not clear after liters of normal saline the patient was admitted to the intensive care unit he was transfused units of packed red blood cells an egd was performed which showed ulcers in the posterior bulb of the duodenum one of which was actively bleeding and was electrocauterized with successful hemostasis there was also a single nonbleeding ulcer in the second part of the duodenum which was not treated at this time his lowest blood pressure was he had no chest pain shortness of breath or palpitations at this time his hematocrit then increased to and after that and on the second day dropped once again to an egd was repeated which showed a single nonbleeding ulcer the patient was once again transfused units of packed red blood cells with his hematocrit increasing to the rest of his hospital course was unremarkable his hematocrit continued to increase spontaneously the patient was advanced on clear diet and then regular diet without any problems was started on pantoprazole iv which was then weaned to pantoprazole mg po bid and discharged on pantoprazole mg po q day for eight weeks after which he should be getting omeprazole mg po q day for life aspirin was held and at the time of discharge it is still held the plan is for the patient to be started after two weeks at this time his discharge hematocrit was coronary artery disease the patient is status post coronary artery bypass graft his lowest pressure during the upper gastrointestinal bleed with and never had any chest pain shortness of breath or palpitations his electrocardiogram had no changes indicating ischemia metoprolol and aspirin were initially held because of the low blood pressure and the risk of bleeding metoprolol was restarted and his blood pressure improved myocardial infarction was ruled out by enzymes aspirin at the time of discharge is still held and as discussed above should not be restarted within the next two weeks pulmonary effusion the patient was found to have bilateral pleural effusions with the right larger than left the pleural effusion was tapped and was found to be an exudate with many white blood cells no organisms and no pmns on gram stain cytology was negative for malignant cells the pleural effusion had a large amount of eosinophils for which pe was considered a possible etiology because of the intermediate risk for pe for this patient who had recent surgery patient initially underwent a vq scan which was read as low probability however low probability vq scan in the context of a moderate chance of missing a pulmonary embolus it was therefore felt that the patient could benefit from a ct angiogram the patient initially received intravenous hydration because of his history of nephrectomy and mucomyst in order to protect his single kidney as much as possible and then underwent a ct angiogram the ct angiogram showed no pulmonary embolus but revealed a sclerotic bone lesion at t a pulmonary consult was called and the pulmonologist felt that the pleural effusion even though had eosinophilia was most consistent most likely with post cabg pleural effusion the patient was started on lasix mg po q day it was felt that otherwise felt that since he is asymptomatic he did not need any further treatment or workup plan is for the patient to get a chest x ray to monitor the progression and hopefully the resolution of pleural effusion within one month and in discussion with his primary care physician is to followup with pulmonary clinic here at sclerotic bone lesion a sclerotic bone lesion at t was accidentally found on ct scan patient and his family were made aware of this finding and because of his history of prostate cancer at this time they were recommended to followup with his primary care physician discharge diagnoses upper gastrointestinal bleed duodenal ulcer coronary artery disease pleural effusions sclerotic bone lesion other diagnoses he presented with follow up plan referred the patient to followup with his primary care physician and the patient s primary care physician s discretion with the pulmonary clinic here and with a the clinic also here discharge medications pantoprazole mg po q h for eight weeks after which he should be switched to omeprazole mg po q day for life furosemide mg po q day metoprolol mg po bid bupropion mg po q day atorvastatin mg po q day hydrochlorothiazide po q day finasteride mg po q day aspirin is to be held for the next two weeks after which it could be restarted discharge status to home with physical therapy as recommended by the physical therapist and will see the patient in house discharge condition good m d dictated by medquist d t job,"{
""Diagnoses"": [""coronary artery disease"", ""catheterization"", ""severe greater than mid left anterior descending coronary artery stenosis"", ""left circumflex diffuse mild disease with obtuse marginal probably the graft target showed a total mid right coronary artery occlusion with bridging collaterals"", ""coronary artery bypass graft""],
""Medications"": [""nitro"", ""heparin"", ""saphenous vein graft""]
}"
19154,admission date discharge date date of birth sex m service allergies patient recorded as having no known allergies to drugs attending chief complaint mcc unhelmeted thrown into fence major surgical or invasive procedure i d of scalp repair of facial and scalp degloving injuries ventriculostomy placement anterior cervical diskectomy and fusion of c peg tube placement bedside orif of leforte iii fx s tracheostomy history of present illness y o man unhelmeted involved in a mcc who was thrown from his bike into a fence at mph gcs of on scene moving all extremities pt was intubated on scene and taken to ohs pt was transferred to for management of his massive head and facial trauma past medical history none social history lives with wife family history non contributory physical exam pe on admission vs temp c hr bp sat gen intubated gcs i heent massive right sided degloving injury to scalp with palpable depressed skull fracture avulsion of nose tip mid face instability bilateral orbital ecchymosis per mm minimally reactive tm clear neck no crepitus chest stable no crepitus equal breath sounds bilaterally cv rrr abdomen soft non distended fast neg pelvis stable to rectal no tone guiac neg ext no visible deformity paralyzed pertinent results ct reconstruction pm impression fractures through the basion c c and c the fracture through the c lateral mass extends crossing the vertebral artery foramen in addition there is slight anterior displacement of the right posterior arch of c overall anterior posterior alignment is preserved ct orbit sella iac w o contrast am ct of the facial bones there has been interval reduction and internal fixation with metallic plates and fixation screws seen along the bilateral zygomatic bones maxilla and nasal bone there has also been placement of mesh material along the right inferior orbit there is near anatomic alignment of the reduced fractures a surgical drain is seen in the frontal scalp there are numerous other facial and skull fractures seen as described previously particular note is made of an osseous fragment seen superior to the left cribriform plate which projects into an area of hypodense brain parenchyma there is persistent opacification of the visualized sinuses impression anatomic alignment of multiple fracture reductions with fixation plates and screws as well as placement of mesh along the inferior right orbit c spine portable pm ap and lateral bedside radiographs of the cervical spine are suboptimal due to portable technique and large patient size there is anterior fusion of c with corresponding perforated plate and vertebral body screws however the spine is inadequately assessed below the c level in lateral projection despite several attempts a tracheostomy tube is in place and an apparent left subclavian line has its tip just reaching the svc there is a poorly visualized fracture of the posterior elements of c and apparent fractures elsewhere in the spine the visualized upper lungs are clear the previous apparent intraoperative radiographs also inadequately assessed the fusion ct sinus mandible maxillofacial w o contrast am impression near anatomic alignment with multiple facial fractures with microfixation plates and compression screws there is placement of mesh material in the right inferior orbit no significant interval change since examination left cribriform plate fracture with an osseous fragment which projects into the left inferior frontal lobe this finding was noted on as well and also discussed with house staff at that time this raises concern for an area of potential future cerebrospinal fluid leak and or meningitis brief hospital course overnight to transfer to head ct revealed bilateral sah with left frontal lobe contusion large iph with ventricular bleed right occipital bone fx no midline shift pt taken to or for i d of open skull fx cranialization of frontal sinus placement of ventricular catheter and i d of scalp wound admitted to tsicu ortho spine ct c spine with c left lamina fx entering the vertebral foramen c left facet fx c left facet fx neurosurgery vessel cerebral angio no carotid or vertebral injury to tsicu monitoring and icp and abx therapy zosyn and gent for possible sinus infection pt remains intubated anterior cervical diskectomy and fusion of c peg tube placement bedside plastic surgery consult regarding nasal repair to orif of leforte iii fx s by omfs plastics and neurosurgery tracheostomy vancomycin started on for continued fevers extubated and placed on trach collar transferred to floor on with continued abx therapy on zosyn and vanc to pt stable on floor with sitter neurologic status continued to improve pt fitted for pmv to enable vocalization still unable to pass swallow continued on tube feeds fevers continued although no source was identified id consult obtained on suggested persistent fevers could be related to abx zosyn vanc d c after full day course respectively fevers subsided by day off abx pt continued with pt and was able to ambulate with assistance medications on admission none discharge medications docusate sodium mg ml liquid sig one ml dose po bid times a day disp ml dose refills lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po qd once a day disp capsule delayed release e c s refills chlorhexidine gluconate liquid sig fifteen ml mucous membrane tid times a day disp ml s refills albuterol mcg actuation aerosol sig puffs inhalation q h every hours as needed disp mdi refills polyvinyl alcohol povidone dropperette sig drops ophthalmic prn as needed disp months supply refills oxycodone acetaminophen mg ml solution sig mls po q h every hours as needed disp ml s refills artificial tear ointment ointment sig one appl ophthalmic prn as needed disp months supply refills bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po qd once a day as needed disp tablet delayed release e c s refills atenolol mg tablet sig one tablet po bid times a day disp tablet s refills haloperidol lactate mg ml concentrate sig two ml po tid times a day as needed for agitation disp ml refills acetaminophen mg ml elixir sig five ml po q h every hours disp ml refills ibuprofen mg ml suspension sig thirty ml po q h every hours disp ml refills discharge disposition extended care facility hospital discharge diagnosis i d of scalp repair of facial and scalp degloving injuries ventriculostomy placement anterior cervical diskectomy and fusion of c peg tube placement bedside orif of leforte iii fx s tracheostomy discharge condition improving discharge instructions the pt should be continued on tube feeds with a goal of cc hr oral hygeine is very important in this pt as he has a wound on his hard palate continue peridex cc swish and swallow and ns rinses every to hours you may brush hard palate gently two to three times a day continue pt and consider reevaluation of swallowing function when appropriate pt has pmv to enable speech followup instructions omfs pt should follow up with oral maxillofacial surgery to weeks after discharge call the clinic at the clinic is located at hospital when you call they will give you directions to the clinic opthomology pt should follow up in the eye clinic in to weeks call to schedule an appt they will give you directions to the location of the clinic at that time neurosurgery the pt should follow up with dr in to weeks prior to this appt the pt should have a repeat head ct please call and ask to schedule an appt and time for head ct trauma pt should follow up in trauma clinic in weeks call to schedule an appt for the clinic is located in the in department a on [NEW_RECORD] admission date discharge date date of birth sex m service nsu the patient is a year old gentleman who was originally admitted status post a motorcycle accident in he sustained multiple head and facial fractures traumatic brain injury and a cervical spine fracture at the time of admission an incidental finding of a left anterior communicating artery aneurysm was discovered on magnetic resonance imaging he was admitted in had an angiogram which showed thrombosed aneurysm no further treatment was performed the patient was then discharged he is re admitted now for repeat angiogram the patient was admitted and had an angiogram which showed left anterior communicating artery aneurysm that had reexpanded from mm to a diameter of mm the patient was therefore taken back for angiogram on for elective coiling after days of plavix anti platelet therapy at the time of the angiogram on the aneurysm was noted to only fill to mm again having thrombosed nonetheless he underwent coiling of the angiographically evident portion using coils with no intraoperative complications postop his vital signs were stable he was afebrile neurologically at his baseline awake alert and oriented times two to three pupils down to on the right on the left it was down to both are sluggish eom s are full face is symmetric strength is full no drift his pulses were palpable his groin sites were clean dry and intact he also had a repeat bed side swallow which demonstrated inconsistent signs and symptoms of aspiration at the bedside with thin liquids and purees so the patient was scheduled for video swallow on his neurologic status remained stable he had a repeat angiogram after coiling which showed a small amount of recanalization at th eneck of the aneurysm of mm discharge medications erythromycin ophthalmic ointment ou four times a day ferrous sulfate mg per g tube q daily multivitamin one cap per his g tube daily quetiapine fumarate mg per g tube twice a day donepezil mg p o q night ranitidine mg per percutaneous endoscopic gastrostomy twice a day trazodone mg per percutaneous endoscopic gastrostomy q night p r n valproic acid mg per percutaneous endoscopic gastrostomy tube q hours colace mg per percutaneous endoscopic gastrostomy twice a day the patient s condition was stable at the time of discharge he will follow up with dr with a repeat angiogram in one month his systolic blood pressure should be kept less than condition on discharge stable dictated by medquist d t job,"{
""Diagnoses"": [""Massive head and facial trauma"", ""Scalp repair"", ""Facial and scalp degloving injuries"", ""Ventriculostomy placement"", ""Anterior cervical diskectomy and fusion"", ""C-Peg tube placement"", ""Bedside ORIF of leforte III FX"", ""S tracheostomy""],
""Medications"": [""Intubation"", ""Tamiflu"", ""Pain management medication"", ""Antibiotics"", ""Muscle relaxants"", ""Anti-seizure medication"", ""Pain medication"", ""Anti-inflammatory medication""]
}"
64773,admission date discharge date date of birth sex f service medicine allergies sulfur norvasc attending chief complaint abd pain crohns flare major surgical or invasive procedure none history of present illness f with pmhx of renovascular htn c b nstemi now s p renal stents gout and h o crohn s disease who presented to the ed on with rlq pain for approx days she denies any nausea vomiting diarrhea or constipation but has not been taking po well and felt dehydrated initial vs on arrival to the ed t bp hr rr sats on ra pt was noted to have a leukocytosis with bandemia and underwent a ct abd which showed inflammation in the terminal ileum likely consistent with crohns flare she was noted to be guaic negative with normal lactate and was given l of ivf prior to admission to the floor on arrival to the floor pt was reporting rlq pain decreased appetite and general lethargy she denied any fevers chills n v d c and had her last bm approx hrs ago which was soft but non bloody ros denies cp sob cough congestion fevers rash dysuria sick contacts unusual food exposures but does report days of general malaise and poor po intake past medical history crohn s disease accelerated hypertension renal artery stenosis s p stents to renal arteries in gout b deficiency past surgical history fibrous tumor requiring abd rescection in s p appendectomy at age and tonsillectomy at age social history divorced and lives alone pt has many supportive friends and does not smoke cigarettes denies any etoh daughter is likely her health care proxy but not officially appointed family history cad father died at age of cad after having rheumatic fever as a child physical exam vs t bp hr rr sats ra gen nad tired appearing but responds appropriately to questions heent ncat eomi dry mm no apprec lad cv rrr no apprec mr r g resp ctab no w r apprec no resp distress abd soft nabs mild distended with ttp over rlq no rebound guarding extr warm thin no rash guaic negative in ed 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 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 am blood lactate am blood lactate ct abd prelim read inflammation of the ileum consistent with likely crohn flare ekg from nsr with lvh but otherwise unchanged from prior tracings with some tw flattening in iii brief hospital course y o f with pmhx of renovascular htn s p stenting gout and crohns dz who presents with rlq pain and ct findings consistent with crohns flare hospital course pt slowly improved with bowel rest ivf antibiotics initially ciprofloxacin and flagyl and ultimately ciprofloxacin flagyl and vancomycin she was evaluated by general surgery who assessed her as a risky surgical candidate she was intermittantly delerious however this ultimately resolved cultures were negative during the hospitalization she experienced atrial fibrillation and flutter with rapid ventricular response this was rate controlled with metoprolol anticoagulation was considered and was not started she was also noted to have a coagulopathy attributed to malnutrition this was treated with oral vitamin k supplementation with some improvement medications on admission carvedilol mg calcium d protonix mg daily aspirin mg daily lisinopril mg daily isosorbide mononitrate mg daily colchicine mg daily discharge medications acetaminophen mg tablet sig two tablet po q h every hours as needed for pain fever calcium carbonate mg tablet chewable sig one tablet chewable po tid times a day cholecalciferol vitamin d unit tablet sig two tablet po daily daily mesalamine mg capsule sustained release sig three capsule sustained release po bid times a day aspirin mg tablet chewable sig one tablet chewable po daily daily metoprolol tartrate mg tablet sig one tablet po tid times a day discharge disposition extended care facility care center of discharge diagnosis primary crohns flare delirium paroxysmal atrial fibrillation and flutter secondary cri renovascular disease discharge condition mental status clear and coherent level of consciousness alert and interactive discharge instructions you were admitted with a crohns flare and you were evaluated by our gastroenterologists you have been treated with antibiotics and you also experienced an abnormal heart rhythm known as atrial fibrillation this was largely controlled with medication it does place you at risk for strokes however and in order to minimize this risk anticoagulation with blood thinners was dr will dictate an addendum with updated discharge instructions followup instructions department primary care when wednesday am name k md location healthcare address phone department gastroenterology when wednesday at am with md building lm bldg campus west best parking garage department west clinic when wednesday at am with m d building de building complex campus west best parking garage [NEW_RECORD] name unit no admission date discharge date date of birth sex f service medicine allergies sulfur norvasc attending addendum see below chief complaint abdominal pain major surgical or invasive procedure none history of present illness f with pmhx of renovascular htn c b nstemi now s p renal stents gout and h o crohn s disease who presented to the ed on with rlq pain for approx days she denies any nausea vomiting diarrhea or constipation but has not been taking po well and felt dehydrated initial vs on arrival to the ed t bp hr rr sats on ra pt was noted to have a leukocytosis with bandemia and underwent a ct abd which showed inflammation in the terminal ileum likely consistent with crohns flare she was noted to be guaic negative with normal lactate and was given l of ivf prior to admission to the floor on arrival to the floor pt was reporting rlq pain decreased appetite and general lethargy she denied any fevers chills n v d c and had her last bm approx hrs ago which was soft but non bloody past medical history crohn s disease accelerated hypertension renal artery stenosis s p stents to renal arteries in gout b deficiency past surgical history fibrous tumor requiring abd rescection in s p appendectomy at age and tonsillectomy at age social history divorced and lives alone pt has many supportive friends and does not smoke cigarettes denies any etoh daughter is likely her health care proxy but not officially appointed family history cad father died at age of cad after having rheumatic fever as a child physical exam vs ra gen alert and oriented to person place and situation no apperent distress heent no trauma pupils round and reactive to light and accomodation no lad oropharynx clear no exudates cv regular rate and rhythm no murmurs gallops rubs pulm clear to auscultation bilaterally no rales crackles rhonchi gi soft non tender non distended no guarding rebound ext no clubbing cyanosis edema distal pulses pneumoboots in place derm no lesions appreciated pertinent results ct abdomen w contrast impression moderate amount of free air within the abdomen of undetermined source which is a new finding when compared to study bowel wall thickening and wall enhancement of colon and ileum these findings are consistent with an inflammatory process namely crohn s disease flare and or ischemic enteritis diffuse pericolic fat stranding and inflammatory changes are noted within the abdomen and pelvis interval increase of fluid collections in the pelvis fluid collection with associated pocket of air is seen within the pelvis which is concerning for an abscess formation interval increase of bilateral pleural effusions and atelectasis stable splenic hypodensity which likely represents a splenic infarct moderate hiatal hernia stable appearance of bilateral renal cysts and multilobular septated left renal cyst brief hospital course y o with crohns disease initially p w rlq pain for d ct with terminal ileal inflammation concerning for crohns flare hospital course has been complicated first by episodes of afib with rvr second with pt developing episode of acute gib and most recently with pt developing perforated viscous with an acute abdomen pt was trasferred to the icu but was determined that pt is not a surgical candidate and that pt would not want surgery anyway morning pt became hypotensive and very tachycardic to s with evidence of ischemic changes on telemetry i called and discussed pt s current clinical condition with her hcp pt was already dnr dni based upon decisions in the icu and after further repeat discussion with hcp daughter a move with comfort measures oriented therapy was initiated she was provided morphine iv which she frequently declined as she denied discomfort she denied hunger or thirst palliative care consult was placed and meds were changed to concentrated morphine solution mg q hr prn along with oral ppi therapy a signed dnr dni order was signed by hcp and placed in the chart discussion with the patient s family undertaken and family was informed that a time course is unpredictable though patient s prognosis is grim with high mortality patient may continue in current condition for days to weeks diagnoses perforated viscous crohn s flare with terminal ileal inflammation acute gi bleed with anemia due to acute blood loss atrial fibrillation with rvr renovascular htn bp as above medications on admission carvedilol mg calcium d protonix mg daily aspirin mg daily lisinopril mg daily isosorbide mononitrate mg daily colchicine mg daily discharge medications omeprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily disp capsule delayed release e c s refills morphine concentrate mg ml solution sig five mg po q h every hours as needed for pain labored breathing disp bottle refills discharge disposition extended care facility care center of discharge diagnosis primary crohns flare delirium paroxysmal atrial fibrillation and flutter perforated viscous with abscess secondary cri renovascular disease discharge condition mental status clear and coherent level of consciousness lethargic but arousable activity status bedbound discharge instructions you were admitted with a crohns flare and you were evaluated by our gastroenterologists you have been treated with antibiotics unfortunately during your hospitalization you had a rupture of your intestine you were evaluated by surgery but you decided that you did not want surgery for this issue with the understanding that this will likely be a terminal condition comfort oriented care was instituted along with palliative consult visit your pain has been well controlled your family is also aware of your current condition and you and they have decided to move you to skilled nursing facility closer to your family with request for hospice evaluation followup instructions none md completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex f service medicine allergies sulfur norvasc attending addendum discharge instructions you were admitted with a crohns flare and you were evaluated by our gastroenterologists you have been treated with antibiotics unfortunately during your hospitalization you had a rupture of your intestine you were evaluated by surgery but you decided that you did not want surgery for this issue with the understanding that this will likely be a terminal condition comfort oriented care was instituted along with a palliative consult visit your pain has been well controlled your family is also aware of your current condition and you and they have decided to move you to a skilled nursing facility closer to your family with request for hospice evaluation you also experienced an abnormal heart rhythm known as atrial fibrillation during your hospitalization this was controlled with heart rate medications although this condition places you at risk for strokes anticoagulation with blood thinners was not started in the setting of your acute crohn s flare because of the possibility of sending you for surgery at that time and the potential risk of bleeding that would have resulted from starting an anticoagulant discharge disposition extended care facility care center of discharge diagnosis primary crohns flare delirium paroxysmal atrial fibrillation and flutter perforated viscous with abscess secondary cri renovascular disease discharge condition mental status clear and coherent level of consciousness lethargic but arousable activity status bedbound discharge instructions as above followup instructions none md completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex f service medicine allergies sulfur norvasc attending addendum brief hospital course y o with crohns disease initially p w rlq pain for d ct with terminal ileal inflammation concerning for crohns flare hospital course has been complicated first by episodes of afib with rvr second with pt developing episode of acute gib and most recently with pt developing perforated viscous with an acute abdomen pt was trasferred to the icu but was determined that pt is not a surgical candidate and that pt would not want surgery anyway morning pt became hypotensive and very tachycardic to s with evidence of ischemic changes on telemetry i called and discussed pt s current clinical condition with her hcp pt was already dnr dni based upon decisions in the icu and after further repeat discussion with hcp daughter a move with comfort measures oriented therapy was initiated she was provided morphine iv which she frequently declined as she denied discomfort she denied hunger or thirst palliative care consult was placed and meds were changed to concentrated morphine solution mg q hr prn along with oral ppi therapy a signed dnr dni order was signed by hcp and placed in the chart discussion with the patient s family undertaken and family was informed that a time course is unpredictable though patient s prognosis is grim with high mortality patient may continue in current condition for days to weeks diagnoses perforated viscous crohn s flare with terminal ileal inflammation acute gi bleed with anemia due to acute blood loss atrial fibrillation with rvr renovascular htn bp as above discharge disposition extended care facility care center of md completed by,"{
""Diagnoses"": [""Crohn's flare"", ""Renal stents"", ""Gout""],
""Medications"": [""Norvasc"", ""IVF""]
}"
53873,admission date discharge date date of birth sex m service cardiothoracic allergies penicillins percocet attending chief complaint esophageal cancer major surgical or invasive procedure esophagectomy laparoscopy thoracoscopic mobilization of esophagus and intrathoracic esophagogastric anastomosis history of present illness the patient is a year old male with a t n esophageal adenocarcinoma of the gastroesophageal junction he received induction chemoradiation therapy and is being admitted for esophagectomy social history married live with wife pack years quit etoh occasional drink family history non contributory physical exam vs t hr sr bp sats ra general year old male no apparent distress heent normocephalic mucus membranes moist neck supple no lymphadenopathy card rrr normal s s no murmur gallop or rub resp breath diminished but clear gi bowel sounds positive abdomen soft non tender non distended extr warm no edema skin right flank induration erythema no warmth incision right abdominal chest site clean dry intact neuro non focal pertinent results wbc rbc hgb hct plt ct wbc rbc hgb hct plt ct wbc rbc hgb hct plt ct glucose urean creat na k cl hco glucose urean creat na k cl glucose urean creat na k cl hco mrsa screen final no mrsa isolated esophagus study impression status post esophagectomy with no evidence for leak or obstruction cxr there is a small right pleural effusion with right lower lobe atelectasis small left pleural effusion and left lower lobe atelectasis brief hospital course mr was admitted on and taken to the operating room for esophagectomy laparoscopy thoracoscopic mobilization of esophagus and intrathoracic esophagogastric anastomosis he tolerated the procedure was transferred to the sicu while in the sicu he responded to a fluid resuscitation for hypotension he was extubated without difficulty the acute pain service managed his with pain with an bupivicaine epidural pod he transferred to the floor the chest tube and nasogastric tube were placed to low wall suction a dilaudid pca was started for better pain control tube feeds were started at cc hr pod the ng tube accidently came out the tube feeds were increased to cc which he tolerated he ambulated in the room pod the drain was removed and a follow up chest x ray revealed no pneumothorax pod his tube feeds were increased to goal and cycled pod he was seen physical therapy who deemed him safe for home the epidural was removed and he voided without difficulty his pain was well controlled with dilaudid pca pod he had an esophagus study which revealed no anastamotic leak he was started on a full liquid diet which he tolerated his right flank region was noted to have mild edema slight erythema tender no warmth he was started on clindamycin x days he was converted to po dilaudid with good pain control pod he had an abdominal pelvic ct for the right flank and it showed tissue edema no hematoma or infection his wife was taught tube feed teaching and flushing he continued to ambulate in the halls and was discharged to home with vna he will follow up with dr as an outpatient medications on admission tenoretic mg daily allopurinol mg daily lipitor mg daily nexium mg daily ativan q prn discharge medications tube feeds isosource full strength goal rate ml hr cycle start cycle end prevacid solutab mg tablet rapid dissolve dr one tablet rapid dissolve dr once a day disp tablet rapid dissolve dr s refills hydromorphone mg tablet tablets po q h every hours as needed for pain disp tablet s refills tenoretic mg tablet one tablet po once a day allopurinol mg tablet one tablet po once a day hold until seen by dr docusate sodium mg ml liquid five po bid times a day as needed for constipation clindamycin palmitate mg ml recon soln twenty ml po every six hours for days disp ml refills lipitor mg tablet one tablet po once a day mg tablet one tablet po once a day meclizine mg tablet one tablet po once a day as needed for dizziness ambien mg tablet one tablet po at bedtime as needed for insomnia sodium fluoride cream one dental twice a day apply as directed discharge disposition home with service facility discharge diagnosis esophageal cancer gerd hypertension hyperlipidemia l s disc herniation s p surgery discharge condition stable discharge instructions call dr office if experience fevers or chills increased cough or chest pain nausea vomiting diarrhea abdominal pain incision develops drainage j tube call with any questions or concerns should tube fall out call immediately to have it replaced flush j tube with cc water every hours or more to maintain patency no medications through j tube unless it is liquid daily weights keep log bring to your appointment head of bed elevated degrees at all times wedge under mattress yogurt while taking clindamycin please call if develops diarrhea followup instructions follow up with dr am on the clinical center report to the radiology department for a chest x ray minutes before your appointment completed by,"{
""Diagnoses"": [""Esophageal cancer"", ""Major surgical or invasive procedure (esophagectomy)"", ""Laparoscopy"", ""Thoracoscopic mobilization of esophagus and intrathoracic esophagogastric anastomosis""],
""Medications"": [""Penicillins"", ""Percocet""]
}"
4577,admission date discharge date date of birth sex f service history of present illness the patient is a year old female with end stage renal disease secondary to diabetes she also has a history of hypertension peripheral vascular disease and hypothyroidism who presented with chest pain the patient felt chest pressure while walking and had associated shortness of breath and emesis she did have relief with rest on admission she did also note that her blood sugars were running higher than normal she did have a stress test five years ago as a possibility for transplant option which was normal in the emergency department the patient was given aspirin ceftriaxone lopressor and was chest pain free past medical history her past medical history includes type diabetes with associated retinopathy and neuropathy hypertension peripheral vascular disease end stage renal disease hemodialysis dependent her hemodialysis schedule is on monday wednesday and friday history of hypothyroidism status post percutaneous transluminal coronary angioplasty of the bilateral lower extremities status post amputation of her right foot social history the patient moved here from and lives with her mother in she does not smoke she does not drink alcohol she does not use intravenous drugs she does ambulate with a cane allergies the patient has allergies to clindamycin which gives her diarrhea levaquin which gives her gastrointestinal upset and zemplar which gives her a rash medications on admission her medications on admission included plavix mg by mouth once per day atenolol mg by mouth once per day nph insulin units subcutaneously in the morning with units subcutaneously regular in the evening units subcutaneously of regular and units subcutaneously of nph tums by mouth three times per day epogen units with each dialysis iron vitamin d review of systems the patient s review of systems was positive for diarrhea for four days no hematochezia no orthopnea positive for chest pain as in history of present illness positive for a dry cough physical examination on presentation the patient s physical examination revealed she was a pleasant female in no apparent distress although she did look malnourished the patient s vital signs revealed her temperature was degrees fahrenheit her heart rate was her blood pressure was her respiratory rate was and her oxygen saturation was on room air head eyes ears nose and throat examination revealed multiple large cystic lesions on her face and under her chin that were confluent there was no warmth but there was positive pigmentation the patient s pupils were equal and reactive the oropharynx was clear her chest examination revealed the lungs were clear to auscultation bilaterally cardiovascular examination revealed a regular rate and rhythm there was a systolic murmur at the right upper sternal border the abdomen was soft nontender and nondistended there were positive bowel sounds extremity examination revealed no edema her right foot had a partial amputation her left foot had a dorsalis pedis pulse of she had good capillary refill on the right neurologic examination revealed her cranial nerves were intact her strength was grossly intact and symmetric she did have decreased sensation in her lower extremities pertinent laboratory values on presentation the patient s laboratories on admission revealed her white blood cell count was her hematocrit was and her platelet count was the patient s sodium was potassium was chloride was bicarbonate was blood urea nitrogen was creatinine was and her blood glucose was her troponin was and ck mb was pertinent radiology imaging the patient s chest x ray showed cardiomegaly with upper zone redistribution no effusions or consolidations the patient s electrocardiogram revealed mm st depressions in v through v and there were t wave inversions in leads i v and v and minor changes concise summary of hospital course the patient was admitted and eventually was sent for cardiac catheterization the cardiac catheterization revealed an ejection fraction of and vessel disease including occlusion of the right left anterior descending artery and posterior descending artery the patient was then referred to dr for coronary artery bypass grafting while awaiting surgery the patient s plavix was held and had no complications on the patient underwent coronary artery bypass grafting times three with left internal mammary artery to left anterior descending artery saphenous vein graft to the distal left anterior descending artery and a saphenous vein graft to the posterior descending artery the surgery was performed by dr with dr and pa c as assistants the surgery was performed under general endotracheal anesthesia with a cardiopulmonary bypass time of minutes and a cross clamp time of minutes the patient tolerated the procedure well and was transferred to the intensive care unit with two atrial and two ventricular pacing wires with one left pleural chest tube and dobutamine levophed and propofol drips the patient was in a normal sinus rhythm over the postoperative night the patient was extubated without complications she remained on her dobutamine drip and the levophed drip was weaned as tolerated by postoperative day one the patient was to have hemodialysis and her plavix restarted following dialysis her chest tubes were discontinued without incident the patient s dobutamine was weaned off over this day by postoperative day two the patient was started back on her beta blocker throughout the early postoperative period over the first two days postoperatively the patient was on an insulin drip for tighter control of her blood sugars on postoperative day five the patient was finally off of her insulin drip and her blood sugars were maintained with nph and sliding scale the patient continued during that time to receive regular hemodialysis at the bedside on postoperative day six the patient was transferred to the regular floor and was continued on vancomycin and gentamicin especially for the lesions on her face by postoperative day seven the patient was switched to by mouth medications for the pustule lesions on her face this medication was keflex she had her pacing wires discontinued without incident on this day and the plan was for her to be discharged to rehabilitation the following day on postoperative day eight the patient was doing well she did receive an additional course of hemodialysis on this day it was felt that she was ready and stable to be discharged to rehabilitation for further continuation and recovery from her cardiac surgery physical examination on discharge the patient s discharge examination revealed her vital signs to be stable with a temperature of degrees fahrenheit her heart rate was her blood pressure was her respiratory rate was and her oxygen saturation was on room air in general the patient was alert and oriented times three in no apparent distress cardiovascular examination revealed a regular rate and rhythm her wounds were clean dry and intact the lungs were clear to auscultation bilaterally her abdomen was soft nontender and nondistended the patient s legs revealed no clubbing cyanosis or edema her wounds were clean dry and intact pertinent laboratory values on discharge the patient s laboratories on discharge revealed her white blood cell count was her hematocrit was and her platelet count was the patient s sodium was potassium was chloride was bicarbonate was blood urea nitrogen was creatinine was and her blood glucose was pertinent radiology imaging on discharge a chest x ray showed very small bilateral pleural effusions but no signs of infiltrate discharge disposition the patient was to be discharged to rehabilitation today condition at discharge the patient s condition on discharge was good medications on discharge discharge medications included colace mg by mouth twice per day aspirin mg by mouth once per day percocet one to two tablets by mouth q h as needed for pain atenolol mg by mouth once per day keflex mg by mouth once per day for days plavix mg by mouth once per day renagel mg by mouth three times per day protonix mg by mouth once per day multivitamin one tablet by mouth once per day epogen units subcutaneously with each hemodialysis calcium carbonate antacid mg tablets one tablet by mouth three times per day nph insulin units subcutaneously in the morning and nph units subcutaneously in the evening humalog insulin sliding scale which varies depending during the day discharge instructions followup the patient was instructed to follow up with her primary care physician dr in one to two weeks the patient was instructed to follow up with her cardiologist in two to three weeks the patient had several appointments the first of which was on with a physician at the clinic at p m the patient was instructed to follow up with dr in four weeks m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies clindamycin zemplar levofloxacin trazodone doxycycline attending chief complaint hypotension line infection major surgical or invasive procedure ir placement on tunelled hd line on history of present illness f with esrd on hd dm cad s p cabg h o poor access with failed av fistulas presenting with pus coming from hd line systolic bps to s patient appeared sick and was not mentating well lactate was therefore peripheral dopamine started patient did not want central line she did not have arterial line on arrival on the floor hypotensive to sbp of but talkative mentating says baseline bp is in s given that patient does not have dialysis access she was not given ivf pressure has now improved to mid s systolic of note patient admitted to for tunelled line infection the line was removed and replaced at that time a tte did not show evidence of endocarditis at that time a tee was attempted but not completed because of patient intolerance she denies known exposure to line site to cause infection she wonders about sterility of dressings at her outpatient hd center upon arrival at the ed patient was febrile to later peaking at central line considered but patient refused past medical history cad s p cabg x in dm since age of esrd on hd being worked up for transplant h o mrsa rt stump infection anemia pvd s p tma h o epistasis from right nostril bell s palsy right side s p valtrex x days last aaa repair in h o previous tunelled line infection social history no tobacco alcohol or illicit drug use family history mother disease and cad father deceased from prostate ca siblings are all alive and well physical exam exam on transfer to floor vitals t doppler ra general well appearing neck no jvd cv rrr nl s s no murmurs lungs crackles at bases bilaterally abd soft nt nd bs ext no c c pitting edema in l neuro mentating well conversant slightly aggitated aggravated with concern over bp skin multiple excoriations and scabbed over lesions on arms pertinent results cxr on admission findings there has been interval placement of a large bore dual lumen dialysis catheter with the distal tip projecting over the right atrium prominence of the pedicle is again identified with mild cephalization this is relatively stable no overt edema is noted there is no consolidation lung volumes are low the cardiac silhouette remains enlarged but stable clips and median sternotomy wires are consistent with prior cabg no effusion or pneumothorax is evident the bones are diffusely osteopenic the patient has had prior cholecystectomy impression interval placement of a dialysis catheter stable findings otherwise with no definite superimposed acute process hd line placement impression uncomplicated ultrasound and fluoroscopically guided tunneled dialysis catheter placement via the left internal jugular venous approach 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 neuts bands lymphs monos eos baso am blood neuts lymphs monos eos baso pm blood pt ptt inr pt am blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood vanco am blood vanco pm blood vanco pm blood lactate prelim the left atrium is elongated the left atrium is dilated there is severe regional left ventricular systolic dysfunction with akinesis and thinning of the entire inferior wall and hypokinesis of the remaining segments diastolic function could not be assessed the remaining left ventricular segments are hypokinetic right ventricular chamber size is normal with borderline normal free wall function the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve but cannot be fully excluded due to suboptimal image quality there is no aortic valve stenosis trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no masses or vegetations are seen on the mitral valve but cannot be fully excluded due to suboptimal image quality mild mitral regurgitation is seen due to acoustic shadowing the severity of mitral regurgitation may be significantly underestimated the tricuspid valve leaflets are mildly thickened there is mild pulmonary artery systolic hypertension there is no pericardial effusion impression no vegetation seen mild mitral and tricuspid regurgitation severe regional and moderate global lv systolic dysfunction compared with the prior study images reviewed of the pulmonary artery systolic pressures are slightly elevated the other findings are similar if clinically suggested the absence of a vegetation by d echocardiography does not exclude endocarditis brief hospital course mrsa sepsis patient has history of line sepsis previously with mrsa source of sepsis unclear had a tte to evaluate valves which was of suboptimal quality but did not show large vegetations plan is for two weeks of treatment with vancomycin starting on if after two week course of treatment patient has persistent bacteremia she should be considered for tee hypotension when hypotensive on admission patient was not mentating well and had elevated lactate hypotensive on the floor to mid s systolic however patient was mentating well on discharge bp she required peripheral dopamine in the icu esrd on hd patient was without hd between and she did not have uremic signs or symptoms except for some non specific itching we continued nephrocaps cinacalcet and calcium carbonate she may have a high protein diet while on hd dm i continued outpatient insulin regimen of units nph qam fasting blood glucose in am was elevated however given multiple periods of being npo her regimen was not adjusted this may be titrated at rehab diarrhea patient had hrs of diarrhea and was c diff negative x diarrhea resolved with imodium she was afebrile and had minimal abdominal pain skin breakdown patient was admitted with skin breakdown felt to be from prolonged imobilization she was treated with therapeutic boots air mattress and skin care she refused air mattress after an explanation of the risks and benefits including development of pressure ulcers medications on admission folic acid mg po qd nephrocaps po qd calcium carbonate mg po qid w meals pantoprazole mg po qd insulin nph u qam w insulin lispro sliding scale cinacalcet mg po qd heparin u sc tid aspirin mg po qd allergies adverse reactions clindamycin diarrhea zemplar rash levofloxacin diarrhea trazodone unknown doxycycline nausea vomiting discharge medications bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed senna mg tablet sig one tablet po bid times a day as needed heparin porcine unit ml solution sig one inj injection tid times a day aspirin mg tablet sig one tablet po daily daily folic acid 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 calcium carbonate mg tablet chewable sig one tablet chewable po three times a day as needed give with meals b complex vitamin c folic acid mg capsule sig one cap po daily daily cinacalcet mg tablet sig two tablet po daily daily cortisone cream sig one appl topical qid times a day as needed for itching hydroxyzine hcl mg tablet sig one tablet po tid times a day as needed for itching insulin nph human recomb unit ml cartridge sig twelve units subcutaneous qam insulin lispro unit ml cartridge sig sliding scale subcutaneous four times a day loperamide mg capsule sig one capsule po qid times a day as needed vancomycin in dextrose gram ml piggyback sig one gram intravenous hd protocol hd protochol for days last day discharge disposition extended care facility courtyard discharge diagnosis primary mrsa septic shock infected tunelled hd line diabetes mellitus type i discharge condition good blood pressure at discharge discharge instructions you were admitted because of septic shock with pus coming from your hemodialysis catheter this was treated with a stay in the icu with temporary use of medications to support your blood pressure the old line was removed and your were given antibiotics you have had a new line put in for dialysis access you had an to find a source for your recurrent mrsa infections it is not clear why you are having recurrent infections of your hemodialysis line you will continue to get vancomycin at dialysis for a total of two weeks after this time if you have recurrent positive cultures we would recommend having a trans esophageal please speak with your kidney doctor regarding this followup instructions please followup with your pcp when you leave rehab please continue to have dialysis [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies clindamycin zemplar levofloxacin trazodone doxycycline haldol attending chief complaint hypoxia altered mental status major surgical or invasive procedure hd translumen cath history of present illness ms is a yof with dm esrd diabetic nephropathy on hd hx mrsa hd line infections hx of cabg and aaa repair who presented to the ed on with multiple vague complaints patient was reportedly hypoxic confused and febrile at her nursing home she is anuric so no urine sample was sent cxr was clear given her h o aaa she underwent a ct torso with iv contrast which demonstrated no evidence of pe aortic dissection or aaa no parenchymal lung process other than dependent atelectasis and a small right pleural effusion she was hypotensive in the ed but intially responded to fluids bcx drawn prior to vancomycin gm iv past medical history cad s p cabg x in chf ef severe regional and moderate global lv systolic dysfunction mild mitral and tricuspid regurgitation dm since age of esrd on hd failed r and l avg now has tunneled hd catheter lij most recently replaced changed from rij mrsa infection catheter changed clot in r ij rx vanc til then another line change for infected tunneled line h o mrsa rt stump infection anemia pvd s p tma h o epistasis from right nostril bell s palsy right side s p valtrex x days last aaa repair in h o previous tunelled line infection social history no tobacco alcohol or illicit drug use family history mother disease and cad father deceased from prostate ca siblings are all alive and well physical exam physical exam vitals t bp hr rr sao l nc general pleasant chronically ill appearing a ox neck supple no lad jvp cm h o cv rrr nl s s no murmurs rubs or gallops no tenderness at recently removed l sided tunnelled line site cdi lungs crackles at bases bilaterally no wheezes abd soft nt nd bs ext no c c e s p r foot amp multiple small shallow ulcers all appearing clean with no purulent discharge skin multiple excoriations at various stages of healing over arms legs and back pertinent results pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm glucose urea n creat sodium potassium chloride total co anion gap pm calcium phosphate magnesium pm alt sgpt ast sgot ck cpk alk phos tot bili pm pt ptt inr pt pm ctropnt pm ck mb ctropnt pm ck cpk final report blood culture routine final staph aureus coag final sensitivities oxacillin resistant staphylococci must be reported as also resistant to other penicillins cephalosporins carbacephems carbapenems and beta lactamase inhibitor combinations rifampin should not be used alone for therapy sensitivities mic expressed in mcg ml staph aureus coag clindamycin r erythromycin r gentamicin s levofloxacin r oxacillin r penicillin g r rifampin s tetracycline s trimethoprim sulfa s vancomycin s aerobic bottle gram stain final reported by phone to jini on gram positive cocci in pairs and clusters anaerobic bottle gram stain final gram positive cocci in pairs and clusters brief hospital course sepsis on arrival to the floor she became hypotensive which was unresponsive to ivf and she was transferred to the icu she received a few hours of iv dopamine but was then weaned off with spontaneous improvement in her blood pressures while in the unit blood culture bottles grew out gpcs in pairs and clusters she was continued on vanco for presumed recurrent mrsa line infection her tunnelled hd line was removed for a line holiday then replaced by interventional radiology once repeat blood cultures were negative for growth patient currently on day of treatment with vancomycin she will need to complete a full course for days and then have blood cultures checked a few days later to ensure resolution of the infection elevated transaminases pt was also noted to have elevated transaminases and direct bilirubin likely due to cholestasis pt was very itchy without jaundice pbc was ruled out as anti mitochondrial antibody was negative ruq u s ruled out cholelithiasis cholecystitis pt was symptomatically treated with benadryl with improvement of symptoms chf the importance of ace inhibitors and beta blockers as a part of her heart failure regimen was discussed with patient but pt refused to take lisinopril beta blockers were not started because of pt s low normal blood pressure these medications should restarted as tolerated at rehabilitation facility diarrhea pt developed diarrhea while receiving vancomycin for her line infection stool was checked for c diff toxin and was negative x diabetes pt s blood sugars were labile throughout her hospital stay we are discharging her on insulin nph units in the morning and insulin lispro sliding scale her insulin regimen should be titrated up or down at the rehabilitation facility according to her finger sticks and she should be kept on a consistent diet medications on admission asa mg folic acid g qd renagel cac mg tid nph u qam lispro ssi loperimide mg q prn biscodyl prn senna benadryl mg heparin u sq tid protonix mg qd mvi cinacalcet discharge medications aspirin mg tablet sig one tablet po daily daily senna mg tablet sig one tablet po bid times a day as needed for constipation 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 bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for constipation folic acid mg tablet sig one tablet po daily daily b complex vitamin c folic acid mg capsule sig one cap po daily daily calcium carbonate mg tablet chewable sig one tablet chewable po tid times a day cinacalcet mg tablet sig three tablet po daily daily insulin lispro unit ml cartridge sig sliding scale subcutaneous four times a day diphenhydramine hcl mg capsule sig one capsule po q h every hours as needed for itching docusate sodium mg capsule sig one capsule po bid times a day as needed for constipation lisinopril mg tablet sig tablet po daily daily acetaminophen mg tablet sig tablets po q h every hours as needed for pain or temp not to exceed gm per day vancomycin mg recon soln sig one grm intravenous hd protocol for days currently day on insulin nph human recomb unit ml suspension sig eight units subcutaneous qam discharge disposition extended care facility care center discharge diagnosis primary dx methicillin resistant line infection secondary dx cad s p cabg x in chf ef severe regional and moderate global lv systolic dysfunction mild mitral and tricuspid regurgitation dm since age of esrd on hd failed r and l avg now has tunneled hd catheter lij most recently replaced changed from rij mrsa infection catheter changed clot in r ij rx vanc til then another line change for infected tunneled line h o mrsa rt stump infection anemia pvd s p tma h o epistaxis from right nostril bell s palsy right side s p valtrex x days last aaa repair in h o previous tunelled line infection discharge condition fair discharge instructions you had a hd line infection which caused you to become septic making your blood pressure low and caused you to go to the icu the infected line was removed and you were treated with antibiotics vancomycin while we waited for the new blood cultures to come back we placed a temporary line and then you had the line replaced with the permanent one before you were sent back to the rehabilitation center if your symptoms worsen or you develop a fever please return to the ed immediately please keep all follow up appointments please take all medications as directed followup instructions please follow up with your pcp upon leaving call to schedule an appointment please return to your dialysis center to resume regular dialysis your last dialysis completed by,"{
""Diagnoses"": [""End Stage Renal Disease"", ""Secondary to Diabetes"", ""Hypertension"", ""Peripheral Vascular Disease"", ""Hypothyroidism""],
""Medications"": [""Aspirin"", ""Cefotaxime"", ""Lopressor""]
}"
4240,admission date discharge date date of birth sex m service medicine allergies penicillins sulfa sulfonamides attending chief complaint shortness of breath major surgical or invasive procedure cardiac catheterization history of present illness patient is a y o active m who has been feeling bad for the last days his girlfriend had a gi illness previously and developed symptoms of urti and diarrhea he went to ed at yesterday with sob and was found to be in heart failure and was to be admitted but left ama patient then was seen by his cardiologist who performed an echo at and found to have reduced lvef of patient returned to where he recieved aspirin plavix and started on nitro gtt and then transferred to for cath where he was found to have vessel disease with proximal lad mid lad mid lcx and rca lesions patient also with elevated wedge of and ci of he was given iv lasix in cath lab and gentle dobutamine patient denies any chest pain no current chest pain no shortness of breath states he had several episodes of pnd and chest tightness a few days prior no fever or chills past medical history s p appy prostate procedure social history retired plumber plays hockey x week currently non etoh however previous history of heavy drinking quit years ago no drugs no tobacco family history father had mi died age mother died of tb all children healthy physical exam t hr rr o sat l gen nad lying flat heent perrl eomi scelra anicteric mmm neck no carotid bruits chest crackles at r base clear ant lat cardiac rrr s s s no murmurs abdomen soft ext no edema dp neuro aaox pertinent results cardiac catheterization selective coronary angiography of this right dominant system demonstrated a three vessel coronary artery disease the lmca had mild non obstructive disease the lad had diffuse disease along with a proximal stenosis and an bifrucation lesion at the mid distal segment the lcx had a stenosis in its mid vessel as well as a diffuse disease the dominant rca had a mid vessel stenosis as well as the diffuse disease throughout resting hemodynamics revealed a severely elevated right and left sided filling pressures with an rvedp of mm hg and a mean pcwp of mm hg the cardiac index was severely depressed at l min m left ventriculography was deferred given elevated filling pressures tte the left atrium is elongated no atrial septal defect is seen by d or color doppler left ventricular wall thicknesses are normal the left ventricular cavity is moderately dilated there is severe global left ventricular hypokinesis no masses or thrombi are seen in the left ventricle tissue doppler imaging suggests an increased left ventricular filling pressure pcwp mmhg there is no ventricular septal defect right ventricular chamber size and free wall motion are normal there are three aortic valve leaflets the aortic valve leaflets are mildly thickened 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 borderline pulmonary artery systolic hypertension there is a trivial physiologic pericardial effusion ekg nsr low voltage in limb leads normal intervals flat t v v persantine myocardial perfusion study severe globally decreased left ventricular wall motion with an lvef of moderate fixed inferior wall defect dilated lv cavity there is no significant change in reduced uptake in the inferior wall on delayed hour images which suggests non viability these findings can be further evaluated with an fdg pet viability scan if clinically indicated pm wbc rbc hgb hct mcv mch mchc rdw pm triglycer hdl chol chol hdl ldl calc pm hba c hgb done a c done pm glucose urea n creat sodium potassium chloride total co anion gap pm tsh pm caltibc ferritin trf brief hospital course mr was initially admitted from the cath lab to the ccu on a low dose dobutamine drip and with an iabp in place overnight he was aggressively diuresed with lasix and has a significant improvement in his cardiac index the dobutamine was quickly weaned off and his iabp was removed his tsh and ferritin were normal and helped rule out metabolic causes of his cardiomyopathy he was started on low dose digoxin and spironolactone and was titrated up on an acei and carvedilol he was called out to the floor where he underwent evaluation for cabg by the ct surgery team carotid dopplers showed an insignificant amount of atherosclerosis a persantine myocardial viability study confirmed his markedly depressed lvef and delyaed images showed no evidence of uptake throughout his fixed inferior wall defect which is suggestive of nonviability since he was asymptomatic and being maximally medically managed he was discharged home with plans to followup with cardiology and cardiac surgery medications on admission none 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 spironolactone mg tablet sig tablet po daily daily disp tablet s refills digoxin mcg tablet sig one tablet po daily daily disp tablet s refills lisinopril mg tablet sig one tablet po daily daily disp tablet s refills carvedilol mg tablet sig one tablet po bid times a day disp tablet s refills discharge disposition home discharge diagnosis congestive heart failure discharge condition stable discharge instructions please take all medications as prescribed please keep all follow up appointments please weigh yourself every morning and md if weight lbs please also adhere to gm sodium diet please notify your primary care doctor if you experience shortness of breath chest pressure or pain light headedness or dizziness nausea vomitting heartburn or any symptoms that concern you followup instructions you have a follow up with the cardiologist you met in the ccu dr on am his office is located in the building on the office number you have an echocardiogram to look at you heart s pumping function scheduled for at am this will be done on the of the building the contact number is you also have follow up with dr the cardiothoracic surgeon on at pm his office is located at office number [NEW_RECORD] admission date discharge date date of birth sex m service cardiothoracic allergies penicillins sulfa sulfonamides attending chief complaint dyspnea on exertion major surgical or invasive procedure cabg x svg lad svg diag om svg am pda history of present illness year old gentleman recently diagnosed with ischemic cardiomyopathy with symptoms of dyspnea on exertion he has improved on medical therapy and currently denies symptoms a cardiac catheterization was performed which revealed severe three vessel disease he now presents for surgical management past medical history s p appy prostate procedure ischemic cardiomyopathy glaucoma social history retired plumber plays hockey x week currently non etoh however previous history of heavy drinking quit years ago no drugs no tobacco family history father had mi died age mother died of tb all children healthy physical exam sr gen energenic elderly male in nad heent unremarkable neck from supple no carotid bruits lungs clear heart rrr soft sem abd benign extr pulses no edema neuro nonfocal pertinent results echo pre bypass the left atrium is mildly dilated no spontaneous echo contrast or thrombus is seen in the body of the left atrium left atrial appendage or the body of theright atrium right atrial appendage no atrial septal defect is seen by d or color doppler left ventricular wall thicknesses are normal the left ventricular cavity is mildly dilated no left ventricular aneurysm is seen there is moderate to severe global left ventricular hypokinesis overall left ventricular systolic function is severely depressed right ventricular systolic function is borderline normal there are simple atheroma in the ascending aorta there are complex mm atheroma in the descending thoracic aorta the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation there are filamentous strands on the aortic leaflets consistent with lambl s excresences normal variant the mitral valve leaflets are mildly thickened the mitral annulus is mm and there is a central regurgitant jet c w with mild mitral regurgitation there is no pericardial effusion post bypass normal rv systolic function patient is on epinephrine mcg kg min with overall lvef of to trivial to mild mr preserved aortic contour am blood hct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt inr pt am blood plt ct am blood pt ptt inr pt am blood urean creat k am blood glucose urean creat na k cl hco angap brief hospital course mr was admitted to the on for surgical management of his coronary artery disease he was taken directly to the operating room where he underwent coronary artery bypass grafting to five vessels postoperatively he was taken to the cardiac surgical intensive care unit for monitoring by postoperative day one mr had awoke neurologically intact and was extubated aspirin a statin and beta blockade was resumed on postoperative day two he 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 developed atrial fibrillation which was treated with amiodarone and increased beta blockade and he converted to normal sinus rhythm he was ready for discharge home on pod medications on admission aspirin mg daily lipitor mg daily aldactone mg daily digoxin mg daily lisinopril mg daily coreg mg twice daily discharge medications docusate sodium mg capsule sig one capsule po bid times a day disp capsule 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 every hours as needed for pain disp tablet s refills atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills carvedilol mg tablet sig one tablet po bid times a day disp tablet s refills amiodarone mg tablet sig one tablet po daily daily disp tablet s refills furosemide mg tablet sig one tablet po q h every hours for weeks please take twice a day for days and then decrease to once daily and follow up with your cardiologist within weeks disp tablet s refills lisinopril mg tablet sig one tablet po daily daily disp tablet s refills discharge disposition home with service facility discharge diagnosis coronary artery disease s p cabg atrial fibrillation ischemic cardiomyopathy prostatitis glaucoma discharge condition good discharge instructions shower 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 dr in weeks please call for appointment dr in week please call for appointment dr in weeks please call for appointment wound check appointment as instructed by nurse completed by [NEW_RECORD] admission date discharge date date of birth sex m service cardiothoracic allergies penicillins sulfa sulfonamides attending chief complaint sternal drainage major surgical or invasive procedure sternal derbridement sternal plating and bilateral pectoralis flap closure history of present illness the patient is a year old gentleman who underwent coronary artery bypass grafting almost weeks ago he was doing well at home when it was noted that he had some erythema involving his wound he was placed on antibiotics by his primary cardiologist he was at home last night and his wound opened up and pus began draining from the wound this was cultured and he was placed on antibiotics the patient appeared to be nontoxic with a stable sternum initially however upon inspection this morning on morning rounds it was noted that his sternum was unstable it was felt that he needed to proceed with sternal debridement past medical history s p appy prostate procedure ischemic cardiomyopathy glaucoma af s p cabgx htn hyperlipidemia social history retired plumber plays hockey x week currently non etoh however previous history of heavy drinking quit years ago no drugs no tobacco family history father had mi died age mother died of tb all children healthy physical exam admission hr sr rr bp gen elderly male in nad heent unremarkable neck from supple no carotid bruits lungs clear heart rrr sternum cm opening with pus draining sternum unstable with cough abd benign extr pulses no edema neuro nonfocal discharge vs t hr sr bp rr o sat ra gen nad neuro a o nonfocal exam pulm ctab cv rrr s s sternum stable abdm soft nt nd bs ext warm well perfused no edema left arm picc line no erythema pertinent results am wbc rbc hgb hct mcv mch mchc rdw am glucose urea n creat sodium potassium chloride total co anion gap am pt ptt inr pt echo 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 pm blood alt ast alkphos amylase totbili pm blood albumin echo conclusions no atrial septal defect is seen by d or color doppler overall left ventricular systolic function appears depressed there are complex mm atheroma in the aortic arch there are three aortic valve leaflets there is a small x mm vegetation on the noncoronary cusp of the aortic valve with trace aortic regurgitation there is no aortic ring abscess the mitral valve appears structurally normal with trivial mitral regurgitation no mass or vegetation is seen on the mitral valve no vegetation mass is seen on the pulmonic valve or tricuspid valve impression small vegetation on the noncoronary cusp of the aortic valve without associated abscess or fistula seen trace aortic regurgitation cxr single upright radiograph of the chest comparison demonstrates a right central venous catheter terminating in the cavoatrial junction a small right apical pneumothorax is present left chest tube appears to be in unchanged position on single view lungs are clear and increased opacity at right lower lung has resolved there has been interval placement of flexible plates with fixation screws overlying the chest wall radioopaque catheter overlying right mediastinum may represent a mediastinal drain significant degenerative change is evident within right shoulder brief hospital course mr was admitted to the on for further management of his sternal wound infection vancomycin and levofloxacin were started as he had some sternal instability he was taken to the operating room where he underwent a debridement on cultures were sent which revealed staph aureus his chest was left open with the plan for the plastic surgery service to close him in the next day or two they were consulted intraoperatively and agreed to the plan postoperatively he was taken to the intensive care unit for monitoring as the echocardiogram showed a aortic valve vegetation the cardiologys service was consulted tube feeds were started for nutritional support a repeat echocardiogram showed a small vegetation on the noncoronary cusp of the aortic valve with trace regurgitation no associated abscess or fistual was seen on mr returned to the operating room with the plastic surgery service where he underwent a sternal debridement and closure with sternal plating and bilateral pectoralis flap coverage postoperatively he was returned to the intensive care unit for monitoring on postoperative day one mr neurologically intact and was extubated his cultures ultimately grew out mrsa and vancomycin was continued and the levofloxacin was stopped the infectious disease service was consulted and followed him throughout his hospital course the physical therapy service was consulted for assistance with his postoperative strength and mobility a swallowing evaluation was performed by the speech and swallow service as he had some coughing with oral intake no signs of aspiration were found and he was cleared to eat a regular diet on postoperative day three he was transferred to the step down unit for further recovery the infectious disease service recommended weeks of vancomycin over the next several days the patient did well and on pod it was decided he was ready for discharge to rehabilitation at rehab ma medications on admission docusate sodium mg capsule sig one capsule po bid times a day aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily oxycodone acetaminophen mg tablet sig tablets po every hours as needed for pain atorvastatin mg tablet sig one tablet po daily daily carvedilol mg tablet sig one tablet po bid times a day amiodarone mg tablet sig one tablet po daily daily furosemide mg tablet sig one tablet po q h every hours for weeks please take twice a day for days and then decrease to once daily and follow up with your cardiologist within weeks lisinopril mg tablet sig one tablet po daily daily discharge medications furosemide mg tablet sig one tablet po once a day for weeks potassium chloride meq tablet sustained release sig two tablet sustained release po once a day for weeks docusate sodium mg capsule sig one capsule po bid times a day ranitidine hcl mg tablet sig one tablet po once a day aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily oxycodone acetaminophen mg tablet sig tablets po every hours as needed for pain magnesium hydroxide mg ml suspension sig thirty ml po hs at bedtime as needed for constipation bisacodyl mg suppository sig one suppository rectal prn as needed for constipation atorvastatin mg tablet sig one tablet po daily daily fluticasone mcg actuation aerosol sig two puff inhalation times a day albuterol ipratropium mcg actuation aerosol sig two puff inhalation every hours as needed for shortness of breath or wheezing carvedilol mg tablet sig one tablet po bid times a day lisinopril mg tablet sig tablet po daily daily vancomycin in dextrose g ml piggyback sig one gram intravenous q h every hours continue through discharge disposition extended care facility healthcare center discharge diagnosis sternal wound infection instability bacteremia s p cabgx ischemic cardiomyopathy atrial fibrillation appy glaucoma discharge condition stable 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 no lotions creams or powders to incision until it has healed you may shower and wash incision 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 followup instructions follow up with dr in weeks follow up with dr in weeks follow up with dr on at pm phone call all providers for appointments provider phone date time provider cardiac surgery lmob a date time completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex m service medicine allergies penicillins sulfa sulfonamides attending addendum see below addendums to major surgical procedures and brief hospital major surgical or invasive procedure cardiac catheterization with iabp placement brief hospital course mr was initially admitted from the cath lab to the ccu while in cardiogenic shock on a low dose dobutamine drip and with an iabp in place overnight he was aggressively diuresed with lasix and has a significant improvement in his cardiac index the dobutamine was quickly weaned off and his iabp was removed due to resolution of his cardiogenic shock his tsh and ferritin were normal and helped rule out metabolic causes of his cardiomyopathy he was started on low dose digoxin and spironolactone and was titrated up on an acei and carvedilol he was called out to the floor where he underwent evaluation for cabg by the ct surgery team carotid dopplers showed an insignificant amount of atherosclerosis a persantine myocardial viability study confirmed his markedly depressed lvef and delyaed images showed no evidence of uptake throughout his fixed inferior wall defect which is suggestive of nonviability since he was asymptomatic and being maximally medically managed he was discharged home with plans to followup with cardiology and cardiac surgery discharge disposition home discharge diagnosis cardiogenic shock resolved dilated cardiomyopathy md completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex m service cardiothoracic allergies penicillins sulfa sulfonamides attending addendum this is a clarification of chf noted on previous discharge summary mr has severely depressed lv systolic function as noted on the echo of brief hospital course discharge disposition home with service facility md completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex m service medicine allergies penicillins sulfa sulfonamides attending addendum an iabp was not placed as erroneously stated in previous discharge summary cardiogenic shock was diagnosed by a ci of major surgical or invasive procedure cardiac catheterization brief hospital course an iabp was not placed as erroneously stated in previous discharge summary cardiogenic shock was diagnosed by a ci of discharge disposition home md completed by,"{
""Diagnoses"": [""Heart Failure"", ""Vessel Disease"", ""Proximal Lad Mid Lad Mid Lcx And Rca Lesions""],
""Medications"": [""Aspirin"", ""Plavix"", ""Nitro GTT"", ""Lasix"", ""Dobutamine""]
}"
22494,admission date discharge date date of birth sex f service med icu history of present illness is a year old female with a past medical history of high cholesterol mitral valve prolapse and recent history of falls and unsteady gait the patient s husband describes approximately two to three months of ill health with symptoms mainly consisting of some dyspnea on exertion breathing trouble non specific weakness and several falls today miss fell while on the toilet the patient denies loss of consciousness family reports loss of consciousness the patient was brought to the emergency room at an outside hospital where she was alert and oriented times three and in respiratory distress she was treated for congestive heart failure and transferred to here in the emergency room she was tachypneic and hypertensive and arterial blood gas revealed ventilatory failure for which she was intubated in the emergency department ct scan of the head revealed a question of left frontal early ischemic lesion neurology was consulted the patient was treated with additional lasix and triaged to medical intensive care unit past medical history mitral valve prolapse right carotid stenosis hypercholesterolemia question of hypertension breast ca question tamoxifen history of unsteady falls medications atenolol mg p o q day zocor mg p o q day detrol aspirin allergies tamoxifen leads to a rash social history the patient lives in is married and was in the area visiting family no tobacco son whose name is has a phone number of physical examination on admission temperature f heart rate to blood pressure respiratory rate intubated generally intubated and sedated pupils equally round and reactive to light and accommodation face was symmetrical neck was supple increased jugular venous distention to approximately to cm lungs with bibasilar crackles cardiac regular with ii vi at left lower sternal border abdomen was soft nontender nondistended positive bowel sounds extremities warm with good pulses positive edema laboratory on admission white blood cell count of hematocrit of platelets sodium potassium chloride co of bun creatinine glucose alt ast ldh urinalysis was nitrite positive positive white blood cells positive bacteria cpk went from to arterial blood gas revealed gas of ekg was normal sinus rhythm normal axis large p wave in ii t s decreased in iii avf and v through v chest moderate congestive heart failure no infiltrates ct scan of the head showed negative bleed question left frontal cortex hypodense question edema and infarction brief summary of hospital course this is a year old female with question of neurological history who presents status post syncope with respiratory distress requiring intubation intermittent hypertension and evidence of congestive heart failure ekg and head ct scan was suggestive of ischemic process of the brain also urinalysis is suggestive of urinary tract infection the patient had a right arterial line placed as well as right internal jugular catheter centrally placed this was done without complications on the day of admission the patient was started on nitroprusside ggt for unstable systolic blood pressure the patient was continued on a propofol drip lopressor zocor levaquin for urinalysis and zantac for gi prophylaxis the patient was not aggressively diuresed chest was revealing of only mild congestive heart failure with oxygen saturations stable the patient underwent cardiac echocardiogram on which showed positive left ventricular hypertrophy no thrombus was seen and ejection fraction estimated at with apical lateral hypokinesis the patient had an episode in the evening of to of bloody gastric drainage and was started on protonix mg p o twice a day and subcutaneous heparin was discontinued in favor of venodyne the patient s neurologic examination at this time the patient squeezes with left hand only and wiggles left toes only the patient opens eyes to command an mri mra performed on showed hemorrhage into the left frontal infarction with midline shift no significant carotid stenosis was seen and right frontal area of apparent hemorrhage the patient s carotids appeared normal on mra the patient had a transesophageal echocardiogram on which showed left atrium normal in size no mass or thrombus was seen in the left atrium or left atrial appendage no mass or thrombus was seen in the right atrium or right atrial appendage no asd or patent foramen ovale was seen by d color doppler or saline contrast maneuvers moderate symmetric left ventricular hypertrophy left ventricle cavity is unusually small left ventricular systolic function is hyperdynamic with ejection fraction greater than the right ventricular free wall is hypertrophied aortic leaflets appear structurally normal no aortic regurgitation small pericardial effusion no vegetations or thrombi were identified compared to trans thoracic study of right ventricular function was probably also depressed in the prior study but the right ventricular free wall was less well seen in the prior study the patient had a head ct scan done on which showed two areas of hemorrhage the first was located in the left frontal lobe in the region of the infarction first seen on the size of the hemorrhage and extensive surrounding edema and mass effect is unchanged from the mri of the left lateral ventricle is mildly compressed and shifted to the right there is no hydrocephalus a second area of hemorrhage is seen as a small mm hyperdense region high in the sulcus of the parietal lobe bone windows show fluid levels within the sphenoid sinus these are unchanged from mri of no fractures were identified on the patient self extubated thought to be secondary to a respiratory muscle weakness and shallow breaths with respiratory rate into the fifties and delta mf the patient was reintubated and put on assist control the patient s blood pressure was labile throughout her intensive care unit stay the patient would have episodes of blood pressure to which would resolve either spontaneously or with lopressor she would then drop down to the s systolic lability of the blood pressure stabilized throughout her intensive care unit stay the patient was put on atenolol mg p o q day and blood pressure ranged at the end of the micu stay was from to systolic the patient had no readily appreciated changes in mental status during these episodes neurology recommended an mr of the cervical spine which was done on showed no evidence of cord compression or neural impingement cord signal is normal the etiology of the patient s failure for extubation was thought to be possibly centrally mediated the patient had a tracheostomy placed on without complications a peg tube was successfully placed on using standard techniques an esophagogastroduodenoscopy at the time showed normal egd to the stomach the patient was started on tube feeds and tolerated them well the patient s sedation was weaned off and the patient was alert and responsive to questions and commands the patient had a ct scan of the chest on to assess for possible primary pulmonary process and to assess for previous needs for intubation and prolonged ventilation this study revealed no gross evidence of interstitial lung disease bibasilar dependent opacities more prominent on the right lower lobe than the left may represent atelectasis a small pericardial effusion and cardiomegaly on the patient was changed to a tracheostomy mask with of fio the patient tolerated trache mask and was briefly put on respiratory support on the evening of and was switched back to tracheostomy with face mask of fio of the patient had original respiratory rate of to this slowly came down into the s repeat arterial blood gas on trache mask revealed no elevated hypercarbia above normal the patient s ph of pco of and po of the patient s pco was in line with previous pco while intubated increased respiratory rate did not lead to respiratory alkalosis and there was no failure of total volume the patient was discharged to the medical floor on in stable condition and awaiting placement condition on discharge stable discharge diagnoses ischemic transformed into hemorrhagic stroke hypercarbic respiratory failure discharge medications zocor mg p o q day atenolol mg p o q day prevacid mg p o q day promod with five hour tube feeds at cc per hour oxygen through her tracheostomy mask to keep oxygen saturation greater than code status the patient is full code disposition the patient was discharged to rehabilitation facility at follow up instructions the patient should follow up with neurologist follow up with primary care physician m d dictated by medquist d t job,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""f"", ""service"", ""ICU history"", ""illness"", ""history of present illness"", ""falls"", ""unsteady gait""],
""Medications"": [""medication"", ""treated for congestive heart failure"", ""intubated in the emergency department"", ""lasix"", ""triaged to medical intensive care unit""]
}"
15648,admission date discharge date service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint respiratory distress major surgical or invasive procedure intubated history of present illness yo male with pmh significant for afib chf with diastolic dysfunction htn restrictive lung disease who was transferred from for hypoxic respiratory failure pt was admitted to osh on with doe non purulent cough and orthopnea the patient was treated with lasix chf and rate control was attempted with iv diltiazem and bb without significant improvement in his symptoms pt remained in afib and on dccv was attempted unsuccessfully pt was also treated with levoflox for possible cap chest ct showed new diffuse ground glass opacities on day of transfer to the pt had increased sob rr and decreased o sats abg on nrb was hospital also significant for acute on chronic rf and new coagulopathy with inr requiring vit k past medical history htn a fib on coumadin bb and propafenone aaa by ct in prostate cancer s p turp in cad details unknown no known mi klebsiella cholecystitis cholecystostomy tube and s p lap ccy on social history pack year smoking quit years ago etoh drinks week no drugsformer accountantserved in united states navy family history non contributory pertinent results pm pt ptt inr pt pm fdp pm type art temp rates tidal vol peep o po pco ph total co base xs assist con intubated intubated pm urine color straw appear hazy sp pm urine blood lg nitrite neg protein glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg pm urine rbc wbc bacteria mod yeast none epi pm urine hyaline pm glucose urea n creat sodium potassium chloride total co anion gap pm ck cpk tot bili pm ck mb notdone ctropnt pm calcium phosphate magnesium iron pm caltibc haptoglob ferritin trf pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm hypochrom pm plt count pm pt ptt inr pt brief hospital course this patient was admitted to the micu for respiratory failure requiring intubation the cause of his respiratory distress was probably multifactorial including chf infection amiodarone toxicity a chest ct showed apical scarring bullous changes and bronchiectasis pfts prior to amiodarone initiation showed restrictive pattern the patient also had suspect underlying granulomatous disease and copd with acute volume overload versus infection the patient was in the icu from to at which time the family chose to change their care goals to comfort measures only the patient was extubated and died within a few hours discharge medications none discharge disposition expired discharge diagnosis respiratory arrest discharge condition dead,{}
382,admission date discharge date date of birth sex f service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint increasing angina at rest and with exertion major surgical or invasive procedure s p cabgx lima lad svg om diag pda history of present illness yo f referred for cardiac catheterization which showed three vessel disease past medical history cad htn hyperlipidemia gerd dm c b neuropathy interstitial nephritis glaucoma hiatal hernia endometriosis thyroid cyst right cataract surgery bladder biopsy c b hemorrhage csection x carpal tunnel surgery x right hand trigger finger s p release right salpingo oopherectomy breat bx x social history tob etoh works as secretary family history brother deceased from mi at age sister with mi at father deceased from mi at age physical exam nad skin unremarkable heent r eye mm reactive l eye mm and nonreactive neck no lad lungs ctab heart rrr no m r g abdomen benign extrem warm no edema le pulses radial pulses bilat no carotid bruits pertinent results am blood wbc hct plt ct 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 alt ast alkphos amylase totbili am blood glucose urean creat na k cl hco angap brief hospital course cardiac catheterization on showed no mr lvef three vessel disease on he underwent a cabg x he was transferred to the sicu in critical but stable condition she awoke neurologically intact and was extubated that same day she had a brief episode of post op afib which converted with amiodarone she was transferred to the floor on pod she continued to do well postoperatively she was seen in consultation by who changed her insulin regimen she remained in the hospital for further blood sugar management medications on admission lisinopril nexium ditropan nph lactaid hctz cartia nitro asa chromium tums restasis systane discharge medications docusate sodium mg capsule sig one capsule po bid times a day disp capsule 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 atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills ferrous gluconate mg tablet sig one tablet po daily daily disp tablet s refills furosemide mg tablet sig one tablet po daily daily for days disp tablet s refills ascorbic acid mg tablet sig one tablet po bid times a day disp tablet s refills potassium chloride meq capsule sustained release sig two capsule sustained release po daily daily for days disp capsule sustained release s refills metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet s refills nexium mg capsule delayed release e c sig one capsule delayed release e c po twice a day disp capsule delayed release e c s refills cephalexin mg capsule sig one capsule po q h every hours for days disp capsule s refills oxybutynin chloride mg tablet sig tablet po qid times a day disp tablet s refills insulin glargine unit ml solution sig thirty units subcutaneous q am disp qs month refills humalog unit ml solution sig one unit subcutaneous every six hours please see printer sliding scale disp qs month refills discharge disposition home with service facility vna assoc of discharge diagnosis cad htn lipids dm neuropathy interstitial nephritis right cataract glaucoma c section x carpal tunnel surgery x right trigger finger surgery endometriosis r oopherectomy salpingectomy hital hernia gerd discharge condition good discharge instructions follow medications on discharge instructions do not drive for weeks do not lift more than lbs for months shower daily let water flow over wounds pat dry with a towel do not use powders lotions or creams on wounds call our office for temp sternal drainage followup instructions make an appointment with dr for weeks make an appointment with dr for weeks make an appointment with dr for weeks see dr from the clinic on at am completed by,{}
98254,admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint fatigue dark stool major surgical or invasive procedure edg c scope small bowel follow thru history of present illness female h o nash upper gib in secondary to gastric ulcers presenting with two days of black stool and fatigue patient with recent admission from for klebseilla urosepsis pyelo as well as presumed c dif colitis infectious work up notable for osh urine and blood cultures both positive for klebsiella patient was started on gentamycin transitioned to cefepime cipro and discharged on st generation cephalosporin cefadroxil additionally patient noted to have watery bm day with associated leukocytosis though cdiff toxin and pcr returned negative decision made to empirically treat for colitis with flagyl additional issues during that hospitalization anemia hct trended down from on admission to on hd but then remained stable iron studies were consistent w anemia of chronic disease normal b folate no note of guaiac stool cirrhosis patient with h o nash labs significant for elevated inr low albumin exam with e o progressive liver disease spider angiomas ascites hbv and hcv titers were negative pt reported rare etoh plan to proceed with outpatient biopsy no egd in our system patient discharged and returned home had been in usoh when developed painless melena generalized weakness and orthostasis x days reports associated nausea with one episode of vomiting brown material denies abdominal pain dysphagia hoarseness tenesmus chest pain palpitations does endorse lb weight loss over last month in setting of hospitalization denies fevers chills sweats reports gastric ulcers in past with vomiting of coffee ground emesis but never black stools this feels somewhat similiar to previous episode in the ed initial vs ra frank melena on exam labs with hct on inr patient type and crosses x u gi consulted patient started on ppt bolus ggt unable to pass ngt in ed attempts failure thought secondary to irregular anatomy no transfusion as of yet though received l ns vs prior to transfer hr ra access g bilaterally on arrival to the micu patient without complaint though does cite intermittent nausea as well as slow speech denies abdominal pain review of systems per hpi doe denies fever chills night sweats recent weight loss or gain denies headache sinus tenderness rhinorrhea or congestion denies cough shortness of breath or wheezing denies chest pain chest pressure palpitations or weakness denies nausea vomiting diarrhea constipation abdominal pain or changes in bowel habits denies dysuria frequency or urgency denies arthralgias or myalgias denies rashes or skin changes past medical history type diabetes insulin dependent hypertension nash hypercholesterolemia osteoarthritis depression upper gi bleed gastric ulcers social history lives alone at home has worked at financial as a scanner for past years no tobacco alcohol or drug use family history significant for heart disease and diabetes mother has afib husband died of liver disease physical exam on admission general alert oriented no acute distress slow speech heent conjunctival pallor mmm oropharynx clear without exudates or lesion no subinguinal jaundice neck supple jvp not elevated no lad lungs clear to auscultation bilaterally no wheezes rales ronchi cv regular rate and rhythm soft sem rubs gallops no peripheral edema abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly gu no foley ext pale warm well perfused pulses no clubbing cyanosis or edema 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 pm blood ret aut pm blood glucose urean creat na k cl hco angap pm blood alt ast ld ldh alkphos totbili pm blood albumin calcium phos mg pm blood hapto pm blood lactate 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 microbiology pm serology blood source venipuncture final report helicobacter pylori antibody test final positive by eia reference range negative imaging egd esophagus other no esophageal varices seen stomach normal stomach duodenum mucosa mild erythema at the junction between the duodenal bulb and the second portion of the duodenum consistent with duodenitis other findings no source of bleeding identified to explain melena impression no esophageal varices seen abnormal mucosa in the duodenum no source of bleeding identified to explain melena otherwise normal egd to second part of the duodenum recommendations plan for colonoscopy tomorrow morning please start moviprep tonight advance diet to clears npo after midnight stop ppi drip colonoscopy findings other no bleeding source identified to explain anemia and melena impression no bleeding source identified to explain anemia and melena otherwise normal colonoscopy to cecum recommendations will proceed with inpatient capsule endoscopy d c ppi colonoscopy should be repeated given fair preparation therefore small polyps may have been missed capsule endoscopy multiple angioectasias were seen from the mid jejunum to the distal ileum no active bleeding sites were seen in the small bowel summary recommendations summary multiple angioectasias were seen from the mid jejunum to the ileum no active bleeding sites were seen in the small bowel at this time small bowel enteroscopy the scope was advanced upto mid distal jejunum the distal most portion of the small bowel reached was tattood with ink four to five angioectasias noted in the jejunum apc treatment of the angioectasias were performed with success injection thermal therapy a previously administered capsule pillcam was noted in the colon or distal small bowel by fluoroscopy otherwise normal small bowel enteroscopy to mid jejunum cxr on admission findings no previous images the heart is normal in size and there is no evidence of vascular congestion pleural effusion or acute focal pneumonia brief hospital course female h o upper gi bleed in secondary to gastric ulcers presenting with two days of black stool and fatigue active issues gastrointestinal bleed thought to be related to gi bleed after report of days of melena gi was consulted on admission differential diagnosis included bleeding gastric or esophageal ulcer tear variceal bleeding or malignancy she was initially on pantoprazole gtt transitioned to pantoprazole mg iv bid then to po therapy for h pylori treatment she underwent upper endoscopy and colonoscopy without clear source of bleed gi recommended further investigation with a capsule study to better visualize the small bowel which showed multiple angioectasias in the small bowel in the icu she was transfused units prbc for a hct of with resulting bump to which then remained stable additional anemia work up including hemolysis labs reticulocyte count were within normal limits patient was without further episodes of gi bleeding while hospitalized small bowel enteroscopy was performed and aforementioned angioectasias were cauterized patient was discharged with stable hematocrit she does not require gastroenterology follow up but should return to for repeat imaging if she experiences another gi bleed helicobacter pylori infection patient was noted to have positive h pylori testing and was started on omeprazole clarithromycin and amoxicillin for planned day course which she will continue as an outpatient toxic metabolic encephalopathy per patient as well as daughter patient more mentally slow in the days preceding admission patient denied any focal complaints however felt as if her speech was slurred she had a non focal neurologic exam kidney and liver function was only mildly abnormal then improved patient was without asterixis tsh was within normal limits after acute treatment of anemia patient s confusion resolved dyspnea likely related to anemia no focal consolidation or signs of volume overload on exam or chest x ray patient was transfused with improvement in symptoms acute kidney injury mild elevation in creatinine to on admission likely pre renal in etiology in setting of gi bleed hypovolemia patient received liters of normal saline in the ed as well as units prbcs in the icu with improvement of creatinine to chronic issues diabetes mellitus type ii poorly controlled with last a c in po diabetic regimen was held while npo and she was maintained on an insulin sliding scale hyperlipidemia continued home rosuvastatin depression continued fluoxetine transition of care follow up patient has scheduled follow up with her pcp does not require gastroenterology follow up but should return to for repeat imaging if she experiences another gi bleed there are no pending studies at the time of discharge code status full discussed with patient contact daughter medications on admission fluoxetine mg capsule sig three capsule po daily daily trazodone mg tablet sig tablet po hs at bedtime as needed for insomnia lantus unit ml solution sig forty units subcutaneous at bedtime metformin mg tablet sig one tablet po twice a day glyburide mg tablet sig one tablet po twice a day rosuvastatin mg tablet sig one tablet po once a day apidra unit ml solution sig twenty five units subcutaneous four times a day discharge medications fluoxetine mg capsule sig three capsule po daily daily trazodone mg tablet sig tablet po hs at bedtime as needed for insomnia lantus unit ml solution sig forty units subcutaneous at bedtime metformin mg tablet sig one tablet po twice a day glyburide mg tablet sig one tablet po twice a day rosuvastatin mg tablet sig one tablet po once a day omeprazole mg capsule delayed release e c sig one capsule delayed release e c po bid times a day for days disp capsule delayed release e c s refills clarithromycin mg tablet sig two tablet po q h every hours for days disp tablet s refills amoxicillin mg capsule sig four capsule po q h every hours for days disp capsule s refills apidra unit ml solution sig twenty five units subcutaneous four times a day insulin syringes disposable ml syringe sig one syringe miscellaneous as needed disp syringes refills discharge disposition home discharge diagnosis primary diagnosis gastrointestinal bleeding likely from small bowel angioectasias acute blood loss anemia helicobacter pylori infection acute renal failure prerenal secondary diagnosis metabolic encephalopathy diabetes mellitus type ii uncontrolled hypertension hyperlipidemia depression discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms it was a pleasure taking care of you at the you came for further evaluation of bloody bowel movements further tests showed that you likely bled from your small intestine from blood vessel malformations called angioectasias a colonoscopy egd capsule endoscopy and small bowel enteroscopy was performed to identify these areas it was also found that you have an infection with helicobacter pylori for which you are being treated it is important that you continue your medications and follow up with the appointments listed below the following changes have been made to your medications we added omeprazole clarithromycin and amoxicillin to treat an infection in your stomach called h pylori please take these medications for the full course outlined followup instructions pcp wednesday at am with md location healthcare upper falls address phone department liver center when tuesday at am with md building lm bldg campus west best parking garage department surgical specialties when thursday at am with md building campus east best parking garage md,"{
""Diagnoses"": [""admission from for klebseilla urosepsis"", ""pyelo"", ""presumed c dif colitis"", ""infectious work up""],
""Medications"": [""gentamycin"", ""cefepime"", ""cipro"", ""st generation cephalosporin"", ""cefadroxil"", ""flagyl""]
}"
42809,admission date discharge date date of birth sex f service cardiothoracic allergies lisinopril attending chief complaint rul nodule major surgical or invasive procedure flexible bronchoscopy video assisted thoracic surgery mediastinal lymph node dissection video assisted thoracic surgery right upper lobe and right middle lobe wedge resection history of present illness year old lady with a rul nodule the patient was recently hospitalized for acute pancreatitis in and during her admission her initial chest x ray revealed evidence of a nodule on the right lung a follow up the ct scan showed evidence of diffuse bilateral ground glass nodularity in both upper lobes and a larger confluent nodule in the right upper lobe with some more dense component and air bronchogram repeat ct scan showed persistence of this x cm nodule follow up pet ct scan performed in showed nodularity of both upper lobes however the larger nodule on the right upper lobe was persistent and had a suv level of the patient is completely asymptomatic other than anxiety she had lb weight loss during the pancreatitis episode but has gained this back she has no cough or chest pain no neurologic symptoms or bone pain past medical history htn gerd s p lap chole s p tah for fibroids social history tobacco negative etoh alcoholic drinks per day days out of the week drugs none lives with husband works for the state at a group home for the mentally retarded family history one of her sons has ulcerative colitis her father has multiple myeloma no fh of lung ca physical exam physical exam heart rate was respiratory rate was blood pressure temperature and oxygen saturation of while breathing room air wt lbs general x all findings normal wn wd wd x nad x aao abnormal findings heent x all findings normal nc at x eomi x perrl a anicteric op np mucosa normal tongue midline palate upper symmetric trachea midline neck supple nt without mass thyroid normal size contour abnormal findings respiratory x all findings normal clear to auscultation and percussion excursion normal no fremitus no egophony no spine costovertebral angle tenderness abnormal findings cardiovascular x all findings normal rrr no m r g no jvd normal peripheral pulses pmi normal no edema no abdominal bruit no carotid bruit abnormal findings gi x all findings normal soft nt nd no mass hsm no hernia abnormal findings skin x all findings normal no rashes lesions ulcers no induration nodules tightening abnormal findings gu x all findings normal normal external genitalia normal pelvic testicular exam normal dre abnormal findings neuro x all findings normal strength intact symmetric sensation intact symmetric reflexes normal no facial asymmetry cognition intact cranial nerves intact abnormal findings lymph nodes x all findings normal cervical normal supraclav normal axillary normal inguinal normal abnormal findings ms x all findings normal no clubbing no cyanosis no edema gait normal no tenderness normal tone alignment rom normal palpation normal nails abnormal findings psychiatric x all findings normal normal judgement insight normal memory normal mood affect abnormal findings 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 wbc rbc hgb hct mcv mch mchc rdw plt ct pm 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 glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap am blood ck cpk pm blood ck cpk am blood ck cpk am blood ck cpk pm blood ck cpk am blood ck mb ctropnt pm blood ck mb ctropnt am blood ck mb mb indx ctropnt am blood ck mb mb indx ctropnt pm blood ck mb mb indx ctropnt am blood calcium phos mg am blood calcium phos mg am blood calcium phos mg pm blood calcium phos mg pm tissue right upper lobe nodule gram stain final per x field polymorphonuclear leukocytes no microorganisms seen tissue final no growth anaerobic culture preliminary no growth acid fast smear final no acid fast bacilli seen on direct smear acid fast culture preliminary fungal culture preliminary potassium hydroxide preparation final no fungal elements seen specimen submitted r lymph node r lymph node level lymph node right middle lobe wedge r lymph node right upper lobe wedge procedure date tissue received report date diagnosed by dr ttl diagnosis lymph nodes r a b no malignancy identified lymph nodes r c no malignancy identified lymph nodes level d e no malignancy identified lymph nodes r f no malignancy identified lung right middle lobe wedge resection g l bronchioloalveolar carcinoma cm see synoptic report benign meningothelial like nodule chemodectoma cm lung right upper lobe wedge resection m r adenocarcinoma cm see synoptic report lung cancer synopsis macroscopic specimen type wedge resection laterality right tumor site upper lobe tumor size greatest dimension cm microscopic histologic type adenocarcinoma mixed subtypes the tumor is composed of predominantly bronchioloalveolar carcinoma a focus of invasive adenocarcinoma acinar subtype is present in slide n histologic grade g well differentiated extent of invasion primary tumor pt tumor cm or less in greatest dimension surrounded by lung or visceral pleura without bronchoscopic evidence of invasion more proximal than the lobar bronchus ie not in the main bronchus lymph nodes location r number examined number involved location r number examined number involved location level number examined number involved location r number examined number involved regional lymph nodes pn no regional lymph node metastasis distant metastasis pmx cannot be assessed margins margins uninvolved by invasive carcinoma distance from closest margin mm specified margin parenchymal margin staple line direct extension of tumor none venous invasion v absent lymphatic invasion l absent additional pathologic findings none note a focus of bronchioloalveolar carcinoma measuring cm in maximum dimension is present in the right middle lobe slide l the margins are uninvolved no invasive carcinoma is noted in this focus tte 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 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 borderline pulmonary artery systolic hypertension there is no pericardial effusion brief hospital course the patient was admitted to the thoracic surgery service on and had a flexible bronchoscopy video assisted thoracic surgery mediastinal lymph node dissection video assisted thoracic surgery right upper lobe and right middle lobe wedge resection intraoperatively right upper lobectomy was aborted secondary to ekg changes and tee hypokinesis she also had an episode of hypotension bradycardia and was given atropine neo and ephedrine post operatively she was transferred to the sicu for observation recovery she was finally transferred to the floor on pod when she was off pressors neuro the patient initially received dilaudid pca with adequate pain control when tolerating oral intake the patient was transitioned to oral pain medications she was also given ativan for anxiety cv postoperatively cardiac enzymes were cycled and monitored and echo was performed showing lvef with global hypokinesis cardiology was consulted and she was put on aspirin and metoprolol she continued to be on pressors for hypotension until pod after which she was stable and transferred to the floor her cardiac enzymes troponin levels continued to drop repeat tte on pod revealed lvef with intraop cardiac event thought to be a transient episode she was eventually discharged on metoprolol and aspirin pulmonary postoperatively chest tubes were kept to suction mmhg it was put to ws on pod and finally removed on pod daily cxrs were done to monitor her pulmonary status throughout her hospital stay with no evidence of a pneumothorax by the time of her discharge gi gu post operatively the patient was given iv fluids until tolerating oral intake her diet was advanced when appropriate which was tolerated well she was also started on a bowel regimen to encourage bowel movement foley was removed on pod intake and output were closely monitored heme id post operatively the patient was transfused u prbc for hct cbc was monitored daily the patient s temperature was closely watched for signs of infection prophylaxis the patient received subcutaneous heparin during this stay and was encouraged to get up and ambulate as early as possible at the time of discharge on pod the patient was doing well afebrile with stable vital signs tolerating a regular diet ambulating voiding without assistance and pain was well controlled medications on admission metoprolol prilosec fosamax vitamin d calcium asa ativan discharge medications metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po daily daily disp tablet sustained release hr s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills fosamax mg tablet sig one tablet po once a week prilosec mg capsule delayed release e c sig one capsule delayed release e c po once a day ativan mg tablet sig one tablet po prn as needed for anxiety calcium oral vitamin d oral aspirin mg tablet sig one tablet po daily daily disp tablet s refills acetaminophen mg tablet sig tablets po q h every hours as needed disp tablet s refills hydromorphone 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 as needed disp tablet s refills discharge disposition home discharge diagnosis bilateral pulmonary nodules discharge condition good discharge instructions call dr office at if if you are vomiting and cannot keep in fluids or your medications if you have shaking chills fever greater than f degrees or c degrees increased redness swelling or discharge from incision chest pain shortness of breath or anything else that is troubling you any serious change in your symptoms or any new symptoms that concern you please resume all regular home medications and take any new meds as ordered do not drive or operate heavy machinery while taking any narcotic pain medication you may have constipation when taking narcotic pain medications oxycodone percocet vicodin hydrocodone dilaudid etc you should continue drinking fluids you may take stool softeners and should eat foods that are high in fiber followup instructions follow up with dr in weeks call his office at to schedule an appointment follow up with oncology in week call the office at to schedule an appointment follow up with cardiology in month call to schedule an appointment completed by,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""service cardiothoracic allergies"", ""lisinopril"", ""attending chief complaint"", ""rul nodule"", ""major surgical or invasive procedure"", ""flexible bronchoscopy"", ""video assisted thoracic surgery"", ""mediastinal lymph node dissection"", ""video assisted thoracic surgery"", ""right upper lobe and right middle lobe wedge resection""],
""Medications"": [""none""]
}"
43697,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint mitral prolapse major surgical or invasive procedure mitral valve repair mm ring closure of patent foramen ovale history of present illness this year old white male has known mitral prolapse the regurgitation has increased on serial echocardiograms and he is admitted for repair v replacement past medical history hypertension hypercholesterolemia obesity h o thyroid cancer s p neck exploration and thyroidectomy degenerative joint disease bilateral pulmonary nodules social history lives with significant other dental employment food broker nonsmoker drinks week caucasian family history father s p strke valve surgery physical exam admission kg lt arm pulse reg at rr ra o sem precordium to neck cor rsr ext no cce pulses pertinent results intraop tee pre bypass the left atrium is mildly dilated 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 the left ventricular cavity is mildly 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 there are simple atheroma in the descending thoracic aorta there are three aortic valve leaflets there is no aortic valve stenosis mild aortic regurgitation is seen the aortic regurgitation jet is eccentric directed toward the anterior mitral leaflet the mitral valve leaflets are myxomatous an eccentric anteriorly directed jet of moderate to severe mitral regurgitation is seen due to the eccentric nature of the regurgitant jet its severity may be significantly underestimated coanda effect there is a trivial physiologic pericardial effusion post bypass the patient is not receiving inotropic support post cpb there is a well seated mitral annuloplasty ring there is no mitral regurgitation there is a transvalvular mean gradient of mm hg at a cardiac output of l min biventricular systolic function is preserved and all findings are consistent with pre bypass findings the aorta is intact post decannulation all findings were discussed with the surgeon intraoperatively blood wbc rbc hgb hct plt ct wbc rbc hgb hct plt ct wbc rbc hgb hct plt ct wbc rbc hgb hct plt ct wbc rbc hgb hct plt ct wbc rbc hgb hct plt ct wbc rbc hgb hct ct wbc rbc hgb hct plt ct pt inr pt pt inr pt pt ptt inr pt glucose urean creat na k cl hco angap glucose urean creat na k cl hco glucose urean creat na k cl hco glucose urean creat na k cl hco glucose urean creat na k cl hco glucose urean creat na k cl hco glucose urean creat na k cl hco mg brief hospital course on dr performed a mitral valve repair and closure of a patent foramen ovale see operative note for details following surgery he was transferred to the cvicu for invasive monitoring within hours he awoke neurologically intact and extubated without incident chest tubes were removed per protocol and low dose beta blockade was initiated he went on to develop complete heart block requiring temporary pacing beta blockade was subsequently stopped ep service was consulted and attributed av block to av nodal edema his rhythm was observed for several days and his av block resolved he went on to develop first degree av block with conversion to persistent atrial fibrillation flutter he remained asymptomatic and pacing wires were eventually removed on postoperative day nine warfarin was eventually started and dosed for a goal inr between and all nodal agents continued to be withheld and ep service felt pacemaker was not indicated at this time mr will followup with ep cardiology as an outpatient at time of discharge inr was subtherapeutic but will be followed closely by cardiology clinic the remainder of his postoperative course was routine and he was cleared for discharge to home on postoperative day nine medications on admission amlodipine mg daily levoxyl mcg daily hctz mg daily simvastatin mg daily trazadone prn fish oil vitamins 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 levothyroxine mcg tablet sig two tablet po daily daily disp tablet s refills oxycodone acetaminophen mg tablet sig tablets po every hours as needed for pain for weeks disp tablet s refills ranitidine hcl mg tablet sig one tablet po bid times a day disp tablet s refills simvastatin mg tablet sig one tablet po at bedtime disp tablet s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills furosemide mg tablet sig one tablet po daily daily for days take for days then stop please take with kcl disp tablet s refills potassium chloride meq tab sust rel particle crystal sig one tab sust rel particle crystal po daily daily for days please take with lasix stop after days disp tab sust rel particle crystal s refills warfarin mg tablet sig two tablet po qpm take as directed by md daily dose may vary according to inr goal inr between disp tablet s refills discharge disposition home with service facility vna discharge diagnosis mitral regurgitation prolapse patent foramen ovale transient av block postop atrial fibrillation flutter postop obesity hypertension hypercholesterolemia degenerative joint disease s p thyroidectomy h o thyroid cancer s p neck exploration s p tonsillectomy pulmonary nodules bilateral discharge condition alert and oriented x nonfocal ambulating with steady gait incisional pain managed with oral analgesics incisions sternal healing well no erythema or drainage edema none discharge instructions 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 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 surgeon dr on tuesday at pm please call to appointments with primary care dr in weeks cardiologist dr in weeks wound clinic in weeks your nurse 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 mv repair atrial fibrillation atrial flutter goal inr first draw results to cardiology clinic phone fax vna to call or fax results to completed by,"{
""Diagnoses"": [""mitral prolapse"", ""regurgitation"", ""hypertension"", ""hypercholesterolemia"", ""obesity"", ""thyroid cancer"", ""degenerative joint disease"", ""bilateral pulmonary nodules""],
""Medications"": [""none""]
}"
73558,admission date discharge date date of birth sex f service medicine allergies penicillins attending chief complaint fevers fatigue and headaches for month transfer from osh after liver biopsy complicated by bradycardia hypotension and basal ganglion bleed major surgical or invasive procedure liver aspiration and drain placement history of present illness this is a year old female with pmh of gastric bypass surgery who presented for further evaluation of necrotic inflammatory liver lesions found on imaging at an osh during a work up for a month history of fevers fatigue and headaches an osh cxr showed possible lymphadenopathy and an osh abdominal ct showed multiple liver lesions and portal vein thrombosis she had a biopsy performed on at the osh following the biopsy she became hypotensive and bradycardic to the s s she was in the icu at the osh with sbp in the s and received l ns and was placed on a dopamine gtt of mcg she experienced bradycardia to the s s while on dopamine and received atropine mg x an echo was performed and demonstrated an ef cardiology consult at osh did not find bradycardia to be concerning a gram stain of her liver aspirate showed gram cocci she also had blood cx for strep viridans from her pcp s office she was started on vanco flagyl and meropenem id consult thought not likely an infectious etiology of liver mets and they recommended continued meropenem until liver biopsy back on she became diaphoretic with decreased bps lg vomiting and developed frank hemiplegia with left facial droop cta of the brain showed right basal ganglia bleed and she was intubated for airway protection a follow up abdominal ct showed increased necrosis of the liver and portal vein thrombosis pathology showed inflammation with increased amyloid uptake she was then transferred to micu intubated mostly to protect her airway in the setting of basal ganglia bleed and on pressors she was extubated on and has done very well her pressors were weaned shortly thereafter her bps have remained stable for the most part with a few episodes of sbps in the s that have responded well to ivf boluses she has remained asymptomatic during these episodes tte performed at bedside showed possible aortic valve vegetation id was consulted and recommended a course of vanc ceftriaxone flagyl she spiked to on she underwent tee on which showed a focal thickening of the aortic valve and no vegetation liver u s concerning for metastatic disease as opposed to infection given that she was doing well off pressors she was transferred to the floor on upon arrival the patient has no acute complaints she is anxious to find out the results of her liver biopsy she denies any dizziness or lightheadedness even when her blood pressures dip to the s she does not report any pain or sob past medical history history of gastric bypass history of cholecystectomy alcoholism depression dm resolved with bypass surgery mood instability previous severe sleep apnea now resolved active tobacco use s p cesarean section new medical hx at osh multiple liver lesions with progressive necrosis core biopsy non diagnostic with evidence of inflammation right portal vein thrombosis cannot anticoag due to hemorrhagic cva persistent hypotension following core biopsy acute basal ganglia bleed bradycardia hypokalemia and hyponatremia social history smoked and drinks occasionally per osh records h o etoh abuse family history non contributory physical exam tm tc hr s bp s s s s rr pox ra last bm on general pleasant but anxious overweight female in nad heent mmm oropharynx clear eomi perrl mild left sided facial droop neck supple lungs clear to auscultation bilaterally cv regular rate and rhythm normal s s no murmurs rubs gallops abdomen surgical scars noted obese soft tender to palpation in area surrounding drain non distended no rebound or guarding ruq drain is in place draining cloudy material bandaged no erythema around site access picc line in place on right arm gu fungal rash noted on inner thighs ext warm well perfused pulses no clubbing cyanosis or edema no splinter hemorrhages or osler nodes neuro a ox resolving left sided facial droop no dysarthria noted right sided upper and lower extremity motor strength with intact sensation left sided upper and lower motor strength with intact sensation left arm finger to nose compromised unsteady gait pertinent results am type art po pco ph total co base xs am lactate am urine blood mod nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg am glucose urea n creat sodium potassium chloride total co anion gap am alt sgpt ast sgot ld ldh alk phos tot bili am albumin calcium phosphate magnesium am wbc rbc hgb hct mcv mch mchc rdw am neuts lymphs monos eos basos am plt count echo the left atrium is mildly dilated the estimated right atrial pressure is mmhg left ventricular wall thickness cavity size and regional global systolic function are normal lvef the estimated cardiac index is high l min m 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 a small nodules on the left coronary cusp could be vegetation cannot rule out calcium nodule clip there is no valvular aortic stenosis the increased transaortic velocity is likely related to high cardiac output trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse no mass or vegetation is seen on the mitral valve trivial mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened there is mild pulmonary artery systolic hypertension there is a trivial physiologic pericardial effusion impression normal left ventricular systolic function a small nodule on the left coronary cusp could be vegetations cannot rule out calcium nodules if clinically suggested the absence of a vegetation by d echocardiography does not exclude endocarditis abdominal u s impression no portal vein thrombosis identified however the posterior right portal vein imaging is limited limited views of the right lobe of the liver demonstrate at least two hypoechoic lesions the largest of which measures cm ddx includes primary multifocal vs metastatic tumor splenomegaly subcentimeter aml in the right kidney echo the left atrium and right atrium are normal in cavity size no spontaneous echo contrast or thrombus is seen in the body of the left atrium left atrial appendage or the body of the right atrium right atrial appendage no atrial septal defect is seen by d or color doppler overall left ventricular systolic function is 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 no masses or vegetations are seen on the aortic valve there is focal thickening of the non coronary cusp of the aortic valve but no vegetation the mitral valve appears structurally normal with trivial mitral regurgitation there is no mitral valve prolapse no mass or vegetation is seen on the mitral valve no vegetation mass is seen on the pulmonic valve there is no pericardial effusion impression no echocardiographic evidence of endocarditis mri abdomen impression multiple lobulated peripherally enhancing lesions in the right lobe of the liver with central necrosis the imaging features of which are consistent with abscesses no definite evidence of portal or hepatic vein thrombosis although the peripheral segments of the right portal vein are not well assessed small right pleural effusion with atelectasis in the right base of the lung cta head impression stable large right basal ganglionic hemorrhage with surrounding edema no aneurysm in the arteries of the anterior or posterior circulation minimal nodularity along the superior aspect of the right middle cerebral artery m segment may represent irregularity due to atherosclerosis or an infundibulum from a perforating lenticulostriate artery cxr findings in comparison with study of there has been placement of a right subclavian picc line that extends to the mid portion of the svc bibasilar atelectatic changes are seen brief hospital course this is a year old female with pmh of gastric bypass surgery presenting with constellation of fevers malaise liver lesions hypotension bradycardia and basal ganglion bleed that was confirmed to have hepatic abscesses which were aspirated and drained liver lesions and fevers liver ultrasound revealed two hypoechoic lesions of unclear etiology given her fevers it was likely that the lesions were hepatic abscesses but hepatic malignancy could not be ruled out biopsy results from osh showed benign liver tissue with focal acute and chronic inflammation there was also focal deposition of congophilic material consistent with amyloid per report blood and liver aspirate cultures drawn in were also negative given her chronic fevers and basal ganglion bleed endocarditis was considered but a tee performed on was negative for endocarditis infectious disease was consulted and recommended iv ceftriaxone and iv flagyl which was started on vanco was also intially recommended to cover for endocarditis but was discontinued when her tee results were read as negative the liver team was consulted and recommended sending afp and ca to rule out malignancy which were both negative entamoeba histolytica antibody was also sent given her hepatic and cns findings and was still pending at time of discharge an mri mra liver was obtained on which showed multiple lobulated peripherally enhancing lesions in the right lobe of the liver with central necrosis which were consistent with abscesses there was no definite evidence of portal or hepatic vein thrombosis although the peripheral segments of the right portal vein were not well assessed given these findings both the liver and id teams agreed that aspiration and drainage of these abscesses would be the best course of action ct guided drainage was therefore performed on with frank pus aspirated and a drain left in place the patient had multiple abscesses that were not aspirated gram stain shows gpcs in pairs and polys but the culture has shown no growth likely given that she was empirically treated with abx for several days prior to the drain being placed she was started on oxycodone po prn pain with a proper bowel regimen for pain related to her drain placement the drain should be left in place until follow up ct scan imaging is obtained a confirms resolution of her abscesses the drain should be flushed with cc of sterile saline and aspirated back every hours this should be repeated until the aspirate is clear do not continue to flush if the volume out is significantly less than the volume in if there is pain with flushing this may mean that the abscess cavity has collapsed if the drain stops draining suddenly check that the stopcock is open remove dressing carefully and inspect to make sure that there is no kink in the catheter inspect to be sure that there is no debris blocking the catheter if there is then firmly flush cc of sterile saline into the catheter an initial follow up ct abdomen on showed interval decrease in size of hepatic collections with the largest measuring about cm in diameter she should be scheduled for a follow up ct as an outpatient in about a week from discharge to monitor the size of her abscesses and evaluate whether the drain should be pulled otherwise she should continue on iv ceftriaxone flagyl to cover liver abscesses for an empiric course of at least weeks a picc line was placed for long term antibiotics her only positive set of blood cultures was drawn in on which was blood cultures positive for strep viridans of the anginosus variety that was sensitive to pcn ctx and vanco but resistant to clindamycin all microbiology data from blood and urine has been negative to date at she should be followed by infectious disease doctors and she should get a colonoscopy as an outpatient right basal ganglia bleed unclear etiology but likely hypertensive bleed after being started on pressors at osh neurology was consulted and suggested a follow up cta of her head which was performed on and showed stable large right basal ganglionic hemorrhage with surrounding edema there was no aneurysm in the arteries of the anterior or posterior circulation but minimal nodularity was noted along the superior aspect of the right middle cerebral artery m segment which may represent irregularity due to atherosclerosis or an infundibulum from a perforating lenticulostriate artery her neuro exam was significant for mild left sided facial droop and left sided weakness her exam should continue to be monitored closely and her blood pressure should remain well controlled she should follow up with a neurologist hypotension likely secondary to infection and unlikely to be a cardiac event as her echo confirms good cardiac output she was quickly weaned off of pressors upon arrival to the icu on she maintained good urine output with systolic bps ranging from s s throughout her inpatient stay all blood cultures at remained negative bradycardia she had asymptomatic bradycardia to the s of unclear etiology at the osh that resolved she received atropine x at osh anemia it is unclear what the patient s baseline hct is her hct on admission and has been stable in the high s throughout her admission depression continued outpatient regimen of prozac mg daily and xanax mg prn anxiety sleep history of gastric bypass no acute issues continued outpatient management with vitamin c mg daily calcium vitamin d units and mvi daily code confirmed full code medications on admission vit b mcg by mouth daily coenzyme q daily vit c mg daily centrum women s daily calc mg and vit d units hctz mg daily buproprion xl mg daily topiramate mg qam and mg qhs prozac mg daily alprazolam mg prn discharge medications cyanocobalamin mcg tablet sig one tablet po once a day coenzyme q mg capsule sig one capsule po once a day ascorbic acid mg tablet sig one tablet po daily daily multivitamin tablet sig one tablet po daily daily calcium carbonate mg tablet chewable sig one tablet chewable po bid times a day cholecalciferol vitamin d unit tablet sig two tablet po bid times a day bupropion hcl mg tablet sustained release hr sig one tablet sustained release hr po once a day topiramate mg tablet sig one tablet po qam once a day in the morning topiramate mg tablet sig three tablet po qhs once a day at bedtime fluoxetine mg capsule sig four capsule po daily daily alprazolam mg tablet sig one tablet po qhs once a day at bedtime as needed for anxiety insomnia acetaminophen mg tablet sig tablets po q h every hours as needed for fevers pain 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 polyethylene glycol gram dose powder sig seventeen grams po daily daily miconazole nitrate powder sig one appl topical qid times a day as needed for fungal rash oxycodone mg tablet sig one tablet po q h every hours as needed for pain metronidazole flagyl mg iv q h ceftriaxone gm iv q h discharge disposition extended care facility discharge diagnosis primary diagnoses pyogenic liver abscess right basal ganglion bleed 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 to for further evaluation of fevers fatigue and headaches for month in the setting of liver lesions seen on imaging your initial work up at another hospital included a liver biopsy that was complicated by low blood pressure after the procedure which required an iv medication to increase your blood pressure unfortunately you also developed a right sided head bleed and have some residual left sided body weakness a repeat liver aspiration was performed here and a drain was placed it appears that the fluid that is draining is infected which means that you have abscesses in your liver the follow up cat scan shows that the abscesses have gotten smaller you will continue to have the drain in place and your progress will be tracked by future cat scan imaging a picc line was placed and you will remain on iv antibiotics for at least weeks until your infection is treated the following changes have been made to your home medication regimen you will continue on iv ceftriaxone and iv metronidazole for at least weeks but the full course will have to be re evaluated by your infectious disease providers you should stop your home hctz you should start oxycodone as needed for your pain you should remain on a good bowel regimen with docusate senna and miralax to prevent constipation followup instructions please follow up with your pcp you have the following appointment s scheduled pcp am primary care me your pcp office will call with times of appointments with neurology liver and infectious disease please call on monday if you haven t heard from them,"{
""Diagnoses"": [""necrotic inflammatory liver lesions"", ""bradycardia"", ""hypotension"", ""basal ganglion bleed"", ""liver aspiration and drain placement"", ""gastric bypass surgery""],
""Medications"": [""penicillins"", ""atropine"", ""dopamine"", ""mcg""]
}"
23147,admission date discharge date service medicine allergies nsaids attending chief complaint altered mental status major surgical or invasive procedure triple lumen placed on intubation history of present illness patient is an year old female with esrd on hemodialysis mwf mild dementia hypertension cad statsu post cabg in who presented with two days of confusion and mental status changes at her nursing home son reports that he saw her days prior to admission and she was her usual self conversational alert oriented and with mild memory difficulties son went to see her on the morning of and noted that she was writhing lying in the fetal position and noticed shallow breathing he could not elicit more detailed complaints out of her as she was not verbal on the day of admission per the nursing home reports she was hypoxic to the s on the morning of admission it increased to the s on l nc vomited x on morning of admission emesis was nonbilious and nonbloody she was incontinent of stool x when she is typically continent last hemodialysis was on friday is on mwf schedule has had increasing confusion over the last few days in the ed she was febrile to and was cultured she was hypertensive to s s systolic cxr demonstrated fluid overload with a question of pneumonia a blood gas revealed an abg initial lactate was she was placed on bipap and as she could not be weaned from bipap was admitted to micu she initially received one gram of vanco g of ceftaz mg of gentamicin he received one dose of asa mg pr in the micu patient was getting dialyzed and was found to be more unresponsive cyanotic not at all moaning or responding to sternal rub she was intubated for airway protection tachypneic appeared moribund l subclavian triple lumen placed as well hd was discontinued and l ns was run in through the hd catheter wide open at that point patient appeared somewhat more responsive past medical history esrd on hd m w f status post right hip repair in which has prompted prolonged nursing home stay hypertension cabg x in at found to have vd on cath arthritis neuropathy laparscopic cholecystectomy in summer left temporal cva pneumothorax after line placement in status post chest tube herpes zoster right t t in social history widowed resides at nh four children no tobacco no etoh generally pleasant but tends to isolate her four children visit her but she does not speak with them very often family history mother had coronary artery disease physical exam physical exam on admission to micu vs bad pleth on bipap gen moaning does not respond verbally to questions not responding to commands heent mask interfering with exam neck jvd to cm cv rrr nl s s no m r g chest r tunneled s c dialysis catheter no surrounding erythema pulm ctab anteriorly abd soft nt nd bs no masses ext no c c e onychomycosis neuro delirium cannot answer questions physical exam on admission to floor t bp hr rr o saturation on room air blood sugar gen laying in bed minimally responding knew year and city but assumed in nursing home elderly woman in no apparent distress heent slight conjunctival pallor no icterus slightly dry mucous membranes ngt in place neck no cervical or supraclavicular lymphadenopathy no jvd no thyromegaly hemodialysis catheter in left upper chest cv rrr normal s and s no murmurs rubs or appreciated lungs clear to auscultation bilaterally decreased breath sounds in lower lung fields bilaterally slight crackles appreciated bilaterally abd normal active bowel sounds in all four quadrants soft nontender and nondistended no guarding or rebound liver edge not palpated no splenomegaly appreciated no abdominal aortic bruit ext distal extremities cool and cyanotic no lower extremity edema bilaterally radial pulses bilaterally skin several ecchymoses pertinent results images av fistulogram left av fistulogram demonstrates good flow in the anterior side of the fistula to the cephalic vein also there is patent subclavian and svc veins ekg bpm nsr lafb twi in v old chest xray portable perhaps slight improvement in pulmonary edema persistent left lower lobe atelectasis or consolidation chest xray left subclavian vein catheter tip is in the lower svc right subclavian catheter tip is in the right atrium left lower lobe collapse is persistent small right pleural effusion is stable ng tube tip is in the stomach there is no pneumothorax mild cardiomegaly is stable cxr pulmonary edema with bilateral pleural effusions new since the plain radiograph confluent opacity in the right mid lung zone and base likely represents alveolar edema though pneumonic consolidation is a consideration no supine evidence of pneumothorax cardiac the left atrium is mildly dilated there is mild symmetric left ventricular hypertrophy the left ventricular cavity size is normal there is mild regional left ventricular systolic dysfunction with mid to apical anteroseptal anterior hypokinesis overall left ventricular systolic function is mildly depressed right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened there is a minimally increased gradient consistent with minimal aortic valve stenosis mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened there is mild pulmonary artery systolic hypertension there is a small pericardial effusion no vegetation seen abdominal u s unremarkable liver and no biliary dilatation status post cholecystectomy bilateral pleural effusions loculated on the right atrophic kidneys tte dilated rv mildly dilated ef mr mild pulmonary htn micro blood staph aureus coag endotracheal yeast staph aureus coag stool c dificile negative labs wbc hgb hct plt pt ptt inr wbc hgb hct plt pt ptt inr na k cl hco bun cr glu na k cl hco bun cr glu ca mg po ca mg po 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 plt ct am blood pt ptt inr pt pm blood pt ptt inr pt pm blood plt smr normal plt ct 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 alt ast alkphos amylase totbili pm blood alt ast ld ldh ck cpk alkphos amylase totbili am blood lipase pm blood lipase am blood ck mb notdone ctropnt pm blood ck mb ctropnt pm blood ck mb ctropnt am blood ck mb mb indx ctropnt pm blood ck mb ctropnt am blood calcium phos mg am blood albumin calcium phos mg am blood genta vanco am blood genta vanco pm blood po pco ph caltco base xs pm blood po pco ph caltco base xs pm blood lactate brief hospital course hospital course assessment plan patient is an year old female with a history of cad status post cabg esrd on hemodialysis cva with dementia who presents with worsening mental status who was admitted to the icu for hypoxic respiratory failure hypoxic respiratory failure on admission most likely related to excess fluid despite stable hemodialysis schedule pleural effusions and pulmonary edema on chest xray no history of copd appears to have underlying pna as well continue hemodialysis for fluid removal blood culture on revealed staph aureus coag positive blood initial antibiotic was ceftazidime but discontinued as infection thought to be related to hd line decision made to treat through with vancomycin and gentamycin for potential line sepsis flagyl continued for two weeks despite stool that was negative for c difficile will be discharged on vancomycin and flagyl by patient maintaining oxygen saturation on liters nasal canula on patient oxygen saturation on room air fever and leukocytosis multiple sources of infection sputum on revealed some yeast stool on was c dificile negative and negative for salmonella shigella and campylobacter treated presumed hd line infection with gentamicin and vancomycin av fistulogram revealed av fistula in left arm functioning removed tunneled left catheter line on so will continue only vancomycin for two weeks until dosing of antibiotics after hemodialysis sessions for vancomycin trough less than will continue metronidazole for two weeks on left triple lumen placed on appeared infected line removed abnormal lfts most likely due to shock liver right upper quadrant ultrasound did not reveal any obstructive picture urinary tract infection patient had positive urine analysis on admission as above treated with broad spectrum antibiotics mental status changes presented to hospital and unresponsive most likely due to multiple conditions initially had fluid overload and hypoxia in days prior to discharge patient s mental status improved much more lucid and requesting to eat on own consulted speech and swallow to assist continued with thickened pureed liquids with aspiration precautions diarrhea patient presented with recent vomiting and diarrhea most likely due to viral gastroenteritis rectal tube in place c dificile culture from negative despite this will continue on po flagyl as previous c dificile infection and patient has been hospitalized for extended period cad status post cabg elevated troponin compared with previous troponins with similar degree of renal failure but ekg shows no changes most likely due to demand ischemia in setting of hypoxia and respiratory distress factors continued aspirin initially held beta blocker and ace i as hypotensive trended cardiac enzymes did not start heparin tight glycemic control initiated for tight glycemic control in icu setting no history of diabetes blood sugars remained in good control esrd on hd patient with right hd line with l fistula not being used initially held nephrocaps and fosrenal as couldn t take po medications continued with hd on m w f schedule restarted nephro caps dementia mild at baseline per son avoided ativan depression initially held effexor fen gi initially npo with ngt placed secondary to altered mental status consulted speech and swallow with altered mental status concern for aspiration tolerated thickened liquids ngt removed per patient on prophylaxis placed on sc heparin and ppi access r tunneled line for hd pulled on l subclavian triple lumen catheter pulled on right av fistula with good flow code dnr dni ok to be intubated for a short period of time family said that no heroic measures or long term intubation or feeding tubes would not want a trach but ok to intubate if we project that it would be a temporizing measure for example while we remove fluid son is hcp medications on admission lisinopril mg daily marinol mg daily prednisone mg daily prilosec mg daily pravachol mg qhs calcium carbonate mg senna tab qhs lopressor mg tid nephrocaps tab qam asa mg daily effexor mg daily ativan mg daily mg qpm prn norvasc mg daily fosrenal mg tid discharge medications metronidazole mg tablet sig one tablet po q h every hours continue for weeks stop on aspirin mg tablet sig one tablet po once a day b complex vitamin c folic acid mg capsule sig one cap po daily daily senna mg tablet sig one tablet po bid times a day as needed vancomycin in dextrose g ml piggyback sig one intravenous qhd each hemodialysis give after dialysis treatments if trough give until camphor menthol lotion sig one appl topical times a day as needed heparin porcine unit ml solution sig one injection tid times a day metoprolol tartrate mg tablet sig one tablet po tid times a day docusate sodium mg capsule sig one capsule po bid times a day as needed pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours acetaminophen mg suppository sig one suppository rectal q h every hours as needed for fever pravachol mg tablet sig one tablet po at bedtime discharge disposition extended care facility nursing home discharge diagnosis primary hypoxic episode requiring intubation esrd dialysis treatments m w f secondary status post right hip repair in which has prompted prolonged nursing home stay hypertension cabg x in at found to have vd on cath arthritis neuropathy laparscopic cholecystectomy in summer left temporal cva pneumothorax after line placement in status post chest tube herpes zoster right t t in discharge condition stable discharge instructions you were admitted for depressed oxygenation levels initially you needed to be intubated you were found to have an infection in your blood several antibiotics vancomycin gentamicin and metronidazole were started one of these medications vancomycin can be administered after dialysis sessions and should be administered for two more weeks until an av fistulogram demonstrated patent flow your right tunneled catheter line was pulled on if you experience any more increased shortness of breath chest pain fever or any other concerning symptoms call your pcp or come to the ed immediately followup instructions you are scheduled to continue to receive vancomycin until this medication should be administered following dialysis sessions dose for vancomycin troughs less than your pcp will continue to follow your progress,"{
""Diagnoses"": [""Confusion"", ""Mental status changes"", ""Hypertension"", ""Dementia"", ""ESRD"", ""Hemodialysis"", ""Post-CABG""],
""Medications"": [""Nsaids"", ""Cad"", ""Statins""]
}"
13694,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint presenting for elective cardiac catheterization major surgical or invasive procedure cardiac catheterization history of present illness m cad s p cabg in chf dm admitted to ccu for hypotension heamturia during elective cath procedure he presented for a relook cardiac catheterization and possible icd placement since stress testing has revealed new fixed defects and recent holter monitoring has demonstrated an increase in ventricular ectopy at the end of the procedure the pt was noted to have sbp in s with hr s and was treated with atropine mg iv x to treat presumed vagal reaction he required dopamine drip briefly as well with regard to symptoms the patient reports that in he had several episodes of classic angina with exertion responding to sl nitroglycerin currently he describes intermittent chest heaviness often occurring in the evening when climbing the stairs to go to bed these episodes resolve with rest he has also had some episodes that have woken him from sleep ros denies claudication le edema orthopnea pnd lightheadedness patient reports being diagnosed with neuropathy and complains of burning of the soles of his feet when lying down past medical history mi x one of his mi s was treated with thrombolysis cabg lima to lad svg to rca svg to diagonal cath for ett lvef lad occluded at its origin cx with mild disease rca with sequential tight lesions lima to lad widely patent svg to diagonal widely patent svg to rca totally occluded at its origin patient underwent successful ptca stenting of the proximal mid and distal rca with three bx velocity stents eps inducible avnrt s p ablation no inducible ventricular arrhythmias holter predominant rhythm was sinus low grade atrial ectopy noted very frequent isolated vpb s noted including episodes of ventricular bigeminy trigeminy and quadrageminy frequent couplets and twelve beat runs of nsvt ventricular ectopy has increased since holter study dated echo moderately dilated lv cavity with an lvef anterior and inferior walls near akinetic with severe hypokinesis of the remaining segments moderately thickened aortic valve leaflets peak gradient mmhg mean gradient mmhg cm ai mr tr moderate systolic pulmonary hypertension compared with prior study dated the severity of the aortic stenosis mr and pulmonary artery pressure have all increased lv systolic function is slightly worse abi s right left impression bilateral tibial disease with predominant involvement of the anterior tibial and dorsalis pedis arteries ett minutes modified protocol max phr stopping due to mm st depression in the inferolateral leads no anginal symptoms rhythm was sinus with frequent isolated polymorphic vpb s at rest and low level exercise imaging new moderate to severe fixed anteroseptal and moderate fixed apical defects stable mild to moderate fixed inferolateral defect global hypokinesis calculated lvef lv cavity size significantly enlarged worsened from the prior study rca stenting ischemic cardiomyopathy paroxysmal atrial fibrillation svt s p ablation adult onset diabetes hyperlipidemia seasonal allergies social history patient was born in poland immigrated to the us in he is remarried his wife and his son accompanied him to the hospital family history father with an mi at age mother with diabetes physical exam upon arrival in the ccu pertinent results pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm glucose k cardiac catheterization see full report for details native three vessel coronary artery disease severe aortic stenosis with dobutamine occluded svg rca svg d patent lima lad severe instent restenosis of the rca successful ptca and stenting of the proximal and mid rca with drug eluting stents icd placement virtuoso dual cahmber via left cephalic not tested b c mild as and recent stents ra p imp rv r imp brief hospital course this year old male with cad history s p cabg as chf dm was admitted to ccu for hypotension heamturia during elective cath procedure cardiovascular patient presented for elective cardiac catheterization for new fixed defects in the anteroseptal and apical regions which resulted in two overlapping mm and mm cypher stents the patient was continued on his aspirin and statin and treated with plavix he remained chest pain free for the duration of his admission b pump during his catheterization patient had a brief hypotensive episode which was thought likely secondary to a vagal reaction he briefly required dopamine with resolution of his sbps to baseline from his past history patient was known to have severe ischemic cardiomyopathy with a recent ef and noted to have a mildly elevated wedge pressure he remained on his home diuretic regimen and after his blood pressures normalized he was resumed on his home dose of acei following his icd placement he was started with beta blockade with metoprolol qid c valves patient with known as with mean gradient by echo had a dobutamine challenge during catheterization to measure the degree of stenosis which showed significant aortic stenosis with a low cardiac index d vasculature pcp concern for tibial vascular disease recommending that bed be kept in a reverse trendelenburg position at all times genitourinary upon placement of a foley catheter s p cardiac catheterization for feeling of bladder fullness patient had bright red blood which prompted urology evaluation and subsequent placement of a large bore catheter and chronic foley flushes to be discontinued hours after passage of blood clots urology recommended initiation of flomax with recommendation to continue for days and to send for urine cytology when urine is clear yellow which could not be done as an inpatient since bloody urine was not completely resolved follow up with dr in urology was arranged to address above as well as to check psa if pt has yr life expectancy upper tract imaging ct urogram cystosopy and to assess luts lower urinary tract symptoms to see if he should continue flomax dm upon admission patient po medications metformin and glipizide were initially held and patient was covered successfully with an iss medications on admission glipizide mg three times a day lipitor mg daily every evening enalapril mg daily every morning digitek mg tablets on sunday one and a half tablets all other days metformin mg two tablets every morning one tablet every evening plavix mg daily every evening aspirin mg daily every evening b complex mvi senekot lasix mg daily on monday s and friday s 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 atorvastatin mg tablet sig one tablet po hs at bedtime b complex with vitamin c 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 tamsulosin mg capsule sust release hr sig one capsule sust release hr po hs at bedtime disp capsule sust release hr s refills enalapril maleate mg tablet sig tablet po daily daily metformin mg tablet sig two tablet po qam once a day in the morning metformin mg tablet sig one tablet po qpm once a day in the evening levofloxacin mg tablet sig one tablet po q h every hours for days please take this medication for as long as you have the foley catheter plus an additional days disp tablet s refills docusate sodium mg capsule sig one capsule po bid times a day as needed digoxin mcg tablet sig tablets 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 glipizide mg tablet sig one tablet po three times a day disp tablet s refills lasix mg tablet sig one tablet po qmonday lasix mg tablet sig one tablet po qfriday discharge disposition extended care facility discharge diagnosis primary coronary artery disease stable angina aortic stenosis chf systolic non sustained ventricular tachycardia hematuria secondary diabetes mellitus type controlled discharge condition patient discharged in stable condition with stable vital signs oxygenating well on room air ambulating unassisted discharge instructions you have been evaluated and treated for your coronary disease your irregular heart beat and your aortic stenosis the testing resulted in a new stent being placed in one of your coronary arteries a pacemaker icd being placed more evidence of your heart muscle s response to the aortic stenosis you did develop blood in the urine during this hospitalization you will need to keep the foley catheter in your bladder until you see the urologists in clinic a visiting nurse will come to your house to flush the catheter once a day please make sure that you discuss with your primary care physician the metformin in the setting of heart failure many physicians prefer to use other agents for blood sugars as we have discussed there are some risks associated with metformin use in heart failure followup instructions provider clinic phone date time provider m d phone date time provider m d phone date time please call dr to set up an appointment within weeks to address these medical issues [NEW_RECORD] name unit no admission date discharge date date of birth sex m service medicine allergies metformin attending addendum see hospital course below chief complaint see prior portion of d c summary major surgical or invasive procedure right heart catheterization left heart catheterization with angioplasty and stent placement icd placement history of present illness see prior portions of d c summary past medical history see prior portions of d c summary social history patient was born in poland immigrated to the us in he is remarried his wife and his son accompanied him to the hospital family history father with an mi at age mother with diabetes physical exam see prior portions of d c summary pertinent results see prior portions of d c summary brief hospital course on the day of expected discharge patient s hematocrit was noted to be slightly lower than previous checks patient remained in house and resuscitated with uprbcs with appropriate response on the morning of expected patient had minute run of svt with retrograde p waves patient was asymptomatic during this period dr recommended ep comment on his event and whether or not reprogramming of the icd could be performed and or if pacing was an option patient found to have asymptomatic non hemodynamically compromising runs of nsvt at rate of the ep consult service recommended adding sotalol as an anti arrhythmic to suppress the ventricular rhythm the ventricular rhythm was suppressed with this regimen the patient will follow up with the device clinic within one week his ace inhibitor was discontinued during this hospitalization due to mild hypotension the medication can be resumed as directed by his pcp diabetes the patient had adequate blood sugar control during hospitalization however he was noted to have a mildly elevated lactic acid which was thought secondary to the metformin this medicine was discontinued and added to his medicine allergy list consult was obtained which recommended glipizide twice daily with insulin sliding scale for additional coverage the patient can have the sliding scale adjusted as needed abdominal pain the patient had intermittent abdominal pain during his hospital stay physical exam and lab testing supported constipation as the likely cause of the symptom he should continue on adequate bowel regimen to maintain at least one bowel movement per day please note that the medicines listed in the addendum are the correct medicines for this patient at the time of discharge medications on admission see prior complete d c summary 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 atorvastatin mg tablet sig one tablet po hs at bedtime b complex with vitamin c 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 tamsulosin mg capsule sust release hr sig one capsule sust release hr po hs at bedtime disp capsule sust release hr s refills docusate sodium mg capsule sig one capsule po bid times a day as needed digoxin mcg tablet sig tablets 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 lasix mg tablet sig one tablet po qmonday lasix mg tablet sig one tablet po qfriday cephalexin mg capsule sig one capsule po q h every hours for days capsule s sotalol mg tablet sig one tablet po bid times a day glipizide mg tablet sig one tablet po bid times a day please give with breakfast and dinner senna mg tablet sig one tablet po bid times a day lactulose g ml syrup sig thirty ml po q h every hours as needed to at least bm per day foley care please flush foley catheter daily with cc normal saline insulin regular human unit ml solution sig asdir units injection asdir as directed see attached sliding scale ferrous sulfate mg tablet sig one tablet po daily daily for months acetaminophen mg tablet sig tablets po q h every to hours as needed for pain bisacodyl mg suppository sig one suppository rectal times a day as needed discharge disposition extended care facility discharge diagnosis primary coronary artery disease stable angina aortic stenosis chf systolic non sustained ventricular tachycardia hematuria secondary diabetes mellitus type controlled discharge condition patient discharged in stable condition with stable vital signs oxygenating well on room air ambulating unassisted discharge instructions you have been evaluated and treated for your coronary disease your irregular heart beat and your aortic stenosis the testing resulted in a new stent being placed in one of your coronary arteries a pacemaker icd being placed more evidence of your heart muscle s response to the aortic stenosis you did develop blood in the urine during this hospitalization you will need to keep the foley catheter in your bladder until you see the urologists in clinic the nurses at the rehab facility should flush the catheter daily please note that your regimen to control your diabetes has changed the new regimen does not contain metformin you should not take this medication any longer followup instructions provider clinic phone on at center provider m d phone date time provider m d phone date time please call dr at to set up an appointment within weeks md completed by,{}
65670,admission date discharge date date of birth sex f service medicine allergies sulfa sulfonamide antibiotics tetracycline penicillins attending chief complaint respiratory failure major surgical or invasive procedure none history of present illness this is an year old female with chronic diastolic heart failure chronic obstructive pulmonary disease chronic bilateral pleural effusions status post pleurex cathether placement in diabetes mellitus hypertension and anemia who precented from rehab with acute respiratory failure she had been at rehab after a prolonged admission chf and pleural effusions requiring pleurex catheter placement her effusions were transudative and thought to be due to her chf her medical regimen was optimized and she was sent to rehab at rehab she had been doing well except for a fall complicated by a left hip fracture and was awaiting orif at the time of her presentation here she had also received units prbcs for anemia during her stay and had her left sided pleurex catheter removed on after pleurodesis and reported talc therapy there was also report of a recent ct scan prior to admission noting a right pleural effusion with question of loculations on the morning of transfer she was noted to be tachypneic and in respiratory distress abg was she was put on bipap with improvement thoracentesis was attempted but fluid could not be removed so she was given lasix mg iv x and transferred to on arrival to the micu she was on a nrb and somnolent not arousable to stimuli bipap was initiated and cxr was performed she was started on vancomycin and aztreonam and ruled out for influenza she improved rapidly and was oxygenating normally on room air review of systems negative except per hpi past medical history chronic bilateral effusions thought secondary to chf were transudative during last admission s p pleurex catheter placement on l in congestive heart failure diastolic dysfunction copd anemia hypertension hypercholesterolemia type diabetes mellitus breast ca s p lumpectomy radiation in right cae pvd social history married lives with husband who has dementia until recently discharged to rehab after previous admission tobacco pack year quit years ago etoh none family history father died lung cancer age physical exam vs hr bp rr sat nc gen alert conversant in nad heent mmm op clear perrl anicteric sclera neck supple jvp to cm heart rrr sem at base no radiation lungs crackles to midlung r l abdomen soft nt nd bs no rebound or guarding ext warm well perfused no pitting edema dp pulses skin diffuse ecchymoses neuro moves all extremities follows commands pertinent results cxr bilateraly pulm infiltrates with small bilat pleural effusions and mild pulm edema effusions intervally improved since last study ekg nsr bpm nl axis and intervals good r wave progression no significant change from prior dated radiology ct chest w o contrast more loculated moderate bilateral pleural effusion slightly decreased in size on the right unchanged on the left with new dense opacities probably due to talc injection in the intervall diffuse septal thickening and ground glass opacity likely due to pulmonary edema enlarging mediastinal lymph nodes likely reactive patent left lower lobe bronchus with improved aeration of the left lower lobe but persistent peripheral opacities and atelectasis extensive coronary artery calcification mitral annulus and aortic annulus calcifications clips in the left breast and left axillary region likely due to prior breast cancer prior vertebroplasty small hiatal hernia radiology hip unilat min views fluoroscopic images show placement of a gamma nail and metallic plate transfixing previously described comminuted fracture of the inner trochanteric region with apparent separation of the lesser trochanter further information can be gathered from the operative report brief hospital course f with chf copd who sustained a hip fracture and pneumonia after pleuodesis pleurx placement for chronic pleural effusions now s p orif on delirium patient with delirium in setting of morphine use mild hypoxia and hosptialization for hip fracture currently improved after mimized narcotics antipsychotics as needed continued reorientation low dose quetiapine for sleep geriatrics followed pneumonia and hypoxia patient presented with acute hypoxia likely related to volume overload and pneumonia she lives in and thus is at risk for mrsa acute decompensation in the setting of leukocytosis and bilateral pulmonary infiltrate consistent with healthcare assoc pneumonia she was treated with vanc levofloxacin for day course to viral respiratory panel prelim result was negative a repeat ct showed effusions to be not increased in size from prior per ip consulatants likely will not benefit from thoracentesis o sat remained in s on room air but easily rose to low s on l of room air continued hypoxia presumed due to a degree of persistent heart failure exacerbation chronic diastolic heart failure she has diastolic heart failure with an ef of on she was volume overloaded on exam and x ray on transfer from the icu she responded well to two days of mg twice daily iv lasix diuresis was limited by renal function as hydralizine and afterload reduction has no demonstrated role in the treatment of diastolic heart failure and is difficult to take because of frequent dosing this medication was stopped she was started on an increased dose of metoprolol she will also be discharged on a slightly increased furosemide dose of mg po bid hip fracture she tolerated orif on very well with a plate and gamma nail placed she was anticoagulated with lovenox physical therapy evaluated she will be discharged to acute rehab for further pt ot she may weight bear as tolerated per orthopedics copd at baseline with abg evidence of chronic retention she was continued on bronchodilators and given oxygen with goal sat she was unable to get back down to room air during this admission so will be discharged on l o by nasal cannula expectation is she may be able to be advanced back to room air with further gently diuresis ckd she is at her baseline of medications were renally dosed and cr remained stable mediastinal lymphadenopathy she was noted to have mediastinal lymphadenopathy at her presentation that was considered most likely due to reactive lymphadenopathy secondary to her pneumonia this should be followed up with a repeat scan in months diabetes type she was continued on glargine and a humalog sliding scale htn she was continued on her metoprolol on isosorbide fen she received a regular heart healthy diet prophylaxis lovenox ppi bowel regimen access midline was discontinued piv code dnr dni discussed with family medications on admission lispro insulin sliding scale glargine units qpm bimatoprost drop qhs folic acid mg daily simvastatin mg hs zolpidem mg qhs protonix mg daily furosemide mg daily hydralazine mg tid metoprolol mg qid tylenol mg q prn percocet tab q prn lorazepam mg q prn keterolac mg q prn loperamide mg q prn risendronate mg qsaturday epo qmonday discharge medications insulin glargine unit ml solution sig fifteen units subcutaneous at bedtime insulin lispro unit ml cartridge sig subcutaneous as directed per sliding scale bimatoprost drops sig one ophthalmic at bedtime folic acid mg tablet sig one tablet po daily daily simvastatin mg tablet sig two tablet po daily daily pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours metoprolol succinate mg tablet sustained release hr sig two tablet sustained release hr po daily daily acetaminophen mg tablet sig two tablet po tid times a day risedronate mg tablet sig one tablet po once a week on saturday epoetin alfa unit ml solution sig one ml injection once a week on monday docusate sodium mg capsule sig one capsule po bid times a day senna mg tablet sig one tablet po bid times a day calcium citrate d mg unit tablet sig two tablet po twice a day quetiapine mg tablet sig tablet po qhs once a day at bedtime as needed for insomnia isosorbide mononitrate mg tablet sustained release hr sig one tablet sustained release hr po daily daily tramadol mg tablet sig tablet po bid times a day as needed for pain enoxaparin mg ml syringe sig one inj subcutaneous q h every hours lidocaine mg patch adhesive patch medicated sig one adhesive patch medicated topical daily daily hours on furosemide mg tablet sig tablets po twice a day please note patient s baseline regimen is mg po bid this increased dose is to achieve some increased diuresis please continue this dose until patient is able to be weaned to o sats of on room air then reduce patient back to mg po bid outpatient lab work please check bun cr na k cl hco twice a week while on increased furosemide dose mg po bid contact md with results discharge disposition extended care facility oak knowle discharge diagnosis delirium pneumonia acute on chronic diastolic heart failure left hip fracture copd chronic kidney disease diabetes type discharge condition stable discharge instructions you were admitted with a fracture and pneumonia we treated your pneumonia with antibiotics and did operative repair on your hip you developed delerium and shortness of breath during your hospital course which were treated by adjusting your medications please take your medications exactly as instructed to avoid future problems please visit your local emergency department or call your doctor if you have chest pain shortness of breath fevers chills acute worsening of your pain or any other dramatic changes in your health followup instructions provider md phone date time orthopedics np on at am appointment is at ortho clinic if need to reschedule or cancel call completed by,"{
""Diagnoses"": [""chronic diastolic heart failure"", ""chronic obstructive pulmonary disease"", ""chronic bilateral pleural effusions"", ""status post pleurex catheter placement"", ""diabetes mellitus"", ""hypertension"", ""anemia""],
""Medications"": [""units prbcs"", ""talc therapy""]
}"
20949,admission date discharge date date of birth sex m service history of present illness the patient is a year old male who is a welder from who was at work this morning when he had complaints of sudden severe headache and witnessed seizure with loss of consciousness he has a history of an assault which was a closed fist punch to the face a week prior to admission the patient was med flighted to the emergency department lethargic complaining of headache and nausea and vomited times two head ct reveals extensive subarachnoid hemorrhage right frontal intracranial hemorrhage and anterior communicating artery aneurysm the patient was started on nipride and given dilantin loads the patient neurologically was lethargic on admission with garbled speech he was able to state his name and year he thought he was at work he was arousable following commands inconsistently times four pupils are equal round and reactive to light mm and brisk no seizure activity noted cardiovascular sinus rhythm in the s with no ectopy hypertensive to s to s on nipride to keep his blood pressure less then lungs clear to auscultation he was on o at liter prongs with sats at to abdomen was soft bowel sounds present he had a foley to gravity running yellow urine he was afebrile his white count was hematocrit coags within normal limits the patient had an arteriogram and underwent coiling of the anterior communicating artery aneurysm without intraprocedure complication the patient was monitored in the surgical intensive care unit he also had a vent drain placed at the time of the coiling postoperatively he complained of out of headache his mental status waxed and waned he was awake but drowsy extraocular movements were full face was symmetric he had no drift he had good strength in his lower extremities out of the patient showed evidence of vasospasm with severe headache the patient was treated with hypertensive therapy and albumin with some relief of headache tcds consistent with vasospasm the patient had repeat head ct on which showed no changes the patient continued to have waxing and mental status and was awake and alert moving everything strongly with no drift on the vasospasm was somewhat relived by evidence shown on transcranial doppler the patient spiked a temperature to with foley cultured the patient was seen on the patient discontinued his own vent drain head ct showed no evidence of hydrocephalus although the patient did have a new vent drain placed on the patient was awake alert and oriented conversant smiling extraocular movements were full moving all extremities he continued on neosinephrine to keep his cvp to his icp was to cpp was to his white count was he continued to spike temperatures and despite being fully cultured on several occasions had no growth from blood cultures sputum urine or cerebral spinal fluid cultures the patient s temperature trended downward on cerebral spinal fluid culture that was sent on grew gram positive cocci in broth from one culture the patient was started on vancomycin and treated for a complete ten day course with repeat cultures negative the patient was scheduled for vp shunt placement but it was felt that the patient s mental status had improved and that he would not require a vp shunt he had an arteriogram done on which showed small amount of vasospasm the patient s temperature was he was awake alert and oriented times three iwth no complaints of headache pupils are equal round and reactive to light he had mild lateral gaze nystagmus with no drift and ip of out of bilaterally this was the patient was subarachnoid day at this point triple h therapy was discontinued and the patient was transferred to the regular floor on where his fluids were weaned off by and he was alert and oriented times three moving everything strongly with no drift neurologically improving he was followed by physical therapy and occupational therapy and found to require rehab prior to discharge to home discharge medications zantac mg po b i d dilantin mg po t i d heparin units subq q hours tylenol po q hours prn ultram mg po q hours discharge condition stable follow up the patient will follow up with dr in two to four weeks time m d dictated by medquist d t job,"{
""Diagnoses"": [""extensive subarachnoid hemorrhage"", ""right frontal intracranial hemorrhage"", ""anterior communicating artery aneurysm""],
""Medications"": [""nipride"", ""dilantin""]
}"
20962,admission date discharge date date of birth sex f service neonatology history of present illness baby girl i is a and week gestational age birth weight grams twin a born to a year old gravida i para mother by cesarean section secondary to breech presentation of twin a and transverse presentation of twin b mother had a history of spontaneous premature rupture of membranes at on with clear fluid accompanied by preterm labor mom did not receive any steroids she is gbs positive but did not receive intrapartum antibiotics due to her immediate delivery upon arrival at laboratory data positive antibody negative rubella immune rpr nonreactive hepatitis b negative gbs positive maternal history is significant for depression previously treated with prozac but not during pregnancy in the delivery room twin girl a was delivered via cesarean section with breech presentation she exhibited spontaneous cry and respirations blow by oxygen was applied for several minutes at which point she exhibited excellent perfusion and regular respirations the patient was transferred to the neonatal intensive care unit for further management physical examination birth weight grams vital signs temperature pulse respirations to blood pressure is general preterm female in radiant warmer in no apparent distress head eyes ears nose and throat afof op clear palate intact red reflex present bilaterally neck supple no crepitus respiratory clear to auscultation bilaterally clear air expansion no retractions on examination cardiac regular rate and rhythm s and s normal no murmur on examination abdomen soft nondistended normoactive bowel sounds no hepatosplenomegaly uvc in place extremities no cyanosis or edema well perfused femoral pulses brisk bilaterally spine intact no dimpling no ortalani or barlow sign present neurologic spontaneously moving all four extremities appropriate tone on examination suck moro grasp plantar reflex intact hospital course respiratory the patient remained on room air from her delivery throughout her hospital course with no problems she exhibited no signs of apnea or prematurity throughout her hospital course cardiovascular the patient remained cardiovascularly stable throughout her hospital course fluids electrolytes and nutrition the patient was placed on intravenous fluids of d w at cc per kg on day of life number one on day of life two she was started on enteral feeds of breast milk or special care she was advanced to full volume feeds on on her caloric intake was increased to kilocalories per ounce of breast milk at the time of discharge the patient was on feeds of breast milk kilocalories per ounce administered by gavage gastrointestinal the patient s initial bilirubin was peaked at received phototherapy briefly with the most recent bilirubin off phototherapy being on hematology the patient s initial cbc revealed a white count of hematocrit of platelet count of the differential on the white count was neutrophils lymphocytes enucleated red blood cells the patient was started on ampicillin and gentamicin which were discontinued at hours due to negative blood cultures neurology the patient remained neurologically stable with a normal examination throughout her hospital course sensory the patient did not receive a hearing screening prior to transfer ophthalmology the patient was not eligible for an opthalmologic examination prior to transfer condition on discharge stable discharge disposition transfer to level ii name of primary pediatrician unknown care recommendations feeds at discharge include breast milk kilocalories per ounce at cc per kg per day administered via p g medications ferrous sulfate cc p o very day car seat test car seat position test was not performed prior to transfer state newborn screen newborn screen sent immunizations none administered during this hospitalization discharge diagnoses prematurity and weeks gestational age twin respiratory distress resolved immature feeding rule out sepsis resolved reviewed by dictated by medquist d t revised job,"{
""Diagnoses"": [""history of present illness"", ""breech presentation"", ""transverse presentation"", ""preterm labor"", ""spontaneous premature rupture of membranes""],
""Medications"": [""prozac"", ""oxygen"", ""blow by oxygen""]
}"
28934,admission date discharge date date of birth sex f service surgery allergies penicillins attending chief complaint biliary stricture major surgical or invasive procedure right extended hemi hepatectomy ious redo roux en y hepaticoojejunostomy for cbd stricture central bile duct excision history of present illness this is a year old woman with a biliary stricture her story begins with a laparoscopic cholecystectomy performed in in this was complicated by a bile duct injury and she required an immediate operative repair in the setting of bile peritonitis a hepaticojejunostomy was performed due to a high bile duct injury i personally reviewed the operative note which was sent to me from the original surgeon from and realized that there was a single anastomosis created with silk sutures on the bile duct furthermore an omega limb drainage procedure was created rather than a roux en y recently the patient has presented with a right upper quadrant pain this was worked up and it was found that she had right sided ductal dilation this was pursued with a ptc cholangiogram at which time a stricture of the right ductal system was identified unfortunately this could not be balloon dilated brushings and biopsies were negative the cholangiogram was performed and no drainage was achieved subsequent to this she developed a full rip roaring cholangitis and it was in the setting of this that she was referred to me for further care we found her in good shape actually and treated her with antibiotics and continued the investigation of this biliary stricture situation also of very important interest here is the fact that her ca has been high starting at a month and a half ago and elevated up to within the last weeks i performed an mrcp as well as a cta at our institution to try and understand if malignancy was in play here i had a very real concern that this was the case her ct scan showed a general hypodensity of the whole right anterior right drainage system and there were enhancing features on the mri as well furthermore it was clear from the cta that there was no evidence of a right hepatic artery in play and i surmised that this was injured at the original operative endeavor years ago past medical history pmh biliary stricture asthma depression psh lap ccy in bile leak hepaticojejunosotmy also c section x social history lives with husband and daughter family history nad physical exam avss gen nad anicteric abd soft nontender and nondistended with positive bowel sounds she has no masses or hernias in her prior incision site which is well healed ext warm and well perfused 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 alt ast alkphos amylase totbili am blood lipase am blood albumin liver or gallbladder us single organ port am conclusion scans show mild dilatation of the central left hepatic duct and marked dilatation of all of the peripheral and central ducts in the anterior right lobe the trunks of the right and left bile ducts could not be joined together but were separated by cm of soft tissue near the anastomotic bowel loop this could represent neoplastic or fibroinflammatory tissue small intraductal stones were also noted on the right side color flow and pulse doppler assessment demonstrates what appears to be occlusion of the right hepatic artery with numerous collaterals in the right porta hepatis a small accessory left hepatic artery is also noted chest portable ap am impression retrocardiac airspace disease atelectasis versus developing pneumonia postoperative changes in the abdomen bilat lower ext veins port pm impression no evidence of bilateral dvt ct abdomen w contrast pm impression small fluid collection near the surgical bed in which an external drain is appropriately placed dilated small bowel loops up to cm suggestive of an ileus small bilateral pleural effusions right greater than left with associated atelectasis left adnexal lesion which likely represents a dermoid fibroid uterus am blood wbc rbc hgb hct mcv mch mchc rdw plt ct brief hospital course this is a year old female with biliary stricture who went to the or on for takedown of biliary drainage limb conversion of omega limb drainage to roux en y right extended hemihepatectomy intraoperative ultrasound biliary reconstruction consisting of hepaticojejunostomy to left ductal system pain she had an epidural for pain control she was followed by aps and the epidural was removed on pod she was started on a pca and once tolerating a diet she was switched to po meds cv she had post op tachycardia on she had lenis that were negative she received several fluid boluses for post op hypotension and had an appropriate hr and bp response gi abd she was npo with ivf and a ngt the ngt was removed on pod the jp was sent for culture on pod and showed gnrs it then grew out escherichia coli and enterococcus sp she was started on flagyl and already being treated with cefepime her abdomen was soft and nontender erythema was noted on the right side of the incision and staples were removed and the incision packed her wbc climbed to and a ct was ordered ct showed small fluid collection near the surgical bed in which an external drain is appropriately placed dilated small bowel loops up to cm suggestive of an ileus the drain was removed and dressing changes were continued wbc was on and ucx bcx and cxr orderded her cxr was negative for pneumonia she had ecoli in her urine cx and wound culture she was sent home on po antibiotics her wbc on was stable at she was afebrile she had occasional post op emesis we awaited return of bowel function we slowly increased her diet and she was tolerating regular diet at time of post op blood loss anemia on pod she received units prbcs for a hct of her inr was also elevated to and she received units of ffp her hct was stable at and inr recovered to post op uti e coli was found in her urine she was treated with cefepime she was discharged home to complete a course of augmentin to cover both the urine and the wound culture medications on admission tylenol percocet albuterol mdi discharge medications albuterol mcg actuation aerosol sig puffs inhalation q h every hours as needed for sob wheeze acetaminophen mg tablet sig tablets po q h every hours as needed for fever 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 docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills hydromorphone mg tablet sig tablets po q h every hours as needed disp tablet s refills augmentin mg tablet sig one tablet po twice a day for days disp tablet s refills discharge disposition home with service facility multicultural home care discharge diagnosis biliary stricture wound infection leukocytosis discharge condition good continue wound care discharge instructions please call your doctor or return to the er for any of the following you experience new or worsening abdominal pain 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 see blood or dark black material when you vomit or have a bowel movement 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 and take any new meds as ordered do not drive or operate heavy machinery while taking any narcotic pain medication you may have constipation when taking narcotic pain medications oxycodone percocet vicodin hydrocodone dilaudid etc you should continue drinking fluids you may take stool softeners and should eat foods that are high in fiber continue to increase activity daily no heavy lifting lbs until your follow up appointment followup instructions please follow up with dr in weeks call to schedule an appointment,"{
""Diagnoses"": [""Biliary stricture"", ""Right upper quadrant pain"", ""Ductal dilation"", ""Stricture of the right ductal system""],
""Medications"": [""Penicillins"", ""Omega limb drainage""]
}"
76845,admission date discharge date date of birth sex f service medicine allergies no allergies adrs on file attending chief complaint respiratory failure unresponsive major surgical or invasive procedure endotracheal intubation history of present illness pt initally listed as an eu critical is a f w ams etoh with no signs of trauma in the ed it was felt she was unable to protect her airway vomiting and so intubated she came to the micu on propofol for sedation she was found by her friend down talking to patient was identified as pt and friend were in a limo with other friends when she got to red game after drinking heavily amount unknown and then vomiting several times red wine vomit she then walked out of the limo at gate b at around pm at wich point she just dropped to the ground she as not seen seizing ems was called and she was taken to emergency department ed course labs imaging interventions consults diagnosis ams alcohol intoxication intubated initial vitals trigger unresponsive urine benzos barbs opiates cocaine amphet mthdne negative ua negative ph pco po hco post intubation ph pco po hco lactate pt ptt inr wbc hgb hct plt head ct negative ekg sinus tachycardia on arrival to the micu patient s vs hr bp rr on cmv with tv cc rr peep fio past medical history depression unconfirmed social history student at cc etoh use unable to obtain further substance use hx family history unknown physical exam admission exam general intubated mildly responsive especially to a paging beeper heent sclera anicteric neck supple jvp not elevated no lad cv tachycardic normal s s no murmurs rubs gallops lungs clear to auscultation bilaterally no wheezes rales ronchi abdomen soft non distended bowel sounds present no organomegaly no tenderness to palpation no rebound or guarding gu no foley ext warm well perfused pulses no clubbing cyanosis or edema neuro moving all extremities spontaneously discharge exam general awake alert oriented conversng appropriately extubated heent sclera anicteric neck supple jvp not elevated no lad cv tachycardic normal s s no murmurs rubs gallops lungs clear to auscultation bilaterally no wheezes rales ronchi abdomen soft non distended bowel sounds present no organomegaly no tenderness to palpation no rebound or guarding gu no foley ext warm well perfused pulses no clubbing cyanosis or edema neuro moving all extremities spontaneously pertinent results pm type art rates tidal vol peep o po pco ph total co base xs aado req o assist con intubated intubated pm lactate pm o sat pm urine hours random pm urine ucg negative pm urine color straw appear clear sp pm urine color straw appear clear sp pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg pm type art po pco ph total co base xs comments green top pm glucose lactate na k cl pm freeca pm urea n creat pm estgfr using this pm lipase pm asa neg ethanol acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm pt ptt inr pt pm fibrinoge ct head no acute intracranial process cxr et and ng tubes positioned appropriately diffuse mild ground glass opacity within the lungs possibly indicative of pulmonary edema brief hospital course year old woman with unknown past medical history found down by friend was not protecting airway in the was intubated unresponsiveness etoh intoxication pt did not have any evidence of infectious process ct head was unremarkable she did not have any other toxidromes and serum tox was only for etoh pt was weaned off of propofol in icu and extubated without complication she was monitored overnight and her mental status improved she tolerated a normal diet had negative orthostatics and was able to ambulate normally at time of discharge issues and dangers of acute alcohol intoxication were discussed with the patient prior to discharge at time of discharge a friend drove her home medications on admission none discharge medications acetaminophen extra strength mg tablet sig two tablet po every eight hours as needed for headache ibuprofen mg tablet sig tablets po q h every hours as needed for headache discharge disposition home discharge diagnosis primary ethanol intoxication discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions ms it has been a pleasure taking care of you here at you were admitted to the hospital because you were very sedated you were found to have a high alcohol level a breathing tube was used briefly to protect your airway because you were so sleepy when you were more awake the breathing tube was removed we encourage you to abstain from alcohol in the future and to stay well hydrated at home we made the following changes to your medications you may take acetamnophen tylenol g extra strength three times a day as needed for headache you can use ibuprofen advil or motrin mg tablets every hours in between as needed please continue all other medications as previosuly prescribed followup instructions please follow up with your primary care doctor or student health clinic in the next weeks md,"{
""Diagnoses"": [""Alcohol intoxication"", ""Intubated""],
""Medications"": [""Propofol"", ""Etomidate""]
}"
85176,admission date discharge date date of birth sex m service surgery allergies no known allergies adverse drug reactions attending chief complaint s p trauma fall major surgical or invasive procedure none history of present illness year old male who complains of flail chest trauma transfer s p fall year old male and status post mechanical feet off a ladder onto concrete onto his back he had no head trauma or loss of consciousness he does complain of severe her right posterior back pain and was found to have a flail chest posteriorly with rib fractures diffuse on the back and a small pneumothorax by ct scan by report there were no other injuries he denies any chest pain belly pain vomiting diarrhea he did have some transient numbness and tingling of his fingers that has since resolved denies any weakness or neck pain past medical history pmh hypertension hyperlipidemia sleep apnea social history no tobacco etoh or drugs patient is a monk from lives in a monastery and is visiting this area emergency contact is sister in ny family history non contributory physical exam hr bp over palp resp o sat low constitutional uncomfortable heent normocephalic atraumatic pupils equal round and reactive to light extraocular muscles intact chest clear to auscultation bony crepitus right t t cardiovascular normal first and second heart sounds regular rate and rhythm abdominal soft nontender nondistended masses negative extr back no cyanosis clubbing or edema skin no rash warm and dry neuro speech fluent strength out of in upper and lower extremities pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood hct 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 am blood plt ct 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 calcium phos mg am blood calcium phos mg pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg cat scan pelvis impression consistent with the given history and apparent verbal report from outside hospital there is a flail chest segment involving the posterior and lateral aspects of the right sixth through ninth ribs ribs five ten and eleven on the right are also fractured in a single place each as above there is a small hemopneumothorax as detailed above no signs of tension at this time there is likely associated pulmonary contusion the aorta is intact without apparent injury cat scan of c spine impression no evidence of acute fracture or subluxation multiple degenerative changes with no evidence of cord compression as detailed above within the findings x ray of the pelvis impression within the limitations above no metallic radiopaque foreign body is seen though the bladder is opacified with contrast limiting assessment mr cervical spine multilevel grade spondylolisthesis is likely degenerative there is no evidence of ligamentous disruption or edema multilevel spondylosis and facet arthropathy resulting in narrowing of multiple neural foramina as detailed above chest x ray findings in comparison with the study of several of the previous fractures are again noted on the right there is a developing moderate right pneumothorax mild atelectatic changes are seen at the bases chest x ray findings as compared to the previous radiograph the appearance of displaced right rib fractures is unchanged also unchanged is the presence of a small pleural effusion and focal parenchymal opacity at the level of the changes the small apical right pneumothorax is of unchanged millimetric dimensions and has not increased unchanged right basal and left retrocardiac atelectasis presence of a small left pleural effusion cannot be excluded unchanged borderline size of the cardiac silhouette without evidence of pulmonary edema brief hospital course was evaluated by the trauma team in the emergency room and his scans were reviewed he was admitted to the trauma icu for pain control in light of his multiple rib fractures as well as pulmonary toilet the pain service was consulted for placement of an epidural catheter for pain control however the patient s pain was adequately controlled with prn dilaudid and he was able to cough deep breath and use his incentive spirometer effectively he complained of bilateral hand paresthesias following his fall and his c spine was negative the ortho spine service was consulted and recommended an mri of the c spine which ruled out ligamentous injury and noted grade spondylolisthesis likely degenerative his hand paresthesias gradually resolved following transfer to the surgical floor he continued to make good progress he remained free of any pulmonary complications was up and walking independently and tolerating a regular diet his vital signs are stable and he is afebrile his foley catheter has been removed and he is voiding without difficulty he is maintaining his oxygen saturation at on room air he has demostrated good saturations with ambulation as well he will be discharged to a rehab facility largely due to social concerns his pain medication regimen has provided adequate pain control medications on admission statin atenolol mg discharge medications docusate sodium mg ml liquid sig one po bid times a day tramadol mg tablet sig tablet po q h every hours disp tablet s refills acetaminophen mg tablet sig two tablet po q h every hours oxycodone mg tablet sig tablet po q h every hours as needed for pain disp tablet s refills atenolol mg tablet sig one tablet po daily daily simvastatin mg tablet sig one tablet po daily daily albuterol sulfate mg ml solution for nebulization sig one inh inhalation q h every hours as needed for sob wheeze ipratropium bromide solution sig one neb inhalation q h every hours discharge disposition extended care facility nursing and rehab discharge diagnosis s p fall right rib fractures right pneumothorax bilateral pleural effusions discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent assistance when getting out of bed discharge instructions you were admitted to the hospital after falling feet and breaking your ribs your injury caused right rib fractures thru which can cause severe pain and subsequently cause you to take shallow breaths because of the pain you should take your pain medication as directed to stay ahead of the pain otherwise you won t be able to take deep breaths if the pain medication is too sedating take half the dose and notify your physician pneumonia is a complication of rib fractures in order to decrease your risk you must use your incentive spirometer times every hour while awake this will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs you will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing symptomatic relief with ice packs or heating pads for short periods may ease the pain narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible do not smoke if your doctor allows non steroidal antiinflammatory drugs are very effective in controlling pain ie ibuprofen motrin advil aleve naprosyn but they have their own set of side effects so make sure your doctor approves return to the emergency room right away for any acute shortness of breath increased pain or crackling sensation around your ribs crepitus followup instructions call the acute care clinic at for a follow up appointment in weeks call dr for a follow up appointment in weeks completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex m service surgery allergies no known allergies adverse drug reactions attending addendum please include the following medication to the medication list heparin units subcutaneous three times daily discharge disposition extended care facility nursing and rehab md completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex m service surgery allergies no known allergies adverse drug reactions attending addendum please change ultram mg tab sig mg po every hours as needed for pain discharge disposition extended care facility nursing and rehab md completed by,"{
""Diagnoses"": [""Flail chest"", ""Posterior rib fractures"", ""Pneumothorax""],
""Medications"": [""None""]
}"
60919,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 gi bleed major surgical or invasive procedure intubation on central venous line placement on bronchoscopy on history of present illness mr is a year old man with a history of alcoholism cirrhosis hepatitis c and multiple ed admissions for intoxication and falls who is transferred from hospital for further management of acute gi bleed and evaluation for tips he was admitted to hospital on from jail after being arrested for public intoxication and developing hematemesis and falling in jail on presentation to their ed his initial vs were hr with a hct of he had an episode of coffee ground emesis and an ngt was placed with aspiration of cc dark red blood and coffee grounds he also underwent an abdominal ct that demonstrated cirrhosis with severe esophageal varices extending to the portal vein and a head ct that was negative his cxr was read as question lll consolidation vs atelectasis and he was started on octreotide and a ppi drip and admitted to the micu for further management he underwent egd on with grade i esophogeal varices but no active bleeding though there were stigmata of recent bleeding six bands were placed he then was noted to be acutely sedated in the setting of receving diazepam for withdrawal and underwent head ct that afternoon which was again read as negative however afterward he had recurrent hematemesis he was intubated and lost approximately cc of blood he underwent emergent egd at this point which was complicated by episodes of hypoxia however blood was found in the entire esophagus and no clear site of bleeding was noted though bands appeared to have come loose he had a witnessed aspiration event and was started on imipenem emperically for aspiration pna and variceal bleeding he did receive ciprofloxacin on total transfusions were u prbc and u ffp with and mg iv sc vitamin k because of continued bleeding and need for a possible or tips procedure he was transferred to on arrival he was hemodynamically stable and scoped emergently by gi with demonstration of no active bleeding last abg prior to transfer was on cmv rate peep vt fio review of sytems per hpi denies fever chills night sweats recent weight loss or 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 alcoholism cirrhosis s p egd on without varices acute febrile mucocutaneous lymph node syndrome seizure disorder subgaleal bleed s p head trauma mrsa positive social history currently homeless history of alcoholism tobacco use denies illicit drug use lives at family history non contributory physical exam vitals t bp p r o intubated general intubated responds to noxious stimuli heent ett in place sclera icteric mmm oropharynx clear neck supple jvp not elevated no lad lungs scattered rhonchi cv regular rate and rhythm normal s s sm abdomen soft non distended gu foley in place ext warm well perfused pulses no clubbing cyanosis or edema 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 plt smr low plt ct pm blood glucose urean creat na k cl hco angap pm blood alt ast ld ldh alkphos totbili dirbili indbili pm blood albumin calcium phos mg pm blood hcv ab positive pm blood type art po pco ph caltco base xs pm blood glucose lactate na k cl calhco pm blood hgb calchct pm blood freeca pertinent labs studies images cxr ett at level of clavicles cm above carina bilateral perihilar opacities retrocardiac opacity egd esophagus protruding lesions cords of grade ii varices were seen starting at cm from the incisors in the gastroesophageal junction and lower third of the esophagus the varices were not bleeding other bands at cm and bands at cm no bleeding stomach mucosa diffuse continuous erythema congestion nodularity and petechiae of the mucosa were noted in the whole stomach these findings are compatible with extensive portal hypertensive gastropathy duodenum normal duodenum other findings no blood in stomach or duodenum impression varices at the gastroesophageal junction and lower third of the esophagus bands at cm and bands at cm no bleeding erythema congestion nodularity and petechiae in the whole stomach compatible with portal hypertensive gastropathy no blood in stomach or duodenum otherwise normal egd to second part of the duodenum ekg nsr nl axis nl intervals mm q wave in iii no acute st t wave changes no priors brief hospital course year old man with history of hiv hepatitis and cirrhosis who is transferred from hospital for management of upper gi bleed gi bleed egd showed bleeding varices and he underwent banding at hospital he received u prbcs and u ffp at osh prior to arrival at he received two more prbc and more ffp transfusion he was placed on octreotide and pantoprazole ggt subsequently his hct remained stable during this admission despite having guaiac positive stools on he again was noted to have melanotic stools and ngt suction demonstrated gastric blood he had another egd performed on which again demonstrated varices in the lower of the esophagus two of which were banded he was again placed on iv ppi and sucralfate and he did not have any further episodes of bleeding respiratory failure initially he was intubated for hypoxia and airway protection in the setting of ugib and possible aspiration cxr was concerning for aspiration pneumonia he was empirically treated with vancomycin and piptazo for day course last dose please follow vanc levels and dose to keep levels between current dose of mg his extubation was delayed by sedation but as this improved the patient was extubated successfully his post extubation respiratory status remained stable although there was concern for a rul lesion on cxr this remained unchanged on repeat evaluations while the patient defevresced and his white count remained stable at this rul lesion was attributed to accumulating secretions we recommend a ct chest be performed within the next week if the patient tolerates to eval for any change altered mental status on intial presentation he was noted to be sedated which was attributed to diazepam that he received at osh his sedation slowly improved with minimizing sedative medication use and he was able to respond to questions and commands on discharge another contributor to his ams was hepatic encephalopathty which was treated with lactulose and rifaximin also he was noted to have seizures see below and therefore his ams was likely affected by post ictal confusion his seizures were treated as noted below once his sedation improved he was noted to be agitated restless and this was treated with seroquel and prn haldol seizures mri with evidence of hypoxic encephalopathy and eeg with occipital focus for seizures he was treated with keppra phenytoin and ativan he will need follow up of phenytoin levels to keep in therapeutic range free phenytoin specifically dilantin levels and albumin should be checked twice per week and keppra can be increased to mg once his renal function improves cirrhosis alcohol and hepatitis c are most likely etiology his encephalopathy was treated with lactulose and rifaxamin ffp was given to correct his inr on discharge alcoholism no evidence of whithdrawl on discharge he was given folate and thiamine medications on admission home medications none medications on transfer albuterol inhaler puffs qid chlorhexidine folic acid mg iv daily imipenem cilastin mg iv q h mvi ml iv daily pantoprazole mg iv q h thiamine mg iv daily lorazepam mg iv q h prn octreotide gtt ondansetron mg iv q h prn discharge medications folic acid mg tablet sig one tablet po daily daily rifaximin mg tablet sig two tablet po tid times a day albuterol sulfate mg ml solution for nebulization sig one inhalation q h every hours as needed for shortness of breath or wheezing lactulose gram ml syrup sig thirty ml po q h every hours as needed for bm acetaminophen mg tablet sig one tablet po q h every hours as needed for fever phenytoin mg tablet chewable sig two tablet chewable po tid times a day levetiracetam mg ml solution sig seven y ml po bid times a day quetiapine mg tablet sig one tablet po bid times a day haloperidol mg tablet sig one tablet po bid times a day as needed for agitation ondansetron hcl pf mg ml solution sig one injection q h every hours as needed for nausea lorazepam mg ml syringe sig one injection q h every hours as needed for seizure like activity piperacillin tazobactam gram recon soln sig one recon soln intravenous q h every hours finish course on sucralfate gram tablet sig one tablet po qid times a day thiamine hcl mg tablet sig one tablet po daily daily hydrochlorothiazide mg capsule sig one capsule po daily daily trazodone mg tablet sig tablet po hs at bedtime as needed for insomnia pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours vancomycin mg recon soln sig seven y mg intravenous q h every hours discharge disposition extended care facility discharge diagnosis aspiration pneumonia upper gastrointestinal bleeding seizure hypoxic brain injury hemoptysis respiratory failure status post intubation acute renal failure discharge condition vs lt stable melena and hemoptysis discharge instructions you were admited to with gastrointestinal bleeding you were found to have bleeding from varices swollen vessels in your stomach you were intubated breathing tube for a brief period of time to protect your airway you were found to have seizures and were started on new anti seizure medications including keppra dilantin and ativan you were noted to have an infection in your lung and are being treated with antibiotics including vancomycin and zosyn you are being discharged to the intensive care unit of rehab facility please call your regular doctor or return to the ed if you have chest pain shortness of breath bleeding from anywhere or any other concern followup instructions please follow up with your regular a when completing rehab course completed by,"{
""Diagnoses"": [""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 gi bleed"", ""major surgical or invasive procedure"", ""intubation on central venous line placement on bronchoscopy"", ""history of present illness"", ""mr is a year old man with a history of alcoholism"", ""cirrhosis"", ""hepatitis c"", ""multiple ed admissions for intoxication and falls""],
""Medications"": [""octreotide"", ""ppi drip"", ""egd""]
}"
29008,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint s p motor vehicle crash major surgical or invasive procedure exploratory lap and repair of diaphragmatic injury washout and debridement of left open tibia fracture to bone closed reduction left supracondylar femur fracture with manipulation closed reduction left proximal tibia fracture with manipulation application multiplanar external fixator im nail left femur and closed reduction right wrist fracture with manipulation history of present illness year old male restrained driver who was involved in a motor vehicle crash he was speaking in the field was brought to an area hospital and ultimately intubated electively he was found to have a tension pneumothorax initially treated by needle decompression followed by placement of a left chest tube a chest x ray suggested the presence of the stomach within the left chest supporting the diagnosis of a traumatic diaphragmatic eventration he was hemodynamically stable he was also noted to have a comminuted closed femur fracture with intact distal pulses he was transferred emergently to for further care given his injuries past medical history none social history graduate student at suffock patient graduated from he is a talented musician family history noncontributory physical exam vitals t f tm f bp hr rr sat ra general well appearing no acute distress heent mild anisocoria mucus membranes moist no sinus tenderness neck supple trachea midline card tachycardic normal s s no m r g resp clear to auscultation bilaterally abd soft non distended mildly tender to palpation over surgical scar no rebound guarding normal bowel sounds ext lle in brace rle leg wrapped right forearm in cast lue wrapped non pitting edema of ue le neuro difficult to perform exam able to move all extremities alert and oriented x fluent speech that psych denies si hi endorses occasional visual and auditory hallucinations no command auditory hallucinations pertinent results ct head w o contrast impression no acute intracranial hemorrhage ct torso with intravenous contrast impression stomach and spleen located within the thoracic cavity very concerning for extensive left diaphragmatic rupture with retraction left lower lobe collapse consolidation patchy opacities predominantly at the right lung base in the setting of trauma likely represent parenchymal contusions aspiration is another diagnostic consideration small amount of intraperitoneal air an unusual finding in a setting of blunt trauma and free fluid likely related to chest tube placement traversing the peritoneal space while no bowel injury is seen this cannot be completely excluded comparison with any ct done prior to the chest tube placement would be most helpful if available left elbow film impression extensively comminuted intra articular left olecranon fracture left leg film impression extensively comminuted fractures of the distal femur and proximal tibia with displaced and angulated fractures of the proximal femur and fibula brain mri impression normal study lenis impression no ultrasonographic evidence of dvt echo impression normal study normal biventricular cavity sizes with preserved global and regional biventricular systolic function no pericardial effusion resting tachycardia wbc rbc hgb hct plt ct glucose urean creat na k cl hco alt ast ld ldh alkphos totbili am blood albumin calcium phos mg brief hospital course in summary mr is a year old male admitted following motor vehicle accident for multiple fractures and diaphragmatic rupture hospital course was complicated by delerium peristent tachycardia and transaminitis s p mva patient was admitted to the trauma service and taken directly to the operating room for exploratory lap and repair of his diaphragmatic injury orthopedics was consulted given his multiple bone fractures he was taken to the operating room for washout and debridement of left open tibia fracture to bone closed reduction left supracondylar femur fracture with manipulation closed reduction left proximal tibia fracture with manipulation application multiplanar external fixator im nail left femur and closed reduction right wrist fracture with manipulation there were no intraoperative complications pain patient had difficulty with pain control initially pca dilaudid was initiated and the dose was quickly increased to mg dilaudid mg iv prn for rescue pain was also added and he did seem to benefit from this it was discussed with patient and his mother that at some point long acting narcotics would likely be initiated for long term pain control he was placed on an aggressive bowel regimen however patient developed delerium in setting of opioid use so opioids were discontinued and patient was started on ultram tylenol is being avoided due to elevated lfts nsaids are being avoided due to impaired bone healing opioids are being avoided due to recent delerium pain was adequately controlled at time of discharge on standing ultram delerium patient developed delerium during hospitalization it was felt to be due to opioid pain medications which were stopped patient was evaluated by neurology and psychiatry vit b folate tsh rpr within normal limits lp performed showed no evidence of infection eeg and brain mri were normal he was placed on standing seroquel at night opioids were avoided delerium resolved and patient was alert and oriented on day of discharged elevated transaminases likely multifactorial etiology including systemic inflammatory response medications including zosyn lfts continue to trend down alt peaked at on ast peaked at on ldh peaked at on alk phos continued to trend up on discharge likely secondary to active bone remodeling acetaminophen was discontinued on please check lfts weekly until fully resolved thrombocytosis patient had elevated platelet count to million likely reactive thrombocytosis due to systemic inflammatory state due to trauma and multiple operations platelets were trending down and were million at time of discharge tachycardia patient had sinus tachycardia post operatively to the s that was thought to be pain and stress related a pe ct was done and was negative for pe metoprolol was started to prevent tachycardia induced cardiomyopathy an echo was done and was normal metoprolol is being titrated down beginning on goal is to stop metoprolol as hr improves overall tachycardia is improving insomnia patient reported difficulty sleeping due to discomfort multiple braces casts in place etc he was getting standing seroquel at night with minimal improvement benzodiazepines and ambien were avoided due to delerium he was given prn benadryl and standing seroquel seroquel should ultimately be stopped but patient is currently using it for insomina prophylaxis patient was maintained on lovenox daily s p prophylactic ivc filter placement communication patient and mother medications on admission none discharge medications docusate sodium mg capsule sig one capsule po bid times a day enoxaparin mg ml syringe sig one subcutaneous qd miconazole nitrate powder sig one appl topical qid times a day as needed pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours quetiapine mg tablet sig two tablet po hs at bedtime diphenhydramine hcl mg capsule sig one capsule po q h every hours as needed for itching hexavitamin tablet sig one cap po daily daily tramadol mg tablet sig two tablet po q h every hours as needed for pain metoprolol tartrate mg tablet sig tablet po q h every hours discharge disposition extended care facility medical center discharge diagnosis primary diagnosis s p motor vehicle crash right pulmonary contusion left diaphragmatic rupture left olecranon fracture left femoral shaft fracture left supracondylar femur fracture left proximal tibia fracture left distal radius fracture delirium resolved discharge condition good patient is tolerating oral intake with assistance and able to work effectively with physical therapy discharge instructions you were admitted to the hospital after your car accident you were found to have broken many bones and to have ruptured your diaphragm you were treated in surgery for your bone fractures and your diaphragm rupture and have done well after surgery you also became quite confused after your surgery which was thought most likely secondary to your strong pain medications after your narcotic pain medications were stopped your confusion improved greatly please take all your medications as prescribed we have started you on ultram as needed for pain if you have any symptoms of fevers chills night sweats shortness of breath chest pain lower extremity swelling upper extremity swelling lightheadedness or dizziness please seek immediate medical attention followup instructions please follow up with your primary care doctor dr his address office is the medical group inc please call him at to schedule an appointment follow up with dr orthopedics thursday pm call if you need to re schedule your appointment please arrive minutes early the office is located on the of clinical center on the of follow up with dr trauma surgery in at am his office is located on the of the clinical center on the of please call if you need to re schedule md,"{
""Diagnoses"": [""traumatic diaphragmatic eventration"", ""tension pneumothorax"", ""comminuted closed femur fracture""],
""Medications"": [""medicine"", ""electively"", ""needle decompression"", ""placing a left chest tube"", ""emergency transfer""]
}"
78063,admission date discharge date date of birth sex f service surgery allergies no known allergies adverse drug reactions attending chief complaint neck and back pain major surgical or invasive procedure none history of present illness f unbelted driver of rollover mvc at high speed extricated by ems c o low back pain luq flank pain no head or neck pain transfer from with ct head neck torso showing fracture of left occipital condyle inferiormedially at c articulation grade iii splenic lac left rib fractures small left pneumothorax t spinous process fractures l left transverse process fractures past medical history none social history smokes ppd no etoh or drugs family history non contributory physical exam hr bp over p resp o sat normal constitutional uncomfortable on backboard and c spine precautions heent normocephalic atraumatic pupils equal round and reactive to light extraocular muscles intact oropharynx within normal limits chest clear to auscultation cardiovascular regular rate and rhythm normal first and second heart sounds abdominal soft moderate tenderness to palpation left side of abdomen with guarding abrasion to left no flank gu flank no costovertebral angle tenderness extr back no cyanosis clubbing or edema skin no rash neuro speech fluent moves all extremities pertinent results pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm urea n creat pm glucose lactate na k cl tco pm pt ptt inr pt pm hgb calchct ct abd pelvis splenic laceration grade with associated subcapsular hematoma no evidence of active extravasation on the current study though evaluation is limited by phase of contrast timing this is stable compared to study performed earlier the same day hemoperitoneum with small to moderate hyperdense fluid seen in the pelvis this is also unchanged from prior study whether the reflects extension of perisplenic process or a second pelvis injury cannot be definitively determined right colonic wall thickening and adjacent stranding which may reflect bowel or mesenteric injury small left anterior pneumothorax posterior pulmonary contusions and multiple left sided rib fractures likely nondisplaced left l transverse process fracture left shoulder no evidence of fracture or dislocation mri c spine seen on the thin section axial images of the occipital atlantal articulation a thin rim of elevated t signal along the lateral aspect of the left occipital condyle which converges to the area of the left jugular foramen it is quite possible that this finding simply represents a norml venous channel as opposed to edema from recent trauma there is as seen on the stir images as well as the sagittal t weighted scans slightly elevated t signal within the c disc relative to other cervical discs but without apparent disruption of contiguous structures thus the pathological significance of this finding regarding recent trauma is dubious the spinal cord signal pattern foramen magnum and its contents are otherwise within normal limits brief hospital course ms was evaluated by the trauma service in the emergency room and admitted to the hospital for further management of her multiple injuries post mvc she required serial hematocrits to assess the severity of her splenic laceration and she remained npo in case surgery was necessary her hematocrit dropped to from on admission but then stabilized out in the range for hours she was hydrated with iv fluids during that period but eventually was placed on a regular diet and she tolerated it well she was seen by the ortho spine service to evaluate her c fracture and an mri of the c spine was done which showed some increased signal in the ligaments and c joint therefore she will remain in a hard cervicle collar for weeks her other fractures are transverse process fractures in the thoracic spine and are stable requiring no treatment or restrictions she was able to effectively use her incentive spirometer and maintain adequate saturations with minimal pain dilaudid was effective for pain and she was up and ambulating with her hard collar on without difficulty she was discharged to home on and will follow up in the clinic in weeks medications on admission none discharge medications cyclobenzaprine mg tablet sig one tablet po tid times a day as needed for back spasm disp tablet s refills docusate sodium mg capsule sig one capsule po bid times a day as needed for constipation hydromorphone mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills discharge disposition home discharge diagnosis s p mvc c fracture small left pneumothorax grade splenic laceration left sided rib fracures t l transverse process fractures discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires requires a hard cervical collar for weeks discharge instructions you were admitted to the hospital after your accident with multiple injuries including spinal fractures rib fractures a laceration on your spleen and a small collapse of the left lung possibly from a rib puncture your blood count has been checked frequently to make sure there is no active bleeding and at this time it has been stable for hours your cervical spine fracture is non operative but you will need to wear a hard collar for weeks the fractures in the thoracic spine do not require any surgery or brace and will heal on their own your injury caused left sided rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain you should take your pain medication as directed to stay ahead of the pain otherwise you won t be able to take deep breaths if the pain medication is too sedating take half the dose and notify your physician pneumonia is a complication of rib fractures in order to decrease your risk you must use your incentive spirometer times every hour while awake this will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs you will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing symptomatic relief with ice packs or heating pads for short periods may ease the pain narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible do not smoke if your doctor allows non steroidal antiinflammatory drugs are very effective in controlling pain ie ibuprofen motrin advil aleve naprosyn but they have their own set of side effects so make sure your doctor approves return to the emergency room right away for any acute shortness of breath increased pain or crackling sensation around your ribs crepitus followup instructions call the acute care clinic at for a follow up appointment in weeks call dr from ortho sapine at for a follow up appointment in weeks completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex f service surgery allergies no known allergies adverse drug reactions attending addendum ms was also evaluated by the occupational therapy servic due to her high speed accident and question of loss of consisciousness she does have some difficulty with memory and should be folowed by dr as an out patient in month she was given the appropriate information to make an appointment discharge disposition home md completed by,{}
58771,admission date discharge date date of birth sex m service neurology allergies no known allergies adverse drug reactions attending chief complaint unresponsiveness major surgical or invasive procedure intubation history of present illness mr is an unfortunate year old man who presents as a transfer from an outside hospital for unresponsiveness this is a very limited history that was obtained through his health care proxy his nephew he states that this morning mr was awake at am took a shower and at breakfast around am at that time he went back to take a nap his wife called him at am that he would not wake up for her he told her to let him sleep she called at pm and pm again that he wouldn t wake up they thought he had overheated and placed the air conditioning at pm he was not responsive and they notified ems who took him to an outside hospital where he was transferred to for further evaluation ros unable to be performed past medical history diabetes htn social history former smoker and drinker but none presently family history noncontributary physical exam vitals t p r bp sao general awake cooperative nad heent nc at no scleral icterus noted mmm no lesions noted in oropharynx neck supple pulmonary lungs cta bilaterally without r r w cardiac rrr nl s s no m r g noted abdomen soft nt nd no masses or organomegaly noted extremities warm and well perfused skin no rashes or lesions noted neurologic mental status does not open eyes cranial nerves pupils mm and nonreactive no dolls no corneals gag motor sensory decreased tone throughout flicker withdrawal on the right upper extremity at the bicep otherwise no withdrawal or posturing to noxious ugpoing toes bilaterally physical exam at time of death am gen lying in bed not moving heent mouth open pupils fixed and non reactive cv no heart beat ausculated or palpated pulm no breaths auscultated or palpated ext cold and not moving pertinent results admission labs pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood pt ptt inr pt pm blood fibrino pm blood urean creat am blood alt ast ld ldh ck cpk alkphos totbili pm blood lipase am blood ck mb ctropnt am blood albumin calcium phos mg labs at the time of expiration no labs were done on the day of pt s death as he was already cmo reports cxr impression nasogastric and endotracheal tubes in standard positions opacity in the left lung base which could reflect infection atelectasis or aspiration small left pleural effusion right basilar atelectasis ct cta ct head edema and loss of grey white matter differentiation in bl aca and right mca distribution suggestive of infarction cta reconds pending bl ica are occluded originating from the cervical segment just distal to bifrication vertibral arteries are diminutive right mca is occluded left mca is patent likely filled from posterior circulation there is apparent wall thickening of the aortic arch and great vessels suggestive of arteritis brief hospital course mr is an unfortunate year old man who presented as a transfer from an outside hospital for unresponsiveness his exam demonstrated nonresponsive to even noxious nonreactive pupils at mm gag and a flicker of withdrawal to noxious in the right bicep his ct demonstrated vessel wall thickening of all major vessels with bilateral clotted off icas and right vert but his left mca appeared to be getting collateral filling there are hypodensities and loss of white differentiation in the right aca mca pca territory and the left aca territory given his poor prognosis he was made cmo by his family on and terminally extubated he passed away on at am his hcp was contact via voicemail and then his daughter was reached and verbally notified via telephone medications on admission lasix mg daily crestor mg daily metformin mg tricor mg daily metoprolol er mg daily vitamin d daily vites discharge medications n a discharge disposition expired discharge diagnosis deceased discharge condition deceased discharge instructions n a followup instructions n a md,"{
""Diagnoses"": [""Unresponsiveness""],
""Medications"": []
}"
73654,admission date discharge date date of birth sex f service medicine allergies sulfamethoxazole penicillins attending chief complaint epiglottitis major surgical or invasive procedure scope with ent history of present illness ms is a year old female with no significant past medical history who initially started having uri symptoms including a sore throat about one week ago she initially thought that this was related to allergies and her symptoms started to improve however over the weekend her symptoms worsened on sunday her throat pain worsened she had subjective fever and chills she was only able to take in fluids and at that time she called her pcp started her on azithromycin over the phone overnight sunday she was unable to sleep because she felt like she was drowning because she was having difficulty tolerating her own secretions she also had increased pain with moving her head this morning she was unable to swallow her azithromycin or any fluids so she presented to the er for further evaluation on arrival to the er she was noted to have swelling of her left submandibular glands on exam and had difficulty opening her mouth she underwent a ct of her neck that showed supraglottitis and epiglottitis so she was given solumedrol hydrocortisone levofloxacin and ceftriaxone she was then transferred to for further management in the ed initial vs were on ra she was seen by ent in the er and underwent an ent evaluation which showed mild watery edema of the epiglottis and the left supraglottis ae fold on the left is obscured without clear view into the pyriform left cord obscured by local edema but appears that vocal cords are b l mobile airway is patient and there is a clear view into the trachea there is pooling of secretions l r and valecula is obscured she was given dexamethasone mg and clindamycin mg and admitted to the icu for observation vs prior to transfer were on ra on the floor initial vs were and on lnc she is currently complaining of pain with swallowing and no desire to try to eat anything she would also like to be able to go home tomorrow she says that her children have received all of their immunizations and she received all of her childhood immunizations as well and believes that she is up to date on her tetanus shot review of systems per hpi denies fever chills night sweats recent weight loss or gain denies headache sinus tenderness rhinorrhea or congestion denies cough shortness of breath or wheezing denies chest pain chest pressure palpitations or weakness denies nausea vomiting diarrhea constipation abdominal pain or changes in bowel habits denies dysuria frequency or urgency denies arthralgias or myalgias denies rashes or skin changes past medical history none social history lives at home with her husband and children and years old her year old recently had a sore throat but that has since resolved her yo had an earache but he is otherwise well tobacco denies alcohol occasional drinks socially illicits denies family history noncontributory physical exam on admission to medicine floors vitals t bp p r o ra general alert oriented no acute distress pleasant healthy female appears stated age appears comfortable heent ncat eomi sclera anicteric mildly dry mm oropharynx clear neck supple jvp not elevated swelling of anterior cervical ln s mildly tender to palpation lungs clear to auscultation bilaterally no wheezes rales ronchi cv rrr normal s s no murmurs rubs gallops abdomen bs soft non tender non distended no rebound tenderness or guarding no organomegaly gu no foley ext warm well perfused pulses no clubbing cyanosis or edema neuro a ox cn ii xii grossly intact moving all extremities no gross deficits gait deferred on discharge afebrile normotensive general alert oriented no acute distress appears comfortable heent ncat eomi slight facial and chest erythema without warmth no appreciable hives neck supple jvp not elevated swelling of anterior cervical ln s mildly tender to palpation lungs clear to auscultation bilaterally no wheezes rales ronchi cv rrr normal s s no murmurs rubs gallops abdomen bs soft non tender non distended no rebound tenderness or guarding no organomegaly gu no foley ext warm well perfused pulses no clubbing cyanosis or edema neuro a ox cn ii xii grossly intact moving all extremities no gross deficits gait deferred pertinent results admission labs pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood glucose urean creat na k cl hco angap pm blood calcium phos mg discharge labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct micro monospot final negative by latex agglutination blood cultures pending respiratory viral screen insufficient specimen brief hospital course hospital course ms is a year old female with no past medical history who presents with epiglottitis with no current evidence of airway compromise she was admitted to icu overnight for close monitoring treated with iv steroids and clindamycin she was transferred to the medicine floors on hod where she continued to improve she was discharged on oral clindamycin and steroids epiglottitis seen on ct scan and direct visualization by ent patient has no evidence of abscess or phlegmon formation seen on imaging evaluated by ent with endoscopy pt had no evidence of airway compromise no stridor much improved after iv steroids admitted to icu for airway monitoring patient was treated with dexamethasone mg q for two days and clindamycin mg iv q for planned seven day course patient was able to tolerate po and was called out to the medicine floor on the medicine floors she continued to improve and was discharged on oral clindamycin and medrol dose pack she will follow up with her pcp in one week and was given warning symptoms for which she would need to call her pcp facial erythema slight facial flushing erythema without pruritis or respiratory compromise on hod no rash unclear if reaction to clindaymcin pt was continued on clindamycin and given warning symptoms leukocytosis wbc elevated likely recent steroids infection as above wbc remained stable and she had no other signs of infection blood cultures from were pending at the time of discharge transitional care code full contact husband c h follow up pcp week medical management complete day course of clindamycin medrol dose pack outstanding tasks blood cultures from pending at the time of discharge medications on admission none discharge medications medrol pak mg tablets dose pack sig one tablets dose pack po once a day as directed disp pack refills clindamycin hcl mg capsule sig three capsule po q h every hours for days disp capsule s refills discharge disposition home discharge diagnosis primary epiglottitis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms it was a pleasure taking care of you during this admission you were admitted from the outside hospital for epiglottitis you were seen by the ent doctors who did a scope and saw swelling you were monitored closely in the intensive care unit overnight and treated with intravenous steroids and clindamycin you were transferred to the medicine floor and were able to take food and swallow pills you will need to continue the antibiotics and a course of oral steroids when you leave the following medications were started during this admission start clindamycin mg tablets tablets at a time total of mg by mouth every hours for more days start medrol dose pack and complete it mg tablets you will take tablets the first day starting today then tablets the next day then then then then until they are done if you develop any difficulty breathing facial swelling or other concerning symptoms please call your doctor immediately or call followup instructions please follow up with the following appointments department primary care name dr when thursday at am location internal medicine address phone completed by,"{
""Diagnoses"": [""epiglottitis"", ""supraglottitis""],
""Medications"": [""azithromycin"", ""sulfamethoxazole"", ""penicillins""]
}"
11490,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint s p fall major surgical or invasive procedure none history of present illness pt was working on roof and fell feet he hit back and head w no loc reported in trauma bay pt w diffuse back pain w no c o neck pain no visual changes no ha injuries included l posterior lateral rib fx t grade splenic laceration l hemothorax effusion small l pneumothorax l non displaced skull fracture past medical history none social history occasional cocaine ppd smoker works construction family history non contributory physical exam vss gen gcs heent perrla no hemotypanum stable midface cardiac no contusions left flank pain resp bs equal b l no crackles gi soft min luq tenderness no rebound or guarding gu no blood at the meatus nl prostate stable pelvis good rectal tone guiac negative ext warm good dp pulses neuro a ox pertinent results rads cxr multiple rib fractures no pelvic fracture ct head no hemorrhage l skull fracture ct c spine no fx or dislocation ct t l s spine no fx or dislocation ct chest small left pneumothorax rib fx t effusion ct abd grade splenic lac w some surrounding fluid am blood hct pm blood hct am blood hct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood hct pm blood hct am blood hct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos amylase totbili am blood calcium phos mg am blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg am blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg brief hospital course pt presented to trauma bay s p fall from roof w of loc pt w complaints of back flank pain pt had imaging that revealed cxr multiple rib fractures no pelvic fracture ct head no hemorrhage l skull fracture ct c spine no fx or dislocation ct t l s spine no fx or dislocation ct chest small left pneumothorax rib fx t effusion ct abd grade splenic lac w some surrounding fluid neuro cgs in trauma bay and throughout stay pain controlled w dilaudid normal neuro exam hospital stay cardiac no acute issues resp pt w rib fractures pt used is throughout stay gi pt w splenic laceration w a surrounding hematoma pt originally had stable hct but then it dropped re scan showed a stable hematoma surrounding the spleen but some extravasation of contrast pt was admitted to the icu for serial crits and serial abdominal exams both remained stable throughout his stay gu no acute issues msk hd pt began having some pain and numbness into left buttock w some complaints of l spine pain ct of t l s spine w no evidence of fracture ortho spine consulted and felt that pt did not have any evidence of spinal injury to explain pt s symptoms be due to sciatica pt encouraged to follow up with his physician and return to er if numbness continues spreads foot drop new weakness tingling incontinence pt understands and will folow up as necessary pt also had left shoulder pain w movement xrays revealed ac joint separation pt put in sling and will follow up with orthopedics in the next few weeks medications on admission none discharge medications ibuprofen mg tablet sig one tablet po q h every hours take this with food disp tablet s refills dilaudid mg tablet sig tablets po every hours as needed for pain disp tablet s refills bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for constipation colace mg capsule sig one capsule po twice a day as needed for constipation discharge disposition home discharge diagnosis splenic laceration pneumothorax hemothorax discharge condition good discharge instructions you should not return to work until you are feeling better you should do range of motion exercises with your shoulder a few times a day to prevent the shoulder from freezing you should follow up with the orthopedics doctors below you should call the doctor or return to the er for abdominal pain nausea vomiting new numbness tingling weakness bowel or blader incontinence fevers chills or any ohter changes in your medical condition that concern you followup instructions you need to follow up in trauma clinic next tuesday please call to make an appointment you should also call and make an appointment for outpatient physical therapy you have given a prescription for this you can call to make an appointment to see the orthopedic doctors regarding your injury if the numbness pain in your buttocks continues you should follow up with your primary care physician who may recommend that you see a neurologist for further testing,"{
""Diagnoses"": [""surgery"", ""fall"", ""major surgical or invasive procedure"", ""posterior lateral rib fx"", ""grade splenic laceration"", ""hemothorax"", ""effusion"", ""small pneumothorax"", ""non-displaced skull fracture"", ""past medical history of none"", ""social history of occasional cocaine use"", ""smoker"", ""works in construction""],
""Medications"": [""none""]
}"
13958,admission date discharge date date of birth sex m service plastic surgery history of present illness the patient is a year old male who fell on a scaffold at his construction job lost his balance and put his right arm through a plate glass window he presented to the emergency room with a to cm laceration of the proximal forearm through his flexor compartment per report at the scene the patient immediately complained of burning pain to the fourth and fifth right digits followed by numbness in these digits he also complains of severe flexion weakness in the hand compression bandage was applied at the scene and the patient was transferred to the emergency room in the emergency room the patient complained of extreme pain with the laceration past medical history none medications on admission none allergies the patient has no known drug allergies social history the patient is a haitian immigrant came to the country approximately three months ago he denies any smoking or alcohol use physical examination on physical examination the patient had a pulse of blood pressure respiratory rate and oxygen saturation in room air general agitated male in distress complaining of increased pain despite narcotics lungs clear to auscultation bilaterally cardiovascular regular rate and rhythm s and s appreciated abdomen soft nontender nondistended extremities right upper extremity approximately cm laceration across the volar forearm running from the ulna to approximately the middle of the volar surface there was a large amount of exposed muscle belly there was oozing of venous blood additionally there was bright red arterial blood which came out once the compression bandage was removed the patient had no sensation throughout the fourth and fifth digits and he had very poor flexor function throughout the entire hand radial and ulnar pulses were palpable there was good capillary refill of all fingers flexor function while impaired was somewhat present in the first through fourth digits patient had no extensor function of the fingers secondary to pain difficult to obtain a lumbar column or osseous examination on the patient laboratory data admission white blood cell count was hematocrit platelet count radiologic data x rays showed no fracture and no evidence of foreign bodies given that the patient had a traumatic laceration of his right forearm with arterial bleeding as well as severe disruption of the flexor compartment and an exam consistent with disruption of the ulnar nerve the patient was transferred immediately to the operating room for ulnar nerve repair incision and drainage and vascular exploration hospital course the patient underwent an ulnar nerve repair on as well as ligation of bleeding during the operation the ulnar artery was found to be intact with laceration of one of the major branches of that artery throughout the flexor compartment approximately of the patient s flexor forearm muscles were noted to be completely or partially lacerated these were additionally repaired during this operation the patient tolerated the procedure well however following the operation during anesthesia the patient was extubated prematurely and bag masked and went into pulmonary edema in the operating room with saturations dropping into the s it was decided at that time to reintubate the patient he was found to be in laryngospasm and his tracheal tube was passed over a guiding stilette the patient s saturations improved after that the patient was transferred to the post anesthesia care unit intubated sedated and paralyzed in the post anesthesia care unit the surgical intensive care unit team was consulted given that the patient had a chief complaint of pulmonary edema he was admitted to the surgical intensive care unit service arterial blood gases obtained immediately postoperatively revealed a ph of pco and po the patient remained intubated and sedated on the ventilator throughout the night of postoperative day zero to postoperative day one on postoperative day number one the patient continued to do well he was weaned from the ventilator and extubated on in the evening overnight events from also included decreased blood pressure which responded well to fluid boluses the patient was diuresed with lasix once on overnight from the patient did well he was extubated however he was noted to have a hypertensive episode with blood pressures ranging up into the s and s the patient was begun on lopressor mg three times a day which controlled his blood pressure adequately also on the patient was again diuresed with lasix he responded well and was able to decrease his oxygen requirement from the patient continued to do well it was decided at that time to transfer the patient back to the plastic surgery service however he was unable to be discharged from the unit due to bed availability on with the patient tolerating oral pain medications and an oral diet it was decided at that point that it was possible to discharge the patient to home the orthopedic technician was consulted who applied a cast to the patient s right upper extremity holding the elbow in degrees of flexion approximately degrees of wrist flexion degrees of mp flexion and pip extension with the wrist supinated as well so as to prevent tension on the ulnar nerve condition on discharge good discharge diagnose laceration of the right forearm status post ulnar nerve repair status post flexor muscle repairs pulmonary edema status post intubation and diuresis follow up the patient was instructed to follow up with his primary care physician within the week to evaluate him for long term blood pressure control the patient is also to follow up with dr in the plastic surgery clinic in approximately one week from tuesday for cast removal and evaluation of the wound it is expected that the ulnar nerve repair should be stable in the cast that is presently applied discharge medications lopressor mg p o b i d for blood pressure control m d dictated by medquist d t job,"{
""Diagnoses"": [""Laceration of the proximal forearm"", ""Compartment syndrome""],
""Medications"": [""None""]
}"
12240,admission date discharge date service micu history of present illness this is a year old female with history of hepatitis c cirrhosis bleeding varices who was transferred to the micu for undergoing an egd for banding of her varices during which time she began to bleed she arrived to the micu tube was placed and she was monitored once it was determined her creatinine was stable the tube was removed her creatinine remained stable during the hospital course however the patient was intubated and sedated during the acute episode the sedation was weaned off and the patient did not become conscious after the sedation probably secondary to decreased liver clearance or hepatic encephalopathy her blood pressure was problem throughout the hospitalization she required initially fluid boluses to maintain her blood pressure with max about however at one point her blood pressure became unresponsive to fluid boluses albumin was also tried however to no avail the family was consulted as to their wishes they decided that using pressors at this time would not be what the patient had expressed the patient after discussion with her family and the prognosis of the diagnosis with the new turn of events including hypertension unresponsive to fluid and abdominal rising creatinine and decreased mental status it was discussed and thought best that the patient s status be changed to comfort measures only the family agreed the patient was then changed to comfort measures only extubated on at approximately pm and placed on a morphine drip the patient then expired at on the family was present during this time m d dictated by medquist d t job,"{
""Diagnoses"": [""Hepatitis C"", ""Cirrhosis"", ""Bleeding Varices"", ""Acute Liver Failure""],
""Medications"": [""Tamiflu"", ""Lidocaine"", ""Epinephrine"", ""Midazolam"", ""Fenoldopam""]
}"
21719,admission date discharge date date of birth sex f service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint syncope major surgical or invasive procedure avr mm st regent sa mechanical valve placement of sigma sdr d ddd mode history of present illness the patient is a year old woman who has a history of aortic stenosis with syncope workup demonstrated severe aortic stenosis with aortic valve area calculated to be less than cm squared the patient had a diagnostic cardiac cath done approximately a year ago which showed normal coronaries with a left dominant system the patient was therefore referred for an aortic valve replacement past medical history migraines bicuspid aortic valve hypothyroid social history lives in with husband and children denies smoking history drinks socially drinks week family history father cabg in s mother with cardiomyopathy in s physical exam avss heent ncat perrl anicteric sclera op benign teeth in good repair heart rrr sem carotids lungs ctab extrem warm no edema pertinent results echo post cpb there is normal biventricular systolic function left ventricular diastolic size is small consistent with decreased preload there is a bileaflet mechanical prosthesis located in the aortic position it is well seated and both leaflets can be seen moving there is mild ai in total which is normal for this valve there may be a small perivalvular jet though this can not be well seen the maximum gradient through the valve is about mm hg the recorded table showing a gradient of is an error initially when coming off of cpb there was a rhythm abnormality that resulted in increased mr rhythm was reestablished the mr was back down to pre cpb levels cxr status post median sternotomy and avr heart size is within normal limits there are small bilateral pleural effusions with associated atelectasis at the lung bases but no definite pulmonary edema there is a dual chamber left sided with atrial and ventricular leads in situ in good location no pneumothorax impression bilateral pleural effusions slightly smaller than on prior film no evidence for pulmonary edema no pneumothorax or chf no change in location of pacer leads am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt am blood pt ptt inr pt pm blood pt ptt inr pt am blood glucose urean creat na k cl hco angap brief hospital course she was taken to the operating room on where she underwent an avr with a regent sa mechanical valve she was transferred to the csru in critical but stable condition she was extubated and weaned from her vasoactive drips later that same day postoperatively she was found to be in complete heart block requiring epicardial pacing she was seen in consultation by electrophysiology who followed closely she was started on heparin for her mechanical valve she remained in complete heart block and a permenant was placed on she was then transferred to the floor she was started on coumadin for her mechcanical valve she awaited therapeutic inr and was ready for discharge on pod medications on admission mucinex synthroid lasix augmentin lisinopril kcl discharge medications atorvastatin 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 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 levothyroxine mcg tablet sig one tablet po daily daily disp tablet s refills pantoprazole 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 discharge disposition home with service discharge diagnosis bicsupid aortic valve migraine hypothyroid 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 no lotions creams or powders to incision until it has healed you may shower and wash incision 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 followup instructions follow up with dr in month follow up with cardiologist dr st medical center am for pacer check and coumadin check provider clinic phone date time provider call phone date time lab monday for inr check completed by,"{
""Diagnoses"": [""aortic stenosis"", ""syncope"", ""severe aortic stenosis"", ""aortic valve area less than 0.5 cm^2"", ""cardiac cath showed normal coronaries with a left dominant system""],
""Medications"": [""sigma sdr d ddd mode"", ""mechanical valve placement"", ""avr mm st regent sa""]
}"
23907,admission date discharge date date of birth sex f service neurology history of the present illness the patient is a year old woman with a past medical history significant for prader willi syndrome that includes mild mental retardation hearing impairment and hyperphagia who developed type ii diabetes mellitus requiring insuline the patient is living in a group home works as a mail sorter in a work program she was in her usual state health until p m on the day of admission when her case worker noted left facial droop and decreased ability to talk she was taken to an outside hospital and then to for evaluation the stroke service was called at p m hours minutes after the onset there was no further history available at this time in the er a head ct showed an old left frontal stroke intravenous tpa was not given at this time because the patient was outside the hour window in addition the patient s mother who is the legal reppresentative for the patient declined enrolment in any study protocol the patient was then admitted to the neurology stroke service for further management head mri showed diffusion weighted lesion in the right fronto parietal region suggestive of acute ischemia head mra showed decreased flow signal at the right mca branches distal to the m segment good flow was seen in both intracranial icas the patient was then diagnosed with a right frontal parietal stroke physical examination on admission vital signs blood pressure pulse afebrile with a regular respiratory rate she had no murmurs rubs or gallops benign abdomen good peripheral pulses on neurological examination the patient was awake somewhat sleepy but easily arousable oriented speech was dysarthric the patient was able to name and follow commands the patient did not have any right left confusion the pupils were reactive and round to light eyes were deviated to the right the patient had a positive doll s the patient also had a decrease response on the left and a flat left nasolabial fold she had a left hemiparesis upper extremity greater than lower extremity and the left lower extremity was distally four modalities were intact in sensation but the patient did extinct to double simultaneous stimulus the patient had decreased cortical sense in the left hand and left toe was upgoing pertinent laboratory data x ray ekg and other tests the patient was admitted carotid ultrasound showed no flow abnormalities mra showed good flow in both intracranial arteries with decreased flow signal in right mca branches distal to m segment hospital course the patient was admitted to the stroke service clinically the patient s left sided hemiparesis improved somewhat but was still present on discharge she also had extinction to the left with a considerable neglect the patient s mother noted that when the patient washed her face the patient did not wash the left side of face or body the patient was placed on heparin and ptts were meticulously checked q six hours to maintain therapeutic range of coumadin was also started once the inr was to heparin was discontinued the patient was ruled out via cardiac enzymes times three a tee did not show valvular disease thrombus or septal defects the serology for hypercoagulable w u included protein c protein s factor antithrombin iii anticardiolipin antibody and was sent prior to heparin initiation most of the results were normal and the remaining will be evaluated at the next f u outpatient clinic appointment the patient had a normal lipid profile and was thus not placed on lipitor prior to discharge the patient passed a swallow study and was started on a p o diet and advanced to a regular consistency diet the patient will be discharged to medical facility where inr will be checked on days subsequent after discharge as well as three to four days postdischarge prior to discharge the patient s mother was informed of the follow up stroke appointment on at p m with dr condition on discharge stable discharge status stable discharge diagnosis right frontoparietal stroke discharge medications insulin sliding scale regular for the patient s diabetes mellitus miconazole powder apply to sweaty areas b i d fluoxetine mg p o q d metformin mg p o b i d protonix mg p o q hours buspirone mg p o t i d coumadin mg p o h s with repeat inrs to be scheduled on thursday and monday the patient s primary care doctor at the clinic will be e mailed regarding the patient s current admission the patient will be transferred to facility for rehabilitation m d dictated by medquist d t job,"{
""Diagnoses"": [""Prader-Willi syndrome"", ""Type II diabetes mellitus"", ""Hyperphagia"", ""Mental retardation"", ""Hearing impairment""],
""Medications"": [""Insulin""]
}"
17859,admission date discharge date date of birth sex m service cardiothoracic allergies penicillins vancomycin propoxyphene morphine sulfate attending chief complaint increased difficulty breathing increased secretions major surgical or invasive procedure bronchoscopy tracheoplasty tracheostomy history of present illness yo m admitted for diagnostic bronch on pt has hx of tracheomalacia and is s p tracheobronchoplasty in dr developed increased secretions cough and resp difficulty since bronch shows a way collapse and secretions s p tracheoplasty redo portex exchanged past medical history pmhx mounier syndrome tracheomalacia parkinson s dz retinitis pigmentosa legally blind esophageal stricture s p dilatation mrsa in sputum multiple ortho surgeries digits and back s p nissen fundoplication rhabdomyelosis left shoulder parkinson s disease gastroesophageal reflux disease legally blind with macular degeneration and retinitis pigmentosa chronic bronchitis tracheobronchitis tracheobronchomalacia social history lives in has fiance and mother who reside there as well pertinent results hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct am basic coagulation pt ptt plt inr pt ptt plt ct inr pt am am heparin dose note new normal range as of am chemistry renal glucose glucose urean creat na k cl hco angap am enzymes bilirubin alt ast ld ldh ck cpk alkphos amylase totbili dirbili am other enzymes bilirubins lipase am cpk isoenzymes ck mb mb indx ctropnt am add on chemistry totprot albumin globuln calcium phos mg uricacd iron cholest am lipid cholesterol triglyc hdl chol hd ldlcalc am ldl calc invalid if trig or non fasting sample hepatitis c serology hcv ab pm negative radiology final report ct trachea w o c w recons pm medical condition year old man with trachemomalacia reason for this examination need dynamic ct of airways to evaluate for tracheomalacia contraindications for iv contrast none indication year old man with tracheomalacia technique contiguous mm axial ct images of the chest were obtained without the administration of iv contrast additional images at dynamic expiration at end expiration and during cough were obtained multiplanar reformations are reconstructed comparison ct trachea dated findings again note is made of tracheomegaly transverse diameter measuring cm note is made of thickening of tracheal wall with calcification which somewhat obscures posterior membrane at end expiration and dynamic breathing note is made of excessive collapsibility of trachea and bilateral main stem bronchus representing severe tracheobronchomalacia note is made of multiple areas of air trapping at end expiration there is no mediastinal or hilar lymphadenopathy note is made of coronary artery calcification the limited evaluation of upper portion of the lungs demonstrates non calcified pulmonary nodules measuring mm in diameter in the superior segment of right lower lobe unchanged since previously noted multiple patchy opacities appear to be resolved again note is made of focal thickening of right major fissure there is no suspicious lytic or blastic lesion noted in the skeletal structures within the scan area impression severe tracheobronchomalacia mild tracheomegaly with tracheal wall thickening with calcification the wall thickening of the trachea may be due to relapsing polychondritis or due to prior stenting provided in the history please correlate clinically with the patient history and also with physical findings unchanged appearance of mm non calcified nodule in the right lower lobe coronary artery calcification air trapping multiplanar reformation images confirmed the above finding the study and the report were reviewed by the staff radiologist dr dr approved wed pm radiology final report shoulder view left port pm medical condition year old man s p tracheoplasty now with pain reason for this examination fracture history shoulder pain this exam consists of internal and external rotation frontal radiographs of the left shoulder additional views not ordered or obtained no fracture or bone destruction on limited views available i cannot entirely exclude anterior subluxation of the humerus doubtful no periarticular soft tissue calcifications and no comparison exams dr m approved fri pm radiology final report chest portable ap am medical condition yo male s p ct removal reason for this examination eval for ptx indication year old male patient status post chest tube removal comments portable ap radiograph of the chest is reviewed and compared with the previous study of yesterday the right chest tube has been removed no pneumothorax is identified there is continued small loculated right pleural effusion with subcutaneous emphysema in the right chest wall the tracheostomy tube right jugular iv catheter and right sided picc line remain in place the left lung appears clear there is continued mild cardiomegaly impression no pneumothorax dr approved sun pm brief hospital course y o w complex medical and surgical history admitted for evaluation of increased difficulty breathing and increased secretions w trachealmalacia and s p tracheoplasty bronchoscopy done severe tbm right mainstem patent left mainstem patent bal of rll placed on antibiotics for prophylaxis of increased secretions bal pending pt maintained on antibiotics receiving aggressive nutritional tpn cpt physical therapy support and picc line placement in preparation for re do tracheoplasty done episode of conjuctivitis treated w days of erythromycin opthal ointment and ciprofloxacin optahlmic solution s p re do tracheoplasty via r thoracotomy hour surgery see operative note stable post op tracheostomy portex in place on ventilator and transferred to sicu pain service consulted controlled to fentanyl bupivicaine epidural as well as fentanyl gtt bronchoscopy pod mild edema repair successful small amt of secretions cleared via scope see report c o and observation of significant l shoulder ac joint pain tenderness swelling after being in left lateral decub position for duration of surgery via right thoracotomy seen by ortho diagnosis of l shoulder rhabdomyelosis w cpk s peaking and starting to decrease pod continues on ventilator simv ps w good abg vent weaned w o complication to trach mask chest tube d c pain control continues w fentanyl epidural and fentanyl gtt pod foley removed transitioned off fentanyl drip to meperidine and fentanyl patch heplocked except for tpn epidural catheder removed ck continued to decline pod pt transfered to floor after d c of fentynal drip pain control on floor optimized trach changed at beside from portex w cuff to portex with no cuff pod tpn d c ed and diet advanced to clears adequate pain control optimized by aps with decrease on fentynal patch opthamology consult obtained for erythema and drainage from r good eye started on erythromycin and ciloxan for putative conjuctivitis pod diet advanced slowly tolerated well nutrition consult suggested full liquids pt evaluation progressed well but continued on iv linezolid pod continued to assist with pulm toilet diet advanced to pos as tolerated and pain controlled on fentynal patch ot evaluation cleared pt for discharge pod bronchoscopy for final evaluation before discharge medications on admission prilosec cough syrup sinemet neurontin discharge medications guaifenesin mg ml syrup sig mls po q h every hours as needed cetylpyridinium chloride lozenge sig one lozenge mucous membrane five times a day as needed polyvinyl alcohol povidone dropperette sig drops ophthalmic prn as needed albuterol sulfate solution sig one inhalation q h every hours acetaminophen mg tablet sig two tablet po tid times a day as needed meperidine hcl mg tablet sig tablets po q h as needed gabapentin mg capsule sig two capsule po qid times a day docusate sodium mg capsule sig one capsule po tid times a day senna mg tablet sig two tablet po hs at bedtime erythromycin mg g ointment sig one drops ophthalmic qhs once a day at bedtime disp refills ibuprofen mg tablet sig one tablet po q h every hours as needed linezolid mg tablet sig one tablet po q h every hours for days disp tablet s refills discharge disposition home discharge diagnosis mounier syndrome tracheomalacia gerd parkinson s dz retinitis pigmentosa legally blind esophageal stricture s p dilatation mrsa in sputum multiple ortho surgeries digits and back s p nissen fundoplication rhabdomyolysis of left shoulder discharge condition good discharge instructions call dr office or dr office for fever chest pain shortness of breath clogging of tracheostomy resume all medications as prior to hospitalization take all medications as directed documents to be discharged with discharge summary operative note note for airline followup instructions follow w md pulmonologist as per dr instructions completed by [NEW_RECORD] admission date discharge date date of birth sex m service admission diagnoses parkinson s disease gastroesophageal reflux disease legally blind with macular degeneration and retinitis pigmentosa chronic bronchitis tracheobronchitis tracheobronchomalacia history of present illness additionally upon admission this is a year old man who had a difficult extubation three years ago after hand surgery and was diagnosed with tracheobronchomalacia the patient has since had six stents placed with a good initial result until larger stents were needed the patient now has a tracheostomy and has no significant relief with his last stent placed which was in he now presents for a definitive tracheobronchoplasty laboratory data the patient s preoperative cbc and bmp were all stable and the following labs were obtained cbc white blood cell count hemoglobin hematocrit platelets serum sodium potassium chloride bicarbonate bun creatinine blood glucose calcium magnesium and phosphorus allergies the patient is allergic to vancomycin morphine sulfate dilaudid penicillin and darvocet hospital course on the patient went to the or for a removal of a previous stent and placement of a tracheostomy the patient had tolerated the procedure very well removal of the stent and went to the floor on postoperative day one had no problems and was in no acute distress lungs are clear to auscultation bilaterally and was kept npo overnight for a next morning swallow study the patient was recommended to have a p o diet that was regular consistent with solids and thin liquids medications should be hold with liquids the patient had a stable postoperative course after the stent removal and was taken again to the or on for definitive tracheobronchoplasty the patient again tolerated the procedure very well was transferred to the icu postoperatively had no issues in the icu and was again stable he was on a trachea mask for his oxygenation which was stable he had one episode of elevated temperature while in the icu he was c diff negative the patient had epidural for pain control he was weaned off his trachea mask his chest was clear to auscultation he had a bronchoscopy on that showed some fluid and mucus in his airways with copious secretions the patient did well on the floor had no untoward events after his tracheoplasty his thoracotomy wounds were clean dry and intact his chest tube was removed on postoperative day he was restarted on his sinemet on postoperative day two the patient had been on linezolid since first postoperative day of his removal of the stent placement for what seemed to be some copious and purulent secretions the patient was allergic to vancomycin and that is why he was on po linezolid his foley was discontinued on postoperative day we continued to follow cultures on postoperative day two of his tracheobronchoplasty the main issue was pain control the patient initially had an epidural and then was switched to a pca for pain control the patient had a fentanyl pca because again he had multiple different allergies to different pain medications he was bronchoscoped again on which showed some severe malacia of his distal airways he still had some copious purulent secretions and the trachea tube was seen to be in accurate position and his floor course was good neurologically he was intact cardiac the patient was regular rate and rhythm but his chest had some coarse rhonchi throughout bilaterally the patient had a central line previously and that was discontinued the patient again was bronchoscoped on showing that trachea tube is in good position he had a moderate amount of secretions and on the left with some moderate malacia on the right he had more severe malacia and some thick secretions the patient was weaned to a smaller trachea tube and he was switched to p o pain medication on postoperative day again all the while he remained on linezolid the patient again was bronchoscoped on showed copious secretions on the right side and the left which looked clear the trachea was seen again to be in good position the patient had his central line discontinued on the fifth postoperative day had a peripheral iv established and had a chest x ray where his lungs looked pretty clear the patient was up mobilizing walking around and desired to go outside his pain was better controlled per the nursing staff again he had been started previously on his parkinson s drugs on postoperative day he was doing well his wounds again were clear dry and intact he had less rhonchi he was switched to a fentanyl patch of mcg and the patient did well on postoperative day the patient again had his trachea tube changed to a number portex cuffless trachea and had a bronchoscopy again that showed a moderate amount of secretions on the right side the left was clear and some other purulent secretions on the right the patient was discharged on to stay in a hotel until which is a thursday he was to return again for bronchoscopy and then return the following monday on to see dr before going home to multiple calls were made to the pharmacy in with respect to payment for linezolid and they were awaiting and the case manager was awaiting a call back from the medical director to ensure that the patient would be covered for his po linezolid when he went home the patient went to a hotel on p o pain medications went out on antibiotics specifically linezolid and he was to restart all his prior medications which includes medications with respect to his parkinson s disease gerd and some other medications he took previously mentioned other past medical histories the patient was mrsa positive hence the antibiotics he also had some left sciatica follow up the patient will followup with dr on disposition the patient was discharged to a hotel discharge instructions the patient is to ad lib his activity and diet discharge medications his medications are his previous home medications along with the linezolid and a fentanyl patch for pain dictated by medquist d t job,{}
52278,admission date discharge date date of birth sex m service cardiothoracic allergies lisinopril moexipril attending chief complaint chest pressure major surgical or invasive procedure avr mechanical septal myomectomy history of present illness year old male with known biscuspid aortic valve and aortic stenosis who was admitted to the for new onset atrial fibrillation and chest pain he underwent tee guided expedited cardioversion and discharged on warfarin and no antiarrhythmic since discharge issues have been coumadin management and he notes edema at the end of the day with improvement in the morning he continues with chest pressure with activity that resolves with rest occuring a few times a week he is now admitted for surgery and heparin bridge past medical history hypertrophic cardiomyopathy severe aortic stenosis secondary to bicuspid aortic valve hypertension hyperlipidemia diabetes mellitus type ii obstructive sleep apnea kidney stones social history never smoked drinks on the weekends large cup of coffee daily works as an attorney lives at home and performs all activities of daily living independently family history father died of mi in s had first mi at age mother died of lung ca in s no children with known heart disease physical exam pulse resp o sat ra b p right left general no acute distress skin dry x intact x skin tags right shoulder heent perrla x eomi x neck supple x full rom x chest lungs clear bilaterally x heart rrr x irregular murmur iii vi sem abdomen soft x non distended x non tender x bowel sounds x no palpable masses extremities warm x well perfused x edema trace bilateral le varicosities none x neuro alert and oriented x nonfocal pulses femoral right left dp right left pt left radial right left carotid bruit transmitted murmur bilateral pertinent results intra op tee pre cpb 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 there is moderate symmetric left ventricular hypertrophy the left ventricular cavity is moderately dilated overall left ventricular systolic function is normal lvef right ventricular chamber size and free wall motion are normal the ascending aorta is mildly dilated there are simple 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 moderate mitral regurgitation is seen excessive motion of anterior leaflet chordae tendineae noted this could represent a ruptured chord or redundant chordae length moderate tricuspid regurgitation is seen dr was notified in person of the results post cpb the patient is atrial paced the biventricular systolic function is preserved there is a mechanical valve in the aortic position with a peak gradient of mmhg which is mechanically stable with good leaflet excursion there is moderate mitral regurgitation with an eccentric posteriorly directed regurgitation jet the mitral valve demonstrates systolic anterior motion sequential pwd through the lvot demonstrated step up of the peak velocity to m s there is moderate tricuspid regurgitation the visible contours of the thoracic aorta are intact dr was notified in person of the results brief hospital course the patient was brought to the operating room on where the patient underwent avr mm st mechanical valve and a septal myomectomy 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 the patient was transferred to the telemetry floor for further recovery anticoagulation therapy was started with coumadin on and heparin intravenous therapy was started on until the inr was chest tubes and pacing wires were discontinued without complication he did develop post op a fib and was started on amiodarone the patient was evaluated by the physical therapy service for assistance with strength and mobility by the time of discharge on pod number the patient was ambulating freely the wound was healing and pain was controlled with oral analgesics the patient was discharged to home with visiting nurses in good condition with appropriate follow up instructions dr will continue to manage coumadin dosing medications on admission glyburide mg one tablet once a day metformin mg one tablet twice a day simvastatin mg one tablet by mouth once a day verapamil mg one tablet by mouth twice a day warfarin mg tab x wk tabs twice wk antibiotic prophylaxis multivitamin one tablet by mouth once a day discharge medications 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 docusate sodium mg capsule sig one capsule po bid times a day as needed for constipation disp capsule 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 lasix mg tablet sig one tablet po twice a day for days disp tablet s refills glyburide mg tablet sig tablet po daily daily disp tablet s refills simvastatin mg tablet sig two tablet po daily daily disp tablet s refills oxycodone acetaminophen mg tablet sig one tablet po q h every hours as needed for pain disp tablet s refills amiodarone mg tablet sig two tablet po bid times a day mg x weeks then mg daily x week then mg daily until further instructed disp tablet s refills ranitidine hcl 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 coumadin mg tablet sig one po once a day take mg on monday wednesday and friday disp refills coumadin mg tablet sig one tablet po once a day take mg every saturday sunday tuesday and thursday disp tablet s refills metformin mg tablet sig one tablet po twice a day disp tablet s refills ibuprofen mg tablet sig one tablet po every eight hours for weeks disp tablet s refills outpatient lab work labs pt inr for coumadin indication mechanical aortic valve goal inr first draw results to dr phone confirmed discharge disposition home with service facility home health care discharge diagnosis s p avr septal myomectomy atrial fibrillation hypertrophic cardiomyopathy severe aortic stenosis with bicuspid valve hypercholesterolemia hypertension diabetes mellitus type ii obesity pulmonary artery hypertension sleep apnea does not tolerate cpap coronary artery disease gout kidney stones discharge condition alert and oriented x nonfocal ambulating with steady gait incisional pain managed with incisions sternal healing well no erythema or drainage edema bilateral lower extremities 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 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 thurs pm cardiologist dr date time please also call for appointment with dr in weeks primary care dr pm 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 goal inr first draw results to dr phone confirmed completed by,"{
""Diagnoses"": [""atrial fibrillation"", ""chest pain"", ""new onset atrial fibrillation"", ""chest pressure""],
""Medications"": [""lisinopril"", ""moexipril"", ""warfarin"", ""heparin""]
}"
932,admission date discharge date date of birth sex m service hiof present illness this year old diabetic male with a history of atypical chest pain and dyspnea on exertion referred for cardiac catheterization after a positive stress test cardiac catheterization showed ejection fraction of left main disease left circumflex rca the patient remained in house after his cardiac catheterization and was taken to the operating room on with dr past medical history noninsulin dependent diabetes mellitus history of prostate cancer status post prostatectomy years ago asbestosis hypertension a to pack year smoking history quit in the s status post biopsy of a right anterior tibial lesion with a follow up bone scan and ct scan of the abdomen and pelvis to rule out metastasis from prostate cancer results are unknown allergies no known drug allergies preoperative medications imdur milligrams po q day lipitor milligrams po q day glucotrol milligrams po q day tiazac milligrams po q day diovan milligrams po q day aspirin milligrams po q day laboratory data white blood cell count hematocrit platelet count sodium potassium chloride bicarb bun creatinine blood sugar ho course the patient was taken to the operating room on with dr for cabg times three in the operating room it was difficult to place a foley catheter preoperatively urology was consulted flexible cystoscopy showed a bladder neck stricture a wire was placed and the stricture was dilated a foley catheter was inserted the patient underwent cabg times three lima to diagonal saphenous vein graft to rca saphenous vein graft to om the patient was transferred to the intensive care unit in stable condition the patient was weaned and extubated from mechanical ventilation on postoperative day one the patient remained in the intensive care unit requiring neo synephrine infusion to maintain adequate blood pressure the patient was transferred out of the intensive care unit on postoperative day two the patient s chest tubes were removed on postoperative day two post chest tube removal chest x ray demonstrated a small left apical pneumothorax from which the patient was asymptomatic the patient was transferred to the floor and began ambulating with physical therapy the patient s temporary pacing wires were removed on postoperative day three the patient s foley catheter was removed on postoperative day five the patient is to void prior to discharge otherwise foley catheter will be re inserted repeat chest x ray on demonstrated a continued small left apical pneumothorax unchanged from previous chest x ray of it is felt that the size and stability of the pneumothorax did not require any intervention the patient was cleared for discharge on to rehabilitation facility as it was felt that the patient would need continued physical therapy and short term rehabilitation condition at discharge tmax f t current f pulse sinus rhythm blood pressure oxygen saturation on two liters nasal cannula the patient s weight on is kilograms the patient was kilograms preoperative white blood cell count hematocrit platelet count sodium potassium chloride bicarbonate bun creatinine blood sugar the patient is alert and oriented times neurologically grossly intact cardiovascular regular rate and rhythm no audible rub or murmur extremities are warm and well perfused respiratory breath sounds are decreased bilaterally with crackles at the left base gi abdomen is obese soft positive bowel sounds nontender nondistended positive bowel movement extremities right lower extremity incision is clean dry and intact the patient has dermabond over the incision sternal incision steri strips are intact no erythema or drainage is noted there is scant amount of serosanguinous drainage from the medial chest tube site with no erythema noted discharge medications lopressor milligrams po bid lasix milligrams po bid times days kcl milliequivalents po bid times days colace milligrams po bid ranitidine milligrams po bid enteric coated aspirin milligrams po q day lipitor milligrams po q hs glucotrol milligrams po q day ibuprofen milligrams po q four to six hours prn oxycodone one to two tablets q four to six hours prn dulcolax suppository one po q day prn regular sliding scale insulin for blood sugar of to give three units subcutaneous for blood sugar to give five units subcutaneous blood sugar to give seven units subcutaneous blood sugar to give units subcutaneous discharge diagnosis coronary artery disease status post cabg noninsulin dependent diabetes mellitus history of prostate cancer status post prostatectomy ten years bladder neck stricture status post dilation history of asbestosis die instructions the patient is to be discharged to a rehabilitation facility in stable condition the patient is to follow up with dr in three to four weeks the patient is to follow up with dr in three to four weeks the patient is to follow up with dr upon discharge from rehabilitation m d dictated by medquist d t job,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""m"", ""service"", ""hiof"", ""present illness"", ""this year"", ""old"", ""diabetic"", ""male"", ""with a history of atypical chest pain and dyspnea on exertion"", ""referred for cardiac catheterization after a positive stress test"", ""cardiac catheterization showed ejection fraction of left main disease"", ""left circumflex rca""],
""Medications"": [""imdur"", ""lipitor"", ""glucotrol"", ""tiazac"", ""diovan"", ""aspirin""]
}"
74010,admission date discharge date date of birth sex f service medicine allergies coumadin penicillins iv contrast sulfa sulfonamide antibiotics prednisone latex attending chief complaint hemoptysis septic arthritis nstemi major surgical or invasive procedure bronchoscopy history of present illness yo female with h o htn type ii dm cad s p remote lad stent copd and recent right total knee replacement complicated by infected hardware s p removal transferred from osh for further management of hemoptysis and nstemi patient was admitted to hospital in late with right knee septic arthritis following a right total knee replacement cultures grew group b strep hardware was removed at hospital on replaced by antibiotic spacer per report the patient had bilateral dvts on noted again on lenis from at this time it appears the patient was on prophylactic dose of enoxaparin patient was then discharged to rehab following hardware removal per report she developed respiratory distress on with hypoxia and wheezing no aspiration event was witnessed there was a question of excess sedation after being re admitted to hospital she was initially treated with bipap and nebulizers with good effect iv fluids were given for hypotension and tachycardia she had a second episode of respiratory distress and was transferred to the icu for further management she then underwent diuresis and was placed on bipap she was intubated on a swan ganz catheter was placed on for hemodynamic monitoring in the setting of possible cardiogenic shock she was then started on levofloxacin and clindamycin for aspiration pneumonia and was transitioned to vancomycin cefepime and metronidazole she also received pulse dose methylprednisolone for possible copd exacerbation over past few days vent wean has been complicated by low minute ventilation and airway secretions today patient had episode of hemoptysis with cc of bright red blood suctioned through et tube bronch showed lesions in left main stem bronch near second carina one suspicious for an eroding broncholith a bleeding lesion was injected with epinephrine and iced saline with hemostasis patient was then transferred via directly to icu for further management upon arrival to the icu patient was intubated alert on minimial sedation she complained of pain in her right knee and denied any other pain past medical history copd osa htn cad s p stent to lad in left subclavian occlusion critical left internal carotid stenosis s p cea type ii dm hypothyroidism gerd dvt in bilateral social history lives in nursing home recently no history of recent tobacco or alcohol use recently family history non contributory physical exam vs t hr bp fio peep gen elderly female nad alert heent perrl eomi anicteric mmm op without lesions no supraclavicular or cervical lymphadenopathy jvd to angle of jaw no thyromegaly or thyroid nodules resp cta b l with good air movement throughout although dimished in axillae cv rr s and s wnl no r g ii vi systolic murmur at lusb with radiation to right carotid abd nd b s soft nt no masses or hepatosplenomegaly ext no c c e skin fungal rash in inguinal folds neuro alert d tr s patellar and biceps pertinent results admission 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 ck cpk alkphos totbili am blood ck mb ctropnt am blood calcium phos mg am blood type art rates tidal v peep fio po pco ph caltco base xs assist con intubat intubated am blood lactate cardiac enzymes cpk isoenzymes ck mb ctropnt probnp source line right cvl source line cvl source line picc source line central imaging cxr findings the tip of the endotracheal tube is cm above the carina there is a right ij central venous catheter with distal lead tip in the proximal svc there is a nasogastric tube whose tip and side port are below the gastroesophageal junction the cardiac silhouette is enlarged there is a left ij and subclavian central lumen catheters with the distal lead tip in the mid svc there is prominence of the pulmonary interstitial markings compatible with fluid overload there is left retrocardiac opacity and a small left sided pleural effusion tte echocardiographic measurements results measurements normal range left atrium long axis dimension cm cm left atrium four chamber length cm cm left atrium peak pulm vein s m s left atrium peak pulm vein d m s 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 left ventricle stroke volume ml beat left ventricle cardiac output l min left ventricle cardiac index l min m aorta sinus level cm cm aorta ascending cm cm aortic valve peak velocity m sec m sec aortic valve peak gradient mm hg mm hg aortic valve mean gradient mm hg aortic valve lvot pk vel m sec aortic valve lvot vti aortic valve lvot diam cm aortic valve valve area cm cm aortic valve pressure half time ms mitral valve e wave m sec mitral valve a wave m sec mitral valve e a ratio mitral valve e wave deceleration time ms ms tr gradient ra pasp to mm hg mm hg pulmonic valve peak velocity m sec m sec findings left atrium normal la size right atrium interatrial septum mildly dilated ra normal interatrial septum no asd by d or color doppler left ventricle normal lv wall thickness normal lv cavity size moderately depressed lvef no lv mass thrombus no resting lvot gradient no vsd right ventricle normal rv chamber size borderline normal rv systolic function aorta normal aortic diameter at the sinus level normal ascending aorta diameter aortic valve mildly thickened aortic valve leaflets mild as area cm mild ar mitral valve mildly thickened mitral valve leaflets moderate mitral annular calcification mild thickening of mitral valve chordae no ms mild mr due to acoustic shadowing the severity of mr may be significantly underestimated tricuspid valve mildly thickened tricuspid valve leaflets no ts mild tr mild pa systolic hypertension pulmonic valve pulmonary artery no ps pericardium trivial physiologic pericardial effusion regional left ventricular wall motion the left atrium is normal in size no atrial septal defect is seen by d or color doppler left ventricular wall thicknesses are normal the left ventricular cavity size is normal overall left ventricular systolic function is moderately to severely depressed lvef with infeior lateral anterior and apical hypokinesis to akinesis no masses or thrombi are seen in the left ventricle there is no ventricular septal defect right ventricular chamber size is normal with borderline normal free wall function the aortic valve leaflets are mildly thickened there is mild aortic valve stenosis valve area cm mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen due to acoustic shadowing the severity of mitral regurgitation may be significantly underestimated the tricuspid valve leaflets are mildly thickened there is mild pulmonary artery systolic hypertension there is a trivial physiologic pericardial effusion persantine stress test impression no anginal symptoms or additional st segment changes from baseline nuclear report sent separately nuclear imaging status post persantine stress test the image quality is adequate but limited due to soft tissue breast and left arm attenuation left ventricular cavity size is increased rest and stress perfusion images reveal a predominantly fixed moderate reduction in photon counts involving the entire inferior wall and the mid and basal inferolateral walls gated images akinesis of the entire inferior wall and the mid and basal inferolateral walls the calculated left ventricular ejection fraction is with an edv of ml impression predominantly fixed large moderate severity perfusion defect involving the pda lcx territory increased left ventricular cavity size severe systolic dysfunction with akinesis of the entire inferior wall and the mid and basal inferolateral walls knee x ray findings overlying knee brace obscures the bony detail of the knee multiple calcifications are seen in the soft tissues cement spacers are present at the distal femur and proximal tibia no definite fractures impression right knee cement spacers micro data sputum gram stain final pmns and epithelial cells x field per x field gram negative rod s respiratory culture final commensal respiratory flora absent yeast rare growth ucx yeast bcx negative x brief hospital course mrs is a yo female with a pmh significant for cad s p pci htn hld copd recent right knee replacement complicated by septic joint bilateral dvt s p ivc filter transferred from osh for management of hemoptysis and respiratory failure hemoptysis submassive in the icu bronch showed two areas of ulceration of unclear etiology and a possible polypoid lesion no diagnostic or therapeutic intervention performed by ip no further hemoptysis upon transfer to the floor discussion about repeat bronchoscopy to r o any oozing lesions prior to starting anticoagulation for dvt s per below went to ip procedure lab but ip decided she was too high risk given recent cardiac pathology see below given her stable hct and no further hemoptysis since transfer from osh suggested starting systemic anticoagulation with a heparin gtt and following up with rigid bronchoscopy under general anesthesia if repeat bleeding were to occur started hepar gtt without issue hct was stable no further interventions were needed she will need a repeat bronchoscopy with biopsy in one month when her cardiac issues have stabilized interventional pulmonology has the patient s information and said they would contact the patient for arrangement of a follow up appointment this was confimred with dr the patient was given contact information of the interventional pulmonology suite at as well as main line at with the ip fellows pager number at in the event she has not been contact within weeks of discharge the patient confirmed understanding of this issue prior to discharge hypotension acute on chronic systolic heart failure in the icu her hypotension was thought to be secondary to acute systolic heart failure secondary to her nstemi and worsening systolic function she had no evidence of distributive shock sedation also thought to be contributing dobutamine was weaned upon arrival without difficulty tte showed worsening systolic function with new ef of from baseline of upon transfer to the floors did not require further diuresis as physical exam was nt consistent with hf no sob bilateral lower extremity was present throughout duration of stay thought to be due to bilateral dvt s given depressed ef will need follow up evaluation by cardiology to assess the need for pacemaker placement once hf class can be determined with activity patient claims to have her own cardiologist but also given the number of the cardiology clinic if she would like to transition her care to the system respiratory failure likely a component of pulmonary edema from acute systolic heart failure given her improvement with diuresis low suspicion for pna pe was a possibility although less likely given ivc filter she was successfully extubated on she had no return of sob while on the general medical floors no further thoracic imaging was done to look for pe as patient was to receive systemic anticoagulation regardless for b l dvt s nstemi patient was found to have elevated cardiac enzymes with tnts peaking at bnp k mb flat no ekg changes cardiology was consulted but anticoagulation plavix and heparin gtt was held due to hemoptysis due to risk of bleeding she was treated with asa mg daily and started on a statin and metoprolol she had a tte which showed an overall left ventricular systolic function which was moderately to severely depressed lvef with infeior lateral anterior and apical hypokinesis to akinesis which is worse then her baseline ef of upon transfer to the medical floor troponin continued to downtrend no ekg telemetry changes were observed had pharmacologic stress test with persantine followed by mibi stress was negative for ekg changes anginal symptoms and mibi showed irreversible defect in the pad lcx distribution given irreversibility cath not indiciated and plavix not indciated given the duration post nstemi continued to medically manage nstemi with asa metoprolol lisinopril and high dose atorvastatin without issue placed back on home fenofibrate upon discharge not given as non formulary in house bilateral dvt patient had an ivc filter placed at an osh in mid per her son systemic anti coagulation was held as above in setting of hemoptysis however she was given sc heparin as prophylaxis after acute hemorrhaging was ruled out per above was started on heparin gtt hct stable on heparin gtt and tranisitioned to enoxaparin mg for at least months of treatment started anticoagulation given provoked development of dvts in the setting of orthopedic surgery and lack of mobility will need follow up in months with f u lower extremity ultrasounds to assess for dissolution of blood clots should be scheduled by her pcp septic right knee s p hardware removal x ray of knee showed hardware cement spacers in place she was continued on ceftriaxone grams iv daily with day one of abx treatment being will need at days worth of antibiotics with ortho f u for hardware replacement once infection has been deemed cleared discharged on pain control with mg oxycodone q hours prn and oxycontin mg patient s orthopedic surgeion dr was contact regarding this issue and faxed a discharge summary patient also provided with dr contact information chronic issues dm continued ssi regimen w o issue gerd disconitnued home ppi as past duration of therapy for gerd can restart if symptoms of gerd return copd continued albuterol ipratropium nebs prn without issue contact precautions has history of vre per osh records will need to continue on contact precautions comm patient home code full discussed with son hcp pending labs at discharge none transitional issues will need f u us for dvt reassessment in months to be completed by pcp pcp should also affirm cardiovascular follow up bronchoscopy follow up by orthopedist aware of issues and has also been provided with copies of hospital course pcp and orthopedist both faxed copies of dc summary on medications on admission medications at rehab enoxaparin mg q gabapentin mg tid metoprolol tartrate po bid fenofibrate mg daily zetia mg daily cefazolin gram iv q asa mg daily prilosec mg daily vitamin b mcg po daily vitamin d units po daily hydromorphone mg po q h prn pain meds on transfer furosemide mg iv q enalapril mg iv q h methylprednisilone mg iv q dobutamine gtt nitro paste inch q h ceftriaxone grams daily pantoprazole mg iv daily asa mg daily fentanyl gtt midazolam gtt linezolid mg x vre in urine tfs albuterol ipratropium nebs q h prn discharge medications miconazole nitrate powder sig one appl topical prn as needed as needed for rash insulin lispro unit ml solution sig per ssi per ssi subcutaneous asdir as directed 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 hr prn as needed for shortness of breath or wheezing ipratropium bromide mcg actuation hfa aerosol inhaler sig two puff inhalation q h prn atorvastatin mg tablet sig one tablet po daily daily aspirin 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 for knee pain oxycodone mg tablet sig one tablet po q h every hours as needed for pain hold for sedation rr disp qs for rehab tablet s refills metoprolol tartrate mg tablet sig one tablet po bid times a day acetaminophen mg tablet sig two tablet po tid times a day lisinopril mg tablet sig 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 enoxaparin mg ml syringe sig one subcutaneous q h every hours polyethylene glycol gram dose powder sig po daily daily as needed for constipation patient may refuse at risk for constipation given need for opiods hold if having regular bowel movements dextrose gm iv prn hypoglycemia protocol ceftriaxone gm iv q h start in am 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 magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed for constipation hold if patient is having regular bowel movements lactulose gram ml syrup sig thirty ml po tid times a day hold if patient is having regular bowel movements enema enema sig one rectal prn for constipation can use tap water enemas soap enemas and sodium phosphate enemas oxycontin mg tablet sustained release hr sig one tablet sustained release hr po twice a day hold for sedation rr disp qs rehab tablet sustained release hr s refills zeita sig ten mg once a day discharge disposition extended care facility jml center discharge diagnosis primary septic arthritis non st elevation myocardial infarction hemoptysis bilateral lower extremity deep vein thromboses secondary chronic obstrucitve pulmonary disease hypertension coronary artery disease with stenting of left anterior descending artery in internal carotid stenosis status post coronary artery dissection type ii diabetes mellitus gastroesophageal reflux disease osteoarthritis 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 dear ms it has been a pleasure taking care of you you were originally transferred to for management of multiple medical issues outlined below at the previous hospital you experience a heart attack known as a non st elevation myocardial infarction or nstemi for short it is a heart attack which occurs without changes seen on an ekg but is detected by blood tests which tell your medical team that your heart muscle has been affected you were evaluated by cardiologists here that placed you on medication to optimize your cardiac function outlined below during your stay you had a pharmacologic stress test with a medication known as persantine which mimics an exercise stress test you also had a radionucleotide test to look at the tissue and function of your heart the results of these two tests informed your physicains that having a repeat catherization of the vessels of your heart would not be beneficial at this time thus you should continue to take your cardiac medication as prescribed to decrease the risk of having another cardiac event in the future additionally you will need to follow up with a cardiologist you can follow up with your own cardioloigst or the number of the cardiology department at has been provided for you to make a follow up appointment at your convenience at the outside hospital you had an episode of coughing up blood while you were intubated this phenomenom is known as hemoptysis given this condition the physicians at reimaged your airway while you were in the icu and found an ulceration in one of the larger airways bronchus intermedius with friable mucosa this was most likely thought to be due to airway irritation from suctioning while you were intubated you had prior to coming to you had septic arthritis after you right knee replacement this is a complication that can occur in patients who experience a knee replacement which you had you had your knee replacement hardware removed and cement spacers were placed between the bones of your leg for stability you will need to continue antibiotic treatment for at least four weeks with follow up with your orthopedic surgeon dr to decide when would be the best time for you to have your knee replacement performed again additionally you will need to conintue physical rehabilitation to keep the condition of your muscles up in order to optimize your recovery you have started many new medications and some of your home medications have been changed please continue to take your medications as directed ipratropium bromide mdi puffs inhaled every hours for copd albuterol inhaler puff inhaled every hours as needed for shortness of breath lisinopril mg orally daily new cardiac medication controls blood pressure helps heart muscle furosemide mg orally daily for fluid retention heart failure metoprolol tartrate mg by mouth x a day cardiac medication controls heart rate blood pressure aspirin mg daily zetia mg daily for cholesterol atorvastatin mg daily cardiac medication controls cholesterol and improves heart function reduces risk of recurrent heart attack ceftriaxone gm iv daily iv antibiotic for septic arthritis oxycodone immediate release mg every hours as needed for pain oxycontin mg x a day long acting pain medication for basal pain control enoxaparin sodium mg injections x a day for blood clots in legs insulin sliding scale for glucose control we have discontinued your prilosec mg daily aka omeprazole a medication typically used for gastric reflux the duration of being on this medication was longer than the usual therepeutic course please follow up with your primary care doctor if you have returning symptoms of reflux including heart burn sour taste in the morning it has been a pleasure taking care of you followup instructions you will need to follow up with your primary care doctor your listed pcp is at please schedule follow up within week after your discharge form rehab you will need to be seen by a cardiologist given your recent heart attack you can follow up with your own cardiologist if you have one if you would like to be seen by a cardiologist the number to our cardiology clinic is while in the hospital you were seen by md md you may try to request follow up with them if you like given your episodes of hemoptysis coughing up blood you will need to follow up with interventional pulmonology for a repeat bronchoscopy to image your airway interventional pulmonology would like you to be seen for a repeat procedure within days they have your information and will contact you for arrangement of follow up appointment dr or one of her colleagues will be in touch with you in the following weeks if you do not hear from this team within the month please call the interventional pulmonology suite at or you can call and have the number paged to speak with one of the interventional pulmonology fellows to rectify the issue you will need to be followed up by your orthopedic surgeon dr please contact him at at your convenience regarding the status of your knee and when further interventions can be performed to replace your knee,"{
""Diagnoses"": [""septic arthritis"", ""NSTEMI"", ""COPD"", ""remote lad stent"", ""infected hardware"", ""SP removal"", ""hemoptysis"", ""type II DM"", ""CAD"", ""s p remote lad stent"", ""bronchoscopy"", ""history of present illness"", ""yo female with h o htn"", ""latex allergy""],
""Medications"": [""coumadin"", ""penicillins"", ""iv contrast"", ""sulfa"", ""sulfonamide"", ""antibiotics"", ""prednisone""]
}"
41782,admission date discharge date date of birth sex m service neurosurgery allergies trazodone naltrexone wasp venom yellow hornet venom honey bee venom attending chief complaint trauma major surgical or invasive procedure right craniotomy for evacuation of hematoma peg placement history of present illness y o male motorcycle vs car unresponsive at scene gcs and therefore he was intubated at the scene he was found to have absent r lung sounds requiring needle decompression with rush of air pt was transfered to for further care past medical history multiple motorcycle accidents what injuries prev oxycontin addiction now on methadone social history unknown family history non contributory physical exam on admission p bp palp intubated sedated and paralyzed pupils fixed mm bilaterally bilateral hemotympanum blood in the right ear canal bilateral breath sounds r chest tube in place no chest crepitus heart rrr abdomen soft nt nd abrasion r hand contusion bilateral knees contusion left pretibia contusion right occiput pt had purposeful movement of right upper extremity when sedation was held on discharge aox following complex commands slight left ptosis perrla eoms full tongue midline mae with full and equal strength walking the floor without assistance good comprehension fluent speech pertinent results labs 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 plt count pm pt ptt inr pt pm fibrinoge pm type art o po pco ph total co base xs aado req o intubated intubated pm lipase pm asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg pm urine bnzodzpn pos barbitrt neg opiates neg cocaine neg amphetmn neg mthdone pos imaging ct head noncontrast impression large right epidural hematoma adjacent to right temporal fracture hemorrhagic contusion in the left inferior frontal and temporal lobe small extra axial hemorrhage along the left posterior frontal lobe complex skull base fracture as detailed above extending along the sphenoid at the midline and laterally to involve both temporal bones diffuse ventricular sulcal and cisternal effacement portable cxr single bedside frontal radiograph of the chest an endotracheal tube is in place terminating cm above the carina the lung volumes are low there is no pleural effusion or pneumothorax there is no focal consolidation ct cervical spine impression no acute fracture or traumatic malalignment involving the cervical spine extraaxial blood about the cord at the foramen magnum likely reflects tracking from blood seen in the basilar cisterns ct chest abdomen pelvis impression et tube and og tube positioned appropriately right chest tube tip terminates at the right lung apex bilateral posterior lung consolidations likely represent combination atelectasis aspiration localized hemothorax at the right apex tiny right pneumothorax could represent the sequelae of chest tube insertion no acute injuries in the abdomen or pelvis postoperative ct head noncontrast status post right craniotomy and evacuation of epidural hematoma the majority of the epidural blood is no longer present there is a small amount of expected pneumocephalus and small amounts of residual blood products on the left side note is made of subarachnoid and parenchymalhemorrhage unchanged from the comparison study and most notable in the left frontal and temporal lobes there is no new intracranial hemorrhage edema or mass effect the degree of mass effect exerted by the right epidural hematoma has been alleviated the previously noted hemorrhage on the right side of the foramen magnum upper cervical region is decreased on the present study a small hypodense area in the left temporal lobe poster medially is unchanged extracranial soft tissues reveals small amount of subgaleal gas as expected given the recent procedure intracranial drain entering the cranium at the superior margin of the osseous surgical defect and with the tip terminating in the right middle cranial fossa cta head the major intracranial arteries are patent no flow limiting stenosis or occlusion is noted ct head noncontrast impression no significant interval change compared to postoperative study ct sinus mandible maxillofacial noncontrast findings again seen are multiple complex facial skull base and temporal fractures facial fractures include comminuted nasal fractures skull base fractures include the sphenoid body and both greater wings extending into the bilateral carotid canals high attenuation material persists in the left maxillary sinus sphenoid sinuses and ethmoid air cells compatible with evolving blood products note is made of mild pan nasal mucosal thickening and aerosolized secretions the frontal sinuses are under pneumatized bilateral haller cells are present right greater than left the lamina papyracea and cribriform plates are intact type olfactory fossa are noted bilaterally there is mild s shaped deviation of the nasal septum apparently due to an acute fracture with a rightward bony spur that does not obstruct the middle meatus orbits and intraconal structures appear preserved in the right temporal anterior longitudinal fracture involves the mastoid and petrous segments and extends into the middle ear there is dislocation of the incus from the maleus in the left temporal a transverse fracture involves the petrous portion extending to the temporomandibular joint anteriorly and the middle ear posteriorly there is high density fluid within both external auditory canals extending into the middle ears with complete encasement of the auditory ossicles and partial opacification of the mastoid air cells structures of the inner ear including the cochlea vestibule semicircular canals and internal auditory canals appear intact changes of right temporal craniotomy are noted with lateral fixation plate and screws moderate soft tissue swelling and trace subcutaneous gas is noted overlying the craniotomy site residual pneumocephalus is present in the right middle cranial fossa along with a heterogeneous extra axial fluid collection measuring up to mm in depth hemorrhagic contusions measuring x cm in the left temporal lobe and x cm in the left frontal lobe continue to evolve subarachnoid hemorrhage along the left cerebral and convexity and suprasellar perimesencephalic cistern also persists the ventricles and basal cisterns are persistently effaced there is contour deformity of the inferior left maxilla with abnormal lateral concavity and absence of the maxillary left bicuspids and molars suggesting remote injury on the right the maxillary second molar is absent with fluid opacification of the bony cavity and erosion of the lateral maxillary wall the mandible appears intact but there is absence of the left mandibular first and second bicuspid and the right mandibular second bicuspid upper cervical spine alignment is preserved note is made of congenital non fusion of the posterior arch of c impression multiple facial skull base and temporal fractures as described above extensive blood throughout paranasal sinuses and middle ear structures incomplete dentition right craniotomy with residual epidural blood products left frontotemporal hemorrhagic contusions and multifocal subarachnoid hemorrhage ct head noncontrast stable appearance of brain with multiple fractures right craniotomy and residual extra axial fluid collection left frontotemporal contusion diffuse subarachnoid and subdural hemorrhage global cerebral edema and blood in paranasal sinuses and middle ear cavities chest xray lung volumes are low the new left sided picc tip is difficult to see but extends at least into the right atrium and should be pulled back by at least cm supine portable view exaggerates the cardiac size there is bibasilar atelectasis but otherwise the lungs appear clear there is no pleural effusion or pneumothorax ct orbit impression complex longitudinal right temporal fracture involving middle ear with mm incudomalleal diastasis given the large amount of surrounding blood it is difficult to determine whether this finding represents true dislocation repeat imaging following resolution of hemorrhage would be helpful nondisplaced transverse left temporal fracture extending through middle ear and mastoid segment of the facial nerve canal multiple facial and skull base fractures better evaluated on prior maxillofacial ct decreased sinus hemorrhage and evolving intracranial hemorrhage ct head impression continued evolution of left inferior frontal and temporal hemorrhagic contusions with expected decreased density of edema but no increase in the hyperdense hemorrhagic components and no increased mass effect stable small residual right extra axial collection evalution of subarachnoid hemorrhage is limited by artifacts diffuse cerebral edema grossly unchanged allowing for artifacts multiple skull base bilateral temporal and facial fractures better assessed on prior studies cxr negative brief hospital course on the patient was transferred to the operating room emergently for right epidural hematoma evacuation on repeat ct head was stable epidural drain was removed patient not responding to commands plastic surgery was consulted for extensive facial fractures he was started on a day course of clindamycin and placed on sinus precautions for sinus fractures no urgent intervention required on dilantin dose was increased ct head was stable and the patient was started on precedex and fentanyl infusions in an attempt to wean sedation for extubation he had no cough or gag reflex so extubation was deferred on he was extubated without complication although he continued to not follow commands right chest tube was withdrawn he remained in the unit until when he was transferred to the regular floor onto the neurosurgery service ent was consulted for bilateral temporal fractures and a dedicated ct temporal was obtained pt will need an audiogram and ent followup at a later date on the patient s potassium was repleated for a level of the patient was evaluated by trauma service for gastric feeding tube the team felt that the patient was at high risk for pulling out his feeding tube once placed due to his current mental status and decisded to defer placement of a gastric feeding tube over weekend to see if patient can tolerate a po diet it was felt that he would require placement of a peg for nutrition as he was unable to take adequate po due to his depressed mental status and inability to follow commands patient was ordered for physical and occupational therapy consults who recommended acute rehab on exam the patient was more alert his diet was advanced to sips of nectar liquids the patient was transitioned to keppra for seizure prophylaxis he was started on a dose of he was noted to have right sided facial twitching that resolved within minutes the patient s potassium was repleated for a level of the patient s inr was fpund to be slightly elevated the decision was made to not reverse this inr for risk of dvt pe per dr a non contrast head ct was ordered which was stable the patient foley catheter was discontinued on the patient was neurologically stable but continued to be restless he was evaluated by speech and swallow who did not clear him for a full diet acs was consulted for peg placement inr was again elevated and it was decided to continue to monitor on a u a was obtained for preop which was postitive therefore he was started on a course of cipro a culture was added on wbc was noted to be elevated which was thought to be due to uti but inr was within normal limits he went to the or for peg placement which he tolerated well on the patient was started on tube feeds with a goal of replete with fiber at ml hr per nutrition recommendation he was switched to oral cipro for uti on overall he was somewhat brighter on exam attending to examiner but still with dysphasia nonsensical words at times he is awaiting rehab disposition pending procuration of insurance on the family requests transfer of the patient to medical center to the care of dr as it is a hardship for them to travel in and out of with the associated expenses and time off from work the transfer was not able to happen given the bed situation at dr from cognitive neurology was contact to give input regarding his care and the plans were for him to be seen on friday speech and swallow was reconsulted as patient s neuro status was improved they recommended to advance diet to soft with thin liquids pt remained neurologically stable he was started on calorie counts in hopes of weaning his tube feeds on his tf s were changed to cycle overnight only he was able to walk with physical therapy and his neurological status continued to improve with improving comprehension and speech on a family meeting was requested but do to inabilty of case management involvement the meeting was delayed a family meeting was scheduled for with case management pt ot the neurosurgery team and social work with a goal set to discuss a safe plan for the patient to return home with supervision as he no longer qualified for rehab due to his improvements in mobility and adls however the patient s mother cancelled the meeting stating that she would prefer to talk over the phone with individuals his clinical status continued to improve and he was ambulatory independently he consistently was oriented x and more appropriate when interacting he was started on calorie counts and continued to tolerate a good oral diet thus tfs were discontinued and his medications were transition to oral gen was contact and they recommend at least weeks from initial placement to remove the peg tube he had completed pt ot but continues to require cognitive therapy at this time a home plan with hour supervision is recommended as he continues to improve at the time of discharge he is tolerating a regular diet ambulating without difficulty afebrile with stable vital signs his plan of care involves hour supervision provided by family and friends outpatient occupational therapy and outpatient cognitive therapy medications on admission methadone discharge disposition home discharge diagnosis right epidural hematoma right traumatic pneumothorax multiple facial fractures including commminuted nasal fxs bilat ethmoid fxs complex skullbase fractures bilateral temporal fractures agitation confusion dysphagia uti e coli insomnia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions general instructions daily wound check 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 your week wound check in clinic 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 unless directed by your doctor do not take any anti inflammatory medicines such as motrin aspirin advil and ibuprofen etc clearance to drive and return to work will be addressed at your post operative office visit make sure to continue to use your incentive spirometer while at home unless you have been instructed not to call your surgeon immediately if you experience any of the following new onset of tremors or seizures any confusion 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 any signs of infection at the wound site redness swelling tenderness or drainage fever greater than or equal to f 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 followup with plastic surgery to follow facial fractures please call dr office to make an appointment followup with ent for bilateral temporal fractures and audiogram as an outpatient in weeks follow up with dr in the eye clinic as an outpatient in weeks for your th nerve palsy the eye clinic is followup in general surgery in early to evaluate your peg for removal call to schedule an appointment completed by,"{
""Diagnoses"": [""Trauma"", ""Motorcycle accident""],
""Medications"": [""Trazodone"", ""Naltrexone"", ""Oxycontin"", ""Methadone""]
}"
50049,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint abdominal pain sigmoid volvulus major surgical or invasive procedure open sigmoid colectomy history of present illness year old male who states that over the past days he has had intermittent crampy abdominal pains and a sensation of bloating no nausea or vomiting no fever chills or night sweats has had a watery bowel movement in the last hour positive flatus no blood per rectum no melena bending forward would help alleviate the pain he had similar pain on when he was diagnosed with sigmoid volvulus the sigmoid volvulus was reduced by sigmoidoscopy the pain in was much worse past medical history pmh hypertension hypothyroidism psh appendectomy shoulder surgeries social history lives by himself denies etoh denies tobacco family history non contributory physical exam pe vs fs gen wa wd nad cv rrr no m r g nl s s pulm cta b l abdomen nbs soft nt minimally distended extremities no edema pertinent results admission glucose urea n creat sodium potassium chloride total co anion gap alt sgpt ast sgot alk phos tot bili lipase calcium phosphate magnesium wbc rbc hgb hct mcv mch mchc rdw neuts lymphs monos eos basos plt count pt ptt inr pt discharge ua positive urine culture imaging kub findings which raise concern for early sigmoid volvulus kub similar appearance to the prior study with a distended left upper quadrant air filled viscus lack of additional change might be seen with an ileus ekg normal sinus rhythm rsr pattern in lead v early r wave transition left axis deviation no previous tracing available for comparison brief hospital course the patient was admitted to the general surgical service for evaluation and treatment of his recurent abdominal pain patient was diagnosed with recurrent sigmoid volvulus in the ed he was then admitted to icu for sigmoidoscopy and decompresion of the volvulus by the gastroenterology service this was performed and patient felt resolution of the abdominal pain for about one hour after which the abdominal discomfort returned the kub was repeated approximatelly hours after the decompression was read as unchanged at that time gastroenterology service was reconsulted they felt there was no more procedures indicated from their service and recommended surgical intervention patient was complaining of discomfort yet was quite comfortable at that time continued to pass flatus he was thus transferred to the floor from the icu and observed on the floor for days on hd he went to the operating room and resection of sigmoid colon was performed the surgery was non complicated after a brief uneventful stay in the pacu the patient arrived on the floor npo on iv fluids with a foley catheter and morphine pca for pain control the patient was hemodynamically stable neuro the patient received pca morphine with good effect and adequate pain control when tolerating oral intake the patient was transitioned to oral pain medications cv the patient remained stable from a cardiovascular standpoint vital signs were routinely monitored pulmonary the patient remained stable from a pulmonary standpoint vital signs were routinely monitored good pulmonary toilet early ambulation and incentive spirrometry were encouraged throughout hospitalization gi gu fen pre operatively and post operatively the patient was made npo with iv fluids diet was advanced when appropriate which was well tolerated patient s intake and output were closely monitored and iv fluid was adjusted when necessary electrolytes were routinely followed and repleted when necessary id the patient s white blood count and fever curves were closely watched for signs of infection on pod patient developed uti that was treated with levofloxacin wound care endocrine the patient s blood sugar was monitored throughout his stay insulin dosing was adjusted accordingly hematology the patient s complete blood count was examined routinely no transfusions were required prophylaxis the patient received subcutaneous heparin and venodyne boots were used during this stay was encouraged to get up and ambulate as early as possible at the time of discharge the patient was doing well afebrile with stable vital signs the patient was tolerating a regular diet ambulating voiding without assistance and pain was well controlled the patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan medications on admission lisinopril mg po daily synthroid mcg po daily discharge medications polyvinyl alcohol povidone dropperette sig drops ophthalmic tid times a day disp bottle refills oxycodone acetaminophen mg tablet sig tablets po every hours as needed for pain disp tablet s refills docusate sodium mg capsule sig one capsule po bid times a day as needed for constipation disp capsule s refills senna mg tablet sig one tablet po bid times a day as needed for constipation over the counter tablet s lisinopril mg tablet sig one tablet po daily daily levothyroxine mcg tablet sig one tablet po daily daily discharge disposition home with service facility homecare discharge diagnosis sigmoid volvulus discharge condition stable discharge instructions please call your doctor or nurse practitioner or return to the emergency department for any of the following you experience new chest pain pressure squeezing or tightness new or worsening cough shortness of breath or wheeze if you are vomiting and cannot keep down 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 see blood or dark black material when you vomit or have a bowel movement you experience burning when you urinate have blood in your urine or experience a discharge your pain is not improving within hours or is not gone within hours call or return immediately if your pain is getting worse or changes location or moving to your chest or back you have shaking chills or fever greater than degrees fahrenheit or degrees celsius any change in your symptoms or any new symptoms that concern you please resume all regular home medications unless specifically advised not to take a particular medication also please take any new medications as prescribed please get plenty of rest continue to ambulate several times per day and drink adequate amounts of fluids avoid lifting weights greater than lbs until you follow up with your surgeon avoid driving or operating heavy machinery while taking pain medications incision care please call your doctor or nurse practitioner if you have increased pain swelling redness or drainage from the incision site avoid swimming and baths until your follow up appointment you may shower and wash surgical incisions with a mild soap and warm water gently pat the area dry if you have staples they will be removed at your follow up appointment if you have steri strips they will fall off on their own please remove any remaining strips days after surgery followup instructions please call dr to set up an appintment in weeks you may reach her office at please call the clinic to schedule a follow up appointment at your earliest convenience at completed by [NEW_RECORD] admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint abdominal pain anastomotic leak days after sigmoid colectomy major surgical or invasive procedure exploratory laparotomy small bowel resection and sigmoid colostomy history of present illness year old gentleman presents days s p sigmoid colectomy for sigmoid volvulus with abdominal pain and distention patient has been feeling distended for the past days he was seen in the ed on for small wound infection and was discharged as he was still tolerating po diet and having bms however patient came back to the ed with abdominal pain and distention that has been progressive through the day he had formed bms and tolerated lunch without vomiting however he had been having more frequent hiccups and he has noted his abdomen getting much larger through the day he is finding it much harder to breath he reports that he has had to sleep sitting upright the previous night he denies fevers chills past medical history pmh hypertension hypothyroidism psh appendectomy shoulder surgeries social history lives by himself denies etoh denies tobacco family history non contributory physical exam on admission vs t hr bp rr l gen slightly anxious a o x lungs clear b l cv rrr nl s and s abd soft ttp diffusely more so in llq very distended no guarding slight rebound incision healing well with slight erythema at inferior aspect ext no c c e at discharge afebrile vital signs are normal heent perrla sclera anicteric eomi cv rrr no m r g chest clear b l without rhonchi or rales abd incision with small areas of wound breakdown packed with moist gauze staple line otherwise c d i and healing well colostomy pink bag with stool and gas j p site c d i gu wnl ext edema of le pt reports this is baseline pertinent results pm blood wbc rbc hgb hct plt ct am blood wbc rbc hgb hct plt ct pm blood wbc rbc hgb hct plt ct am blood wbc rbc hgb hct plt ct am blood wbc rbc hgb hct plt ct am blood wbc rbc hgb hct plt ct pm blood wbc rbc hgb hct plt ct pm blood glucose urean creat na k cl hco am blood glucose urean creat na k cl hco pm blood glucose urean creat na k cl hco am blood glucose urean creat na k cl hco pm blood glucose urean creat na k cl hco am blood glucose urean creat na k cl hco am blood glucose urean creat na k cl hco pm blood glucose urean creat na k cl hco pathology specimen diagnosis small bowel resection a b small intestinal mucosa with no diagnostic abnormalities recognized mesentery with serositis and foreign body giant cell reaction colostomy incision line c fragments of intestine with acute and chronic inflammation hemorrhage and necrosis brief hospital course the patient was admitted to the general surgical service on for treatment of an anastomotic leak pod after a sigmoid colectomy for sigmoid volvulus he presented to the ed with an acute abdomen and underwent an ex lap with a small bowel resection and sigmoid colectomy on he tolerated the procedure well on pod patient was initially well but developed hypotension and hypoxia and was re intubated there was concern for aspiration pna and subsequent sepsis and he was started on antibiotics cipro vanc flagyl zosyn and pressors he stayed in the icu while intubated and extubation occured on pod at that time he was off of pressors and his respiratory status was significantly improved he was transferred to the floor on pod and had an uneventful recovery for the rest of his hospital stay neuro the patient received fentanyl while in the icu and was transitioned to morphine for pain with good effect and adequate pain control when tolerating oral intake the patient was transitioned to percocet without problem cv aside from the aforementioned episode of hypotension on pod once the patient was transferred to the floor his cardiovascular status was stable without episodes of hypotension his home diuretics were restarted without event pulmonary aside from the re intubation mentioned above the patient remained stable from a pulmonary standpoint vital signs were routinely monitored good pulmonary toilet early ambulation and incentive spirrometry were encouraged immediately following his extubation he was up and ambulating by pod and was quite participatory in his own rehabilition gi gu fen post operatively the patient was made npo with iv fluids he received multiple fluid bolus in the icu during his period of hypotension following his icu stay he was slowly advanced in his diet which was well tolerated he began producing gas in his ostomy bag on pod and stool on pod patient s intake and output were closely monitored and iv fluid was adjusted when necessary he has baseline venous edema for which he takes diuretics at home he received lasix on several occasions to diurese extra fluid electrolytes were routinely followed and repleted when necessary id the patient s white blood count and fever curves were closely watched for signs of infection on pod he was noted to have small areas of wound breakdown these were treated with wet to dry packing endocrine the patient s blood sugar was monitored throughout his stay insulin sliding scale was adjusted accordingly hematology the patient s complete blood count was examined routinely no transfusions were required prophylaxis the patient received subcutaneous heparin and venodyne boots were used during this stay was encouraged to get up and ambulate as early as possible at the time of discharge the patient was doing well afebrile with stable vital signs the patient was tolerating a regular diet ambulating voiding without assistance and pain was well controlled the patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan he will be discharged to house rehab for ongoing wound stoma care until he feels comfortable going home where he lives by himself medications on admission alprazolam mg tablet tablet s by mouth three times a day as needed for anxiety levothyroxine synthroid mcg tablet tablet s by mouth daily lisinopril mg tablet tablet s by mouth once a day discharge medications polyvinyl alcohol povidone dropperette sig drops ophthalmic tid times a day alprazolam mg tablet sig one tablet po tid times a day as needed for anxiety lisinopril mg tablet sig one tablet po daily daily levothyroxine mcg tablet sig one tablet po daily daily polyethylene glycol gram dose powder sig one dose po daily daily for weeks disp dose refills furosemide mg tablet sig one tablet po daily daily for weeks disp tablet s refills oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain for days disp tablet s refills pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours discharge disposition extended care facility for the aged discharge diagnosis small bowel obstruction s p sigmoid colectomy with primary anastomosis on and then take back for exploratory laparotomy small bowel resection and sigmoid colostomy discharge condition good discharge instructions please call your doctor or nurse practitioner or return to the emergency department for any of the following you experience new chest pain pressure squeezing or tightness new or worsening cough shortness of breath or wheeze if you are vomiting and cannot keep down 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 see blood or dark black material when you vomit or have a bowel movement you experience burning when you urinate have blood in your urine or experience a discharge your pain is not improving within hours or is not gone within hours call or return immediately if your pain is getting worse or changes location or moving to your chest or back you have shaking chills or fever greater than degrees fahrenheit or degrees celsius any change in your symptoms or any new symptoms that concern you please resume all regular home medications unless specifically advised not to take a particular medication also please take any new medications as prescribed please get plenty of rest continue to ambulate several times per day and drink adequate amounts of fluids avoid lifting weights greater than lbs until you follow up with your surgeon avoid driving or operating heavy machinery while taking pain medications incision care please call your doctor or nurse practitioner if you have increased pain swelling redness or drainage from the incision site avoid swimming and baths until your follow up appointment you may shower and wash surgical incisions with a mild soap and warm water gently pat the area dry if you have staples they will be removed at your follow up appointment if you have steri strips they will fall off on their own please remove any remaining strips days after surgery monitoring ostomy output prevention of dehydration keep well hydrated replace fluid loss from ostomy daily avoid only drinking plain water include gatorade and or other vitamin drinks to replace fluid try to maintain ostomy output between ml to ml per day if ostomy output liter take mg of imodium repeat mg with each episode of loose stool do not exceed mg hours followup instructions please follow up with dr in the next days you can call to confirm you appointment time,"{
""Diagnoses"": [""Sigmoid volvulus""],
""Medications"": [""None""]
}"
32566,admission date discharge date date of birth sex m service cardiothoracic allergies codeine attending chief complaint known mvp since childhood asymptomatic major surgical or invasive procedure min inv mvrepair history of present illness yom known mvp followed w serial echocardiograms now with worsening mr asymptomatic past medical history mvp r inguinal hernia repair l knee arthroscopy r thumb social history lives with wife works in textile industry denies tobacco use social etoh use family history mother dies yo y physical exam admission vs hr bp rr ht wt lbs gen nad heent perrl eomi anicteric mmm nl oropharynx neck supple no jvd pulm cta bilat cv rrr sem abdm soft nt bs ext warm well perfused no c c e neuro grossly intact discahrge vs t hr sr bp rr o sat ra gen nad neuro a ox nonfocal exam pulm cta bilat rt thoracotmy incision with steris cdi abdm soft nt bs ext warm well perfused trace edema bilat pertinent results pm glucose na k pm urea n creat chloride total co pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm pt ptt inr pt pm fibrinoge am 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 radiology preliminary report chest pa lat am chest pa lat reason eval for pleural effusions medical condition year old man s p mvr reason for this examination eval for pleural effusions pa and lateral chest history mvr check for pleural effusions impression pa and lateral chest compared to and and elevation of the right lung base which became evident following extubation on may be due in part to a small subpulmonic right pleural effusion but phrenic nerve dysfunction or a subtle right lower lobe collapse is the likely reason tiny right pneumothorax is noted not clinically significant left lung is clear heart size is normal was paged to report these findings at the time of dictation dr hocardiography report complete done at am final referring physician information division of cardiothoracic status inpatient dob age years m hgt in bp mm hg wgt lb hr bpm bsa m indication mitral valve disease palpitations 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 depressed laa emptying velocity m s no thrombus in the laa right atrium interatrial septum normal ra size 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 and cavity size mildly depressed lvef right ventricle normal rv chamber size and free wall motion aorta normal ascending transverse and descending thoracic aorta with no atherosclerotic plaque normal aortic diameter at the sinus level normal ascending aorta diameter normal aortic arch diameter normal descending aorta diameter aortic valve normal aortic valve leaflets no as no ar no as no ar mitral valve moderately thickened mitral valve leaflets elongated mitral valve leaflets no mass or vegetation on mitral valve mild mitral annular calcification eccentric mr jet moderate to severe mr tricuspid valve normal tricuspid valve leaflets with trivial 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 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 conclusions pre cpb the left atrium is mildly dilated the left atrial appendage emptying velocity is depressed m s no thrombus is seen in the 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 mildly depressed lvef the ef may be overestimated in setting of mr 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 there is no aortic valve stenosis no aortic regurgitation is seen the mitral valve leaflets are moderately thickened the mitral valve leaflets are elongated with a long posterior leaflet and severe prolapse of p no mass or vegetation is seen on the mitral valve an eccentric anteriorly directed jet of moderate to severe mitral regurgitation is seen there is a trivial physiologic pericardial effusion dr was notified in person of the results post cpb on infusion of phenylephrine well seated annuloplasty ring in the mitral position trace mr there is no evidence for biventricular systolic function is preserved lvef i certify that i was present for this procedure in compliance with hcfa regulations electronically signed by md interpreting physician brief hospital course patient was a direct admission to the operating room where he had a minimally invasive mitral valve repair with ce annuloplasty band please see or report for details he tolerated the operation well and was transferred to the cardiac surgery icu in stable condition he did well in the immediate post op period was weaned from the ventilator and extubated on pod he continued to be hemodynamically stable and was transferred from the icu to the cardiac surgery floor his activity was increased with the assistance of pt and nursing on pod it was decided he was ready for discharge home with visiting nurses he is to follow up with dr in weeks medications on admission toprol xl lisinopril kcl lasix 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 furosemide mg tablet sig one tablet po daily daily for days disp tablet s refills oxycodone acetaminophen mg tablet sig tablets po every hours as needed disp tablet s refills potassium chloride meq tab sust rel particle crystal sig one tab sust rel particle crystal po once a day for days disp tab sust rel particle crystal s refills ibuprofen mg tablet sig one tablet po q h every hours for months disp tablet s refills discharge disposition home with service facility homecare discharge diagnosis s p minimally invasive mitral valve repair ce annuloplasty band pmh mv prolapse r ing hernia repair l knee arthroscopy r thumb discharge condition stable discharge instructions keep wounds clean and dry ok to shower no bathing or swimming take all medications as prescribed call for any fever redness or drainage from wounds followup instructions dr in weeks pt to call for appt completed by,{}
1276,admission date discharge date date of birth sex f service medicine allergies haldol attending chief complaint cocaine overdose overdose major surgical or invasive procedure none history of present illness the pt is a year old woman with distant pmh of sz d o who presented to ed on s p having used cocaine liquid ecstacy and klonipin w c o becoming completely rigid in upper body with b l arm extension not making sense when talking ems assessment showed no upper body rigidity but patient was not making sense when talking in pt was agitated confused combative found to have t to hr bp rr wbc cr hco ag urine tox was for cocaine serum tox negative head ct negative for acute bleed or mass cxr infiltrate in rll l wrist plain film without evidence of fracture ekg with sinus tachycardia non specific st t wave changes she received mg ativan l ns tylenol ceftriaxone x and was transferred to micu for further care in micu pychiatry and toxicology were consulted pt was managed with high dose benzos mg valium day and iv haldol for withdrawl presedex was also used during micu course micu course also notable for transaminitis on with alt ast alt ast flat alk phos and t bili hep panel pending new murmur also noted on exam echo nl arf on presentation to ed cr resolved ag and low bicarb lactic acidosis resolved fever and leukocytosis resolved repeat cxr day after admission clear other infectious w u negative urine cxs on admission negative blood cxs from admission ngtd currently pt is maintained on valium mg po q hr also mg iv q hr prn haldol mg iv bid also mg im q hr prn with improvement in her agitation she currently denies any pain just states she is sleepy past medical history infantile seizures requiring barbituate coma social history lives with her boyfriend who supports her financially and is abusing and crack cocaine as well had been working in a restaurant but not working currently high school graduate by chart report patient denies recent alcohol use by records history of alcohol abuse states she occasionally uses cocaine in denies iv drug use or heroin use smokes cigarettes denies other drug use patient is a twin her mother has been in and out of rehab uses twice daily chronically cocaine abuse alcohol use drinks day family history mother suffers from social anxiety and other types of anxiety and takes klonopin twin sister with hx of od on x in past per patient her sister twin mother and father have all had psychiatric hospitalizations in past physical exam physical exam vitals avss general sleepy easily arousable alert nad heent nc at perrl eomi without nystagmus no scleral icterus noted mmm no lesions noted in op neck supple no jvd or carotid bruits appreciated pulmonary lungs cta bilaterally without r r w cardiac rrr nl s s grade ii vi sem noted over lusb abdomen soft nt nd normoactive bowel sounds no masses or organomegaly noted extremities no c c e bilaterally skin no rashes or lesions noted neurologic mental status alert oriented x cranial nerves ii xii intact from x extremities non focal neuro exam pertinent results labs on admission pm glucose urea n creat sodium potassium chloride total co anion gap pm pt ptt inr pt pm lactate pm urine hours random pm urine ucg negative pm urine bnzodzpn neg barbitrt neg opiates neg cocaine pos amphetmn neg mthdone neg pm urine color yellow appear hazy sp pm urine blood sm nitrite neg protein glucose neg ketone tr bilirubin neg urobilngn ph leuk neg pm urine rbc wbc bacteria none yeast none epi pm urine am biur many pm glucose urea n creat sodium potassium chloride total co anion gap pm ck cpk pm ck mb ctropnt 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 labs on discharge am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood ck cpk microbiology urine cx negative blood cx negative urine cx negative blood cx ngtd fungal blood cx ngtd swab for gc chlamydia negative swab for tss and viral cx hsv negative c diff negative imaging wrist films normal appearing radiograph of the left wrist cxr question of infiltrate in the right lower lung zone dedicated pa and lateral chest recommended for complete evaluation ct head no intracranial hemorrhage or mass effect cxr no active lung disease echo left ventricular wall thickness cavity size and systolic function are normal lvef regional left ventricular wall motion is normal cxr normal chest brief hospital course pt is a yo woman who presented with acute cocaine and intoxication with hospital course complicated by withdrawl pt arrived to ed with evidence of cocaine intoxication and intoxication including urine tox elevated hr and bp slight fever and leukocytosis change in mental status per interviews with patient s mother and brother and later after she became more lucid patient herself patient determined to be chronic user of patient s vital signs were stabilized following use of lorazepam to treat acute cocaine intoxication she was transferred to the micu for further detoxification managment upon arrival in micu pt was no longer hypertensive or hyperthermic by next morning pt had no further evidence of cocaine intoxication as would expected given rapid metabolism per toxicology and psychiatry consultants patient was placed on diazepam for withdrawal initially requiring mg day per literature research high dose benzos typically required in withdrawl by hospital day three patient was more lucid and able to answer medical history questions though intermittently agitated by hospital day four patient was stabilized on a po regimen of mg of diazepam in divided doses a day to be tapered day patient was also initially on standing haldol she was tranferred to the floor with a sitter to continue her valium taper st day on floor was on mg valium q hr next day mg q hr next day mg q hr etc hospital course on floor was complicated by fever spike to and development of leukocytosis on hospital day blood cultures urine cultures c diff cultures and vaginal swab cultures were sent which were negative cxr done which was negative as patient was on standing haldol at this time a ck was ordered even though patient did not complain and was not observed to have any muscle rigidity ck returned elevated at urinalysis red cell findings were likewise consistent with nms therefore haldol was discontinued as fever and leukocytosis though to be secondary to early nms patient s fever subsided and wbc decreased to normal without any further events ck was monitored which also normalized during remainder of hospital course of note patient also noted to have elevated transaminases on admission which were followed throughout hospital course and shown to normalize prior to discharge this was thought secondary to her acute intoxication at time of presentation patient completed benzo taper on the floor and was placed on zyprexa prn for agitation she was discharged with prescription for zyprexa prn appointment with primary care clinic for follow up after hospitalization set up for week after discharge and appointment with primary care clinic for new patient physical weeks after discharge patient also set up with psychiatry follow up at health center days after discharge and with plans to offer psychiatry and social work follow up through primary care center medications on admission medications on admission none medications on transfer valium mg po q hr valium mg iv q hr prn agitation haldol mg iv bid haldol mg im q hr prn nicotine patch mg qd thiamine mg po daily multi vit qd heparin u sc qd discharge medications multivitamin capsule sig one cap po daily daily olanzapine mg tablet sig one tablet po q hr prn as needed for agitation or insomnia disp tablet s refills discharge disposition home discharge diagnosis acute intoxication with cocaine and withdrawl discharge condition stable patient completed high dose benzo taper for withdrawl without any complications remained hemondynamically stable no seizures discharged with plans for primary care and psychiatric follow up discharge instructions please contact physician if fever seizures any other questions concerns please take medications as directed please follow up with appointments as directed followup instructions appointment with at tricity mental health monday at pm location in ma provider md where phone date time provider md where phone date time will be set up with pyschiatry either through tricity mental health or through primary care doctor s office if needed md [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies haldol attending chief complaint gamma hydroxybutyrate withdrawal major surgical or invasive procedure none history of present illness y o f w a hx significant for severe withdrawal requiring a micu stay as well as cocaine abuse who presented to the ed today c o chest pain and wanting to detox from history obtained per notes as pt obtunded she stated that she didn t feel well yesterday and went to the ed was told she has a heart murmur and was asked to f u today day of admission she consumed once per hour last pm had chest pain and presented to the ed in the ed she was tachycardic in the low s but otherwise hemodynamically stable she had an initial set of cardiac enzymes that was negative her urine tox was positive only for cocaine serum tox negative she received valium mg iv x and was admitted to medicine for treatment of her likely withdrawal on the floor she became persistently more tachycardic to the s and her mental status became more disoriented she received valium mg po and the micu was called to evaluate her past medical history withdrawal required large doses of valium mg day as well as precedex was never intubated neuroleptic malignant syndrome experienced during her hospital course reaction to haldol infantile seizures requiring barbituate coma social history lives with her boyfriend who supports her financially and is abusing and crack cocaine as well had been working in a restaurant but not working currently high school graduate by chart report patient denies recent alcohol use by records history of alcohol abuse states she occasionally uses cocaine in denies iv drug use or heroin use smokes cigarettes denies other drug use patient is a twin her mother has been in and out of rehab uses twice daily chronically cocaine abuse alcohol use drinks day family history mother suffers from social anxiety and other types of anxiety and takes klonopin twin sister with hx of od on x in past per patient her sister twin mother and father have all had psychiatric hospitalizations in past physical exam t bp p r o sat ra gen pt standing in room shaky on feet alert and oriented x after much prompting forgets what has been said immediately after it s said thinks her friend is taking her somewhere wants to go smoke cigarettes also hallucinating that her boyfriend is talking to her heent nc at perrl eomi mm dry neck supple lungs cta bilaterally no w r c cv tachycardic regular difficult to appreciate a murmur at this rate but ii vi sem noted at lusb on prior exam today when pt not as tachycardic abd soft nt nd bs ext warm dry no edema radial pulses bilaterally neuro a ox but confused and hallucinating as above gait unsteady physical exam on discharge vs ra gen pt alert and oriented conversant able to remember discharge instructions neuro no hallucinations normal gait pertinent results pm urine bnzodzpn neg barbitrt neg opiates neg cocaine pos amphetmn neg mthdone neg pm glucose urea n creat sodium potassium chloride total co anion gap pm ck cpk pm ctropnt pm ck mb pm asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg pm wbc rbc hgb hct mcv mch mchc rdw pm plt smr normal plt count cxr normal ecg i and ii unusable rate normal intervals twi in iii avf v v bisphasic t in v am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood plt ct am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap pm blood ck mb ctropnt am blood ck mb ctropnt pm blood ctropnt am blood calcium phos mg pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg brief hospital course a p y o f w hx of severe withdrawal who presents with similar as well as with chest pain in the setting of cocaine use withdrawal half life of is usually minutes and withdrawal symptoms usually begin hours after last dose her last dose at pm this made her current presentation consistent with withdrawal given her tachycardia hypertension and altered mental status treatment of this is with high dose benzos which is what she required last time at doses of mg day she also did well last time with precedex which likely helped her to avoid intubation there was no indication for antipsychotics or anticonvulsants and drugs like haldol can actually precipitate seizures in this setting she was treated with high dose valium in the icu and on transfer to the floor was tapered down mg tid of valium she was discharged with this dose she was given tablets of valium to last until monday when she has an appointment at the clinic with dr to establish a drug contract she was also given tablets of zyprexa to use at bedtime on discharge her mental status was normal alert and oriented able to remember date time of f u appointments able to understand importance of calling rehab facilities she was given list of phone numbers and told to call project cope on monday to arrange residential rehab this was discussed with psych addiction consult service and medicine attending chest pain concerning that she had chest pain and ecg changes in setting of cocaine use she ruled out for mi an echo done on showed normal lv systolic fxn no significant valvular disease leukocytosis wbc elevated may have been due to stress reaction from current situation however pt also c o difficulty urinating so ua checked cxr negative possible she may have aspirated as she reports vomiting earlier today abd nontender urine culture negative here on d c wbc normal anion gap had anion gap of for unclear reasons checked urine for ketones which was negative starvation ketoacidosis if she s not taking po checked venous lactate have had other ingestion ethylene glycol methanol but didn t have any other symptoms consistent with those syndromes vision problems renal failure salicylate negative not uremic not diabetic on d c ag closed to fen pt dehydrated given sodium likely poor po intake while constantly intoxicated so given ivf in icu on floor pt transitioned to normal diet medications on admission bactrim prn uti symptoms discharge medications valium mg tablet sig one tablet po three times a day for days disp tablet s refills zyprexa mg tablet sig one tablet po at bedtime for days disp tablet s refills discharge disposition home discharge diagnosis primary gamma hydroxybutyrate withdrawal cocaine abuse delirium secondary heart murmur discharge condition good discharge instructions you should take all your medications as directed you should keep all appointments with health care providers especially the appointment on monday at pm with dr take your valium as directed do not take it more frequently you should be in touch with project cope in ma regarding joining their residential program for addiction you also can contact mental health or club in ma their phone numbers are listed below do not use gamma hydroxy butyrate followup instructions you should join the residential program at project cope you should call them by monday before your appointment you can also use club in ma they have a hour drop in service for substance abuse their phone number is the phone number for mental health is provider md phone date time provider md phone date time,"{
""Diagnoses"": [""Cocaine overdose"", ""Overdose"", ""Major surgical or invasive procedure""],
""Medications"": [""Haldol"", ""Ativan"", ""Tylenol"", ""Ceftriaxone"", ""Presedex"", ""Valium""]
}"
31488,admission date discharge date date of birth sex f service medicine allergies penicillins codeine attending chief complaint osh transfer for severe anemia acute renal failure and left leg hematoma major surgical or invasive procedure left leg debridement and lavage with vac dressing right ij central line peripherally inserted central catheter left peripherally inserted central catheter right esophagogastroduodenoscopy egd history of present illness ms is an year old female with history of atrial fibrillation anemia of unclear etiology baseline hct and asthma who presented to an osh on with malaise and le swelling after a mechanical fall one week prior she was found to be in arf with creatinine baseline and k of her hct was down from baseline her hyperkalemia was treated and she was transfered to icu for arf anemia and hypotension past medical history atrial septal defect pulmonary hytpertension chronic atrial fibrillation no anti coagulation because of frequent bleeding previously on digoxin but was d c d for hypotension y ago papillary tcc grade ii iii dx chronic anemia of unclear etiology baseline hct colonoscopy revealed mm benign polyp in descending colon diverticulitis large internal hemorrhoids barrett s esophagus with high grade esophageal dysplasia dx by egd social history lives with daughter no smoking no etoh family history non contributory physical exam physical exam on transfer to the medical floor vitals ra gen a ox nad smiling heent op clear mmm neck jvp difficult to assess because of neck size and ij catheter cv irregular ii vi sem at upper borders no g r pulm ctab diffuse expiratory wheeze no rales speaking in short sentences abd soft nt nd bs ext pedal edema bilaterally lle dressed with some serosanguinous drainage toes warm and well perfused pertinent results pertinent 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 am blood neuts lymphs monos eos baso am blood pt ptt inr pt am blood pt ptt inr pt am blood plt ct am blood pt ptt inr pt am blood fibrino am blood ret aut am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood ld ldh ck cpk totbili am blood ck mb probnp am blood ctropnt am blood caltibc vitb folate ferritn trf am blood tsh am blood cortsol epo level pending micro data blood cx negative urine cx escherichia coli organisms ml presumptive identification lactobacillus species organisms ml sensitivities mic expressed in mcg ml escherichia coli ampicillin r ampicillin sulbactam i cefazolin s cefepime s ceftazidime s ceftriaxone s cefuroxime s ciprofloxacin r gentamicin r meropenem s nitrofurantoin s piperacillin i piperacillin tazo s tobramycin s trimethoprim sulfa r lle wound gram stain final per x field polymorphonuclear leukocytes per x field gram positive cocci in pairs and clusters per x field gram negative rod s wound culture final due to mixed bacterial types colony types an abbreviated workup is performed including a screen for pseudomonas aeruginosa staphylococcus aureus and beta streptococcus susceptibility will be performed on p aeruginosa and s aureus if sparse growth or greater staph aureus coag moderate growth sensitivities performed on culture l anaerobic culture final bacteroides fragilis group moderate growth beta lactamase positive h pylori negative studies ct lle large hematoma of the medial calf located within the subcutaneous fat there is no involvement of the underlying muscle no fracture of the tibia or fibula please note the study is not tailored to evaluate the knee if there is clinical suspicion for fracture about the knee then radiographs or ct would be recommended for further evaluation cxr right sided central venous line is again seen with tip overlying the svc heart size again appears enlarged there is unchanged pulmonary congestion compared to prior study no new focal consolidations are identified lle us limited examination but no evidence of dvt in the left lower extremity tte the left atrium is mildly dilated no left atrial mass thrombus seen best excluded by transesophageal echocardiography the right atrium is moderately dilated there is mild symmetric left ventricular hypertrophy with normal cavity size and regional global systolic function lvef right ventricular chamber size and free wall motion are normal the ascending aorta is mildly dilated 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 the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function mild aortic regurgitation dilated ascending aorta this constellation of findings is c w hypertensive heart lue us no evidence of deep vein thrombosis in the left arm ct abd pelvis no evidence of retroperitoneal hematoma focal fluid density cystic structure in the retroperitoneum adjacent to the aorta the lesions is incompletely characterized without intravenous contrast but likely benign possibilities include an enteric duplication cyst or a low attenuation lymph node egd normal mucosa in the whole esophagus erosions in the antrum normal mucosa in the first part of the duodenum and second part of the duodenum otherwise normal egd to second part of the duodenum brief hospital course year old female with asthma anemia and afib transferred from an osh s p fall with lle hematoma arf anemia l lower leg hematoma occurred s p fall at home followed by plastics in house underwent i d of the wound with initial removal of cc of clot this was felt to be a large cause of her anemia a vac dressing was placed wound culture had heavy growth of mssa but this was felt to be most likely a contaminant she was initially started on vancomycin but this was discontinued went to or today for further wound debridement and now has vac dressing in place iv dilaudid was required for pain control with dressing changes acute blood loss anemia felt to be multifactorial in large part her anemia was due to her lle hematoma as evidenced by the fact that cc of clot was removed initially on her admission here however her hematocrit remained low during the remainder of her hospitalization ranging despite receiving prbc transfusions during her admission there was no evidence for iron deficiency hemolysis or b deficiency spep upep normal she was intermittently guaiac and had one episode of a small amount of brbpr on raising concern for a gi blood as a potential source of blood loss had a colonoscopy in with only a benign polyp and internal hemorrhoids gi felt that her brbpr most likely represented hemorrhoidal bleeding and there was no indication for colonoscopy later during her hospitalization she had an egd in the setting of a self limited episode of small amount of coffee grounds emesis which was only notable for mild gastritis with no evidence of active bleeding given that her hematocrit remained low hematology was consulted as well they felt there was no need for a bone marrow biopsy at this time and that her anemia is likely multifactorial but mostly related to her bleed another possibility is that her kidneys were not able to mount a sufficient hematopoietic response to her recent blood loss given her acute renal failure epo level was checked and is pending at the time of discharge she is being discharged to rehab today with a hematocrit of she will receive a unit of prbc at rehab hematocrit will be monitored there with transfusions given as needed to maintain her hct above acute renal failure arf her arf was thought to be multifactorial due to nsaids which she had been taking high doses of after the fall ace i lasix and hypotension volume depletion secondary to the hematoma renal us was normal her creatinine gradually improved with time and fluids and her creatinine is now at the time of discharge hyperkalemia resolved the renal team followed her initially while she was in house coagulopathy inr was increased to and felt likely nutritional deficiency no history of liver disease not on coumadin inr normalized with po vitamin k uti urine culture from and with k e coli resistant to cipro she completed a day course of ciprofloxacin fever pt initially had low grade temps which quickly resolved most likely due to the hematoma and her uti no evidence for pneumonia on cxr blood cultures were negative sob wheeze per the patient she has shortness of breath and wheezing at baseline she reports a long history of asthma denies any history of tobacco use so copd unlikely she had been using her albuterol inhaler at home regularly every hour but was not on long acting b agonist or steroid as an outpatient she was initially on supplemental oxygen in the icu but this was weaned quickly on the medical floor she was started on long acting inhaled steroid and beta agonist she should have formal testing with pfts when she is medically more stable afib she is not chronically anticoagulated was taking a baby aspirin as an outpatient which was held in the setting of her bleed rate control was adequate without meds anticoagulation should be considered as an outpatient aspirin will be restarted on discharge constipation on arrival to the medical floor she was severely constipated she had no bm for over one week symptoms became so severe that she had several episodes of vomiting and developed one episode of coffee grounds emesis subsequently likely from esophageal irritation or a small tear she was treated with an aggressive bowel regimen and her symptoms resolved thrombocytopenia platelets dropped from to heparin was stopped and her platelet count rose to by the time of discharge seizures pt had seizures benign brain tumor in the and has been on carbamazepime since this was continued in house but should be re addressed as an outpatient hypertension her outpatient acei was held for arf she remained normotensive while in house she will be re started on the acei upon discharge code dnr dni confirmed with patient and her daughter is her hcp dispo pt is being discharged to rehab medications on admission tegretol mg po bid lisinopril mg po daily lipitor mg po daily digoxin mg po daily lasix mg po daily asa mg po daily pantoprazole mg po daily multivitamin with iron daily ibuprofen mg po q h for past weeks allergies pcn codeine discharge disposition extended care facility northeast discharge diagnosis primary left leg hematoma acute on chronic blood loss anemia uti acute renal failure secondary gastroesophageal reflux disease asthma atrial fibrillation and seizures discharge condition vitals stable pain controlled hct stable discharge instructions you came to the hospital with a left leg injury kidney injury and anemia you will be leaving the hospital and going to a rehabilitation facility to help you continue to recover from your left leg injury and anemia you are being discharged with medications to help with your left leg pain and previously diagnosed health problems please take all medications and change wound dressing as prescribed if you develop chest pain shortness of breath or fevers you should return to the emergency room followup instructions you will be followed while at the rehabilitation facility md,"{
""Diagnoses"": [""severe anemia"", ""acute renal failure"", ""left leg hematoma"", ""major surgical or invasive procedure"", ""left leg debridement and lavage with vac dressing"", ""right IJ central line"", ""peripherally inserted central catheter"", ""left peripherally inserted central catheter"", ""right esophagogastroduodenoscopy (EGD)"", ""history of present illness"", ""MS (age 50) with history of atrial fibrillation"", ""anemia of unclear etiology"", ""baseline HCT and asthma""],
""Medications"": [""penicillins"", ""codeine""]
}"
44408,admission date discharge date service surgery allergies no known allergies adverse drug reactions attending chief complaint symptomatic right carotid stenosis major surgical or invasive procedure right carotid endarterectomy evacuation of right neck hematoma history of present illness yo m w h o multiple lacunar infarcts hld presented to ed after two eposides of dysarthria and left sided weakness each lasting about minutes which occured on the morning of admission this was witnessed by both the pt s son and wife family notes that pt had word finding difficulties and left leg weakness on presentation to the ed the pt s symptoms had resolved an ultrasound at proximal right ica stenosis he was transferred to for surgery past medical history bph hld osteopenia basal ganglial and cerebellar lacunar infarcts first lacunar infarct years ago past surgical herniorrhaphies tonsillectomy social history lives with wife in one bedroom apartment two sons live nearby and help with adls family history n c physical exam alert and oriented x vs bp hr resp lungs clear abd soft non tender ext pulses left femoral palp dp palp pt palp right femoral palp dp palp pt palp feet warm well perfused no open areas incision right neck steristripped soft no hematoma but there is ecchymosis pertinent results pm blood tsh 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 mr head w o contrast impression new small foci of slow diffusion in the left parietal lobe which may relate to small acute infarcts stable small acute subacute infarct in the right internal capsule moderate ventriculomegaly which may relate to volume loss with or without a superimposed component of nph obstruction at cerebral aqueduct no significant interval short term change compared to the recent study follow up as clinically indicated and correlate clinically cta ct head small vessel ischmic changes no hemorrhage cta moderate to severe aortic arch atheropsclerosis changes of r cea moderate atherosclerotic calcification and non calcified plaque in the left cca bifurcation and left proximal ica with approximately stenosis moderate calcification in both cavernous ica moderate stensis at the origin of one of right m branches mild irregularity of the left m without occlusion mild narrowing of the right p segment brief hospital course year old man with symptomatic right carotid stenosis was brought to the operating room on and underwent a right carotid endarterectomy the procedure was without complications postoperatively he had several issues tia on pod he developed a mild fluent expressive aphasia significant for neologisms with paraphasic errors word substitution and slight right facial asymmetry and dysarthria without other focal deficits mri showed a new small foci of slow diffusion in the left parietal lobe which may relate to small acute infarcts and stable small acute subacute infarct in the right internal capsule his symptoms completely resolved within a few hours after being started on a heparin infusion later in the day patient was noted to have new right neck swelling requiring surgical revision with hematoma evacuation atrial fibrillation on pod mr had episodes of artrial fibrillation with rapid venticular response he was briefly on amiodarone cardiology was consulted who recommended anticoagulation as his score was they felt the bilateral nature of his original neurological deficet dysarthria and left sided weakness may have been secondary to atrial fib he was started on pradaxa and is presently in sinus rhythm urinary retention uti mr had several episodes of urinary retention with post void residuals of cc he had not been on his home med of doxazosin and he also had a urinary tract infection we restarted the doxazosin and treated his uti with cipro he will follow up with his pcp regarding issue he was cleared by speech and swallow for a regular diet he has no signs of aspiration he is ambulatory with a slightly unsteady gait he worked with physical therapy who recommended home with services she was discharged to home on pod in stable condition follow up has been arranged with dr in one month with surveillance carotid duplex medications on admission exelon mg folic acid mg qday aspirin mg daily doxazosin mg po daily plavix mg asa mg discharge medications aspirin mg tablet chewable sig one tablet chewable po daily daily ciprofloxacin mg tablet sig one tablet po twice a day for the next days disp tablet s refills dabigatran etexilate mg capsule sig one capsule po bid times a day disp capsule s refills atorvastatin mg tablet sig one tablet po once a day disp tablet s refills folic acid mg tablet sig one tablet po daily daily docusate sodium mg capsule sig one capsule po twice a day disp capsule s refills exelon mg capsule sig one capsule po once a day doxazosin mg tablet sig one tablet po once a day folic acid mg tablet sig one tablet po once a day discharge disposition home with service facility vna discharge diagnosis symptomatic right internal carotid artery stenosis 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 transferred to from for surgery to remove a blockage in your right carotid artery this was felt to be the cause of the left sided weakness and speech problems called tias that you had the day of admission while you were in the hospital you had problems with an irregular heart rate called atrial fibrillation we have started you on new medications pradaxa blood thinner to prevent complications of clots associated with this irregular heart rate atorvastatin for cholesterol we have arranged follow up with a new cardiologist dr you also had a problem with urinary tract infection and urinary retention the inability to fully empty your bladder we have added new medications cipro for the next days to treat the infection division of vascular and endovascular surgery carotid endarterectomy surgery discharge instructions what to expect when you go home surgical incision it is normal to have some swelling and feel a firm ridge along the incision your incision may be slightly red and raised it may feel irritated from the staples you may have a sore throat and or mild hoarseness try warm tea throat lozenges or cool cold beverages you may have a mild headache especially on the side of your surgery try ibuprofen acetaminophen or your discharge pain medication if headache worsens is associated with visual changes or lasts longer than hours call vascular surgeon s office it is normal to feel tired this will last for weeks you should get up out of bed every day and gradually increase your activity each day you may walk and you may go up and down stairs increase your activities as you can tolerate do not do too much right away it is normal to have a decreased appetite your appetite will return with time you will probably lose your taste for food and lose some weight eat small frequent meals it is important to eat nutritious food options high fiber lean meats vegetables fruits low fat low cholesterol to maintain your strength and assist in wound healing to avoid constipation eat a high fiber diet and use stool softener while taking pain medication what activities you can and cannot do no driving until post op visit and you are no longer taking pain medications no excessive head turning lifting pushing or pulling greater than lbs until your post op visit you may shower no direct spray on incision let the soapy water run over incision rinse and pat dry your incision may be left uncovered unless you have small amounts of drainage from the wound then place a dry dressing over the area that is draining as needed take all the medications you were taking before surgery unless otherwise directed take one full strength mg enteric coated aspirin daily unless otherwise directed followup instructions please call dr office pcp to make an appointment for next week she will review monitor the new medications we have started you on dr cardiology tuesday at am dr neurology tuesday at pm department vascular surgery when wednesday at am with vascular lmob nhb building lm bldg campus west best parking garage department vascular surgery when wednesday at pm with md building lm campus west best parking garage completed by [NEW_RECORD] admission date discharge date service neurology allergies no known allergies adverse drug reactions attending chief complaint aphasia major surgical or invasive procedure none history of present illness neurology initial consult note year old right handed man was discharged from the vascular surgery service yesterday after a right carotid endarterectomy on which was prompted by tia symptoms that were found to be tissue positive mr diffusion changes initially on his recent hospital course was also notable for post operative stroke and afib he was started on pradaxa and a statin and continued on baby aspirin and his wife agree that he was neurologically stable from discharge yesterday through around or pm today the only abnormality of note relative to his prior baseline was that he had to self cath due to bph and uti related urinary retention acquired during the recent hospitalization today in the two o clock hour he and his wife were paying their bills together at home he was having no difficulty with this task then shortly after his sister arrived to visit he started speaking gibberish per his wife he says that he could understand others speech and he knew that his speech was not making any sense just he could not speak the words he wanted to say his wife says this episode was different from his initial aphasia in that this time he was saying many sounds like he was speaking a foreign language whereas before he had limited verbal output they are not sure whether this episode was like the one he expreienced in the hospital after the cea pod see dr note he denies palpitations before or during this episode no other symptoms see ros below the gibberish speech resolved within an hour or less while they were at ed this osh noted a left facial droop on he had a right facial droop which improved during his visit there due to the improvement in his symptoms and recent surgery they did not give iv t pa they got nchct and ct neck which were unrevealing routine lab studies and vitals were reportedly unremarkable except for a mildly elevated wbc they transferred him here for neurologic evaluation and we were consulted in addition to the vascular surgery team dr vascular fellow and dr attending on call plan to admit him to the vascular service and are interested in opinions from our service and from cardiology who made the initial recommendation for pradaxa after his post operative a fib with rvr improved with amiodarone to that point drs and had recommended in their stroke consultation note yesterday that antiplatelet therapy be stopped and that the patient be anticoagulated with warfarin not pradaxa with a heparin bridge due to rely results with increased hemorrhage risks with increased age and due to their strong suspicion that his the etiology of his strokes was cardioembolic rather than vessel to vessel thromboembolic the patient was discharged with pradaxa and aspirin and it is unclear at this time whether their recommendations which differed from those of the primary vascular team and from the cardiology consult team were known to the primary service prior to his discharge that afternoon review of systems negative except as above denies headache loss of vision blurred vision diplopia dysarthria dysphagia lightheadedness vertigo change in hearing denies difficulty comprehending speech and says speech language is back to normal now denies focal weakness numbness parasthesiae no bowel incontinence stable urinary retention presumed from uti dx here last week still self cathing and taking cipro denies cough shortness of breath denies chest pain or tightness palpitations denies nausea vomiting diarrheadenies arthralgias or myalgias denies rash except for iv related hematomas and red irritated bumpy rash on r forearm from recent hospitalization vascular surgery admission note m s p cva on subsequent r cea here at on with mild fluent expressive aphasia significant for neologisms with paraphasic errors word substitution and slight right facial asymmetry and dysarthria without other focal deficits on pod he also had newly diagnosed a fib with rvr during his admission which occurred on pod he was discharged home yesterday on pradaxa and asa daily pt returns today with aphasia which lasted approximately one hour and is now resolved to his baseline and a new left sided facial droop that is mild but persistent pt is also being evaluated by both neurology and cardiology in the ed today he initially presented to an osh where a non contrast head ct was done of the head and neck which showed no evidence of bleeding past medical history stroke tia history as above now s p r carotid endarterectomy now s p doses of dabigatran pradaxa and continued on aspirin past history of basal ganglial and cerebellar lacunar infarcts first lacunar infarct years ago mild cognitive impairment on excelon rivastigmine managed by dr neurologist in afib dx during hospitalization here at hld mild hyperhomocysteinemia facet arthritis cervicogenic traction headaches bph on doxazosin uti currently on cipro elevated wbc on urinalysis but all urine cultures negative no growth osteopenia double hernia repair y ago the last time i was in the held in the hospital before this month remote h o tonsillectomy social history lives with wife married years navy veteran retired insurance salesman walks eats other adls independent at baseline but cannot remember what he ate for breakfast memory problems x years per wife smoking ex pipe smoker quit many years ago alcohol never illicits denies family history mother died stomach ca father died rectal ca sibs brother mi brother died lung ca children sons with and had mental health problems and died after motorcycle accident there is no history of seizures developmental disability learning disorders migraine headaches strokes less than neuromuscular disorders or movement disorders physical exam admission physical examination vital signs on my exam bp s hr regular rr low s with speech non labored sao on l nc afeb f at triage general lying in bed awake cooperative nad frequently c o needing to urinate again in urinal positioned the whole time between his legs says he is a bit cold but otherwise comfortable and back to normal heent steri strips and mild underlying swelling over right upper neck no scleral icterus mucous membranes are moist no lesions noted in oropharynx neck supple no bruits that i can appreciate in loud ed no lymphadenopathy pulmonary lungs cta anteriorly non labored breathing cardiac rrr normal s s no loud m r g appreciated abdomen soft non tender and non distended normoactive bowel sounds extremities wwp no cce intact radials dps neurologic examination mental status awake alert oriented to name reason for treatment able to relate history with minimal difficulty endorses baseline memory deficit attentive and able to name backward tangential at times re history prior experiences in the navy etc but re directable speech was not dysarthric language is fluent with intact repetition and comprehension normal prosody and normal affect there were no paraphasic errors or neologisms on my exam he was able to read without difficulty naming is intact to low medium frequency objects and some high frequency knuckles hammock feather of for feather moderate difficulty with high frequency objects e g ring finger and cactus in the desert what are those plants i can t remember able to follow both midline and appendicular commands memory registers objects and recalls at minutes with hint cannot get honesty even from multiple choice calculation was intact answers seven quarters in there was no evidence of apraxia or neglect or left right confusion pt blinks deliberately and frequently using whole forehead cranial nerves i olfaction not tested ii perrl to mm brisk visual fields are full iii iv vi eoms full and conjugate no nystagmus v facial sensation intact and subjectively symmetric to light touch v v v vii left facial weakness evident on smile left lips cheek do not elevate moreso than at rest minimal to no dysarthria evident pt can pronounce all consonants ba la ma ca pa etc no ptosis no flattening of either nasolabial fold brow elevation is symmetric eye closure is strong and symmetric viii hearing grossly intact ix x palate elevates symmetrically with phonation equal strength in trapezii bilaterally xii tongue protrusion is midline motor no drift but some cupping of the right hand with eyes closed repeatable no asterixis no tremor normal tone in the right arm but paratonia in the left arm and both legs no spasticity or flaccidity delt bic tri we ff fe io ip q ham ta tes gastroc l r the right triceps and fe weakness not docmented previously sensory no gross deficits to pinprick in any extremity joint position sense is mildly decreased in the left great toe and more significantly impaired in the right cold sensation is impaired in the feet and distal les but present in the hands and face eyes closed finger to testing revealed no proprioceptive deficit did not miss reflexes left right pec delt biceps triceps brachioradialis quadriceps patellar gastroc soleus achilles plantar response was flexor bilaterally coordination finger finger testing with no dysmetria or intention tremor mirroring arm behavior was normal with minimal to no overshoot no dysdiadochokinesia noted on rapid alternating movements of hands but there is poor rhythm toe tapping with the left foot gait deferred bed urinal discharge physical examination slight dysarthria no evidence of aphasia cn examination reveals right facial droop and no other findings full strength and decreased temperature and propriocption in the les and no ataxia increased tone in legs reflexes diminished in legs and plantars flexor bilaterally pertinent results laboratory investigations admission 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 other pertinent labs am blood alt ast alkphos totbili am blood cortsol am blood albumin calcium phos mg inr trend am blood pt ptt inr pt am blood pt ptt inr pt am blood pt ptt inr pt am blood pt ptt inr pt am blood pt ptt inr pt am blood pt ptt inr pt 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 neg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks tr pm urine rbc wbc bacteri few yeast none epi am urine mucous rare am urine color yellow appear clear sp am urine blood lg nitrite neg protein glucose neg ketone neg bilirub neg urobiln neg ph leuks sm am urine rbc wbc bacteri few yeast none epi transe micriobiology am urine source catheter urine culture pending radiology mr head w o contrast study date of pm findings in comparison with the most recent mri examination a new small focus of restricted diffusion is identified lateral to the caudate nucleus on the left measuring approximately mm in size image series persistent foci of restricted diffusion are identified in the left parietal region and and right basal ganglia grossly unchanged since the prior study diffuse and confluent areas of high signal intensity are identified in the subcortical and periventricular white matter consistent with chronic microvascular ischemic disease similar areas are identified in the pons and lacunar ischemic changes in both cerebellar hemispheres there is no evidence of acute intracranial hemorrhage or mass effect unchanged prominent sulci and ventricles likely age related and involutional in nature the orbits are unremarkable as well as the mastoid air cells and the paranasal sinuses impression new focus of restricted diffusion identified in the left cerebral hemisphere lateral to the body of the caudate nucleus image series unchanged areas of restricted diffusion in the left parietal region and right basal ganglia as described above unchanged confluent areas of high signal intensity in the subcortical white matter on flair and t weighted sequences likely reflecting chronic microvascular ischemic disease carotid duplex normal right carotid system approximately stenosis involving the left ica at its origin resulting from a calcific plaque cardiology tte complete done at pm final conclusions the left atrium is mildly dilated no atrial septal defect or patent foramen ovale is seen by d color doppler or saline contrast with maneuvers there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded 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 trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened trivial mitral regurgitation is seen the estimated pulmonary artery systolic pressure is high normal there is no pericardial effusion impression suboptimal image quality mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function aortic valve sclerosis dilated thoracic aorta no definite structural cardiac source of embolism identified these findings are c w hypertensive heart brief hospital course rhm with a past history of prior multiple lacunar infarcts hld symptomatic right ica with new acute embolic infarcts in the right internal capsule and caudate nucleus on mri s p cea and complicated by right neck swelling requiring surgical revision transient aphasia attributed to hypoperfusion due to focal left m stenosis with new post op left parietal lobe infarct on mri new af on initially treated with dabigatran and aspirin and latterly with aspirin and warfarin who re presented on with recurrent transient aphasia likely secondary to recurrent hypoperfusion related to left mca stenosis with a new infarct lateral to the left caudate nucleus seen on mri patient was initially admitted to the vascular surgery service and transferred to the stroke neurology service on patient had bp dependent aphasia and bp lowering medications were stopped and eventually stopped with no symptoms on ambulation or on pt evaluation patient had urinary retention and urology were consulted who recommended intermittent straight cathing however he did not tolerate removal of catheter and had a catheter replaced due to his high inr he had clots requiring re insertion of a wide bore foley catheter by urology patient was admitted to vascular surgery on transferred to neurology on and discharged on with vna and home pt he has stroke vascular surgery and urology follow up neurology his previous episode of aphasia had been in the context of a sbp in s and symptoms resolved with a sbp in s his initial episode had occurred on pod when he developed a mostly fluent aphasia in the setting of a borderline bp s in the setting of iv nitroglycerine for hypertension as above this was felt hypoperfusion due to multisegmental mca stenoses and he was followed by the stroke consult service he was also started on a high dose statin initial cta revealed a tight left m stenosis without clear new infarct and mri showed a small left parietal lobe infarct and stable small acute subacute infarct in the right internal capsule in addition to ventriculomegaly he was started on iv heparin but this was stopped after he developed neck swelling and required revision and hematoma evacuation and he was continued on aspirin and clopidogrel due to the bleeding post extubation he developed new af atrial flutter with rvr on and this was treated with amiodarone cardiology were consulted he was transitioned to dabigatran although the preference of neurology was warfarin he was discharged on with aspirin and dabigatran patient was readmitted on the following day after a further transient episode of speaking gibberish which sound similar to his initial presenting symptoms and what neurology had witnessed on the floor on examination patient had a right facial droop with mild dysarthria and no evidence of aphasia with good strength and decreased temperature and proprioception in the les no ataxia with increased tone in legs brisker reflexes in the rue and diminished reflexes in the legs and plantars flexor bilaterally repeat mri revealed a new focus of restricted diffusion in the left cerebral hemisphere lateral to the body of the caudate nucleus and an unchanged areas of restricted diffusion in the left parietal region and right basal ganglia with small vessel disease a search for possible embolic sources was performed and patient had a limited but normal echo with ef with mild symmetric lvh with preserved global biventricular systolic function aortic valve sclerosis dilated thoracic aorta and no definite structural cardiac source of embolism identified furthermore carotid ultrasound demonstrated a normal right carotid system with approximately stenosis involving the left ica at its origin resulting from a calcific plaque patient was monitored on telemetry and ua was negative with am cortisol he was advanced on a regular diet shortly after admission and had problem taking pos neurology recommended changing dabigatran to warfarin and the likely cause of his symptoms was felt to be hypoperfusion due to his high grade left m stenosis he was therefore bridged from heparin to warfarin and heparin drip was stopped on after his inr was therapeutic he was continued on aspirin the patient had further episodes of transient expressive aphasia in the setting of reduced bps generally with sbp that would resolve within minutes to hour given this all bp lowering medications doxazosin were stopped including tamsulosin neurosurgery were consulted regarding potential stenting for his left m stenosis and they felt that this was too high risk patient was transferred to the neurology service on the patient s cardiologist will monitor his inr on discharge inr was on discharge and patient was instructed to have his inr rechecked on patient had no further aphasia and his bp remained mainly in the s s although when working with pt when sbp fell into s and he did not have recurrence of his aphasia patient was assessed by pt ot who recommended home pt he was discharged home with home pt and vna on he has neurology follow up cvs patient had an echo as above due to his above aphasia the goal was to keep his systolic bp between no pressors were used for this but all bp lowering agents were stopped his bp remained mainly in the s s although when working with pt when sbp fell into s he did not have recurrence of his aphasia on his last admission he had difficulty with voiding and was recommended for straight cath at home by urology on returning to the hospital he was again having small voids and high pvr a foley was placed and his urine output picked up afterwards his cr was at baseline throughout urology was consulted again and found to have urinary retention and they recommended removal of catheter with intermittent straight caths unfortunately he did not tolerate removal of catheter with significant pain with urinary retention and this was re inserted he developed clots in his bladder and he had manual bladder irrigation urology assisted with placement of a large bore urinary catheter and they felt he was ok to go home after he drained good urine volumes following more vigorous manual bladder irrigation performed by them due to his multiple catheter insertion and on mobilising he had slight bleeding from the penile tip but this was minimal and since the patient was keen to go home he was discharged on with vna and with instructions to be vigilant of clot retention or significant penile bleeding the vna should also check that he is ok from a urological perspective he knows to represent to hospital if either of these happen he will be assessed by urology as an outpatient week post discharge for a voiding trial medications on admission aspirin daily ciprofloxacin dabigatran etexilate atorvastatin folic acid colace exelon mg daily doxazosin mg daily discharge medications aspirin mg tablet chewable sig one tablet chewable po daily daily disp tablet chewable s refills folic acid mg tablet sig one tablet po daily daily rivastigmine mg capsule sig one capsule po qday atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills warfarin mg tablet sig one tablet po once daily at pm disp tablet s refills warfarin mg tablet sig one tablet po as needed for dose changes additional mg tablets for dose changes disp tablet s refills amoxicillin pot clavulanate mg tablet sig one tablet po q h every hours for days disp tablet s refills outpatient lab work patient needs inr check on monday and faxe to dr on senna mg tablet sig one tablet po twice a day as needed for constipation for days disp tablet s refills docusate sodium mg tablet sig one tablet po twice a day as needed for constipation disp tablet s refills discharge disposition home with service facility vna discharge diagnosis primary diagnoses transient aphasia likely secondary to hypoperfusion from left middle cerebral artery stenosis new left cerebral infarct lateral to the left caudate nucleus and previously noted subacure infarcts in the right basal ganglia and left parietal lobe atrial fibrillation on warfarin secondary diagnosis urinary retention discharged with urinary catheter with clots in bladder secondary to warfarin and multiple catheter insertions and minimal penile bleeding urinary tract infection discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane neurology slight dysarthria no evidence of aphasia cn examination reveals right facial droop and no other findings full strength and decreased temperature and propriocption in the les and no ataxia increased tone in legs reflexes diminished in legs and plantars flexor bilaterally discharge instructions it was a pleaure taking care of you during your stay at the you presented with recurrent transient word finding difficulties where you were noted to be speaking gibberish similar to before you were admitted and an mri showed a new stroke on the left side in addition to older strokes from your previous admission one on the left in an area called the parietal lobe and another on the right in an area called the basal ganglia the cause of your speech difficulties was felt to be reduced blood flow due to a tight narrowing of an artery supplying the left side of your brain in the setting of lower blood pressures we therefore stopped your medications which can lower blood pressure doxazosin in addition to your tamsulosin you were changed from pradaxa dabigatran to warfarin to esure your blood is sufficiently thin in addition to a baby aspirin had an echocardiogram heart ultrasound which was not concerning and an ultrasound of your carotid arteries which showed good flow in both carotid arteries you were also seen by neurosurgery regarding any intervention and they felt that this would be too high risk your blod ppressure was controled and other than one more episode of speech difficulties you had no further episodes you also had no symptoms when working with physical therapy who recommended home pt since you are now on warfarin you will have a higher chance of bleeding if you cut yourself and especially if you hit your head if you do so please seek medical attention you should also be mindful of starting new medications including some antibiotics which can interact with warfarin in addition you will need to be mindful of your diet please see information sheets regarding warfarin you were also seen by neurosurgery regarding any intervention and they felt that this would be too high risk your next warfarin level inr wil need to be taken on monday and your cardiologist will follow the result you also developed urinary retention requiring replacement of a urinary catheter you were seen by urology who advised a trial of straight cath but when the catheter was removed you had significant pain and the catheter was replaced you also developed bleeding and this is likely due to your blood thinner and multiple catheter insertions with latterly some minimal bleeding from the tip of your penis urology saw you again and a larger catheter was placed and your bladder was irrigated from their standpoint they were happy for you to go home you must be vigilant regarding ensuring that you continue to pass urine which may indicate a blockage of your catheter by clots or worse penile bleeding if either of these occur you must re present to the hospital you have a urology appointment as below you also were found to have a possible urinary infection and we have started you on a week course of a different antibiotic to treat this you were discharged with a catheter and this will be assessed at the time of your urology appointment we tried to call your pcp to arrange but the office is closed on fridays and we have left a message if you do not hear from them please call to arrange an appointment we have arranged stroke follow up and you have vascular surgery follow up as below medication changes we started warfarin mg we increased atorvastatin to mg we stopped doxazosin and tamsulosin we stopped dabigatran pradaxa please continue your other medications as previously prescribed followup instructions your pcp will call you on monday regarding setting up a follow up appointment within week if you do not hear from them please call yourself to schedule an appointment name md when they will call on monday address phone we have arranged the following stroke follow up department neurology when monday at pm with md building sc clinical ctr campus east best parking garage you have the exisiting vascular surgery follow up appointments department vascular surgery when wednesday at am with vascular lmob nhb building lm bldg campus west best parking garage department vascular surgery when wednesday at pm with md building lm campus west best parking garage your coumadin levels will be followed by your cardiologist whose information is below md location internal medicine associates address phone fax we have arranged the following urology follow up department urology with rn when thursday at am sc clinical ctr campus east best parking garage,{}
7044,admission date discharge date date of birth sex m service neonatology history of present illness baby boy is the former and week male infant twin admitted for issues of prematurity this infant was born to a year old gravida para mother with an of blood type a antibody negative hepatitis b surface antigen negative rpr nonreactive unknown gbs rubella immune prenatal course spontaneous mono di twins concordant growth cerclage placed declined amniocentesis preterm labor on at and weeks received betamethasone and magnesium labor resolved mother remained on bed rest until the day of delivery when twin ruptured ob history spontaneous vaginal delivery in full term spontaneous vaginal delivery in full term week loss in the infant delivered on by cesarean section following rupture of membranes two hours prior to delivery no maternal fever antepartum antibiotics on physical examination nondysmorphic premature baby birth weight g th percentile discharge weight g th percentile admission head circumference cm th percentile discharge head circumference cm greater than th percentile admission length cm th percentile discharge length cm th percentile active anterior fontanel soft and flat normal s and s no murmur breath sounds slightly coarse but equal mild intercostal subcostal retractions abdomen soft nontender nondistended no hepatosplenomegaly extremities well perfused tone aga spine intact no bruising noted patent anus testes palpable bilaterally red reflex present bilaterally hospital course respiratory the baby remained in room air with mild retractions baseline respiratory rate s did not require any respiratory support currently remains in room air with a baseline respiratory rate of s no issues the baby did have an occasional episode of apnea and bradycardia he did not require any methylxanthine treatment he had some desaturation events with spits at the time of discharge the baby is without apnea and bradycardia for greater than five days cardiovascular the baby initially had no murmur but developed a soft systolic murmur a lead ekg was normal chest x ray with slightly increased heart size the baby has had a soft intermittent murmur thought to be persistent pulmonary stenosis the baby has had a baseline blood pressure with systolics in the s diastolics in the s means in the s the murmur will need to be followed as an outpatient fluid and electrolytes the baby initially had maintenance intravenous fluids enteral feedings were started soon after delivery the baby has advanced to full feedings without issue ml kg day and caloric density was increased to cal oz at the time of discharge the baby did exhibit some symptoms of reflux the baby was transitioned to ar which he is currently receiving ad lib receiving some breast milk half ar half breast milk he is taking in greater than ml kg day he is voiding and stooling without issue electrolytes soon after admission day of life the baby is currently receiving some prune juice ml p o daily for symptoms of constipation note weight length and head circumference on initial physical examination gi the baby did have some physiologic jaundice he had a peak bilirubin of on day of life and did not require any phototherapy infectious disease because of prematurity and prolonged rupture of membranes the baby initially had a cbc and blood cultures sent with a white count of polys bands lymphs platelets hematocrit with nucleated red blood cells the baby was started on ampicillin and gentamicin at hours of age the baby was clinically well the cultures were negative and the antibiotics were discontinued the baby did demonstrate some symptoms of oral thrush which was treated with nystatin with a good response this was discontinued on day of life hematology the baby did not require any blood products during this admission neurology the baby has been neurologically appropriate for gestational age no head ultrasound was indicated based on gestational age greater than weeks audiology hearing screen initially was referred bilaterally a repeat hearing screen was passed on but because of the initial referral an early follow up post discharge audiology was recommended that appointment has been set up for at a m at health alliance parents are aware of this appointment ophthalmology eye exam not indicated based on gestational age greater than weeks red reflex present bilaterally psychosocial parents look forward to their infant transitioning home with the rest of his siblings and his twin discharge disposition home with parents primary pediatrician dr parents are to make follow up appointment before the weekend care recommendations continue ad lib feeding breast milk or ar medications prune juice as above car seat position screening passed state newborn screening last screen was sent on previous screen with slightly elevated thyroid hormone normal tsh pediatrician will need to send repeat newborn screen and following thyroid hormone levels immunizations received hepatitis b vaccine immunizations recommended 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 two of the following daycare during rsv season a smoker in the household neuromuscular disease airway abnormalities or school age siblings or with chronic lung disease 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 mos of the child s life immunization against influenza is recommended for household contacts and out of home caregivers follow up with primary care pediatrician within the next several days mother is to make this appointment network fax follow up hearing screen on a m at needs repeat newborn screen by pedi to follow thyroid hormone level discharge diagnosis former premature and week twin a status post rule out sepsis with antibiotics status post circumcision intermittent murmur dictated by medquist d t job,"{
""Diagnoses"": [""prematurity"", ""issues of prematurity"", ""twin admitted for issues of prematurity""],
""Medications"": [""betamethasone"", ""magnesium"", ""cesarean section""]
}"
840,admission date discharge date date of birth sex f service ccu chief complaint v fib arrest history of present illness the patient is a year old female with no past medical history found dyspneic by her roommate in her dorm room and subsequently syncopal the bu police were called hooked up an automated defibrillator which advised shock patient was defibrillated subsequently emt arrived patient was in complete heart block with slow escape she was intubated and given epinephrine times four atropine times three she subsequently became tachycardiac again went into ventricular fibrillation was shocked times two and started on lidocaine bolus and then drip she was then transported to in the emergency department patient was given liters of fluid she was given magnesium and charcoal gm of iv calcium her workup included a head ct which was negative chest ct showed no evidence of pe subsequently in the emergency department patient was becoming progressively more hypoxic and difficult to ventilate requiring bagging and continuous suctioning of pink frothy secretions chest x ray showed pulmonary edema she became more hypotensive as well with a nadir blood pressure in the s to s systolic requiring neosynephrine drip with sedation and paralysis she became easier to ventilate after that she was then transferred to the cardiac catheterization lab on mcg per kg of neosynephrine for pa catheterization and intra aortic balloon pump placement past medical history none allergies no known drug allergies medications on admission adderall which is dextroamphetamine and racemic amphetamine oral contraceptive pills ephedrine containing diet medication social history the patient is a sophomore at family history no history of sudden death no history of coronary artery disease physical examination on admission temperature rising to heart rate in the s to s blood pressure s to s systolic s to s diastolic o sat ranging from to on o and of peep in general intubated sedated overbreathing the vent heent charcoal stained et tube carotid pulses thorax coarse bilaterally breath sounds cardiovascular exam regular tachycardiac no rv heave distant heart sounds extremities warm with no edema neurological exam intubated sedated thrashing about and bucking vent one episode of extensor posturing laboratory data on admission white blood count hematocrit platelets pt ptt inr sodium potassium chloride bicarbonate bun creatinine glucose alt ast alka phos bili ck mb troponin less than lactate at a m was at a m was and at p m was free calcium was urinalysis showed specific gravity of greater than with greater than protein no glucose trace ketones no leukocyte esterase to rbcs to white blood cells ua showed similar results serum tox no aspirin alcohol acetaminophen benzos no barbiturates no tricycles urine tox was positive for amphetamines otherwise negative abg was patient was put on imv with settings of fio and of peep chest x ray showed initially mild interstitial edema at a m and at p m showed worsening chf and interval placement of a right ij sheath head ct showed no evidence of acute bleeding or intracerebral hemorrhage chest ct showed no evidence of pulmonary embolism patchy bilateral opacities ekg taken from strips from the emts showed complete heart block with slow junctional escape then sinus then v fib after shocking back to sinus ekg on arrival showed sinus tachycardia with normal axis echocardiogram showed global hypokinesis with severely depressed lvef left atrium was normal in size left ventricle mildly dilated right ventricle normal in size right ventricular systolic function was somewhat depressed mr no pericardial effusion the patient was taken to the cardiac catheterization lab where pa cath showed ra mean of rv of pa of pulmonary capillary wedge pressure of to pa sat of cardiac index of patient was placed on dopamine in the cath lab neo synephrine was weaned off and an intra aortic balloon pump was placed left sided catheterization showed a right dominant system with normal coronary arteries impression the patient is a year old female status post v fib arrest now in normal sinus rhythm in cardiogenic shock with nonischemic cardiomyopathy of unclear etiology and arrhythmia of unclear etiology hospital course cardiovascular coronaries there was no evidence of ischemia during initial evaluation and cardiac catheterization showed no evidence of lesions in the coronary arteries pump initially the patient was found to be in cardiogenic shock requiring intra aortic balloon pump and pressors including dopamine and dobutamine with global hypokinesis and ef estimated to be about with depressed cardiac output and cardiac index on dopamine and dobutamine were slowly weaned repeat echocardiogram was performed which showed no significant interval change from echocardiogram done on admission patient s cardiac output and index remained stable off the pressors the intra aortic balloon pump was discontinued on pressures continued to be consistently with mean arterial pressures greater than patient was gradually diuresed with iv lasix and over the course of the next three days achieved a euvolemic volume status rhythm the patient was started on an iv amiodarone drip as prophylaxis against further episodes of ventricular fibrillation after two days there were no episodes of significant ectopy and amiodarone was discontinued and then changed to p o amiodarone from onward patient was no longer having episodes of hypotension no longer requiring pressors and no longer needed arterial line or pa catheter monitoring and these were discontinued at this time it is still unclear what the etiology of the cardiomyopathy is possibilities include viral myocarditis as well as the possibility of drug ephedrine induced myopathy pulmonary the patient was initially intubated for hypoxic respiratory failure secondary to cardiac arrest was maintained on a propofol drip for adequate sedation while intubated as patient was often fighting the vent when off sedation settings were kept on assist control with several episodes of acute desaturation whenever patient was moved the pulmonary service was consulted and recommended decreasing the tidal volume as well as the fio as well as further diuresis all of which were done by fio had been weaned down to and assist control was changed over to pressure support of and peep of with continued adequate oxygenation as well as ventilation sedation was gradually titrated down and patient continued to have adequate tidal volumes on pressure support chest x ray on showed evidence of left lower lobe opacity consistent with atelectasis post suctioning and repositioning as well as aggressive chest p t these chest x ray findings resolved and there were no further episodes of desaturation from the pulmonary edema standpoint patient was started on captopril for afterload reduction which she tolerated well and captopril was increased gradually to mg p o t i d she continued to have adequate oxygenation and ventilation and no further evidence of pulmonary edema on she began to develop increasing stridor as well as copious secretions which were becoming more profound pulmonary consult recommended a tracheostomy which was performed on by interventional pulmonology after tracheostomy placement trials of mask ventilation through the tracheostomy allowed adequate tidal volumes as well as oxygenation and ventilation with simv as backup at night infectious disease on initial presentation to the cardiac intensive care unit patient was noted to have a fever of blood cultures were sent as well as chest x ray and urinalysis none of which grew any bacteria there was no evidence of infiltrates and no evidence of a urinary infection antibiotics were started with vancomycin levofloxacin and flagyl for broad spectrum coverage for possible seeding from line placement in the emergency department patient continued to be febrile for several days then running a low grade temperature of about to throughout her hospital stay with no further spiking fever antibiotics were discontinued on day seven there was no further evidence of bacterial infection with negative blood cultures on repeated occasions as well as negative urinalysis patient was noted to have some conjunctivitis on the second day of her hospital stay viral cultures were sent from swabs from the eye and showed no evidence of any viral growth neuro the patient suffered a significant amount of hypoperfusion and anoxic brain injury due to the cardiac arrest for the first four days she was on propofol sedation and neurological status was somewhat difficult to assess however after propofol was discontinued there was very little evidence of purposeful movement very little withdrawal to pain and patient was not able to follow commands consistently at times she was noted to have dilated pupils and gaze deviation which resolved on their own eeg was performed the results of which seemed consistent with medication related effect versus toxic metabolic injury there was no evidence of seizure activity mri showed diffuse anoxic brain injury with multiple areas of cortical white matter infarcts head ct showed no evidence of edema however on funduscopic exam there was some evidence of papilledema the head of the bed was elevated but given the mildness of the increased intracranial pressure there was no indication for using diuresis with mannitol or administration of steroids neurology service was consulted and felt that the overall prognosis for recovery was minimal given the findings on mri as well as the prognosis post cardiac arrest with chance for permanent disability with only about chance of any significant functional improvement these findings were conveyed to the family who still are maintaining hopes of eventual recovery fluids electrolytes and nutrition the patient was initially started on tube feeds as well as reglan for promotility and colace and senna for a bowel regimen on patient underwent percutaneous endoscopic gastrostomy placement by the gastroenterology service without complications this will be used for further tube feedings access initially the patient had a right internal jugular cordis for central access this was then resited to a left internal jugular cordis on central access was then discontinued on as there was no further need for any central access medications or monitoring arterial line placed on was continued until when a line monitoring was no longer needed on a peripherally inserted central catheter was placed for long term access further hospital course to be dictated at a later date m d dictated by medquist d t job [NEW_RECORD] name unit no admission date discharge date date of birth sex f addendum the anticipated date of discharge for this patient is she will be transferred to a hospital in near her home for further care increasing white count to she additionally had increased secretions and a mild tachycardia with a sinus tachycardia of she also had a possible left retro cardiac infiltrate blood cultures urine cultures sputum gram stain and cultures were sent and she was started on levofloxacin mg last dose on and clindamycin mg intravenously q eight hours with the last dose on as well for empiric coverage for aspiration pneumonia the patient s discharge medications are as follows discharge medications amiodarone mg p o q day captopril mg p o three times a day combivent inhaler q six hours one to two puffs reglan mg ng twice a day metoprolol mg p o twice a day heparin units subcutaneously twice a day clindamycin mg intravenously q eight last dose to be given for aspiration pneumonia levofloxacin mg p o q last dose for aspiration pneumonia tylenol mg p o or p r q six hours p r n fever m d dictated by medquist d t job,"{
""Diagnoses"": [""Dyspnea"", ""Complete heart block"", ""Tachycardia"", ""Ventricular fibrillation"", ""Hypoxia"", ""Pulmonary edema""],
""Medications"": [""Epinephrine"", ""Atropine"", ""Lidocaine"", ""Calcium"", ""Magnesium"", ""Charcoal""]
}"
26499,admission date discharge date date of birth sex m service medicine allergies codeine attending chief complaint diabetic ketoacidosis major surgical or invasive procedure none history of present illness m pmh diabetes transferred from an osh for dka per the family s report the patient s girlfriend found him obtunded at home this morning she noted that the patient had vomited and be incontinent of stool which was described as watery diarrhea the patient s girlfriend reported that he had not been feeling well for days prior to admission although the complaints were very non specific of note he had a few days of abd pain and had stopped taking insulin because he wasn t feeling well he was brought to the osh and found to have a bs of k of and ph of he was started on an insulin gtt and given amp of nahco in l ns and a dose of unasyn he was transferred to for managment of dka in the ed the patient was afebrile with a bg of k ag abg wbc and a positive urine tox screen he was started on an insulin gtt given l ns and had of uop past medical history diabetes type i dx d at age when he presented in dka followed at clinic bipolar d o depression no suicide attempts social history lives in with his girlfriend smokes roughly pack a day but may have quit a few months ago denies etoh use reports h o cocaine use most recently days ago the patient was working as a painter but has not worked in several days family history dm father gms liver ca father mi pgm age htn hypercholesterolemia cad physical exam vs ra fs gen somnolent nad heent peerl mm dry neck supple no lad cor hyperdynamic precordium non displaced pmi tachycardic rr nl s s ii vi non radiating systolic murmur loudest in llsb lungs ctab l abd hypoactive bs soft nt nd guaic negative neuro arousable oriented to person only responds to verbal stimuli perrl eomi mafe ext wwp radial and dp pulses pertinent results pm glucose k pm glucose urea n creat sodium potassium chloride total co anion gap pm calcium phosphate magnesium pm urine hours random pm urine bnzodzpn neg barbitrt neg opiates neg cocaine pos amphetmn neg mthdone neg pm urine color straw appear clear sp pm urine blood sm nitrite neg protein neg glucose ketone bilirubin neg urobilngn neg ph leuk neg pm urine rbc wbc bacteria few yeast none epi pm glucose lactate na k cl pm freeca pm glucose urea n creat sodium potassium chloride total co anion gap pm estgfr using this pm lipase pm wbc rbc hgb hct mcv mch mchc rdw pm hypochrom normal anisocyt normal poikilocy macrocyt normal microcyt normal polychrom normal ovalocyt pm plt smr normal plt count pm pt ptt inr pt ct abd pelvis limited study without intravenous or oral contrast normal appendix no evidence of free fluid or free air in the abdomen no acute inflammatory process ct head no evidence of intracranial hemorrhage or mass effect cxr no evidence of pneumonia or chf brief hospital course yo man with history of type i diabetes mellitus presented with diabetic ketoacidosis patient initially presented with diabetic ketoacidosis and fever etiology of fever was not diagnosed but presumed infection was thought to be the source of him going into dka he did have one of six blood culture bottles grow gpc but this was thought to be a contaminant he was initially on an iv insulin drip with aggressive iv fluids and electrolytes monitoring and repletion he is a patient at the clinic and service was consulted he was transitioned to a regimen of nph with a supplemental humalog sliding scale he was instructed on warning signs for dka and how to contact the clinic with questions concerns and to set up follow up he will follow up with dr he is a full code also his tox screen on admission was positive for cocaine he was educated on risks of cocaine use and toxicity medications on admission insulin nph metformin paxil risperidone benzotropine zyprexa discharge medications insulin nph human recomb unit ml suspension sig thirty five units subcutaneous qam disp qs units refills insulin nph human recomb unit ml suspension sig thirty units subcutaneous qhs disp qs units refills humalog unit ml solution sig units subcutaneous three times a day please dispense per sliding scale disp qs units refills lancets misc sig one lancet miscell three times a day disp lancets refills insulin syringe needle u ml x syringe sig one syringe miscell three times a day disp syringe needle refills diabetic supplies miscellan misc sig one test strips miscell three times a day disp test strips refills paxil mg tablet sig one tablet po once a day risperdal mg tablet sig one tablet po at bedtime benztropine mg tablet sig one tablet po once a day zyprexa mg tablet sig one tablet po twice a day discharge disposition home discharge diagnosis diabetic ketoacidosis type i diabetes mellitus cocaine abuse discharge condition stable discharge instructions please continue to take your insulin as prescribed to check your fingerstick three times per day and please follow up with dr at the clinic followup instructions please follow up with dr at the clinc within two weeks you can call to schedule an appointment it is very important that you follow up with dr,"{
""Diagnoses"": [""Diabetic ketoacidosis""],
""Medications"": [""Codeine"", ""Unasyn"", ""Nahco"", ""Insulin""]
}"
75170,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint atrial fibrillation s p ablation unable to extubate major surgical or invasive procedure atrial fibrillation s p ablation cardioversion intubation history of present illness this patient is yo male with a past medical history of paroxysmal afib hyperlipidemia mitochondrial muscular disorder with gait instability who presented today for an atrial fibrillation ablation following which he was difficult to extubate and hypotensive the patient was diagnosed with paroxysmal atrial fibrillation in was cardioverted started on aspirin and rate controlled next in he went into afib was again cardioverted and started on propafenone he had a recent episode of atrial fibrillation flutter and was started on coumadin he underwent cardioversion for a third time in he saw dr in electrophysiology consultation on for treatment of his atrial fibrillation he is not felt to be a good candidate for long term coumadin therapy due to his history of falls secondary to the neuromuscular disorder and had pulmonary vein isolation today in terms of symptoms per cmi note he is reports feeling more fatigued and short of breath when he is in atrial fibrillation he denies chest pain dizziness or syncope today the patient had afib ablation at the end of the case he was given protamine to reverse his anticoagulation and systolic blood pressure dropped to the s after the protamine requiring bolused vasopressors he was also difficult to extubate likely secondary to the neuromuscular disorder an echo at the bedside in the lab showed no effusion the patient has femoral sheaths still in place for access until the am on floor patient was intubated and sedated unable to do review of systems past medical history paroxysmal atrial fibrillation first in s p cardioversion cardioverted and on propafenone now more often recently mitochondrial myotonic dystrophy hyperlipidemia cardiac risk factors diabetes dyslipidemia hypertension cardiac history cabg no percutaneous coronary interventions none pacing icd no social history he is married with no children he does not smoke but drinks socially he is currently on medical disability he is from but has been living in america for years family history he claims his both parents may have arrhythmias they are alive into their s his father may also have a neuromuscular disorder he has one sister age his father and his sister apparently have a slow heart rate although they do not have pacemakers at this time physical exam vs hr rr on fi general intubated and sedated heent ncat sclera anicteric perrl conjunctiva were pink no pallor or cyanosis of the oral mucosa og tube and et tube in place neck supple no lad 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 clear anteriorly and laterally abdomen soft ntnd no hsm or tenderness abd aorta not enlarged by palpation no abdominial bruits extremities no c c e left femoral sheaths right femoral sheath skin no stasis dermatitis ulcers scars or xanthomas pulses b l pedal pulses palpable pertinent results admission 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 pm blood type art po pco ph caltco base xs ct chest with contrast no evidence of pulmonary embolism unchanged low lung volumes and atelectasis improved visualization of a mm nodular opacity at the right upper lobe three month ct followup is recommended heterogeneous left thyroid nodule consider ultrasound if warranted clinically ct chest without contrast enlarged left lobe of the thyroid with some low attenuation foci consider ultrasound if warranted clinically low lung volumes parenchymal opacities at the bases are associated with volume loss and most suggestive of atelectasis minimal retained secretions within the trachea mild thickening of the anterior trachea wall which is nonspecific but could potentially be due to a sequelae or prior intubation or tracheostomy placement mild enlargement of the main pulmonary artery echo the left atrium is mildly dilated no left atrial mass thrombus seen best excluded by transesophageal echocardiography the right atrium is moderately dilated the estimated right atrial pressure is mmhg left ventricular wall thickness cavity size and regional global systolic function are normal lvef transmitral and tissue doppler imaging suggests normal diastolic function and a normal left ventricular filling pressure pcwp mmhg the right ventricular cavity is mildly dilated with normal free wall contractility 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 regurgitation 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 impression mild right ventricular cavity enlargement with preserved global free wall motion biatrail enlargement clinical implications based on aha endocarditis prophylaxis recommendations the echo findings indicate prophylaxis is not recommended clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data cxr lung volumes are lower with increased bibasilar atelectasis bilateral pleural effusions if any would still be tiny there is no other overall change brief hospital course m with history of neuromuscular disorder paroxysmal atrial fibrillation s p ablation complicated by hypotension and difficulty with extubation respiratory distress patient was difficult to extubate after case extubation was attempted briefly but since patient was hypotensive was sent to ccu he received l ivf in ep lab apparently in prior intubation o sats had been low likely due to underlying neuromuscular disorder and baseline as wife said patient has a lot of am secretions patient appeared volume overloaded on xray so was diuresed with good response he tolerated extubation well on but remained hypoxic chest ct was negative for pe but was consistent with low lung volumes and atelectasis pulm was consulted and reported low nif consistant with decreased diaphragmatic weakensss likely to underlying neuromuscular disorder he continued to be hypoxic with ambulation requring l by nasal canula to keep sats at patient will get pfts and be followed by pulm as outpatient as his disorder is likely progressing and will need home oxygen at the very least for now hypotension patient hypotensive after receiving protamine in the ep lab likely protamine reaction since it can cause sudden transient drop in blood pressure required minimal phenylephrine which was weaned off afebrile and no white count so sepsis unlikely resolved and beta blocker was restarted atrial fibrillation s p ablation has been in sinus since continue coumadin propafenone and atenolol followed inr follow up with ep mitochondrial neuromuscular disorder likely reason why low sats with intubation and weak cough post intubation should follow up with neurology as outpatient evaluate my physical therapy who believe he is safe to go home but should get home pt eval medications on admission atenolol mg daily propafenone mg twice daily simvastatin mg daily warfarin mg everyday except mg on mwf aspirin mg discharge medications atenolol mg tablet sig tablet po daily daily propafenone mg capsule sust release hr sig one capsule sust release hr po twice a day simvastatin mg tablet sig one tablet po daily daily warfarin mg tablet sig three tablet po days mo we fr warfarin mg tablet sig one tablet po days tu th sa home oxygen l continuous pulsed dose for portability o sat on ra aspirin mg tablet sig one tablet po once a day ibuprofen mg tablet sig one tablet po q h every hours as needed discharge disposition home with service facility vna discharge diagnosis primary diagnosis atrial fibrillation mitochondrial myotonic dystrophy hypoxia secondary diagnosis hyperlipidemia discharge condition stable patient is ambulating tolerating oral intake and has returned to his baseline condition discharge instructions you were admitted to the hospital for treatment of your atrial fibrillation you underwent a procedure to return your heart to normal rhythm you had some difficulty breathing after your procedure and you were monitored in the intensive care unit for days after your procedure you are now in a normal sinus rhythm we made an appt with dr from pulmonology to get breathing tests these appts are listed below we made the following changes to your medication increase your aspirin to mg daily take ibuprofen for any chest burning or ache that you may have if the ibuprofen does not alleviate the symptoms call dr please seek immediate medical care if you develop shortness of breath light headedness dizziness loss of consciousness fevers shaking chills night sweats abdominal pain back pain or pain in your lower extremities you will be going home on a monitor to evaluate your heart rhythm please follow the instructions given to you you will send strips daily and the monitor will trigger if you go back into atrial fibrillation followup instructions please follow up with your cardiologist md on pulmonology please follow up with dr phone date time wednesday at with dr on pulmonary function tests before the appt at pm on clinical center primary care phone date time at pm completed by,"{
""Diagnoses"": [""atrial fibrillation"", ""paroxysmal atrial fibrillation"", ""hypotension"", ""difficult to extubate""],
""Medications"": [""aspirin"", ""rate controlled"", ""propafenone"", ""coumadin"", ""cardioversion""]
}"
2289,admission date discharge date date of birth sex m service nsu interim care summary date of transfer to hematology oncology service history of present illness mr is a year old male who had known metastatic melanoma his initial illness began in where he had a dark line across his right great toenail which widened he had seen a podiatrist the lesion was getting bigger and ulcerative the toenail was removed he was referred to in and had an amputation of his right toe in he had an extensive work up a full body ct showed bilateral small pulmonary nodules and the spleen limber for which mri of the body was recommended and prominent left pelvic and periaortic lymph nodes were not determined to be pathologic at that time mri of the whole spine showed diffuse metastatic disease without spinal cord involvement a bone marrow biopsy on was positive for extensive melanoma involvement a head ct showed a left frontal metastasis he was seen by dr from neuro oncology at that time it was recommended that he have surgical removal and be treated with srs in the resection cavity however he on developed sudden right sided weakness and underwent an emergent craniotomy physical examination on admission his vital signs were blood pressure respirations he was in no acute distress but uncomfortable lungs clear abdomen benign he had no movement in his right side hospital course he was taken emergently to the operating room and underwent a left sided frontal craniotomy postoperatively he responded to voice but was not able to move his right side postoperatively he had full movement of his left side he remained in the postanesthesia recovery unit overnight on the evening of for pain control and to check his neurologic signs a postoperative mri showed postoperative changes in the posterior left frontal lobe with no increased mass effect as compared to his preop study there was linear enhancement along the anterior aspect of the operative site and a small amount of residual tumor could not be excluded there was an area of t hyperintensity and susceptibility effect in the operative site which might be related to a small amount of blood products following the surgery he remained in the icu until for blood pressure control monitoring and due to his dense right hemiparesis and fever to the range he was more sleepy he had a chest x ray and a urine initially the urine looked like it was positive for a uti but the cultures were negative he did have a chest x ray that was questionable for pneumonia and was started on levaquin for that he continued to have high fevers through the he continued to have full work up surveillance cultures which showed no source of infection at that time we had recommended a meningitis work up and mr refused to have an lp done four different medical providers including his oncologist dr spoke with him of the importance of having a work up for meningitis on he had complained of excruciating back pain which was not relieved with dilaudid percent and his ms contin a pain service consultation was obtained which they recommended placing him on a pca overnight to get his pain under control and then he was started on morphine sulfate ir mg q h p o p r n and morphine sulfate sr mg q h tylenol mg q h and within days his pain was much better under control his dilantin was stopped thinking that may have related his fevers and he was started on keppra he continued to have fevers though they lessened to for the through the he remained neurologically stable awake alert oriented x moving his left side spontaneously with minimal to no movement in his right side tolerating a regular diet and his pain was much more controlled on his morphine sulfate sr and his morphine sulfate ir and it was felt that he could benefit from spinal radiation therapy for that reason he is being transferred to the hematology oncology service of dr service to have radiation to his back on the morning of transfer his hematocrit was and they recommended units of blood however before he left he was unable to be typed and screened due to his appointment for radiation oncology his neurosurgery follow up should be in the brain tumor clinic in the next weeks he should be kept on decadron mg p o q h and keppra mg p o b i d his staples have been removed and his incision is dry and intact without signs of infection the patient is being transferred to the hematology oncology service 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 right sided weakness major surgical or invasive procedure craniotomy on history of present illness the pt is a year old gentleman with a history of stage iv metastatic melanoma who initially presented to on with acute onset right sided weakness and expressive dysphasia he was originally scheduled to undergo craniotomy and stereotactic surgery on for known metastatic lesions to the brain he was started on dacarbazine on and presented on the following day with the acute onset of right sided weakness and dysphasia he was found to have increased size of a left frontal lobe mass cm on to cm on with vasogenic edema exerting a mass effect he was taken to the or for a craniotomy on and a stereotactically guided procedure was performed and the left frontal mass was removed the mass was noted to have associated hemorrhage since surgery he has been treated in the nsicu for blood pressure management nipride then labetolol drip now on p o lopressor blood transfusions seizure ppx and pain control his course has been complicated by post operative fever and ftt in addition to significant pain he was transferred to omed to initiate palliative xrt and continued pain control on transfer to medicine on the pt offered no specific complaints he stated that his back pain was currently well controlled he denied recent fever chills shortness of breath chest pain nausea vomiting abdominal pain past medical history stage iv metastatic melanoma oncologic hx in mid the pt developed a dark line running horizontally across his right great toenail over that time the area widened apparently and an opening appeared close to the cutical which moved with the outward growth of the nail he noted that bloody fluid eventually leaked from this opening a medial and lateral biopsy of the nail bed was performed and initial biopsy was read as potentially a lymphoma however follow up pathology report was read as an ungal melanoma his r great toe was amputated on his melanoma returned on r great toe stump and biopsy on showed dermal metastatic melanoma a full body ct pet was performed and showed metastatic lesions to the vertebral bodies spleen liver and brain l frontal lobe s p r great toe amputation on s p appendectomy s p umbilical hernia repair s p t and a social history the pt is a retired mechanical designer he lives with his wife is a former cigarette smoker pack year history former drink wk alcohol use family history remarkable for mother and a sister with stroke physical exam vitals t f p r bp sao ra general awake alert appears comfortable and in nad heent craniotomy scar noted over l frontal bone perrl eomi without nystagmus no scleral icterus noted mmm no lesions noted in op neck supple no jvd or carotid bruits appreciated pulmonary lungs cta bilaterally without r r w cardiac tachycardic rr nl s s no m r g noted abdomen soft nontender to palpation mildly distended normoactive bowel sounds no masses or organomegaly noted extremities no c c e bilaterally radial dp and pt pulses b l lymphatics no cervical supraclavicular axillary or inguinal lymphadenopathy noted neurologic mental status alert oriented x not date time attends to examiner and follows commands expressive aphasia with intact repitition and comprehension perseverative thought process at times cranial nerves ii vi intact r flattenend nasolabial fold viii xii intact motor tone spastic on right normal bulk throughout delt bic tric wr fl wr ext ffl ip quad ham tiba r n a l no abnormal movements noted sensory no deficits to light touch appreciated although exam limited cerebellar no nystagmus dysarthria dtrs bic tri ffl patellar achilles plantar response r n a l withdrawal sign bilaterally r l pertinent results radiologic data mri of head study performed demonstrating left frontal metastatic lesion which has increased in size compared to vasogenic edema has also increased no new lesions are identified mri of head there are postoperative changes in the posterior left frontal lobe with no increase in mass effect compared to the preoperative study there is linear enhancement along the anterior aspect of the operative site and a small amount of residual tumor cannot be excluded there are areas of t hyperintensity and susceptibility effect in the operative site which might be related to small amounts of blood breakdown products following the surgery although they are also identical in signal intensity to the original melanoma labs on transfer 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 for details of the hospitalization prior to please refer to the hpi metastatic melanoma upon transfer to medicine the goal of care was palliation with xrt to bony metastases he underwent five sessions of xrt his pain was controlled with morphine and acetaminophen the phsyical therapy and speech therapy services were consulted to work with the pt regarding his neurologic residua he was maintained on keppra for seizure prophylaxis he was also maintained on dexamethasone for cerebral edema htn the pt had elevated blood pressure after surgery as discussed in the hpi on transfer to medicine he was placed on metoprolol with adequate blood pressure control anemia secondary to bone marrow involvement with melanoma as diagnosed on bone marrow biopsy he was transfused a total of units of prbcs after transfer to medicine for hct his hct was stable and over for the last days of admission rll pneumonia the pt developed low grade fever seven days prior to discharge a chest x ray was performed that showed a questionable right lower lobe pneumonia he was started on empiric levofloxacin and metronidazole and subsequently defervesced he was discharged with a prescription for a seven day course of these antibiotics to complete a day course brbpr the pt was noted to have scant brbpr on his hematocrit remained stable rectal exam disclosed internal hemorrhoids he was also maintained on a ppi and carafate for gi prophylaxis while on dexamethasone medications on admission medications on transfer acetaminophen mg po pr q h bisacodyl mg po pr daily prn dexamethasone mg po q h docusate mg po bid ferrous sulfate mg po daily gabapentin mg po tid heparin units sc tid regular insulin sliding scale keppra mg po bid lorazepam mg po bid prn metoprolol mg po tid milk of magnesia ml po tid prn morphine sr mg po tid morphine ir mg po q h prn pantoprazole mg po daily senna tab po qhs discharge medications bisacodyl mg suppository sig one suppository rectal times a day as needed disp suppository s refills magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed disp ml s refills docusate sodium mg ml liquid sig one po bid times a day disp qs qs refills senna mg tablet sig two tablet po hs at bedtime disp tablet s refills lorazepam mg tablet sig one tablet po bid times a day as needed disp tablet s refills levetiracetam mg tablet sig one tablet po bid times a day disp tablet s refills dexamethasone mg tablet sig one tablet po q h every hours disp tablet s refills acetaminophen mg tablet sig one tablet po q h every hours disp tablet s refills morphine sulfate mg tablet sustained release sig one tablet sustained release po q h every hours disp tablet sustained release s refills morphine sulfate mg tablet sig tablets po q h as needed disp tablet s refills metoprolol tartrate mg tablet sig two tablet po tid times a day disp tablet s refills levofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills sucralfate g tablet sig one tablet po qid times a day disp tablet s refills protonix mg tablet delayed release e c sig one tablet delayed release e c po twice a day disp tablet delayed release e c s refills gabapentin mg tablet sig one tablet po three times a day disp tablet s refills metronidazole mg tablet sig one tablet po three times a day for days disp tablet s refills discharge disposition home with service facility hospice and vna discharge diagnosis metastatic melanoma s p r craniotomy and stereotactic removal of brain metasases hypertension right lower lobe pneumonia resolved discharge condition stable discharge instructions please continue all medications as prescribed if you experience any concerning symptoms please call your oncologist or come to the emergency department for evaluation followup instructions provider md where hematology oncology phone date time provider hem onc hematology oncology cc where hematology oncology phone date time,"{
""Diagnoses"": [""metastatic melanoma"", ""bilateral small pulmonary nodules"", ""prominent left pelvic and periaortic lymph nodes"", ""diffuse metastatic disease without spinal cord involvement"", ""melanoma involvement""],
""Medications"": [""surgical removal"", ""srs in the resection cavity"", ""emergent craniotomy""]
}"
12342,admission date discharge date date of birth sex m service otolaryngology allergies ancef attending chief complaint laryngeal cancer major surgical or invasive procedure bronchoscopy tracheal biopsy total laryngectomy history of present illness patient is a year old male who presented to medical center on with stridor and respiratory distress prior to presentation he had complained of weeks of cough shortness of breath and a sore throat for which he had been treated with steroids and antibiotics without improvement a laryngoscopy at the osh showed severe narrowing of the subglottic area and ct scan showed a large laryngeal mass concerning for neoplasm an emergent trachestomy bronchoscopy was done by the thoracic surgery team and biopsy of the mass were sent these biopsies were suspicious for adenoid cystic carcinoma of note bronchial washings were sent which were positive for mssa he was therefore started at cefazolin and transferred to for further care past medical history h o sinus surgery chest tube placed unknown reason lle fracture after mvc social history denies alcohol use smoked ppd tobacco for years but quit month prior to presentation works as an electrician family history noncontributory physical exam avss on tm nad oc op wnl no obvious masses symmetric palate elevation midline uvula fom soft normal anterior rhinoscopy nasopharynx with slight fullness on right side patent et bilaterally foe bot appears symmetric normal vallecula crisp epiglottis supraglottis appears slightly erythematous no obvious mass lesions are seen vocal cords have a small amount of abduction bilaterally but to a maximum of mm opening no true vocal fold lesions are seen but cannot rule out a submucosal thickening of the posterior glottis foe via tracheotomy tube reveals circumferential narrowing below tracheotomy tip but patent trachea and clear view to carina with no obvious massess neck supple no lad portex in place cv rrr lungs cta b l abd soft nt nd pertinent results radiology studies ct trachea findings a tracheostomy tube is present with tip terminating within the anterior tracheal lumen above the level of the aortic arch the glottic subglottic and proximal trachea appear diffusely abnormal within the glottic and subglottic airway diffuse soft tissue thickening is present with narrowing of the airway lumen the thickening is most pronounced posteriorly and laterally and results in luminal narrowing to approximately mm in transverse dimension by about mm in the anterior dimension additionally in the proximal trachea at the level of the thyroid gland there is a more discrete mm x mm diameter rounded intraluminal opacity this is contiguous more inferiorly with circumferential wall thickening the tracheal walls remain mildly thickened to approximately the level of the aortic arch diffuse stranding is present throughout the adjacent paratracheal fat most prominent above the level of the aortic arch but continues in a milder degree below this level to the subcarinal region increased number of mediastinal nodes are present but there are no individual nodes measuring greater than cm in diameter air is identified within the tracheal soft tissues adjacent to the tracheostomy tube as well as within the adjacent subcutaneous tissues adjacent to the pectoralis muscles probably reflecting recent placement of the tube a small amount of pneumomediastinum is also present multiple pulmonary emboli are present throughout the right pulmonary arterial system involving the origin of the right middle lobe bronchus and extending into segmental branches and also involving the intralobar and proximal right lower lobe pulmonary artery extending into segmental and subsegmental arteries within the lungs extensive upper lobe predominant centrilobular emphysema is present multiple peribronchiolar ground glass nodular opacities are present in the superior segment of the right lower lobe and a small solid mm diameter left lower lobe nodule image series is also present as well as an additional mm left lower lobe nodule laterally imaged series images obtained during dynamic expiration are suboptimal as the patient did not appear to be able to cooperate with the breathing instructions trace right pleural effusion is present no suspicious lytic or blastic skeletal lesions are identified multiplanar and d images confirm the presence of an intraluminal mass and adjacent luminal narrowing as well as circumferential thickening of the airway additionally on review of thin section axial images there is apparent partial destruction of the cricoid cartilage impression proximal tracheal intraluminal mass with contiguous circumferential thickening of the airway extending proximal to the level of the vocal cords apparent cricoid cartilage destruction less prominent wall thickening below the mass extending at least to the level of the aortic arch with extensive stranding of the adjacent paratracheal fat findings are concerning for circumferential involvement of adenoid cystic carcinoma with associated extensive submucosal spread correlation with bronchoscopy findings recommended increased number of mediastinal nodes without individual nodes meeting size criteria for enlargement malignant involvement is not excluded acute pulmonary emboli in the right pulmonary arterial system as described two solid left lower lobe lung nodules measuring less than mm in diameter although potentially benign early foci of metastatic disease cannot be excluded attention to these on a three month followup ct may be helpful peribronchiolar ground glass nodules superior segment of right lower lobe likely due to aspiration or early infection small right pleural effusion chest pa lat the patient is diagnosed with adenoid cystic carcinoma of the trachea tracheostomy is in place with its tip projecting cm above the carina the heart size and the mediastinal contours are unremarkable the lungs are clear there is no pleural effusion the sub mm left lower lobe nodules diagnosed on the chest ct are below the resolution of this chest radiograph impression no evidence of pneumonia tracheostomy in place known adenoid cystic carcinoma of upper trachea bronchoscopy description of procedure the patient was consented and topical lidocaine was given in the oropharynx in the usual fashion the bronchoscope was inserted via the mouth on inspection of the posterior pharynx there was diffuse tissue infiltration throughout with crowding of the airway the vocal cords were visible only on deep inspiration their movement through the inspiratory cycle could not be well visualized the scope was not inserted past the vocal cords via that approach the bronchoscope was removed and then reinserted via the tracheostomy the airways were normal in appearance grossly distal to the tracheostomy on endotracheal ultrasound immediately distal to the tracheostomy there was diffuse tracheal infiltration an endobronchial biopsy was taken x at the carina as well as on the right and on the left just distal to the trach there was some mild oozing after the biopsy which spontaneously resolved the patient did well throughout the procedure overall impression diffuse posterior pharyngeal tissue infiltration diffuse tracheal thickening by ultrasound bilateral lower extremity ultrasound no prior studies for comparison bilateral scale and doppler son were performed of the common femoral superficial femoral and popliteal veins on the right there is noncompressible thrombus within the right popliteal vein which is only partially occlusive there appears to be a small amount of flow traversing flow on the sagittal images the right common femoral and superficial veins compress normally with normal flow waveforms and augmentation on the left there is no evidence of noncompressible veins and all veins demonstrate normal flow waveforms and augmentation impression near occlusive right popliteal thrombus no dvt in the left lower extremity ivc filter placement procedure doctors and performed the procedure prior to the procedure informed consent was obtained a preprocedure timeout was performed the patient was prepped and draped in standard sterile fashion after multiple attempts the right common femoral vein was entered under ultrasonographic guidance with a micropuncture needle prior to cannulation of the femoral vein the femoral artery was entered with hemostasis achieved by manual compression a guide wire was advanced into the inferior vena cava under fluoroscopic guidance the micropuncture needle was exchanged for a sheath and contrast run was performed which showed a prominent draining vein in the lower ivc the renal veins were shown to drain at the level of the inferior endplate of l there was no evidence of duplication of the inferior vena cava the large draining vein in the left lower ivc was later cannulated with a c cobra catheter with contrast injection demonstrating this to be a prominent lumbar vein thus there was no evidence of circumaortic or duplicated renal vein decision was then made to place the ivc filter at the level of the draining renal vein at the inferior endplate of l under fluoroscopic guidance a bard recovery ivc filter was placed at this level hemostasis was achieved by manual compression anesthesia moderate sedation was achieved via the administration of mcg of fentanyl and mg of versed given in divided doses throughout the intraservice time of minutes the patient s hemodynamic parameters were monitored throughout impression normal ivc gram successful placement of a bard recovery filter in an infrarenal vein location echocardiogram conclusions the left atrium is normal in size left ventricular wall thicknesses are normal the left ventricular cavity size is normal due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded overall left ventricular systolic function is normal lvef tissue doppler imaging suggests a normal left ventricular filling pressure pcwp mmhg right ventricular chamber size and free wall motion are normal the aortic root is moderately dilated athe sinus level the ascending aorta is mildly dilated 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 the estimated pulmonary artery systolic pressure is normal there is no pericardial effusion barium swallow study barium esophagram optiray contrast passes freely through the esophagus there is no aspiration into the airway and no significant retention in the valleculae or pyriform sinuses is seen there is no evidence of active extravasation to suggest a leak in the area of surgery once this was determined thin barium was also administered to the patient in ap and lateral views and again no aspiration or leak at the area of surgery was identified impression no evidence of esophageal leak in the region of recent surgery pathology specimen submitted cervical endobronchial and proximal trachea endobronchial bxs procedure date tissue received report date diagnosed by dr brown lfb diagnosis a carina endobronchial biopsy respiratory mucosa with acute and chronic inflammation and focal squamous metaplasia with mild to moderate atypia no carcinoma seen b proximal trachea endobronchial biopsy respiratory mucosa with acute and chronic inflammation and focal squamous metaplasia with mild to moderate atypia no carcinoma seen specimen submitted consult slides from medical center procedure date tissue received report date diagnosed by dr brown lfb previous biopsies cervical endobronchial and proximal trachea endobronchial diagnosis tracheal biopsy low grade carcinoma with adenoid cystic features see note note although the overall architectural and cytologic features are most suggestive of adenoid cystic carcinoma the tumor shows very focal squamous differentiation which is not typical of adenoid cystic carcinoma another tumor which can occur in this area and mimic adenoid cystic carcinoma on a small biopsy specimen is a basaloid squamous cell carcinoma although they usually show more atypia mitotic activity and necrosis than we see in this case biopsy slides were reviewed with drs and cytology was reviewed by dr who felt the findings were consistent with adenoid cystic carcinoma specimen submitted subglottic larynx fs level lymph node neck larynx fs level lymph node neck left procedure date tissue received report date diagnosed by dr nbh previous biopsies consult slides cervical endobronchial and proximal trachea endobronchial diagnosis larynx subglottic biopsy a carcinoma most consistent with adenoid cystic carcinoma lymph nodes left neck level dissection b c no carcinoma identified in nine lymph nodes lymph nodes left neck level dissection d no carcinoma identified in two lymph nodes larynx laryngectomy e ag a carcinoma most consistent with adenoid cystic carcinoma with focal squamous differentiation larynx see note b no carcinoma identified in two lymph nodes c larynx with extensive squamous metaplasia and chronic inflammation d skin and trachea with changes consistent with tracheostomy site e unremarkable thyroid gland left lobe f parathyroid tissue note the tumor is subglottic in location and measures x cm the microscopic depth of invasion is cm the tumor invades into the cricoid cartilage there is ossification of this cartilage and tumor involves the bone at this site there is a focus suspicious for lymphovascular invasion no definitive perineural invasion is identified the resection margins are free of tumor the tumor is within mm of the posterior soft tissue margin the pathologic stage for this subglottic tumor is t a the main differential diagnosis of this tumor is an adenoid cystic carcinoma with squamous differentiation versus a basaloid squamous cell carcinoma the larynx shows extensive squamous metaplasia and chronic inflammation however no squamous dysplasia carcinoma in situ is identified immunohistochemical stains performed on a section of tumor show the tumor cells are positive for cytokeratin cocktail ae ae cam smooth muscle actin calponin and p cea unabsorbed shows rare positivity of some squamous cells as well as rare ductal type structures s protein is non contributory due to high background staining based on the tumor morphology and results of the immunohistochemical studies particularly cytokeratin and actin positivity this tumor is interpreted to be an adenoid cystic carcinoma with squamous differentiation in the absence of a similar tumor elsewhere this tumor is compatible with a laryngeal primary as adenoid cystic carcinoma may occur in the larynx trachea sections of the tumor h e slides have been reviewed by dr brief hospital course mr was transferred from medical center to on to the interventional pulmonology service on arrival he was continued on the cefazolin for presumed pneumonia based on mssa in a bal a ct trachea was done which confirmed a mm x mm proximal tracheal intraluminal mass in addition multiple pulmonary emboli on the right were noted as well as two solid lll lung nodule benign in appearance for details please see the ct report he was immediately started on a heparin drip with a goal ptt between and for the pulmonary embolus a bronchoscopy was one by the ip service showing diffuse posterior pharyngeal tissue infiltration and diffuse tracheal thickening by ultrasound for details please see the operative report an ent consult was obtained and a total laryngectomy was recommended for t nx laryngeal cancer suspiscious for adenoid cystic carcinoma in preperation for the procedure b l lower extremetiy ultrasounds were done to search for a cause for the pulmonary embolus no dvt was noted in the left leg but a near occlusive popliteal dvt was noted in the right therefore an ivc filter was placed by interventional radiology in anticipation of being off anticoagulation for several days during the immediate postoperative period the heparin drip was stopped hours prior to the procedure and restarted afterwards he tolerated this procedure well for details please see the operative report in addition a medicine consult was obtained for preoperative risk assessment no further testing was recommended however they recommended restarted the heparin drip postoperatively once surgically safe and to discharge him on lovenox perioperative beta blockers were not recommended prior to the surgery the patients pathology including the biopsies from medical center were reviewed at our institution the tracheal biopsies taken during the bronchoscopy at sites distal to the mass were consistent with respiratory mucosa with acute and chronic inflammation and focal squamous metaplasia no cancer was seen in these biopsies the biopsies of the mass taken at the osh were reviewed as well and were felt to show features most consistent with adenoid cystic carcinoma although basaloid squamous cell carcinoma could not be ruled out regardless a total laryngectomy was felt to be the necessary treatment he was therefore transferred to the ent service and on he underwent a total laryngectomy with modified left neck dissection his heparin drip was stopped hours prior to the procedure he tolerated the procedure well and was extubated for details please see the operative report post operatively he was initially transferred to the icu for close monitoring he was kept npo with a dilaudid pca for pain and clindamycin and levofloxacin for perioperative prophylaxis he was transferred out of the icu on pod and started on tube feeds through a dobhoff tube placed intraoperatively in addition he was evaluated by speech therapy who began teaching him how to use an electrolarynx on pod the heparin drip was restarted and the pain service was consulted for continuing pain not controlled by the pca they intially recommended adding neurontin and later recommended adding a fentanyl patch for continued pain on pod mr began complaining of worsening dyspnea and faintness he then developed atrial fibrillation with rvr with a rate of he was given iv lopressor x with no effect and a cardiology consult was obtained he was then given iv diltiazem and became hypotensive with a sbp of he was transferred to the icu where he was started on an amiodarone gtt and given several fluid boluses with good blood pressure response that evening he returned to sinus rhythm and became normotensive he continue to do well until pod when developed nausea and emesis possibly related to the amiodarone which was therefore stopped in discussion with cardiology it was felt that the episode of atrial fibrillation was a one time event and was unlikely to happen again however they did recommend weeks of treatment with a beta blocker he was started on mg lopressor which he tolerated well without any signs of hypotension he continued to remain in sinus rhythm and was transferred out of the icu on pod potassium magnesium and calcium levels were checked daily after the episode of atrial fibrillation his potassium level ranged from requiring potassium supplementation daily he will therefore be discharged home with potassium supplements a barium swallow study was obtained at this time which did not show an esophageal leak or tracheoesophageal fistula he was therefore started on a clear liquid diet which was slowly advanced at the time of discharge pod he was tolerating a regular diet without difficulty prior to discharge he was transitioned from iv heparin to lovenox mg subcutaneous injections these will need to be continued indefinetly he was seen by physical therapy prior to discharge and cleared to go home he will be visited at home by a vna for respiratory care and assistance with tracheal stoma care in addition a suction device was arranged to be delivered to his home he will follow up with dr from ent week after discharge the laryngectomy tube will be left in place for month postoperatively to prevent narrowing of the stoma the stoma stitches and staples were removed prior to discharge in addition he will follow up with his primary care physician for management of the lopressor and lovenox finally he will follow up with dr from radiation oncology regarding future radiation therapy medications on admission at home none discharge medications enoxaparin mg ml syringe sig eighty mg subcutaneous q h every hours disp syringes refills oxycodone acetaminophen mg ml solution sig mls po q h every to hours as needed for pain disp ml s refills metoprolol tartrate mg tablet sig one tablet po twice a day disp tablet s refills ferrous sulfate mg tablet sig one tablet po daily daily disp tablet s refills multi vitamin tablet sig one tablet po once a day potassium chloride meq tab sust rel particle crystal sig one tab po once a day disp tabs refills discharge disposition home with service facility saco discharge diagnosis laryngeal cancer s p total laryngectomy pulmonary embolus deep vein thrombosis postoperative atrial fibrillation discharge condition good discharge instructions call your doctor greater than f persistent nausea pain not relieved by pain medications worsening redness or discharge from incision shortness of breath wheezing chest pain or other symptoms concerning to you do not swim or take baths you may shower do not drive while taking pain medications continue all medications as prescribed continue to take the iron supplements and metoprolol until instructed by your primary care physician to discontinue their use please follow up with your primary care physician soon after discharge in order to determine the need for continuation of the lopressor a visiting nurse will visit you home and a suction setup will be delivered to your home completed by,"{
""Diagnoses"": [""stridor"", ""respiratory distress"", ""laryngeal cancer"", ""neoplasm"", ""adenoid cystic carcinoma""],
""Medications"": [""ancef"", ""cefazolin""]
}"
45866,admission date discharge date date of birth sex f service neurology allergies lipitor attending chief complaint found unresponsive major surgical or invasive procedure peg placement history of present illness ms is a year old woman with a pmh of symptomatic paroxysmal a fib with rvr s p pacer and on coumadin as well as htn and dmii who was found unresponsive this am she was last seen well prior to going to sleep last night this am she was found by family in bed with urinary incontinence and not responding her fsg at that time was per family who arrived later she was last seen well last night around pm and was then found around this morning in bed initially thought to be sleeping but then remained unresponsive when checked again later so ems called and ms was brought to past medical history paroxysmal atrial fibrillation s p permanent pacemaker anticoagulated with warfarin diabetes mellitus type hypertension hyperlipidemia recurrent utis e coli and gnr in recent past social history married her husband has advanced she works in maintenance here at tobacco history denies etoh denies illicit drugs denies family history nc physical exam at admission vitals t p r bp sao on nrb general unresponsive heent nc at no scleral icterus noted mmm no lesions noted in oropharynx pulmonary lcta anteriorly cardiac rrr s s abdomen soft nondistended bs extremities warm well perfused neurologic no eye opening no commands groans to sternal rub r pupil mm irregular and nonresponsive to light l pupil mm and nonresponsive to light r eye deviated to right in primary gaze left eye in midline no blink to threat when eyes held open dolls eyes corneals stronger on right than left gag reflex no spontaneous movements no movement initially to noxious stimuli ue b l though she did have some delayed slight movements of lue after nailbed pressure brisk withdrawal of le b l to nailbed pressure grimaces to noxious stimuli throughout unable to elicit reflexes extensor plantar response on left equivocal response on right at discharge neuro exam responds with moderate stimulation eyes have been opening spontaneously grimaces to noxious says some intelligble words occasionally mod severe dysarthria follows simple commands right pupil left pupil and both non reactive brainstem reflexes intact otherwise moves all ext but the right less briskly makes purposeful movements with all extremities and withdraws to noxious stimuli x pertinent results am wbc rbc hgb hct mcv mch mchc rdw am pt ptt inr pt am asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg am ctropnt 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 bnzodzpn neg barbitrt neg opiates neg cocaine neg amphetmn neg mthdone neg am urine ucg negative pm type art po pco ph total co base xs blood cultures on and on were no growth mrsa screen was negative urine culture urine culture final proteus mirabilis organisms ml presumptive identification piperacillin tazobactam sensitivity testing available on request enterococcus sp organisms ml tetracycline sensitive mic mcg ml sensitivity testing performed by sensititre sensitivities mic expressed in mcg ml proteus mirabilis enterococcus sp ampicillin s s ampicillin sulbactam s cefazolin s cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s tetracycline s tobramycin s trimethoprim sulfa s vancomycin s urine culture urine culture preliminary gram negative rod s organisms ml 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 s cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s tobramycin s trimethoprim sulfa s ekg ventricular paced rhythm compared to the previous tracing of no change head ct and head and neck cta findings head ct mild edema is visualized in the parietal lobe which may represent edema from an ischemic event in the proper clinical setting however there is no evidence of mass effect hemorrhage shift of normally midline structures or large vessel territorial infarction the ventricles and sulci are normal in size and configuration no fracture is identified head and neck cta recons are currently pending however the carotid and vertebral arteries and their major branches are patent with no evidence of stenosis mild atherosclerotic disease is visualized there is no evidence of aneurysm formation or other vascular abnormality impression mild edema is visualized in the right parietal lobe and may represent edema from an acute ischemic event in the proper clinical setting if clinical suspicion for stroke is high mri is the recommended study of choice recons are pending but no evidence of distinct vascular occlusion or aneurysmal formation note added at attending review i do not confirm the right parietal edema there are extensive changes of subcortical white matter hypodensity suggesting chronic small vessel ischemia there are no findings to suggest acute infarction there are scattered cortical calcifications that may reflect old granulomatous disease there is an infundibulum at the origin of the left posterior communicating artery cxr impression no evidence of congestive heart failure or pneumonia apparent widening of mediastinum likely due to accentuation of tortuous aorta by patient rotation attention to this area on a non rotated radiograph would be helpful in this regard abd xray findings one view of the abdomen is provided bowel gas pattern is unremarkable visualized osseous structures are unremarkable the lung bases appear clear there is a pacemaker seen with wires in the atrium and ventricle the ng tube is seen coursing through the esophagus into a low lying stomach impression ng tube in stomach around area of pylorus cxr one view of the chest the lungs are well expanded and clear the cardiac silhouette is enlarged the mediastinal silhouette and hilar contours are normal no pleural effusion or pneumothorax is present an ng tube terminates with its tip out of view below the diaphragm a left sided pacer terminates with its leads in the right atrium and right ventricle impression no acute intrathoracic process cxr line placement findings a left sided picc is seen ending in the right atrium we recommend withdrawing the picc approximately cm for placement at the lower svc cavoatrial junction otherwise good lung volumes without focal radiopacities cardiomediastinal and hilar contours are unremarkable with the exception of a tortuous aorta and a stable moderate cardiomegaly no pleural effusion or pneumothorax pacemaker leads ending in standard positions in the right atrium and right ventricle tip of the ng tube is beyond the frame of the radiograph impression tip of the picc in the right atrium no evidence of acute cardiopulmonary disease portable cxr findings in comparison with study of the patient is somewhat oblique which limits evaluation of the heart and lungs in addition there are extensive pacemaker and other leads obscuring the chest nevertheless there is no definite evidence of acute pneumonia or vascular congestion brief hospital course the patient is a year old woman with a history of paroxysmal atrial fibrillation on warfarin diabetes mellitus hypertension and hyperlipidemia who was found unresponsive on the morning of with at least hours of depressed level of awareness likely due to acute cerebral infarction affecting bilateral thalami from a cardioaortoembolic event while supratherapeutic on warfarin she was brought to late in the am of and she was not given thrombolytic therapy as she was outside the treatment time window on exam she would grimace to noxious stimuli and withdraw in all extremities but not follow commands or verbalize on noncontrast head ct she was found to have likely bilateral thalamic hypodensities and possibly a pontine hypodensity however no brainstem lesion was seen on repeat imaging neuro for her bilateral thalamic infarcts she was started on a heparin infusion to anticoagulate her for prevention of further thromboembolism her exam has steadily improved including the ability to repeat some phrases and follow a few simple commands although she remained very somnolent we started her on modafinil mg qam to help improve her level of awareness and subsequently added methylphenidate mg qam and qnoon with the addition of these stimulant medications she is able to maintain alertness during the day coumadin was started on goal inr is heparin gtt is to be stopped once inr is therapeutic id the patient was mildly febrile and developed a leukocytosis she was pancultured and her ua and ucx were positive she was initially treated with bactrim for proteus but when she continued to have low grade fevers and leukocytosis she was re cultured on these urine cultures are growing types of gnr pan sensitive proteus and enterococcus sensitivites still pending she was switched to ceftriaxone on with a plan to treat for days end date leukocytosis and fevers have resolved since on the ctx cards after initially allowing bp to autoregulate we restarted home meds lostartan mg daily and verapamil mg q h total daily home does additionally we added hctz mg daily blood pressure has been well controlled on this regimen gi the patient has had somnolence and decreased cough and gag reflex that has required an ngt and then a peg for tube feeds and medication delivery the speech and swallow therapy team re evaluated the patient on and found that the patient did well during the day when awake with purreed diet and nectar thick liquids please allow this po intake only while the patient is under supervision please continue tube feeds until the patient is able to take in enough nutrition by mouth endo for her diabetes type the patient was maintained on an insulin sliding scale her hgba c is and her fasting lipid panel showed tc trig hdl ldl pravastatin mg po daily was continued pulm no issues currently maintaining good o sats on room air renal currently no issues social issues the hospital course was complicated by a visitor suspected of inappropriate behavior with the patient subsequently her visitors were screened and a password system was put in place social work was involved also there was concern for long term guardianship and the legal process in appointing a guardian has been initiated during this hospitalization medications on admission coumadin noncompliant metformin noncompliant verapamil xr mg qam and mg qpm sitagliptan unknown dose losartan mg po qam discharge medications insulin regular human unit ml solution sig one unit injection four times a day insulin sliding scale methylphenidate mg tablet sig one tablet po lunch lunch methylphenidate mg tablet sig one tablet po qam once a day in the morning hydrochlorothiazide mg capsule sig two capsule po daily daily warfarin mg tablet sig two tablet po qhs once a day at bedtime please adjust per inr with goal inr value heparin porcine in d w unit ml parenteral solution sig units intravenous continuous please stop once inr is therapeutic pravastatin mg tablet sig two tablet po hs at bedtime ceftriaxone in dextrose iso os gram ml piggyback sig one gram intravenous q h every hours for days for uti famotidine mg tablet sig one tablet po q h every hours verapamil mg tablet sig one tablet po q h every hours docusate sodium mg ml liquid sig one hundred mg po bid times a day as needed for constipation losartan mg tablet sig two tablet po daily daily modafinil mg tablet sig one tablet po qam glucagon human recombinant mg recon soln sig one mg injection q min as needed for hypoglycemia protocol dextrose in water d w syringe sig gram intravenous prn as needed as needed for hypoglycemia protocol acetaminophen mg tablet sig tablets po q h every hours as needed for pain fever discharge disposition extended care facility discharge diagnosis acute ischemic stroke bilateral thalamus discharge condition mental status confused sometimes level of consciousness lethargic but arousable activity status bedbound neuro responds to gentle tactile stimulation with eye opening speaks short words and phrases dysarthric follows simple commands right pupil left pupil and both non reactive brainstem reflexes intact otherwise purposefully moves both upper extremities and spontaneous movement of lower extremities bilaterally upper extremities power is at least antigravity and lower extremities are at least discharge instructions you were admitted to the hospital for decreased level of arousal and found to have strokes in bilateral thalami the most likely cause of this was a clot from your heart given your history of atrial fibrillation with a subtherapeutic warfarin level you were very sleepy when you first came in but slowly improved we started you on two medicines to help your alertness modafinial and methylphenidate unfortunately your swallowing ability was intially affected after your stroke this has continued to improve over time but we had to insert a feeding tube in the interim this would be able to be removed if you are able to eat and take medicines appropriately in the future we have maintained you on a heparin gtt for anticoagulation during your stay please continue on this iv until your inr is therapeutic goal inr followup instructions clinic provider md phd date time pm bldg cardiology provider clinic phone date time provider m d phone date time provider phone date time md [NEW_RECORD] name unit no admission date discharge date date of birth sex f service neurology allergies lipitor attending addendum the patient was not discharged on due to no bed availability the patient has a bed available today and will go to rehab discharge disposition extended care facility discharge diagnosis bilateral thalami infarct complicated uti md completed by,"{
""Diagnoses"": [""Paroxysmal atrial fibrillation"", ""Major surgical or invasive procedure (PEG placement)"", ""Hypertension"", ""Diabetes mellitus"", ""Hyperlipidemia"", ""Recurrent UTIs (E. coli and GNR)"", ""Married"", ""Advanced"", ""Works in maintenance""],
""Medications"": [""Lipitor"", ""Coumadin"", ""Warfarin"", ""Aspirin"", ""Metformin"", ""Losartan"", ""Amlodipine"", ""Atorvastatin""]
}"
53549,admission date discharge date date of birth sex m service neurology allergies patient recorded as having no known allergies to drugs attending chief complaint evaluate for iph major surgical or invasive procedure none history of present illness yo ambidextrous man with htn cad crf who presented to ed from osh medflighted for iph for evaluation he lives in tn with his wife came to yesterday for family reunion last night when he slept he was asymptomatic when he woke up this am at am or so he noted that his left ue felt funny he didnt think it was weak then but felt it was heavy he had breakfast at am he ate doughnut and had coffee with left hand without any trouble and his wife was with him then he went up the stairs and took a shower after coming from shower he noted that he was not able to dress especially with the left hand which was very weak he kept on fumbling with the buttons of his jeans with the hand when his wife went to see him she noted that his left ue was weak but she did not notice any other weakness facial asymmetry or any different speech he did not have any trauma headache fevers or any other symptom he was taken to osh where he was noted to be afebrile bp and noted to have left ue weakness he was given labetalol iv followed by drip and underwent ct head which showed cm right parietal bleed he underwent ekg which did not show any new st t changes cbc was normal chem showed bun cr and ca of after recieving labetelol his blood pressure dropped to high s it was stopped and his bp came up again to s in the meantime he recieved ativan iv for unclear reasons there is no history of seizures or agitation he was medflighted to neurology consult was called after arrival after coming to ed his blood pressure became high at and he was started on nicardipine drip of note he has h o unexplained weight loss of pounds in last months he was admitted for pna in tn few weeks ago and recieved iv abx metoprolol dose was decreased from to few weeks ago other review of systems is negative past medical history htn dyslipidemia cad s p stents cognitive decline over last few years glaucoma crf etiology likely htn bl inguinal hernia s p prostate operation years ago for bph social history retd lives with wife in tn quit smoking years ago about pack years before that non alcoholic no drugs family history no strokes but h o dm and htn in many members physical exam exam vitals gen lying in bed supine not in any acute distress heent ncat moist mucosa neck no tenderness to palpation normal rom supple no carotid or vertebral bruit back no point tenderness or erythema cv rrr nl s and s no murmurs gallops rubs lung clear to auscultation bilaterally abd bs soft nontender ext no edema please note that patient was given ativan this am at osh and hence the examination was difficult as he was becoming drowsy during the examination mental status awake cooperative with exam somewhat drowsy and flat affect oriented to person place and date inattentive unable to say backwards but able to say it forwards able to say dow in backward fashion speech is fluent with normal comprehension and repetition naming intact no dysarthria noted he doesnt attend to objects on the left side of page while or while looking at the picture on the stroke card he missed the kids stealing cookies on the left side of picture registers recalls in minutes no evidence of apraxia he was somewhat inattentive towards left side he kept on calling the right arm as his left arm even after reminding him however he was able to touch right thumb to left ear and was able to identify the fingers cranial nerves pupils equally round and slugggishly reactive to light to mm bilaterally he has bl cataracts has left visual field cut extraocular movements intact bilaterally no nystagmus sensation intact v v face symmetric hearing intact to finger rub bilaterally palate elevation symmetrical sternocleidomastoid and trapezius normal bilaterally motor normal bulk bilaterally tone decreased on the left upper extremity no observed myoclonus or tremor has pronator drift in left upper arm tri wf we fe ff ip h q df pf te tf r l sensation intact to light touch temparature vibration and proprioception on the right he has extinction to dss in the left arm more so than the left leg intact jps and vibration he has loss of cortical sensations on the left hand rams are clumsy on left side reflexes reflexes are on the right and left except ankle jerks which are absent right toe is downgoing left toe is mute coordination finger nose finger normal on right difficult to test on left khs test normal gait deferred 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 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 glucose urean creat na k cl hco angap am blood ctropnt am blood ck mb ctropnt am blood pep no specifi imaging ct overall this examination is unchanged a x right parietal intracerebral hemorrhage is stable there is surrounding edema as well as some extension of hemorrhage through the cortex into the subarachnoid space no new hemorrhage is identified no midline shift or evidence of herniation is seen there is prominence of the ventricles and sulci reflecting generalized atrophy age related lacunes are seen in the bilateral caudates no concerning osseous lesion is seen the visualized paranasal sinuses are clear no evidence of mass effect is seen impression overall unchanged examination with right parietal ich surrounding edema and subarachnoid extension no midline shift mri a as seen on the recent ct there is an approximately x cm acute to subacute right parietal hematoma with surrounding vasogenic edema there is no shift of normally midline structures there is minimal mass effect on the occipital of the right lateral ventricle there are no other areas of susceptibility artifact apart from a small focus within the left middle cerebellar peduncle there is no definite evidence of acute infarct there is a focus of high signal on diffusion weighted images in the periventricular white matter of the right frontal lobe which appears to correspond to a focus of flair signal hyperintensity and may be related to t shine through as it is not resolvable on the adc map otherwise there is no evidence of acute infarct the ventricles and sulci are prominent likely related to age related involutional change the major intracranial flow voids appear maintained mra of the brain there is no abnormal vascular structure in the area of the hemorrhage there is hypoplasia of the a segment of the right anterior cerebral artery normal variant the posterior cerebral arteries bilaterally are somewhat attenuated which may be related to atherosclerosis but there is no evidence of flow limiting stenosis occlusion or aneurysm in the vessels of the anterior or posterior circulation impression no findings on the mri or mra to suggest underlying vascular malformation in the area of the right parietal hematoma punctate focus of susceptibility artifact in the left middle cerebellar peduncle is non specific and could be a calcification microhemorrhage or cavernoma ct there is a x cm right parietal intracerebral hemorrhage stable from prior exam with similar perilesional edema there is no significant midline shift minor subarachnoid extension exists there is no new intraparenchymal hemorrhage prominence of ventricles and sulci relate to age related atrophy lacunes are redemonstrated on the right mastoid air cells are clear visualized paranasal sinuses are unremarkable impression stable appearance to right parietal intracerebral hemorrhage no midline shift eeg this telemetry captured no pushbutton activations however it captured frequent sharp activity in the right parasagittal area which sometimes became more rhythmic and evolving suggestive of electrographic seizures without clear clinical correlate the background activity was also slower in the right parasagittal area suggestive of subcortical dysfunction in the region brief hospital course mr was admitted to neurology icu service for evaluation of iph he was closely monitered in unit and was transfered to neurology floor after initial stabilisation neuro he was closely monitered with neuro checks initially q h signs of new deficits as well as that of raised icp such as headache vomiting visual blurring were monitered and he did not have any of those antiplatelets and heparin sc was avoided given iph he was put on comtinuous ltm eeg for days given history of iph however he did not have any clinical seizures but had few discharges on eeg in the area on right parasaggital region c w iph location he underwent repeat ct scan after hrs which did not show any evidence of edema or increasing bleed or new bleed he underwent mri to evaluate for any underlying mass or other areas of bleed which was negative for the above the mechanism of bleed was thought to be htn or amyloid cards he was closely monitered on telemetry he was ruled out for cardiac ischemia by ekg and cardiac enzymes heart healthy diet was given renal creatinine was closely watched i o was monitered nephrotoxic agents and dyes were avoided spep and upep were done to evaluate for myeloma which was negative endo close watch over blood sugars was kept and he was on riss fen nutrition he was closely monitered and underwent swallow test rehab he was seen by ot pt who felt that the patient needed rehab medications on admission clonidine metoprolol travast eye drops aspirin day fish oil mvi discharge medications multivitamin tablet sig one tablet po daily daily docusate sodium mg capsule sig one capsule po bid times a day as needed for constipation senna mg tablet sig one tablet po bid times a day as needed for constipation omega fatty acids capsule sig one capsule po daily daily dorzolamide timolol drops sig one drop ophthalmic times a day travoprost drops sig one ophthalmic qhs once a day at bedtime clonidine mg tablet sig one tablet po tid times a day amlodipine mg tablet sig two tablet po daily daily metoprolol tartrate mg tablet sig one tablet po tid times a day famotidine mg tablet sig one tablet po q h every hours discharge disposition extended care facility discharge diagnosis right parietal bleed discharge condition awake alert follows commands and steps able to say days of week backward oriented to person place year but not month day spatial memory intact mild naming difficulty to low frequency objects comprehension and repition intact calculation intact attends to both side cn eomi visual fields appear full occ inattentive on left but no extinction to dss tongue midline face symmetric motor slight left sided drift weakness at the left delt tricep finger extensors strong at biceps full at rue full at legs reports slight decreased to light touch and pinprick astereognosis and agraphasthesia on the left hand discharge instructions you were admitted with the onset of left upper extremity weakness you were brought to an outside hospital where an image of your head was performed and you were noted to have a bleed in your brain a small area in the right side called the parietal lobe you were medflighted to for further evaluation here you were admitted to the neuro icu for blood pressure controll and frequent monitoring you did well and were transferred out to the floor for further monitoring you were seen by physical therapy who recommended rehab your medications were changed as follows you clonidine was increase to tid you were started on amlodipine mg daily your aspirin was stopped please take all medications as prescribed please make all follow up appointments if you have any new weakness or any of the symptoms listed below please call your doctor or return to the nearest emergency room followup instructions patient lives in he will need to follow up with his primary care provider when he gets released from rehab and be set up with a neurologist in his home area md,"{
""Diagnoses"": [""iph"", ""neurology""],
""Medications"": [""none""]
}"
84347,admission date discharge date date of birth sex m service orthopaedics allergies patient recorded as having no known allergies to drugs attending chief complaint lower extremity weakness and back pain major surgical or invasive procedure t l laminectomy history of present illness mr has a long history of back and leg pain he has undergone a previous l laminectomy which initially helped but unfortunately his symptoms have returned his lower extremity weakness brought him to the emergency department where he was evaulated for surgical intervention past medical history dm hypercholesterolemia htn obesity congenital spinal stenosis social history lives with wife denies alcohol and tobacco family history n c physical exam a o x nad rrr cta b abd soft nt nd bue good strength at deltoid biceps triceps wrist flexion extension finger flexion extension and intrinics sensation intact c t dermatomes reflexes symmetric at biceps triceps and brachioradialis ble rle at quads anterior tib and gastrocnemius he was at left quad anterior tibia and and at peroneal and gastrocnemius sciatica reflexes deminished and quads and achilles bilaterally good peripheral pulses 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 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 brief hospital course mr was admitted to the spine surgery service on and taken to the operating for t l laminectomy for congenital stenosis please 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 given per standard protocol post op his motor exam showed no movement or sensation of his lower extremities he was administered a stat mri of the cervical thoracic and lumbar spine to assess for cord compression a cord signal change was identified at t he was transfered to the sicu and a neurology consult was obtained and recommendations followed an infarct to the anterior spinal cord was thought to have occurred he was placed on solumedrol for hours with mild improvement in hip internal rotation sensation improved an additional mri was obtained which showed a post operative hematoma at the surgiclal site and this was aspirated under ct guidance he was kept npo until bowel function returned then diet was advanced as tolerated he developed a fever and increasing white count and was placed on antibiotics for a presumed pneumonia he was screened for rehab and will follow up in the orthopaedic spine clinic in two weeks medications on admission amlodipine benzapril toprol lipitor hctz pioglitazone oxycodone amitriptyline hctz ativan discharge medications atorvastatin mg tablet sig one tablet po daily daily amitriptyline mg tablet sig one tablet po hs at bedtime senna mg tablet sig one tablet po bid times a day as needed for constipation famotidine mg tablet sig one tablet po q h every hours heparin porcine unit ml solution sig one syringe injection times a day docusate sodium 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 metformin mg tablet sig one tablet po bid times a day pioglitazone mg tablet sig one tablet po daily daily zolpidem mg tablet sig tablets po hs at bedtime oxycodone acetaminophen mg tablet sig tablets po every hours as needed for pain ciprofloxacin mg tablet sig one tablet po q h every hours for weeks oxycodone mg tablet sustained release hr sig one tablet sustained release hr po q h every hours cyclobenzaprine mg tablet sig one tablet po tid times a day as needed for spasms insulin nph regular human subcutaneous discharge disposition extended care facility discharge diagnosis congenital cervical thoracic and lumbar stenosis cervical and lumbar spondylosis paraplegia post op fever post op ileus post op blood loss anemia post op pneumonia discharge condition stable discharge instructions you have undergone the following operation posterior thoracolumbar decompression t l 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 getting up and walking 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 olimit 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 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 call the office you should resume taking your normal home medications no nsaids 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 please call the office if you have a fever degrees fahrenheit and or drainage from your wound physical therapy activity out of bed w assist treatments frequency please continue to change the dressing daily with dry sterile gauze look for signs of skin breakdown followup instructions please follow up with dr in the orthopaedic spine clinic call to schedule an appointment in weeks completed by,{}
15411,admission date discharge date date of birth sex f service med allergies dairy attending chief complaint hematochezia major surgical or invasive procedure none history of present illness f w diverticulosis dmii htn hyperlipidemia and h o recurrent lgib no known etilogy after colonoscopy egd t rbc scan with sudden lgib at pm on doa similar to prev lgib with red blood and the stool mixed with blood occurred spontaneously while sitting on couch no cp sob syncope presyncope n v diarrhea no fevers chills wt loss change in stool caliber past medical history lgib diverticulosis dmii htn hyperlipidemia djd hip knee gerd social history lives with husband smoked or drank no ivdu or drugs has three kids family history son age has idiopathic lgibs no fhx of colitis crohn s ulcerative colitis no bleeding disorders no crc no heart disease no congenital disorders no avms brief hospital course a p f w recurrent and idiopathic lgib gib pt likely with lower gib diverticulosis pt had one more episode of hematochezia while drinking go lytely hct am hct s checked q hours and pt put on bowel rest with ppi pt was hemodynamically stable except for tachycardia to the s jegers involving s i based on family hx son with multiple episodes gib of unknown etiology and macules over lips and buccal mucosa hct in am recieved units prbc hct then egd revealed small hiatal hernia with short segment of barrett s esophagus colonoscopy revealed blood throughout the colon without definite bleeding site diverticuli but none bleeding ti seen but not intubated trbc study did not reveal any active bleeding pt moved to for hemodynamic monitoring hct given u prbc hemodynamically stable started on clear liquid diet hct no further episodes of bleeding hd stable scheduled for capsule endoscopy no bleeding awaiting pill endoscopy tomorrow no bleeding tolerated pill endoscopy without problems tolerated full dinner at night no bm no bleeding will d c with follow up in clinic gerd pt with barrett s esophagus on egd put on po protonix likely will need h pylori eradication with triple therapy as outpt also may need surveilence egd s to screen for dysplasia will d c pt with anti reflux medications dm on riss htn holding ace i hctz nifedipine gib will d c pt on ace inhibitor but will hold hctz and nifedipine until clinic appointment hypercholesterolemia on atarvostatin last lipid panel quite good medications on admission acetaminophen prn multivitamins cap po qd moexipril hcl mg po qd pantoprazole mg po q h hydrochlorothiazide mg po qd hctz mg po qd glucosamine metformin mg nifedipine mg qd glyburide mg po qd atorvastatin mg po qd discharge medications atorvastatin calcium mg tablet sig one tablet po qd once a day disp tablet 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 moexipril hcl mg tablet sig one tablet po twice a day disp tablet s refills discharge disposition home discharge diagnosis lower gi bleed of unknown source discharge condition stable discharge instructions if you have these symptoms call your doctor or come to the emergency room bloody diarrhea black tarry stools dizziness blurry vision abdominal pain bloody vomitus followup instructions clinic with completed by [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies dairy attending chief complaint rectal bleeding major surgical or invasive procedure colonoscopy history of present illness hpi f with h o multiple lgib s with hrs h o rectal bleeding in the bowel x also passing clots no f c no abd pain no lightheadedness her stools have been loose mixed with blood of note the patient s last c scope was in where she was noted to have grade internal hemorrhoids and diverticulosis of the entire colon she also has a family history of bleeding with her son and daughter having the same problem in er bp hct gi called in er access is piv s hct then has been eating without pain nausea vomitting diarrhea stopped no cp sob orthostasis bilateral le edema not unusual per her ros constitutional x wnl weight loss fatigue malaise fever chills rigors nightweats anorexia cardiac x wnl chest pain palpitations le edema orthopnea pnd doe respiratory x wnl sob pleuritic pain hemoptysis cough gastrointestinal x wnl nausea vomiting abdominal pain abdominal swelling diarrhea constipation hematemesis hematochezia melena musculoskeletal x wnl myalgias arthralgias back pain neurological x wnl numbness of extremities weakness of extremities parasthesias dizziness lightheaded vertigo confusion headache past medical history lgib x diverticulosis dmii htn hyperlipidemia djd hip knee gerd social history lives with husband smoked or drank no ivdu or drugs has three kids family history son age and daughter s p colectomy have lgibs no fhx of colitis crohn s ulcerative colitis no bleeding disorders no crc no heart disease no congenital disorders no avms physical exam vs ra gen well appearing no acute distress awake alert appropriate and oriented x skin warm to touch no apparent rashes heent no conjunctival pallor no scleral jaundice op clear no cervical lad cv rrr no m r g pulses in le lungs clear to auscultation no w r r abd soft nt normal bs nd guaiac stool ext pe bilateral lower extremities neuro gait strength and sensation intact bilaterally pertinent results pm pt ptt inr pt pm glucose urea n creat sodium potassium chloride total co anion gap pm estgfr using this pm wbc rbc hgb hct mcv mch mchc rdw hct pm neuts lymphs monos eos basos pm plt count colonoscopy impression multiple diverticula were seen throughout the colon especially the sigmoid and descending colon diverticulosis appeared to be of moderate severity the lumen of the sigmoid and descending colon contained blood and blood clots the transverse colon contained a small amount of blood only and the right side of the colon contained brown stool indicating that the source of bleeding is in the left colon despite vigorous washing and flushing the site of the bleeding could not be found gi bleeding scan interpretation following intravenous injection of autologous red blood cells labeled with tc m blood flow and dynamic images of the abdomen for minutes were obtained a left lateral view of the pelvis was also obtained blood flow images shows no abnormality dynamic blood pool images shows no abnormality impression no scintigraphic evidence of bleeding gi bleeding scan interpretation following intravenous injection of autologous red blood cells labeled with tc m blood flow and dynamic images of the abdomen were obtained for minutes a left lateral view of the abdomen was also obtained blood flow images are normal dynamic blood pool images show abnormal tracer activity at the splenic flexure at minutes compatible with bleeding this is confirmed on the static left lateral view of the abdomen impression bleeding from the splenic flexure at minutes gi bleeding scan negative for gi bleed am blood wbc rbc hgb hct plt ct am blood glucose urean creat na k cl hco angap brief hospital course f with brbpr and history of diverticulosis who presents with a lower gi bleed acute blood loss anemia gi bleed pt was initially admitted on for brbpr initially thought most likely a diverticular bleed given her history a colonoscopy was performed which showed diffuse moderate divertulosis a clot in the transverse and left colon however the site of the bleeding could not be determined surgery was consulted who recommended tagged rbc scan which was negative repeated showed splenic flexure bleeding and negative again during this time her blood counts persistently dropped requiring a total of unit prbc transfusions on she was transferred to the icu but her counts stabilized and she required no further transfusions she was transferred out again gi and surgery both followed hemicolectomy was discussed if bleeding does not stop her hct remained stable on the floor after several repeat tests with no clinical evidence of rebleeding she will follow up with her pcp early next week for check up and repeat hct and will follow up with clinic in she was instructed to reach her pcp or return to er with any recurrent bleeding or other danger signs was intructed to not take aspirin or nsaids she will take iron mg twice daily hypertension benign held hctz lisinopril nifedical and atenolol in house initially restarted lisinopril on discharge with instructions to continue to hold other three medications until follow up with pcp next week secondary diagnosis hyperlipidemia continued statin secondary diagnosis diabetes type ii uncontrolled w o complications held oral hypoglycemic in house continued metformin on discharge was covered in house with insuling sliding scale medications on admission atenolol mg tablet one tablet s by mouth once a day atorvastatin mg tablet tablet s by mouth once a day glyburide mg tablet one tablet s by mouth q am one half tab at night hydrochlorothiazide mg tablet tablet s by mouth once a day hydrocortisone acetate mg suppository supp rectally twice a day as needed lisinopril mg tablet tablet s by mouth once a day metformin mg tablet tablet s by mouth q am one q pm multivitamins tablet nifedipine nifedical xl mg tablet extended rel hr tab s by mouth once a day omeprazole mg capsule delayed release e c capsule s by mouth once a day discharge medications atorvastatin mg tablet sig two tablet po daily daily glyburide mg tablet sig one tablet po twice a day take tab at night lisinopril mg tablet sig one tablet po once a day metformin mg tablet sig one tablet po twice a day ferrous gluconate mg mg iron tablet sig one tablet po every twelve hours discharge disposition home discharge diagnosis acute blood loss anemia diverticular bleed hypertension benign type diabetes poorly controlled with complications hyperlipidemia diverticulosis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted with a gi bleed your underwent a colonoscopy which showed bleeding and diverticulosis you underwent a bleeding scan which did not precisely pinpoint your bleed the surgeons evaluated you the cause of your bleeding was likely due to a diverticular bleed you required blood transfusion last given and you were observed in icu without further intervention with supoprtive care your bleeding stopped and your blood counts remained stable please resume medications as indicated on your medication sheet make a note of the blood pressure medications you should not take until you are further instructed by your pcp at your appointment next week atenolol hctz nifedipine please follow up with your pcp call your doctor or return to the hospital if you have the symptoms listed below followup instructions appointment md specialty internal medicine pcp time wednesday am location building central suite phone number provider phone date time provider m d phone date time provider imaging phone date time [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies dairy attending chief complaint gi bleed major surgical or invasive procedure colonoscopy ivc filter placement history of present illness year old woman with history of multiple diverticular bleeds type diabetes mellitus hypertension hyperlipidemia gerd and recent dvt s p right tka who presents with bloody stools the patient had been started on coumadin with lovenox bridge after developing a rle dvt the patient had stopped lovenox injections this past monday when her inr but when it dropped to on thursday she was restarted on lovenox the patient woke up at pm today and felt the urge to have a bowel movement when she wiped there were streaks of blood mixed with stool on the toilet paper she proceeded to have two more bowel movements with blood mixed in her stools the patient denies any crampy abdominal pain light headedness chest pain shortness of breath with these episodes she has not had any more bloody stools since arrival to the she does have a history of hemorrhoids as well in the ed initial vs were t p bp r o sat on ra patient was given ivf her labs were drawn which showed stable normocytic anemia from prior hct and therapeutic inr at her creatinine was slightly elevated at baseline she received liters of ivf with improvement in her heart rate two large bore pivs were placed and gi made aware on the floor the patient was resting comfortably in bed past medical history right tka with subsequent dvt diverticulosis type diabetes mellitus benign essential hypertension hyperlipidemia degenerative joint disease hip knee gerd history of lgib x previously considered diverticular although bleed of unclear source splenic flexure bleed on tagged rbc scan no interventions performed social history lives with husband independent adls with currently to help with lovenox injections coumadin inr checks has three children denies tobacco alcohol or illicit drugs family history diverticulosis in all three children son s and daughter s have had colectomies for lgibs father may have had an mi no family history of colitis crohn s ulcerative colitis no bleeding disorders or family history of malignancies physical exam general alert oriented no acute distress heent sclera anicteric mmm oropharynx clear neck soft supple jvp not elevated no lad lungs clear to auscultation bilaterally 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 rectal guaiac positive and streaks of frank blood small clots in rectal vault small hemorrhoids ext warm well perfused pulses no clubbing cyanosis rle edema greater than left no ttp surgical incision site c d i healing well pertinent results pm hct am glucose urea n creat sodium potassium chloride total co anion gap am calcium phosphate magnesium am wbc unable to rbc unable to hgb unable to hct unable to mcv unable to mch unable to mchc unable to rdw unable to am plt count unable to am pt ptt inr pt 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 neuts lymphs monos eos basos am plt count am pt ptt inr pt brief hospital course year old woman with history of multiple diverticular bleeds type diabetes mellitus hypertension hyperlipidemia gerd and recent dvt s p right tka who presents with bloody stools bloody stools she has a personal history of multiple gi bleeds thought to be diverticular in origin her most recent gi bleed in did not have clear etiology however the patient was being anticoagulated for her rle dvt and anticoagulation was held on admission she also has small hemorrhoids but they were not frankly bleeding from these on rectal exam on admission on she had cc of melena frank blood and her hct dropped from to cta was negative she was transfered to the icu and transfused units prbc and units ffp an ivc filter was placed she was transfered back to the floor when stable and her hematocrits were monitored her hematocrits were stable ranging from to she underwent a colonoscopy which did not reveal any active bleeding colonoscopy did show diverticula which were not bleeding her hematocrit was checked post colonoscopy and was stable she will be discharged with f u appointments with her pcp and plan to f u with gi in weeks she will have a repeat hct in week to be followed up upon by her pcp will hold anticoagulation at discharge given her history of gi bleeding she is likely not a good candidate for anticoagulation in the future in addition her dvt was provoked in the setting of surgery the ivc filter is temporary and can be removed eventually at this time we would recommend holding anticoagulation keeping the ivc filter in place for now and repeating a lower extremity us in months we will leave management decisions regarding anticoagulation the ivc filter and any repeat imaging to the pcp and outpatient gi team however right tka with subsequent dvt inr was therapeutic on admission and rle exam stable anticoagulation held given gi bleed her inr was reversed with ffp and an ivf filter was placed oxycodone for pain control was continued she will have f u with orthopedic team as previously scheduled hypertension hyperlipidemia stable her home medications were held in the setting of gi bleeding her blood pressures were stable with sbps around s her home medications will be restarted at discharge type diabetes mellitus stable held metformin and glipizide in house will restart at discharge blood glucose managed with ssi in house gerd stable no signs of upper gi bleed continued home omeprazole medications on admission atenolol mg daily atorvastatin mg daily fluocinonide cream twice daily prn glyburide mg daily hctz mg daily hydrocortisone acetate mg suppository twice daily prn hemorrhoids lisinopril mg daily metformin mg twice daily nifedipine mg er daily omeprazole mg daily oxycodone mg daily q hours prn pain coumadin mg daily per inr lovenox mg injections twice daily discharge medications atenolol mg tablet sig one tablet po once a day atorvastatin mg tablet sig two tablet po daily daily fluocinonide cream sig one application topical twice a day glyburide mg tablet sig one tablet po once a day hydrochlorothiazide mg tablet sig one tablet po once a day hydrocortisone acetate mg suppository sig one rectal twice a day as needed for hemrrhoids lisinopril mg tablet sig one tablet po once a day metformin mg tablet sig one tablet po twice a day nifedipine mg tablet extended rel hr sig one tablet extended rel hr po once a day omeprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily oxycodone mg tablet sig tablets po every hours as needed for pain outpatient lab work please check hematocrit in week please send results to name location east address e cc phone fax email please also send results to name brain np location address phone fax email discharge disposition home with service facility all care of greater discharge diagnosis lower gastrointestinal bleeding unclear etiology right tka with subsequent dvt diverticulosis type diabetes mellitus benign essential hypertension hyperlipidemia degenerative joint disease hip knee gerd history of lgib x previously considered diverticular although bleed of unclear source splenic flexure bleed on tagged rbc scan no interventions performed discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to for bleeding from your rectum you were transfused blood and monitored in the intensive care unit you had a filter placed in the major vein in your body to prevent clots in your legs from traveling to your lungs your blood levels were monitored and were stable you underwent a colonoscopy which did not show active bleeding the following changes were made to your medications stop warfarin stop lovenox please continue you other home medications followup instructions the following appointments have been made for you department gastroenterology when monday at am with md building lm campus west best parking garage department when tuesday at am with np building campus east best parking garage department orthopedics when tuesday at pm with pa building sc clinical ctr campus east best parking garage department center when wednesday at am with eye imaging building campus east best parking garage,{}
3540,admission date discharge date date of birth sex f service surgery allergies demerol nsaids attending chief complaint gi bleed major surgical or invasive procedure exploratory laparotomy enterectomy enteroenterostomy ligation of av malformation x enteroscopy history of present illness this patient had previously been admitted with gastrointestinal bleeding and had had the av malformation coiled to see whether or not it would be therapeutic it was not and she was admitted with another gi bleed past medical history cad s p mi dm s p tia small l posterior limb of the internal capsule seen at gi bleeds since migraines s p ccy s p lumbar surgery fast heart rate anemia nsvd social history lives at home with husband children and grandchild works in medical billing quit smoking many years ago no etoh no other drugs family history daughter with ulcerative colitis brother died of esophageal ca father died of prostate ca mother with heart problems siblings with diabetes physical exam ra gen pleasant lady resting comfortably in bed no acute distress anicteric cardiac regular rate and rhythm ii vi systolic ejection murmur at lusb pulm clear to auscultation bilaterally no wheezes rales or rhonchi abdomen soft nontender nondistended positive bowel sounds extremities no clubbing cyanosis or edema warm 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 am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood hct 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 pt ptt inr pt am 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 thrombn pm blood protcfn protsfn aca igg pnd aca igm pnd 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 ck cpk am blood alt ast alkphos amylase totbili am blood ck cpk am blood lipase pm blood ck mb notdone ctropnt am blood ck mb ctropnt am blood ck mb ctropnt pm blood ck mb ctropnt am blood calcium phos mg am blood albumin calcium phos mg iron am blood albumin calcium phos mg am blood calcium phos mg cholest am blood caltibc ferritn trf am blood triglyc hdl chol hd ldlcalc pm blood homocys am blood ammonia pm blood vanco am blood phenyto am blood phenyto am blood freeca am blood freeca helicobacter pylori antibody test final negative by eia reference range negative am sputum site endotracheal final report gram stain final pmns and epithelial cells x field per x field gram positive rod s per x field gram positive cocci in pairs and clusters per x field gram negative rod s pm catheter tip iv source cvl final report wound culture final no significant growth am urine blood neg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks sm radiology final report distinct procedural service pm reason evaluate for source of bleeding embolize if possible contrast optiray medical condition year old woman with active gi bleed seen on enteroscopy but no site identified reason for this examination evaluate for source of bleeding embolize if possible indication history of recurrent active gi bleeding seen on enteroscopy but no site identified comparison images from a prior mesenteric angiogram from physicians the procedure was performed by drs and with dr the attending radiologist being present and supervising throughout the procedure dr reviewed the exam procedure prior to initiation of the procedure written informed consent was obtained and a preprocedure timeout was performed the right groin was prepped and draped in sterile fashion a gauge needle was used to access the right femoral artery after which a guide wire was advanced through the needle the needle was exchanged for a french sheath a french cobra glide catheter was advanced over the needle and the tip was positioned within the celiac artery the wire was removed and contrast injected with arteriogram demonstrating no areas of active extravasation arising from branches of the celiac artery the catheter was then positioned within the sma contrast was injected and sma arteriogram was performed and a focal area of contrast extravasation was identified localized to a branch of the sma adjacent to the embolized area on the prior exam based on the diagnostic findings it was decided to proceed with embolization a fast tracker microcatheter was then advanced through the cobra catheter and positioned within the bleeding vessel the vessel was then embolized with two mm x cm microcoils contrast was then injected demonstrating successful embolization of this bleeding vessel however bleeding was noted to have started from a new adjacent area which could not be embolized the catheters were then removed the sheath was removed and manual compression was applied for minutes until adequate hemostasis was achieved anesthesia local anesthesia was provided with cc of lidocaine mg of versed and mcg of fentanyl were also administered contrast ml of iv optiray contrast was administered complications no immediate complications impression mesenteric angiogram demonstrated active contrast extravasation from a branch of the sma adjacent to the area of the previously embolized vessel this vessel was successfully embolized with two microcoils subsequent injection after successful embolization demonstrated area of contrast extravasation adjacent to the embolized artery access could not be obtained to this vessel and this could not be embolized results were discussed with the covering attending physician immediately after the procedure radiology final report gi bleeding study gi bleeding study reason egd but continues to have melena indication year old woman with history of upper gi bleeding presenting with continued melena a recent upper endoscopy was negative interpretation following intravenous injection of autologous red blood cells labelled with technetium m blood flow and dynamic images of the abdomen for minutes were obtained the flow images are limited in that they represent posterior views the dynamic blood flow images show bleeding which begins in the distal duodenum or proximal jejunum starting at minutes and then passing distally the more likely source is the proximal jejunum impression evidence of active gastrointestinal bleeding with the source either the distal duodenum or proximal jejunum name birthdate age sex pathology female report to dr gross description by dr dif specimen submitted small bowel parts procedure date tissue received report date diagnosed by dr jip diagnosis i segmental resection of small bowel a f focal fresh hemorrhage in the mucosa submucosa and muscularis propria foci of abnormally large caliber thick and thin walled blood vessels in areas of hemorrhage and non hemorrhagic bowel wall the vessels are in the submucosa and muscularis propria fresh hemorrhage focal in the mesentery ii segmental resection of small bowel g o focal acute hemorrhagic mucosal ischemic infarctions the resection margins contain focal mucosal hemorrhage but no necrosis is identified foci of abnormally large caliber thick and thin walled blood vessels in areas of mural hemorrhage and in non hemorrhagic bowel these vessels are located primarily in the submucosa and muscularis propria but focally involve the adjacent mesentery slide o a recent thrombi present in submucosal arteries slides g i b organized thrombi in arterial vessels slides g n focal fresh hemorrhage in the mesentery radiology final report mr contrast gadolin pm mr head w w o contrast mr contrast gadolin reason mri stroke protocol plus mri with gadolinium contrast magnevist medical condition year old woman with acute ams s p removal of rij cvl please eval acute stroke seizure focus etc reason for this examination mri stroke protocol plus mri with gadolinium contraindications for iv contrast none mr head clinical information acute ams status post removal of right internal jugular cvl evaluate for acute stroke technique multiplanar multisequence mri of the head with dwi d tof mra of the circle of findings the dwi images demonstrate scattered foci of hyperintense abnormality along the expected region of the watershed territory of the aca and mca bilaterally see series image the corresponding coronal t post contrast images demonstrate subtle enhancement along the aca mca watershed territories more prominent on the left these findings are in keeping of acute aca mca watershed territory infarct no further focus of abnormal enhancement is present no additional t or t signal abnormalities within the cerebrum cerebellum or brainstem ventricular size and configuration are within normal limits basal cisterns are patent white matter differentiation is otherwise preserved the d tof mra images demonstrate somewhat narrowed a segments of the acas bilaterally of uncertain significance otherwise the circle of and its principal branches demonstrate normal flow signal with no critical stenosis occlusion or aneurysm greater than mm is evident no evidence of vascular malformation within the field of view conclusion mr features of acute aca mca watershed territory infarcts bilaterally no additional signal abnormality mass or mass effect hypoplastic a segments of the acas bilaterally otherwise a normal cerebral mra radiology final report cta chest w w o c recons pm cta chest w w o c recons ct cc non ionic contrast reason please eval for pe field of view contrast optiray medical condition year old woman with altered mental status and low o sat reason for this examination please eval for pe contraindications for iv contrast none indication assess for pulmonary embolism technique ct examination of the chest utilizing contiguous axial imaging was performed with and without the administration of intravenous contrast bolus per ct pulmonary angiogram protocol images were reformatted in the sagittal and coronal planes findings no prior ct for comparison study is somewhat limited secondary to motion no filling defect is identified within the main or segmental pulmonary arteries no evidence of central pulmonary embolism the thoracic aorta is normal in caliber throughout without aneurysmal dilatation the heart is not enlarged there is no pericardial effusion there are no enlarged mediastinal hilar or axillary lymph nodes small lymph nodes are seen within the prevascular and paratracheal distribution the central airway is patent without filling defect evaluation of the lungs reveals multiple ill defined pulmonary nodules within the right middle lobe there are two nodules measuring and mm respectively images and within the right lower lobe measuring mm image and within the left lower lobe abutting the major fissure measuring mm image no dominant mass is identified there is dependent atelectasis bilaterally there is mild central venous engorgement and mild prominence of the interlobular septum findings most compatible with mild underlying pulmonary edema limited evaluation through the upper abdomen is grossly normal there is degenerative change of the thoracic spine without lytic or sclerotic lesion incidental note is made of hypodensities within the left lobe of the thyroid better evaluated with ultrasound impression no pulmonary embolism multiple small pulmonary nodules as described a followup ct examination is recommended in three months to further evaluate incidental note of hypodense lesion within the left lobe of the thyroid which would be better evaluated with ultrasound mild pulmonary edema radiology preliminary report bilat up ext veins us am bilat up ext veins us reason eval carotids and subclavians i e neck and upper chest fo medical condition year old woman with post ant embolic infarcts on mri reason for this examination eval carotids and subclavians i e neck and upper chest for source indication this patient is a year old female with embolic infarcts on mri the patient had a line in the left subclavian vein comparisons no comparisons are available bilateral upper extremity dvt study grayscale and doppler son of the bilateral internal jugular veins subclavian veins axillary veins and brachial veins were performed there is normal flow compressibility and augmentation of these vessels no intraluminal thrombus was identified impression no evidence of dvt radiology final report carotid series complete port pm carotid series complete port reason post ant embolic infarcts medical condition year old woman with post ant embolic infarcts on mri reason for this examination to evaluated for arterial stenosis history posterolateral embolic infarcts findings technique b mode duplex and doppler interrogation of the extracranial carotid arteries was performed right side no calcified plaques were noted vertebral artery demonstrated antegrade flow peak systolic velocities were as follows cm sec ica cm sec cca cm sec eca cm sec vertebral artery ica cca ratio was left no calcified plaques were identified vertebral arteries demonstrated antegrade flow peak systolic velocities were as follows cm sec ica cm sec cca cm sec eca cm sec vertebral artery the ica cca ratio was impression no hemodynamically significant stenosis in the extracranial internal carotid arteries referring doctor dr measurements left atrium long axis dimension cm nl cm left atrium four chamber length cm nl cm right atrium four chamber length cm nl cm left ventricle septal wall thickness cm nl cm left ventricle inferolateral thickness cm nl cm left ventricle diastolic dimension cm nl cm left ventricle ejection fraction to nl aorta valve level cm nl cm aorta ascending cm nl cm aortic valve peak velocity m sec nl m sec mitral valve e wave m sec mitral valve a wave m sec mitral valve e a ratio interpretation findings lateral and septal e m s left atrium mild la enlargement right atrium interatrial septum normal ra size left ventricle normal lv wall thicknesses and cavity size apical lv aneurysm moderate regional lv systolic dysfunction tvi e e suggesting pcwp mmhg no lv mass thrombus lv wall motion regional lv wall motion abnormalities include mid anterior hypo mid anteroseptal hypo mid inferoseptal hypo anterior apex akinetic septal apex akinetic inferior apex akinetic lateral apex hypo apex dyskinetic right ventricle normal rv chamber size and free wall motion aorta normal aortic root diameter normal ascending aorta diameter aortic valve normal aortic valve leaflets no as no ar mitral valve normal mitral valve leaflets mild mr tricuspid valve normal tricuspid valve leaflets with trivial tr normal pa systolic pressure pulmonic valve pulmonary artery normal pulmonic valve leaflets with physiologic pr pericardium there is an anterior space which most likely represents a fat pad though a loculated anterior pericardial effusion cannot be excluded general comments based on aha endocarditis prophylaxis recommendations the echo findings indicate a low risk prophylaxis not recommended clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data echocardiographic results were reviewed by telephone with the houseofficer caring for the patient conclusions the left atrium is mildly dilated left ventricular wall thicknesses and cavity size are normal there is moderate regional left ventricular systolic dysfunction with hypokinesis of the distal half of the inferior septum and akinesis of the distal third of the anterior septum anterior wall and inferior wall the apex is mildly dyskinetic and anerysmal no masses or thrombi are seen in the left ventricle tissue velocity imaging e e is elevated suggesting increased left ventricular filling pressure pcwp mmhg right ventricular chamber size and free wall motion are normal the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve leaflets are structurally normal mild mitral regurgitation is seen the estimated pulmonary artery systolic pressure is normal there is an anterior space which most likely represents a fat pad though a loculated anterior pericardial effusion cannot be excluded impression regional left ventricular systolic dysfunction c w cad mid lad lesion compared with the study images reviewed of the left ventricular regional dysfunction is new based on aha endocarditis prophylaxis recommendations the echo findings indicate a low risk prophylaxis not recommended clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data radiology final report mr head w w o contrast pm mr head w w o contrast mr contrast gadolin reason stroke protocol contrast magnevist medical condition year old woman s p ex lap coded stroke reason for this examination stroke protocol mri of the brain with contrast indication stroke followup exam multiplanar t and t weighted images of the brain were obtained without and with intravenous gadolinium administration comparison is made to the prior examination from there are persistent foci of restricted diffusion seen on diffusion images involving the right aca and posterior watershed territory a focal area of decreased diffusion is noted along the splenium of the corpus callosum these most likely represent evolving a small infarct which could be related to hypoperfusion they could also be embolic in nature there is t hyperintensity within the mastoid sinuses suggestive of fluid retention or inflammatory mastoiditis there is t hyperintensity along the splenium of the corpus callosum and abutting the adjacent occipital lobes consistent with small evolving infarcts t hyperintensity is also present along the posterior parietal lobes there is no midline shift seen residual cytotoxic edema is present due to the evolution of multiple infarcts described previously signal flow voids are present there is mucosal thickening within the ethmoid and sphenoid sinuses no pathologic enhancement is seen within the brain following intravenous contrast administration impression multiple evolving subacute infarcts involving the occipital posterior parietal and right frontal lobes along the right aca and posterior watershed zone distribution these infarcts persist to be of decreased diffusion as noted on diffusion images there is no intraparenchymal or subdural hemorrhage further follow should be based on clinical grounds there is bilateral inflammatory mastoid sinus disease which was not present on the previous exam ent correlation might be helpful interpretation findings left atrium no spontaneous echo contrast or thrombus in the la laa or the ra raa right atrium interatrial septum normal interatrial septum no asd or pfo by d color doppler or saline contrast with maneuvers left ventricle overall normal lvef no lv mass thrombus aorta no atheroma in aortic arch simple atheroma in descending aorta aortic valve normal aortic valve leaflets no as no ar no masses or vegetations on aortic valve mitral valve normal mitral valve leaflets no mass or vegetation on mitral valve mild mr tricuspid valve normal tricuspid valve leaflets with trivial tr no mass or vegetation on tricuspid valve pulmonic valve pulmonary artery pulmonic valve not well seen general comments a tee was performed in the location listed above i certify i was present in compliance with hcfa regulations the patient was monitored by a nurse throughout the procedure the patient was sedated for the tee medications and dosages are listed above see test information section local anesthesia was provided by benzocaine topical spray the posterior pharynx was anesthetized with viscous lidocaine contrast study was performed with iv injections of ccs of agitated normal saline at rest with cough and post valsalva maneuver echocardiographic results were reviewed with the houseofficer caring for the patient conclusions no spontaneous echo contrast or thrombus is seen in the body of the left atrium left atrial appendage or the body of the right atrium right atrial appendage no atrial septal defect or patent foramen ovale is seen by d color doppler or saline contrast with maneuvers overall left ventricular systolic function is normal lvef the lv apex was not well seen no masses or thrombi are seen in the left ventricle there are simple atheroma in the descending thoracic aorta the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation no masses or vegetations are seen on the aortic valve the mitral valve leaflets are structurally normal no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen brief hospital course this patient had previously been admitted with gastrointestinal bleeding and had had the av malformation coiled to see whether or not it would be therapeutic it was not and she was admitted about hours ago on the medical service and underwent a series of studies including a push enteroscopy by dr which did not see any bleeding followed by a labeled red cell scan which showed bleeding in the left upper quadrant and followed by an angiogram and coiling of an area which they thought showed extravasation she also received a total of u of prbcs with hcts checked every hours she did however continued to bleed and therefore was taken to the icu surgery consult was obtained she was stabilized overnight and the first thing in the morning when the gastroenterologist would be available for the push enteroscopy in case we needed it she was taken to the or for exploratory laparotomy multiple avms were found small bowel resection x were performed with reanastamosis and ligation of avms x patient was extubated in the operating room and then taken to the sicu for overnight monitoring with an ngt and foley catherter patient did well post op pod ngt was dc d and patient was transferred to the floor tpn was also started h pylori cultures were sent which were negative central line was changed over a guidewire pod patient continued to improve foley catherter was dc d and tpn advanced pod tpn was at goal reglan and insulin started pod insulin was advanced patient started on sips pod patient advanced to clears however on removal of rij pt became hypoxic desatted and unresponsive x min code called responded with oxygen pt c sz activity loss of bladder and bowel pe suspected ctpa neg pt eval for cva by neurology c resultant sz in mri requiring intubation mri demonstrative of b l thromboembolic strokes tx to sicu started heparin drip propofol pod b l ue us neg venous thrombosis ct hd x unchanged eeg non status patient had serial neuro exams throughout the day improving in responsiveness and following commands pod was successfully extubated patient appeared to have normal mental status and pre op motor ability later int he day without residual deficits echo done showed lvef with new dysfuction and no vegetations pod repeat mri was unchangedshowing multiple evolving subacute ifracts in watershed distribution patient was started on clears and advanced to soft solids pod repeat echo showed ef and no new deficits no asd or pfo no thrombi patient was trasnferred to the floor in good condition pod patient was restarted on the remainder of her home meds patient was dischraged on pod in good condition on coumadin dilatin and baby aspirin medications on admission protonix folate feso insulin verapamil sa pravachol discharge medications hydrocodone acetaminophen mg tablet sig tablets po q h every to 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 phenytoin sodium extended mg capsule sig one capsule po tid times a day disp capsule s refills folic acid mg tablet sig one tablet po daily daily disp tablet s refills multivitamin tx minerals tablet sig one tablet po daily daily disp tablet s refills pravastatin mg tablet sig one tablet po daily daily disp tablet s refills pantoprazole 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 discharge disposition home discharge diagnosis primary diagnosis upper gi bleed discharge condition good discharge instructions please take all medications as prescribed please keep all follow up appointments seek medical attention for fevers chills chest pain shortness of breath abdominal pain black stools dizziness or any other concerning symptoms please see you primary care physician tomorrow to have your inr checked and coumadin dose adjusted you should have daily inrs checked for the next few days until you are on a stable coumadin regimen followup instructions please call dr office for an appoitnemtn in about weeks please call dr neurologist to schedule a follow up appointment which should be in weeks continue taking dilantin and coumadin until then please see your primary care physician tomorrow to have your inr drawn and coumadin dose adjusted cardiology team will call you to arrange for your follow up and catherization completed by,"{
""Diagnoses"": [""Gastrointestinal bleeding"", ""Av malformation"", ""Migraines"", ""Anemia"", ""Nervous system disorder""],
""Medications"": [""Demerol"", ""NSAIDs"", ""Lumbar surgery"", ""Fast heart rate"", ""Anemia"", ""No other drugs""]
}"
3547,admission date discharge date date of birth sex m service admitting diagnoses post necrotic cirrhosis awaiting liver transplant history of present illness the patient is a year old male with history of hpv and hcc who presents for liver transplantation the patient underwent exlap for his hcc and at that time was unresectable he then underwent chemo embolization rfa which significantly reduced the tumor the patient is currently a good transplant candidate interpreter was present for both history on and on all the history from has not changed the patient currently has no fevers chills nausea vomiting and no abdominal pain the last time the patient ate on was at am past medical history hpv hcc post traumatic stress disorder depression question alcohol abuse quit five years ago past surgical history exlap for liver biopsy of tumor left upper extremity war wound status post chemo embolization rfa in allergies motrin which gives him hives medications on admission wellbutrin mg once a day amitriptyline mg q day epivir mg q day social history married times years history of tobacco quit years ago history of alcohol abuse quit years ago no i v drug abuse family history patient has six daughters alive and healthy seven siblings healthy until killed in war physical examination vital signs temperature blood pressure heart rate respirations percent on room air weight general in no acute distress well appearing male heent atraumatic normocephalic pupils are equal round react to light eoms are full mouth poor dentition tongue midline no exudates neck supple no palpable nodes no thyromegaly no carotid bruits lungs clear to auscultation and percussion bilaterally cv regular rate and rhythm normal s and s without murmurs or rubs abdomen well healed abdominal scar slightly distended but soft positive bowel sounds nontender slight left upper quadrant tenderness no rebound extremities no c c e left upper extremity deformity secondary to injury neuro awake alert oriented times three cranial nerves ii xii intact motor in upper extremity out of bilaterally no drift laboratory data wbc hematocrit of platelets sodium bun creatinine and platelets alt ast alk phos serum bili pt ptt inr ekg normal sinus rhythm no st wave changes chest x ray from lungs clear no infiltrate the patient was typed and crossed for units of ffp packed red blood cells cryo and platelets the patient was currently npo pre meds ordered consent on the chart reviewed information with dr patient went to surgery on with preoperative diagnosis of chronic hep b and hepatoma the suture backtable bench of a deceased donor liver performed by dr please see detailed note regarding surgery also the patient had a piggyback cadaveric liver transplant portal vein to portal vein anastomosis common hepatic artery to hepatic artery branch patch anastomosis bile duct to bile duct performed by dr and dr again please see detailed surgery note for more information postoperatively the patient went to the sicu the patient received ganciclovir hep b immunoglobulin lamivudine was started methylprednisone bactrim and unasyn were started morphine sulfate was started for pain management duplex ultrasound of the liver was obtained on demonstrating normal son appearance of the liver and hepatic duct flow in hepatic veins is normal portal vein is hepatopetal with peak velocity approximately cm second the main hepatic artery demonstrates brisk upstroke with a resistive index of similar brisk upstroke is seen on the left and right hepatic arteries on the postoperative day the patient was intubated sedated the patient had two jps a t tube the patient was extubated on continued on neomycin bactrim lamivudine valcyte ganciclovir right ij was placed postoperatively and chest x ray confirmed placement demonstrating bilateral effusions no pneumothorax on cardiology was consulted for afib suggested rate control with lopressor aspirin as necessary if surgically accepted it was demonstrated that platelets were slightly low at blood tests were sent off which were unremarkable patient was transferred from sicu to far on while in the icu one of the jps were removed t tube to drainage and another jp drain pt and ot were consulted continued to be afebrile vital signs stable continued on sk mmf solu medrol prednisone was started mg q day on foley was removed on cholangiogram was obtained on demonstrating no intra or extrahepatic biliary dilatations narrowing of the common duct t tube insertion pre contrast to the extrahepatic duct into small bowel since surgery all his lfts have been dropping slowly except for the alk phos which slowly increased on alt was ast alk phos total bili on alt was ast alk phos total bili of note when cardiology was consulted troponins were obtained and on troponin was and on troponin was and on the troponin was less than which would rule out patient having myocardial infarction on t tube was capped the patient had stool cultures sent off for c diff on because loose borderline diarrhea which demonstrated that both of those cultures were negative on hepatology was consulted had recommended dc ing lamivudine instead put patient on adefovir mg q day on the patient did receive another dose of hep and prior to receiving the dose quantitative hpv of antigen and antibody was obtained on quantitative hepatitis antigen was negative and quantitative hepatitis antibody was positive greater than miu ml the patient continues to do well with no complaints ambulating a regular diet awaiting medication teaching continues to be afebrile vital signs stable good i os labs on are the following wbc hematocrit of platelets sodium chloride bicarb bun creatinine of with glucose alt ast alk phos total bili ft level on herpsera was the patient is going to be going home tomorrow with services after patient has been taught how to administer insulin the patient will be going home on the following medications discharge medications tylenol to mg p r n dulcolax mg q h s p r n fluconazole mg q hepsera mg q day lopressor mg b i d mms q i d oxycodone mg q hours p r n prednisone mg q day bactrim ss one tab q day regular insulin sliding scale fingersticks q i d prevacid mg q day tacrolimus mg b i d ganciclovir mg q day the patient is to follow up with dr on at a m telephone number is also please arrange an appointment with who is the coordinator for followup appointment next week if has not made an appointment for patient please make sure that patient has an interpreter for followup appointment also please instruct the patient that he should call if any fevers chills nausea vomiting inability to take medications abdominal pain jaundice lethargy lower extremity edema or any problems drinking or taking any foods by mouth the patient should have labs every monday and thursday for cbc chem ast alt alk phos total bili albumin and a prograf trough level the results of those lab tests should be faxed to the transplant office at the patient should not be driving while taking pain medications the patient may shower no heavy lifting discharge is to home with services final diagnoses hepatitis b and hepatocellular carcinoma status post liver transplant discharge condition stable dictated by medquist d t job,"{
""Diagnoses"": [""post necrotic cirrhosis"", ""awaiting liver transplant""],
""Medications"": [""Wellbutrin"", ""Amitriptyline"", ""Epivir""]
}"
15080,admission date discharge date date of birth sex m service card preoperative diagnoses cardiogenic shock coronary artery disease postoperative diagnoses cardiogenic shock coronary artery disease procedures performed emergency coronary artery bypass graft times three placement of left ventricular and right ventricular assisted devices brief history this is a year old male with previous coronary artery disease including placement of several stents and several myocardial infarctions however had done well for the past couple of years who had presented at o clock on the above date with prolonged chest pain he was taken to the local hospital and then subsequently medflighted to he was taken emergently to the catheterization lab where he was found to have a proximal to mid left anterior descending artery stenosis occlusion of a previously patent left posterior descending coronary artery stent and an acute stenosis of the mid circumflex artery the patient had an intra aortic balloon pump placed and was taken emergently to the operating room for coronary artery bypass surgery despite being on plavix and integrilin he underwent the coronary artery bypass graft and due to issues with cardiogenic ability to wean off of bypass a left ventricular and right ventricular assistive devices were placed please refer to the operative note for the details of this he upon the end of the case remained in critical condition only to maintain a saturation of despite having both right ventricular and left ventricular assistive devices in place upon arrival to the intensive care unit he quickly deteriorated from ventricular fibrillation and went flatline and was unable to be resuscitated despite maximal flows on the rved and the lved devices and was pronounced dead at that time the cause of death was a cardiopulmonary failure the coroner was notified the family was notified an autopsy was not requested per the family m d dictated by medquist d t job,"{
""Diagnoses"": [""cardiogenic shock"", ""coronary artery disease""],
""Medications"": [""plavix"", ""integrilin""]
}"
13593,admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint hypotension weakness dizziness major surgical or invasive procedure none history of present illness w w hiv cd hepc esrd on hd chf ef e a mr tr moderate on tte presented to hd this morning weak and dizzy after missing last hd no hd was performed b c of hypotension to sbp and the patient was transferred to the ed in the ed the patient was afebrile w vs l following cc and peripheral dopamine at ug min sbp rose to she was sob at her baseline and could not lie flat ecg demonstrated twi in v flat t in v k was and phos bnp was bedside tte was negative for tamponade she was given vanco ctx flagyl dex mg dextrose cagluconate insulin nephrology was consulted they reported kg weight gain and indicated a desire to initiate gentle hd in the micu ros notable for cough x associated w straining abdominal discomfort and episode emesis at this time she denies fevers chest pain back pain urinary symptoms she says that she forgets her haart about once per week past medical history hiv cd ct in was esrd on hd htn avnrt diagnosed at recent vaginal bleed s p conization hcv esrd on hemodialysis asthma copd on l o at home cardiomyopathy w echo on ef mild mr pneumonitis followed by dr at psurgh c section r knee surgery ovarian cysts removed social history lives with her year old son has been medically handicapped for many years she has children one son is incarcerated pack years tobacco history reports having quit for last weeks denies alcohol or drug use history of crack use family history her mother had a stroke and has dm her daughter only has one kidney and has a thyroid problem physical exam gen well appearing in no acute distress heent nc at mouth dry perrl eomi cv rrr holosystolic murmur s lungs generally clear to auscultation bilaterally with occasional faint rhonchi throughout abd soft nt nd bs ext no cyanosis clubbing or edema neuro alert and oriented x strength of all four extremities nl sensation cn ii xii intact brief hospital course w w hypotension and renal failure after having had more than days since last hd also she had stopped her low dose prednisone since she did not like its side effects hypotension likely multifactorial initially thought to be related to adrenal insufficiency b c patient had self d ced steroids which she was on for pneumonitis as well as in the ed she responded to minimal interventions including a small fluid boluses iv dex and antibiotics however pt had a single cortisol result within normal levels no evidence sepsis lactate but trended down to w hd abx were held ruled out mi three sets of cardiac enzymes tte compared with the prior study images reviewed of findings are similar except that the effusion is now smaller in micu periperal dopa was successfully weaned during dialysis and pt maintained bp s of steroids for two reasons seemed to improve her condition dramatically in ed assume partial adrenal insufficiency asthma cpod exacerbation that is helped with steroids anti hypertensives were held and pt s bp stabilized hd esrd ag metabolic acidosis high k high phos and uremia missed hd underwent hdx in icu first time w high bicarb bath w small amount of dopamine support last plan to repeat in am abg on admission showed bicarb of improved on labs first morning after admission so no repeat abg obtained lactate improved w hd from on admission to renal followed hd friday before d c continued nephrocaps calcium acetate throughout admission pt w copd asthma history of chronic cough and pneumonitis chf w worsening of ef over the past year exacerbated by fluid overload from missed hd currently lungs are clear saturating well on ra completed course of azithromycin because of leukocytosis w left shift and pt s good clinical response to abx continued albuterol nebs and started pt on prednisone taper from doses of steroids pt received while in the icu hiv cd count just above cont ppx with bactrim ds and haart as above hep c stable medications on admission bactrim ds qd imdur mg po qd cozaar mg po qd lopressor po bid cardizem mg po qd nephrocaps qd phoslo tabs tid seroquel mg qhs didanosine mg after each hd nevirapine qd abacavir mg benadryl qhs claritin mg po qd spiriva ug po qd ibuprofren prn discharge medications trimethoprim sulfamethoxazole mg tablet sig one tablet po daily daily b complex vitamin c folic acid mg capsule sig one cap po daily daily calcium acetate mg capsule sig four capsule po tid w meals times a day with meals quetiapine mg tablet sig one tablet po qhs once a day at bedtime tiotropium bromide mcg capsule w inhalation device sig one cap inhalation daily daily abacavir mg tablet sig one tablet po bid times a day nevirapine mg tablet sig one tablet po daily daily didanosine mg capsule delayed release e c sig one capsule delayed release e c po daily daily aspirin mg tablet chewable sig one tablet chewable po daily daily losartan mg tablet sig one tablet po daily daily imdur mg tablet sustained release hr sig one tablet sustained release hr po once a day please hold for sbp disp tablet sustained release hr s refills azithromycin mg capsule sig two capsule po q h every hours for days disp capsule s refills discharge disposition home discharge diagnosis esrd discharge condition stable discharge instructions please present to your outpatient hemodialysis as scheduled it is very important to your health that you do not miss s please call your primary care physician or present to the hospital if you have chest pain or shortness of breath fever or chills headache or dizzyness please follow up with your appointments and take your medications as directed followup instructions you have the following appointments provider md phone date time you should follow up with your primary care physician [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint respiratory distress during hd fevers shooting pains major surgical or invasive procedure none history of present illness mrs is a yo woman with hiv not taking haart wbc of with bands last cd of from chf mitral regurgitation avnrt htn hepc asthma copd on l home o still smoking pneumonitis esrd on hd who was transferred on day of admission from dialysis with chills malaise and mild sob near the end of her hd session two days before admission toward the end of her dialysis session the patient felt like the inside of her body was on fire the pain was not localized was described as burning and lasted about five minutes thereafter she felt cold and had chills and described being lightheaded and that her blood pressure dropped she noted a ringing in her ears when her blood pressure dropped she was then transferred to the ed patient reports usoh prior to hd she denied recent increase in her chronic dry cough denied dysuria denied headache neck stiffness in terms of her sob she did not feel it is far from her baseline and it was worse when she was receiving hd in the ed the patient had blood cultures drawn and was admitted to the micu for respiratory distress her vital signs in the ed were systolic on l up to l nrb due to poor pleth on exam they reported increased wob sob difficulty completing sentences she received methylprednisolone iv combivent nebs aspirin vancomycin gram ceftazadime gram acetaminophen and l ns she was also given enoxaparin subcutaneously she denied any recent weight loss diarrhea vomiting or change in appetite on transfer to cc she felt much better and had no complaints except for a number of itchy skin spots distributed throughout her body this had been evaluated prior to this admission her wbc was with bands past medical history past medical history hiv cd ct in was esrd on hd htn avnrt diagnosed at recent vaginal bleed s p conization hcv esrd on hemodialysis asthma copd on l o at home cardiomyopathy w echo on ef mild mr pneumonitis followed by dr at psurgh c section r knee surgery ovarian cysts removed social history lives with her year old son has been medically handicapped for many years she has children one son is incarcerated pack years tobacco history reports having quit for last week she admits cocaine and speedy pill use she states being clean for years and that she never tried iv drugs because she s scared to death of needles she is in recovery from alcoholism and has been dry for years no travel recently except on a retreat to ct two months prior to admission she said that she went on long walks outside with questionable mosquito exposure she used bug spray at the time pt currently lives in contemplating moving out she has not been sexually active for years in the s she was a nurses aide for years in upstate ny and has lived in for years her last job was with the department of the irs and she worked there for years she is currently unemployed family history her mother had a stroke and her aunt and mother had dm her daughter only has one kidney and has a thyroid problem family history is also significant for glaucoma physical exam vs on lnc general able to sppeak in complete sentences not using accessory muscles nontoxic appearing heent ncat anicteric no conjunctival pallor or injection eomi mm dry neck supple jvp not elevated chest crackles at the right base cardiac rr ns loud s s no appreciable murmurs rubs or gallops abd soft nt nd normoactive bowel sounds ext lue fistula with good thrill no le edema skin warm dry pertinent results wbc rbc hgb hct mcv mch mchc rdw plt ct neuts bands lymphs monos eos baso atyps metas myelos d dimer glucose urean creat na k cl hco angap alt ast ld ldh ck cpk alkphos totbili ck mb ctropnt po pco ph caltco base xs intubat not intuba chest x ray bedside ap examination labeled upright at is compared with two views dated there is cardiomegaly with rounded lv enlargement and thoracic aortic tortuosity as before there is no pulmonary vascular congestion or pleural effusion linear scarring involving the left more than right lung base is unchanged over the series of recent studies with no new airspace process there is stable prominence of the central pulmonary arteries which may reflect underlying pulmonary hypertension 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 wbc rbc hgb hct mcv mch mchc rdw plt ct am blood neuts lymphs monos eos baso am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood neuts lymphs monos eos baso am blood alt ast ld ldh alkphos totbili am blood ck mb ctropnt brief hospital course briefly this is a yo female with hiv off haart wbc of last cd of chf avnrt htn hepc asthma copd on l home o still smoking lip esrd on hd who was transferred on day of admission from dialysis with chills sob way through hd respiratory distress patient with significant baseline pulmonary disfunction secondary to asthma copd lip chf on home o and still smoking who presented with acute sob in addition to chronic sob doe cxr was negative for acute pulmonary edema or focal consolidation pt received enoxaparin methylprednisolone vancomycin and ceftazadime in the ed upon arrival no evidence of acute respiratory distress pt was satting on lnc home level on the floor the patient had no symptoms of respiratory distress and was satting on room air she only became short of breath upon exertion id patient presented with fever leukopenia and bandemia because the patient is immunocompromised and at risk for infections blood and urine cultures were obtained as she was covered empirically with vancomycin and ceftazadime gentamicin was then started and ceftazadime and vancomycin were discontinued she was afebrile with a white count of on the floor the empiric treatment in the ed may have had an effect per id consult recommendations gentamicin was discontinued during her course her bandemia resolved and her white count continued to fall she had no fevers chills nausea or vomiting there was never any growth from any of her cultures hiv followed by dr id was consultd recommended continuing pt on her prior haart regimen abacavir nevirapine ddi despite possibly not being adherent to these meds the theory being that these medications would suppress her wildtype virus and allow for genotyping of likely mutations at her outpatient clinic we continued outpt regimen and carefully monitored for possible reonstitution syndrome given pt may not have been taking haart as outpt patient is scheduled for outpatient follow up with id on esrd on hd had fever chills during hd raising concern for transient bacteremia renal team followed patient during admission and hd was continued as scheduled for m w f she received hd at on the morning of htn continued on outpatient regimen imdur and diltiazem on day of discharge pt was ambulating without difficulty she was afebrile with wbc of no bands vss pt is to follow up at with dr he has been notified of her hospital course with us medications on admission medications on admission per pt does not remember albuterol mcg actuation puffs by mouth to qid abacavir mg tablet s by mouth twice daily bactrim ds mg tablet s by mouth every monday wednesday and friday diltiazem hcl mg capsule s by mouth daily ibuprofen mg one tablet s by mouth q hours as needed for pain imdur mg tablet s by mouth daily nephrocaps mg capsule s by mouth daily nevirapine mg tablet s by mouth twice a day percocet mg mg one to two tablet s by mouth q hours as needed for pain phoslo mg tablet s by mouth tid with food prednisone mg tablet s by mouth daily seroquel mg tablet s by mouth at bedtime synalar apply to scalp qd to triamcinolone acetonide apply twice daily to affected areas for up to weeks month max twice a day as needed for avoid face and folds vicodin mg mg tablet s by mouth hours as needed for pain videx ec mg capsule s by mouth daily medications at time of transfer lidocaine ointment appl tp once abacavir sulfate mg po bid nephrocaps cap po daily albuterol neb soln neb ih q h prn nevirapine mg po bid bisacodyl mg po pr daily prn oxycodone acetaminophen tab po q h prn calcium acetate mg po tid w meals prednisone mg po daily diltiazem extended release mg po daily quetiapine fumarate mg po qhs prn didanosine ec mg po daily senna tab po bid prn docusate sodium liquid mg po bid sulfameth trimethoprim ds tab po qmwf heparin unit sc tid vancomycin mg iv once duration doses order date isosorbide mononitrate extended release mg po daily discharge medications albuterol sulfate mg ml solution sig two puffs inhalation to qid prn as needed for shortness of breath or wheezing disp inhaler refills trimethoprim sulfamethoxazole mg tablet sig one tablet po qmwf disp tablet s refills diltiazem hcl mg capsule sustained release sig two capsule sustained release po daily daily disp capsule sustained release s refills isosorbide mononitrate mg tablet sustained release hr sig one tablet sustained release hr po daily daily disp tablet sustained release hr s refills b complex vitamin c folic acid mg capsule sig one cap po daily daily disp capsules refills nevirapine mg tablet sig one tablet po bid times a day disp tablet s refills oxycodone acetaminophen mg tablet sig tablets po q hours prn as needed for pain disp tablet s refills calcium acetate mg capsule sig three capsule po tid w meals times a day with meals disp capsule s refills prednisone mg tablet sig one tablet po daily daily disp tablet s refills quetiapine mg tablet sig one tablet po qhs once a day at bedtime as needed disp tablet s refills didanosine mg capsule delayed release e c sig one capsule delayed release e c po daily daily disp capsule delayed release e c s refills abacavir mg tablet sig one tablet po bid times a day disp tablet s refills pantoprazole 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 discharge disposition home discharge diagnosis hypotension respiratory distress esrd on hd discharge condition good discharge instructions you were admitted for an episode of pain with fever low blood pressure and an abnormal white blood cell count you were treated with antibiotics and have not been found to have any evidence of ongoing infection please take all medications as prescribed you have an appointment scheduled with the clinic at please call your doctor or return to the emergency room if you experience fevers lightheadedness shortness of breath or for any other concerning symptoms followup instructions provider md phone date time cardiology you have an appointment scheduled at the clinic dr thursday anytime after pm they know you are coming phone please call if you have questions of if you need to reschedule [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint cc weakness and epistaxis x days reason for micu admission hct drop monitoring major surgical or invasive procedure hd nasal packing history of present illness this is a yof w h o esrd on hd hiv cd vl pneumonitis distant h o cocaine use and severe pulmonary htn who presents w days epistaxis and weakness she notes that weeks ago she had epistaxis and associated hct drop which led to admission to on per discharge summary hct on presentation was from baseline one week prior to presentation she received units of prbcs upon admission and this improved to mid s and remained stable throughout the remainder of the hospitalization she was discharged her hemolysis labs were negative there she describes persistent weakness and decreased appetite and notes that everyone around her is sick however denies brbpr only dark stools x day no abdominal pain n v no f c no arthralgias myalgias cough in the ed afebrile tachy to s s s she received cc bolus which brought hr to she did not have active bleeding in right nare but did have cauterization w silver nitrate ros lightheadedness today the patient denies any diarrhea constipation chest pain shortness of breath orthopnea pnd lower extremity edema cough urinary frequency urgency dysuria gait unsteadiness focal weakness vision changes headache rash or skin changes she reports that she has been adherent with her meds except for the prednisone baseline weight is kg per pt past medical history hiv cd vl esrd on hd mwf htn severe pulmonary htn cardiomyopathy lvef severe mr tr pneumonitis lip followed by dr at anemia of chronic disease avnrt diagnosed at recent vaginal bleed s p conization hcv untreated esrd on hemodialysis asthma copd c section r knee surgery ovarian cysts removed social history she lives in with her year old son she has three sons and one daughter she quit smoking on she has a pack year smoking history she has used every drug including cocaine last drug use was three years ago she has never used iv drugs she has a history alcohol abuse and has been sober for six years she has a history of homelessness and has lived in shelters most recently within the past five years she has never been incarcerated but her son has been she is currently medically handicapped and unemployed for many years family history her mother is living in her s and had a stroke hypertension and diabetes her uncle died of kidney disease she never met her father sister was killed in a motor vehicle crash her children are healthy her daughter has a single kidney physical exam on presentation vitals t bp hr rr o sat ra orthostatics sitting hr bp standing hr bp gen thin well nourished no acute distress heent epistaxis right nare oozine eomi perrl sclera anicteric no rhinorrhea mmm op w small amount bright red blood o w clear neck enlarged parotids bl soft tissue protruding supraclavicularly bl no jvd carotid pulses brisk no bruits no cervical lymphadenopathy trachea midline cor rrr split s soft systolic murmur noted no g r normal s s radial pulses pulm lungs ctab no w r r abd distended reducible umbilical hernia soft nt bs no hsm no masses rectal small amount of dark stool in vault guiac ext thin av fistula in place no c c e no palpable cords neuro alert oriented to person place and time cn ii xii grossly intact moves all extremities strength in upper and lower extremities patellar dtr plantar reflex downgoing no gait disturbance no cerebellar dysfunction skin no jaundice cyanosis or gross dermatitis no ecchymoses 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 alt sgpt ast sgot ld ldh alk phos tot bili pm albumin iron pm caltibc haptoglob ferritin trf pm blood hgb hct pm blood hct am blood hgb hct am blood hgb hct cxr conclusion stable cardiomegaly with no pulmonary consolidation brief hospital course this is a year old woman with history of esrd on hd hiv cd vl pneumonitis and severe pulmonary htn who presents with hct drop in the setting of epistaxis she has h o cocaine use she has had guaiac positive stools but they are related to swallowing blood gi bleed concurrently is unlikely no evidence of hemolysis at the osh or here gi stated that guaiac positive stool is from swallowed blood ent saw her and recommended packing to stay in place for at least days however her oozing persisted so they recommended leaving the pack for additional days days we asked her to check to our er in days after discharge for possible removal of the packing if oozing stops they recommended keflex to prevent toxic shock while packing in place she was advised to not use cocaine and come to the er if bleeding recurs she was asked not to manipulate the packing she has been hemodynamically stable for many days total discharge time minutes medications on admission abacavir mg po daily atazanavir mg po daily b complex vitamin c folic acid mg po daily calcitriol mcg po daily cinacalcet mg po daily didanosine mg po daily fluocinonide ointment topical prednisone mg po daily noncompliant with this med quetiapine mg po qhs prior to hd ritonavir mg po daily sevelamer hcl mg po tid w meals triamcinolone acetonide ointment topical as needed trimethoprim sulfamethoxazole mg tablet po daily loratadine mg po once a day cerave cream topical metoprolol succinate mg po daily losartan mg tablet po daily dextromethorphan guaifenesin mg ml ml po q h prn albuterol mcg actuation two puffs inhalation q h prn discharge medications abacavir mg tablet sig two tablet po daily daily atazanavir mg capsule sig two capsule po daily daily ritonavir mg capsule sig one capsule po daily daily cinacalcet mg tablet sig one tablet po daily daily calcitriol mcg capsule sig one capsule po daily daily losartan mg tablet sig tablet po daily daily sevelamer hcl mg tablet sig two tablet po tid w meals times a day with meals b complex vitamin c folic acid mg capsule sig one cap po daily daily trimethoprim sulfamethoxazole mg tablet sig one tablet po daily daily quetiapine mg tablet sig one tablet po qhs once a day at bedtime as needed fluocinonide ointment sig one appl topical times a day didanosine mg capsule delayed release e c sig one capsule delayed release e c po daily daily latanoprost drops sig one drop ophthalmic hs at bedtime sodium chloride aerosol spray sig three spray nasal q h every hours please give sprays each side times daily until follow up disp spray bottles refills mupirocin calcium ointment sig one appl nasal times a day for days please start after packing removal disp tube refills cephalexin mg capsule sig one capsule po q h every hours for days disp capsule s refills oxymetazoline aerosol spray sig one spray nasal times a day as needed for bleeding oozing for days spray in each nose if bleeding again disp spray bottle refills codeine guaifenesin mg ml syrup sig mls po q h every hours as needed for cough disp ml s refills metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po daily daily prednisone mg tablet sig one tablet po daily daily loratadine mg tablet sig one tablet po once a day albuterol mcg actuation aerosol sig puffs inhalation every hours discharge disposition home discharge diagnosis epistaxis discharge condition good discharge instructions you were admitted to the hospital with a nose bleed ent doctors saw and placed packing in your nose you were found to be anemic likely from the nosebleed but your blood count remained stable your bleeding has stopped the ent doctors recommend keeping the packing one more day you need to spray saline sprays in your nose to avoid drying out your nares if you notice bleeding again please use afrin spray once packing is removed please use the mupirocin ointment to your nares as prescribed you need to come back to ed to have the packing removed tomorrow if the nose bleed recurrs please soak the packing with the afrin spray and hold external pressure if it still continues please go to ed please avoid manipulating your nose followup instructions pcp ph pls call and make appt [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint right shoulder pain x days cough sob x months major surgical or invasive procedure left septic wrist debridement and washout on and repeat procedure on history of present illness yo lady with multiple medical problems including hiv pneumonitis pulmonary htn esrd on hd cardiomyopathy and emphysema on o at home who presents with right shoulder pain and worsening cough sob for months right shoulder pain started days ago sudden onset not provoked by any activity no h o trauma or any other event that may have precipitated this pain cough sob this has been chronic apparently at least six months but the frequency and severity of cough has increased the patient has a subconjunctival hemorrhage in the left eye from the coughing cough is productive of white non bloody sputum pt also states i had pneumonia weeks ago but i handled it on my own patient does endorse increasing dyspnea on exertion and states that she uses several pillows and feels that she has more swelling in her legs than usual the patient was on prednisone for her lip but this was discontinued about months ago pt reports chills for the past several days denies chest pain n v diarrhea weight loss no recent history of incarceration or other exposure risk for tb although son has been incercerated no hx of oppotunistic infections in pt with t joint injected with bupicivaine with moderate relief pt then received hd on return to the medical floor she develop severe left wrist pain contralateral to her original left shoulder pain plastics was consulted and attempted drainage of the wrist with no success micu consulted for worsened tachycardia from admission hr of which may be her baseline and worsening tachypnea abg surprisingly despite tachypnea at that time pt reached her tmax shortly thereafter of anaerobic bottles grew gpc past medical history hiv cd vl esrd on hd mwf htn severe pulmonary htn cardiomyopathy lvef severe mr tr pneumonitis lip followed by dr at anemia of chronic disease avnrt diagnosed at recent vaginal bleed s p conization hcv untreated asthma copd c section r knee surgery ovarian cysts removed social history she lives in with her year old son she has three sons and one daughter she quit smoking on she has a pack year smoking history she has used every drug including cocaine last drug use was three years ago she has never used iv drugs she has a history alcohol abuse and has been sober for six years she has a history of homelessness and has lived in shelters most recently within the past five years she has never been incarcerated but her son has been she is currently medically handicapped and unemployed for many years family history her mother is living in her s and had a stroke hypertension and diabetes her uncle died of kidney disease she never met her father sister was killed in a motor vehicle crash her children are healthy her daughter has a single kidney physical exam vitals l gen asleep easy to arouse no acute distress heent left eye with subconjunctival hemorrhage unchanged icteric b l cv rrr no murmur appreciated pulmonary cta b l abd obese distended bs mild epigastric tenderness ext peripheral edema b l le lue with clean wound dressing neuro aox pertinent results pm type art po pco ph total co base xs pm glucose lactate na k cl pm o sat pm freeca am lactate am glucose urea n creat sodium potassium chloride total co anion gap am estgfr using this am alt sgpt ast sgot ld ldh alk phos tot bili am lipase am crp am wbc rbc hgb hct mcv mch mchc rdw am neuts lymphs monos eos basos am plt count am pt ptt inr pt am sed rate c diff negative and hida impression markedly abnormal hepatobiliary scan with no uptake of disida into the liver during minutes of imaging this finding is compatible with severe hepatic dysfunction due to the hepatic dysfunction the biliary system cannot be evaluated radiology report chest portable ap study date of am chest radiograph indication hemoptysis evaluation for changes comparison findings as compared to the previous radiograph the pre existing right sided pleural effusion shows a slightly different distribution but appears to be overall unchanged the subtle suprabasal opacity in the left lung could have minimally increased in extent other opacities are not visible moderate cardiomegaly with signs of mild to moderate pulmonary overhydration no evidence of left sided pleural effusion radiology report ct abdomen w contrast study date of am conclusion the findings of adrenal hyperenhancement and renal hypoenhancement are nonspecific but suggest possible infarction or ischemia to these organs as the proximal arteries appear unremarkable and there is no overt evidence of significant arteriosclerosis hypotension must be considered nonspecific dilatation of the small bowel possibly reflecting ileus no additional findings of note there is joint space narrowing at l l this is felt secondary to degenerative disc disease rather than discitis radiology report ct abd w w o c study date of pm impression homogeneous enhancement of the pancreas mild stigmata of cirrhosis small fat containing ventral abdominal hernia egd report tuesday impression there were no varices seen in the esophagus abnormal mucosa in the stomach biopsy biopsy otherwise normal egd to third part of the duodenum pathology examination diagnosis gastric mucosal biopsies two a fundus superficial fragment of fundic mucosa with no diagnostic abnormalities recognized b antrum antral mucosa with regenerative changes suggestive of chemical injury endoscopic u s eus pancreas parenchyma showed changes c w moderate chronic pancreatic duct was normal bile duct was normal without stones brief hospital course in short patient is a yo lady with multiple medical problems including hiv cd pneumonitis pulmonary htn esrd on hd cardiomyopathy and emphysema on o at home who presented initially with right shoulder pain and worsening cough sob for months she was initially admitted on and has had a protracted hospital course she was found to have mssa bacteremia for which she was treated with cefazolin her shoulder pain had improved but she had developed left wrist pain which was found to be a septic joint and s p wash out with ortho on also during her hospitalization she had difficulty maintaining her bps especially for dialysis and initially it was felt that she potentially had an infection of her avf imaging did not suggest any thrombus source of infection there it is thought that the infection was to her left wrist septic joint her cultures have since cleared with therapy she also had difficulty with respirations and it was thought to be secondary to increased narcotics use and improved once she was switched from iv to po narcotics her lfts gradually improved but she now has a persistently elevated amylase lipase of unclear etiology it is thought that this may be secondary to her haart therapy since her ct of her pancreas did not show any significant abnormalities mrcp cannot be done given her renal failure also during this hospitalization she had black stool guaiac positive mssa bacteremia likely explanation for her fevers sets of blood cx positive on not since risk factors for staph include recurrent hospitalizations hd hiv distant prior staph bacteremia started on vanco and later switched to nafcillin gentamycin was added on neg echo gent was d c d treating with cefazolin s p picc per id if tee negative would treat weeks if no tee would treat weeks d however pt would not cooperate for tee also outpatient id f u with weekly cbc crp esr lfts bmp id signed off hypotension was showing septic physiology and was on dopamine later weaned off started levophed weaned off and responded to steroids after hours off of steroids they were stopped intent to try pt on midodrine but since she refused and bp was stable with it it was also d c d pt s bps were stable when transferred out of icu and continued to be stable on the floor patient s home sildenafil was held b c of persistent hypotension episodes patient normotensive on floor and bp was not much of an issue left wrist pain felt to be septic joint mssa bacteremia went to or for debridement and washings on pain has been well controlled on percocet and with patient in sling splint during hospitalization ot reconsulted and saw patient on now that she had improved wrist function patient still complained of pain and had mild drainage from wound site on when hand re evaluated and brought to or for repeat wash out procedure pus not visualized during operation however and site irrigated and closed right shoulder pain on exam low suspicion for septic joint and pain resolved fairly quickly ortho was consulted managed with sling and pain control cough sob resolved quickly most likely dx seems to be progression of her serious underlying lung pathology no hx of oppotunistic infections prelim ct chest c w emphysematous changes at this point low suspicion for tb as ppd negative f u swab negative was continued on albuterol ipratropium and resolved and pt on home oxygen requirement at conclusion of icu stay patient without symptomatic complaints when on hospital floor esrd pt was continued on hd three times per week renal was following and meds were dosed appropriately tachycardia felt to be a response to infection but per outpt and inpt notes she is chronically tachycardic and may have baseline hr in s sinus on lead plan to restart home beta blocker after hd toprol xl daily this had been stopped because of hypotension restart with renal permission cardiomyopathy chf ef patient s bb was held should be started on acei in the future if bp can tolerate pneumonitits pulmonary hypertension sildenafil was held becuse of hypotension should be restarted when bps more stable asthma copd was continued on iprotrop hiv cd vl was continued on haart meds and bactrim ppx coagulopathy inr elevated in past but not to this range if related to liver enzymes hcv hcv has not been treated hepatology has no new recs stated hcv viral load will not affect current management transaminitis imaging of ruq done increased abd pain and rising t bili hida scan ordered and surgery consulted gent added to abx regimen on but d c d per id bili amylase still elevated however pt had refused mrcp and since ast and tb trending down and renal function would not tolerate dye with increased amylase to the s hepatology was consulted the pt had a normal ct pancreas study and id confirmed that such an increase would also affect her lipase at transfer from icu still unclear etiology liver enzymes down trended while on the floor etiology thought likely due to cholelithiasis causing a brief elevation of liver enzymes erosive gastritis patient had melena with guiaic positive stool during hospitalization on the floor egd showed blood collection questional source but likely erosive gastritis differential also included epistaxis hx of epistaxis risk factors including elevated inr poor liver fx alt ast may be normal poor residual fx egd negative for esophagitis pud patient treated with ppi for erosive gastritis with careful monitoring of hct elevated amylase lipase etiology unclear but patient has risk for gallstone autoimmune pneumonitis hcv hiv and or drug induced haart gallstone likely given initial elevation of t bili cholelithiasis ct pancreas without any obvious abnormalities mrcp to visualize pancreatic ducts unlikely given renal failure eus obtained showing changes consistent with chronic but no gallstones outpatient surgery follow up for elective cholecystectomy is recommended ct suggestive of adrenal infarction endo stated that adrenal response normal if relatively adrenal insufficient can try stress dose steroids without fluid bolus or pressors this was not an issue throughout hospitalization foot pain and leg weakness unlikely gout given recent steroids unlikely sepsis given not febrile and no change in wbc and bilateral actually completely improved as of put in for pt consult hemoptysis likely worsened by coagulopathy had black tarry stools monitored h h inr and sxs and patient was stable gi endoscope am dispo because of prolonged bedrest and left wrist mobility will likely need inpatient rehabilitation before she can go home discharged to rehab medications on admission metoprolol succinate xl mg acetaminophen mg po q h prn pain nephrocaps cap po daily calcitriol mcg po every other day tues thurs sat quetiapine fumarate mg po qmowefr min prior to hd cinacalcet mg po daily raltegravir mg po bid etravirine mg po bid sildenafil citrate mg po tid fexofenadine mg po daily prn hay fever guaifenesin codeine phosphate ml po q h prn cough sulfameth trimethoprim ds tab po qmowefr heparin unit sc tid sevelamer hydrochloride mg po tid w meals lamivudine mg po daily discharge medications metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po once a day acetaminophen mg tablet sig tablets po every six hours as needed for pain nephrocaps mg capsule sig one capsule po once a day sevelamer hcl mg tablet sig four tablet po tid w meals times a day with meals trimethoprim sulfamethoxazole mg tablet sig one tablet po qmowefr monday wednesday friday fexofenadine mg tablet sig one tablet po daily daily as needed for hay fever etravirine mg tablet sig two tablet po bid times a day raltegravir mg tablet sig one tablet po bid times a day heparin porcine unit ml solution sig one injection tid times a day codeine guaifenesin mg ml syrup sig mls po q h every hours as needed for cough cefazolin gram recon soln sig two injection qmowe for weeks please take until last day cefazolin gram recon soln sig three injection qfr for weeks please take until last day lamivudine mg tablet sig tablet po once a day pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours bisacodyl mg tablet sig one tablet po daily daily as needed for constipation docusate sodium mg capsule sig one capsule po daily daily as needed for constipation oxycodone acetaminophen mg capsule sig one tablet po every hours as needed for pain outpatient lab work please draw cbc crp esr lfts bmp weekly from etc and fax results to dr at discharge disposition extended care facility radius of discharge diagnosis primary diagnoses mssa bacteremia septic wrist at the radial carpal joint and mid carpal joint erosive gastritis transaminitis esrd on hd hiv on haart secondary diagnoses hiv cd vl esrd on hd mwf htn severe pulmonary htn cardiomyopathy lvef severe mr tr pneumonitis lip followed by dr at anemia of chronic disease avnrt diagnosed at recent vaginal bleed s p conization hcv untreated asthma copd c section r knee surgery ovarian cysts removed discharge condition afebrile in good condition ambulating alert and oriented x tolerating po intake discharge instructions you were admitted to the hospital on for right shoulder pain and shortness of breath during your hospitalization we found out that you had an infection in your blood you are being treated on an antibiotic for this infection your blood cultures have been negative but it may be bacteria on your heart valve due to previous drug use and you will be taking the antibiotic until also during this hospitalization we found that you had bacteria in your left wrist we took you to an operation on to clean out the wrist the wrist continued to have infection and you were taken back for a repeat operation on we also found that you were bleeding from your stools during this hospitalization we put a scope down your throat to look at your stomach and found generalized inflammation that was likely causing the bleeding we also found out that the enzymes that we use to monitor for inflammation of the pancreas were elevated we did procedures including a ct scan and endoscopic ultrasound which showed changes consistent with chronic changes to your home medications include calcitriol we discontinued this medication cincalcet we discontinued this medication sildenafil we discontinued this medication because of your low blood pressure in the hospital if you should experience signs of infection such as fever greater than chills sweats or chest pain trouble breathing palpitations dizziness fatigue or any other medically concerning symptoms please call your doctor or or go to the emergency room followup instructions please keep the following appointments which have been made for you md dr specialty surgery date and time at pm location phone number special instructions you are going to see surgery because the gi doctors your was due to the gallstones in your gallbladder you have been recommended to talk with surgery about an elective cholecystectomy md md specialty infectious disease date and time at am location community health center phone number md dr specialty gastroenterology for endoscopy date and time at am arrival for pm procedure location phone number special instructions if applicable instructions will be mailed for endoscopy preparation please call the hand clinic at you need to make an appointment for follow up from your surgery on please make this appointment to be within weeks completed by [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies heparin agents cefazolin nelfinavir morphine vancomycin nafcillin attending chief complaint upper back neck pain major surgical or invasive procedure mechanical intubation hd line insertion arterial line insertion history of present illness ms is a yo f with hiv cd pneumonitis pulmonary htn esrd on hd cardiomyopathy and emphysema on o at home who presents with weeks of cough and increased sob and days of upper back neck pain she is more concerned about the back pain than the cough which did not bother her too much she denies f c at home she has produced some sputum is on l home o at baseline last rec d hd on as to her back pain it started gradually days pta and is located around her b l shoulders neck and part of her l arm no trouble holding objects or moving the l arm no h o lifting heavy objects or trauma no lower back pain or trouble walking no photophobia although she says she has cataracts endorses ha that she has had for weeks or so b l frontal ha she tried using gay for her shoulders to no avail in the ed initial vitals were l fiven levaquin was wheezing on arrival received nebulizers and prednisone with improvement of wheezing given her significant comorbidities admitted to medicine for pneumonia got tylenol also percocet for chronic back pain currently she c o persistent upper back neck pain no vomiting dysuria diarrhea is hungry past medical history hiv cd esrd on hd mwf htn severe pulmonary htn cardiomyopathy lvef severe mr tr pneumonitis lip followed by dr at anemia of chronic disease avnrt diagnosed at recent vaginal bleed s p conization hcv untreated asthma copd on home o h o bacteremia and vertebral osteomyelitis past surgical history c section r knee surgery ovarian cysts removed social history she lives in with her year old son she has three sons and one daughter currently smokes a few cigarettes every few days she has a pack year smoking history has used every drug including cocaine last drug use was eight years ago she has never used iv drugs she has a history alcohol abuse and has not drank in many years family history her mother is living in her s and had a stroke hypertension and diabetes her uncle died of kidney disease she never met her father sister was killed in a motor vehicle crash her children are healthy her daughter has a single kidney physical exam admission physical exam vitals l nc gen in nad resting in bed alert responds appropriately to questions heent perrl op clear mmm cv rrr could not appreciate murmurs tachycardic pulm ctab but decreased breath sounds throughout abd umbilical hernia normal bs no tenderness to palpation soft ext no clubbing or cyanosis edema b l pedal pulses skin diffuse dry and flaky skin on trunk arms scalp and less so on legs neuro a o x cn intact b l strength throughout b l discharge physical exam tcurrent c f hr bpm bp mmhg rr spo on lnc general chronically ill appearing no acute respiratory distress at the time of my exam heent perrl eomi sclera icteric dry mucous membranes with and cracked lips op clear wrapped pressure ulcer on occiput neck supple no no thyromegaly no jvd no carotid bruits left ij with mild oozing of blood but site non tender area of soft fullness slightly larger to area on corresponding side and disappears when she lays flat lungs coarse breath sounds and crackles b l reasonable movement throughout heart tachycardic nl s s clear and of good quality rr abdomen nabs soft nt nd no rebound guarding extremities wwp no c c e soft but palpable peripheral pulses neuro awake a ox cns ii xii grossly intact denies sensation of her feet and decreased sensation of her lower legs describes burning sensation in her hands diminished strength but function grossly 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 esr am blood glucose urean creat na k cl hco angap am blood alt ast alkphos totbili am blood ctropnt am blood probnp am blood calcium phos mg am blood crp am blood lactate am blood lactate am blood type art po pco ph caltco base xs am blood type art po pco ph caltco base xs 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 am blood type mix po pco ph caltco base xs comment green top pertinent micro path blood cultures of sets positive as below of set positive as below dates of sets negative am blood culture blood culture routine final staph aureus coag final sensitivities consultations with id are recommended for all blood cultures positive for staphylococcus aureus yeast or other fungi bactrim septra sulfa x trimeth sensitivity testing confirmed by doxycycline and rifampin sensitivities requested by sensitive to doxycycline sensitivity testing performed by sensitivities mic expressed in mcg ml staph aureus coag clindamycin s erythromycin s gentamicin s levofloxacin r oxacillin s rifampin s trimethoprim sulfa r abscess culture am abscess neck abscell for culture staph aureus coag clindamycin s erythromycin s gentamicin s levofloxacin r oxacillin s trimethoprim sulfa r prevertebral tissue culture staph aureus coag clindamycin s erythromycin s gentamicin s levofloxacin r oxacillin s trimethoprim sulfa r anaerobic culture final no anaerobes isolated bal culture no growth negative for pcp picc tip cx no growth no growth hiv vl copies rpr non reactive mrsa screen negative sputum pseudomonas aeruginosa amikacin s cefepime s ceftazidime i ciprofloxacin r gentamicin r meropenem s piperacillin tazo r tobramycin r pseudomonas aeruginosa amikacin s cefepime i ceftazidime s ciprofloxacin r gentamicin r meropenem s piperacillin tazo r tobramycin r pseudomonas aeruginosa amikacin s cefepime s ceftazidime s ciprofloxacin r gentamicin r meropenem s piperacillin tazo r tobramycin i pseudomonas aeruginosa amikacin s cefepime i ceftazidime r ciprofloxacin r gentamicin r meropenem i piperacillin tazo r tobramycin i legionella culture preliminary no legionella isolated stool cdiff negative cdiff negative pathology or specimen of prevertebral tissue diagnosis prevertebral tissue excision a a fibrocartilage with focal acute and chronic inflammation and necrosis see note b fragments of bone intervertebral disc c c excision b a fibrocartilage with degenerative change and crushed cells cannot exclude inflammatory cells b fragments of bone imaging studies cardiology tte impression no echo evidence of endocarditis relatively small hyperdynamic left ventricle dilated and hypokinetic right ventricle with moderate to severe pulmonary hypertension mild mitral and moderate tricuspid regurgitation compared with the prior study images reviewed of the degree of mitral regurgitation has increased the right ventricle appears similar moderately dilated with mild hypokinesis the degree of tricuspid regurgitation has increased left ventricular function is more hyperdynamic on the current study tte impression no echocardiographic evidence of endocarditis cannot exclude due to suboptimal image quality normal regional left ventricular systolic function mildly dilated and mildly hypokinetic right ventricle if clinically indicated a transesophageal echocardiogram may better assess for valvular vegetations compared with the prior study images reviewed of pulmonary artery pressures could not be estimated on the current study the other findings are similar radiology cxr impression overall similar appearance of mild edema and bibasilar scarring and or atelectasis correlate clinically for possibility of early infection no radiographic evidence of confluent consolidation c spine mri impression c marked narrowing of the disc space with kyphosis and a disc osteophyte complex indenting the thecal sac with mild to moderate canal stenosis multilevel foraminal narrowing as described above new small area of increased signal intensity in the c c intervertebral disc edema inflammation infection extensive pre paravertebral and retropharyngeal t hyperintense signal which relates to fluid with or without abnormal enhancement from inflammation or infection assessment is limited given the lack of post contrast images this is seen to extend from the level of the clivus extending into the thorax lower limit is not included there is also mild increased signal intensity in the lateral atlantoaxial joints c spine ct impression findings consistent with c discitis osteomyelitis with x cm prevertebral abscess anterior to c vertebral body massive likely reactive prevertebral effusion phlegmon spanning the entire extent of cervical spine without rim enhancement evaluation of epidural space is highly limited on ct when patient able recommend repeat mri with gadolinium for further assessment of the epidural space and cord prior c osteomyelitis with disc space destruction and fusion of vertebral bodies with mild mm retropulsion of posterior inferior corner of c narrowing the canal at this level medialization of internal carotid arteries which are immersed within the prevertebral fluid phlegmon vascular structures appear patent at this time right maxillary mucosal disease emphysema and evidence of mild edema t and l spine ct impression known large prevertebral fluid collection does not extend below cervicothoracic junction no definite ct evidence of acute process within the thoracic and lumbar spine multilevel degenerative disease worst at l precarinal adenopathy and splenomegaly which may be related to hiv status pulmonary arterial hypertension small bilateral pleural effusions moderate centrilobular emphysema with mild fluid overload ct abdomen pelvis cirrhosis ascites and splenomegaly renal atrophy and multiple hypodense lesions consistent with cysts in keeping with prior ultrasound cholelithiasis bilateral adnexal cystic lesions which should be evaluated by pelvic ultrasound liver gallbladder u s coarse nodular liver consistent with underlying chronic liver disease with findings of portal hypertension no definite hepatic lesion though periphery of the liver was incompletely evaluated no intra or extra hepatic biliary ductal dilatation bilateral pleural effusions and moderate ascites stable splenomegaly cxr moderate pulmonary edema not significantly changed since moderate bilateral pleural effusions slightly increased since prior left lung base consolidation likely atelectasis ct neck spine the small residual fluid collection in the cervical spine does not extend below the cervicothoracic junction no acute abnormality identified in the thoracic spine bilateral pleural effusions increased in size compared to cxr interval placement of left subclavian line with tip at the mid to distal svc right sided picc line in right atrium is withdrawn cm to terminate at the cavoatrial junction nasogastric tube with side port at ge junction could be advanced cm significantly worsened pulmonary edema with worsened bilateral pleural effusions cxr lung volumes have improved and mild pulmonary edema has decreased small right pleural effusion moderate cardiomegaly and generalized pulmonary vascular congestion persist tracheostomy tube in standard placement dual channel left subclavian catheter ends in the mid svc and a right picc line extends to or just beyond the superior cavoatrial junction cxr there are low lung volumes cardiomegaly is stable there is improved aeration in the lower lobes bilaterally small bilateral pleural effusions have decreased lines and tubes are in unchanged position including a right central catheter with tip in the upper right atrium there are no new lung abnormalities or evident pneumothorax there is mild vascular congestion rounded opacities in the right upper lobe could be due to vessels on end and or lung nodules attention in followup studies is recommended and if they are truly lung nodules they will be suspicious for septic emboli cxr improved bibasilar atelectasis with improved lung volumes unchanged mild pulmonary edema ruq u s impression nodular liver consistent with the patient s known cirrhosis with portal hypertension signs that include splenomegaly and ascites cholelithiasis without signs of cholecystitis no evidence of intra or extra hepatic biliary duct dilatation right adnexal cyst for which a dedicate pelvis us or mr are recommended cta chest impression no pulmonary embolism or aortic pathology no focal opacification concerning for pneumonia malignant course of the right coronary artery that is seen passing between the aorta and pulmonary artery but is not definitively seen arising from the left coronary sinus bilateral pleural effusions both small right greater than left findings consistent with provided history of pneumonitis as well as background emphysematous changes partially imaged perihepatic ascites soft tissue swelling evident in the anterior tissues of the neck similar to neck ct ct chest non con impression small bilateral pleural effusions right larger than left are increased in size from rll consolidation very little aerated right lower lobe due to a combination of atelectasis and pneumonia has also worsened in the last days atelectasis or scarring in the lingula and left lower lobe is unchanged mild centrilobular emphysema is unchanged right thin walled cysts are compatible with provided history of pneumonitis though not to the degree expected for this diagnosis increased perihepatic ascites since rue u s doppler impression non occlusive thrombus dvt seen surrounding the picc line within one of the two brachial veins findings of non occlusive thrombus were noted at p m on and conveyed by telephone to dr at p m on the same day ct torso with contrast impression stable to minimally improved right lower lobe consolidation bilateral pleural effusions and small pericardial effusion cholelithiasis multiple renal hypodensities lesions incompletely characterized in this study previously noted to represent cysts right adnexal cystic lesion for which pelvic ultrasound is recommended cirrhosis ascites and splenomegaly with splenic varices consistent with portal hypertension nonspecific ileal thickening which may represent sequelae of portal hypertension brief hospital course ms is a yo f with hiv cd pneumonitis pulmonary htn esrd on hd cardiomyopathy and emphysema on o at home admitted for sepsis from a prevertebral abscess s p anterior discetomy with a hospital course complicated by pseudomonal pneumonia multiple intubations and day micu stay active issues sepsis from prevertebral abscess s p anterior cervical diskectomy patient was found to have blood cultures positive for on so she was initially started on daptomycin due to potential allergy to vancomycin but then switched to nafcillin cefepime and flagyl for broad coverage source was felt to be prevertebral fluid collection noted on ct of the neck on she triggered on the floor for hypotension with sbp which was initially fluid responsive but eventually persisted despite boluses so she was transferred to the icu for further management after discussion between ent ortho spine and neurosurgery the patient went for anterior neck exploration by ent and ortho spine and anterior cervical diskectomy and fusion was performed at c and c along with incision and drainage of prevertebral abscess on patient remained intubated post procedure due to significant procedure related edema and her antibiotics were narrowed to nafcillin single therapy patient s blood pressures were persistently low and she remained pressor dependent until when she was extubated due to patient s persistent hypotension despite resolution of bacteremia and drainage of abscess studies were undertaken to evaluate for other potential sources of infection and she was broadened to dapto meropenem u s of the fistula showed no signs of thrombus tte showed no vegetations and ct abdomen pelvis showed no abscesses or other acute infectious process despite persistent hypotension and elevated lactate patient remained arousable and consistently able to follow commands after days of dapto her antibiotics were changed to nafcillin monotherapy due to improving bp absence of a nd infectious source and decreasing pressor requirement however she developed a cholestatic hepatitis and her nafcillin was switched back to daptomycin id then recommended transitioning daptomycin to cefazolin the pt has a documented cefazolin allergy so desensitization was undertaken but the patient developed anaphylaxis see below she was planned to have a week total course last day of daptomycin for her abscess and will follow up with ortho spine and id for ongoing management her surgical wound had intermittent trace bleeding though her hct remained stable and her incision appeared well healing at the time of discharge cefazolin desensitization anaphylaxis patient developed cholestatic hepatitis thought to be secondary to nafcillin therapy prompting switch to daptomycin to cover sepsis patient had documented cefazolin allergy and desensitization protocol was attempted which she tolerated initially but she then developed anaphylaxis to mg of cefazolin characterized by wheezing sob tripoding stridor and received epinephrine hydrocortisone benadryl and ranitidine with resolution of her symptoms without recrudescence of symptoms in hours pseudomonal pneumonia c b respiratory failure and sepsis pt became stridorous in the setting of a retropharyngeal abscess and was intubated on for airway protection she required massive fluid recussitation for sepsis and developed pulmonary edema which may also have contributed to her failure she also has underlying copd which was a likely contributing factor to her poor pulmonary substrate and respiratory failure her abscess was evacuated and she had acdf of c c and c c with ortho spine she remained intubated due to concern for airway edema until when she was extubated without event she then developed fevers relative hypotension and respiratory distress with sputum cultures growing pseudomonas she ultimately required a second intubation and pressors for a priod of time she was treated with a course of meropenem and amikacin per id recommendation and improved she was extubated without further significant issues and weaned off pressors for weeks prior to discharge she was satting well on nasal cannula afebrile and without respiratory distress at the time of discharge cholestatic hepatitis patient s direct bilirubin and transaminases started to acutely rise on on exam patient was also noted to have increased distention and tenderness u s of the gallbladder and ct of the abdomen showed only cirrhosis and no acute pathology cefepime was discontinued due to concern for liver toxicity etiology was initially thought to be due to acute hepatic decompensation in the setting of critical illness her lfts remained persistently elevated and acutely worsened with initiation of nafcillin therapy which was subsequently discontinued see above her hepatitis was felt to be medication effect though would note that she has underlying hcv hbv serologies were negative multifactorial anemia likely anemia of chronic disease and anemia of esrd she required intermittent blood transfusions throughout her course though had no evidence of active bleeding stool guiac was repeatedly negative she should continue receiving epo with hd per renal ileus in the setting of her acute illness and opiate use for pain control ms developed an ileus for this she received naloxone x as well as an aggressive bowel regemin her ileus was intermittent and resolved at the time of discharge she was tolerating her tube feeds and a po diet of clear liquids hypotension ms was intermittently hypotensive and requiring pressors throughout her course initially her hypotension was almost certainly due to sepsis which was treated with appropriate antibiotics later in her course she continued to require pressors with hd and her midodrine was increased to mg tid she was also started on high dose thiamine due to concern for dry beri beri with marked improvement in her bps picc associated rue dvt given her heparin allergy ms was started on an argatroban gtt for her dvt after her picc was removed hematology was consulted and recommended an argatroban normogram which was continued for the duration of her micu stay hiv versus critical illness neuropathy given her multiple medical problems poor nutrition prolonged hospital course and peipheral neuropathy there was concern for dry beri beri for this she was started on high dose thiamine with initial improvement in her neuropathy however her neuropathy subsequently returned and neurology was consulted who felt it may be consistent with critical illness polysneuropathy her primary team felt her symptoms were likely related to her chronic hiv she was trialed on low dose gabapentin but intermittently appeared sedated so that medication was discontinued chronic issues hiv cd her home haart regemin was continued throughout her course viral load early on in her admission was lip copd asthma her home albuterol ipratroprium were continued throughout her course at the time of discharge she was breathing comfortably on nasal cannula pulm htn her sildenafil mg po tid was initially held for hypotension but was restarted once she was off pressors esrd started on cvvh while on pressor support she had a l subclavian temp hd line placed and received intermittent cvvh until weaned off pressors her temp hd line was pulled on she thereafter she received intermitted hd through her fistula in order to take off acumulated volume she was transistioned to t th sat schedule prior to discharge chronic thrombocytopenia ms is chronically thrombocytopenic though her platelet counts on this admission were markedly lower her chronic thrombocytopenia may be related to her liver disease and her acute decompensation may be multifactorial and due to acute hepatic decompensation and cvvh she had intermittent small volume bleeding through her surgical incision and from her occipital pressure ulcer elevated inr felt to be partly due to decompensation of patient s underlying cirrhosis but also due to antibiotic use patient was intermittently repleted with vitamin k transitional issues goals of care after significant discussions with the patient s family primarily her daughter she was remained full code throughout this admission consider outpatient pelvic us for x cm right ovarian cyst seen on abdominal ct which is unchanged since please follow q month cd counts and re initiate bactrim prophylaxis for cd count below medications on admission discharge medications from pt does not recall any of her rx but says takes hiv rx and then a number of other rx sildenafil mg tablet sig two tablet po qam once a day in the morning sildenafil mg tablet sig five tablet po qpm once a day in the evening sulfamethoxazole trimethoprim mg tablet sig one tablet po qmon wed fri calcium carbonate mg calcium mg tablet chewable sig one tablet chewable po bid times a day lamivudine mg tablet sig tablet po daily daily calcitriol mcg capsule sig one capsule po qtue sat cinacalcet mg tablet sig one tablet po daily daily etravirine mg tablet sig two tablet po bid times a day quetiapine mg tablet sig one tablet po bid times a day raltegravir mg tablet sig one tablet po bid times a day albuterol sulfate mg ml solution for nebulization sig one nebs inhalation q h every hours as needed for sob disp nebs refills ipratropium bromide solution sig one neb inhalation q h every hours disp nebs refills folic acid mg tablet sig one tablet po daily daily levofloxacin mg tablet sig one tablet po q h every hours for doses tale sat mon wed fri disp tablet s refills lidocaine prilocaine cream sig one appl topical qhd each hemodialysis tenofovir disoproxil fumarate mg tablet sig one tablet po qfri every friday prednisone mg tablet sig one tablet po once a day for days mg on and mg daily on and mg daily on and discharge medications calcium carbonate mg calcium mg tablet chewable sig one tablet chewable po bid times a day raltegravir mg tablet sig one tablet po bid times a day etravirine mg tablet sig two tablet po bid times a day acetaminophen mg tablet sig two tablet po q h every hours as needed for pain fever lidocaine diphenhyd mag mg ml mouthwash sig ml mucous membrane four times a day as needed for mouth pain lamivudine mg ml solution sig ml po daily daily total daily dose is mg tenofovir disoproxil fumarate mg tablet sig one tablet po qmon every monday sildenafil mg tablet sig tablets po tid times a day b complex vitamin c folic acid mg capsule sig one cap po daily daily aspirin mg tablet chewable sig one tablet chewable po daily daily albuterol sulfate mg ml solution for nebulization sig one neb inhalation q h every hours as needed for wheeze guaifenesin mg ml syrup sig mls po q h every hours as needed for cough phenol aerosol spray sig one spray mucous membrane q h every hours as needed for irritation petrolatum ointment sig one appl topical tid times a day as needed for rash ipratropium bromide solution sig one neb inhalation q h every hours as needed for wheezing sob quetiapine mg tablet sig two tablet po qhs once a day at bedtime thiamine hcl mg tablet sig two tablet po daily daily pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours midodrine mg tablet sig three tablet po tid times a day lidocaine hcl ointment sig one appl topical q dialysis for needle insertion lidocaine hcl ointment sig one appl topical times a day loperamide mg capsule sig two capsule po qid times a day as needed for diarrhea quetiapine mg tablet sig tablet po qam once a day in the morning as needed for anxiety agitation daptomycin mg recon soln sig four hundred recon soln intravenous q h every hours to be given after dialysis on the day of dialysis last dose is discharge disposition extended care facility hospital discharge diagnosis prevertebral abscess bacteremia hypoxic respiratory failure hepatitis 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 ms you were admitted to with an infection in your neck an operation was performed to remove this infection you also developed a blood stream infection from a bacteria lastly your hospitialziation was complicated by respiratory distress you were in the intensive care unit for many weeks and are being discharged to a rehab center the following changes were made to your medications your sildenafil was changed to mg by mouth three times a day you were started on daptomycin mg by iv infusion to be given after each dialysis session the final dose is to be given on prednisone was stopped bactrim sulfamethoxazole trimethoprim was stopped as well because your cd count has improved calcitriol was stopped per renal recommendations lamivudine was decreased to mg by mouth daily cinacalcet was stopped per renal recommendations quetiapine was changed to mg by mouth each morning as needed for anxiety and mg by mouth at night nephrocaps were started take capsule by mouth daily folic acid was stopped tenofovir was changed to every friday to every monday the dose was not changed you were started on midodrine mg by mouth three times a day to increase your blood pressure followup instructions right adnexal cyst for which a dedicate pelvis us or mr are recommended in the outpatient setting department infectious disease when tuesday at am with md building lm bldg campus west best parking garage please make an appointment to see dr in orthopaeidc surgery ph once you are in better condition md completed by,"{
""Diagnoses"": [""hypotension"", ""weakness"", ""dizziness"", ""major surgical or invasive procedure"", ""history of present illness"", ""W/HIV"", ""CD"", ""ESRD"", ""on HD"", ""CHF"", ""E/F"", ""MR"", ""moderate on TTE"", ""presented to HD""],
""Medications"": [""Vanco"", ""Ctx"", ""Flagyl"", ""Dex"", ""Mg"", ""Dextrose"", ""Insulin"", ""Nephrology"", ""Kg weight gain"", ""Gentle HD in the MICU"", ""Cough"", ""Associated with straining abdominal discomfort"", ""Episode emesis"", ""Forget haart once per week""]
}"
29579,admission date discharge date date of birth sex m service surgery allergies glyburide sulfonylureas attending chief complaint patient transferred from an outside hospital for management of multiple abdominal abscesses major surgical or invasive procedure abscess drain placed at osh drain repositioned on into abscess cavity exploratory laparotomy lysis of adhesions drainage of abdominal wall abscess end left colostomy on history of present illness m with h o colon cancer s p resection pt presented to osh on with crampy lower abdominal pain ct scan on admission showed pre sacral x cm fluid collection with foci of air in collection an additional lobed x cm fluid collection in the r lateral pelvis as well as a cm collection medial to the pelvic collection an attempt for ct guided drainage was made only yielding a scant amount of fluid pt was started on imipenem cilastatin on on the pt was rescanned and a drainage catheter was successfuly placed in one fluid collection and left to gravity drain cultures growing gram negative rods gram positive rods and gram positive cocci per osh wbc on down to on past medical history pmh dm ii esrd from post surgical atn from which pt never recovered currently on dialysis mwf colon ca chf hyperlipidemia htn gout h o ef of while in a flutter echo reports ef moderate as mild ar psh av fistula for dialysis access l arm colon ca resection with j pouch c post op chemo xrt temporary diverting ileostomy subsequently taken down social history lives with wife quit smoking years ago but smoked ppd x years pack years quit etoh years ago drank on weekends denies heavy use denies illicit drug use family history mother alive and healthy father deceased when pt a baby unknown cause son healthy no siblings physical exam on admission vital signs t bp p r o sat ra general year old female cachectic but in no acute distress heent atraumatic normocephalic head sclerae anicteric pupils equal round and reactive to light extraocular movements intact no oral lesions mucous membranes are moist ng tube neck supple lymph no cervical supraclavicular axillary occipital or inguinal lymphadenopathy cv regular rate and rhythm no murmurs gallops or rubs lungs clear to auscultation and percussion bilaterally abdomen soft nontender minimally distended normoactive bowel sounds present liver margin is palpable but non tender no splenomegaly or ascites extremities no clubbing cyanosis or edema pertinent results radiology final report chest portable ap pm medical condition year old man with h o chf baseline cxr findings there is moderate hyperelevation of the hemidiaphragms on both the right and the left side at the right lung base the presence of mild to moderate pleural effusion cannot be excluded hypoventilation of the right lung base on the left there is no reliable evidence of pleural effusion however there is also mild hypoventilation in the retrocardiac area the visible parts of the cardiac silhouette indicates mild cardiomegaly no signs of overhydration no signs of pneumonia in the adequately visible parts of the lung parenchyma radiology final report ct pelvis w contrast pm reason po iv contrast please evaluate abdominal abscesses conclusion free fluid in the abdomen and pelvis along with several small collections along the anterior abdominal wall as well as in the pelvis as described above catheter in a presacral nearly completely drained collection enlarged nodular left adrenal gland is suggestive of adenoma and an mri or non contrast ct could be performed to confirm this diagnosis small atrophic kidneys with cysts atelectasis and consolidation at the lung bases with bibasal effusions expansion of the cortex of left femoral shaft with a ground glass appearance suggestive of fibrous dysplasia portable tte complete done at pm the left atrium is mildly dilated there is mild symmetric left ventricular hypertrophy with normal cavity size and regional global systolic function lvef transmitral doppler and tissue velocity imaging are consistent with grade ii moderate lv diastolic dysfunction the right ventricular cavity is mildly dilated with borderline normal free wall function the aortic root is mildly dilated at the sinus level the ascending aorta is mildly dilated the number of aortic valve leaflets cannot be determined the aortic valve leaflets are severely thickened deformed there is moderate aortic valve stenosis area cm trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen there is moderate pulmonary artery systolic hypertension there is no pericardial effusion impression mild symmetric left ventricular hypertrophy with normal systolic function and moderate diastolic dysfunction moderate aortic stenosis mild mitral regurgitation radiology final report fisutlogram inj thru sinus tract am reason fistula impression malpositioned pigtail catheter terminated in the ileoanal pouch after consultation with dr the catheter was exchanged over a wire and repositioned to terminate in the presacral collection multiple additional intra abdominal abscesses without direct connection demonstrated to the presacral collection unchanged appearance of the bones with lucent lesion of the right acetabulum and of the left proximal femur pouchogram pm medical condition year old man s p j pouch creation for colon ca now with pelvic abscess impression a leak posteriorly from the rectum to the area drained by the catheter with other fistulae demonstrated posteriorly sigmoidoscopy date findings other the patient is status post sigmoid resection the anastamosis was examined and there was no sign of disease recurrence adjacent to the anasatamosis there was both a blind pouch with suture and a probable fistula with purulent material above and to the left on the picture the colon was unremarkable on examination to cm there was an raised and erythematous area on the anal verge impression the patient is status post sigmoid resection the anastamosis was examined and there was no sign of disease recurrence adjacent to the anasatamosis there was both a blind pouch with suture and a probable fistula with purulent material above and to the left on the picture the colon was unremarkable on examination to cm there was an raised and erythematous area on the anal verge otherwise normal sigmoidoscopy to cm recommendations return to hospital radiology final report persantine mibi reason pre op eval perfusion history year old man with history of dm chf cadiomyopathy and moderate aortic stenosis referred for pre operative evaluation impression no perfusion defects identified left ventricle appears enlarged consistent with provided history of cardiomyopathy computer calculated left ventricle volume is ml calculated lvef of pathology examination procedure date diagnosis peritoneal implant fibrin necrotic tissue with acute inflammation clinical fistula of the colon stress test exercise results resting data ekg sinus av delay laa modest rv cond delay pattern nssttw heart rate blood pressure stage time speed elevation heart blood rpp min mph rate pressure mg kg min impression no anginal symptoms or st segment changes from baseline nuclear report sent separately radiology final report unilat up ext veins us right am reason swelling r o dvt rue indication year old male with right arm swelling impression occlusive thrombus within the right cephalic vein no other thrombus detected radiology final report shoulder views non trauma left am medical condition year old man with l shoulder pain history left shoulder pain findings there are degenerative changes around the shoulder joint with some soft tissue ossification medially the alignment is normal and no fracture is identified brief hospital course the patient was transferred from an outside institution after having a drain inserted via ir he was admitted directly to the intensive care unit he was treated with iv fluids and continued on antibiotics imipenem and vancomycin oral antihyperglycemics were held due to low blood glucose levels the patient was transferred to the floor for close monitoring antibiotics changed to meropenem and vancomycin ct performed showing multiple abdominal abscesses a fistulagram demonstrated positioning of the drain within the rectum the drain was changed over a wire and positioned within the pelvic abscess continued to drain feculent drainage multiple cultures were obtained during this admission please refer to pertinent results section the patient s dialysis continued per his normal monday wednesday schedule his most recent medication regimen was confirmed with the dialysis center patient made npo and a picc line was placed and tpn nephramine was started nutrition was consulted and tpn was modified nephramine not indicated in this case since he already has a diagnosis of esrd barium enema revealed a fistula decision for surgical intervention was considered due to multiple medical concerns patient required pulm cardiac clearance underwent a sigmoidoscopy prepped with enema confirmed site of fistula he continued on tpn and iv antibiotics prepped consented for or medical team was consulted for pre op evaluation of patient due to multiple medical concerns recommendations included a pmibi to assess cv status pulmology and cardiology consults he underwent a pmibi on cardiology reviewed case and cleared patient for surgery adjustments were made to his cardiac regimen amiodarone decreased to mg po from mg toxicity likely related to decompensated pulmonary status cardizem changed to mg po qid and toprol xl remains unchanged both his blood pressure and hr have remained stable he underwent diverting colostomy with dr he tolerated the procedure well he was monitored in the pacu longer than usual due to low oxygen sats when attempting to wean from vent he was eventually extubated successfully with stable sats on l he was transferred to cc pulmonology team consulted due to patient s intermittent need of supplemental oxygen during this admission patient also states using intermittent oxygen at home he is a poor historian and was not able to explain reasoning for home use during this admission oxygen needs likely related to fluid volume overload which was confirmed with ra sats after dialysis in addition he uses cpap at home for osa his oxygen sats have remained stable with minimal to no supplemental oxygen use he will follow up with pulmonolgy outpatient for pft s and sleep studies tpn was weaned and regular diet re started received oral dose of glyburide medication regimen confirmed per out patient dialysis center due to esrd and renal excretion of glyburide patient became hypoglycemic dropped to s treated with d intravenous drip with frequent blood sugar monitoring resulting in transfer of patient to pacu for closer monitoring in addition he became lethargic weak with some cognitive changes iv antibiotics discontinued in the morning he was dialyzed and then transferred to the pacu despite dialysis and d drip his blood sugars remained low ranging for which he received multiple boluses of d q h by evening his sugars he was transferred to with hour blood sugar checks and continuous d iv drip blood sugars remained stable blood sugar checks decreased to every hours and iv d was discontinued he continued with his regular diet with adequate ostomy output and flatus he continued to work with physical therapy he ambulated well with rolling walker and supervision he has been evaluated per the ostomy care specialist throughout this admission he has had an ostomy in past and was semi independent with care with wife s assistance at home he has decreased lue rom exact etiology unknown xray on revealed degenerative changes but no trauma or fracture please refer to physical therapy evaluation he continued to be dialyzed mwf during this admission he was last dialyzed on medications on admission riss imipenem cilastatin amiodarone celexa cardizem cd colace metoprolol crestor allopurinol protonix glyburide flomax loperamide lipitor mg nephrocaps cap qd tylenol prn percocet prn morphine prn zofran prn discharge medications amiodarone 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 succinate mg tablet sustained release hr sig one tablet sustained release hr po daily daily citalopram mg tablet sig two tablet po daily daily allopurinol mg tablet sig one tablet po every other day every other day tamsulosin mg capsule sust release hr sig one capsule sust release hr po hs at bedtime b complex vitamin c folic acid mg capsule sig one cap po daily daily calcium acetate mg capsule sig one capsule po tid w meals times a day with meals diltiazem hcl mg tablet sig one tablet po qid times a day amoxicillin pot clavulanate mg tablet sig one tablet po q h every hours lorazepam mg tablet sig one tablet po q h every hours as needed for anxiety acetaminophen mg tablet sig two tablet po q h every hours hydromorphone mg tablet sig tablets po q h every hours as needed for pain for weeks aspirin mg tablet sig one tablet po daily daily colace mg capsule sig one capsule po twice a day as needed for constipation lipitor mg tablet sig one tablet po once a day insulin regular human unit ml solution sig one injection qid hs refer to sliding scale regular insulin sliding scale regular insulin sliding scale check blood sugars qid hs mg dl units mg dl units mg dl units mg dl units titrate sliding scale accordingly discharge disposition extended care facility health care center discharge diagnosis primary multiple abdominal abscesses rue thrombosis hypoglycemia acute pulmonary edema heart failure diastolic secondary dm ii esrd from post surgical atn dialysis mwf colon ca chf hyperlipidemia htn gout h o ef of while in a flutter echo reports ef moderate as mild ar discharge condition stable tolerating a regular diet adequate pain control with oral medication discharge instructions 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 see blood or dark black material when you vomit or have a bowel movement 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 avoid driving or operating heavy machinery while taking pain medications 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 and take any new meds as ordered continue to ambulate several times per day drain care please look at the site every day for signs of infection increased redness swelling odor yellow or bloody discharge fever note color consistency and amount of fluid in drain call doctor if amount increases significantly or changes in character be sure to empty the drain frequently you may shower wash area gently with warm soapy water maintain the site clean dry and intact avoid swimming baths hot tubs do not submerge yourself in water keep drain attached safely to body to prevent pulling monitoring ostomy output prevention of dehydration keep well hydrated replace fluid loss from ostomy daily avoid only drinking plain water include gatorade and or other vitamin drinks to replace fluid try to maintain ostomy output between ml to ml per day if ostomy output liter take mg of imodium repeat mg with each episode of loose stool do not exceed mg hours sulfonylurea s please hold all sfu s ie glyburide due to renal excretion patient developed profound hypoglycemia in patient after taking po glyburide as indicated per out patient dialysis medication list further evaluation required per primary care physician nephrologist regular insulin sliding slide due to hypoglycemic episode during this admission related to po glyburide the patient s regular insulin sliding scale was adjusted to low dose coverage starting at please titrate sliding scale accordingly blood sugars have remained stable and have continued to trend up to s followup instructions please make a follow up appointment with dr in weeks make a follow up appointment with your primary care provider nephrologist dr in for further evaluation of your respiratory status including pft s and sleep study management of your diabetes and hypoglycemia and management of kidney function please follow up with your cardiologist dr in weeks follow up with diabetes center as needed you were seen by np in patient she may be reached at completed by [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies glyburide sulfonylureas attending chief complaint r hip pain major surgical or invasive procedure ct guided right iliac biopsy history of present illness m w pmhx of colon cancer s p resection w colsotomy esrd developed abdominal abscess in then fell in during a dialysis session w r hip fx w o surgical correction given abscses at that time ct scan supported metastatic disease later a biopsy was performed which demosntrated possible spindle cells he is being tx to the for further oncology managment by dr he states that since his hospital admission in he has been at rehab and has had rle weakness and been unable to ambulate he also has had a chronic o requirement since he otherwise has chronic pain in his right hip and r l leg weakness chronic numbness in his lower extremities is anuric has an ostomy no saddle anesthesia o w denies cp f c n v past medical history o requirement l since dm ii esrd from post surgical atn from which pt never recovered currently on dialysis mwf colon ca chf hyperlipidemia htn gout afib psh av fistula for dialysis access l arm colon ca resection with j pouch c post op chemo xrt temporary diverting ileostomy subsequently taken down social history social history lives with wife quit smoking years ago but smoked ppd x years pack years quit etoh years ago drank on weekends denies heavy use denies illicit drug use family history family history mother alive and healthy father deceased when pt a baby unknown cause son healthy no siblings physical exam vs lnc gen nad pleasant speaking in full sentences comfortable heent perrl eomi op clear no lad cv rrr sem iii vi greatest lusb radiating to axilla chest crackles left lung fields up abd bs soft nt nd ostomy hemorrhoids no decub ext no c c e neuro aaox motor lle rle ue symmetric labs see below 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 calcium phos mg am blood calcium phos mg am blood caltibc ferritn trf am blood cea psa bilat hips ap lat ap pelvis pm bilat hips ap lat ap pelvis reason please eval fracture medical condition year old man with rectal cancer s p r hip fracture in reason for this examination please eval fracture bilateral hips clinical information rectal cancer status post right hip fracture marginally findings ap view of the pelvis and two coned down views of the right hip are submitted comparison is made with the ct of the abdomen and pelvis from which demonstrates a lytic destructive lesion of the right acetabulum since the prior study there has been interval progression of the destructive lesion within the right acetabulum and iliac bone there is now destruction of the acetabular wall with medial migration of the femoral head there is medial displacement of the acetabular wall into the pelvis there is a lucency at the femoral head neck junction which may represent a non displaced fracture further evaluation with ct or mri is recommended evaluation for fine osseous detail is limited by the osteopenia there are multiple lytic lesions throughout the osseous pelvis and the left femur as well there is old osseous deformity of the left proximal femur there is severe degenerative change in the lower lumbar spine impression progression of large lytic destructive lesion in the right acetabulum and iliac bone with fracture of the medial acetabular wall with displacement of fracture medially into the pelvis question non displaced fracture of the femoral neck at the subcapital region old fracture deformity of the left proximal femur further evaluation with ct or mri is recommended bilat lower ext veins am bilat lower ext veins reason bilateral leg edema dvt medical condition year old man with colon cancer pathalogic fracture of hip bilateral lower extremity swelling r l reason for this examination dvt indication bilateral lower extremity swelling right greater than left comparison none bilateral lower extremity venous ultrasound the right and left common femoral greater saphenous superficial femoral popliteal demonstrate wall to wall flow and normal compressibility and response to valsalva and augmentation wall to wall flow is seen in the posterior and tibial veins bilaterally edema is seen in both legs impression no son evidence for dvt edema bone scan whole body images of the skeleton and planar views of the thorax were obtained in anterior and posterior projections images show focal abnormal uptake of tracer in the right acetabulum and right inferior pubic ramus increased uptake is seen within the left proximal femur diaphysis associated with bony deformity additionally there is focal uptake in the bilateral shoulders right greater than left as well as the bilateral knees right greater than left consistent with degenerative changes focal uptake within the distal ends of the th and th left ribs is likely secondary to prior trauma the above described findings are consistent with focal tracer uptake within the known lytic lesion in the right acetabulum as well as within the right inferior pubic ramus concerning for metastatic disease the kidneys and urinary bladder are visualized the normal route of tracer excretion impression focal tracer uptake within the known lytic lesion of the right acetabulum and pubic symphysis concerning for metastatic disease likely degenerative changes of the bilateral shoulders and knees ct guided biopsy procedure findings the risks and benefits of the procedure were explained to the patient and informed written consent was obtained preprocedural timeout was performed confirming the patient s identity and the procedure to be undertaken the patient was placed in the left lateral decubitus position on the ct scanner the patient was prepped and draped in the usual sterile fashion using cc of lidocaine for local anesthesia under direct ct fluoroscopic guidance a gauge coaxial needle was inserted into the destructive lytic lesion within the right ilium subsequently five core biopsy samples were obtained with a gauge biopsy gun device with the samples were placed in formalin additionally one core biopsy sample was placed in cytolite for cytology analysis patient tolerated the procedure well and there were no immediate post procedural complications dry sterile dressing was placed moderate sedation was provided by administering divided doses of versed and fentanyl throughout the total intraservice time of minutes during which the patient s hemodynamic parameters were continuously monitored a total dose of mcg of fentanyl and mg of versed were administered the procedure was performed by drs and dr the attending radiologist present and supervising throughout impression technically successful ct guided core biopsy of right iliac bone lesion biospy diagnosis right iliac lytic lesion biopsy a connective tissue scant fragments of bone and fibrin no malignancy identified in this specimen ct torso ct chest with iv contrast bilateral pleural effusions and associated atelectasis are greater on the right than the left there is associated volume loss on the right with segmental collapse the right lower lobe bronchus remains patent the trachea and left bronchi are patent to the subsegmental level the aorta and its branches and the coronary arteries demonstrate heavy calcifications the heart aorta and great vessels are otherwise unremarkable there is mild thyroid enlargement without a discrete thyroid nodule identified there is no supraclavicular axillary or mediastinal lymphadenopathy there is a soft tissue mass involving the right rotator cuff muscles and causing erosion into the right humeral head which demonstrates pathologic fracture there is no apparent involvement of the glenoid fossa ct abdomen with iv contrast a x cm adrenal nodule is low in attenuation and unchanged since prior studies likely representing an adrenal adenoma the kidneys are atrophic bilaterally a x cm exophytic cyst is identified arising from the interpolar region of the left kidney a and a simple renal cyst is identified arising from the inferior pole of the right kidney a the liver spleen pancreas right adrenal gland large bowel and small bowel are unremarkable there is no mesenteric or retroperitoneal lymphadenopathy and no intra abdominal free air or fluid is identified the abdominal aorta and its branches are heavily calcified ct pelvis with iv contrast the left lower quadrant demonstrates sigmoid colostomy a rectosigmoid anastomosis site is identified there is a small amount of calcification in the prostate gland the rectum and bladder are unremarkable no pelvic or inguinal lymphadenopathy is identified there is a x cm fluid collection anterior to the inferior sacrum and posterior to the rectum axial coronal there is diffuse edema and soft tissue enlargement involving the right flank right psoas muscle and iliopsoas with erosion of a soft tissue mass into the right acetabulum and femoral head although previously involving the right acetabulum there has been progression of pathologic fracture of the acetabulum as well as femoral head the left iliopsoas muscle is also enlarged indicative of a soft tissue mass with pathologic fracture of the left acetabulum and extensive lytic lesions of the left femoral head without definite cortical breakthrough the origin of the left hamstring muscle is asymetrically enlarged with obliteration of the fat planes at the medial aspect of the posterior thigh impression soft tissue metastases with bony erosion and pathologic fracture involving the right humeral head right femoral head and acetabulum and left acetabulum lytic lesions without definite cortical breakthrough involving left femoral head bilateral pleural effusions right greater than left with associated atelectasis and volume loss no lymphadenopathy in the chest abdomen or pelvis left adrenal adenoma bilateral renal cysts significant atherosclerotic disease involving the aorta and its branches brief hospital course m w pmhx of rectal cancer presented for evaluation of likely pathologic right hip fracture the patient had undergone an ir guided needle biopsy of his right iliac crest in order to obtain for diagnosis the initial examination hsowed predominantly fibrosis with spindle cells raising the possibiltity that the pathalogic fracture may be from a new primary sarcoma as opposed to metastatic rectal cancer the biopsy specimen was sent to and woman s hospital for further examination on arrival to pelvis x ray showed widespread metastatic involvement of the bony pelvis orthopedics evaluated the patient and found his hip unable to be surgically repaired they recommended the patient be seen by radiation oncology for treatment of his metastatic disease however radiation oncology deferred until pathology on his planned biopsy returned furthermore he had previously received radiation therapy at an outside provider and they recommended that if radiation was needed he should return there as they have his previous mapping they also recommended the patient get a bone scan in order to find other metastatic sites which may be easily accesible for further biopsy and identification the bone identified the lesions in the right hip that were suspicious and he underwent a ct guided biopsy of the right ilium by orthopedic oncology on however this biopsy show no malignancy furthermore and spep and upep were negative his right hip lesion may be severe bony disease in a patient in a patient on hemodialysis in discussion with the orthopedic oncologist and his primary oncologist the decision was made to observe the patient in one month with a repeat ct scan if his disease has progressed at that time the orthopedic oncologist will pursue an open biopsy he will follow up with his primary oncologist dr and the orthopedic oncologist dr he should also be evaluated by his nephrologist to evaluate his metabolic status in regards to his bone health his pain was controlled with oxycontin on after receiving more extensive iv fluids prior to his bonescan the patient developed respiratory distress and subsequent hypercarbic respiratory failure he was transferred to the medical icu he was briefly placed on non invasive ventilation and emergently dialyzed to remove fluid the previous day his long acting oxycontin was also increased from mg to mg it is felt that both the volume overload and the increase in his narcotics contributed to his respiratory failure he continued to have fluid removed by hd and improved he presented with a chronic oxygen requirement of approximately l he was using l nc at the time of discharge and this may continue to be weened as more fluid is removed at hemodialysis at it is felt that the cause of his oxygen requirement is continued volume overload esrd on hd mwf continued on nephrocaps and calcium acetate he will continue on an oral fluid restriction as outlined above afib he was continued on his home doses of amiodarone metoprolol and diltiazem with good effect his lfts and tfts were normal here the patient may benefit from pfts as an outpatient ischemic cardiomyopathy continued on asa metoprolol and statin with fluid removal at hemodialysis gout continued renally dosed allopurinol dm continued humalog iss depression continued home celexa ppx cont ppi sc heparin fen renal diet as tolerated monitor lytes code full code confirmed with wife on transfer medications on admission oxycontin mg oxycodone mg q hr prn nephrocaps prilosec mg daily crestor mg daily diltiazem mg qid amiodraone mg daily metoprolol mg daily asa daily allopurinol mg daily citalopram mg daily lorazepam mg po q hr prn iss discharge medications b complex vitamin c folic acid mg capsule sig one cap po daily daily pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours atorvastatin mg tablet sig one tablet po daily daily amiodarone mg tablet sig one tablet po daily daily allopurinol mg tablet sig one tablet po every other day every other day acetaminophen mg tablet sig tablets po q h every hours as needed calcium acetate mg capsule sig one capsule po tid w meals times a day with meals hydrocortisone acetate ointment sig one appl rectal times a day diltiazem hcl mg tablet sig one tablet po q h every hours hold for sbp hr metoprolol tartrate mg tablet sig one tablet po tid times a day hold for sbp hr citalopram mg tablet sig two 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 aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily oxycodone mg tablet sig one tablet po q h every hours as needed ibuprofen mg tablet sig one tablet po q h every hours heparin porcine unit ml solution sig one ml injection tid times a day oxycodone mg tablet sustained release hr sig one tablet sustained release hr po q h every hours insulin lispro unit ml solution sig see sliding scale subcutaneous asdir as directed discharge disposition extended care facility health care center discharge diagnosis rectal carcinoma pathologic hip fracture end stage renal disease on hemodialysis diabetes type hyperlipidemia hypertension gout atrial fibrillation discharge condition all vital signs stable discharge instructions you were admitted to the hospital for evaluation of your hip fracture you had a biopsy done which showed no cancer you will follow up with dr and dr for further observation if the problem has progressed dr would consider an open biopsy your hip problem may be from severe osteooporosis caused by your dialysis you should discuss this with your kidney doctor you also have accumulated more fluid which will continue to be taken off at dialysis please continue to take your medications as prescribed please follow up as described below please call your doctor or return to the hospital if you experience any worrisome symptoms followup instructions please call dr office at to schedule a follow up appointment towards the end of provider xray scc phone date time provider md phone date time [NEW_RECORD] name m unit no admission date discharge date date of birth sex m service surgery allergies glyburide sulfonylureas attending addendum addendum to physcial exam section physical exam physical exam on admission vital signs t bp p r o sat ra general yo male in no acute distress heent atraumatic normocephalic head sclerae anicteric pupils equal round and reactive to light extraocular movements intact no oral lesions mucous membranes are moist ng tube neck supple lymph no cervical supraclavicular axillary occipital or inguinal lymphadenopathy cv regular rate and rhythm no murmurs gallops or rubs lungs clear to auscultation and percussion bilaterally abdomen soft nontender minimally distended normoactive bowel sounds present liver margin is palpable but non tender no splenomegaly or ascites extremities no clubbing cyanosis or edema discharge disposition extended care facility health care center md completed by,{}
24476,admission date discharge date date of birth sex m service cardiothoracic allergies penicillins attending chief complaint fatigue dyspnea major surgical or invasive procedure aortic valve replacement mm st mechanical and mitral valve replacement mm st mechanical history of present illness this is a y o male with ai mr who had av repair pericardial patch and left commisure stitch and mv commissuroplasty in abnormal on led to cardiac cath in which showed severe ai and mr on confirmed ai and mr ascending aorta will now be admitted for elective surgical intervention past medical history aortic insufficiency mitral reurgitation ascending aorta rheumatic heart disease s p aortic and mitral valvuloplasty history of migraine ha social history bc bs worker in behav health admits to rare cigarette and drinks per week he denies recreational drug use currently lives with roommates and his girlfriend family history non contributory parents are alive and well physical exam vs general nad young active fit man heent perll eomi non icteric neck supple from jvd chest ctab well healed keloid sternotomy scar l ant chest sm keloid heart rrr sem diastolic murmur abd warm well perfused c c e varicosities neuro a o x mae non focal pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt pm blood pt ptt inr pt pm blood pt ptt inr pt pm blood pt ptt inr pt am blood pt ptt inr pt am blood calcium mg chest x ray pa and lat resolving pneumopericardium no evidence of pneumothorax small pleural effusions brief hospital course mr was electively admitted and taken directly to the operating room where dr performed aortic and mitral valve replacements please see operative report for further surgical details he tolerated the procedure well and was transferred to the csru for invasive monitoring within hours he awoke neurologically intact and was extubated he maintained stable hemodynamics as beta blockers and diuretics were started on postoperative day one warfarin anticoagulation was initiated and he transferred to the sdu for further care and recovery over several days medical therapy was optimized and he continued to make clinical improvements with diuresis and physical therapy by discharge he reached his preoperative weight and diuretics were discontinued he tolerated beta blockade and remained in a normal sinus rhythm warfarin was dosed daily for a goal inr between he temporarily required intravenous heparin for a subtherapeutic prothrombin time blood cultures were taken for low grade fevers but no obvious source of infection was identified by discharge his fevers improved and his white count was normal his hospital course was otherwise uneventful and he was medically cleared for discharge on postoperative day five arrangements have been made with dr to monitor his warfarin as an outpatient at discharge his bp was with a hr of his oxygen saturations were on room air and his discharge chest x ray showed only small bilateral pleural effusions all surgical wounds were clean dry and intact medications on admission lisinopril mg qd discharge medications docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills oxycodone acetaminophen mg tablet sig tablets po every hours as needed for pain disp tablet s refills metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet s refills ibuprofen mg tablet sig one tablet po q h every hours disp tablet s refills warfarin mg tablet sig one tablet po qpm every vary according to pt inr disp tablet s refills discharge disposition home with service facility homecare discharge diagnosis aortic insufficiency and mitral regurgitation s p aortic valve replacement and mitral valve replacement pmh s p aortic and mitral valvuloplasty migraines rheumatic heart disease discharge condition good discharge instructions patient may take shower no baths no creams ointments or lotions to incision no driving for month no lifting more than pounds for months if you develop a fever redness or drainage from incision please contact office immediately take warfarin as directed please have inr checked within hours of discharge dr will manage warfarin as an outpatient warfarin should be adjusted for goal inr between vna will fax results to dr at followup instructions dr in weeks dr in weeks dr in weeks please call to schedule all follow up appointmets completed by,"{
""Diagnoses"": [""cardiothoracic"", ""allergies"", ""penicillins"", ""aortic valve replacement"", ""mm st"", ""mechanical and mitral valve replacement"", ""ascending aorta will now be admitted for elective surgical intervention"", ""aortic insufficiency"", ""mitral reurgitation"", ""rheumatic heart disease"", ""sp aortic and mitral valvuloplasty"", ""history of migraine"", ""social history"", ""bc bs worker in behav health"", ""admits to rare cigarette and drinks per week"", ""denies recreational drug use""],
""Medications"": [""pericardial patch"", ""left commissure stitch"", ""mv commissuroplasty""]
}"
55370,admission date discharge date date of birth sex f service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint shortness of breath major surgical or invasive procedure coronary artery bypass grafting x with a reverse saphenous vein graft from the aorta to the first obtuse marginal coronary artery reverse saphenous vein graft from the aorta to the left anterior descending coronary artery reverse vein graft from the aorta to the distal right coronary artery repair of postinfarct ventricular septal defect with a bovine pericardial patch technique history of present illness y o female with iddm presented to hospital with h o sob since noon progressive denied chest pain taken to er by ambulance at severely sob diaphoretic on arrival required intubation ekg rbbb troponin given mg asa plavix mg cath at caritas showed lm prox lad diffuse disease in circumflex prox rca bp on cath iabp placed patient with wide open mr on lv gram stepup in saturation ra vs pa accepted by ccu patient medievaced no inotropes in transit past medical history insulin dependent diabetes mellitus breast cancer s p bilateral mastectomies social history tobacco smokes cigarettes per day family history non contributory physical exam t bp hr sr iabp sat general intubated has moved all extremities heent pupils pin point neck supple lungs rales rhonchi cardio difficult to hear secondary to balloon abd soft obese ext iabp left groin swan right groin dp and pt pulses present by doppler pertinent results pre op pm pt ptt inr pt pm plt count pm wbc rbc hgb hct mcv mch mchc rdw pm albumin calcium phosphate magnesium pm ck mb mb indx ctropnt pm alt sgpt ast sgot ld ldh ck cpk alk phos tot bili pm 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 pt ptt inr pt am blood glucose urean creat na k cl hco angap intra op echo prebypass no atrial septal defect is seen by d or color doppler there is mild regional left ventricular systolic dysfunction with severe hypokinesis of the distal infero and anteroseptal walls there is a muscular ventricular septal defect vsd located in the mid to distal inferior septum right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened no aortic regurgitation is seen the mitral valve leaflets are mildly thickened physiologic mitral regurgitation is seen within normal limits there is an intra aortic balloon pump catheter well positioned in the descending thoracic aorta postbypass left ventricular systolic function remains unchanged compared to pre bypass rv systolic function remains normal color flow doppler is no longer seen across the interventcicular septum the study is otherwise unchanged from pre bypass chest pa lat pm medical condition year old woman with s p cabg reason for this examination evaluate for effusion final report indication year old female post cabg chest ap moderate bilateral effusions are likely unchanged given differences in positioning mild interstitial edema persists left lower lobe atelectasis is stable the right lung is clear the cardiomediastinal and hilar contours have a normal post cabg appearance right venous introduction sheath has been removed there is no pneumothorax impression stable bilateral effusions the study and the report were reviewed by the staff radiologist dr ho dr brief hospital course ms presented to hospital with chest paina and shortness of breath she was brought emergently to the cardiac catheterization lab and found to have vessel cad wide open mitral regurgitation and a vsd she was intubated and an iabp was placed she was then transferred to for further care once at she was evaluated by cardiac surgery and brought to the oerating room for coronary artery bypass grafting x with a reverse saphenous vein graft from the aorta to the first obtuse marginal coronary artery reverse saphenous vein graft from the aorta to the left anterior descending coronary artery reverse vein graft from the aorta to the distal right coronary artery repair of postinfarct ventricular septal defect with a bovine pericardial patch technique her bypass time was minutes with a cross clamp of minutes please see or report for details she tolerated the operation well and was transferred from the operating room to the cardiac surgery icu in stable condition she was kept sedated on the day of surgerey on pod her iabp was weaned and removed following the removal of the iabp sedation was stopped she woke neurologically intact was weaned from the ventilator and extubated over the next several days she was weaned from all iv medications all tubes lines and all drains were removed per cardiac surgery protocols on pod she was transferred from the icu to the stepdown floor for continued care and recovery she continued to make slow progress in her physical activity and on pod she was cleared for transfer to rehabilitation at in medications on admission insulin and oral diabetic meds discharge medications 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 ipratropium albuterol mcg actuation aerosol sig puffs inhalation q h every hours as needed for bronchospasm wheezing docusate sodium mg capsule sig one capsule po bid times a day heparin porcine unit ml solution sig units injection tid times a day oxycodone acetaminophen mg tablet sig tablets po every hours as needed for pain magnesium hydroxide mg ml suspension sig thirty ml po hs at bedtime as needed for constipation glipizide mg tablet sig one tablet po bid times a day lisinopril mg tablet sig one tablet po daily daily metolazone mg tablet sig tablet po daily daily metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po daily daily bupropion hcl mg tablet sig two tablet po bid times a day lasix mg tablet sig one tablet po once a day insulin glargine unit ml solution sig thirty units subcutaneous qam insulin regular human unit ml solution sig sliding scale units injection qac hs ranitidine hcl mg tablet sig one tablet po once a day discharge disposition extended care facility tba discharge diagnosis acute myocardial infarction coronary artery disease s p coronary bypass grafting ventricular septal defect s p closure discharge condition alert and oriented x nonfocal ambulating gait steady sternal pain managed with oral analgesics sternal wound healing well no erythema or drainage 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 females please wear bra to reduce pulling on incision avoid rubbing on lower edge followup instructions please call with any questions or concerns provider will be paged during off hours please call to schedule appointments surgeon dr in weeks primary care dr in weeks cardiologist dr pm office of dma completed by,{}
31235,admission date discharge date date of birth sex f service medicine allergies penicillins flagyl attending chief complaint transfer from osh with dka and ams major surgical or invasive procedure picc line placement subclavian line placement endotrachial intubation history of present illness y o female with history of type i diabetes found down at home with critically high blood sugars transferred from osh for further evaluation and management of note the patient is intubated and unable to provide a medical history the following was obtained from notes and from her parents the patient was in her usoh until days prior to admission when she reported feeling generally unwell to her family the family is unclear regarding any specific symptoms she was having two nights prior to admission she spent the night with a friend the last time she was seen was am on the day of admission on the day of admission after not being able to be contact by her friend she was found down on the floor in her father s house posturing and unresponsive according to osh note ems was called atd the patient was sent to for further evaluation on presentation to the osh she had fixed and dilated pupils her rectal temperature was she was hypotensive to s s but her blood pressure increased to on an unknown amount of levophed after not responding to initial fluid bolus she was put on a bearhugger the patient was intubated and a femoral line was placed initial labs after intubation notable for abg of glucose cr k serum tox screen negative for amphetamine barb benzo cannabinoids cocaine methadone opiates pcp neg etoh neg tylenol tca asa cxr was megative for pna a head ct demosntrated a questionable area near the left temporal tip which was concerning for epidural blood collection versus artifact an lp was done that demonstrated tube wbc rbc tube wbc rbc gram stain on lp negative glucose protein bacterial antigens negative for n meningitidis s pneumoniae h flu patient was given vancomycin ceftriaxone l ns started on an insulin drip and transferred to the for further management upon presentation to the ed vitals were c hr bp on two pressors sating on ventilator she was transferred to the icu for further management in the icu she was continued on her insulin drips and had her pressors titrated a femoral a line was placed past medical history alopecia diabetes type i diagnosed at the age of social history patient works as a telemarketer parents are divorced patient goes back and forth between their houses patient has too much etoh use according to father smokes mj and a pack of cigarettes per day unclear if she uses other drugs family history non contributory physical exam vs temp bp hr rr o sat gen intubated slightly agitated moving all four limbs no purposeful movement heent pupils equal and reactive anicteric mmm op without lesions erythema around earlobe resp cta b l with good air movement throughout cv rr s and s wnl no m r g abd nd b s soft nt no masses or hepatosplenomegaly gu femoral line in right groin c d i patient menstruating ext no c c e skin no rashes no jaundice neuro intubated sedated as above spontaneous movements withdraws to pain in all four extremities pertinent results 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 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 pt ptt inr pt am blood pt ptt inr pt am blood fibrino pm blood fdp pm blood esr am blood ret aut 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 am blood alt ast ld ldh ck cpk alkphos totbili am blood ctropnt am blood ck mb mb indx am blood ck cpk am blood albumin calcium phos mg am blood calcium phos mg am blood caltibc ferritn trf am blood hba c am blood osmolal pm blood osmolal am blood acetone large pm blood acetone neg am blood acetone small pm blood acetone negative pm blood tsh pm blood t free t am blood cortsol am blood cortsol pm blood cortsol pm blood hcg pm blood anca negative b pm blood negative pm blood rheufac crp am blood c c pm blood asa neg am blood asa ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg am blood type po pco ph caltco base xs comment green ntop am 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 rates tidal v fio po pco ph caltco base xs intubat intubated am blood type art tidal v peep fio po pco ph caltco base xs intubat intubated vent spontaneou pm blood type art temp fio po pco ph caltco base xs intubat not intuba alcohol profile test result reference range ethanol isopropanol methanol none detected acetone b glucan 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 pm aspergillus galactomannan antigen test result expected values aspergillus ag s index pm ct abdomen w o contrast ct pelvis w o contrast impression bilateral pleural effusions with likely aspiration and developing consolidation at the right lung base free fluid tracking along the paracolic gutter with associated bowel wall thickening the possibility of ischemic bowel is raised given the recent hypotensive episode infectious and inflammatory etiologies also should be considered no dilated loops or pneumatosis likely biliary sludge pm abdomen u s complete study impression fluid collection within the pelvis of unknown source a ct is recommended for further evaluation to exclude the presence of an abscess chest portable ap am findings the tip of the ett is cm above the carina an ngt is visualized below the diaphragm with its tip in the body of the stomach compared to the prior study there is continued distention of pulmonary vessels the latter appear more prominent but positioning differences could be contributory no definite new consolidations pm ct head w o contrast ct head there is no evidence of acute intracranial hemorrhage edema mass mass effect hydrocephalus or of large vascular territory infarction in particular the white matter differentiation appears to be preserved the basal cisterns are also preserved fluid is seen within the mastoid air cells a small amount of mucosal thickening and layering fluid is also noted in the sphenoid sinuses these likely relate to recent intubation impression no ct evidence of acute intracranial process however as ct would not be sensitive to early or less extensive anoxic brain injury followup would be recommended as clinically indicated pm ct chest w o contrast impression multifocal pneumonia no evidence of ards pulmonary embolism cannot be excluded by this non contrast examination but findings do not suggest pulmonary infarctions hilar adenopathy small bilateral pleural effusions probably reactive to pulmonary infection pm mr head w o contrast impression no acute infarction punctate focus of susceptibility in the right anteroinferior frontal lobe which can represent small focus of early calcification or microhemorrhage subcortical in location moderate amount of fluid versus mucosal thickening in the mastoid air cells on both sides sphenoid sinus and minimal in the right maxillary sinus additional details the study was reviewed with dr by dr on at pm as the clinical team was concerned about possible diffuse cortical hyperintensity on dwi related to hypoxic injury apparently the areas that were of concern appear to be related to artifacts from brain bone interface in the left inferior frontal lobe series im and as a continuous rim in the peripheral cortex which is not hyperintense enough on dwi to be called as abnormal and does not have associated corresponding abnormality on adc and flair hyperintensity opinion was also sought from senior radiologists of the section who agreed that these were artifacts and do not represent acute infarction so based on the present study there is no evidence of acute infarction if there is continued concern about encephalopathic changes or infarction a follow up study can be considered at clinical discretion eeg study date of object unresponsive r o seizures impression this is an abnormal portable eeg due to the abnormal background consisting of low voltage fast beta frequency activity with admixed slower beta and delta frequencies along with bursts of moderate amplitude generalized slowing this constellation of findings is consistent with a mild to moderate global encephalopathy suggesting dysfunction of bilateral subcortical or deeper midline structures medications metabolic disturbances and infection are among the common causes of encephalopathy but there are others the widespread beta frequency activity likely reflects medication effects from concomitant propofol administration there were no areas of prominent focal slowing although encephalopathic patterns can sometimes obscure focal findings there were no clearly epileptiform features and no electrographic seizure activity was noted 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 left ventricular wall thicknesses and cavity size are normal due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded overall left ventricular systolic function is low normal lvef there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation no masses or vegetations are seen on the aortic valve the mitral valve appears structurally normal with trivial mitral regurgitation no mass or vegetation is seen on the mitral valve the estimated pulmonary artery systolic pressure is normal no vegetation mass is seen on the pulmonic valve there is no pericardial effusion impression no valvular vegetations seen pm ct chest w o contrast impression worse multifocal peribronchial nodular opacities with increasing large bilateral pleural effusions and bibasilar atelectasis multifocal pneumonia remains the likely etiology the distribution and morphology are not typical for pulmonary infarction or septic emboli which are differential considerations tee no spontaneous echo contrast or thrombus is seen in the body of the left atrium left atrial appendage or the body of the right atrium right atrial appendage no atrial septal defect is seen by d or color doppler overall left ventricular systolic function is 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 to cm from the incisors the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation no masses or vegetations are seen on the aortic valve there are filamentous strands on the aortic leaflets consistent with lambl s excrescences normal variant seen on clips and the mitral valve leaflets are structurally normal no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen no vegetation mass is seen on the pulmonic valve there is no pericardial effusion impression no echocardiographic evidence of endocarditis abscess or valvular mass normal biventricular function mild mitral and tricuspid regurgitation brief hospital course year old woman with dm who presented with severe dka and unresponsiveness hospital course by problem acidemia dka the patient had persistent acidemia thought to be due to a combination of dka and acute renal failure she was continued on an insulin drip and her anion gap began to resolve however her acidemia persisted as her renal function worsened and she was started on a bicarb drip once her cr peaked and her renal functioned began to improve her acidemia began to resolve she did have recurrence of her ag on and had ketones in her blood but this trended down as a d drip was started her metabolic acidosis resolved and the bicarb drip was weaned off by and she was extubated d drip was stopped as the patient was extubated and was able to eat she was transitioned from an insulin drip to sc insulin on with nph in the afternoon and lantus qhs recs with iss once off the insulin gtt she was called out to the floor where her insulin regimen was adjusted by daily to meet her requirements she was discharged on a lispro sliding scale with units of lantus in the evenings she was seen by a dietician prior to discharge to review diabetic dietary restrictions her insulin sliding scale was also reviewed neurologic status on admission the patient was minimally responsive to painful stimuli and only moving her extremities without crossing the midline there was concern for anoxic brain injury given her period of hypotension other etiologies of altered mental status considered included uremia infection acidemia ct head was unremarkable neurology was consulted mri obtained on showed no evidence of infarct csf at the osh was unrevealing hsv pcr also was negative so acyclovir was d c ed eeg was unrevealing over the course of the first week sedation was weaned daily for evaluation she began to have more spontaneous movements and by around hospital day her extremity movements crossed the midline and she was pulling at the et tube as her renal function and acidemia improved her ms improved daily and she began to answer yes and no questions and follow commands by days on she was extubated successfully and subsequently was able to follow commands and converse her neurologic status improved to her baseline per her family at discharge she was ambulating without any assistive devices a behavioral neurology follow up appointment was scheduled for the patient respiratory failure the patient had been intubated at the osh for altered mental status she had been started on vancomycin ceftriaxone at the outside hospital for possible pneumonia vancomycin was continued dosed by level due to renal failure but ceftriaxone was held she remained afebrile a cxr on was concerning for a lll infiltrate so a chest ct was obtained which showed development of most likely a multifocal pna v inflammatory disease anca rf returned neg bal was performed but only grew yeast cefepime was added to broaden coverage for gnrs after repeat ct showed worsening of the multifocal pneumonia flagyl was added to cover for oral organisms out of concern for aspiration pneumonia however this was stopped on out of concern for drug rash clinically she improved and remained afebrile she was extubated on and was breathing well on ra she had a b glucan which was elevated so id was consulted to help interpretation and the test was repeated and though positive felt to be unconcerning by the infectious disease team id also recommended changing cefepime to ciprofloxacin out of concern for drug rash this was switched though likely the drug rash was just remnants from the flagyl drug rash the patient completed a fourteen day course of antibiotics for likely ventilatory associated pneumonia a picc line was placed while the patient was on the general medicine floor to facilitate ease of administration of her intravenous antibiotics it was discontinued on the day of discharge renal failure the patient presented with acute renal failure thought due to atn from hypotensive shock her cr peaked at and then trended down she always maintained at least a uop of cc hr renal was consulted and felt her renal failure was most likely secondary to hypoperfusion injury her creatinine continued to improve and was within normal limits at discharge from the hospital monitor renal labs and urine output volume overload the patient required volume resuscitation and many ivfs due to insulin sedation and bicarb drips she was grossly overloaded perhaps positive l in consultation with renal she was started on a lasix drip and diuresed well as her renal function improved she began to autodiurese and was transitioned to prn iv lasix for goal l once the patient began to ambulate she started to autodiurese and had significantly improved anasarca at discharge anemia the patient s hct slowly trended down from to and then remained stable there was no clear source of bleed her hct drop was felt to be due to a combination of frequent blood draws chronic inflammation and impaired ability to produce more rbcs iron studies were consistent with anemia of chronic inflammation her hematocrit remained stable throughout her admission she was advised to follow up with her primary care physician fen the patient initially received gluten free tube feeds while intubated per nutrition recs once extubated she passed a speech and swallow evaluation and her diet was advanced to diabetic gluten free diet dietary recommendations were made prior to discharge the patient was discharged with close follow up at clinic for further management of her diabetes she also received one month supply of her medications from pharmacare pending approval of her insurance application which case management had been assisting with while the patient was in house medications on admission lantus u qhs humalog sliding scale discharge medications hexavitamin tablet sig one cap po daily daily disp capsules refills insulin glargine unit ml solution sig twenty four units subcutaneous at bedtime disp qs qs refills humalog unit ml solution sig as directed units subcutaneous qachs please use according to sliding scale disp qs qs refills test strips please dispense one touch test strips quantity refills three discharge disposition home discharge diagnosis primary diabetic ketoacidosis septic shock ventilator associated pneumonia acute renal failure discharge condition stable afebrile with stable vital signs discharge instructions you were admitted to the hospital with diabetic ketoacidosis while you were in the hospital you developed a pneumonia you were treated with antibiotics you completed a course of antibiotics while in the hospital it is extremely important that you take your insulin as prescribed and follow your fingersticks if for any reason you are unable to take your insulin please call your physicians as soon as possible if your fingersticks are below or above please call your physician carry either candy or glucose tablets with you for times when your glucose is below please use your incentive spirometer as directed please call your physician or come to the emergency room with any fevers chills increasing cough or extreme fluctuations in your glucose levels followup instructions please follow up at the clinic on at pm with dr provider md phone date time,"{
""Diagnoses"": [""Dka"", ""Ams"", ""Intubation""],
""Medications"": [""Penicillins"", ""Flagyl""]
}"
98871,admission date discharge date date of birth sex m service medicine allergies prozac attending chief complaint alcohol intoxication fall major surgical or invasive procedure none history of present illness this is a year old male with a history of etoh abuse who presents to the ed after being found unresponsive at his home per the reports of his friend roommate he appeared normal when she returned from work and went outside to smoke a cigarette on returning she found him slumped in a chair and then fell onto the carpeted floor she was unable to arouse him was able to find a pulse but wasn t sure if he was breathing and called ems he was found to have respiratory depression and was given narcan at that time and per report became more responsive with spontaneous respirations never requiring intubation according to his friend he has had a long term alcohol problem and has been in detox on multiple occasions the most recent sometime late early he has been seen at for alcohol intoxication in the past he most recently has been very depressed though she denies his mention of suicidal ideation after his father was diagnosed with rhabdomyosarcoma of the lung also recently divorced on arrival to the ed his vitals were af on ra he did not require intubation but had end tidal co monitoring which was normal ct head and c spine were performed and showed no acute injury bleed or fracture etoh level was found to be per ed report he was awake and alert x at the time of transfer upon arrival to the icu the patient is alert and oriented x he denies symptoms of withdrawal states that he feels well denies suicidal ideation states that he drank approx pint of vodka today otherwise he has intermittent binges but usually only has glass of wine with dinner he denies any prior hospitalizations for alcohol intoxication he denies ever having sx of withdrawal including seizures ros the patient denies any fevers chills nausea vomiting abdominal pain diarrhea constipation chest pain shortness of breath cough urinary frequency lightheadedness gait unsteadiness focal weakness vision changes headache rash or skin changes past medical history alcohol abuse alcoholic hepatitis social history as above heavy drinker for many years in and out of detox heavy tobacco use works as a researcher at lives with close friend who is also his collegue recent divorce family history father rhabdomyosarcoma of lung no heart disease or other cancers physical exam tmax c f tcurrent c f hr bpm bp mmhg rr insp min spo ra heart rhythm sr sinus rhythm wgt current kg admission kg height inch gen well appearing no acute distress conversive heent eomi perrl sclera anicteric no epistaxis or rhinorrhea mmm op clear neck no jvd carotid pulses brisk no bruits no cervical lymphadenopathy trachea midline cor rrr no m g r normal s s radial pulses pulm lungs ctab no w r r abd soft nt nd bs no hsm no masses ext no c c e no palpable cords neuro alert oriented to person place and time though speaks slowly cn ii xii grossly intact moves all extremities strength in upper and lower extremities nl finger to nose skin no jaundice cyanosis or gross dermatitis no ecchymoses pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap pm blood alt ast ld ldh ck cpk alkphos totbili pm blood ctropnt am blood calcium phos mg am blood ethanol pm blood asa neg ethanol acetmnp neg bnzodzp neg barbitr neg tricycl neg pm blood glucose lactate ct head prelim no intracranial hemorrhage or mass effect stable mm hypodensity of left cerebral white matter unchanged since ct spine impression no acute fracture or malalignment brief hospital course assesment this is a yo m with hx of alcohol abuse presenting with respiratory depression secondary to alcohol intoxication with etoh level of now with normalization of respiratory status without need for intubation mechanical ventilation plan alcohol abuse intoxication on arrival to the ed his vitals were af on ra he did not require intubation but had end tidal co monitoring which was normal ct head and c spine were performed and showed no acute injury bleed or fracture etoh level was found to be per ed report he was awake and alert x at the time of transfer upon arrival to the icu the patient is alert and oriented x he denies symptoms of withdrawal states that he feels well denies suicidal ideation states that he drank approx pint of vodka today otherwise he has intermittent binges but usually only has glass of wine with dinner he denies any prior hospitalizations for alcohol intoxication he denies ever having sx of withdrawal including seizures pt denies prior hospitalizations however per friend he has been hospitalized in the past and participated in rehab no reported hx of alcohol withdrawal or seizures denies daily alcohol ingestion pt had pint of vodka pta denies si etoh level pt was been stable overnight and was monitored on a ciwa scale but only recieved mg ativan for sleep pt was given thiamine folate mvi pt oriented and mentating at baseline in the am no signs of acute intoxication pt was offered sw and resources for alcohol abuse but declined pt states hewill follow up at his work at respiratory depression pt back to baseline respiratory status at admission to icu end tidal co monitoring was normal in the emergency department the patient s tox screen was negative so presumably related etoh overdose which is most likely given level pt is awake and alert pt off nc and back to baseline in the morning depression the patient s friend describes his depression as severe the patient was offered social work consultation and or psych but declined the patient denied si hi he expressed sadness over his father s recent diagnosis and reports drinking excessively in response to this the patient states that he will see psych at transaminitis the patient reports he has alcoholic hepatitis he denies a h o viral hepatitis and states he was vaccinated for hep b the patient has mildly elevated lft alt ast the patient is being followed by his pcp fen regular diet replete lytes as needed access piv ppx heparin sc bowel regimen code full confirmed with patient and icu consent signed dispo if patient is able to ambulate tolerate po shows no active signs of intoxication or withdrawl can be discharged will arrange transport for the patient home pt was offered resources but declined comm dr cell medications on admission none discharge disposition home discharge diagnosis alcohol abuse intoxication respiratory depression alcoholic hepatitis discharge condition stable ambulating tolerating po diet normotensive oxygenating well on room air discharge instructions it was a pleasure taking care of you at you were admitted to the hospital because of alcohol intoxication and problems breathing however when you arrived in the icu you were back to your baseline respiratory status your alcohol level was elevated in the morning but you did not show signs of acute intoxication you were offered social work and psychiatry but declined please follow the medications shown below please follow up with the appointments made below please call your pcp or go to the ed if you experience worsening headache dizziness loss of conciousness nausea vomiting tremor seizure shortness of breath chest pain increased heart rate fever chills or other concerning symptoms followup instructions please follow up with your pcp in week you can schedule an appointment by calling completed by,"{
""Diagnoses"": [""Alcohol intoxication"", ""Respiratory depression"", ""Narcan administration""],
""Medications"": [""Prozac""]
}"
96537,admission date discharge date date of birth sex f service surgery allergies no known allergies adverse drug reactions attending chief complaint cholangitis biliary obstruction major surgical or invasive procedure placement of left external biliary drain placement of right internal external biliary drain and internalization of left biliary drain history of present illness ms is a year old female transferred from osh w persistent cholangitis biliary obstruction s p stent x for malignant biliary stricture at level of common hepatic duct extending to hilum she was in usual state of health prior to when she noted gradual onset nausea abdominal discomfort and unintentional pound weight loss this progressed to jaundice prompting admission to osh and diagnosis of stricture on ruq us on she at osh with sphincterotomy she was transferred to on for repeat by dr who replaced stent for finding of mm common hepatic duct stent and obtained brushings which ultimately revealed atypical cells she was discharged from the osh on but returned to osh ed withchills rigors and fever to on ct scan was obtained findings below and transferred to for repeat which found purulence at cbd orifice at that time the stent was replaced for finding of worsening chd stricture wire was placed into the rh system after the stent placement a second wire placed into the left hepatic system wire was unable to reach the dominant branch following return to osh ms was still febrile to transferred to the hepatobiliary service for management of her refractory stricture past medical history essential thrombocytosis hx l breast ca s p lumpectomy axillary lymoh node dissection chemoxrt r breast dcis s p lumpectomy xrt fibromyalgia djd hld depression anxiety mitral valve prolapse social history lives with husband as ophthalmology technician denies tobacco etoh and recreational drugs family history mother breast ca age father gastric ca age four sisters w breast ca siblings w melanoma physical exam vs t p bp rr o sat ra gen nad aox wn f in nad heent eomi cv rrr pulm cta b l no respiratory distress abd soft mild ruq tenderness to moderate palpation nd no mass no hernia right and left ptbd in place capped surrounding skin without erythema dressings c d i ext wwp no cce neuro a ox no focal neurologic deficits pertinent results common bile duct brushings negative for malignant cells common bile duct stent negative for malignant cellss rare groups of reactive and degenerated epithelial cells numerous neutrophils bile pigment and bacteria common bile duct brushing atypical rare group of atypical epithelial cells in a background of benign appearing ductal epithelial cells cxr impression pa and lateral chest compared to through small bilateral pleural effusions and severe bibasilar atelectasis are unchanged since upper lungs are clear heart size normal no pneumothorax impression successful uncomplicated internalization of the external drain left in the left biliary system an french internal external percutaneous transhepatic biliary drain was placed successful uncomplicated placement of a new french percutaneous transhepatic biliary drain through the right anterior system with the pigtail locked in the duodenum cxr findings in comparison with the study of the endotracheal and nasogastric tubes have been removed the patient has taken a much better inspiration there is continued bibasilar opacification most likely consistent with pleural fluid and compressive atelectasis more prominent on the right the possibility of supervening pneumonia would certainly have to be considered in the appropriate clinical setting no evidence of pulmonary edema biliary endoscopy impression high grade obstruction at the level of the hepatic confluence left moderate to severe biliary dilatation no right biliary dilatation plastic stent in place brushing of the hepatic confluence placement of french external drain in the left biliary ductal system ct abdomen with and without contrast final report history year old female with a history of biliary stricture status post and stent placement and persistent cholangitis now status post left external percutaneous biliary drain study cta of the abdomen with and without contrast mdct images were generated through the abdomen without iv contrast subsequent mdct images were generated through the abdomen after the uneventful iv administration of omnipaque intravenous contrast in the arterial venous and three minute delayed phases coronal and sagittal reformatted images were generated in the arterial and venous phases comparison outside hospital ct of the abdomen findings small bilateral pleural effusions consisting of minimally complex pleural fluid are present with associated compressive atelectasis these are new compared to prior exam an endogastric tube courses into the stomach a cbd stent is in place there has been interval placement of a percutaneous biliary drain from a left sided approach its course demonstrates either possibly a kinked contour or a sharp bend around a drainage hole and a the liver demonstrates definite improvement of the intrahepatic biliary dilatation periportal edema is still present the gallbladder shows no definite evidence of stones or wall edema the spleen is normal in size and appearance the pancreas shows no ductal dilatation peripancreatic inflammation or hypoenhancement however a small amount of peripancreatic fluid or hypodense tissue is present and while is not definitely organized it does not appear to have appreciable fat stranding associated with it the visualized portion of the small and large bowel show no evidence of obstruction or wall edema the kidneys enhance with and excrete contrast symmetrically without evidence of a mass or hydronephrosis a subtle area of cortical thinning in the mid pole of the left kidney may represent an area of prior infection or infarct a subtle perinephric fat stranding is present on the right likely reactive in nature there is no free air or lymphadenopathy cta the aorta is of a normal caliber along its course the celiac artery demonstrates conventional branching pattern with a patent hepatic artery branching to both the right and left lobes the renal arteries sma and common iliac arterial branches are widely patent there is no evidence of a pseudoaneurysm ctv the hepatic veins are patent the portal vein splenic vein and smv are patent the renal veins are patent bilaterally bones no aggressive appearing lytic or sclerotic lesion is present mild to moderate degenerative changes are seen throughout the visualized portion of the spine primarily in the form of endplate sclerosis and small osteophytes impression small bilateral pleural effusions with associated atelectasis status post left percutaneous biliary drain placement with marked improvement of intrahepatic biliary dilatation questionable area of kinking within its course as described above patent hepatic arterial and venous vasculature small amount of fluid or hypodense soft tissue around the pancreas without appreciable surrounding inflammation may represent sequela of prior pancreatitis post surgical change adenopathy or mass endoscopic ultrasound and biopsy may be considered brief hospital course ms was admitted to west surgery team on she placement of a left side external biliary drain on this was complicated by difficult intubation aspiration event and subsequent admission to the icu she was weaned off ventilation and repeat cxr on showed resolution of her right side opacity she was on room air following her extubation and icu stay she had no further respiratory issues during her hospital stay on ms placement of a right side internal external biliary drain and internalization of her left side biliary drain she tolerated this well she was afebrile with stable vital signs for the remainder of her hospital stay her biliary drains were capped on which she tolerated well she was discharged home with vna on medications on admission hydroxyurea qod fluoxetine mg po q day asa mg q day discharge medications fluoxetine mg capsule sig two capsule po daily daily mirtazapine mg tablet sig one tablet po hs at bedtime docusate sodium mg capsule sig one capsule po bid times a day senna mg tablet sig one tablet po daily daily hydroxyurea mg capsule sig one capsule po every other day every other day acetaminophen mg tablet sig two tablet po q h every hours as needed for pain oxycodone mg tablet sig one tablet po q h every hours as needed for pain at drain sites do not drive while on this medication use an over the counter stool softener such as colace while on this medication disp tablet s refills ciprofloxacin mg tablet sig one tablet po q h every hours disp tablet s refills aspirin mg tablet delayed release e c sig one tablet delayed release e c po once a day discharge disposition home with service facility vna of central discharge diagnosis biliary stricture discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you placement of an external left biliary drain on on you placement of a right biliary drain that has an internal and external component at the same time you also had internalization of the left drain your bile is draining from your right and left liver into your small bowel both drains should remain capped please call dr office if you have temperature of or greater chills nausea vomiting jaundice increased abdominal pain drain sites appear red or have drainage constipation diarrhea or drain sutures fall or stat lock falls off visiting nurse services have been arranged followup instructions rn coordinator for dr will call you on monday with a follow up appointment next week appointment will likely be on wednesday provider st gi rooms date time provider md phone date time md completed by,"{
""Diagnoses"": [""cholangitis"", ""biliary obstruction"", ""malignant biliary stricture""],
""Medications"": [""stent"", ""sphincterotomy"", ""brushings"", ""antibiotics"", ""pain medication""]
}"
98344,admission date discharge date date of birth sex m service cardiothoracic allergies codeine bactrim zyban flomax iodine containing agents classifier flexeril doxazosin lisinopril attending chief complaint abdominal pain major surgical or invasive procedure emergent repair of ruptured thoracoabdominal aortic aneurysm with a mm dacron tube graft from just beyond the left subclavian artery takeoff all the way down to the mid visceral bearing segment of the abdominal aorta using deep hypothermic circulatory arrest and a separate side branch to revascularize the celiac artery the graft data is the following vascutek gelweave graft reference lot serial tracheostomy percutaneous gastrostomy debridement of open wound left scapular region with debridement of muscle subcutaneous tissue and skin latissimus flap reconstruction history of present illness this year old male has a known thoracoabdominal aneurysm and a two day history of abdominal pain he presented to hospital and had a cta which revealed a contained thorocoabdominal rupture he was transfered to for surgical evaluation past medical history bph diabetes hypercholesterolemia hypertension v tach lung nodules aaa pad nodular thyroid complex renal cyst tendon cyst cerebrovascular disease colitis impotence inguinal hernia insomnia rectal polyp right bundle branch block asbestos exposure h o hyponatremia h o tobacco abuse turp excision hydrocele excision spermatocele social history former smoker x years quit years ago no etoh married with adult children retired family history non contributory physical exam pe on admission vs afebrile hr s bp s s rr gen nad aox neck trachea midline neck supple palpable carotid pulses cvs rrr no m r g pulm no resp distress abd s nd min ttp to deep palpation pulsatile mass upper abdomen consistent with known aaa le no lle edema warm lack of hair distal le bilaterally pulse rle femoral palpable dp pt dop lle femoral palpable dp pt p dop 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 inr pt am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap pm blood alt ast ld ldh alkphos amylase totbili am blood alt ast ld ldh alkphos amylase totbili 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 m indication atrial fibrillation endocarditis mitral valve disease source of embolism icd codes test information date time at interpret md md test type tee complete son doppler full doppler and color doppler test location west echo lab contrast none tech quality adequate tape w machine vivid i echocardiographic measurements results measurements normal range findings left atrium no spontaneous echo contrast or thrombus in the la laa or the ra raa good cm s laa ejection velocity right atrium interatrial septum no asd by d or color doppler left ventricle overall normal lvef right ventricle normal rv chamber size and free wall motion aortic valve mildly thickened aortic valve leaflets no masses or vegetations on aortic valve trace ar mitral valve mildly thickened mitral valve leaflets no mass or vegetation on mitral valve trivial mr tricuspid valve normal tricuspid valve leaflets no mass or vegetation on tricuspid valve mild tr pulmonic valve pulmonary artery normal pulmonic valve leaflets no vegetation mass on pulmonic valve physiologic normal pr pericardium no pericardial effusion general comments informed consent was obtained a tee was performed in the location listed above i certify i was present in compliance with hcfa regulations the patient was monitored by a nurse throughout the procedure local anesthesia was provided by benzocaine topical spray echocardiographic results were reviewed with the houseofficer caring for the patient conclusions no spontaneous echo contrast or thrombus is seen in the body of the left atrium left atrial appendage or the body of the right atrium right atrial appendage no atrial septal defect is seen by d or color doppler the thoracoabdominal aortic graft is intact up to cm from the incisors overall left ventricular systolic function is normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve trivial mitral regurgitation is seen no vegetation mass is seen on the pulmonic valve there is no pericardial effusion impression no evidence of intracardiac thrombus pfo or asd seen no echocardiographic evidence of endocarditis seen intact thoracoabdominal graft from the anastomosis site just below the left subclavian up to cm from the incisors was notified in person of the results i certify that i was present for this procedure in compliance with hcfa regulations electronically signed by md interpreting physician m radiology report cta head w w o c recons study date of am csru am cta head w w o c recons cta neck w w oc recons clip reason r o basilar infarct medical condition year old man with thorocoabdominal aneurysm repair reason for this examination r o basilar infarct contraindications for iv contrast none final report study cta of the head and cta of the neck clinical indication year old man with history of thoracoabdominal aneurysm repair rule out basilar infarct comparison prior mri of the head dated technique contiguous axial mdct images were obtained through the brain without contrast material subsequently rapid axial imaging was performed from the aortic arch through the brain during the infusion of omnipaque intravenous contrast material images were then processed on a separate workstation with display of curved reformats d volume rendered images and maximum intensity projection images findings head ct there is no evidence of acute intracranial hemorrhage mass effect or shifting of the normally midline structures vague areas of low attenuation are noted in the centrum semiovale likely representing edema or areas of small vessel disease previously demonstrated by mri of the brain on the bone structures are grossly unremarkable the patient is intubated the orbits and mastoid air cells as well as the paranasal sinuses are grossly normal head cta there is vascular enhancement along the internal carotid arteries with no evidence of critical stenosis throughout the anterior middle and posterior cerebral arteries the basilar artery appears patent with codominance of the vertebral arteries no aneurysms larger than mm in size are seen cta of the neck the origin of the supra aortic vessels appears normal with no evidence of critical stenosis including the cervical carotid bifurcations the left carotid bifurcation demonstrates mild irregular contour at the posterior wall of the left internal carotid artery consistent with soft plaque material both vertebral arteries are patent there is no evidence of dissection the bony structures demonstrate multilevel degenerative changes throughout the cervical spine with anterior and posterior spondylosis more severe at c c c c and c c levels impression there is no evidence of acute or subacute intracranial hemorrhage or mass effect vague areas of low attenuation are identified in the subcortical white matter likely representing areas of small vessel disease and subacute ischemic changes previously noted on mri of the head dated there is no evidence of flow stenotic lesions in the circle of the basilar artery appears patent with codominance of the vertebral arteries the neck vessels demonstrate mild irregular contour in the posterior wall of the left internal carotid artery at the cervical bifurcation likely consistent with soft plaques however there is no evidence of significant stenosis these findings were communicated to dr in person by dr on at hours dr approved tue pm imaging lab there is no report history available for viewing caregroup is all rights reserved brief hospital course year old male with abdominal pain and cta demonstrating thoracic aortic aneurysm descending to level of celiac artery with contained rupture into lateral wall at level of diaphragm on he was taken to the or for an emergent repair of ruptured thoracoabdominal aortic aneurysm with a mm dacron tube graft from just after the left subclavian artery takeoff all the way down to the mid visceral bearing segment of the abdominal aorta using deep hypothermic circulatory arrest and a separate side branch to revascularize the celiac artery the graft data is the following vascutek gelweave graft reference lot serial co surgeons m d and m d cardiopulmonary bypass time minutes the visceral ischemic time was minutes circulatory arrest time minutes please see operative report for further surgical details he was transferred intubated and sedated to the cvicu requiring pressor support in critical condition in summary he had a very complicated postoperative course due to cerebral and spinal infarcts with scans showing multiple areas of slow diffusion predominantly in left parietal and occipital lobe concerning for sub acute infarcts paraplegia s marascens bacteremia with presumed graft infection vap and post op wound infection at the back of the thoracotomy site with coag negative staph the patient had remained intubated until pod rn mr never followed commands for her and noted a change with the lack of gross motor movement of his extremities he was noted not to be moving the lower extremities and had asymmetry in the exam of the arms along with mental status changes after transient episode of hypotension atrial arrhythmia and shocks necessitated he was reintubated mri brain and spine performed mri of brain showed no significant ischemic changes to explain such a poor mentation neurology was consulted and felt imaging findings are consistent with multiple brain infarcts left right and cord infarction likely attributed to perioperative hypotension and aortic manipulations eeg negative anticoagulation was not initially started however after his continued paroxysmal afib and neuro event coumadin was ultimately initiated the patient remains with afluent aphasia and paraplegic mr was taken to the operating room for trach and peg placement on with dr mr postoperative course continued to get more complicated when he became bacteremic id was consulted broad spectrum antibiotics were initiated cultures revealed e coli uti serratia pna and s marascens bacteremia pod from initial ta aaa repair now with ischemic eschar around the inferior portion of the wound general surgery and plastics was consulted it was suspected that the latissimus was perforated below the area of eschar due to the perigraft and surrounding intrathoracic inflammatory changes and fluid evident all teams agreed that debridement was required on mr debridement of open wound left scapular region with debridement of muscle subcutaneous tissue and skin latissimus flap reconstruction please see operative report for further details the patient had a flexiseal in place for several days in the setting of his critical illness hematochezia became evident gi and acs was consulted the patient was scoped by gi who visualized active rectal bleeding and was concerned for perforation on anoscopy likely secondary to flexi seal s p packing seemingly with hemostasis hematocrits remain stable mr began to slowly improve id signed off after recommending antibiotics for wound infection would continue vanco flagyl for weeks from day of debridement for serratia aaa graft infection plan to continue cipro iv for weeks for presumed serratia endovascular infection and will require life long suppression with cipro po after this given presence of graft speech and swallow had been consulted and following throughout mr course he remains npo with continued nutrition hydration and medication via the peg in place he was fitted for a passy muir valve he weaned to trach collar and pmv during the day hours and is rested overnight on cpap after a complicated course from his initial emergent repair of ruptured thoracoabdominal aortic aneurysm mr has made slow progress on the day of his discharge to rehab on he remains paraplegic anticoagulated for paf cva with a jp drain and sutures intact s p thoracoabdominal debridement he is completing his antibiotics per id recs all follow up apppointments were advised medications on admission hydrochlorothiazide mg tab lorazepam mg t tab hs prn pindolol mg tab qd pravastatin mg aspirin mg mvi psyllium powder packet prv ranitidine mg discharge medications aspirin mg chewable one chewable po daily daily docusate sodium mg ml liquid one po bid times a day magnesium hydroxide mg ml suspension thirty ml po daily daily as needed for constipation pravastatin mg one po daily daily ipratropium albuterol mcg actuation aerosol six puff inhalation q h every hours white petrolatum mineral oil ointment one appl ophthalmic prn as needed as needed for unresponsive and eyes open bisacodyl mg suppository one suppository rectal hs at bedtime as needed for constipation insulin regular human unit ml solution one injection every six hours per riss acetaminophen mg two po q h every hours as needed for pain fevers chlorhexidine gluconate mouthwash one ml mucous membrane times a day potassium chloride meq packet one packet po prn as needed lansoprazole mg rapid dissolve dr one rapid dissolve dr daily daily sertraline mg two po daily daily oxycodone mg ml solution one po q h every hours as needed for pain furosemide mg one po three times a day albuterol sulfate mg ml solution for nebulization one inhalation q h every hours ipratropium bromide solution one inhalation q h every hours metoprolol tartrate mg three po tid times a day warfarin mg two po once once for doses heparin porcine pf unit ml syringe one ml intravenous prn as needed as needed for line flush olanzapine mg one po tid times a day as needed for delirium metronidazole in nacl iso os mg ml piggyback one intravenous q h every hours dc ciprofloxacin in d w mg ml piggyback one intravenous q h every hours dc then convert to oral cipro for life vancomycin mg recon soln one recon soln intravenous q h every hours dc warfarin mg daily md once a day discharge disposition extended care facility hospital for continuing medical care center discharge diagnosis ruptured thoracoabdominal aneurysm s p emergent repair cerebral and spinal infarcts scans showing multiple areas of slow diffusion predominantly in l parietal and occipital lobe concerning for sub acute infarcts paraplegia s marascens bacteremia with presumed graft infection vap and post op wound infection at the back of the thoracotomy site with coag negative staph discharge condition afluent aphasia alert oriented x intermittently pt is paraplegic incisional pain managed with oral analgesia incisions thoracotomy jp sutures intact healing well no erythema or drainage discharge instructions for wound infection would continue vanco flagyl for weeks from day of debridement for serratia aaa graft infection plan to continue cipro iv for weeks for presumed serratia endovascular infection will require life long suppression with cipro po after this given presence of graft please check cbc with differential bun creatnine in week and fax results to clinic dr 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 please schedule appointments when you are discharged from rehab with cardiac surgeon dr vascular surgeon dr office will contact you to arrange a follow up appointment cardiologist dr neurology please follow up in the stroke prevention clinic in about months when stable id dr at am at clinic please check cbc with differential bun creatnine in week and fax results to plastics surgery follow up dr suite ma date time at pm please call to schedule appointments with your primary care dr when discharged from rehab 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 paroxysmal afib cva goal inr first draw results to phone fax completed by,{}
13686,admission date discharge date service history of present illness the patient is an year old male with a history of coronary artery disease atrial fibrillation on coumadin gastroesophageal reflux disease who was brought to the emergency department by the emt after he complained of intermittent chest pain for three days nausea and lethargy the patient has had some episodes of constipation as well as dark stools increasing lower extremity edema for the past two to three weeks he denies any vomiting abdominal pain or diarrhea the chest pain resolved after arrival to the emergency department the emts found him to have a heart rate in the s irregular and he was given diltiazem which decreases heart rate to the s electrocardiogram was consistent with rapid atrial fibrillation in the emergency department his heart rate was in the s and electrocardiogram showed atrial fibrillation with inferolateral st segment depressions hematocrit was noted to be his baseline is his stool was black and guaiac positive systolic blood pressure was to nasogastric lavage was performed and noted to be negative the wife reports multiple urinary tract infections since with courses of augmentin keflex and now ciprofloxacin the patient had noted diarrhea in and constipation for the last three to four weeks he denies any dysuria shortness of breath paroxysmal nocturnal dyspnea headache fevers chills or coughs he has noted increasing lower extremity edema and weight gain since early he manages with an increased lasix dose he also noted an increased blood sugar over the weekend and his wife gave him glyburide past medical history atrial fibrillation on coumadin noninsulin dependent diabetes mellitus coronary artery disease myocardial infarction x with stents to his lad x and circumflex in atrial stenosis congestive heart failure with an ejection fraction of to status post cea on the right gastroesophageal reflux disease status post abdominal hernia repair recurrent urinary tract infection umbilical hernia repair in gout allergies levaquin causes high inr captopril causes low blood pressure he is questionably allergic to celexa and zoloft medications allopurinol mg po q day lipitor mg po q hs lasix mg po qd aspirin mg po qd potassium chloride milliequivalents prevacid mg q day aldactone mg q day flomax mg q hs iron sulfate mg po qd coumadin mg alternating with mg q day calcium multivitamin tablet vitamin e social history the patient lives with his wife denies any alcohol use he has a remote smoking history family history noncontributory physical exam vital signs temperature pulse blood pressure respiratory rate o saturation on liters general he is a pale alert elderly gentleman in no acute distress head ears eyes nose and throat head is normocephalic atraumatic pupils equal round and reactive to light conjunctivae is pale mouth and oropharynx are clear without any erythema or exudate neck supple there is no lymphadenopathy pulmonary he has deep bibasilar rales no wheezes cardiovascular irregularly irregular with systolic ejection murmur at the right upper sternal border abdomen soft nontender nondistended with palpable liver edge approximately cm below the costophrenic angle extremities edema to the knees feet are warm with no palpable pulses rectal per the emergency department is black ob is positive labs white cell count hematocrit platelets his hematocrit on discharge was pt inr ptt creatinine bun troponin on admission was imaging electrocardiogram showed atrial fibrillation with heart rate in the s chest x ray showed cardiomegaly with mild congestive heart failure linear opacities in the mid right lung no change from assessment this is an year old man who presents with a history of coronary artery disease rapid atrial fibrillation who presents with severe anemia and guaiac positive stool consistent with a gastrointestinal bleed hospital course gastrointestinal the patient was admitted to the medical intensive care unit with a hematocrit of thought to be secondary to an active gastrointestinal bleed nasogastric lavage was negative in the emergency department but he was noted to have dark black melanotic guaiac positive stools the gastroenterology team was consulted and they initially recommended transfusing to keep his hematocrit over with plans for endoscopy when he troponin decreased he was transfused units of packed red blood cells initially with an adequate increase in his hematocrit he underwent an esophagogastroduodenoscopy on hospital day which showed gastritis because his hematocrit continued to trend downward the patient underwent a colonoscopy to rule out a lower gastrointestinal bleed colonoscopy showed a few diverticula as well as a single mm nonbleeding polyp of benign appearance which was removed for biopsy he was also noted to have some diverticulosis of the sigmoid colon his hematocrit has been subsequently stable with no evidence of active gastrointestinal bleeding hematology the patient was admitted with a hematocrit of thought to be secondary to a gastrointestinal bleed in the setting of a supratherapeutic inr he was given a dose of vitamin k subcutaneously to reverse his inr and his coumadin withheld throughout his hospitalization he was transfused periodically to keep his hematocrit above given his history of coronary artery disease his hematocrit was stable upon discharge and his coumadin was restarted upon discharge cardiovascular he was found to be in atrial fibrillation with rapid ventricular response that slowed with diltiazem troponins were elevated with flat cks this was felt to be secondary to demand ischemia in a setting of an acute blood loss his troponin was trending downward and given a history of coronary artery disease a persantine thallium was performed for further risk stratification the study showed global hypokinesis with an ejection fraction of and a severe fixed defect in the distal anterior apical myocardial wall he was also started on lasix and aldactone as he was felt to be in congestive heart failure renal his increased creatinine on admission was felt to be secondary to intervascular depletion given his blood loss and his creatinine decreased with blood transfusions and intravenous fluids infectious disease the patient had a history of recurrent urinary tract infection a routine urinalysis was sent and noted to be negative the patient was afebrile and his white cell count was stable throughout his hospitalization disposition the patient has been severely deconditioned over the past few months given his multiple hospitalizations and his comorbidities he was screened by the physical therapy team who recommended a short term stay in rehabilitation prior to being discharged to home discharge medications digoxin mg po q day lipitor mg po q day protonix mg po q day iron sulfate mg po q day multivitamin tablet tablet po q day allopurinol mg po q day flomax mg po q hs lasix mg po q day spironolactone mg po q day colace mg po bid coumadin mg po q day with potentially variable doses related to his inr levels m d dictated by medquist d t job [NEW_RECORD] admission date discharge date service medicine history of present illness the patient is an year old male with severe aortic stenosis with an aortic valve area of square centimeters coronary artery disease status post stent placement in complicated by in stent restenosis in who was admitted to on with right lower quadrant pain he was diagnosed with a right lower quadrant abscess possibly related to diverticulosis and underwent percutaneous drainage on cultures grew out a mixture of alpha streptococcus and streptococcus milleri haemophilus and d fragilis the patient was initially treated at that time with ampicillin gentamicin and flagyl and was subsequently changed to unasyn after the patient s abdominal drain was removed the patient was sent to rehabilitation the patient completed his course of unasyn on within the next hours the patient developed recurrent fevers while at rehabilitation on the patient was admitted to for investigation of recurrent right lower quadrant pain ct scan revealed a by centimeter fluid pocket in his right lower quadrant this fluid pocket communicated with the skin by a sinus tract from the prior drain physical examination on physical examination on admission the vital signs were notable for a temperature of heart rate was in the s the blood pressure was the patient was saturating in room air in general the patient appeared weak and ill appearing the patient s head eyes ears nose and throat examination was notable for a normocephalic and atraumatic head the extraocular movements were intact the neck was supple without lymphadenopathy the lung examination revealed lungs which were clear to auscultation bilaterally cardiovascular examination revealed an irregular pulse irregular heart sounds with a iii vi systolic crescendo decrescendo murmur at the right upper sternal border abdominal examination revealed positive bowel sounds soft mildly distended abdomen with the right lower quadrant tenderness the extremities showed edema bilaterally neurologically the patient was grossly intact laboratory data on admission laboratory data was notable for a white blood cell count of a hematocrit was the platelet count was the differential was neutrophils and lymphocytes the sodium level was potassium chloride bicarbonate blood urea nitrogen creatinine and the glucose was digoxin level was urinalysis revealed trace blood red blood cells white blood cells and rare bacteria abdominal ct revealed the aforementioned by centimeter fluid collection in the right lower quadrant hospital course the patient was originally admitted to the acove service he underwent a drainage procedure for the right lower quadrant abscess on over the course of his hospitalization on the acove service the patient developed acute renal failure with a rising creatinine to with an admission value of urinary output decreased and the patient developed increasing edema the patient also developed episodes of bradycardia with heart rate dropping to the s initially these episodes of bradycardia were asymptomatic however the patient subsequently developed episodes of recurrent bradycardia with heart rate into the s with these episodes the patient became presyncopal the episodes resolved spontaneously at least once atropine was given but the heart rate did not improve the electrophysiology service was consulted they recommended discontinuation of digoxin which was done the patient developed increasing dyspnea over his hospital course his secretions increased as did his oxygen requirement his respiratory status improved somewhat with an increase in his lasix dosing on the night of the patient developed frequent pauses in his ventricular response to his atrial fibrillation lasting up to six seconds at a time with these pauses in ventricular response the patient was noted to have his eyes rolling back into his head and unresponsiveness at that time the electrophysiology service was reconsulted and the patient was transferred to the for transvenous pacemaker placement a vvi pacemaker was placed externally with a temporary wire to the right ventricle the patient was stable after pacemaker placement in the intensive care unit from the standpoint of his cardiac rhythm the pacemaker was placed externally on the upper right chest wall and was dressed and taped in place the patient s subsequent intensive care unit course was notable for worsening of his respiratory status chest x rays were notable for the appearance of probable multilobar pneumonia the patient s p o intake decreased due to lack of appetite the patient was maintained on intravenous antibiotics permanent pacemaker implantation was deferred because of ongoing questions of infection related to his abdomen and subsequently to his multilobar pneumonia extensive meetings with the patient and his family were held regarding the patient s wishes for continuation of intensive treatment the patient decided that his goals for care were to return to the home deferring more intensive in hospital care for his multiple medical problems the patient decided that he did not want to pursue resuscitation and was made do not resuscitate on further discussions with the patient regarding his prognosis the patient determined that he wished to return home and no longer pursue in hospital care due to the patient s poor prognosis hospice services were determined to be the most appropriate in home care method for the patient and his family at the time of this dictation on the patient is to discharge the patient home with hospice care on discharge status the patient will be discharged to home on with home hospice care discharge diagnoses intra abdominal abscess severe aortic stenosis bradycardia and symptomatic pauses status post vvi external pacemaker atrial fibrillation congestive heart failure pneumonia renal failure medications on discharge morphine to mg q hours sublingual p r n pain or shortness of breath lorazepam to mg q hours sublingual p r n anxiety levsin to mg q hours p r n pulmonary edema nitroglycerin mg sublingual p r n chest pain tylenol mg p o q hours p r n pain trazodone mg p o q h s p r n insomnia protonix mg p o once daily lasix mg p o twice a day discharge diet the patient s discharge diet is a regular diet as tolerated the patient will be discharged with a foley catheter for comfort the patient s discharge services will include home hospice services m d dictated by medquist d t job,"{
""Diagnoses"": [""coronary artery disease"", ""atrial fibrillation"", ""gastroesophageal reflux disease""],
""Medications"": [""coumadin"", ""diltiazem"", ""augmentin"", ""keflex"", ""ciprofloxacin""]
}"
92772,admission date discharge date date of birth sex m service neurosurgery allergies patient recorded as having no known allergies to drugs attending chief complaint struck in the back of the head major surgical or invasive procedure left temporal craniotomy and evacuation of epidural hematoma history of present illness year old man who was witnessed to be struck in the back of the head by an unidentified object in earlier this morning roughly hours ago patient then fell backward striking the occiput ems was called and he was found supine on the ground ems trip sheet not available and initial examination unclear past medical history unknown at present social history only child mother and stepfather from he is a senior family history unknown physical exam physical exam o t f bp hr r o sats gen lying in bed with eyes closed heent scalp laceration over occiput oozing blood neck in hard collar lungs cta bilaterally cardiac rrr s s abd soft nt bs extrem warm and well perfused neuro mental status off sedation does not open eyes to command or follow commands cranial nerves i not tested ii pupils equally round and reactive to light to mm bilaterally iii iv vi gaze is dysconjugate with slight lateral deviation of the left eye unable to perform doll s eyes maneuver due to hard collar v vii grimaces in response to supraorbital stimulation no overt facial droop though somewhat obscured by ett motor withdraws to noxious stimulation throughout no abnormal movements noted sensation as above withdraws to noxious stimulation throughout reflexes b t br pa ac right left toes mute bilaterally pertinent results cardiology report ecg study date of am sinus bradycardia modest early repolarization changes no previous tracing available for comparison ct c spine w o contrast sat am impression no fracture identified relative narrowing of the c spinous processes interspace with relative widening of the anterior intervertebral disc space at this level may be positional ct head w o contrast am non displaced fracture of the squamous part of the left temporal bone left extra axial collection likely epidural hematoma right extra axial blood most likely subarachnoid hemorrhage and or subdural hematoma chest portable ap am et tube terminating cm above the carina the ng tube is high terminating at the level of the diaphragm and should be advanced this was discussed with dr at am on clear lungs ct head w o contrast am marked increase in size of the left epidural hematoma overlying the left temporal lobe with new uncal herniation and increase in rightward subfalcine herniation no interval change in additional foci of extra axial hematoma overlying the right temporal lobe likely also reflecting areas of epidural hematoma ct l spine w o contrast am impression no fracture or malalignment ct t spine w o contrast am no evidence of fracture or malalignment ct head w o contrast pm no interval change in residual left temporal epidural hematoma status post partial evacuation compared to examination from six hours prior no overt interval change of multiple small foci of extra axial hematomas overlying the right frontal lobe which may also reflect smaller areas of epidural hematoma persistent mild shift of normally midline structures to the right of mm ct head w o contrast am status post left temporal craniotomy with stable appearance of the bilateral extra axial temporal hemorrhage and the right frontal extra axial hemorrhage interval improvement in the left uncal herniation unchanged subfalcine herniation brief hospital course pt was admitted through the emergency room after tbi on in the early morning repeat ct scan of the brain showed interval increase in the size of edh he was taken to the or emergently for evacuation his operative and post operative periods were without event he was returned to the icu where he was later extubated he was placed on dilantin on arrival for sz prophylaxis his neuro status was monitroed closely he was placed on one to one observation for safety as he was found to be impulsive and combative after exutbation serial ct scans demonstrated postoperative changes with good decompression of edh he was transferred to step down on he was advanced in his diet and activity and seen and evaluated by pt and ot and recommended for acute rehab his incision was clean and dry he continued on pain medication for incisional pain headache diet was advanced medications on admission unknown discharge medications levetiracetam mg tablet sig one tablet po bid times a day famotidine mg tablet sig one tablet po bid times a day oxycodone acetaminophen mg tablet sig tablets po q hours prn as needed for pain discharge disposition extended care facility discharge diagnosis left temporal edh discharge condition stable discharge instructions general instructions have your incision checked 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 staples have been removed 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 unless directed by your doctor do not take any anti inflammatory medicines such as motrin aspirin advil and ibuprofen for month you have been prescribed keppra levetiracetam for anti seizure medicine you will not require blood work monitoring clearance to drive and return to work will be addressed at your post operative office visit make sure to continue to use your incentive spirometer call your surgeon immediately if you experience any of the following new onset of tremors or seizures any confusion 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 any signs of infection at the wound site redness swelling tenderness or drainage fever greater than or equal to f followup instructions follow up appointment instructions please return to the office in days from your date of surgery for removal of your staples or they can be removed at the please call to schedule an appointment with dr to be seen in weeks you will need a ct scan of the brain without contrast you will not need an mri of the brain completed by,"{
""Diagnoses"": [""neurosurgery"", ""craniotomy"", ""epidural hematoma"", ""scalp laceration"", ""occiput fracture"", ""brain contusion""],
""Medications"": [""ems"", ""sedation""]
}"
11182,admission date discharge date service history of present illness ms is a year old female with a history of gastroesophageal reflux disease who presented to at a m after two episodes of coffee grounds emesis as her nursing home on the night of admission she vomited cc of coffee grounds and then subsequently had another episode of cc of frank blood at p m she said she had not been feeling well the entire day in the emergency department the patient had another cc episode of bright red hematemesis nasogastric lavage did not clear after one liter she was originally admitted to the medical intensive care unit an esophagogastroduodenoscopy showed a gastric ulceration with a large adherent blood clot on the posterior wall of the mid body of the stomach the clot was removed revealing an underlying cm cratered ulceration with a visible vessel endoclips were applied to the ulceration base helicobacter pylori serologies were sent there was also evidence of a small hiatal hernia duodenitis and duodenal ulcerations when seen in the medical intensive care unit the patient had no complaints she denied any chest pain shortness of breath abdominal pain or lightheadedness the patient also denied any history of nonsteroidal antiinflammatory drug use or significant alcohol history she denied any previous bleeding episodes however she did report several days of black tarry stools prior to admission and said that overall she was not feeling well the patient denied any fevers or chills in the medical intensive care unit she was transfused with units of packed red blood cells and was hemodynamically stable past medical history gastroesophageal reflux disease paroxysmal atrial fibrillation with a rapid ventricular rate rectal prolapse and hemorrhoid surgery in colonic polyps benign allergies the patient has no known drug allergies medications on admission colace aspirin mg by mouth once per day multivitamin one tablet by mouth once per day zoloft mg by mouth once per day digoxin mg by mouth once per day ritalin os cal aricept mg by mouth once per day remeron by mouth at hour of sleep social history the patient is a nursing home resident she lives at in she reports occasionally smoking approximately five cigarettes per week the patient reports occasional alcohol use she denies any other drug use family history family history was noncontributory physical examination on presentation vital signs revealed her temperature was degrees fahrenheit her heart rate was her blood pressure was her respiratory rate was and her oxygen saturation was on room air in general she was an elderly female sitting comfortably in a chair she was in no acute distress head eyes ears nose and throat examination revealed the pupils were equal round and reactive to light the extraocular muscles were intact the neck was without appreciable jugular venous distention at degrees there was no lymphadenopathy her heart was regular there was a systolic ejection murmur at the left lower sternal border as well as systolic the lungs were clear to auscultation bilaterally the abdomen was soft nontender and nondistended she had decreased bowel sounds the extremities were thin with good pulses she had pneumatic boots in place pertinent laboratory values on presentation laboratories on admission with a complete blood count which revealed a white blood cell count of her hematocrit was in the medical intensive care unit after receiving units of packed red blood cells her hematocrit prior to transfusion was and her platelets were she had a prothrombin time of her partial thromboplastin time was and her inr was her serum chemistries were all normal other than a blood urea nitrogen of she had helicobacter pylori serologies sent at the time of the esophagogastroduodenoscopy concise summary of hospital course by issue system gastrointestinal issues the patient was admitted with an upper gastrointestinal bleed with an esophagogastroduodenoscopy showing evidence of a gastric ulceration with stigmata of recent bleeding and underlying blood vessel that was clipped at the time of the esophagogastroduodenoscopy the patient received units of packed red blood cells in the medical intensive care unit on the night after transfer to the floor the patient s hematocrit fell from to and she received another unit from that time forward her hematocrit was stable the patient was hemodynamically stable throughout her admission the patient was placed on protonix mg intravenously q h which was subsequently changed to mg by mouth q h the patient s diet was advanced as tolerated helicobacter pylori serologies done at the time of the esophagogastroduodenoscopy were positive on the day prior to discharge and she was started on clarithromycin mg by mouth twice per day amoxicillin gram by mouth q h and was continued on her protonix mg by mouth q h the patient was to stay on the protonix for two months and clarithromycin and amoxicillin for two weeks her aspirin will be held indefinitely the patient was to have followup with the division of gastroenterology and will most likely require a repeat endoscopy in several months cardiovascular issues per her granddaughter the patient has a history of paroxysmal atrial fibrillation with rapid ventricular response it was unclear at the time of admission why she was on digoxin however her granddaughter stated that she was placed on it when her atrial fibrillation was first noted however the patient has never been anticoagulated the patient was continued on digoxin mg by mouth every day and had no other cardiac events neurologic issues the patient has an underlying history of dementia and is on aricept and ritalin as an outpatient it was noted two days prior to discharge and on the day of discharge that her memory was somewhat worse with very low short term memory her daughters felt that this was most likely secondary to disorientation and confusion after being in the hospital and displaced from familiar surroundings the patient was continued on her aricept ritalin and remeron discharge diagnoses upper gastrointestinal bleed dementia helicobacter pylori infection gastric ulceration medications on discharge protonix mg by mouth q h times two months clarithromycin mg by mouth twice per day times days amoxicillin gram by mouth q h times days digoxin mg by mouth once per day multivitamin one tablet by mouth once per day ritalin mg by mouth twice per day remeron mg by mouth at hour of sleep zoloft mg by mouth once per day aricept mg by mouth at hour of sleep condition at discharge at the time of discharge the patient was confused but redirectable she was repeatedly asking why she was here and clarifying where she was she was without other physical complaints her vital signs were stable her hematocrit was stable at approximately discharge status the patient was to be discharged back to nursing home and was to be scheduled for gastrointestinal followup and will need follow up with her primary care physician in the next week m d dictated by medquist d t job [NEW_RECORD] name a unit no admission date discharge date date of birth sex f service addendum ms was ready to go home on however her morning hematocrit came back at down from she also passed several large melanic stools as well as having two episodes of bright red blood per rectum a repeat hematocrit was still low at and she was taken back for an endoscopy endoscopy revealed a single crated ulceration in the stomach body there was a visible vessel suggesting recent bleeding the three previously placed hemoclips were no longer seen and electrocautery was applied for hemostasis successfully the patient was hemodynamically stable throughout and returned to the regular floor serial hematocrits were followed which were stable she was continued on protonix mg intravenously twice per day as well as treatment for her helicobacter pylori infection including protonix clarithromycin and amoxicillin discharge disposition the patient was to be discharged back to the nursing home on with followup with gastroenterology and her primary care physician patient was to continue protonix twice per day for two months and amoxicillin and clarithromycin for two weeks m d dictated by medquist d t job,"{
""Diagnoses"": [""Gastroesophageal reflux disease"", ""Hematemesis"", ""Nasogastric lavage"", ""Esophagogastroduodenoscopy"", ""Helicobacter pylori serologies"", ""Duodenitis"", ""Duodenal ulceration""],
""Medications"": [""Proton pump inhibitors"", ""Antacids"", ""H2 blockers"", ""Prokinetics"", ""Antibiotics"", ""Endoclips""]
}"
8994,admission date discharge date date of birth sex f service history of present illness ms is a year old female with a long standing history of marfan s syndrome and severe thoracic kyphosis the patient had a previous thoracic fusion done at posterior segmental instrumentation became dislodged and the patient had to be revised with removal of instrumentation this patient was seen on by spine surgeon dr at that time the patient had such a progression of upper back curvature that her breathing became restricted and she became dependent on portable oxygen patient had restrictive lung disease she elected to undergo a revision osteotomy and fusion from t l level the risks and benefits of surgery were discussed and the patient opted for surgery she was admitted for elective anterior thoracolumbar fusion on past medical history marfan s syndrome gastroesophageal reflux disease restrictive lung disease bladder infection arthritis anemia previous thoracic fusion posterior removal of dislodged segmental instrumentation allergies motrin bactrim medications on admission prevacid guaifenex clonazepam clarinex atenolol cyclobenzaprine metoclopramide piroxicam effexor xr furosemide trazodone senna physical examination on admission well nourished white female with kyphosis heent patient with eyeglasses no sinus tenderness oropharynx clear chest kyphosis as above lung sounds clear bilaterally respiratory rate regular cardiac examination normal s s regular rate and rhythm abdomen soft non tender extremities warm well perfused strength in upper extremities is good throughout as well as in her lower extremities the patient complains of progressive weakness in both legs her examination is throughout without evidence of clonus and negative babinski sign hospital course the patient was admitted to on and underwent anterior thoracolumbar t l fusion on the same day the surgery was done by dr the patient tolerated the procedure well and was transferred to medical surgical floor with plan to return to operating room for posterior thoracolumbar spine fusion on drainage from left sided chest tube was carefully monitored the patient underwent a second surgery and posterior thoracolumbar fusion with a kyphosis correction the patient was intubated on ventilator and remained tachycardic throughout this admission the patient was extubated on a tlso brace was ordered for the patient she was mobilized with physical therapy pulmonary toilet was provided on a daily basis patient was encouraged to use incentive spirometry patient was screened and accepted by center and will be discharged on her foley catheter was discontinued on staples were removed from her wound she was started on iron supplements for postoperative anemia patient will need to follow up with dr in two weeks please call for appointment patient needs to wear tlso brace and out of bed weightbearing as tolerated discharge diagnoses status post left anterior thoracotomy with thoracic vertebrectomy on status post posterior thoracic osteotomy with correction of kyphosis and tsf with instrumentation t l marfan s syndrome chronic depression arthritic pain in joints gastroesophageal reflux disease postoperative anemia and preoperative anemia history of mitral valve replacement history of tachycardic discharge medications trazodone mg two tablets p o at h s docusate sodium mg ml liquid mg p o b i d atenolol mg p o q day clonazepam mg one tablet p o b i d mg one cap p o q day cyclobenzaprine mg p o b i d metoclopramide mg one tab p o q i d piroxicam mg one tablet p o q day venlafaxine xr mg q h p o q hs percocet mg one to two tablets p o q h p r n seroquel mg one tablet p o q day m d dictated by medquist d t job,"{
""Diagnoses"": [""Marfan syndrome"", ""severe thoracic kyphosis"", ""restrictive lung disease"", ""gastroesophageal reflux disease"", ""arthritis"", ""bladder infection"", ""anemia""],
""Medications"": [""Motrin"", ""Bactrim"", ""Prevacid"", ""Guaifenex"", ""Clonazepam"", ""Clarinex"", ""Atenolol"", ""Cyclobenzaprine"", ""Metoclopramide"", ""Piroxicam"", ""Effexor XR"", ""Furosemide"", ""Trazodone"", ""Senna""]
}"
68175,admission date discharge date date of birth sex m service cardiothoracic allergies percocet percodan attending chief complaint exertional angina major surgical or invasive procedure coronary bypass grafting x with a left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the second diagonal artery and sequential reverse saphenous vein grafts to the distal posterior left ventricular branch artery and the posterior descending artery and reverse sequential saphenous vein grafts to the obtuse marginal artery and the ramus intermedius artery cardiac cath history of present illness year old male with a history of high cholesterol gout and a fatty liver who has been experiencing exertional angina he states for the past six months he has been complaining of stomach discomfort while exercising describing as substernal gas belching and substernal pressure he has been experiencing pain in his left shoulder and bicep for the past six months he associated this with his tendonitis at rest patient will occasionally experience chest discomfort and complains of increased stress in his personal life as well as at his job he was referred for a cardiac catheterization which revealed severe three vessel coronary artery disease past medical history high cholesterol elevated psa benign gout fatty liver previous kidney stones steatohepatitis s p discetomy x s p vasectomy social history race caucasian last dental exam month ago lives with alone patient has three grown children occupation works in sales tobacco denies etoh drinks a week family history brother with pci at age grandfather with cad physical exam pulse resp o sat ra b p right left height weight lbs general skin dry x intact x 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 neuro grossly intact pulses femoral right left dp right left pt left radial right left carotid bruit right left pertinent results cardiaac cath coronary angiography in this right dominant system demonstrated three vessel disease the lmca had distal stenosis that extended into the proximal lad and lcx the lad had proximal stenosis stenosis of the first diagonal branch and was occluded in the mid vessel the lcx had proximal and omb stenoses the rca had very distal stenosis prior to the nd plb resting hemodynamics revealed mildly elevated left ventricular filling pressures with lvedp mmhg there was no significant pressure gradient across the aortic valve on catheter pullback there was systemic arterial normotension left ventriculography revealed no mitral regurgitation the estimated lv ejection fraction was with normal wall motion vein mapping duplex evaluation was performed of both lower extremity venous systems for evaluation of the greater saphenous veins the right greater saphenous vein is patent with diameters ranging from to on the left to the majority of the vein bilaterally ranges from to echo pre cpb no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage the left atrial appendage emptying velocity is depressed m s no atrial septal defect is seen by d or color doppler left ventricular wall thicknesses are normal 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 aortic root is mildly dilated at the sinus level there are simple atheroma in the descending thoracic aorta there are three aortic valve leaflets there is no aortic valve stenosis trace aortic regurgitation is seen there is no mitral valve prolapse mild mitral regurgitation is seen dr was notified in person of the results post cpb the patient is on a phenylephrine infusion being av paced there is trace mr and trace ai trace pulmonic insufficiency is now seen the biventricular systolic function is preserved the visible contours of the thoracic aorta are intact there is a persistent left sided pleural effusion hematoma which despite many attempts to drain by the surgeon remains unchanged 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 pt inr pt am blood pt ptt inr pt am blood pt ptt inr pt pm blood pt ptt inr pt am blood pt inr pt am blood pt ptt inr pt am blood pt ptt inr pt am blood urean creat na k cl brief hospital course mr a cardiac cath on which revealed severe coronary artery disease and was therefore admitted following cath for pending surgical revascularization he usual pre operative work up while awaiting plavix washout on he was brought to the operating room where he a coronary artery bypass graft x please see operative report for surgical details following surgery he was transferred to the cvicu for invasive monitoring in stable condition he remained intubated on pressors in the initial post op period he also developed a fever and leukocytosis sputum gram stain was positive initially and the patient was started on vancomycin and cipro he has a history of alcohol dependence and he was put on a ciwa scale the patient was placed on precedex and was eventually weaned and extubated on pod he developed rapid atrial fibrillation and meds were adjusted ep was consulted coumadin was initiated the patient was unable to maintain rate control chemically he electrical cardioversion following a negative tee on he successfully converted to sr chest tubes and pacing wires were discontinued without complication cultures were negative wbc normalized fever did not return and antibiotics were discontinued 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 home with vna in good condition with appropriate follow up instructions dr will follow inr coumadin dosing for atrial fibrillation medications on admission allopurinol mg tablet tablet s by mouth once a day atorvastatin lipitor mg tablet one half tablet s by mouth once a day clopidogrel plavix prescribed by other provider mg tablet one tablet s by mouth daily metronidazole metrogel gel apply to affected area once a day as needed for rosacea sildenafil viagra mg tablet to tablet s by mouth once a day as needed for prn medications otc aspirin prescribed by other provider mg tablet one tablet s by mouth daily multivitamin otc capsule one capsule s by mouth daily omega fatty acids fish oil prescribed by other provider otc mg capsule two capsule s by mouth daily vitamin e prescribed by other provider dosage uncertain discharge medications allopurinol mg tablet sig three tablet po daily daily disp tablet 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 multivitamin tablet sig one tablet po daily daily folic acid mg tablet sig one tablet po daily daily disp tablet s refills thiamine hcl mg tablet sig one tablet po daily daily disp tablet s refills omega fatty acids capsule sig one capsule po bid times a day cholecalciferol vitamin d unit tablet sig one tablet po daily daily amiodarone mg tablet sig two tablet po bid times a day mg x week then mg daily x week then mg daily disp tablet s refills ibuprofen mg tablet sig two tablet po q h every hours as needed for pain fever disp tablet s refills tramadol mg tablet sig one tablet po q h every hours as needed for pain disp tablet s refills lorazepam mg tablet sig one tablet po q h every hours as needed for anxiety disp tablet s refills atenolol mg tablet sig three tablet po daily daily disp tablet s refills ranitidine hcl mg tablet sig one tablet po daily daily disp tablet s refills outpatient lab work labs pt inr for coumadin indication a fib goal inr first draw results to dr phone then please do inr checks monday wednesday and friday for weeks then decrease as directed by dr warfarin mg tablet sig one tablet po once a day dr to dose for goal inr for atrial fibrillation disp tablet s refills discharge disposition home with service facility vna discharge diagnosis coronary artery disease s p coronary artery bypass graft x past medical history high cholesterol elevated psa benign gout fatty liver previous kidney stones steatohepatitis s p discetomy x s p vasectomy 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 none 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 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 please get referral to cardiologist from pcp primary dr on at am 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 a fib goal inr first draw results to dr phone then please do inr checks monday wednesday and friday for weeks then decrease as directed by dr completed by,"{
""Diagnoses"": [""cardiothoracic"", ""exertional angina"", ""coronary artery disease""],
""Medications"": [""Percocet"", ""Percodan"", ""Reverse saphenous vein graft""]
}"
68505,admission date discharge date date of birth sex m service cardiothoracic allergies no known allergies adverse drug reactions attending chief complaint chest pain major surgical or invasive procedure cardiac cath urgent coronary bypass grafting x with left internal mammary artery to left anterior descending coronary endoscopic left greater saphenous vein harvesting reverse saphenous vein single graft from the aorta to the first obtuse marginal coronary artery reverse saphenous vein single graft from the aorta to posterior descending coronary artery history of present illness y o with history of htn hyperlipidemia left carotid endarderectomy and current smoker who was transfer from after presenting with about weeks fatigue and intermittent chest pain he also reported doe and decreased exercise tolerance as well as generalized malaise over the past two weeks he went to his pcp and had ekg changes and was subsequently sent to the ed he was ruled out for an mi x sets of enzymes echo lvef he was given ntg and had a significant bp drop he is currently chest pain free he was transferred to for catherization today which revealed vessel cad cardiac surgery was consulted for evaluation for cabg past medical history hypertension hyperlipidemia depression tobacco use ppd x years copd left cea years ago at dr skin graft at years old after traumatic oil truck injury social history race caucasian last dental exam several years ago lives with wife and daughter occupation retired from beverage distributor truck cigarettes smoked no yes x last cigarette yesterday am hx ppd x years etoh drink week drinks week x drinks week illicit drug use none family history father died at mi siblings one had mi physical exam pulse resp o sat ra b p right left height weight kg general aao x in nad skin dry x intact x well healed left neck incision heent perrla x eomi x neck supple x full rom x 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 varicosities none x left shin muscle bulge from old injury with well healed skin graft scars superficial veins lle neuro grossly intact x pulses femoral right cath site left dp right left pt left radial right left carotid bruit right none left none pertinent results cardiac cath selective coronary angiography of this right dominant system demonstrated vessel disease the lmca had mid distal narrowing the lad had a stenosis after s the lcx had sequential mid lesions with a large distal om branch the rca was small with diffuse disease with long moderate mid disease and a stenosis before pda limited resting hemodynamics revealed normal systemic arterial pressures at the aortic level mmhg left ventriculography was defered carotid u s right ica stenosis no left common or internal carotid stenosis status post carotid endarterectomy high grade right external carotid artery stenosis echo pre bypass no spontaneous echo contrast or thrombus 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 right atrium or the right 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 overall left ventricular systolic function is normal lvef right ventricular chamber size and free wall motion are normal there are simple atheroma in the ascending aorta there are simple atheroma in the aortic arch the descending thoracic aorta is mildly dilated there are complex mm atheroma in the descending thoracic aorta 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 mild mitral regurgitation is seen there is a small pericardial effusion the pericardium appears thickened there are pericardial calcifications dr was notified in person of the results in the operating room at the time of the study post bypass the patient is atrially paced there is normal biventricular systolic function the thoracic aorta is intact after decannulation no other changes from the pre bypass study brief hospital course as mentioned in the hpi mr was to for catheterization on cardiac catheterization revealed severe three vessel disease and cardiac surgery was consulted he underwent pre operative work up on while receiving medical care on he was brought to the operating room where he underwent a coronary artery bypass grafting to vessels please see operative report for surgical details following surgery he was transferred to the cvicu for invasive monitoring in stable condition within hours he was weaned from sedation awoke neurologically intact and extubated on post op day one he was started on beta blockers and diuretics and diuresed towards his pre op weight later on this day he was transferred to the step down unit for further care chest tubes and epicardial pacing wires were removed per protocol he was evaluated by physical therapy for strength and conditioning he was noted to have some premature atrial and ventricular contractions and his betabockade was increased his electrolytes were also repleted he continued to make steady progress and was cleared for discharge to home on postoperative day with vna services all post op appointments and instructions were advised of note as there was little room with his blood pressure his lisinopril was not resumed on discharge this can be resumed as an outpatient by either his cardiologist or primary care physician when he has sufficient blood pressure medications on admission spiriva mcg one puff daily labetalol mg lisinopril mg daily citalopram mg daily lipitor mg daily zetia mg daily discharge medications hospital bed dx cad s p cabg copd 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 for months disp capsule s refills atorvastatin mg tablet sig one tablet po at bedtime disp tablet s refills citalopram 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 lasix mg tablet sig one tablet po once a day for days disp tablet s refills potassium chloride meq tablet er particles crystals sig one tablet er particles crystals po once a day for days disp tablet er particles crystals s refills hydromorphone mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills spiriva with handihaler mcg capsule w inhalation device sig one inhalation inhalation once a day disp months supply refills lopressor mg tablet sig one tablet po three times a day disp tablet s refills discharge disposition home with service facility home care services discharge diagnosis coronary artery disease s p coronary artery bypass graft x past medical history hypertension hyperlipidemia depression tobacco use ppd x years copd left cea years ago at dr skin graft at years old after traumatic oil truck injury discharge condition alert and oriented x nonfocal ambulating with steady gait incisional pain managed with oral analgesics incisions sternal healing well no erythema or drainage leg 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 take lasix mg and potassium meq once daily for days then stop 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 on date time pm in the medical office building wound check wound care nurse phone date time am in the medical office building cardiologist dr 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 completed by,"{
""Diagnoses"": [""cardiothoracic"", ""allergies"", ""adverse drug reactions"", ""chest pain"", ""urgent coronary bypass grafting"", ""reverse saphenous vein single graft from the aorta to the first obtuse marginal coronary artery"", ""reverse saphenous vein single graft from the aorta to posterior descending coronary artery"", ""history of present illness"", ""hypertension"", ""hyperlipidemia"", ""left carotid endarterectomy"", ""current smoker""],
""Medications"": [""NTG""]
}"
62730,admission date discharge date date of birth sex f service neurology allergies patient recorded as having no known allergies to drugs attending chief complaint ich major surgical or invasive procedure none history of present illness is a yo woman transferred from for evaluation of ich according to tranfer records the patient was found unresponsive this evening after going to the bathroom and stating that she didn t feel well she had been vomiting all day she was in the batheroom and was heard falling she was found on the floor next to the toilet unresponsive ems was called she was unresponsive on arrival to vitals there where bp pulse resp sating ekg was normal head ct showed a cm pontine bleed with intraventricular and right cerebellar extension she underwent rapid sequence intubation was given mg of labetaolol and mannitol and was transferred here via med flight of note it appears the patinet was recently admitted to the hosptial from for evaluation of mental status changes asceptic meningitis eeg was done and showed mild slowing mri showing extensive confluent flaire signal hyperintensity in the mid brain cerebral pedicles diffusely through the pons also involving the right aspect of the medulla and the medial aspects of both temporal lobes lp was done which showed wbc reds protein glucose csf tb vdrl cytology and hsv pcr where pending she had been on treated with several days of acyclovir but this was discontinued after serum hsv antibodies where negative she improved mildly and was dicharged home with services with plans to follow up with pcp and outpatient neurology past medical history dm hypertension breast cancer social history lives in visiting family family history unknown physical exam exam afebrile bp hr intubated on ac with evidence of spontaneous overbreathing mannitol infusing no sedation no evidence of trauma heart rrr lungs clear anteriorly abdomen soft good distal pulses pupils fixed and dilated mm bilaterally no corneal reflex no oculocephalic reflex no gag no spontaneous movement no withdrawal of the upper extremities non specific movements of the lower extremities in response to noxious stimuli diminishe reflexes throughout toes mute bilaterally pertinent results pm type art rates tidal vol peep o po pco ph total co base xs assist con intubated intubated pm urine color yellow appear clear sp pm urine blood neg nitrite neg protein neg glucose neg ketone bilirubin neg urobilngn neg ph leuk neg pm glucose lactate na k cl tco pm urea n creat pm estgfr using this pm lipase pm asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg pm wbc rbc hgb hct mcv mch mchc rdw pm pt ptt inr pt pm plt count pm fibrinoge cta head w w o c recons study date of pm preliminary report wet read increased size of brainstep hematoma with ext to r cerebellum and surrounding edema increased intraventricular blood now in th rd and vent mild hydrocephalus mild increase since prior exam small sah tonsillar herniation oblitration of basal cisterns mass effect on intraceranial vertebral arteries causing mild narrowing no aneurysm or abnormal enhancement brief hospital course ms is a yo woman who presented with an unfortunately devastating ich at the time of admission she had no brainstem reflexes the cause of her bleed is unknown but she was recently hospitalized and discharged from an osh days ago with presumed aseptic meningitis she was evaluated by neurosurger and they felt her bleed was so extensive that she was not a candidate for surgery her family was informed the patient was admitted allowing time for the family to gather she was made cmo extubated and died shortly thereafter secondary to respiratory arrest medications on admission unknown discharge medications expired discharge disposition expired discharge diagnosis ich discharge condition expired discharge instructions expired followup instructions expired md completed by,"{
""Diagnoses"": [""ICH"", ""Meningitis"", ""Aspectic meningitis""],
""Medications"": [""Labetolol"", ""Mannitol""]
}"
21079,admission date discharge date date of birth sex f service surgery allergies norvasc attending chief complaint pancreatic mass major surgical or invasive procedure pylorus sparing pancreaticoduodenectomy history of present illness year old woman presented a month ago with a biliary stricture and a pancreatic head mass she received a ct scan after her ercp procedure and this demonstrated a large lesion in the head of the pancreas consistent with a pancreatic cancer a fine needle aspiration for cytology demonstrated highly atypical epithelial cells she was scheduled to see dr in the clinic for evaluation of the surgical resection but in the interim became jaundiced and was transferred back to our facility for an emergent ercp to drain her bile duct past medical history diabetes mellitus hypertension pancreatic mass status post appendectomy status post tubal ligation social history no alcohol or taobacco family history noncontributory physical exam general no apparent distress heent neck supple no lymphadenopathy cardiac regular rate and rhythm lungs clear to auscultation abdomen obese soft nontender and nondistended extremities no clubbing cyanosis or edema neuro alert and oriented neurovascularly intact bilaterally on discharge the patient had a well healing abdominal incision that was clean dry and intact the abdomen was soft nontender and nondistended pertinent results discharge labs wbc rbc hgb hct mcv mch mchc rdw plt ct glucose urean creat na k cl hco angap calcium mg the pathology was pending at the time of discharge brief hospital course the patient underwent a pylorus sparing pancreaticoduodenectomy on she tolerate dthe procedure well and the patient had an estimated blood loss of cc the patient remained intubated on the night of the operation given the length of the procedure for this reason the patient was transfered to the surgical intensive care unit for monitoring postoperatively the patient had some decreased urine output over the night of postoperative day and the patient received some fluid boluses which led to increased uring output she received aggressive resucitation overnight she had a favorable course for extubation on the morning of postoperative day and the patient was extubated without event she was placed on an insulin drip for tight glucose control the patient also had an epidural for pain relief the patient remained in the icu overnight for low urine output on postoperative day this had improved substantially and the patient was ready for transfer to the surgical floor consult was obtained to assist in tight glucose control the patient was continued on the whipple clinical pathway and the epidural ng and foley were discontined on post operative day her sliding scale was increased on post operative day physical therapy was consulted to help in mobility postoperatively the patient also recieved sips on postoperative day on post operative day the pca was discontinued and the patient was transferred to po pain meds and advanced to a clear liquid diet on post operativd day the patient ha flatus and was advanced to a full liquid diet the patients jp amylase was checked and was within normal limits and the patient had bowel movements on post operative day the patient was advanced to a regular diet and the patients jp drain was discontinued the patient was in stable condition and ready for discharge to home with follow up with dr and the clinic medications on admission lisinopril protonix lipitor insulin lantus humalog metformin atenolol discharge medications oxycodone acetaminophen mg tablet sig tablets po q h every to hours as needed for pain disp tablet s refills metoclopramide hcl mg tablet sig one tablet po qidachs times a day before meals and at bedtime disp tablet s refills lantus unit ml solution sig twenty units subcutaneous at bedtime disp ml refills other meds continue your home medications protonix qd atenolol qd lisinopril qd discontinue your metformin please take colace bid while you are using percocets insulin lispro human unit ml solution sig one dose subcutaneous four times a day follow attached sliding scale follow up with as instructed disp ml refills discharge disposition home discharge diagnosis status post pylorus sparing pancreaticoduodenectomy pancreatic mass hypertension diabetes hypovolemia oliguria discharge condition good discharge instructions md with any worsening abdominal pain intractable nausea or vomiting inability to tolerate food yellowing of your skin increased itching you may shower but do not bathe you should resume taking any medications you were taking prior to this hospitalization you should not do any heavy lifting objects greater than pounds for weeks you should resume your regular diet make sure that you take sufficient fluids you will be prescribed narcotics for pain relief you should not drive while on these medications these medications may also cause constipation and you should take a stool softner such as colace while on these medications you should check your blood sugars several times a day and administer the regular insulin via a sliding scale provided in your discharge instructions followup instructions you should follow up with dr in weeks call with any other questions you should follow up with dr at the clinic today completed by,"{
""Diagnoses"": [""pancreatic cancer"", ""biliary stricture"", ""pancreatic head mass""],
""Medications"": [""Norvasc"", ""Pylorus sparing pancreaticoduodenectomy""]
}"
26569,admission date discharge date service this is an incomplete discharge summary please see discharge addendum for completion of the hospital course discharge diagnoses and discharge medications history of present illness the patient is a year old male with hypertension portal vein thrombosis secondary to pancreatitis leading to portal hypertension no history of coronary artery disease he presented to the emergency room on after having black maroonish stools since the patient says he took approximately six aspirin mg strength the week prior for an upper respiratory tract infection the patient denies any abdominal pain nausea vomiting or gastroesophageal reflux disease type symptoms the patient was very weak dizzy and lightheaded he denies any chest pain but did have shortness of breath in the emergency room the patient was noted to have a blood pressure of with a heart rate of and a hematocrit of with a baseline hematocrit of to an nasogastric lavage was performed which was clear cc the patient was subsequently admitted to the medical intensive care unit past medical history hypertension b deficiency pernicious anemia status post cholecystectomy gastritis empyema in choledocholithiasis pancreatitis in right portal vein thrombosis portal hypertension ascites colonic polyps on colonoscope in allergies no known drug allergies medications at home norvasc mg p o q day tylenol mg p o q day b injections q month social history the patient lives at he is a retired engineer and is widowed drinks one alcoholic drink per week the patient quit tobacco years ago he normally swims approximately three times a week and walks a mile and a half per day without difficulties family history noncontributory physical examination in general a pale appearing elderly male in no acute distress temperature f blood pressure heart rate respiratory rate oxygen saturation on room air heent mucous membranes were moist conjunctivae pale no oral lesions detected neck jugular venous pressure at centimeters without lymphadenopathy chest with diffuse expiratory wheezes without crackles cardiovascular iii vi systolic ejection murmur at the left lower sternal border regular rate and rhythm abdomen with positive bowel sounds distended no hepatosplenomegaly nontender plus minus fluid wave rectal examination revealed occult blood positive maroon stool extremities with three plus pitting edema bilaterally neurological alert and oriented times three moves all four extremities laboratory white blood cell count hematocrit platelets differential is polys lymphocytes monocytes sodium potassium chloride bicarbonate bun creatinine glucose alt ast alkaline phosphatase bilirubin inr pt ptt ck mb ck mb index troponin ekg with sinus rhythm at beats per minute with pr intervals of qtc of depressions noted in ii iii avf v through v with t wave inversions in v and i chest x ray with questionable pulmonary edema no focal consolidations hospital course upper gastrointestinal bleed the patient was transfused a total of units of blood for a hematocrit of which was stable the patient underwent an esophagogastroduodenoscopy on which revealed grade varices which were nonbleeding with a nonbleeding pedunculated polyp that was benign appearing in the stomach the patient was started on octreotide for a hour course as well as propranolol the patient will undergo a repeat esophagogastroduodenoscopy prior to discharge in order to pursue variceal banding as well as to re evaluate the gastric polyp ischemia upon admission the patient was noted to have inferior lateral ischemia changes on ekg as well as an elevated troponin and mb fraction the patient s cardiac enzymes were cycled and peaked at a troponin of and a ck of with a ck mb of it was thought that this troponin leak was secondary to demand ischemia from his anemia the patient will likely need an outpatient stress test in the future the patient remained completely chest pain free during his hospital stay congestive heart failure the patient was noted to have an intermittent oxygen requirement on with his oxygenation saturation changing from on room air to on room air the patient was noted to have crackled on examination and was thought to be volume overloaded secondary to his numerous blood transfusions the patient responded well to lasix mg intravenously an echocardiogram was performed on which revealed an ejection fraction of greater than with mild left ventricular hypertrophy and two plus aortic regurgitation which was worse than prior examination two plus mitral regurgitation two plus tricuspid regurgitation moderate pulmonary artery systolic hypertension and mild aortic stenosis which was new since his prior examination the patient was continued on spironolactone during his hospital stay ascites the patient had portal hypertension secondary to a portal vein thrombosis which was chronic and seemed to have occurred during an episode of pancreatitis the patient had an abdominal ultrasound on which showed moderate ascites with chronic occlusion of the right portal vein with cavernous transformation and a heterogeneous echogenic liver consistent with cirrhosis the patient underwent a diagnostic peritoneal tap on which revealed culture negative just ascites the patient was started on initially ciprofloxacin and then switched over to ceftriaxone grams q hours for treatment throat culture negative will check ascites for a four or five day total course the patient likely has cirrhosis and will need to be followed up with dr in order to arrange for a liver biopsy to confirm this diagnosis in addition the patient was started on propranolol and spironolactone this is an incomplete discharge summary please refer to following discharge addendum for completion of the hospital course discharge diagnoses and discharge medications m d dictated by medquist d t job [NEW_RECORD] admission date discharge date service medicine this is a discharge summary addendum to discharge summary this addendum covers from to hospital course the patient remained stable in the hospital he received two more units of packed red blood cells for a low hematocrit as the risk of rebleeding is high in the setting of grade iii varices he went for a repeat esophagogastroduodenoscopy the day prior to discharge which again showed grade iii varices in the lower third and mid third of the esophagus and portal gastropathy he had two bandings successfully without any complications he was also evaluated by the liver service the day prior to discharge the liver team recommended repeat esophagogastroduodenoscopy as an outpatient with dr in ten to fourteen days the liver service recommended no biopsy as the results will not change the management his liver workup including negative hepatitis b and c serologies and normal ferritin no workup for autoimmune hepatitis was done since his liver function tests were within normal limits the liver team also recommended ciprofloxacin mg p o once daily for life for sbp prophylaxis as he likely had an episode of sbp in the setting of cirrhosis and ascites they also recommended changing propranolol to nadolol and add carafate in addition to protonix condition on discharge stable discharge status rehabilitation discharge diagnoses upper gastrointestinal bleeding status post esophagogastroduodenoscopy and banding for grade iii esophageal varices grade iii esophageal varices portal gastropathy status post non st elevation myocardial infarction portal vein thrombosis with portal hypertension questionable cirrhosis culture negative neutrocytic ascites b deficiency anemia medications on discharge protonix mg p o once daily carafate one gram p o four times a day one gram one hour before each meal and two hours before other medications one gram q h s spironolactone mg p o once daily lasix mg p o once daily lisinopril mg p o once daily vitamin b mcg q month nadolol mg p o once daily ciprofloxacin mg p o once daily for life for prophylaxis of sbp discharge follow up the patient will need to call dr to schedule appointment for esophagogastroduodenoscopy in ten to fourteen days the patient will need to call the doctor s office to make the appointment m d dictated by medquist d t job,"{
""Diagnoses"": [""hypertension"", ""portal vein thrombosis"", ""secondary to pancreatitis""],
""Medications"": [""aspirin""]
}"
5892,admission date discharge date date of birth sex f service neonatology history of the present illness this delightful baby girl is now days old she was born at weeks gestation and was admitted to our nicu because of prematurity and respiratory distress her obstetrician was dr the mother is a year old gravida v para iii now iv prenatal screens were o positive antibody negative hepatitis b surface antigen negative rpr nonresponsive rubella immune the mother s past obstetric history was remarkable for pregnancy induced hypertension resulting in preterm deliveries at weeks for two children and one at weeks this pregnancy was again complicated by pregnancy induced hypertension the mother also had hypothyroidism treated with synthroid the decision was made to induce labor the mother was not treated with betamethasone rupture of membranes occurred one hour prior to delivery there was no maternal fever the gbs status was unknown the delivery was uncomplicated the infant was born via a vaginal delivery the baby was initially suctioned with a bulb syringe and blow by oxygen she was vigorous with good respiratory effort however she developed retractions and grunting while still in l d of note the placenta was small with a velamentous cord insertion on admission to the nicu the infant was noted to have deep retractions and grunting with an oxygen saturation of and blow by oxygen of she was therefore intubated and treated with surfactant with significant clinical improvement physical examination on her initial examination her weight was grams th percentile length cm th percentile head circumference cm th percentile vital signs her admission vitals were a heart rate of respiratory rate blood pressure with a mean of mmhg she was pink alert she did not appear dysmorphic her anterior fontanelle was slightly enlarged her palate was intact she had normal leg reflexes bilaterally prior to intubation she had deep retractions with clear air entry at the bases which improved with intubation with coarse rales and equal air entry cardiovascular she had normal heart sounds with no audible murmurs and good femoral pulses abdomen soft no organomegaly she had normal premature female external genitalia she had good tone with symmetrical movements stable hip examination hospital course she was assessed to be week gestation preterm infant with respiratory distress and clinical picture consistent with hyaline membrane disease she was admitted to the neonatal intensive care unit for further management respiratory she had clinical radiological evidence of hyaline membrane disease she was initially intubated ventilated and received two doses of survanta she was extubated on day of life number two onto cpap she was weaned onto nasal cannula oxygen by day of life number five and weaned to room air by day of life number she has subsequently remained stable in room air she has had no apnea of prematurity and has not required any caffeine cardiovascular on day of life number eight she was noted to have slightly prominent heart sounds with a soft murmur she had an echocardiogram which revealed evidence of a tiny patent ductus arteriosus a possible patent foramen ovale and trivial left peripheral pulmonary stenosis with good ventricular function her echo was repeated on day of life number which revealed that her pda had now closed she continues to have a small pfo versus asd she has remained hemodynamically stable throughout and continues to have a soft grade i vi ejection systolic murmur at the upper left sternal edge dr of pediatric cardiology was planning to follow up following discharge parents are aware of these plans fluids electrolytes and nutrition she was initially n p o and was started on hyperalimentation feeds were initiated on day of life number six she was advanced well with her feeding and now takes all of her feeds by bottle she is currently on breast milk which is made up of enfamil powder kilocalories per ounce she takes cc per kilogram minimum ad lib and generally was taking cc per kilogram per day her discharge weight is gastrointestinal she developed hyperbilirubinemia of prematurity and required phototherapy from day of life number two to day of life number her maximum bilirubin was on day of life number four hematology her admission cbc had a white cell count of hematocrit platelets the differential on the white cell count was polymorphs with band her last hematocrit was on day of life number two she is currently on iron supplementation and poly vi infectious disease she underwent an initial sepsis evaluation her blood cultures were negative there was no left shift on her cbc antibiotics were discontinued after two days she has had no infectious disease issues since then neurology she has not had any neurological issues during this admission sensory she passed her newborn hearing screen on ophthalmology she did not require to be examined for rop condition on discharge stable on full enteral feeds with a soft clinical murmur due to an underlying pfo versus asd discharge disposition home to parents primary pediatrician dr telephone number fax number care and recommendations feeds at discharge breast milk with calories made from enfamil powder kilocalories per ounce ad lib medications ferrous sulfate mg per cc mg p o q d poly vi cc p o q d car seat position screening passed on state newborn screening sent immunizations hepatitis b received immunizations recommended 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 chronic lung disease immunizations should be considering 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 influenzae to protect the infant follow up appointments dr pediatrician on hours visiting nurse sentra vna inc on dr pediatric cardiology at on at p m discharge diagnosis prematurity hyaline membrane disease sepsis evaluation status post patent ductus arteriosus left peripheral pulmonic stenosis patent foramen ovale versus atrial septal defect m d dictated by medquist d t job,"{
""Diagnoses"": [""prematurity"", ""respiratory distress"", ""neonatology"", ""hypertension"", ""hypothyroidism"", ""induced labor"", ""rupture of membranes"", ""GBS status unknown""],
""Medications"": [""synthroid"", ""betamethasone""]
}"
22878,admission date discharge date date of birth sex f service cardiothor history of present illness the patient is a year old woman who was admitted with chest pain and shortness of breath which started about two weeks ago this was described as sharp pain of very short duration the patient also claimed that at the same time she felt like everything was shutting down with decreasing urine output and decreasing bowel movements she rested times four days with some improvement but then felt stressed about her personal life her blood pressure was up in the range this was checked by her sister who was an r n about one week prior to admission the patient noticed increasing dyspnea at night with stabbing left chest pain and the sensation of her heart racing about five to six days prior to admission the patient went to an outpatient center because she had the same pain which was also associated with heavy wheezing this was worse with lying down and with exertion the patient complained of positive nocturnal dyspnea she fell asleep lying flat but then awoke gasping sitting upright for the rest of the night she tried albuterol inhaler but worsened after the use of the albuterol she also complained of a sore throat for the past two weeks with a sensation of pills sticking in her throat the patient claimed to have a low grade fever with morning chills positive cough but no sputum positive nausea but no vomiting and positive constipation past medical history the past medical history was significant for a prosthetic mitral valve and aortic valve both bjork shiley valves implanted in secondary to rheumatic heart disease gastroesophageal reflux disease atrial fibrillation since endocarditis in a motor vehicle accident in with a pinched cervical nerve suffered from that accident a cardiac catheterization in with no intervention and a history of fibroid tumors medications on admission digoxin mg p o q d claritin mg p o q d prilosec mg p o q d spironolactone mg p o t i d atenolol mg p o q d coumadin mg p o q d lasix mg p o b i d captopril mg p o t i d potassium chloride meq t i d allergies the patient had allergies to atrovent ampicillin amoxicillin sulfa macrodantin biaxin and erythromycin social history the patient had no tobacco use and no alcohol use since prior to that she was a social drinker she was a disabled schoolteacher who lived alone family history the family history was significant for coronary artery disease and cancer but no diabetes physical examination on admission vital signs revealed a blood pressure of a heart rate in the s a respiratory rate of and an oxygen saturation of on one liter on general examination the patient was an obese white woman in bed who was alert and in no acute distress on head eyes ears nose and throat examination the sclerae were anicteric and noninjected the mucous membranes were moist the oropharynx was without lesions there was no exudate or erythema the neck was supple with a soft collar in place there was no lymphadenopathy or jugular venous distention the chest was clear bilaterally with well healed surgical scars the cardiovascular examination revealed a regular mechanical s and s the abdomen was obese and soft with minimal tenderness normal active bowel sounds and no masses the extremities had no clubbing or cyanosis there was positive edema to the knees nonpitting on neurological examination the patient was alert and oriented times three with a nonfocal examination laboratory data there was a sodium of potassium of chloride of bicarbonate of bun of creatinine of and glucose of calcium was magnesium was and phosphate was ck was there was a white blood cell count of hematocrit of and platelet count of prothrombin time was partial thromboplastin time was and inr was radiology a chest x ray showed mild pulmonary vascular engorgement but no overt pulmonary edema electrocardiogram the electrocardiogram showed atrial fibrillation with a rate of and diffuse small st segment depressions in ii v and v inferolateral hospital course the patient was admitted to the medicine service for rule out myocardial infarction with a plan to reverse her inr and then repeat her cardiac catheterization she had an echocardiogram done on the day of admission which showed an aortic gradient of and a mitral valve gradient of both increased from the prior month s echocardiogram the patient underwent cardiac catheterization on and the catheterization showed normal coronary arteries except for a ostial stenosis of the right coronary artery with moderate to severe pulmonary artery hypertension cardiothoracic surgery was consulted and her case was reviewed by them it was felt that the patient would benefit from mitral valve replacement however the patient stated that there were technical problems with her prior surgery at and the surgery was delayed until the records could be obtained and reviewed the patient was brought to the operating room on for re do mitral valve replacement with a carbomedics valve via a right thoracotomy she tolerated the procedure well and was transferred from the operating room to the cardiothoracic intensive care unit please see the operative note for full details at the time of transfer she had an arterial line a swan ganz catheter two atrial pacing wires and two pleural chest tubes at the time of transfer her heart rate was atrially paced and her blood pressure was with a central venous pressure of and a pulmonary artery pressure of with a mean of the patient did well in the immediate postoperative period she was weaned from her propofol and weaned from the ventilator and extubated on the morning of postoperative day later in the day she was transferred from the intensive care unit to for continuing postoperative care and cardiac rehabilitation once on the floor the patient did well her chest tubes were discontinued and she was started back on her coumadin to protect her remaining mechanical valve over the next several days the patient s activity level was gradually increased to the point where she was walking feet in the hallways with minimal assistance during that time her hemodynamic status remained stable as did her respiratory status on postoperative day the patient was noted to again be in atrial flutter at that time she was treated with lopressor and started on procainamide however she remained in atrial flutter both her lopressor and procainamide were continued on postoperative day it was deemed that the patient was stable and ready for transfer to rehabilitation at that time she was screened for rehabilitation of note her inr was slow to respond to her being started back on her coumadin and from postoperative day through her coumadin dose was gradually increased also on postoperative day she was started on heparin to further anticoagulate her while waiting for her inr to respond to the increasing coumadin doses on postoperative day the patient remained stable and she was accepted to a rehabilitation facility closer to her home she remained hemodynamically stable and ready for transfer physical examination at transfer vital signs revealed a temperature of f a heart rate of with atrial flutter a blood pressure of a respiratory rate of and an oxygen saturation of on two liters weight preoperatively was kg at discharge it was kg the patient was alert and oriented times three moving all extremities and following commands breath sounds were clear to auscultation bilaterally heart sounds were regularly irregular s and s with a positive mechanical click the abdomen was soft nontender and nondistended with positive bowel sounds the extremities were warm and well perfused the thoracotomy incision with staples was open to air clean and dry with small ecchymotic areas along the margin and no erythema the right groin incision with staples continued to drain clear serous fluid with no erythema or ecchymosis this was felt to be a seroma laboratory data on transfer there was a white blood cell count of hematocrit of prothrombin time of inr of and partial thromboplastin time of on heparin at units hour there was a sodium of potassium of chloride of bicarbonate of bun of creatinine of and glucose of discharge medications metoprolol mg p o b i d lasix mg p o b i d potassium chloride meq p o q d protonix mg p o q d procan sr mg p o every six hours ibuprofen mg p o every six hours levofloxacin mg p o q d through heparin units per hour until she reaches her goal inr of to coumadin mg on day of discharge the previous three days were all mg and the preadmission dose was mg percocet mg one to two tablets p o every four hours p r n disposition the patient is to be discharged to rehabilitation follow up the patient is to have follow up with dr in one month discharge diagnoses re do mitral valve replacement with carbomedics aortic valve replacement bjork shiley done in gastroesophageal reflux disease atrial fibrillation endocarditis motor vehicle accident with resultant pinched cervical nerve history of uterine fibroids m d dictated by medquist d t job,"{
""Diagnoses"": [""Chest pain"", ""Shortness of breath"", ""Dyspnea"", ""Heart racing""],
""Medications"": [""Albuterol""]
}"
27176,admission date discharge date service medicine allergies codeine attending chief complaint osh transfer sob major surgical or invasive procedure intubation arterial line placement history of present illness limited history from pt yr old male hx of cabg chf hypercholesterolemia atrial fibrillation on coumadin presenting from hospital today pt reports over last two months increasing dyspnea on exertion general fatigue sob with exercise especially while walking up several stairs pt able to walk several feet on flat ground without sx no reported orthopnea weight gain or worsening le edema pt on torzamide with no change in dose reported last thursday pt cleaning fireplace with vac when hose peice came off blowing into his mouth nose and over the entire room immediate sob no pleuritic chest pain fevers chills nausea or vomiting now pt able to walk only a few feet w o shortness of breath to no dc summary but apparently treated with abx unknown for pneumonia and chemical pneumonitis and discharged continued to feel unwell with worsening sob returned to hospital ct chest performed with extensive bilateral alveolar infiltrates small bilateral pleural effusions of note ivc filter present no definite pe ceftriaxone azithromycin mg iv solumedrol iv lasix given and pt transferred to the given concern for higher level of care ed course vs l bibasilar crackles wbc to unclear baseline cr trop ck inr cr unknown baseline but at osh cxr extensive coarse and nodular air space and interstitial process with requip given asa mg given pt admitted for further work up past medical history cabg unknown territory ivc filter placed pt does not recall reason atrial fibrillation on coumadin restless leg syndrome chf unknown ef arthritis hypercholesterolemia social history social history lives with wife previous opera and show singer pack yr smoking hx quit years prior no alcohol or drug use family history nc physical exam micu admission pe t bp hr rr o sat on nrb gen nad speaking in full sentences with slight sob heent ncat perrl eomi jvp cm below jaw cervical lad and tenderness cv irregular rhythm no mrg nl s s resp coarse bs throughout lung fields abd benign rectal guaiac deferred per patient overnight ext no le edema venous stasis changes dp pertinent results ekg atrial fibrillation no acute ischemic changes labs see attached ct chest preliminary report wet read large multifocal areas of ground glass opacities dignostic considerations include nonspecific interstitial fibrosis nsip inflammatory process or possibly infectious less likely edema small pleural effusions cxr extensive diffuse coarse and nodular airspace consolidation in upper r and b l lung bases along w diffuse coarse prominence of interstitial markings c w chronic pulmonary disease overall picture c w pneumonia w underlying chronic interstitial disease cxr per cardiologist background interstitial markings w calcified granuloma and no evidence of chf echo the left atrium is mildly dilated left ventricular wall thicknesses are normal the left ventricular cavity is mildly dilated there is mild regional left ventricular systolic dysfunction with inferior hypokinesis and inferolateral thinning akinesis the remaining segments contract normally lvef the right ventricular cavity is mildly dilated with mild global free wall hypokinesis 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 no mitral valve prolapse mild mitral regurgitation is seen moderate tricuspid regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion impression dilated left ventricle with mild regional systolic dysfunction c w cad mild right ventricular systolic dysfunction mild aortic regurgitation moderate tricuspid regurgitation mild pulmonary hypertension echo per cardiologist preserved lv fxn w post wall hypokinesis and no evidence of lv dilation nuclear stress test per cardiologist fixed inf posterolateral wall defect est ef and mild lv dilation w exercise brief hospital course a p year old male w hx of chf s p cabg and pk yr smoking hx presenting with acute shortness of breath in the setting of recent inhalation hypoxemic respiratory failure resulting in ards from inhalation injury and exacerbated by pulmonary edema ventilator associated pneumonia vap and yeast infection the patient has had a prolonged icu course secondary to his tenuous respiratory status given his pa fio ratio bilaterall infiltrates on imaging he was intubated per ards net protocol early on in his course the patient was doing well and was extubated however he was re intubated the same day due to respiratory distress during this time the patient became anxious sbp and rr s despite non invasive ventilation lasix morphine and nitrates the patient continued to do poorly and was re intubated the patient course has since been complicated by vap per vap protocol he was started on vanc cipro zosyn the patient was also on steroids initially for his inhalation injury but this was quickly tapered as it was felt there was no added benefit the patient was bronched on the cultures from the bronchs have grown yeast on and the patient s clinical course deteriorated he became septic id was consulted they initially approved dose of fluconazole this was later changed to caspofungin the patient later became dysynchronous with the vent the decision was made to paralyze him and to chnage his mode of ventilation to pcv which he has tolerated given the patient s cardiac function volume overload was also felt to be a factor he was intermittantly diuresed with iv lasix and albumin blood the patient respiratory status continued to worsen and he was unable to be weaned from the vent after multiple discussions with the family the decision was made to make the aptient comfortable and he expirted on septic shock etiology of the patient s sepsis was felt to be his lungs he was maintained on vanc he was later started on meropenem flagyll for presumptive c diff and levofloxacin at one point the patient was on pressors id encouraged looking for other sources of his infection c diff was ordered and was negative x kub was ordered and was negative ct torso was not ordered initially because of the patient s dysynchrony with the vent and need for pressors levo was d cd the patient was started on gentamycin the patient was also started on caspofungin on id encouraged the discontination of vanc and meropenem the patient s clinical status had stabilized ct torso was performed there was no abdominal pathology noted but there was persistence of the b l pleural effusion vanc meropenem and flagyll have all been discontinued chf patient has an ischemic cardiomyopathy per echo with ef diuresis was initially held given cr bump from to his respiratory status was quite tenuous and it was later felt that volume overload was contributing to his inability to wean from the vent and he was given prn lasix boluses albumin cad continued aspirin and statin afib aflutter the patient is rate controlled with lopressor he was on propofol initially however due to the exacerbation of the aflutter he was changed to fentanyl versed medications on admission lipitor mg zetia mg oxycontin mg q d torsemide mg requip mg several a day coumadin mg t mg other days celebrex mg folic acid mg zetia mg bisoprolol mg celexa mg asa mg discharge medications n a discharge disposition expired discharge diagnosis respiratory failure discharge condition expired discharge instructions n a followup instructions n a,{}
57126,admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint altered mental status major surgical or invasive procedure endotracheal intubation history of present illness year old man with a history of hiv last cd and polysubstance abuse presents with apnea cyanosis and hypoxia after doing poppers amyl nitrate with friends apparently the patient was at a party with a large supply of amyl nitrate he mistakenly ingested the amyl nitrate was also drinking alcohol and smoking cocaine during this time his friends noticed he became altered and called ems who brought him to the ed in the ed initial vs were nrb patient had pivs g placed he was apneic and lethargic and given mg of narcan with minimal response he desated to the on nrb and was given etom and succ and intubated easily with he was given fentanyl and versed mcg and mg for sedation and mg vecuronium iv once patient was found to have evidence of methemoglobinemia on labs he was seen by toxicology who recommended methylene blue mg kg patient was given l ns and neosynephrine transiently for hypotension to the s but this was stopped after pressures normalized last set of vitals no pressors on ac peep on the floor the patient remains intubated and sedated but responsive and denies pain his methemoglobinemia was still noted to be elevated at and therefore was given a second dose of methylene blue at mg kg review of systems unable to obtain per family no complaints he is a very private person past medical history hiv last cd count on atripla last vl unknown alcohol abuse multiple ed admissions for intoxication marijuana abuse chronic back pain seen by pain clinic h o klonopin abuse tobacco abuse pack year depression s p ex lap after stabbing incident social history msm patient currently on disability for back pain has smoked ppd for past years has beers per day vs half pints of vodka per day has history of marijuana use recent cocaine use denies ivdu family history diabetes no history of tb physical exam pe on admission to micu general intubated sedated responsive young man in nad 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 discharge exam vs ra general resting in bed pleasant nad heent ncat sclera anicteric mmm neck supple no cervical lad cardiac rrr no r m g lungs ctab no wheezes crackles rhonchi abdomen bowel sounds present soft nt nd no hepatosplenomegaly well healed vertical incision scar ruq incision scar extremities warm dt pt radial pulses bilaterally no edema neuro aaox moving all four extremities skin excoriations on upper back no other rashes noted pertinent results admission labs am wbc lymph abs lymph cd abs cd cd abs cd cd abs cd cd cd am lactate am hgb calchct o sat carboxyhb met hgb am fibrinoge am plt count am pt ptt inr pt am asa neg ethanol acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg am albumin calcium phosphate magnesium am ck mb ctropnt am lipase am alt sgpt ast sgot ck cpk alk phos tot bili am glucose urea n creat am urine hyaline am urine rbc wbc bacteria few yeast none epi am urine blood sm nitrite neg protein glucose tr ketone neg bilirubin neg urobilngn neg ph leuk tr discharge labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap imaging ekg sinus tachycardia baseline artifact poor r wave progression non specific st t wave changes compared to the previous tracing of baseline artifact is more pronounced cxr low lung volumes retrocardiac opacity concerning for aspiration endotracheal tube in appropriate position ng tube with tip below ge junction not clearly visualized probably projecting at the stomach cxr pulmonary vascular engorgement has resolved heart size is normal there is no focal pulmonary abnormality or pleural effusion brief hospital course yo male with history of hiv and polysubstance abuse admitted with apnea and hypoxia in setting of methemoglobinemia after ingestion of amyl nitrate methemoglobinemia almost certainly secondary to amyl nitrate toxicity a level of was moderately severe and toxicology was consulted amyl nitrate is a well known hemoglobin oxidizer per toxicology and explains the patients hypoxemia and altered mental status received two treatments of methylene blue mg kg and methemoglobin levels trended down to within normal limits patient was initially intubated secondary to his altered mental status apnea and hypoventilatory hypoxia but was improved rapidly after treatment and was extubated on he was stable for transfer to medicine floor on and respiratory status remained stable for remainder of his hospital course lactic acidosis most likely secondary to reduced o delivery secondary to methemoglobinemia resolved with correction with methylene blue leukocytosis wbc elevated at on presentation given finding of retrocardiac opacity on cxr with air bronchograms was concern for an aspiration pneumonitis or aspiration pna ceftriaxone gm iv q h and azithromycin mg po q h were started however subsequent cxr showed that areas of atelectasis had improved and antibiotics were discontinued patient s wbc continued to trend down and was within normal limits on day of discharge depression history of suicidal ideation patient with history of depression and polysubstance abuse he recently told mother his back pain was so severe that he wanted to kill himself initially it was unclear if this incident was secondary to lapse in judgement or a suicidal attempt psychiatry consulted on and did not feel patient had suicidal or homicidal ideation per psych recs patient restarted on zoloft mg daily at time of discharge he will follow up with his pcp will likely be able to coordinate outpatient pysch follow up at center patient s cr elevated at on presentation was most likely prerenal and promptly resolved with fluids hiv last known cd was in patient had not been taking atripla as directed and of note his family was unaware of his diagnosis his cd count viral load and hiv genotype were checked with results still pending at time of discharge patient discharged on atripla and will follow up with pcp next week transaminitis chronic most likely secondary to alcoholism although alt ast ratio not consistent patient had hepatitis serologies sent which were still pending at time of discharge will follow up with pcp alcoholism patient has history of heavy alcohol abuse and reports having up to beers per day last drink was just prior to admission he received a banana bag on admission and was continued on thiamine folic acid and mvi he was monitored per ciwa protocol and did receive diazepam in setting of mild anxiety restlessness and tachycardia no evidence of severe withdrawal including dt social work was consulted and patient was also seen by substance abuse nurse he was strongly encouraged to seek to treatment but declined any inpatient treatment detox programs at this time was given information about potential programs and hotlines cocaine abuse patient endorsed use of crack cocaine the night before admission and tox screen positive for cocaine social work and substance abuse rn consulted as above labs pending at time of discharge hiv viral load cd count hepatitis b c serologies hiv genotype transitional issues patient was a full code during this admission patient was counseled about polysubstance abuse as above will need outpatient follow up with pcp work psych medications on admission atripla tab po daily discharge medications atripla mg tablet sig one tablet po once a day disp tablet s refills zoloft mg tablet sig one tablet po once a day for weeks disp tablet s refills discharge disposition home discharge diagnosis primary diagnosis methemoglobinemia secondary to amyl nitrate ingestion secondary diagnoses polysubstance abuse hiv depression discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions mr you were admitted to the hospital after you ingested amyl nitrate poppers at a party which caused your oxygen levels to drop dangerously low and also caused you to stop breathing for periods of time you were diagnosed with a condition called methemoglobinemia in which your blood is unable to carry enough oxygen to the rest of your body you were treated with a substance called methylene blue which helps to reverse this condition you initially had to be admitted to the icu because you required a breathing tube but we were able the take this tube out later that night your breathing significantly improved and your oxygen levels returned to we are very concerned about your tobacco alcohol and drug use and strongly urge you to seek treatment with your primary care doctor after you leave the hospital you were seen by the psychiatry team and also the substance abuse nurse while you were in the hospital they gave you information about the lark program at the an inpatient month program for people with hiv and addiction and also spoke with you about other resources at the health center they gave you a self help fact sheet with a hour hot line number to call if you need to it is very important that you follow up with your doctor for treatment in order to prevent another life threatening event while you were here we made the following changes to your medications started zoloft continued atripla please follow up with dr in clinic followup instructions name c location center address phone we are working on a follow up appointment with dr within week you will be called at home with the appointment if you have not heard from the office within days or have any questions please call the number above you also have an appointment scheduled with him for do bdu,"{
""Diagnoses"": [""apnea"", ""cyanosis"", ""hypoxia"", ""methemoglobinemia""],
""Medications"": [""narcan"", ""etomidate"", ""succinylcholine"", ""fentanyl"", ""versed"", ""methylene blue"", ""neosynephrine""]
}"
30522,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint chest discomfort major surgical or invasive procedure cardiac catherization coronary artery bypass graft x left internal mammary artery left anterior descending saphenous vein graft ramus saphenous vein graft obtuse marginal saphenous vein graft posterior descending artery history of present illness y o male with history of hypertension not on medication no other risk factors and generally is averse to medical care presents for evaluation of chest discomfort at rest patient first noticed intermittent exertional chest discomfort week pta walking minutes after dinner with substernal chest tightness non radiating not associated with any shortness of breath diaphoresis or nausea and resolved with rest after minutes he subsequently had episodes after similar amount of activity on the day of admission patient had the chest discomfort at rest while sitting down after lunch this time with diaphoresis he initially got in his car and drove to pick up some aspirin which he took he then called his daughter who saw him and said he looked paled which prompted him to call his pcp and be sent to the ed the patient s symptoms were essentially continuous for a period of about hour until he arrived in the ed although somewhat improved after taking the aspirin he was found to have sbp in ed and received asa metoprolol mg iv x followed by ntg sl x and then noticed decline of his symptoms and eventual resolution past medical history hypertension bph takes saw otc social history smoked cigars from age for period years quit years ago occasional etoh drink per night works in plumbing pipe repair retired family history no family history of premature coronary artery disease or sudden cardiac death brothers with diabetes and hypertension physical exam admission physical exam vitals bp down from hr rr o sat onra t gen nad overweight reluctant to stay in hospital and wants to go home heent eomi anicteric mmm op clear neck obese jvp not appreciated carotid pulses brisk no bruits no thyromegaly cor rrr no m g r normal s and s radial femoral dp pt pulses intact pulm appropriate respiratory effort ctab no w r r abd soft nt nd bs no pulsatile masses no abdominal or femoral bruits no hepatosplenomegaly ext warm well perfused no oedema neuro a o x cn ii xii grossly intact skin no rashes or ecchymoses 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 neuts lymphs monos eos baso am blood plt ct am blood pt ptt inr pt am blood pt ptt inr pt pm blood plt ct am blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap am blood ck cpk pm blood alt ast alkphos amylase totbili am blood ck mb mb indx am blood ck mb mb indx ctropnt pm blood ck mb mb indx ctropnt am blood calcium phos mg pm blood vitb am blood hba c pm blood triglyc hdl chol hd ldlcalc am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood plt ct am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap brief hospital course the patient was admitted to the cardiology service with an nstemi he had lateral precordial lead st segment depressions and a peak ck of and troponin of he was initally hesitant to undergo cardiac catherization but after explanation of the risks and benefits with the patient and his family he agreed and was taken to the catherization lab catherization showed severe vd a total occlusion of the lcx and lm disease he was continued on integrellin and heparin cardiac surgery was consulted and his integrellin was d c d am on the day prior to surgery on he was transported to the operating room and underwent coronary artery bypass graft surgery please see operative report for further details he tolerated the procedure well and was transferred to the csru for invasive monitoring in stable condition later on op day he was weaned from sedation awoke neurologically intact and was extubated on post op day his chest tubes were removed he remained in the csru for respiratory management he was genly diuresised on post op day three his pacing wires were removed and he was transferred to the telemetry floor physical followed patient during entire post op course for strength and mobility he continued to make steady process without any post op complications and was discharged home with vna services on post op day medications on admission saw discharge medications docusate sodium mg capsule sig one capsule po bid times a day disp capsule 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 atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills ranitidine hcl mg tablet sig one tablet po once a day for months disp tablet s refills metoprolol tartrate mg tablet sig two tablet po tid times a day disp tablet s refills discharge disposition home with service facility discharge diagnosis coronary artery disease s p cabg non st elevation myocardial infarction hypertension 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 in weeks dr in week wound check appointment as instructed by nurse provider md phone date time completed by,"{
""Diagnoses"": [""cardiothoracic"", ""chest discomfort"", ""hypertension""],
""Medications"": [""aspirin""]
}"
18397,admission date discharge date date of birth sex m service neonatology history baby is twin number two the gram product of a week gestation twin pregnancy born to a year old gravida i para woman estimated date of confinement medical history notable for chronic hypertension hypothyroidism irritable bowel syndrome prenatal screens blood type o positive antibody negative rubella immune rpr nonreactive hepatitis b surface antigen negative and group beta strep status unknown this is an in fertilization pregnancy a full course of beta methasone was given at weeks gestation followed for discordant growth this twin mother presented to labor and delivery the date of delivery with decreased movement of this twin a nonstress test was nonreactive without variability the mother was taken for cesarean section under epidural spinal anesthesia this twin emerged from breech position he was initially apneic with poor tone and heart rate less than he received seconds of positive pressure ventilation with onset of cry improvement in heart rate and color tone remained slightly decreased apgar at one minute and at minutes of age cord ph was on this twin onset of retractions and flaring in the operating room infant shown to parents and then admitted to the newborn intensive care unit in the newborn intensive care unit oxygen saturations were percent in room air initial blood glucose intravenous started and d w bolus was given and maintenance fluids of d w cc per kilo per day were started repeat blood glucose was a second bolus was given and maintenance increased to cc per kilogram per day the infant was placed on nasal cannula oxygen cc with saturations of to percent at that point continuous positive airway pressure was initiated a cbc and blood culture were obtained a platelet count of was noted intravenous ampicillin and gentamicin were initiated physical examination weight grams th percentile length cm th percentile head circumference cm th percentile general appearance this is a week infant with good color but decreased tone skin smooth and pink petechiae noted on chest warm and dry bruising noted on the back anterior fontanelle open and flat positive red reflex o u lips gums and palate intact intercostal retractions noted with tachypnea and decreased aeration to bases heart grade ii vi holosystolic murmur at the left sternal border femoral pulses abdomen soft no masses positive bowel sounds genitalia normal male testes descending patent anus trunk and spine straight normal sacrum clavicles intact hips stable neurologic examination positive suck alert positive grasp weak moro review of hospital course by systems respiratory ws initially on nasal cannula oxygen cc his work of breathing increased with an increased oxygen requirement he was place on continuous positive airway pressure with minimal improvement and was subsequently intubated and received one dose of surfactant he also received one sodium bicarbonate bolus for metabolic acidosis self extubated to room air on day of life two he remained in room air for the remainder of his hospitalization no issues of apnea of prematurity were noted and no methylxanthines were required cardiovascular received one normal saline bolus on day of life one for blood pressure support and metabolic acidosis murmur was noted on day of life one at which time cardiology was consulted the murmur was consistent with a closing patent ductus arteriosus murmur was gone by day of life four and no intervention was required soft murmur has been audible intermittently consistent with peripheral pulmonic stenosis his cardiovascular status has been stable for the remainder of his hospitalization fluid electrolytes and nutrition intravenous fluids of d w were initiated on admission at cc per kilogram per day he received multiple d w boluses shortly after admission for hypoglycemia his hypoglycemia was resolved by hours of age replogel tube was placed by day of life one for abdominal distention it was discontinued on day of life two enteral feeds were started on day of life three and he was successfully advanced to enteral feeds of cc per kilogram per day of breast milk or premature enfamil was made n p o on day of life seven for noted seizure activity a picc line was placed on day of life nine for parenteral nutritional support the picc line was discontinued on day of life feeds were restarted on day of life and advanced without difficulty to cc per kilogram per day caloric density was increased to calories per ounce with promod after onset of seizure activity p o feeding efforts were markedly diminished but improved over time electrolytes have been within normal limits throughout his hospitalization his last set of electrolytes on were sodium of a potassium of a chloride of and a total co of his discharge weight is o gms length is cm and head circumference cm he is being discharged to home on neosure enriched to calories per ounce gastrointestinal phototherapy was started on day of life two for a total bilirubin of phototherapy was discontinued on day of life five with a rebound bilirubin of on day of life six hematology received a platelet transfusion on day of life one for a platelet count of his platelet count has remained stable thereafter n other blood products were given hematocrit on was with a reticulocyte count of infectious disease a cbc and blood culture was sent on admission white blood cell count of hematocrit of platelet count of with neutrophils and percent bands he received a hour course of ampicillin and gentamicin his blood culture was negative was started on vancomycin gentamicin and acyclovir on day of life seven with onset of seizure activity his cbc at that time was a white count of hematocrit of platelet count of with percent neutrophils and percent bands his lumbar puncture was unremarkable with a white blood cell count of and red blood cells is cerebrospinal fluid glucose was and a protein of his blood culture at that time was negative his cerebrospinal fluid culture was negative and his cerebrospinal fluid pcr for hsv was negative vancomycin and gentamicin were discontinued after hours and the acyclovir was discontinued at four days of treatment neurologic had his first head ultrasound on day of life four which was read as normal increased irritability was noted on day of life six and seizure activity noted on day of life seven in he form of arching jitteriness bicycling movement an eeg confirmed seizure activity with a four minute seizure initiating in the right temporal region then generalizing a ct scan at that time showed right occipital and right caudate bleeding and diffuse edema was started on phenobarbital and dilantin at this time an mri on day of life showed bilateral hemorrhagic white matter injury and possible area of dysgenesis in the frontal gyri and a pattern less mature than expected for his gestational age the dilantin was discontinued on day of life his electrolytes at this time were within normal limits calcium was his liver function tests were within normal range and his ammonia level was his current neurologic examination was remarkable for hypertonicity of his extremities he remains on phenobarbital mg per kilogram per dose his last phenobarbital level on was his last head ultrasound on showed bilateral periventricular leukomalacia and mild ventriculomegaly and bilateral subependymal hemorrhages his head circumference at discharge is cm sensory the hearing screen was performed with automated auditory brain stem responses he passed in both ears on an ophthalmologic examination was not indicated for this week infant psychosocial a social worker has been involved with the family the contact social worker os and she can be reached at genitourinary circumcision was performed on and is healing nicely condition at discharge neurologic status is stable he is taking all feeds by mouth his weight gain has been variable and will need to be monitored name of primary pediatrician is dr phone number fax care recommendations feeds at discharge ad lib demand feedings of neosure enriched to calories four calories by concentration and four calories of corn oil medications iron supplements cc q d and phenobarbitol mg po qday car seat positioning screening passed his car seat test on state newborn screening status the last newborn screen was sent on and no abnormal results have been reported immunizations received has not received any immunizations his first hepatitis b vaccine is being deferred to his primary pediatrician immunizations recommended synagis rsv prophylaxis should e considered from through for infants who meet any of following three criteria number one born at less at weeks number two born between and weeks with plans for day care during rsv season with a smoker in the household or with preschool sibs or number three with chronic lung disease influenza immunizations 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 follow up appointment has been arranged with dr in the neonatal neurology follow up program at six weeks after discharge will also be followed by early intervention at regional child developmental center phone number and the infant follow up program discharge diagnoses prematurity at weeks gestation twin respiratory distress syndrome rule out sepsis hypoglycemia thrombocytopenia hyperbilirubinemia seizure activity rule out herpes bilateral periventricular leukomalacia vancomycin resistant entercocci vre colonization m d dictated by medquist d t job,"{
""Diagnoses"": [""chronic hypertension"", ""hypothyroidism"", ""irritable bowel syndrome"", ""prenatal screens"", ""blood type O positive"", ""antibody negative"", ""rubella immune RPR nonreactive"", ""hepatitis B surface antigen negative"", ""group B strep status unknown""],
""Medications"": [""beta-methasone""]
}"
18508,admission date discharge date service vascular surgery chief complaint ruptured abdominal aortic aneurysm history of present illness year old non diabetic white female with coronary artery disease coronary artery bypass graft in hypertension had an endovascular abdominal aortic aneurysm repair by dr in routine follow up ct scan done on showed the presence of an endo leak the patient was asymptomatic and hemodynamically stable on the morning of the patient became dizzy at a m when she awoke and went to the bathroom while sitting down she felt like the room was spinning she did not move her bowels this weakness and dizziness lasted approximately to minutes she denied chest pain diaphoresis or abdominal pain there was no shortness of breath no nausea or vomiting and no loss of consciousness the patient returned to bed but still felt a persistent weakness she presented to the emergency room at for evaluation a repeat ct scan in the emergency room showed no evidence of rupture or retroperitoneal hematoma the area of the known endo leak was the same diameter her hematocrit was unchanged at vascular surgery was consulted the decision was made to admit the patient to the medical service to rule out myocardial infarction angiography of the endograft was scheduled for the following morning past medical history coronary artery disease coronary artery bypass graft x in at history of aortic stenosis hypertension history of nephrolithiasis with hematuria chronic low back pain osteoarthritis past surgical history endovascular abdominal aortic aneurysm repair on by dr family history noncontributory social history not available allergies penicillin and morphine medications on admission toprol xl mg by mouth once daily doxazosin mg by mouth once daily lasix mg by mouth every hours lescol mg by mouth once daily aspirin mg by mouth once daily physical examination vital signs temperature pulse respirations blood pressure oxygen saturation general alert cooperative white female in no acute distress head eyes ears nose and throat pupils equal round and reactive to light and accommodation extraocular movements intact neck range of motion within normal limits no jugular venous distention carotids palpable no bruits chest lungs clear bilaterally heart regular rate and rhythm with ii vi systolic ejection murmur best heard along the left upper sternal border well healed sternotomy incision present abdomen soft nontender nondistended bowel sounds present palpable pulsatile upper abdominal mass present no bruit extremities non pitting edema of the ankles bilaterally well healed left leg saphenectomy incision pulse examination femoral and pedal pulses bilaterally no bruits neurological examination nonfocal laboratory data white blood cells hematocrit platelets pt ptt inr sodium potassium chloride bicarbonate bun creatinine glucose electrocardiogram showed a normal sinus rhythm in the s poor r wave progression no change from previous electrocardiogram in ct of the abdomen on showed an endo leak at the proximal aspect of the stent in the abdominal aorta aneurysm x cm hospital course the patient was admitted to dr on the medical service abdominal aortogram was scheduled for the following morning just before midnight on the night of admission the patient complained of abdominal pain her blood pressure fell to with a heart rate between to her hematocrit had dropped from to ultrasound done at the bedside showed a small amount of fluid around the aorta the patient underwent an emergent repair of her ruptured abdominal aortic aneurysm with an aortobi iliac graft and removal of the endograft her abdominal incision was left open and two drains were left in place estimated blood loss was between and liters the patient received units of packed red blood cells intraoperatively the patient was transferred to the surgical intensive care unit intubated paralyzed and sedated extended intubation was expected because of the open abdominal wound the patient was maintained on kefzol while her abdomen was open she was started on total parenteral nutrition she was hypotensive and required pressor support she developed thrombocytopenia with platelets as low as heparin was discontinued until the patient was determined to be hit negative and then subcutaneous heparin was resumed the patient was diuresed with intravenous lasix dr general surgery was consulted for future abdominal wound closure partial closure of the abdominal wound with silastic mesh was done on the drains were left in place on a fascial closure of the abdominal wound was done after excision of the mesh secondary to fibropurulent peritonitis normal saline wet to dry dressings were ordered for the incision which has been healing well postoperatively the patient developed leukocytosis with a white count of the culture of the line tip grew enterococcus kefzol was changed to ampicillin however the sputum culture grew serratia and the patient was started on ceftazidime and vancomycin for seven days the patient s white count decreased however she had another spike to on infectious disease was consulted and concluded that the patient had serratia peritonitis they recommended stopping the vancomycin after seven days if the patient remained afebrile they recommended extending treatment with ceftazidime for a total of days because of the patient s open abdominal wound she remained intubated paralyzed and sedated for an extended period of time on paralysis was discontinued however she still remained sedated on sedation was stopped and on the patient was extubated the patient managed to avoid a tracheostomy which had been considered earlier because of the patient s peritonitis and abdominal wound the patient was not a candidate for a percutaneous endoscopic gastrostomy therefore a dobbhoff nasogastric catheter was placed and total parenteral nutrition was transitioned over to tube feedings the patient attained her goal of cc hour which is cycled between p m and a m tube feedings consist of the promote with fiber at full strength her residuals are checked every four hours and feedings are held for a residual of greater than cc the patient was transferred from the surgical intensive care unit to the vascular intermediate care unit on a speech and swallow consult was requested a modified barium swallow was done on which showed no aspiration however the patient was at high risk for aspiration and pureed diet with honey thick liquids and strict aspiration precautions was recommended the patient started a trial of eating on she complained of some abdominal pain and cramping the kub was unremarkable a c difficile culture was sent off this came back positive for c difficile she was started on a ten day course of flagyl her white count again went up to but the patient remained afebrile her blood cultures are negative to date her urine culture grew greater than yeast the foley catheter is still in place because the patient is being diuresed further treatment of the yeast urinary tract infection is being considered physical therapy was reconsulted on the patient on for full weight bearing ambulation as tolerated at the time of dictation the patient s abdominal wound is healing well her pedal pulses are palpable bilaterally she has a dobbhoff nasogastric tube in place her foley is still in place she currently does not have a peripheral intravenous the patient will be discharged to a rehabilitation facility she will follow up with dr after discharge from this facility for further instructions discharge medications metoprolol mg via nasogastric tube three times a day amlodipine mg by mouth once daily hydralazine mg intravenously every four hours as needed to keep systolic blood pressure less than lasix mg intravenously twice a day protonix mg intravenously once daily albuterol nebulizer one treatment every six hours as needed ipratropium two puffs every four to six hours as needed albuterol ipratropium one to two puffs every four hours as needed heparin units subcutaneously twice a day flagyl mg via nasogastric tube three times a day from to colace liquid mg by mouth twice a day hydromorphone to mg intravenously every three to four hours as needed for pain lorazepam to mg intravenously every six hours as needed for agitation tylenol one to two tablets by mouth every four to six hours as needed nystatin mg by mouth swish and swallow four times a day as needed nystatin ointment topically four times a day as needed calcium carbonate mg by mouth four times a day artificial tears one to two drops to both eyes as needed saliva substitute to ml by mouth as needed miconazole powder topically three times a day as needed regular insulin sliding scale while on tube feedings condition at discharge satisfactory disposition rehabilitation discharge diagnosis ruptured abdominal aortic aneurysm after endovascular abdominal aortic aneurysm repair emergent repair of ruptured abdominal aortic aneurysm removal of endograft and open abdominal wound on partial closure of abdominal wound on fascial closure of abdominal wound on secondary diagnoses blood loss anemia status post multiple blood transfusions serratia peritonitis serratia pneumonia c difficile colitis yeast urinary tract infection malnutrition treated with tube feedings via dobbhoff catheter extended intubation aspiration precautions coronary artery disease hypertension m d dictated by medquist d t job [NEW_RECORD] name unit no admission date discharge date date of birth sex f service discharge summary addendum the patient was kept through the weekend here on tube feeding after a discussion with nutrition it was decided that the patient did not need a g tube and that her lack of oral intake was simply due to deconditioning it was felt that with time she will be able to meet her caloric requirements orally it was decided to send her with dobbhoff feeding tube with tube feeds which can appropriately be weaned at the rehabilitation facility a nutritionist will evaluate the patient at the rehabilitation facility the patient had a foley catheter attempted to be removed and she failed a voiding trial she was sent to the rehabilitation facility with foley catheter in place she will be discharged continues to be stable the patient had some fungus in the urine but since she was afebrile and asymptomatic it was decided to not be treated m d dictated by medquist d t job,"{
""Diagnoses"": [""ruptured abdominal aortic aneurysm"", ""endovascular abdominal aortic aneurysm repair"", ""asymptomatic endoleak""],
""Medications"": [""hypertension medication"", ""coronary artery disease medication"", ""endoleak medication""]
}"
29746,admission date discharge date date of birth sex f service nb history of present illness the patient is a kg female infant product of a week gestation born to a year old gravida para mother after an apparently uncomplicated pregnancy mother presented with preterm labor no sepsis risk factors noted prenatal screens mother s blood type was positive antibody negative hepatitis b negative rpr nonreactive rubella immune group beta strep status unknown it was a vaginal delivery apgars were and infant was brought to the nicu after visiting parents for late preterm infant physical examination current weight on the st was grams neuro infant bundled in an isolette active on examination respiratory infant is in room air breath sounds were equal and clear cardiac color pink with mild underlying jaundice no audible murmur on examination pulses skin is intact gastrointestinal abdomen soft and round positive bowel sounds genitourinary normal female genitalia extremities infant moves all extremities well infant has symmetric tone and reflexes hospital course respiratory infant has been in room air since admission to the nicu infant did have occasional episodes of apnea of prematurity at rest she has been free of these episodes for at least days prior to discharge cardiovascular infant has been cardiovascularly stable since admission to the nicu no audible murmur heart rate is to s with a stable blood pressure of with a mean of fluids electrolytes and nutrition infant began enteral feeds on admission to the nicu of breast milk or enfamil initially requiring partial gavage feedings she did have uncoordinated suck swallow and breath pattern during feeds she has fed well without episodes for several days prior to discharge her weight a day prior to discharge is grams gastrointestinal maximum bilirubin was over on day of life phototherapy began on day of life phototherapy was discontinued on on day of life for a bilirubin of over on day of life rebound bilirubin was hematology infant s blood type is positive coombs negative infant has not received blood transfusions recent hematocrit was on admission to the nicu which was and then actually was repeated on day of life which was and also had a reticulocyte count of infectious disease cbc obtained on admission to nicu white count was with polys and bands infant did not require antibiotics neurology infant does not meet criteria for head ultrasounds infant is appropriate easily aroused and has symmetric tone and has been neurologically appropriate since her admission to the nicu sensory audiology hearing screening will be performed prior to discharge home immunization hepatitis vaccine given on medications infant is on cc ferrous sulfate and tri vi 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 should be done prior to discharge home state newborn screen has been sent per protocol results are pending 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 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 followup appointments scheduled for vna to visit day post discharge discharge diagnoses late preterm infant immature breathing pattern feeding immaturity hyperbilirubinemia dictated by medquist d t job,"{
""Diagnoses"": [""preterm labor"", ""premature infant""],
""Medications"": [""none""]
}"
22745,admission date discharge date service medicine allergies meclofenamate sodium attending chief complaint sob major surgical or invasive procedure intubation history of present illness yo f admitted on for progressively worsening dyspnea x week felt to be a chf exacerbation nstemi developed dizziness tonight and per tele became bradycardic w complete heart block she then became unresponsive w pea arrest she was intubated w o event abg and received epinephrine x atropine x and bicarb x with establishment of a palpable pulse by rhythm strip then appeared to be in sinus tach bp stable w sbp in s r femoral line was placed for central access lead ekg was obtained and revealed st elevations in avr and v v with reciprocal st depressions in v and v repeat ekgs revealed persistence of st elevations and plans were made to take her to cath stat cxr revealed improvement in her pleural effusions from earlier today but still w persistent hilar fullness labs were drawn and were pending at time of cath for pmh she has known cad s p pci to lcx in at the time was found to have vd chf htn dm type ii and copd per her admission note by dr she began developing sob week ago she would have sob gasping for air mostly with walking feet these episodes lasted min and resolved with deep breathing these episodes became more frequent over the last few days she normally sleeps with the head of her bed elevated but the night prior to admission she awoke gasping for air at am the episode resolved on its own and she went back to sleep in the morning she was again sob when speaking and her family called ros for angina recently had not had it for several yrs described as bilateral shoulder discomfort squeezing w o radiation associated w sob relieved w ntg lle unchanged no medication noncompliance or dietary indiscretion per ed trip sheet osh records pt was on ra on arrival on nrb at osh given asa ntp lasix mg iv heparin bolus and morphine for anxiety was transferred to our ed where her vs were t hr bp rr sats of nrb on exam she had rales bilaterally and pitting edema labs were notable for elevated bnp and trop ekg with nsr rate st dep mm in i avl v v no st segment elevation twi in i avl v flat tw in v v she was admitted to the service for chf exacerbationwas transferred up to the floor where she appeared to do well overnight she received additional doses of iv lasix with net i o of cc on exam this am was sob at rest sitting degrees upright in a chair past medical history cad cath done for postitive ett a limited angiography of the left coronary artery demonstrated moderate disease of the lad with stenoses of the proximal and mid artery the circumflex artery had a total occlusion after the takeoff of a large first om the distal circumflex and om filled by retrograde left to left collaterals b resting hemodynamics were normal c successful ptca of the totally occluded mid lcx chf copd on home o of l htn dm on insulin hypothyroidism sleep apnea on cpap bilateral tkr hearing loss with hearing aid basal and squamous cell skin cancer s p resection mastectomy for benign breast tumor social history per admit note lives with grandson in performs all adls quit smoking years ago unable to quantify how much occ etoh family history nc physical exam on admission to ccu vs t bp hr rr sats by vent vent ac fio tv set tv actual peep rr gen sedated intubated heent sclera anicteric neck supple jvp cv rr nl s s no m r g appreciated lungs vented bs anteriorly no crackles wheezes abd soft obese nt nd bs no masses ext bilateral le edema up of shins chronic venous stasis changes pertinent results labs on admission 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 ck cpk pm blood ck mb probnp pm blood ctropnt pm blood ck cpk pm blood ck mb notdone pm blood ctropnt labs on discharge am blood ck cpk am blood ck mb ctropnt am blood caltibc ferritn trf am blood tsh pm blood type art po pco ph calhco base xs pm blood glucose k calhco pm blood lactate k pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts bands 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 ck cpk alkphos totbili pm blood ck mb mb indx ctropnt imaging cxr pa and lateral views of the chest pulmonary edema and bilateral pleural effusions are present obscuring the cardiac contours mediastinal contours are within normal limits there is no pneumothorax degenerative changes are noted in the thoracic spine impression congestive heart failure with bilateral pleural effusions brief hospital course mrs is an yo f admitted on for progressively worsening dyspnea x week felt to be a chf exacerbation nstemi developed dizziness tonight and per tele became bradycardic w complete heart block she then became unresponsive w pea arrest she was intubated w o event abg and received epinephrine x atropine x and bicarb x with establishment of a palpable pulse by rhythm strip then appeared to be in sinus tach bp stable w sbp in s r femoral line was placed for central access lead ekg was obtained and revealed st elevations in avr and v v with reciprocal st depressions in v and v repeat ekgs revealed persistence of st elevations and plans were made to take her to cath stat cxr revealed improvement in her pleural effusions from earlier today but still showed persistent hilar fullness labs were drawn and showed elevated cardiac enzymes her family was contact and made aware of need for urgent cardiac cath and with her ekg changes the likely possibility of left main disease with probable need for cabg pt is a poor surgical candidate currently and with this in mind and with the knowledge of the patient s wishes the family did not want to proceed with cardiac catheterization ms family said that the patient did not want to intubated so they decided to extubate her and to continue with medical management knowing that she may not survive once extubated she was given morphine to help with her tachypnea and apparent dyspnea thirty minutes after being extubated mrs passed away from respiratory failure medications on admission isosorbine mononitrate naproxen mg levoxyl mcg qd metroprolol mg lasix mg qd insulin u nph u nph pm ecotrin quinine sulfate mg qhs discharge medications none discharge disposition expired discharge diagnosis stemi cardiopulmonary arrest respiratory failure discharge condition expired discharge instructions not applicable followup instructions not applicable,{}
12170,admission date discharge date date of birth sex f service medicine allergies dilantin zithromax tetanus erythromycin base phenobarbital attending chief complaint s p fall major surgical or invasive procedure none history of present illness patient is a yo f s p c type odontoid fracture after falling downstairs admitted to trauma service now transferred to medicine per report the patinet has a known history of alcohol abuse and previous subdural hematoma fell while at home and intoxicated on she was brought in by ambulance and was found to have a c fracture on ct initially seen at she was then transferred for furhter management while on the trauma service she was initially admitted to the trauma sicu for the management of her fracture she was placed in a hard collar and managed conservatively additionally she was managed with a ciwa scale for alcohol withdrawal and given morphine for pain additionally she was persistently hypertensive and was treated with metoprolol hydralazine and clonidine geriatrics was consulted and recommended management of alcohol withdrawal with smaller doses of ativan given that the patient was elderly and for assistance with placement upon exam today the patient is sedated but arousable and able to communicate with me she reports no pain and does recall that she can t hold her liquor anymore past medical history h o falls h o subdural hematoma s p bilateral cataract surgery rheumatic fever at age social history etoh remote tobacco history lives alone niece involved in her care family history notable for father with brain cancer mother with stroke physical exam t bp hr rr o sat ra fs i o gen somnolent but awakens able to answer questions somewhat but still with eyes closed last dose of ativan at am heent op clear mmm perrl neck hard collar in place cv rrr mgr pulm cta b abd soft nt nd ext no edema pulses neuro moves all extremities intact sensation le ue unable to acquire rest of exam pertinent results am glucose urea n creat sodium potassium chloride total co anion gap am ck mb ctropnt am asa neg ethanol acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg am wbc rbc hgb hct mcv mch mchc rdw am plt count am pt ptt inr pt cardiology report ecg study date of pm sinus rhythm normal ecg compared to the previous tracing of the rate is slower and ventricular premature beats are no longer present intervals axes rate pr qrs qt qtc p qrs t chest single view reason fx medical condition year old woman with fall reason for this examination fx indication year old female with fall and cervical spine fractures findings ap portable supine chest radiograph is reviewed and compared to allowing for technique cardiomediastinal contours are normal the lungs are clear and there is no pleural effusion or pneumothorax no fracture is seen note is made of contrast excretion in the renal collecting system bilaterally from recent ct scan impression no acute cardiopulmonary process ct abdomen w contrast ct pelvis w contrast reason trauma no po contrast field of view contrast optiray medical condition year old woman with fall height reason for this examination trauma no po contrast contraindications for iv contrast none indication year old female with cervical spine fractures bruising unclear trauma comparison none technique mdct acquired axial images from the lung bases to the pubic symphysis after administration of intravenous contrast no oral contrast was administered ct abdomen visualized lung bases demonstrate minor dependent bibasilar atelectasis there is no pleural or pericardial effusion liver is unremarkable gallbladder pancreas and spleen are normal stomach and intra abdominal loops of bowel are unremarkable there is a small splenule at the splenic hilum kidneys enhance and excrete contrast symmetrically there is no hydronephrosis scattered hypodensities are seen throughout both kidneys likely representing cysts but too small to definitively characterize there is no free air free fluid or abnormal intra abdominal lymphadenopathy note is made of a small hiatal hernia ct pelvis rectum is unremarkable there is mild sigmoid diverticulosis without evidence of diverticulitis urinary bladder is partially decompressed with a foley catheter balloon in place there is no free pelvic fluid or abnormal pelvic or inguinal lymphadenopathy osseous structures there are no fractures no suspicious osteolytic or sclerotic lesions are seen mild degenerative changes of the lower lumbar spine are present with grade i anterolisthesis of l on l impression no acute intraabdominal abnormality no fractures technique non contrast head ct findings there is no acute intra or extra axial hemorrhage mass effect shift of normally midline structures or change in the ventricular size the ventricles and sulci remain prominent consistent with brain atrophy moderate in degree the bone graft in the region of the past right frontotemporal craniotomy is unchanged there is a new region of soft tissue swelling over the left frontal region superficially the paranasal sinuses demonstrate no air fluid level but a small amount of mucosal thickening in the visualized left maxillary sinus likely inflammatory in origin impression no evidence of intracranial hemorrhage soft tissue swelling over the left frontal region correlate with clinically observed areas of head trauma if known brief hospital course trauma she was admitted to the trauma service orthopedic spine surgery was immediately consulted given her injuries she was treated nonoperatively a hard cervical collar will need to remain in place for months she will need to follow up with dr in weeks time she was treated with acetaminophen for pain with good effect alcohol abuse given her history of long standing etoh use she was placed on a ciwa scale and did require prn ativan to manage her withdrawal symptoms she also required a sitter for maintaining safety given her intermittent agitation and restlessness her ativan dose was decreased given that it contributed to a worsening delirium as she was tapered off the ativan her mental status slowly improved geriatrics was also consulted given her age mechanism of injury and history of multiple falls several recommendations were made including reducing ativan dosing per ciwa scale given the effects of benzodiazepines on older individual s physical and occupational therapy were consulted and felt that the patient was suitable for rehab depression family reports that the patient has had some depressive symptoms currently but it is difficult to assess given concommitant dementia dementia initially the patient had significant delirium likely secondary to lorazepam for alcohol withdrawal as well as her acute trauma at the time of discharge her delirium has largely resolved but patient has a persistent dementia she is perseverative and has difficulty remembering where she was per psychiatry she had a low score on the mmse for now she has been treated with haloperidol prn diabetes does not carry this diagnosis prior to admission but had persistently elevated fs when not on diabetic diet once transitioned to diabetic diet glucose levels were controlled she was kept in a sliding scale while inpatient but will only need daily fingersticks if she remains controlled she should stay on diet anemia hct decreased since admission but with macrocytosis previously and currently elevated b folate iron studies were also ok cardiac initially with some tachycardia and rate related st depressions that improved with beta blockers given this ordered cardiac enzymes which were negative q h likely not secondary to ischemia there were no events on telemetry and the patient was given metoprolol mg tid with good effect hypertension though she does not carry this diagnosis patient does report being prescribed some medications that she would not take i suspect that she may have been diagnosed hypertension in the past as she was hypertensive in the absence of agitation well controlled on metoprolol tid initially with some concern for aspiration but passed speech and swallow evaluation at bedside dispo family had applied for guardianship during which time the patient remained in the hospital pending the application approval she remained entirely medically stable during this time though she was pleasantly confused and perseverative comm with medications on admission not taking any discharge medications bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for constipation thiamine hcl 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 hexavitamin tablet sig one cap po daily daily folic acid 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 metoprolol tartrate mg tablet sig one tablet po tid times a day trazodone mg tablet sig tablet po hs at bedtime as needed acetaminophen mg tablet sig two tablet po q h every hours as needed for pain discharge disposition extended care facility the cedars discharge diagnosis s p fall type ii c dens fracture etoh withdrawal discharge condition stable discharge instructions you must continue to wear your hard cervical collar for the next months followup instructions follow up with dr orthopedics spine surgery in weeks by calling for an appointment md,"{
""Diagnoses"": [""yo_f_s_p_c_type_odontoid_fracture"", ""subdural_hematoma"", ""alcohol_abuse"", ""ciwa_scale_alcohol_withdrawal"", ""hypertension"", ""metoprolol_hydralazine"", ""clonidine""],
""Medications"": [""morphine"", ""ativan""]
}"
26195,admission date discharge date date of birth sex m service csu history of present illness this year old male had no prior history of coronary artery disease but reported a year history of angina with progressive angina in the past year electrocardiogram showed st depressions in leads i ii and v through v as well as st elevations in v he was admitted to the hospital on and cardiac catheterization was performed which showed a percent distal left vein lesion a percent left anterior descending lesion percent circumflex lesion and a totally occluded rca in the mid portion his ejection fraction was percent intra aortic balloon pump was placed in the cardiac cath laboratory at the time of catheterization it also showed anterolateral and distal inferior hypokinesis past medical history angina bell s palsy hypertension hypercholesterolemia past surgical history repair of his left shoulder tonsillectomy allergies no known drug allergies medications he was on no medications daily social history the patient was a cab driver who said that he never smoked and had no history of alcohol use family history unknown as the patient was adopted physical examination he is feet inches tall and pounds he is in sinus rhythm at blood pressure respiratory rate sating percent on three liters nasal cannula he was in bed in the coronary care unit he was in no apparent distress he was alert oriented and appropriate he had a slight left facial droop due to his bell s palsy and no carotid bruits his lungs were clear to auscultation anteriorly bilaterally his heart was regular rate and rhythm with s and s tones his balloon pump was on his abdomen was soft round obese nontender and nondistended with positive bowel sounds his extremities were warm and well perfused with no edema or varicosities noted he had bilateral radial dorsalis pedis and posterior tibial pulses preoperative laboratory data white count hematocrit platelet count sodium potassium chloride bicarb bun creatinine with a blood sugar of pt ptt inr alt ast alkaline phosphatase amylase total bilirubin albumin chest x ray showed no acute cardiopulmonary disease his urinalysis was negative the patient was referred immediately in the cath laboratory to dr additional history showed that the patient in the morning of admission had walked to the and thinks he passed out or almost passed out he was brought in to the emergency room directly at that time dr saw the patient emergently in the cath laboratory and in consultation asked by dr the cathing cardiologist and the patient consented to have surgery the following morning that day in the evening in the coronary care unit the patient was started on captopril and metoprolol as well as a nitroglycerin drip with good effect he did not have any complaints at that time he was also given aspirin and lipitor and remained stable overnight on the morning of the th he was taken to the operating room where he had a coronary artery bypass grafting times three by dr with a left internal mammary artery to the left anterior descending a vein graft to the obtuse margin and a vein graft to the distal rca with a balloon pump in place he was transferred to the cardiac cath intensive care unit in stable condition on the neo synephrine drip at mcg kg minute and a propofol drip at mcg kg minute he was extubated on the evening of the th without incident sating percent the balloon remained in place with good augmentation and systolic and diastolic unloading he did have some episodes of sinus tachycardia to the s s he awakened in pain and he was monitored without any intervention his heart rate was in the s at rest his neo synephrine was weaned off his nitroglycerin was started after extubation and weaned off through the night he was taking sips of water and also remained on an insulin drip with plans to remove his balloon he was also seen by case management in the csru his balloon was removed later that day and he was transferred out to the floor the patient was also seen by social work as the patient had few supports and there was concern about his ability to care for himself and have rehabilitation the patient was living in a rooming house at at the time with three roommates on postoperative day two the patient was in sinus rhythm at a blood pressure of postoperative labs were as follows white count hematocrit platelet count potassium bun creatinine and inr he began his beta blockade with lopressor b i d he continued with lasix intravenous diuresis aspirin also had been restarted his chest tubes remained in place his intravenous line was removed pacing wires remained in place later that day his chest tubes were discontinued the patient was encouraged to get up with physical therapist and the nurse he was evaluated by the staff of physical therapy to work on his ambulation he was switched over to percocet p r n for pain control his pacing wires were discontinued on postoperative day three his blood pressure remained stable he was alert with a nonfocal examination his heart was regular in rate and rhythm his lungs were clear bilaterally he had one episode of mild heart palpitations while on the stairs which subsided immediately with rest he was steady on his feet though and quite independent and discharge planning continued he had some trace ankle edema bilaterally the patient had a complaint of constipation on he did have flatus milk of magnesia was also given as well as prune juice percocets were providing good pain relief he was also given a dulcolax suppository incisions were clean dry and intact the patient continued on telemetry monitoring with encouragement to increase his pulmonary toilet and continue to ambulate the patient did verbalize some fears and despondent thoughts secondary to his home situation nursing staff continued to work with social work and case manager to help plan postoperative services with the for counseling etc on postoperative day four the patient s examination was unremarkable he continued on diuresis and his medications he continued with physical therapy and working with the social work staff to plan for his discharge case management also agreed to help the patient fill out his health insurance paperwork as he was slightly anxious about it the patient was discharged to his rooming house with services on with the following discharge diagnoses status post emergency coronary artery bypass grafting times three bell s palsy hypertension discharge instructions the patient was instructed to follow up with his primary care physician in approximately two weeks and to follow up with dr his cardiac surgeon in the office first postoperative surgical visit in approximately one month discharge medications potassium chloride meq p o twice a day for seven days lasix mg p o twice a day for seven days zantac mg p o twice a day enteric coated aspirin mg p o once a day percocet one tablet p o p r n every four hours for pain lipitor mg p o daily metoprolol mg p o twice a day the patient was discharged with care group home care services on in stable condition dictated by medquist d t job,"{
""Diagnoses"": [""Coronary artery disease"", ""Angina"", ""Hypertension"", ""Hypercholesterolemia""],
""Medications"": [""Intra aortic balloon pump""]
}"
92281,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 cough and diarrhea major surgical or invasive procedure bronchoscopy with lavage history of present illness year old male with past medical history significant for hiv aids diagnosed in most recent cd count and vl and hep c presents with days duration of diarrhea cough and fever days prior to admission he began to experience non bloody watery diarrhea this was followed by subjective fevers with chills possible night sweats but no rigors he began to have a persistent cough productive of thick white phlegm no hemoptysis describes shortness of breath with exertion patient also complains of body aches myalgias generalized weakness and malaise patient s fiance noticed his heart was beating fast yesterday he has an intermittent frontal headache since sunday denies vision changes photophobia or neck stiffness on the day of admission patient had one episode of nausea which has since resolved with no vomiting denies decreased po intake pain or weight loss denies pain with swallowing describes chronic abdominal pain following meals patient describes pruritic papules on his lower extermities of weeks duration and has had a similar rash in the past he denies any sick contacts recent travel and has resided in the northeast since moving from at age denies ever having a positive ppd his last ppd was months ago at detox rehab he has spent time in a homeless shelter x month months ago and was incarcerated last in he denies any known exposure to tb patient has had inconsistent haart due to non compliance and substance abuse patient has history of alcohol and heroine abuse has not used either in months he was seen in clinic and was restarted on his art with combivir and lopinavir ritonavir as well as bactrim ss daily for pcp he states he has been taken azithromycin weekly for mac prophylaxis patient presented to er with temp po hr bp rr sa o ra received levaquin mg po x diflucan mg po x normal saline x l ibuprofen in er past medical history hiv aids diagnosed in cd and vl most recent art lopinavir ritonavir and combivir hx of exposure to stavudine lamivudine nevirapine hepatitis c diagnosed in genotype he has never been on therapy for this he is hepatitis b cab positive and sag negative and hep b dna negative when last checked in he is seronegative for hepatitis a and has had the vaccination twice bipolar disorder schizoaffective disorder obstructive sleep apnea in intravenous drug abuse alcohol abuse appendicitis e coli bacteremia of unknown etiology c difficile colitis esophagitis hospitalized at the in for abdominal pain a ct scan of the abdomen revealed thickening of the cecum and ascending colon but no pneumatosis his blood cultures were negative and no discrete cause was revealed he was discharged on azithromycin ciprofloxacin and metronidazole social history family from moved to at age live with fiance who is hiv negative sexually active condoms of time etoh abuse sober x months pint of vodka ivda heroin sober x months heroin crack cocaine tobacco cigarettes a day years hx of incarceration in s x and no travel multiple cats on disability stayed at pine street shelter x month months ago family history his mother had hypertension and type ii diabetes mellitus died age of unknown malignancy his father had hypertension died at of head trauma he has one sister who he thinks is in good health no contact with her in years and a brother who has aids due to drug abuse and who died of unknown malignancy physical exam physical exam t p bp rr o sat ra fsbs gen wdwn in nad lying down watching tv heent ncat perrl mm a mm bilaterally oropharynx moist some posterior white thrush neck supple no jvd cv rr nl rate nl s s no m r g lungs breathing comfortably ctab no rales wheezes rhonchi abd soft mildly distended and tense nontender normal bs no masses palpated ext pitting edema bilaterally dp pulses skin no lesions neuro alert awake oriented x answers questions and follows commands appropriately cn intact strength in upper and lower extremties bilaterally normal finger to nose no pronator drift no asterixis pertinent results pm urea n creat sodium potassium chloride total co anion gap pm alt sgpt ast sgot alk phos tot bili pm lipase pm urine bnzodzpn neg barbitrt neg opiates neg cocaine neg amphetmn neg mthdone neg pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count pm pt ptt inr pt pm urine blood neg nitrite neg protein neg glucose neg ketone tr bilirubin sm urobilngn ph leuk neg 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 wbc lymph abs cd abs cd cd abs cd cd abs cd cd cd pm blood wbc lymph abs cd abs cd cd abs cd cd abs cd cd cd am blood ret aut am blood glucose urean creat na k cl hco angap am blood alt ast alkphos totbili admission cxr pa and lateral views of the chest are obtained low lung volumes limit evaluation there is ill definition of the left heart border which may be related to early lingular pneumonia in addition there are increased bronchovascular markings in the right cardiophrenic recess which is likely related to crowding of bronchial vasculature low lung volumes there is no pleural effusion or evidence of pneumothorax heart size does not appear enlarged mediastinal contour is unremarkable osseous structures appear intact possible early pneumonia in the lingula somewhat limited study due to low lung volumes cxr there is minimally increased opacity seen projecting over the left heart margin this is likely a focus of lingular consolidation there is also new opacity projecting over the right lung base and right costophrenic angle given the history this may also represent a focus of infection otherwise there are no new foci of infection the cardiomediastinal contours are unchanged the visualized soft tissue structures and bony thorax are unremarkable impression mild interval increase in left lingular opacity likely pneumonia new right lung base opacity may be a second focus of pneumonia ct head with contrast there is no acute intracranial hemorrhage or major vascular territorial infarct white matter differentiation is preserved the ventricles are normal in size and configuration the calvarium and soft tissues are normal following administration of contrast there are no abnormally enhancing masses impression no evidence of enhancing intracranial mass or fluid collection ct chest w o contrast multifocal peribronchovascular and peripheral ground glass opacities and consolidation progressive over a week most likely viral or mycoplasma pneumonia pulmonary hemorrhage or idiopathic pneumonia such as acute interstitial or eosinophilic varieties anemia tiny amount of perihepatic ascites multiple enlarged mediastinal lymph nodes could be related to the acute process or to hiv ct abd w contrast massive abdominal and pelvic ascites with thickened bowel most likely consistent with anasarca nodular liver with recanalization of umbilical vein and underlying splenomegaly concerning for cirrhosis multilobular ground glass pulmonary opacities with no definite cause most likely due to underlying edema however inflammatory and infectious process cannot be ruled out peritoneal fluid no polymorphonuclear leukocytes seen no microorganisms seen fluid culture no growth anaerobic culture no growth duplex doppler abdomen cirrhosis without a focal liver lesion seen patent hepatic vasculature moderate abdominal ascites mostly surrounding the liver no safe spot for paracentesis could be marked brief hospital course y o male with hiv aids presented to ed with days hx of subjective fevers cough headache and diarrhea diagnosed with pcp pcp bactrim begun on pcp confirmed by bronchoscopy performed on steroids begun due to worsening inflammation and po on abg bactrim changed to primaquine clindamycin on due to bactrim induced leukopenia down to plan to continue prednisone d clindamycin d and primaquine d to plan for prednisone taper mg from to mg qd from to and mg qd from to pt scheduled for f u with dr as of ambulating sats ra at rest to ra walking discharged feeling well and not sob lactic acidosis lactate peaked at on trended down after haart discontinued because of concern meds were contributing to lactic acidosis ultimately believed haart therapy which was held from to resolved on its own headache ct and lp were negative for intracranial mass or infection hypothermia hypothermic to on second transfer from micu resolution with warming blankets and broad spectrum antibiotics vancomycin and zosyn vancomycin and zosyn discontinued after blood cultures returned negative hepatitis c previously diagnosed never treated because of psychiatric history and adherence issues acute decompensation during hospital stay with distended abdomen abdominal pain and mental status changes attributed to hepatic encephalopathy sbp ruled out by peritoneal fluid analysis imaging of abdomen negative treated with lactulose and rifaximin with improvement in mental status anemia lowest hematocrit at hematocrit on admission two units transfused with good effect hematocrit returned to concern for hemolysis given low haptoglobin but few schistocytes on smear so low concern for ttp despite mental status changes hypothermia acute renal failure and thrombocytopenia near baseline low retic count suggests bone marrow suppression as well as possible hemolytic component acute renal failure creatinine on admission with peak at on likely multifactorial given nephrotoxicity of bactrim and ct contrast as well as hypovolemia full code fiancee named as health care proxy authorization in chart medications on admission combivir tab po twice daily lopinivir ritonavir mg tab po twice daily lotrisone topical mvi bactrim ss daily allergies nkda discharge medications primaquine mg tablet sig one tablet po daily daily please stop taking on rifaximin mg tablet sig one tablet po tid times a day lamivudine zidovudine mg tablet sig one tablet po bid times a day lopinavir ritonavir mg tablet sig two tablet po bid times a day nicotine mg hr patch hr sig one patch hr transdermal daily daily clindamycin hcl mg capsule sig three capsule po q h every hours please stop taking on lactulose gram ml syrup sig thirty ml po bid times a day as needed for goal bms per day trazodone mg tablet sig tablet po hs at bedtime as needed for sleep nystatin unit ml suspension sig five ml po qid times a day folic acid mg tablet sig one tablet po daily daily multivitamin 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 please stop taking on bumetanide mg tablet sig two tablet po daily daily spironolactone mg tablet sig two tablet po daily daily prednisone mg tablet sig one tablet po daily daily please stop taking on dapsone mg tablet sig one tablet po daily daily discharge disposition home discharge diagnosis primary pneumocystis jiroveci pneumonia pcp hiv aids hepatitis c virus and cirrhosis with acute liver decompensation hepatic encephalopathy hemolytic anemia thrombocytopenia discharge condition hemodynamically stable in no respiratory distress discharge instructions you were admitted to the hospital because of fever and cough you were diagnosed with pcp known as pneumocystis jiroveci pneumonia you were treated for this pneumonia with antibiotics and steroids because your white blood cell count dropped your antibiotics were changed to a different antibiotic you also were anemic while you were here and you received two units of blood during your hospitalization your liver disease became worse and you had some extra fluid in your belly and your legs because of this at home it is very important that you complete your antibiotics return to your doctor or to the emergency department if you have a fever a cough or changes in your mental status please follow up with your doctor for treatment of your liver disease we have made some changes to your medications please follow the list closely return to the er if you experience shortness of breath fever chills confusion bleeding increase in stomach size or any other concerning symptoms followup instructions provider m d phone date time provider md phone date time completed by [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 fever abdominal pain major surgical or invasive procedure diagnostic paracentesis history of present illness mr is a y o m with aids cd on hepatitis c cirrhosis recently discharged on after a five day admission for abdominal pain worsening ascites jaundice and diarrhea now presents with fever and abdominal pain during his prior admission from he presented with abdominal pain worsening ascites jaundice and diarrhea ct scan on admission showed colitis stool cultures and cmv were negative he underwent egd and colonoscopy which were unrevealing biopsies were negative he underwent therapeutic paracentesis removing liters of ascites he was started on immodium for diarrhea lasix and aldactone the patient mentions that week ago he started having diarrhea with dark stools about days ago he had worsening abdominal pain and chills he has been having bowel movements per day which is more than usual even with taking lactulose and rifaximin he has had poor po intake over the past days secondary to nausea and vomiting emesis has been non bloody non bilious patient denies any cough shortness of breath or chest pain no brbpr no dysuria he does not believe his abdomen is larger than baseline in the ed initial vs he was found to have diffuse abdominal tenderness and brown guaiac positive stool abdominal paracentesis was attempted twice however was stopped due to bleeding given inr of further attempts were not pursued he received levofloxacin mg vancomycin g empirically for community acquired pneumonia with flagyl for abdominal coverage and bactrim he also received pantoprazole mg x ct abdomen pelvis revealed colitis he received l iv fluids on transfer vital signs were hr bp rr on ra on evaluation in the icu the patient has some mild abdominal pain and weakness but no other complaints ros denies night sweats headache vision changes rhinorrhea congestion sore throat cough shortness of breath chest pain abdominal pain nausea constipation brbpr hematochezia dysuria hematuria past medical history hiv aids diagnosed in cd vl h o heart murmur since childhood bronchospastic lung disease bipolar disorder osa hepatitis c diagnosed in genotype he has never been on therapy for this due to his psychiatric problems is hepatitis b cab positive and sag negative and hep b dna negative when last checked in h o e coli bacteremia in with no identified source appendicitis in managed medically with antibiotics clostridium difficile colitis gerd h o polysubstance abuse heroin etoh cirrhosis pt reports diagnosed year ago thought hep c denies being followed by gi liver specialist child class c based on most recent lab values h o candidal esophagitis s p treatment for tb per patient completed month course social history family from but pt born in live with fiance who is hiv negative sexually active condoms of time etoh abuse sober ivda heroin sober tobacco hx of incarceration in s and no travel multiple cats on disability stayed at pine street in x month family history noncontributory physical exam vitals t bp hr rr sat ra general alert nad heent sclera icteric mm slightly dry cardiac rrr no murmurs rubs gallops lung ctab except bibasilar crackles abdomen bs somewhat tense and distended non ttp no rebound or guarding ext warm well perfused le edema neuro a o to self location not date interacts appropriately derm tattoo over l chest no rashes pertinent results pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm neuts lymphs monos eos basos pm pt ptt inr pt pm alt sgpt ast sgot ck cpk alk phos tot bili pm lipase pm glucose urea n creat sodium potassium chloride total co anion gap pm lactate pm urine color yellow appear hazy sp pm urine blood neg nitrite neg protein glucose neg ketone neg bilirubin lg urobilngn neg ph leuk neg pm urine rbc wbc bacteria mod yeast none epi ascites wbc polys lymph monos hct t protein alb mico blood cultures pending urine culture negative cmv viral load detectable but copies ml ascites pending stool negative for c diff o p negative ct abd pelvis diffuse bowel wall thickening of the ascending and transverse colon appearing similar to ct from while liver failure may contribute to this appearance infectious inflammatory colitis cannot be excluded cirrhosis with large volume ascites hematocrit level in the pelvic ascites suggests a component of blood in the fluid possibly secondary to traumatic paracentesis cxr findings there has been interval clearing of the airspace opacity in the right lower lung with stable airspace opacities in the right upper lung and unchanged left retrocardiac atelectasis cardiomediastinal silhouette is unchanged and normal position of the left internal jugular central venous line tip is at the cavoatrial junction no pneumothorax or pleural effusion impression interval improvement with clearing of the right lower lung stable airspace opacities in the right upper lobe most likely pneumonia brief hospital course mr is a year old man with aids and hcv with decompensated cirrhosis who presented on with fevers and abdominal pain with hypotension requiring icu admission goal of care given the patient s end stage liver disease and advanced aids the palliative care service was consulted in discussion with the patient and his family the decision was reached to make him dnr dni and comfort measures only he will be treated with anxiolytics and pain medications as needed hypotension likely due to volume depletion and possible sepsis improved with ivf resuscitation and antibiotics fever possible sbp patient underwent a therapeutic paracentesis complicated by bleeding hct a component of sbp could not be absolutely excluded therefore he was treated empirically with ceftriaxone cmv assay showed detectable virus but at a very low level copies below limits of assay to quantify and was felt to most likely be a false positive aids patient had supressed viral load with poor immunologic recovery after being made cmo his antiretrovirals and prophylactic antimicrobials were discontinued hcv cirrhosis he was continued on lactulose and rifaximin for management of encephalopathy once made cmo his nadolol was discontinued he may undergo therapeutic paracentesis if required for symptomatic relief with his large ascites acute renal failure likely pre renal on presentation with atn in setting of hypotension with his tense ascites abdominal compartment syndrome was a consideration as was hepatorenal syndrome given possible sbp further workup was deferred once he was made cmo to do comfort measures only please titrate dilaudid as needed medications on admission atazanavir reyataz mg po daily ritonavir norvir mg po daily truvada tab daily azithromycin mg po q tuesday furosemide mg po daily lactulose gram ml solution ml s by mouth one table spoon once per day as needed for for bms per day nadolol mg po daily omeprazole mg po daily rifaximin xifaxan mg po tid spironolactone mg po daily trimethoprim sulfamethoxazole mg mg po daily ferrous sulfate mg po tid multivitamin po daily discharge medications lorazepam mg ml concentrate sig mg po q h every hours as needed for anxiety give sl disp day supply refills haloperidol lactate mg ml concentrate sig mg po q h as needed for agitation give sl disp day supply refills hydromorphone mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills discharge disposition extended care facility discharge diagnosis possible spontaneous bacterial peritonitis cirrhosis aids discharge condition fair hemodynamically stable comfort measures only dnr dni discharge instructions you came into the hospital because of fever and abdominal pains because your blood pressure was low you were treated in the intensive care unit you had a procedure called a paracentesis to examine the fluid in your abdomen you were treated for a possible infection of this fluid upon further discussion with you and your family a decision was reached to avoid further aggressive medical care and focus on your comfort with discharge to hospice please let your doctors know if are in pain and we will make every effort to improve your comfort followup instructions no appointments as pt is comfort measures only completed by,"{
""Diagnoses"": [""HIV AIDS"", ""Bronchoscopy with lavage"", ""Non-bloody watery diarrhea"", ""Cough"", ""Fever"", ""Body aches"", ""Myalgias"", ""Generalized weakness"", ""Malaise""],
""Medications"": [""""]
}"
4194,admission date discharge date date of birth sex m service chief complaint the patient is admitted for cardiac catheterization history of present illness the patient is a year old man referred by dr for outpatient cardiac catheterization due to a routine positive stress test history of present illness the patient had a coronary artery bypass graft times one saphenous vein graft to the left anterior descending in in he had a stress test during which he exercised on for minutes achieving of his predicted maximal heart rate stopping due to fatigue he had no angina and due to baseline abnormalities the electrocardiogram was non diagnostic myoview showed a small apical infarct with a small anterior apical ischemia revealed left ventricular function of mr denied any angina he also has a history of hypertension hypercholesterolemia polio as a child as stated previously coronary artery bypass graft times one catheterization done at on showed left anterior descending with occlusion after d filled via collaterals from the circumflex and the right coronary artery of the circumflex with a mid stenosis obtuse marginal was large and it was non obstructed obtuse marginal two was small with an ostial obstruction right coronary artery proximal occlusion saphenous vein graft to the left anterior descending was occluded at the stump and his ejection fraction was following cardiac catheterization the patient was referred to ct surgery for coronary artery bypass grafting he has an allergy to penicillin medications aspirin mg p o q day atenolol mg q day phenocol one tablet q day lipitor mg q day social history denies cigarette use alcohol two to three beers per week he lives with his wife family history significant for coronary artery disease in eight uncles all who died of myocardial infarction all under the age of review of systems unremarkable physical examination young man in no acute distress vital signs heart rate blood pressure respiratory rate of oxygen saturation on room air head eyes ears nose and throat pupils are equal round and reactive to light and accommodation extraocular movements intact non injected anicteric oropharynx is benign neck is supple with no lymphadenopathy or thyromegaly carotids are without bruits lungs are clear to auscultation anteriorly there is a well healed sternal incision cardiovascular regular rate and rhythm without murmurs rubs or gallops abdomen is soft nontender no masses positive bowel sounds extremities warm and well perfused with no edema and a well healed right lower extremity incision the patient also has an abdominal splenectomy scar pulses are throughout neurologic examination is nonfocal hospital course on the patient was brought to the operating room please see the operating room for full details in summary the patient had a coronary artery bypass graft times four with a left internal mammary artery to the left anterior descending saphenous vein graft to the distal right coronary artery saphenous vein graft to the obtuse marginal one and saphenous vein to the diagonal he tolerated the procedure well his bypass time was minutes with a cross clamp of minutes following surgery the patient was transferred from the operating room to the cardiothoracic intensive care unit the patient did well in the immediate postoperative period his anesthesia was reversed he was weaned from the ventilator and successfully extubated on postoperative day number one the patient remained hemodynamically stable however he did require a small amount of neo synephrine to maintain an adequate blood pressure also on day one his swan ganz catheter was removed on postoperative day number two the patient was weaned off his neo synephrine drip his mediastinal chest tubes were removed leaving a pleural chest tube due to a right apical pneumothorax revealed by chest x ray he was transferred to the floor for continuing postoperative care and cardiac rehabilitation on the floor the patient was followed with serial chest x rays his chest tube was put to water seal on postoperative day number four there was no change in the size of the pneumothorax on day four or day five having been on water seal for hours and the chest tube was removed at that time the patient s activity level was increased with the assistance of the nursing staff and the physical therapy department he remained hemodynamically stable throughout his stay on the floor on postoperative day number six it was decided that the patient will be stable and ready to be discharged to home on the following day on postoperative day number seven the patient was discharged to home his physical examination at that time is as follows vital signs temperature heart rate sinus rhythm blood pressure respiratory rate of oxygen saturation of on room air weight preoperatively was kg at discharge weight is kg laboratory data white blood cell count of hematocrit of platelets of pt of ptt of inr of sodium of potassium of chloride c bun creatinine glucose neurologic alert and oriented times three moves all extremities follows commands respiratory breath sounds scattered rhonchi on the right clear to auscultation on the left cardiovascular regular rate and rhythm s and s with no murmurs sternum was stable and incision with staples open to air clean and dry abdomen is soft nontender nondistended with normoactive bowel sounds extremities are warm and well perfused with minimal pedal edema left lower extremity incision with steri strips open to air clean and dry discharge medications metoprolol mg three times a day niferex mg q day lasix mg q day times days potassium chloride meq q l day times ten days atorvastatin mg q day enteric coated aspirin mg q day colace mg twice a day percocet one to two tablets every four to six hours prn condition at discharge good discharge diagnoses coronary artery disease status post redo coronary artery bypass grafting with left internal mammary artery to the left anterior descending saphenous vein graft to the distal right coronary artery saphenous vein graft to the obtuse marginal and saphenous vein graft to diagonal hypercholesterolemia polio as a child disposition the patient is to have discharge to home he is to have follow up with dr in two to three week and follow up with dr in six weeks m d dictated by medquist d t job,"{
""Diagnoses"": [""cardiac catheterization"", ""coronary artery bypass graft"", ""hypertension"", ""hypercholesterolemia"", ""polio""],
""Medications"": [""""]
}"
1227,admission date discharge date date of birth sex f service micu history of present illness this is a year old woman with autoimmune hepatitis and secondary cirrhosis who presented to on on advice from her pcp who noted sodium of potassium of on a scheduled appointment she has been admitted and found to have also an increased bilirubin over her hospital stay the patient as per the printout the sodium remained in the mid s potassium was reduced with kayexalate and aldactone was held coagulopathy pt of inr of on admission was treated with fresh frozen plasma and vitamin k prior to this admission in the patient developed lower extremity edema fatigue and decreased mobility she was found to have increased lfts and was started on imuran lasix and aldactone with some improvement of symptoms mri revealed cirrhosis it was confirmed by biopsy one week prior to admission approximately one month ago the patient is evaluated for transplant and was given an increase in aldactone and subsequently admitted for pyelonephritis then she was given levofloxacin and also an esophagogastroduodenoscopy was performed which revealed grade i varices and colonoscopy revealed multiple diverticulosis and two polyps during this current hospital stay the patient began developing low blood pressures systolics in the s s for approximately hours before transfer to the micu urine culture grew two species of gram negative rods o sats remained in the mid s and mental status decreased with orientation only to person past medical history autoimmune hepatitis cirrhosis secondary to chronic hepatitis history of pyelonephritis one month ago breast cancer status post lumpectomy and radiation therapy in perirectal abscess hypertension medications prednisone mg q day norvasc mg q day imuran mg q day lasix mg q day aldactone mg tid allergies no known drug allergies family history mother deceased from colon cancer at father deceased in the s from stroke siblings with heart disease social history lives with husband in has four children no alcohol or smoking or drugs physical examination temperature of heart rate blood pressure and o sat is on liters nasal cannula in general the patient is alert responds to questions knows she is in a hospital and knows her name follows simple commands heent pupils are equal round and reactive to light positive scleral icterus bilaterally neck is supple lungs decreased breath sounds at the bases no wheezes heart is regular rate and rhythm heart sounds soft abdomen is soft and nondistended with fluid wave extremities edematous hematomas in upper extremities and venous stasis changes in the lower extremities bilaterally skin jaundiced positive actinic keratoses on face and back multiple hematomas at puncture site laboratories hematocrit of potassium of sodium of pt ptt inr of alt ast alkaline phosphatase total bilirubin albumin cultures grew klebsiella hospital course the patient was consulted by transplant surgery and hepatology as well as renal patient was transfused with unit of packed red blood cells on on the patient had a difficult to control blood pressure with blood pressures in the s s and was started on a neo drip the patient was transfused with units of packed red blood cells and given normal saline maintenance fluid there was a plan for a right ij to be placed in the morning urology saw the patient concerning a left renal mass which appeared to be renal cell carcinoma per mri ercp fellow asked to evaluate for ercp indications for cystic pancreatic lesions but there is no biliary dilatation on mrcp and no urgent indication for ercp the patient should await medical stabilization to arrange ercp on the patient had received several boluses of normal saline to decrease blood pressure and responded well the patient had dyspnea overnight with high o sats and stable vital signs the patient then subsequently began to require more and more pressors including vasopressin and neo synephrine the patient was continued on lactulose and renal was consulted stating that the patient likely had hepatorenal syndrome started on octreotide midodrine and continued on the vasopressin in an attempt to increase perfusion to the kidneys was also continued on a prednisone taper the patient appeared to have urosepsis as well as perhaps hemolysis condition began to deteriorate throughout the admission and was then deemed not a transplant candidate or an operative candidate per the hepatology service renal mass remained highly suspicious for renal cell carcinoma and the patient was deemed not a transplant candidate due to infection her need for pressors and her respiratory and renal condition then began to also develop abdominal pain suspicious for pancreatitis versus ascites with svp it is also question that the vasopressin was causing ischemic bowel on there was a family meeting and the family and the family agreed to hold resuscitation and nutrition and to keep the patient comfortable at the patient s o sats decreased to the high s and low s on liters nasal cannula chest x ray showed congestive heart failure and the patient had no response to lasix patient s stool was guaiac positive at this point and the bun was increasing there was likely slow bleed in the gastrointestinal tract in addition the patient developed atrial fibrillation and spontaneously cardioverted the patient additionally runs of nsvt on the patient was changed to dnr dni and placed on morphine drip for comfort the neo synephrine was continued but there is no titration for systolic blood pressure the vasopressin was discontinued due to question of ischemic bowel and the patient s systolic blood pressure slowly decreased overnight the patient was unresponsive at that point at am on the patient became apneic and passed away the patient was without heart sounds and no respirations pupils were dilated and fixed the family refused postmortem examination m d dictated by medquist d t job,"{
""Diagnoses"": [""Autoimmune hepatitis"", ""Secondary cirrhosis"", ""Pyelonephritis""],
""Medications"": [""Kayexalate"", ""Aldactone"", ""Lasix"", ""Levofloxacin"", ""Fresh frozen plasma"", ""Vitamin K""]
}"
24671,admission date discharge date date of birth sex f service medicine allergies codeine morphine lidocaine attending chief complaint chest pain major surgical or invasive procedure s p diagnostic cath s p pci with stenting of svg graft to rca history of present illness yo female with pmh cad s p cabg and pci x with stenting of svg to lcx presents from osh with substernal chest pain since pt had chest epigastric discomfort on sunday which seemed worse with food pain did not resolve no radiation sob nausea pt seen in clinic on thursday with persistent cp and found to have anterior st depressions in v along with stable st elevations inferiorly pt admitted to hospital where chest pain was relieved with nitro drip has been chest pain free since at pt found to have positive troponin and negative ck which coupled with ekg changes led to the diagnosis of nstemi sent to ccu here at for potential cath pt is currently without complaints denies cp sob doe pnd ros negative for fever chills nausea vomiting diarrhea abdominal pain past medical history significant for cad s p cabg s p pcix angina hypertension anxiety depression history of tias carotid endarterectomy bilateral spinal stenosis social history denies tobacco etoh drugs family history non contributory physical exam vs afebrile p rr lnc heent perrl eomi mmm neck jvp cm heart rrr nl s s sem lungs ctab abd soft nt nd bs groin no bruits bilaterally ext no edema bilaterally dp neuro cn intact upper and lower extremity strength pertinent results pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm pt ptt inr pt pm glucose urea n creat sodium potassium chloride total co anion gap pm calcium phosphate magnesium pm ck cpk pm calcium phosphate magnesium pm ck cpk pm ck mb notdone ctropnt am blood ck cpk am blood ck mb notdone ctropnt pm blood ck cpk pm blood ck mb notdone ctropnt am blood ck cpk pm blood ck cpk am blood ck cpk pm blood ck cpk ekg sinus brady with new st depressions in v and old mm st elevation in inferior leads inferior q waves anterior tw flattening brief hospital course cad pt admitted s p nstemi with positive tn and negative ck with new anterior st depressions and old inferior st elevations on admission pt was chest pain free she was continued with medical management on asa heparin drip integrillin drip nitro drip ezetimibe lipid lowering beta blocker and acei on the night of admission pt developed episodes of chest pain each associated with hypertension each time the pt was given iv lopressor to lower blood pressure sublingual nitro and increase in nitro drip with resolution of chest pain the second episode of chest pain was associated with st depressions in anterolateral leads cardiology fellow was consulted and emergent cardiac cath was considered after the third episode of chest pain pt had slowly resolving chest pain on maximal dose of nitro drip pt was taken to emergent cath and found to have fully occluded native vessels and svg grafts the only vessel that was patent was her lima graft to lad which was stenosed beyond the anastomosis left ventriculography found lvef of with inferior akinesis ct surgery was consulted for potential cabg however they felt that she was not a good surgical candidate given the high risk of the surgery with only one patent major artery pt was taken back to cardiac cath during which a cypher drug eluding stent was placed in the svg graft to the rca pt had no post procedure complications her medical management was optimized pt remained hemodynamically stable and chest pain free throughout the rest of the hospitalization pump pt was euvolemic on admission left ventriculography during cardiac cath found lvef of with inferior akinesis rhythm no arrythmias were noted on telemetry hypertension pt s blood pressure was managed with beta blocker and ace she was given iv lopressor for transient episodes of hypertension associated with chest pain anemia on admission hct was hct decreased to after the first cardiac cath pt was transfused unit with hct bump to prior to discharge pt was transfused for hct of with hct bump to hx cva tia stable with non focal neuro exam on admission pt was continued on asa hx depression and anxiety pt remained stable without any psych medications prophylaxis pt was given ppi and initially on heparin drip medications on admission lopressor colace iron mvi maalox cc q h zetia mg qd zebeta mg qd ativan prn norvasc qd nitrostat imdur dyazide tab qd zoloft qd discharge disposition extended care facility rehab center discharge diagnosis nstemi discharge condition stable discharge instructions if you develop chest pain or difficulty breathing call your pcp or return to the emergency immediately followup instructions follow up with your primary care doctor dr follow up with your cardiologist,"{
""Diagnoses"": [""NSTEMI"", ""Hypertension"", ""Anxiety"", ""Depression"", ""CAD"", ""CABG"", ""PCIx"", ""Carotid endarterectomy"", ""Bilateral spinal stenosis""],
""Medications"": [""Codeine"", ""Morphine"", ""Lidocaine"", ""Tias""]
}"
89040,admission date discharge date date of birth sex f service medicine allergies morphine ace inhibitors attending chief complaint shortness of breath came to hospital for le weakness major surgical or invasive procedure emg history of present illness mrs is a year old female with a history of coronary artery disease s p cabg congestive heart failure ef and copd who initially presented to an osh with a three week history of progressive lower extremity weakness and falls at home she denies specific trauma on presentation she also complained of an involuntary lb weight loss over a period of months she has chronic dyspnea on exertion thought to be secondary to her severe cad and congestive heart failure but she had not had a worsening of these symptoms prior to presentation she was transferred to this hospital for neurology consultation for possible syndrome she was admitted to the neurology service on she initially underwent non contrast ct scan of the abdomen and pelvis which showed no clear etiology of her weakness of weight loss she underwent emg which showed no electrophysiologic evidence for a generalized polyneuropathy including a demyelinating radiculopolyneuropathy or for a lumbosacral polyradiculopathy on the right on she underwent non contrast ct c spine which showed multilevel degenerative changes as well as a ct of the abdomen with contrast which showed no active malignancy she received iv hydration prior to her ct scan since her ct scan she has had a worsening of her creatinine from on admission to on and on she received iv hydration at cc hr for her acute renal failure overnight on she was noted to have worsening dyspnea she underwent cxr which showed hyperinflation but no evidence of pneumonia or volume overload the micu consult service was called on at approximately pm for worsening respiratory distress on arrival the patient was audibly wheezing and was using accessory muscles of respiration while previously satting well on room air she was noted to be on ra and was placed on a non rebreather prior to arrival she had received mg iv lasix with no effect previously on torsemide mg daily abg showed acute respiratory acidosis on a non rebreather repeat cxr was concerning for mild worsening of pulmonary edema she did not have improvement after nebulizer therapy she was transferred to the micu for respiratory distress micu course on arrival to the micu she was placed on bipap out of concern for pulmonary edema she was somnolent and not responsive to questions she was continuing to use accessory muscles of respiration nitro gtt was given for a few hours despite minimal urine output from furosemide patient s respiratory status rapidly improved her acute renal failure was thought to be from contrast loads in the morning after micu transfer patient started to autodiurese past medical history coronary artery disease s p cabg and s o inferior myocardial infarction cardiac catheterization in with significant disease not amenable to intervention systolic heart failure ef atrial fibrillation on coumadin sinus bradycardia s p pacemaker placement hypertension hyperlipidemia type ii diabetes history of tias peripheral vascular disease gout copd stage ii chronic kidney disease creatinine social history lives alone in a housing complex in in a single floor apartment w an elevator in the building she pays her own bills smoked up until years ago w recent relapses no alcohol or drug use family history heart disease and cancer she is of children but only of them are living physical exam vitals t bp hr rr o on l nc general elderly woman in nad heent sclera anicteric mm moist oropharynx clear neck jvp elevated at cm cardiac regular rate and rhythm s s no murmura rubs gallops chest khyphotic lungs diffuse inspiratory and expiratory wheezes crackles throughout r side halfway up on left side hyperinflation gi soft non tender non distended bs ext cool pulses dopplerable no clubbing cyanosis or edema neurologic cn ii xii intact motor symm u and le symm cereb fnf intact gait assessment deferred ms a ox speech fluent tp linear pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts lymphs monos eos baso am blood glucose urean creat na k cl hco angap pm blood ck mb ctropnt probnp am blood ck mb ctropnt probnp pm blood ck mb ctropnt am blood caltibc ferritn trf pm blood hb pm csf spinal fluid source lp tube final report gram stain final no polymorphonuclear leukocytes seen no microorganisms seen this is a concentrated smear made by cytospin method please refer to hematology for a quantitative white blood cell count fluid culture final no growth a c conclusions the left atrium is elongated the estimated right atrial pressure is mmhg left ventricular wall thicknesses and cavity size are normal there is severe global left ventricular hypokinesis lvef the basal anterior wall contracts best but is also hypokinetic no masses or thrombi are seen in the left ventricle the estimated cardiac index is low l min m tissue doppler imaging suggests an increased left ventricular filling pressure pcwp mmhg right ventricular chamber size is normal with mild global free wall hypokinesis the aortic valve leaflets are mildly thickened but aortic stenosis is not present there is no aortic valve stenosis no aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild to moderate mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is a trivial physiologic pericardial effusion impression normal left ventricular cavity size with severe global hypokinesis and mild right ventricular free wall hypokinesis c w diffuse process toxin metabolic etc cannot exclude multivessel cad mild pulmonary artery systolic hypertension mild moderate mitral regurgitation radiology report ct abdomen w contrast study date of pm impression severe atherosclerotic stenosis at the origins of the celiac axis and sma with post stenotic dilatation these findings raise the possibility of intestinal angina particularly given the patient s history of weight loss there is no ct evidence of acute ischemia enlargement of the adrenal glands bilaterally without focal nodules likely adrenal hyperplasia a cm right adnexal cyst which is abnormal in this postmenopausal patient pelvic ultrasound is recommended for further characterization two peripherally enhancing hepatic lesions consistent with hemangiomas patent aorto bifem graft and mm pulmonary nodules at the lung bases the patient is scheduled to have a dedicated chest ct shortly at which time the remainder of the chest can be evaluated brief hospital course ms year old woman with a history of coronary artery disease s p cabg congestive heart failure ef and copd who initially presented to an osh with a three week history of progressive lower extremity weakness and falls at home who was admitted to the neurology service initially acute chf exacerbation the pt developed respiratory failure in the setting of receiving iv hydration prior to contrast administration cardiac enzymes were unremarkable the pt was initially diuresed with iv lasix and was then changed to her home torsemide regimen when her renal failure began to improve progressive lower extremity weakness the pt had a head ct ct c spine and emg which were largely unremarkable and did not show evidence of syndrome malignancy workup included ct torso with contrast which was unrevealing on transfer to the floor following the chf exacerbation the pt s strength in her lower extremities was the pt worked with physical therapy and was discharged with plans for home pt on discharge the pt was able to walk comfortably with a walker acute renal failure the pt s creatinine rose to from baseline of following administration of iv contrast the pt s creatinine improved over the rest of admission the renal failure was likely contrast induced nephropathy in the setting of two dye loads urine eosinophils were negative coronary artery disease s p cabg reportedly the pt was known to have persistent lesions not amenable to intervention and as an outpatitient was on nitrates and ranolazine for persistent dyspnea on exertion and angina the pt s home isosorbide mononitrate simvastatin metoprolol and aspirin were continued and the pt s cardiac enzymes trended down during this admission the pt was noted to have an ace inhibitor intolerance atrial fibrillation the pt has a pacemaker and on discharge coumadin was restarted diabetes mellitus the pt s home glyburide was changed to glipizide due to the patient s decreased creatinine clearance in the setting of contrast induced nephropathy medications on admission spironolactone mg po daily metoprolol po bid potassium meq daily ranexa ranolazine g daily omeprazole mg simvastatin mg daily torsemide mg po daily isorbide mononitrate daily glyburide mg colchicine daily coumadin mg qd discharge medications simvastatin mg tablet sig one tablet po daily daily spironolactone mg tablet sig one tablet po daily daily isosorbide mononitrate mg tablet sustained release hr sig one tablet sustained release hr po daily daily colchicine mg tablet sig one tablet po daily daily potassium chloride meq tab sust rel particle crystal sig one tab sust rel particle crystal po daily daily for weeks torsemide mg tablet sig one tablet po once a day ranolazine mg tablet sustained release hr sig two tablet sustained release hr po qday as needed for cad warfarin mg tablet sig one tablet po daily daily please do not restart your warfarin until you have your inr checked and dr office calls you to tell you to restart your warfarin omeprazole mg capsule delayed release e c sig one capsule delayed release e c po twice a day outpatient lab work check inr on glipizide mg tab sust rel osmotic push hr sig one tab sust rel osmotic push hr po bid times a day disp tab sust rel osmotic push hr s refills toprol xl mg tablet sustained release hr sig one tablet sustained release hr po once a day disp tablet sustained release hr s refills discharge disposition home with service facility discharge diagnosis acute on chronic congestive heart failure diabetes hypertension gout discharge condition stable discharge instructions ms you were admitted with leg weakness you had a muscle test to look at the nerve function in your muscles and this was normal you had a number of radiology studies to look for anatomical causes of your weakness and there was no evidence of any dangerous abnormality during this hospitalization you developed respiratory distress which was probably caused by the fluids you were given for hydration prior to a radiology study you were treated with diuretic medicines to allow you to get rid of the fluid in your lungs and you improved you worked with physical therapy and your leg weakness resolved most of your home medications remain the same please continue to take your home medications as directed some changes have been made to your home medications metoprolol has been changed to toprol xl your warfarin has been stopped please do not restart your warfarin until you have your inr checked and dr office calls you to tell you to restart your warfarin your glyburide has been stopped you have been started on glipizide if you develop any chest pain shortness of breath wheezing or any other distressing symptom please return to the emergency room followup instructions appointment md dr specialty cardiology date and time wednesday at pm location medical center dr ma phone number appointment md dr specialty internal medicine date and time wednesday at pm location medical center dr ma phone number [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies morphine ace inhibitors attending chief complaint osh transfer for evaluation of abdominal pain major surgical or invasive procedure stenting of sma and celiac arteries history of present illness ms is a f w dm htn hl cad s p cabg pvdz known celiac sma stenosis paf on home coumadin chr sys chf ef sinus bradycardia s p ppm recent admission to and osh for sob s p micu and intubation who originally presented to osh days ago w acute on chronic abdominal pain and is now transferred to for further evaluation pt reports chronic rlq abd pain x mos pain is intermittent sharp worse w food better w not eating gradually worsening associated w nausea and nbnb vomiting at least once daily she also reports chronic diarrhea loose stools per day yellow non bloody tarry in general though occasional drops of red blood no fevers but often feels cold sxs have been worse in the last weeks which prompted presentation to osh days prior to transfer at osh pt was started empirically on metronidazole d for c diff colitis though c diff toxin negative ct a p w o contrast showed diffuse thickening of colon left transverse rectosigmoid gi there recommended evaluation by surgery for mesenteric ischemia and likely gi here for colonoscopy now still having diarrhea but less and nausea and vomiting resolved of note sister has similar sxs recently no recent travel no sick contacts no new food items no urinary sxs past medical history cad s p cabgx and s p inf mi chr sys chf ef in paf on home coumadin sinus bradycardia s p ppm in htn hl dm h o tias pvd severe celiac sma stenosis gout copd ckd stage creatinine s p hemigastrectomy for pud in remote past social history lives alone in a housing complex in in a single floor apartment w an elevator in the building she pays her own bills patient states she quit smoking month ago was smoking cigarettes per day for most of life denies smoking more than this previously had etoh drink per day family history heart disease and cancer she is of children but only of them are living physical exam exam on admission vs ra gen pleasant ill appearing elderly woman lying in bed supine in nad heent nc at perrl eomi mmm op clear neck supple no lad normal jvp cv irregular s s no m r g chest diffuse crackles b l midway up abd ttp in rlq non distended nabs extr wwp no c c e dp rad pulses b l neuro aox cnii xii intact motor strength in ue le b l 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 alt ast alkphos totbili am blood lipase am blood ck mb ctropnt pm blood probnp pm blood ck mb ctropnt pm blood albumin calcium phos mg labs on discharge 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 urine studies am urine color red appear hazy sp am urine blood tr nitrite pos protein tr glucose neg ketone neg bilirub neg urobiln neg ph leuks lg am urine rbc wbc bacteri many yeast none epi transe am urine casthy am urine color yellow appear clear sp am urine blood neg nitrite neg protein tr glucose neg ketone tr bilirub neg urobiln neg ph leuks sm am urine rbc wbc bacteri none yeast none epi am urine casthy micro data c diff negative x urine cultures contaminated studies angiography cath of mesenteric vessels angiographic findings elongated cm long stenosis of approximately to the superior mesenteric artery with post stenotic dilatation there was some sparing of the orifice of the vessel because of the length two mm genesis sounds stents were deployed to cover the lesion appropriately the stents expanded to their nominal size without difficulty there was an initial mm gradient which was reduced to less than mm systolic after second ablation of the mm balloon focal stenosis of the proximal celiac artery successfully stented with a x mm genesis stent there was no residual systolic gradient after completion of the stent a small brachial artery required cutdown initially for access and was repaired using interrupted prolene sutures without difficulty cxr the pacemaker leads are in the right atrium and right ventricle the cardiomediastinal silhouette is stable in the patient after cabg there is still present interstitial pulmonary edema slightly asymmetric with more involvement of the right side most likely due to patient positioning small right pleural effusion is noted slightly increased since the prior study but still small there are no areas of focal consolidation worrisome for infection kub supine and upright film of the abdomen demonstrate scattered gas filled loops of bowel with loops of transverse colon measuring up to cm air fluid levels are seen in the upright film but the majority of these appear to be within the colon this most likely represents an ileus rather than an sbo ct abd pelvis non contrast findings compatible with anasarca with diffuse soft tissue stranding edema marked bilateral effusions and free fluid within the abdomen and pelvis no specific evidence of bowel ischemia no pneumotosis or free air no obstruction cxr pa and lateral slight worsening of congestive heart failure with increasing interstitial edema kub improved bowel gas pattern with air noted throughout non distended loops of large and small bowel no evidence of obstruction cxr portable there is no significant change in the right picc line pacemaker sternal wires and mediastinal clips small bilateral effusions left greater than right and mild interstitial edema similar in appearance compared to the prior study the right ij line has been removed kub stents are seen in the upper abdomen likely in the celiac and sma the colon is prominent measuring up to cm with some air fluid levels gas is seen in the rectum impression ileus brief hospital course yo f w hx of cad chf pvd dm afib who presents as a transfer from an osh for evaluation of abdominal pain and mesenteric ischemia on admission gi and surgery were consulted her inr was elevated and she was given ffp with plans for egd colonoscopy to further evaluate her symptoms her inr was still therapeutic and this procedure was deferred on patient became hypoxic and tachypneic likely secondary to volume overload she was given lasix and transferred to the micu then she was taken to the or by the team and had a brachial artery exposure and repair with celiac artery stent x and superior mesenteric stent x placed postoperatively she was admitted to the cvicu on the surgery service for closer monitoring on hd pod patient was kept npo ivf cipro flagyl was restarted for bowel flora colitis she was later transferred to the vicu on and given gentle hydration on hd pod she was advanced to clear liquid diet she began to c o increased abdominal distention abdominal xray revealed likely ileus she was made npo on hd pod she was advanced to clears again telemetry was discontinued and she was made floor status she only could tolerate minimal clears with recurrent abdominal pain on hd pod noncontrast ct abd pelvis was done which showed findings compatible with anasarca with diffuse soft tissue stranding edema marked bilateral effusions and free fluid within the abdomen and pelvis but no specific evidence of bowel ischemia pneumotosis free air or obstruction she remained on clears on hd pod patient was advanced to regular diet which she initially tolerated with improved abdominal distension foley was also removed she had an episode of sob lasix and spironolactone was restarted o n she c o worsening lower abd pain with some nausea and minimal emesis on hd pod she was put back on clears she was then transferred back to the medicine team for further evaluation and treatment medicine team updated hospital course upon transfer ms had evidence of pulmonary edema and active heart failure based on symptoms and cxr findings she was aggressively diuresed with iv lasix and improved the egd and colonoscopy were planned given her continued symptoms of abdominal pain nausea and vomiting however these were deferred given her tenuous respiratory status and inability to lie flat her abdominal symptoms improved over the next few days and her was able to tolerate clears on she was slowly advanced to solids on tpn was briefly initiated from but the patient was tolerating clears at that time and it was stopped as symptoms resolved it was felt that egd and colonoscopy were not indicated given risks associated with procedure outpatient plan by problem mesenteric ischemia s p sma and celiac stents needs to be on plavix until follow up with dr on at this time he will recommend stopping or continuing with plavix omeprazole was changed to pantoprazole due to drug interactions with omeprazole and plavix pulmonary edema was diuresed with lasix mg po bid and this was changed to lasix mg po qday on discharge weight on discharge was kg patient should be weighed daily and if weight is increased lbs her primary care doctor should be notified and lasix dose adjusted please check weekly electrolytes until stable on discharge she was on ra and basilar crackles on exam cad chf the patient was kept on aspirin mg po qday toprol xl mg po qday imdur mg po qday spironolactone mg po qday lasix mg po qday losartan was started for heart failure management and she was given mg po qday as tolerated by her blood pressure she has an ace allergy atrial fibrilation coumadin was initially held for planned egd colonoscopy it was restarted on at a dose of mg po qday but inr was still subtherapeutic at on discharge she was discharged on coumadin mg po qday with a lovenox bridge until inr is therapeutic she should have inr checked in days and coumadin dose adjusted if elevated lovenox should be stopped when inr is bowel kub was consistent with ileus which is resolving she was put on colace and senna prn for bowels and had small loose stool on the day of discharge medications on admission home meds coumadin mg po daily furosemide mg po daily spironolactone mg po daily isosorbide dinitrate mg tid metoprolol mg po bid atorvastatin mg po daily glipizide mg po daily advair inh colchicine mg po daily omeprazole mg po daily transfer meds metronidazole mg po tid coumadin mg po daily isosorbide dinitrate mg tid ranolazine mg po daily metoprolol mg po bid atorvastatin mg po daily niacin er mg po daily slntg prn for chest pain riss advair inh albuterol mg inh q h prn sob wheezing colchicine mg po daily allopurinol mg po daily omeprazole mg po daily ondansetron mg iv q h prn n v tylenol prn pain fever tramadol mg po q h prn pain zolpidem mg po qhs prn insomnia discharge medications fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day ipratropium bromide solution sig one nebulizer inhalation q h every hours as needed for sob chf atorvastatin mg tablet sig one tablet po daily daily acetaminophen mg tablet sig tablets po q h every hours as needed for pain allopurinol mg tablet sig one tablet po every other day every other day clopidogrel mg tablet sig one tablet po daily daily continue through then discuss with dr spironolactone mg tablet sig one tablet po daily daily aspirin mg tablet chewable sig one tablet chewable po daily daily metoclopramide mg tablet sig one tablet po qidachs times a day before meals and at bedtime insulin lispro unit ml solution sig per sliding scale unit subcutaneous four times a day please see sliding scale docusate sodium mg capsule sig one capsule po bid times a day metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po daily daily hold if bp hr glyburide mg tablet sig one tablet po bid times a day losartan mg tablet sig tablet po qpm once a day in the evening hold for bp furosemide mg tablet sig tablets po daily daily enoxaparin mg ml syringe sig thirty mg subcutaneous times a day stop this medication when inr is senna mg tablet sig one tablet po bid times a day as needed for constipation warfarin mg tablet sig two tablet po once daily at pm please adjust dose as need based on inr pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours sodium chloride flush ml iv q h prn line flush peripheral line flush with ml normal saline every hours and prn heparin flush units ml ml iv prn line flush temporary central access floor flush with ml normal saline followed by heparin as above daily and prn outpatient lab work please check inr every days until it is stable and if stop lovenox plesae maintain inr between and adjust coumadin as necessary fax results to patient s primary care doctor dr please check electrolytes and renal function in days and after this as needed isosorbide mononitrate mg tablet sustained release hr sig one tablet sustained release hr po daily daily please give only if bp please stagger medications so that they are not all given at the same time weight please check daily weight and call pcp if weight is lbs weight on discharge from is kg picc line please use saline and heparin flushes for picc line please remove picc line by or sooner used for blood draws discharge disposition extended care facility center discharge diagnosis primary diagnosis mesenteric ischemia acute on chronic systolic heart failure secondary cad status post imi and cabg atrial fibrillation sss status post pacemaker stroke ckd stage ii iii pvd status post aorto bifemoral bypass diabetes mellitus type ii copd hypertension gout s p hemigastrectomy for peptic ulcer disease s p cholecystectomy s p bilateral cataract surgeries discharge condition afebrile hemodynamically stable eating and drinking without pain nausea or vomiting discharge instructions you were admitted to the hospital for nausea and abdominal pain you had a stent placed to your arteries in your abdomen which helped your symptoms you were placed on plavix because of this stent and should continue to take it until you see dr on the following changes were made to your medications start plavix mg by mouth once a day stop omeprazole mg by mouth start pantoprazole mg by mouth once a day start aspirin mg by mouth once a day stop ranolazine mg by mouth once a day you should follow up with your primary care doctor dr weeks after discharge from rehab you should follow up with your cardiologist dr after discharge from rehab you should call your doctor or return to the hospital with any fevers chills night sweats chest pain shortness of breath abdominal pain nausea vomiting leg swelling skin rashes or any other symptoms that concern you followup instructions provider nhb phone date time provider md phone date time you should follow up with your primary care doctor dr weeks after discharge from rehab you should follow up with your cardiologist dr after discharge from rehab,{}
25904,admission date discharge date date of birth sex f service obstetrics gynecology allergies penicillins heparin agents attending chief complaint postcoital bleeding major surgical or invasive procedure exploratory laparotomy periaortic lymph node dissection supralevator pelvic exenteration ileal ureteral conduit redo with side side reanastomsis by gu sigmoid neovagina by plastics low rectal anastamosis j flap omentopexy with transverse loop colostomy re exploration repair of ileal conduit rigid rectosigmoidoscopy exploratory lapartomy for partial abd closure with patch maturation of colostomy tracheostomy exploratory laparotomy washout and total abdominal closure with mesh reexploration of abdomen cauterization of perforating vessel thoracentesis drainage of pelvic collection with pigtail catheter picc placement left percutaneous nephrostomy tube placement history of present illness this is a yo g p s p radical hysterectomy bilateral salpingo oophorectomy and pelvic lymphadenectomy on for stage ib endometrioid adenocarcinoma of the cervix s p cycles of cisplatin and pelvic radiation for involvement of two regional lymph nodes who presented with vaginal bleeding a pap smear and biopsy of a right vaginal apex thickening on revealed recurrent adenocarcinoma a pet ct showed no evidence of metastatic disease tumor board recommendation on was for total pelvic exenteration past medical history cervical ca s p exploratory laparotomy radical hysterectomy bilateral salpingoopherectomy and lymph node dissection s p cisplatin pelvic radiation chronic back pain breast reduction social history denies t e d family history significant for a father with cell carcinoma and a maternal grandmother with breast and brain cancer brief hospital course on the patient underwent exploratory laparotomy periaortic lymph node sampling supralevator total pelvic exenteration low rectal anastomosis j flap omentopexy transverse loop colostomy ileal urinary conduit by the urology service and colonic neovagina reconstruction by plastic surgery service significant findings included an isolated lesion in r cuff and negative periaortic nodes as described in the operative note the ileal urinary conduit was redone due to ischemic bowel at the end of the case the bowel was significantly edematous and prevented primary fascial closure pt was brought to the icu intubated for postop reovery she went into septic shock on pod with multiple system failure including liver heme and cardiac see systems list her antibiotic coverage was changed to cefetime vancomycin levofloxacin metronidazole and fluconazole she was started on activated protein c from pt was brought back to the or on pod for re exploration findings were significant for a small leak in the left ureteral ileal conduit junction but no collections abscess or ischemic bowel was found infectious disease and general surgery was consulted cultures returned with e coli in her peritoneal fluid her sputum also yielded e coli and serratia the pt however remained persistently febrile multiple cultures returned with no growth bacterial or fungal after a ruq ultrasound and hida scan were neg for collections multiple ct torso scans showed sinusitis cx by ent was negative possible fungal ball vs collection in the r renal collecting system f u renal u s was negative echocardiogram was negative for vegetations per id aspergillus antigen and beta glucan was drawn aspergillus was negative but the beta glucan was moderately positive this was repeated and returned as mildly positive re exploration for partial abdominal closure on and re exploration total closure on also yielded no significant collections pleural effusions were tapped with no bacterial growth she continued on her antibiotics until which were discontinued due to negative cultures her fever curve and wbc slowly improved a pigtail catheter was placed to drain a pelvic collection seen on ct which also yielded negative cultures she had a brief period of no fevers from to she had another elevated temp on and the source was found to be klebsiella pyelonephritis in the left kidney she was started on levofloxacin and a percutaneous nephrostomy tube placed pt s wbc decreased and she defervesed however she developed an aspergillus infection of her wound she was started on voriconazole on and topical terbinafine while on the floor she continued to spike fevers and found to have an enterococcus pelvic abscess on ct guided drainage of the pelvic collection yielded cc of purulent fluid on vancomycin was started repeat ct of pelvis on showed decreased size of fluid collection given pt was afebrile and clinically improving this fluid was not drained she will continue on vancomycin until appointment with infectious disease on on urine culture grew serratia per id recommendations ceftriaxone was started repeat urine culture on was positive for serratia urine culture on showed no growth she will continue on ceftriaxone for a total of day course klebisella grew from blood cultures on subsequent serial blood cultures showed no growth to date her other issues are as follows wound neovagina her fascia was partially closed with a patch by general surgery on the patch was progressively rolled every days until when the fascia was closed with mesh by general surgery retention sutures were removed by pod and her wound was packed with wet to dry dressings on her wound was noted to be growing fungus later identified as aspergillus fumigata id was reconsulted and she was started on voriconazole on the wound was managed by general surgery the wound improved and a vac was placed prior to discharge of note her anticoagulation was halted while the patch was in place due to bleeding she also had a significant blood loss after her closure on that required reexploration by general surgery where l clot was found in the subcutaneous layer subcutaneous arterial bleeds were identified and cauterized the neovagina was inspected by plastics postoperatively and there was a small separation near the introitus this was repaired on she began vaginal dilators on neuro due to the patient s septic coagulopathy her epidural which was placed preoperatively remained in place until pt was maintained on fentanyl and propofol gtt until she was gradually transitioned to po pain meds with excellent pain control of note she was noted to have decreased gag reflex a head ct on was negative for bleed ischemia cv pt required three pressors postoperatively due to septic shock she was weaned off pressors by pod echo showed global biventricular hypokinesis likely from sepsis ef serial echos showed improvement to an ef of on no vegetations were noted on any of the echos after being transferred to the floor she was tachycardic which was controlled with metoprolol mg pulm a pna sputum grew out serratia and e coli her radiological findings improved over hospitalization b pulmonary effusions pt developed significant pulmonary effusions immediatley postop which was tapped on these returned very quickly ct surgery was consulted for possible u s guided thoracentesis but the effusions dramatically improved and the thoracentesis was cancelled c tracheostomy a tracheostomy was placed by general surgery on she was weaned off the ventilator and trach was discontinued she had no respiratory issues while on the floor gi a liver shock pt s alt and ast rose as high as the and her total bilirubin as high as during her septic shock which slowly resolved over her hospitalization but remained somewhat elevated ruq ultrasounds and hida scans were negative for significant pathology b diet she was started on tpn and then transitioned to tf when her transverse loop colostomy had output tf were held intermittently for ileus she was gradually started on pos while on the floor she continued on the tpn with po intake as well her lfts were slightly elevated on and therefore her voriconazole level was decreased on patient was switched to po voriconazole she will continue on this medication until her infectious disease apppointment on her lft improved she will continue to have lft check once a week renal s p l ileoureteral conduit repair on due to leak ureteral stents were removed ct scan on noted worsening left hydroureter and hydronephrosis per urology a urogram was done on this showed no evidence of extravasation or reflux eventually her ucx returned with klebsiella due to her persistent hydronephrosis a loopogram and then lasix urogram were conducted and she was found to have a left kidney obstruction a percutaneous nephrotomy tube was placed on interventional radiology replaced this with a left nephroureteral stent nephrogram was done which showed a stricture in the left ureter the stent was replaced on pt was noted to have nephroureteral stent protuding from urostomy she also spiked a high fever at this time gu adjusted the stent and patient subsquently clinically improved pt is to have outpt antegrade nephrogram in month and follow up with clinic heme a leukopenia pt s wbc dropped to during sepsis neupogen was given and her wbc rose appropriately to as high as s this slowly improved as her fever curve improved b blood loss and dilutional anemia hct was kept above which required multiple prbcs she was started on epogen and fe supplementation on c coagulopathy likely from sepsis pt received multiple units of ffp this slowly improved d thrombocytopenia persistent beyond sepsis requiring multiple platlet transfusions hematology was consulted pt was found to be hit ab positive with a negative serotonin release assay heparin was stopped and she was started on lepirudin this was stopped after she began bleeding with the patch rolling once her abdomen was closed she was started on fondaparinux lenis done for persistent fever was negative for dvt on she continued to where pneumoboots while on the floor she was discharged to acute rehab on pod medications on admission none discharge medications ferrous sulfate mg tablet sig one tablet po daily daily disp tablet s refills oxycodone acetaminophen mg tablet sig tablets po q h every to hours as needed disp tablet s refills lorazepam mg tablet sig one tablet po q h every to hours as needed for anxiety before walking disp tablet s refills dolasetron mesylate mg iv q h prn docusate sodium mg capsule sig one capsule po tid times a day disp capsule s refills metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet s refills acetaminophen caff butalbital mg tablet sig one tablet po q h every to hours as needed for ha disp tablet s refills epoetin alfa unit ml solution sig one injection qmowefr monday wednesday friday disp q s q s refills conjugated estrogens mg tablet sig one tablet po daily daily disp tablet s refills ceftriaxone dextrose iso osm g ml piggyback sig one intravenous q h every hours for days disp q s q s refills voriconazole mg tablet sig tablets po q h every hours disp tablet s refills fondaparinux mg ml syringe sig one subcutaneous daily daily disp q s q s refills acyclovir ointment sig one appl topical prn as needed for cold sore disp tube refills vancomycin intravenous mg q hours discharge disposition extended care facility hospital discharge diagnosis recurrent cervical cancer septic shock aspergillus wound infection serratia urinary tract infection pelvic abscess left ureteral stricture discharge condition stable discharge instructions acute rehab followup instructions general surgery please follow up with dr in surgery clinic in early please call to setup your appointment the clinic is located at medical building a ma provider b call to schedule appointment provider phone date time completed by,"{
""Diagnoses"": [""Yo-GP-PS"", ""Radical hysterectomy"", ""Bilateral salpingo-oophorectomy"", ""Pelvic lymphadenectomy""],
""Medications"": [""Cisplatin"", ""Pelvic radiation""]
}"
60949,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint hemothorax pneumothorax left rib fracture major surgical or invasive procedure left thoracotomy open reduction and internal fixation with plates of ribs evacuation of hemothorax flexible bronchoscopy history of present illness the patient is a m who was in when he fell coming out of the shower on he hit the left side of his chest against the tub and suffered rib fractures patient also developed a hemothorax for which a chest tube was placed patient initally improved but soon after his respiratory status declined on patient was intubated for desaturation episode and was suctioned to relieve mucous plugging patient was extubated on he was followed with serial cxr s that became concerning for bilateral pneumonias patient was started on antibiotic treatment the hospital course was further complicated by an episode of afib on for which the patient was cardioverted and started on amiodarone drip which was later transitioned to po amiodarone echo was performed that showed lv hypertrophy mitral regurg and an ef sputum cx in grew psa for which patient was getting capsofungin patient came to from for further management of his poor respiratory status past medical history atrial fibrillation hypertension hyperlipidemia gastri ulcer bleed years ago social history married lives with his wife pack year quit with this incident etoh drinks beers night family history non contributory physical exam vs t hr sr bp sats ra w activity general year old male in no apparent distress heent normocephalic mucus membranes moist neck supple no lymphadenopathy card regular normal s s no murmur resp decreased breath sounds faint crackles at base gi benign extr warm bilateral pedal edema incision left thoracotomy site clean dry margins well approximated no erythema neuro awake alert oriented pertinent results wbc rbc hgb hct plt ct wbc rbc hgb hct plt ct wbc rbc hgb hct plt ct wbc rbc hgb hct plt ct wbc rbc hgb hct plt ct wbc rbc hgb hct plt ct wbc rbc hgb hct plt ct neuts lymphs monos eos baso glucose urean creat na k cl hco glucose urean creat na k cl hco glucose urean creat na k cl hco alt ast alkphos totbili alt ast ld ldh alkphos totbili calcium phos mg tsh bronchoalveolar lavage right lung bal gram stain final per x field polymorphonuclear leukocytes per x field multiple organisms consistent with oropharyngeal flora per x field yeast s respiratory culture final organisms ml commensal respiratory flora yeast organisms ml acid fast smear final no acid fast bacilli seen on direct smear no acid fast bacilli seen on concentrated smear acid fast culture preliminary fungal culture preliminary second morphology potassium hydroxide preparation final cxr resolving left upper lobe pneumonia stable right middle lobe opacification may represent stable right middle lobe pneumonia improved right lower lobe opacification likely reflecting resolving right lower lobe atelectasis loculated left pleural effusion resolved retrocardiac opacification cct impression extensive abnormalities involving nearly the entire right upper lobe comprised of ground glass centrally consolidation peripherally and air bronchograms with interstitial thickening this is not a typical distribution for aspiration given the asymmetry compared to the remaining lung this likely represents infection or possibly hemorrhage much less likely asymmetric edema moderate bilateral pleural effusions with collapse of both lower lobes enlarged left adrenal gland with inflammatory changes compatible with adrenal hemorrhage enlarged mediastinal lymph nodes likely reactive and related to infectious process in the right upper lobe comminuted and displaced fractures of left sided ribs echo the left atrium is mildly dilated left ventricular wall thickness cavity size and global systolic function are normal lvef regional left ventricular wall motion is normal right ventricular chamber size and free wall motion are normal the aortic arch is mildly dilated 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 trivial mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened there is moderate pulmonary artery systolic hypertension there is no pericardial effusion impression suboptimal image quality normal global and regional biventricular systolic function moderate pulmonary hypertension ecg afib flutter brief hospital course mr is a year old male transfer from for flail chest hemothorax and pneumothorax right upper lobe pneumonia upon arrival he was fm desaturated requiring cpap for oxygenation left anterior chest tube in place on arrival a chest ct was done see report a right ct was placed with cc of serousanguinous drainage on he was taken to the operating room for left thoracotomy open reduction and internal fixation with plates of ribs evacuation of hemothorax and flexible bronchoscopy he was transferred back to the sicu intubated and was successfully extubated on respiratory nrb oxygen saturations desaturates to on room air aggressive pulmonary toilet nebs around the clock chest tube left chest tube and right chest tubes with liter serous drainage were removed once drainage decreased cardiac atrial fibrillation cardioverted in and started on amiodarone which was continued baseline lfts and tsh echocardiogram moderate pa htn normal ef on he was tachycardic s metoprolol was started with a good response he was discharged on toprol mg amiodarone mg x wk then mg daily he will need follow up with his pcp cardiologist for further recommendation and ecg monitoring blood pressure remained stable s his home dose diovan was not restarted during this hospitalization gi ppi s and bowel regime continued nutrition tolerated a regular diet renal renal function within normal limits good urine out put perpheral edema bilateral lower extemities gentle diuresis was started his electrolytes were monitored closely and repleted as needed id infectious disease was consulted for his pneumonia bal cultures grew nonpathogenic not albican therefore no treatment was recommended pain iv dilaudid converted to po dilaudid with good control heme he was started on aspirin mg for anticoagulation he will follow up with his pcp disposition he was seen by physical therapy who deemed him safe for home he will follow up with dr and his pcp as an outpatient medications on admission home medications diovan mg zetia mg daily aspirin mg mvi discharge medications amiodarone mg tablet sig one tablet po daily daily take twice a day for week then daily starting disp tablet s refills furosemide 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 q h every hours disp tablet sustained release hr s refills 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 zetia mg tablet sig one tablet po once a day aspirin mg one daily discharge disposition home with service facility vna discharge diagnosis mechanical fall with left rib fractures hemo pneumothorax atrial fibrillation converted x hypertension hyperlipidemia gastric ulcer bleed years ago discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions call dr office if you experience fevers or chills increased shortness of breath cough or chest pain incision develops drainage you may shower wash incision with mild soap and water pat dry no tub bathing swimming or hot tub until incision healed no driving while taking narcotics take stool softners with narcotics walk times a day for minutes increasing to a goal of mins daily weights keep alog call your pcp if you have pound weight gain lasix mg daily drink oj or eat a banana to replete your potassium cardiac medication take amiodarone mg twice daily then mg daily call your pcp for appointment followup instructions follow up with dr date time in the building clinic chest x ray radiology clinical center minutes before your appointment please call your pcp for an appointment in weeks completed by,"{
""Diagnoses"": [""hemothorax"", ""pneumothorax"", ""left rib fracture"", ""major surgical or invasive procedure"", ""left thoracotomy"", ""open reduction and internal fixation with plates of ribs"", ""evacuation of hemothorax"", ""flexible bronchoscopy"", ""history of present illness""],
""Medications"": [""antibiotics"", ""amiodarone""]
}"
29318,admission date discharge date date of birth sex m service neurosurgery allergies patient recorded as having no known allergies to drugs attending chief complaint admission for right craniotomy and excision of a brain mass major surgical or invasive procedure right craniotomy for excision of brain mass history of present illness mr is a year old male who is well who was recently admitted for workup of an intraparenchymal hemorrhage which presented in the setting of an excruciating headache outpatient workup to date via detailed mr presence of an intracranial tumor it is for this reason that he was taken electively to the operating room past medical history gerd hypercholesterolemia enlarged prostate recent left rotator cuff surgery with residual deltoid weakness plans for umbilical hernia repair social history lives on with his wife is a phys ed teacher and a congregationalist pastor he has two healthy children one year old son and a year old daughter family history father was diagnosed with alzheimer s disease in his s mother passed away from heart disease physical exam 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 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 alert oriented x cranial nerves eomi perrl no evidence of facial asymmetry tongue midline motor normal bulk tone throughout no pronator drift bilaterally no adventitious movements noted no asterixis noted strength throughout sensory intact to light touch bilaterally plantar response was equivocal bilaterally 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 calcium phos mg am blood phenyto pathology obtained from or most consistent with a malignant glioma final read is pending brief hospital course patient was admitted for tumor resection he tolerated the procedure and was back to full strength on the following day evaluation by pt ot no need for services at home he was started on oral steroids which did make him somewhat anxious during this admission preliminary pathology report was also discussed with the patient and his family revealing the presence of a malignant glioma further therapeutic recommendations were to be discussed in brain tumor clinic as an outpatient medications on admission simvastatin mg tablet sig two tablet po daily daily disp tablet s refills acetaminophen mg tablet sig tablets po q h every hours as needed for headache or fever not to exceed grams per day metoprolol tartrate mg tablet sig tablet in the morning and afternoon tablet at bedtime tablet po tid times a day disp tablet s refills zofran odt mg tablet rapid dissolve sig one tablet rapid dissolve po once a day disp tablet rapid dissolve s refills flomax mg capsule sust release hr sig one capsule sust release hr po once a day discharge medications oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain do not drive or drink alcohol while taking this medication do not take more than grams of acetaminophen in hours disp tablet s refills phenytoin sodium extended mg capsule sig one capsule po tid times a day disp capsule s refills senna mg tablet sig one tablet po bid times a day as needed for constipation disp tablet s refills metoprolol tartrate mg tablet sig one tablet po bid times a day simvastatin mg tablet sig two tablet po daily daily docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills tamsulosin mg capsule sust release hr sig one capsule sust release hr po hs at bedtime omeprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day dexamethasone mg tablet sig four tablet po four times a day mg every hours through mg every hours mg every hours then mg twice daily until follow up appointment disp tablet s refills discharge disposition home discharge diagnosis right parietal brain mass discharge condition stable discharge instructions have a 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 excessive bending you may wash your hair only after sutures and or staples have been removed you may shower before this time with assistance and use of a shower cap increase your intake of fluids and fiber as pain medicine narcotics can cause constipation unless directed by your doctor do not take any anti inflammatory medicines such as motrin aspirin advil ibuprofen etc if you have been prescribed an anti seizure medicine take it as prescribed and follow up with laboratory blood drawing as ordered 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 new onset of tremors or seizures any confusion 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 any signs of infection at the wound site redness swelling tenderness drainage fever greater than or equal to f followup instructions please return to the office in days for removal of your staples sutures please call to schedule an appointment with dr to be seen in days in brain clinic you will need an mri of the brain with or without gadolidium completed by,"{
""Diagnoses"": [""intraparenchymal hemorrhage"", ""intracranial tumor""],
""Medications"": [""GERD"", ""hypercholesterolemia"", ""enlarged prostate"", ""umbilical hernia repair""]
}"
3337,admission date discharge date date of birth sex f service trauma history of present illness the patient is a year old portuguese female with a past medical history of hypertension who presented to the trauma service as a trauma plus on this was activated secondary to the fact that the patient s mechanism of injury was a large tree branch that had fallen and struck her head hitting her in the back of her head and knocking her down she had an obvious open left ankle fracture as well as a deformed left forearm confirming radius and ulnar fractures she was minimally responsive in the field was intubated and brought in by past medical history notable for just hypertension medications on admission diltiazem sr mg p o q d potassium supplement allergies no known drug allergies social history she lives with her daughter she is widowed she has multiple children she is otherwise high functioning at baseline she does not smoke or drink family history noncontributory review of systems otherwise unremarkable and not obtainable at the time of this discharge note she was well however up until the timing of this event physical examination vital signs on presentation temperature was heart rate blood pressure she was vented with an oxygen saturation of on the vent heent pupils were and sluggish and reactive her midface was stable she had an obvious large scalp deformity oropharynx was otherwise satisfactory with endotracheal tube in place cm at the lip trachea was midline there was no neck crepitus chest stable there was no stepoff deformity she had equal breath sounds bilaterally abdomen soft could not assess tenderness her fast exam in the trauma bay was otherwise negative extremities pelvis was stable she had an obvious open fracture with the tibia exposed of the tibiotalar joint complex at the left ankle there was no active bleeding she did have a palpable but thready distal dorsalis pedis pulse her posterior tibial pulse however was not obtainable the foot was somewhat cool however was not cyanotic capillary refill was somewhat delayed at sec her left upper extremity had an obvious deformity however her radius and ulnar arteries were easily palpable her fingers were a little bit dusky but capillary refill again delayed all extremities were somewhat cool and she was somewhat clamped upon rolling she had multiple abrasions but no stepoff or deformity she had abrasions across the kyphotic upper thoracic spine noted rectal loose tone no mass guaiac negative genitourinary unremarkable a foley catheter had been placed the patient thereafter was brought to the operating room where an emergent scalp laceration repair and exploration was done prior to going to scan she did get a ct of her head at which time she actually began to move more her initial gcs was t in the trauma bay this rapidly improved to a t while in the ct scanner she was able to localize and follow commands and open her eyes spontaneously ct scan of the head revealed no intracranial injury or fracture she had an obvious hematoma and laceration to her scalp noted by these films ct of her cervical spine was somewhat limited by motion but was otherwise negative a tls survey was initially read as possible wedge compression fracture of t ct of chest and abdomen were without any obvious visceral injury catalog of her injuries at this time showed that she had what looked like a large occipital scalp avulsion laceration no active exsanguination she had an obvious left arm deformity confirmed by plain films to show a distal radius and ulnar fracture but this was a closed fracture she had an obvious open fracture of the left lower extremity at the tibia and fibula involving the tibiocalcaneal complex of the left ankle this was reduced and splinted in the trauma bay by the orthopedic service she was then whisked off to the operating room where her left ankle was washed out she had previously received tetanus kefzol and gentamicin her scalp flap was also washed and repaired she received a two layer closure interrupted to the deep suturing to the galea aponeurotica and then skin staples thereafter the orthopedic portion of the procedure was open reduction and internal fixation of her left upper extremity and lower extremity were completed please refer to dr dictation noted for further details regarding that procedure she was left intubated and sent back to the trauma intensive care unit over night she required some volume she had been transfused at least u of packed red blood cells on she did not require any further transfusions by postoperative day hospital day she was on kefzol and gentamicin periprocedurally per the orthopedic service repeat ct of the head was done on the following day which again showed no evidence of bleeding or intracranial injury at this time she was moving all four extremities and actually following commands we opted to extubate the patient at this time she did quite well and progressed quite well her cervical collar was then cleared over the next hours she was kept on logroll precautions and follow up mrs the cervical spine revealed in fact a possible acute compression fracture at t at this time consultants with dr of the neurosurgical service recommended a fitting and tlso bracing she did have some mild degree of agitation within the first hours on the floor requiring a sitter and intermittent haldol however her mental status rapidly improved to the point of where she was discontinued from her sitter she was only receiving p r n tylenol and percocet for pain control she was placed on an aggressive bowel regimen she was placed back on her diltiazem mg sr q d for blood pressure maintenance her fractures were healing well and the orthopedic service was following for dressing care to her left lower extremity she ultimately received a short leg cast on her weightbearing status was determined to be nonweightbearing on the left lower extremity and upper extremity she may bear weight on her left elbow her right upper and lower extremity were full weightbearing she was participating with physical therapy and wearing a tlso brace per the recommendations of the neurosurgical spine consultation with dr she was deemed appropriate and stable for discharge on prior to her discharge her lab test on revealed a white count of hematocrit and platelet count this was otherwise stable her chemistries at this time were a sodium of potassium chloride bicarb bun and creatinine and glucose magnesium she had received ekgs during her hospitalization which were otherwise normal she was on telemetry during her intensive care unit stay and for several days on the floor and there was no apparent electrocardiogram activity she otherwise looked quite well clinically and was discharged to acute rehabilitation discharge medications diltiazem sr mg p o q d lovenox mg subcue q while in rehabilitation protonix mg p o q d colace mg p o b i d tylenol mg p o q p r n percocet p o q p r n she should be on a sliding scale insulin regimen as well to check her fingersticks as she did have some mild stress induced hyperglycemia it was unclear of whether or normal the patient had some undiagnosed type diabetes however this did not come with her admission information from her family and she was not on any outpatient insulin regimens or oral hypoglycemics discharge diagnosis status post tree branch falling on head and back with long bone fractures possible closed head injury with concussion only no obvious intracranial lesion by ct scans times two massive occipital scalp laceration and avulsion status post washout and repair on closed left radius and ulnar fracture status post open reduction and internal fixation on with dr of the orthopedic surgery service status post washout and stabilization of left open tibial and fibula fracture of left lower extremity possible recent acute compression fracture of t vertebra which is stable major invasive procedures exploration and washout of the occipital scalp laceration and avulsion with dr of the trauma surgical service please see the dictation of the operative note for further details status post washout and stabilization of left lower extremity open tibia and fibula fracture with dr status post open reduction and internal fixation of left upper extremity radius and ulnar fracture treatments and frequency she will require aggressive physical therapy feeding assistance and occupational therapy evaluation as a rehabilitation patient her diet should be as tolerated she has no evidence of clinical aspiration follow up she will be seen in the trauma clinic one week from the time of discharge for skin clip removal from her scalp laceration call for outpatient clinic appointment she should call dr neurosurgical service and be seen in weeks for her t compression fracture wear her tlso brace in the interim it is not clear if the patient will require any further imaging as an outpatient this can be coordinated with her follow up plan with dr by calling the office at the patient is to follow up with dr of the orthopedic trauma service follow up is in weeks call discharge instructions the patient at this time is deemed appropriate for discharge she will be discharged and follow up as noted above her weightbearing activity will be nonweightbearing to the left lower extremity nonweightbearing to the left upper extremity however she may weightbear on the left elbow she will wear her tlso brace for her t compression fracture she has full weightbearing privileges of right upper and lower extremity m d dictated by medquist d t job,"{
""Diagnoses"": [""Trauma"", ""Head injury"", ""Open left ankle fracture"", ""Deformed left forearm confirming radius and ulnar fractures""],
""Medications"": [""Diltiazem SR"", ""Potassium supplement""]
}"
94821,admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint pericardial effusion major surgical or invasive procedure vagus nerve stimulator generator replacement pericardiocentesis with pericardial drain history of present illness please see original neurology admission note and micu transfer note for details briefly y o man with long standing history of epilepsy s p right temporal lobectomy at age and vns placement years ago h o etoh and cocaine abuse who was having increased seizure frequency in the setting of vns malfunction he was admitted on for elective replacement of the vagus nerve stimulator generator the procedure went without complication overnight he developed af with rvr to the s with hypotension to the s ciwa was with last drink approximately hours prior patient was also noted to be with a ciwa of and is thought that last etoh drink was hours ago he received mg iv ativan with somnolence and apenea afterwards he was subsequently transferred to the micu his micu course was notable for an echocardiogram which showed a large pericardial effusion on he was seen by the cardiology fellow and subsequently underwent pericardial window cc of bloody pericardial fluid was drained patient developed svt in the cath lab and was treated with mg iv metoprolol he was transferred to ccu postprocedurally for monitoring on arrival patient complained of spinal back pain from lying on the operating table he also reports that his lungs feel collapsed but denied shortness of breath review of systems was otherwise negative past medical history epilepsy and nonelectrographic seizures petite mal with rare secondary generalization s p right temporal lobectomy s p vns placement mood disorder and likely borderline personality organization multiple suicide attempts in past largely overdose dm due to medication now apparently resolved cervical strain rosacea esophagus polysubstance abuse etoh mj cocaine crack binges with resultant unsafe sexual practices h o atrial fibrillation not on medication social history unemployed lives alone smokes pk day occasional etoh and omr records indicate some history of crack cocaine use family history states has fh of diabetes and cancer in everyone but no fh of cad htn sudden death or cardiac dysrhythmias physical exam on transfer to ccu vs hr bp o sat l nc gen agitated in fetal position not tachypneic heent perrl mm dry neck neck supple left neck dressing with dried blood no active bleeding or discharge mild tenderness on palpation pulm moving air appropriately diffuse crackles left upper chest vns site c d i card soft heart sound rrr s s present no m g r with pericardial window draining frank blood abd bs soft nt nd ext wwp no edema pd bilaterally skin warm back tenderness to palpation along the spine neuro aox agitated but agreeable on discharge vs ra tele hr in s yesterday afternoon otherwise s sinus this morning short runs of svt to s seconds gen aox nad heent perrla mmm neck neck supple pulm ctab card rrr normal s s no m g r abd soft nontender nondistended ext wwp no edema l calf ttp no swelling or cords noted pertinent results admission labs pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood glucose urean creat na k cl hco angap pm blood calcium phos mg am blood t am blood tsh cardiac biomarkers am blood ck mb ctropnt am blood ck mb ctropnt micro urine cx neg pericardial fluid culture ngtd but pending as of transfer to micu pericardial fluid cytology pnd studies echo left atrium normal la size right atrium interatrial septum increased ivc diameter cm with decrease during respiration estimated ra pressure mmhg left ventricle normal lv wall thickness normal lv cavity size suboptimal technical quality a focal lv wall motion abnormality cannot be fully excluded depressed lvef no resting lvot gradient no vsd right ventricle borderline normal rv systolic function aortic valve no as mitral valve no ms mr tricuspid valve indeterminate pa systolic pressure pericardium moderate to large pericardial effusion no ra diastolic collapse no rv diastolic collapse general comments suboptimal image quality poor echo windows the rhythm appears to be atrial flutter echocardiographic patient poor image quality the estimated right atrial pressure is mmhg with ivc dilation cm left ventricular wall thicknesses are normal the left ventricular cavity size is normal due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded lv systolic function appears mildly depressed there is no ventricular septal defect rv with borderline normal free wall function there is no aortic valve stenosis no mitral regurgitation is seen the pulmonary artery systolic pressure could not be determined there is a moderate to large sized pericardial effusion greatest anteriorly and best seen in the subcostal view no right atrial diastolic collapse is seen no right ventricular diastolic collapse is seen mild rv compression in the subcostal view is suggestive of elevated intrapericardial pressure cardiac cath comments under fluoroscopic guidance cc of bloody pericardial fluid was obtained through subxiphoid approach intrapericardial origin of fluid was confirmed with contrast injection and intrapericardial pressure measurement initial pericardial pressure was elevated at mm hg and dropped to mm hg after remorval of fluid pericaridal drain was sutured in place for hours final diagnosis successful urgent pericardiocentesis through subxiphoid approach for impending pericardial temponade echo impression small amount of echodense pericardial material fluid is seen no evidence of tamponade probable regional lv systolic dysfunction moderately dilated and hypokinetic right ventricle compared with the prior studies images reviewed of and the appearance of the pericardium is similar to that of the post tap echo yesterday the basal to mid inferior inferolateral hypokinesis was probably present in but image quality is poor on all studies the right ventricle appears dilated on studies from yesterday and today it was probably normal in leni s bilateral lower extremity ultrasound grayscale color and doppler images of the bilateral common femoral superficial and deep femoral and popliteal veins were obtained there is non occlusive thrombus in the mid left popliteal vein and left peroneal veins as well as the right posterior tibial vein the bilateral common femoral superficial femoral and right popliteal veins demonstrated normal compressibility and wall to wall color flow impression non occlusive thrombus in left popliteal left peroneal and right posterior tibial veins ct torso prelim pulmonary embolism involving right lower posterior basal segmental and subsegmental branches and subsegmental branch of left lower anterior basal pulmonary artery bilateral moderate sized pleural effusions with adjacent atelectasis evidence of right heart strain manifest as reflux of iv contrast into the ivc and hepatic veins mediastinal and right hilar adenopathy with right hilar soft tissue causing some narrowing of the airways and vessels concerning for malignancy bronchial wall thickening noted particularly along right middle and right lower bronchi perifissural consolidation in posteromedial right middle represent atelectasis or infection however underlying tumor or extension of right hilar mass not excluded mm spiculated nodule in the right upper is suspicious for malignancy predominantly paraseptal emphysema in the right upper with largest bulla measuring x cm tiny pericardial fluid and possible pericardial thickening no evidence of malignancy in the abdomen and pelvis intraabdominal findings include aortic and iliac artery calcifications colonic diverticulosis and tiny bubble of gas within the urinary bladder which could be due to recent catheterization correlate clinically no bony destruction concerning for malignancy evidence of right femoral head avascular necrosis without significant collapse ct head no evidence of an acute intracranial process postoperative changes of right temporal lobectomy pathology pericardial effusion positive for malignant cells consistent with metastatic adenocarcinoma repeat echo lv systolic function appears depressed the right ventricular cavity is borderline dilated with mild global free wall hypokinesis there is a small pericardial effusion the effusion is echo dense consistent with blood inflammation or other cellular elements there are no echocardiographic signs of tamponade brief hospital course yo m with history of epilepsy admitted for elective vagal nerve stimulator replacement transferred to micu for management of tachycardia hypotension and hypoxia found to have pericardial effusion now s p pericardiocentiesis with drain in place transferred to ccu for post operative monitoring with frequent agitation now found to have bilateral pes pericardial effusion in the micu pt noted to be tachycardic with hypotension and found to have pericardial effusion he underwent pericardiocentesis with drain placement with drainage of bloody fluid hct stable despite profuse bloody drainage etiology is likely malignancy given that ct torso showing rul lung spiculated nodule effusion cytology and micro showed cells c w metastatic lung adenocarcinoma drain was eventually pulled without complication and without any further hemodynamic instability pulsus checked for several days after drain pulled and resolved effusion on echo was mmhg on discharge pe dvt pt noted to have enlarged rv on repeat echo so cta was obtained for concern of pes which confirmed b l subsegmental pes lenis also positive for b l dvts he was started on heparin ggt in house and transitioned to an anticoagulation regimen of coumadin with a lovenox bridge he will f u with his pcp on after discharge agitation patient with history of etoh marijuana cocaine crack binges he was significantly agitated throughout admission which was initially thought to be secondary to etoh withdrawal he was maintained on a valium ciwa and klonipin mg tid however agitation persisted despite being well out of the acute withdrawal window he had several code purples called for him and was often violent towards nurses of note pt would be lucid and engaging often during the day with decompensation at night psych was consulted who felt that this was less likely to be withdrawal and instead a behavioral issue delerium likely in setting of supratherapeutic valproate level they recommended haldol for his agitation which was continued mg prn along with mg qhs standing these were discontinued on discharge takes no psych meds at home and delirium apparently cleared evaluated by psychiatry prior to discharge appeared to understand importance of f u he was started on mvi thiamine folate afib with rvr patient oscillates between hr of s s with frequent episodes of rvr on tele asymptomatic based on old records has a history of afib with rvr a flutter was treated with diltiazem and flecainide and was supposed to be on metoprolol increased metoprolol to mg po qid standing which has controlled rate well though still with frequent episodes of rapid ventricular response that respond to iv lopressor mg x because of continued episodes of rvr likely in the setting of pericardial effusion and multiple pes pt started on diltiazem drip weaned off and started on diltiazem er mg daily and metoprolol changed to mg of metoprolol succinate on discharge hr in the s with these changes with short bursts of svt to s prior to discharge would consider uptitrating rate control as an outpatient h o epilepsy and seizure activity vns placed and was re activated about week after placement he was continued home aeds depakote er and oxcarbazepine mg which was often given iv due to inability to take pos from agitation depakote level was found to be elevated in setting of delirium however unclear if this was true trough was discharged on home meds and advised to f u with his outpatient neurologist for management of his depakote foley self d c pt pulled own foley overnight of note there was blood around the uerethral meatus after he pulled it urine output was monitored and foley ended up being replaced on given that he was put back into pt restraints foley dc ed and was able to void on his own with no hematuria for remaineder of admission medications on admission clonazepam mg qid divalproex mg sustained release qam depakote er mg tab tabs qam tabs in the afternoon and tabs qpm omeprazole mg delayed release daily oxcarbazepine mg asa mg daily not taking as prescribed discharge medications lovenox mg ml syringe sig one subcutaneous twice a day for days disp syringe refills oxcarbazepine mg tablet sig one tablet po bid times a day clonazepam mg tablet sig one tablet po four times a day omeprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily warfarin mg tablet sig one tablet po once daily at pm disp tablet s refills diltiazem hcl mg capsule sustained release sig one capsule sustained release po daily daily disp capsule sustained release s refills divalproex mg tablet sustained release hr sig one tablet sustained release hr po qam use in addition to the depakote mg strength tabs for total dose of mg divalproex mg tablet sustained release hr sig three tablet sustained release hr po qafternoon divalproex mg tablet sustained release hr sig three tablet sustained release hr po qhs once a day at bedtime divalproex mg tablet sustained release hr sig two tablet sustained release hr po qam take in addition to mg dose for a total mg every morning nicotine mg hr patch hr sig one patch hr transdermal daily daily disp patch hr 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 aspirin mg tablet sig one tablet po once a day discharge disposition home discharge diagnosis seizure disorder atrial fibrillation lung adenocarcinoma pericardial effusion deep vein thrombosis pulmonary embolism discharge condition mental status confused sometimes level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were seen in the hospital to have your vagal nerve stimulator replaced which has been turned on again for your seizures you were also found to have a very fast heart rate from your atrial fibrillation irregular heart rate and for this we started diltiazem and metoprolol which slow your heart rate in addition you were found to have a pericardial effusion fluid around your heart which is likely due to spreading of lung cancer which was discovered on a ct scan you were seen by the oncologists here who recommended that you go to clinic for follow up to discuss further workup and treatment you were also found to have a pulmonary embolism and deep vein thrombosis blood clots in your lung and legs for which you were started a blood thinner you will be taking a blood thinner called coumadin to prevent more clots from forming and to treat the ones you already have and you should take this medication every day you will be taking lovenox another blood thinner which works immediately temporarily until your blood level of coumadin reaches the therapeutic range changes to your medications start diltiazem mg every day start taking metoprolol mg daily start taking warfarin mg daily start taking lovenox shots twice a day until you are told to stop by your doctor followup instructions in addition to the appointments below the oncologists are trying to schedule you an appointment in clinic the phone number to call with questions is department when friday at pm with mark licsw building sc clinical ctr campus east best parking garage department when friday at pm with mark licsw building sc clinical ctr campus east best parking garage department when thursday at pm with md building campus east best parking garage completed by [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint tachycardia major surgical or invasive procedure s p pericardial window for recurrent malignant pericardial effusion and drainage of large right pleural effusion history of present illness the patient is a yo man with h o epilepsy s p vagal nerve stimulator afib recent diagnosis of stage iv lung ca and pe on lovenox and coumadin and a recent pericardial effusion who presents with one week of worsening sob chest pain and abdominal pain the patient was initially brought in by ems after being noted to be tachycardic to the s he took mg diltiazem po and was transferred to the bied in the ed he received diltiazem mg iv and mg po and his hr remained in the s bedside tte demonstrated a moderate pericardial effusion without evidence of tamponade and pulsus was difficult to obtain secondary to tachycardia cxr demonstrated a right sided pleural effusion cards recomended amiodarone drip with up escalation to dilt as needed he also received l of ns he was admitted to the micu for further management his vs at the time of transfer were p bp on l on hd the patient was taken for a pericardial window by csurg in which they removed cc of pericardial fluid and cc of fluid from his left lung he returned intubated from the pericardial window amio was stopped and metoprolol was uptitrated the patient d c d his own chest tube several times the patient was agitated requiring zydus mg and haldol on hd the decision was made to focus on comfort only past medical history epilepsy and nonelectrographic seizures petite mal with rare secondary generalization s p right temporal lobectomy s p vns placement mood disorder and likely borderline personality organization multiple suicide attempts in past largely overdose dm due to medication now apparently resolved cervical strain rosacea esophagus polysubstance abuse etoh mj cocaine crack binges with resultant unsafe sexual practices h o atrial fibrillation not on medication social history unemployed lives alone smokes pk day occasional etoh and omr records indicate some history of crack cocaine use family history states has fh of diabetes and cancer in everyone but no fh of cad htn sudden death or cardiac dysrhythmias physical exam admission physical exam vitals bp p s r o general unresponsive heent sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs diffuse expiratory wheezes r sided crackles cv distant heart sounds pulsus of abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly pertinent results echo due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded overall left ventricular systolic function cannot be reliably assessed there is considerable beat to beat variability of the left ventricular ejection fraction due to an irregular rhythm premature beats the right ventricular free wall is hypertrophied with borderline normal free wall function there is a moderate sized pericardial effusion the effusion appears circumferential the effusion is echo dense consistent with blood inflammation or other cellular elements no right ventricular diastolic collapse is seen impression moderate sized organized circumferential pericardial effusion without echocardiographic signs of tamponade tachycardia with beat to beat variation in left ventricular systolic function when compared to prior study images reviewed from the effusion is now larger atrial tachyarrhythmia is present echo due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded overall left ventricular systolic function cannot be reliably assessed there is considerable beat to beat variability of the left ventricular ejection fraction due to an irregular rhythm premature beats there is a moderate sized pericardial effusion the effusion appears circumferential the effusion is echo dense consistent with blood inflammation or other cellular elements no right ventricular diastolic collapse is seen impression limited study suboptimal quality moderate sized circumferential pericardial effusion containing echo dense material consistent with blood inflammation or other cellular elements no echocardiographic evidence of tamponade left pleural effusion compared with the prior study images reviewed of the size of the pericardial effusion remains moderate but has decreased minimally in size from centimeters to centimeters in greatest dimension 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 glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap brief hospital course yo man with h o epilepsy s p vagal nerve stimulator afib recent diagnosis of stage iv lung ca and dvt pe on lovenox and coumadin and a recent pericardial effusion who presents with one week of worsening sob chest pain and abdominal pain comfort care patient s family decided to make patient cmo patient when lucid yesterday evening also said that he did not want any further procedures and just wanted his pain to be controlled all medications were discontinued patient passed away on and was noted to be comfortable hospital course tachycardia afib with rvr likely in the setting of pericardial effusion and multiple pes nl tsh and free t on last admission at end of tox screen negative except for asa based on old records has a history of afib with rvr a flutter was treated with diltiazem and flecainide and was supposed to be on metoprolol in ed received diltiazem mg iv and mg po and his hr remained in the s amio drip started hr s all medications were discontinued after patient was made cmo pericardial effusion moderate size on echo in ed but no evidence of tamponade prior pericardial effusion about one month ago showed adenocarcinoma of lung consistent with his lung cancer diagnosis current effusion likely a malignant effusion or blood he was s p pericardial window which he tolerated well pleural effusion patient received l of fluids while in ed chest xray shows r sided pleural effusion new when compared to xray at discharge days prior to admission lung cancer per our oncology team this patients condition was end stage h o seizure disorder vns placed during last admission he was continued on his antiepileptics while be was cmo medications on admission lovenox mg ml sq oxcarbazepine mg po bid clonazepam mg po qid omeprazole mg po daily warfarin mg po daily diltiazem hcl mg po daily divalproex mg daily nicotine mg hr patch daily metoprolol succinate mg po daily asa mg daily discharge medications n a discharge disposition expired discharge diagnosis expired discharge condition n a discharge instructions n a followup instructions n a md,"{
""Diagnoses"": [""admission for elective replacement of vagus nerve stimulator generator"", ""pericardial effusion"", ""hypotension"", ""ciwa of 13"", ""alcohol use disorder""],
""Medications"": [""Ativan (mg)""]
}"
12451,admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint meningitis major surgical or invasive procedure none history of present illness f transferred from osh with meningitis pt developed ear pain four ago and she was diagnosed with otitis media by her pcp and started on azithromycin apparently she took the first dose of mg and did not take mg the next over the next she then progressed with severe headache frontal and orbital bilaterally with some photophobia and fevers as high as she denies any rash the pain in her ear was radiating down to her jaw she states that her children had recent colds and another contact had a severe headache with flulike symptoms but no one had known meningitis she states too that she felt her ear three ago and noticed yellow fluid from her ear because of the worsening headache she presented to osh for further evaluation at the osh an mri showed acute l mastoiditis and sinusitis she never became hypotensive but she was tachycardic to s her temp was as high as a tox screen was negative an lp was performed and looked like frank pus nonbloody with an opening pressure of cm h o she was given ceftriaxone g iv x and zosyn g iv x before the lp was completed she was then rapidly given decadron mg iv x vancomycin mg iv and acyclovir mg iv she also received morphine for pain she was transferred to the ed here her temp was bp ranged in the s s and pulse in s a tube from the lp at osh was sent to the lab she was given morphine mg iv x vancomycin mg iv x tylenol mg x and acyclovir mg iv x ent was consulted pt stable and transferred to floor no change in intervention at this time past medical history none social history sh lives with husband and children works at her parents business a deli denies tobacco occasional social etoh and no ivdu family history noncontributory physical exam vs ra gen appears ill cheeks flushed dozes off frequently but easily arousable no respiratory distress heent perrl mild photophobia eomi op clear mm dry neck stiffness some difficulty touching chin to chest yellow fluid draining from l ear tympanic membrane bulging with small stigmata of blood opacified membrane cv slightly tachycardic nl s s no m r g pulm clear bilaterally abd soft nt nd bs no masses ext no c c e good distal pulses skin no rash neuro cn ii xii intact strength in all extremities sensation intact to light touch no frank neck stiffness but pt does bend knees spontaneously after her legs are straightened out mental status waxing and answers questions appropriately a ox follows commands but often drifts off though easily arousable pertinent results pm urine hours random pm urine ucg negative pm cerebrospinal fluid csf protein glucose pm cerebrospinal fluid csf wbc rbc polys lymphs monos pm lactate pm urine color straw appear clear sp pm urine blood lg nitrite neg protein neg glucose neg ketone tr bilirubin neg urobilngn neg ph leuk neg pm urine rbc wbc bacteria occ yeast none epi pm glucose urea n creat sodium potassium chloride total co anion gap pm estgfr using this pm wbc rbc hgb hct mcv mch mchc rdw pm neuts bands lymphs monos eos basos pm hypochrom normal anisocyt normal poikilocy macrocyt normal microcyt normal polychrom normal ovalocyt pm plt smr normal plt count brief hospital course meningitis likely extension from otitis media wbc count and diff c w bacterial meningitis as well as very elevated protein though gram stains from osh have been negative thus far s pneumo h flu high on list of possibilities meningococcus less likely as no rash and extension from otitis media would be an unlikely route of infection from meningococcus doubt lyme given extension from otitis media and wrong time of year cont with ceftriaxone and vanco for now to cover bacterial pathogens pneumococcus seems most likely given origin of otitis media cont with iv decadron mg iv q as osh s pneumo hsv pcr lyme pending if gram negative rods show up on gram stain would give intrathecal gent u hcg osh id on consult appreciate recs picc for outpt ivabx d w id per osh records of pan sensitive s pneumo pt to receive outpt dose of steroid at home tomorrow and additional of ceftriaxone grams pt will f u in one week for labs and check up with pcp l mastoid opacification ent on consult appreciate recs surgical intervention likely not needed per ent as not c w mastoiditis per se no further interventions pt will f u with pcp om already drained per ent recs medications on admission none discharge medications ceftriaxone g recon soln sig one intravenous twice a for disp refills prednisone mg tablet sig two tablet po twice a for disp tablet s refills discharge disposition home with service facility critical care systems discharge diagnosis strep pneumo meningitis discharge condition stable discharge instructions you were admitted to the hospital for meningitis you were given antibiotics and steroids and your symptoms improved drastically you were felt stable to leave you will get antibiotics ceftriaxone twice a for and you should return immediately to an emergency room for any worsening of change in your improvement followup instructions call dr tomorrow he will see you at the beginning of next week for blood tests and an evaluation,"{
""Diagnoses"": [""Meningitis"", ""Otitis media"", ""Acute mastoiditis"", ""Sinusitis""],
""Medications"": [""Azithromycin"", ""Tox screen"", ""LP""]
}"
11286,admission date discharge date date of birth sex m service medicine allergies nitrofurantoin alpha receptor antagonst antidepresnts attending chief complaint fever confusion major surgical or invasive procedure s p l discectomy and fusion picc line placement history of present illness year old man pmh significant for mrsa osteomyelitis and bacteremia djd back pain diet controlled dm anxiety disorder and bph he underwent turp in c b months of recurrent mrsa uti s cachexia low grade fevers anorexia was rx with intermittent courses of abx duration not known but continued to be ill was readmitted to medical center with intractable back pain found to have mrsa and pseudomonal bacteremia mri with l l osteo discitis paraspinal mass no surgery or biopsy tte negative tee done showed no evidence of endocarditis ef he was treated for weeks with vanco changed to linezolid and cipro for pseudomonas sent to rehab and was doing better starting to walk had peg for weight loss admitted to hospital with weakness fever confusion pain started on levaquin then changed vancomycin and bactrim for when multiple blood cultures grew mrsa urine culture with klebsiella pneumoniae repeat mri shows partial resolution of paraspinal mass improved discitis but small epidural abscess question minor nerve root impingement md neuro exam is significant for generalized weakness but non focal yesterday afternoon had a minute bout of chills hypotension and sob sbp hr transferred to icu cxr normal abg normal buffed up to with ivf comfortable on l o but still with severe back pain wbc plts hct na bun cr alb should be ok for floor as he is in icu because it is a small hospital on arrival to the floor he was awake alert very conversant does not remember much of the details of his most recent hospitalization he states to paim medications he is on his pain is well controlled no dysuria denies chest pain he has not ambulated since arrival no changes in sensation in hands or feet on review of systems the patient denies any chest pain shortness of breath night sweats fevers chills night sweats fatigue headaches dizziness blurred vision sore throat nausea vomiting abdominal pain any new rashes denies dysuria hematuria increased urgency diarrhea constipation hematochezia melena epistaxis all other systems reviewed in detail and negative except for what has been mentioned above past medical history l l osteomyelitis discitis paraspinal mass likely mrsa djd back pain dm ii diet controlled cad s p ptca stent to rca and left circ nstemi in with ptca of rca bph s p turp recurrent mrsa utis s p peg tube placement anxiety disorder social history married lives with wife at home retired from making plastic windows at company in previously healthy prior to turp in previously active now with difficuty walking from pain denies alcohol remote history of tobacco family history nc physical exam vs t hr bp rr sat on ra gen appears well dressed well nourished in no acute distress heent ncat perrl sclera anicteric no ulcers oropharynx otherwise clear throat with no erythema or exudates no thrush no cervical lymphadenopathy jvp is flat cv normal s s rrr systolic flow murmur no r g no tenderness to palpation of precordium pmi non displaced lungs clear to auscultation bilaterally no w r rh abdomen soft nontender nondistended normoactive bowel sounds no hepatosplenomegaly no ascites ext no peripheral edema no clubbing cyanosis no calf pain dp pulses are bilaterally neuro a o x cn ii xii grossly intact motor both upper and lower extremities sensation grossly intact to light touch dtr throughout toes downgoing skin pink warm no rashes 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 neuts lymphs monos eos baso am blood pt ptt inr pt am blood pt ptt inr pt am blood esr am blood ret aut 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 alt ast alkphos totbili am blood albumin calcium phos mg am blood calcium phos mg am blood calcium phos mg am blood caltibc ferritn trf am blood triglyc am blood crp am blood vanco am blood vanco pm blood type art po pco ph caltco base xs pm blood type art po pco ph caltco base xs intubat intubated pm blood glucose lactate na k cl calhco pm blood hgb calchct o sat pm blood freeca transesophageal echo conclusions no spontaneous echo contrast or thrombus is seen in the body of the left atrium left atrial appendage or the body of the right atrium right atrial appendage no atrial septal defect is seen by d or color doppler there is mild to moderate regional left ventricular systolic dysfunction with anterior hypokinesis segmental wall motion was not fully assessed there are simple atheroma in the aortic arch and in the descending thoracic aorta the aortic valve leaflets are mildly thickened no masses or vegetations are seen on the aortic valve no aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve trace mitral regurgitation is seen mri of c t l spine impression discitis osteomyelitis at l with pre paravertebral inflammatory change with no evidence of epidural abscess at this location clumping of the cauda equina nerve roots suggests arachnoiditis stir signal hyperintensity and enhancement at the t intervertebral disc and superior endplate of t also suspicious for discitis osteomyelitis also with no evidence of epidural abscess at this location echo study date of no spontaneous echo contrast or thrombus is seen in the body of the left atrium left atrial appendage or the body of the right atrium right atrial appendage no atrial septal defect is seen by d or color doppler there is mild to moderate regional left ventricular systolic dysfunction with anterior hypokinesis segmental wall motion was not fully assessed there are simple atheroma in the aortic arch and in the descending thoracic aorta the aortic valve leaflets are mildly thickened no masses or vegetations are seen on the aortic valve no aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve trace mitral regurgitation is seen no vegetation or abscess seen prostate u s pm mild bph no son evidence of mass or abscess persantine mibi no definite reversible perfusion defects identified slight apical hypokinesis with low normal calculated lvef of stress study date of no anginal type symptoms or ischemic ekg changes nuclear report sent separately l spine ap lat in o r pm a series of four intraoperative radiographs of the lumbar spine were obtained these demonstrate an anterior interbody fusion device placed in the lumbar spine at l l severe multilevel degenerative changes in lumbar spine are seen evaluation of osseous structures is obscured by overlying bowel contents retractors are seen anteriorly please refer to operative report for full details l spine ap lat pm post surgical changes as described limited study brief hospital course y o man with pmh significant for mrsa osteomyelitis and bacteremia djd back pain diet controlled dm anxiety disorder and bph p w with persistent mrsa bacteremia and disc osteomyelitis s p discectomy with fusion mrsa bacteremia osteomyelitis epidural abscess bacteremia most likely from chronic osteomyelitis disc abscess blood cultures growing mrsa last positive blood culture was on patient does not have any focal neurologic findings repeat mri on showed l l and t discitis without any evidence of epidural abscess based on prior mri from osh tee on negative for vegetations abscess rectal ultrasound to r o prostatic abscess fluid collection was negative leukocytosis likely from intermittent bacteremia crp esr orthopedic spine surgeons were consulted and pt had resection of infected disc abscess with subsequent rod fixation on bone tissue culture from grew coag staph sensitivities pending pt remains afebrile hemodynamically stable without leukocytosis surveillance blood cultures negative last positive blood culture on vancomycin g qday started via picc line to continue for week course pt will need weekly vancomycin level troughs vancomycin level therapeutic on then sub therapeutic on and vancomycin dose was increased to g q h as gfr had improved klebsiella uti pan sensitive on bactrim ds treated with day course completed on cad no evidence of chest pain pmibi and stress test normal done prior to surgery for risk stratification continue aspirin anemia pt with hct of on transfer back to medicine service transfused u prbc with appropriate increase in hct however hct decreased again on orthopedics notified not concerned about this post op hct drop and no need to do imaging studies transfused again with u prbc with appropriate increase in hct hemolysis labs normal iron panel back pain secondary to osteomyelitis continue oxycodone and morphine prn tylenol q h titrate up pain medications as needed epistaxis secondary to trauma s p cautery by ent continue afrin allow nasal packing to dissolve avoid o nc use humidified shovel mask if needed bacitracin to nose qdaily saline nasal spray as needed dm ii diet controlled covered with riss while inpatient anxiety depression continue remeron ativan prn fen pt with hyponatremia and low phos on low sodium from appears to be from dehydration as looked dry on exam will replete with ns ivf check urine na if level not improving continue po diabetic cardiac diet replete lytes prn prophylaxis heparin sq bowel regimen access piv picc line manage per protocol care code full no heroic measures communication with patient dispo dc to rehab in he will followup with orthopedic spine clinic and id both at outpatient send weekly safety labs cbc chem lfts vancomycin level to clinic medications on admission medications at home asa mg daily klonopin mg po daily colace mg po bid senna po bid omeprazole mg po daily remeron mg po qhs vicodin po q h prn fentanyl patch mg q h tube feeds medications on transfer vancomycin mg started vitamin c mg zinc sulfate mg daily multivitamin tylenol q h protonix mg daily aspirin mg daily colace mg daily bactrim ds po bid started remeron mg lortab mg prn roxanol mg prn pain mom ml prn constipation maalox ml q h prn ambien mg po qhs discharge medications ascorbic acid mg tablet one tablet po bid times a day zinc sulfate mg capsule one capsule po daily daily hexavitamin tablet one cap po daily daily aspirin mg tablet chewable one tablet chewable po daily daily mirtazapine mg tablet one tablet po hs at bedtime magnesium hydroxide mg ml suspension thirty ml po q h every hours as needed aluminum magnesium hydroxide mg ml suspension mls po qid times a day as needed zolpidem mg tablet one tablet po hs at bedtime sodium chloride aerosol spray two spray nasal qid times a day as needed bacitracin zinc unit g ointment one appl topical qhs once a day at bedtime docusate sodium mg ml liquid one po tid times a day bisacodyl mg tablet delayed release e c two tablet delayed release e c po daily daily as needed lactulose g ml syrup thirty ml po q h every hours senna mg tablet one tablet po daily daily metoprolol tartrate mg tablet one tablet po bid times a day lansoprazole mg tablet rapid dissolve dr one tablet rapid dissolve dr daily daily oxycodone acetaminophen mg ml solution mls po q h every to hours as needed for pain miconazole nitrate powder one appl topical tid times a day as needed 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 lorazepam mg iv q h prn insulin lispro human unit ml solution sliding scale subcutaneous asdir as directed vancomycin hcl mg iv q h duration weeks start in am acetaminophen mg tablet one tablet po q h every to hours as needed for fever pain discharge disposition extended care facility me discharge diagnosis primary diagnoses s p l discectomy and fusion l l osteomyelitis discitis paraspinal mass likely mrsa djd back pain dm ii diet controlled bph secondary diagnoses cad s p ptca stent to rca and left circ nstemi in with ptca of rca recurrent mrsa utis s p peg tube placement anxiety disorder discharge condition stable discharge instructions you were admitted for bacterial infection in your blood and spine you were treated with antibiotics you had orthopedic spine surgery to remove the source of infection and had the lower part of your spinal cord fused you did not suffer any complications you will be discharged on more weeks of vancomycin please call your pcp or return to the ed if you experience fevers chills back pain nausea vomiting shortness of breath chest pain please take all medications as prescribed followup instructions provider clinic phone date time you should followup with your pcp week of discharge for further medical management call number below to make an appointment pcp dr orthopedics time pm on please have weekly labs cbc chem liver function tests vancomycin level faxed to clinic c o dr fax number md,{}
15851,admission date discharge date date of birth sex m service neonatology history baby delivered at weeks gestation weighing grams and was admitted to the intensive care nursery following delivery for management of perinatal depression for agonal heart rate to a year old gravida ii para i now ii mother prenatal screens revealed blood type o positive antibody screen negative hepatitis b surface antigen negative rpr nonreactive rubella immune and group b streptococcus positive the pregnancy was complicated by fetal hydronephrosis antepartum for vaginal spotting the fetus had a reassuring fetal heart tracing and fetal activity mother presented to the emergency department on the of complaining of abdominal pain on day of delivery she was sent by ambulance to labor and delivery on the and evaluation by ultrasound showed an agonal heart rate of around to beats per minute by verbal report this precipitated the stat cesarean section placental abruption was noted at delivery the baby emerged with dusky body pale extremities no heart rate bag mask ventilation and chest compressions were initiated the infant was intubated and given epinephrine by the endotracheal tube an umbilical venous catheter was placed and two more doses of epinephrine were given followed by a normal saline bolus sodium bicarbonate and then a second and third normal saline bolus the baby s color was pink with a heart rate of around nine minutes of age and compressions were stopped the heart rate increased to greater than beats per minute by ten minutes of life cord ph was apgar scores were at one five ten and fifteen minutes respectively physical examination on admission weight was grams th to th percentile head circumference centimeters th percentile length centimeters th to th percentile on examination an immobile pink baby mechanical ventilation head normal flat anterior fontanelle no molding normal neck and ears normal mouth and palate skin pink perfused tiny skin tag below left nipple chest clear equal breath sounds no rales no spontaneous respiratory effort the heart was normal rhythm no murmur pulses full and equal abdomen no bowel sounds the abdomen was soft no hepatosplenomegaly no masses genitourinary normal male both testes descended hips extremities spine showed stable hips normal spine normal hand and foot anatomy neurologic no response to pain no spontaneous respirations no movement spontaneous or provoked later developed sustained tonoclonic movements first of the left arm and then right arm minimal tone in legs and arms no deep tendon reflexes no corneal reflexes the pupils are midposition with minimal if any response red reflex positive bilaterally hospital course respiratory the infant was placed on ventilator pressures with a simv rate of oxygen initial venous blood gas showed a ph of co and was treated with sodium bicarbonate subsequent gases continued to show severe metabolic acidosis treated with serial doses of sodium bicarbonate ventilator support was weaned to with a rate of for adequate ventilation but continued to have metabolic acidosis treated with sodium bicarbonate cardiovascular initially maintained blood pressure well perfused without a murmur but developed severe hypotension treated with several more normal saline boluses then dopamine escalated to mcg per kilogram per minute and next dobutamine also rapidly escalated to mcg per kilogram per minute and then finally one dose of hydrocortisone the pulses became thready as the hypotension progressed a chest x ray showed a normal size heart without evidence of pericardial effusions despite maximum support the baby was unable to maintain a blood pressure and progressed to no detectable blood pressure by about am fluids electrolytes and nutrition placed npo started initially on d w at mg per kilogram per day then increased to mg per kilogram per day to maintain glucose within normal limits received calcium gluconate times two doses for an initial ionized calcium of that increased to hematology hematocrit on admission was blood loss to placenta most likely all maternal initial platelets no evidence of disseminated intravascular coagulation it is noteworthy that the nrbc count was only suggesting no chronic hypoxia infectious disease a complete blood count and blood culture was drawn on admission and started on ampicillin and cefotaxime for rule out sepsis the initial complete blood count showed a white count of with polys and bands neurology seizures were noted at two hours of life was treated for a total of mg per kilogram of phenobarbital and then mg per kilogram of dilantin to stop the seizure activity remained comatose without any response psychosocial mother held before and after he died father came in from home to be with the baby at the time of death discharge disposition despite maximum support was unable to maintain cardiac output and blood pressure the baby died at cause of death perinatal depression primary pediatrician dr in i telephoned his office to convey the information at the mother s request autopsy both parents granted autposy consent the autopsy was performed by the pathology service at on discharge diagnoses term appropriate gestational age male perinatal depression hypotension hypocalcemia rule out sepsis m d dictated by medquist d t s job,"{
""Diagnoses"": [""Perinatal depression"", ""Agonal heart rate""],
""Medications"": [""Epinephrine"", ""Oxygen""]
}"
4329,admission date discharge date service ccu chief complaint status post left internal carotid artery angioplasty and stenting history of present illness this is an year old woman with a history of diabetes coronary artery disease carotid until three months ago when she developed word finding difficulty her carotid doppler on showed to stenosis of left carotid artery and to stenosis of the right carotid artery otherwise she denied any focal deficits including weakness numbness diplopia dysphasia field cuts or gait difficulty she is known to have stocking glove numbness and hypesthesia secondary to diabetic she was admitted on for a left internal carotid artery angioplasty and stenting her creatinine on admission was she was prehydrated with normal saline and was given mucormyst she went for left internal carotid artery angioplasty and stenting on the date of transfer to ccu without any complications she was on dopamine drip initially due to carotid procedure which induced bradycardia and no hypotension she was transferred to ccu for close monitoring past medical history carotid disease left internal carotid and right carotid artery stenosis for details see carotid doppler coronary artery disease status post cabg in status post ptca of lima in chronic anemia iron deficiency small asd by echo in history of tia and cva in aspirin and plavix since post stroke seizure in diabetes with peripheral neuropathy retinopathy and nephropathy hba c in was chronic renal insufficiency creatinine ranging from to cervical spondylosis c c c c t t l s left chronic lumbosacral radiculopathy hypertension hypercholesterolemia status post bilateral cataract surgery status post left upper extremity fracture repair medications aspirin mg q d plavix mg q d lipitor mg q d glyburide mg b i d imdur mg b i d neurontin mg b i d zyprexa mg q h s atenolol mg q d iron sulfate mg q d depakote mg q h s lasix mg b i d calcium mg b i d tylenol p r n allergies no known drug allergies family history negative for cva father passed away in car accident mother passed away from colon cancer social history no tobacco or alcohol lives with husband at home ambulates with cane for a short distance wheelchair for a long distance physical examination on admission to ccu temperature heart rate blood pressure o sat to on room air to with liters by nasal cannula general lying in bed in no acute distress head and neck normocephalic atraumatic oropharynx clear soft left carotid bruit cardiovascular normal s and s s present lungs are clear to auscultation bilaterally anteriorly abdomen soft obese nondistended nontender extremities no pitting edema bilateral distal pulses right groin has small ecchymosis no bruit slightly tender neuro awake alert and oriented cranial nerves ii xii grossly intact sensory decreased in bilateral lower extremities strength to bilaterally nonfocal exam laboratory white count of hematocrit which is down from pre procedure platelets sodium potassium chloride bun creatinine glucose calcium mag phos she had a head mri without contrast on no acute infarct advanced chronic microvascular ischemic changes involving deep central white matter stenosis precavernous and cavernous portion of the left internal carotid artery less than stenosis of the mid basilar artery significant carotid stenosis by doppler left carotid to hospital course the patient remained stable during the hospital stay she was off dopamine soon in ccu she was transfused with units of packed red blood cells for a hematocrit of post procedure and her hematocrit has remained stable since she was restarted on all her home medications on hospital day she was scheduled for discharge the next day however on hospital day she was found to have a soft bruit at her right groin site an ultrasound revealed a cm pseudoaneurysm just superior and medial to the puncture site therefore she stayed in the hospital awaiting ir to perform ultrasound guided thrombin injection after physical therapy evaluation rehab was recommended given the patient s poor functional status discharge condition stable discharge status rehab facility discharge diagnoses carotid disease status post left internal carotid artery stent right femoral pseudoaneurysm status post thrombin injection coronary artery disease diabetes hypercholesterolemia chronic renal insufficiency discharge medications furosemide mg b i d atenolol mg q d imdur mg b i d olanzapine mg q d lipitor mg q d glyburide mg b i d calcium carbonate mg b i d potassium acetate tablets t i d iron sulfate mg q d depakote mg q h s neurontin mg t i d plavix mg q d aspirin mg q d sublingual nitroglycerin p r n her most labs on discharge show a white count crit platelets sodium potassium chloride bicarb bun creatinine glucose calcium mag phos m d dictated by medquist d t job [NEW_RECORD] admission date discharge date service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint lethargic major surgical or invasive procedure central line placement arterial line placement history of present illness pt is a yo female with h o dm cad s p cabg carotid stenosis s p stent to l ica asd tia cri seizure d o presents to the ed with lethargy and non specific complaints the symptoms had been increasing and were accompanied by decreased po intake per the patient s family in addition she had developed n v d and more recently abdominal pain in the pt was found to be anemic to with a creat of baseline k of lactate ua was c w infection and a low grade temp to pt was hypotensive to s and s she received ivf without resolution and was entered into the sepsis protocol r ij was placed total of l ivf given dopamine started and vanc levo flagyl were started pt also reported to have been hypoxic with sats in low s and put on nrb dopamine was weaned off in micu past medical history dm type cad s p vessel cabg and pci to lima lad in carotid stenosis s p stent to left ica in atrial septal defect tia cva chronic kidney disease stroke induced seizures htn hyperlipidemia cervical spondylosis lumbar radiculopathy s p cataract repair s p lue fx repair depression social history retired math professor married husband is health care proxy etoh family history non contributory physical exam vitals art bp oxygen sats on l nc gen arousable and will follow very simple commands appears pale heent perrl op clear mmm no lad cv rrr ii vi systolic murmur at lsb lungs clear abd soft mild tenderness bs protruberant but no fluid wave ext trace edema left surgical scar and mild erythema at shin neuro cn ii xii intact grossly no droop mae pertinent results labs on admission pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts bands lymphs monos eos baso pm blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap pm blood ast ck cpk alkphos amylase totbili am blood calcium phos mg am blood type po pco ph calhco base xs pm blood lactate k other labs pm blood ck mb ctropnt am blood ck mb ctropnt am blood ck mb ctropnt pm blood ast ck cpk alkphos amylase totbili am blood ck cpk am blood ck cpk am blood caltibc ferritn trf am blood cortsol am blood cortsol am blood cortsol am blood crp pm blood valproa labs on discharge am blood glucose urean creat na k cl hco angap am blood calcium phos mg radiology cxr ap impression no free intraperitoneal air or evidence of pneumonia is identified brief hospital course yo female admitted to micu from ed under sepsis protocol found to be in urosepsis pt was septic and entered sepsis protocol she was on dopamine for bp support in the micu overnight and started on vancomycin levaquin and flagyl initially urine grew gnr and blood had bottles of staph coag negative additionally ct scan showed minimal diverticulitis and thus all those things were being covered the staph was likely contaminant as it grew out four different species additionally urine grew e coli pansensitive and pt was started on amoxicillin vancomycin levaquin and flagyl were then d cd pt was then hemodynamically stable and did well pt with hct that had decreased to on admission with a normal hct in low s and here with guaiac positive stool requiring two units of prbc also appeared to have anemia of chronic disease on iron studies low iron low tibc high ferritin an active t s was kept at all times as well as large bore ivs ppi was changed to hct after transfusions remained stable cv a ischemia ekg showed inferolateral twi and st depressions cardiac enzymes x were done troponins were up to but cks and mbs flat this was thought to demand a low pressure state and increased hr we continued asa beta blocker statin and ace inhibitor b pump echo with ef pt was euvolemic on exam initially we held her lasix as she was auto diuresing and did not take in a lot of po except for when her husband was present lasix was restarted on discharge continued beta blocker ace as above c rhythm normal sinus metabolic acidosis pt had a non gap hypochloremic metabolic acidosis initially it was likely renal failure as well as normal saline this resolved arf baseline creatinine on admission it was from a prerenal etiology low blood pressure and decreased forward flow this resolved during hospitalization dm gets units at home continued home insulin slightly decreased as pt was taking poor pos she was also on a riss seizure disorder continued valproate per outpatient dosages psych continued zyprexa per home dosages f e n cardiac low salt diet electrolytes were checked and repleted ppx subcutaneous heparin bowel regimen ppi refused to work with physical therapy code status code status was full code access ij cvl arterial line while in micu pivs on floor medications on admission aspirin mg daily atorvastatin mg daily gabapentin mg tid isosorbide mononitrate mg qd lansoprazole mg capsule once daily atenolol mg tablet daily glyburide mg tablet daily zyprexa mg tablet at bedtime zyprexa mg tablet prn riss check fsg qidachs lisinopril mg tablet daily lasix mg tablet po daily humulin units qam depakote mg discharge medications amoxicillin mg capsule sig one capsule po q h every hours for days disp capsule s refills aspirin mg tablet chewable sig one tablet chewable po daily daily atorvastatin mg tablet sig one tablet po daily daily olanzapine mg tablet sig one tablet po hs at bedtime olanzapine mg tablet sig one tablet po bid times a day as needed divalproex mg tablet delayed release e c sig one tablet delayed release e c po bid times a day atenolol mg tablet sig one tablet po daily daily lisinopril mg tablet sig one tablet po once a day glyburide mg tablet sig one tablet po once a day insulin per outpatient dose units humulin qam lasix mg tablet sig one tablet po once a day prilosec mg capsule delayed release e c sig one capsule delayed release e c po once a day capsule delayed release e c s discharge disposition home with service facility caregroup discharge diagnosis primary diagnosis urosepsis anemia acute renal failure secondary diagnosis coronary artery disease diabettes mellitus seizure disorder hypertension hyperlipidemia discharge condition hemodynamically stable she is refusing physical therapy discharge instructions please call your doctor or go to the ed immediately if you have fever chills feel dizzy lightheaded shortness of breath breathing problems or any other health concern take your medications as prescribed you are on a new medication called amoxicillin which is an antibiotic your stool tested positive for blood here a few times you should follow up with dr you may need an outpatient colonoscopy if you have not had one recently followup instructions please call dr for follow up in the next week [NEW_RECORD] admission date discharge date 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 with hx of dm cad s p cabg cri s p recent admission for urosepsis admitted with mild left sided abd pain non bloody emesis and bloody stool anoscopy showed hemorrhoids and dried blood in vault and ng lavage was negative an abd ct showed wall thickening beginning in transverse colon and extending throughout remainder of colon as well as evidence of recurrent diverticulitis in the rectosigmoid given lactate sbp s t in ed must protocol was initiated rij placed and she received l ns in ed se was transiently on levophed she received flagyl cefepime vanco for presumed colitis and possible pneumonia given lll infiltrate on cxr she was briefly on the sicu service but was transferred to the micu service on the same day for further management while in the micu she received additional l ns and u prbc for hct given she remains hemodynamically stable she is being transferred to the general medical service for further management past medical history recent admission for urosepsis pan e coli s p day course of amoxicillin dm type cad s p vessel cabg and pci to lima lad in carotid stenosis s p stent to left ica in atrial septal defect tia cva chronic kidney disease baseline cr stroke induced seizures htn hyperlipidemia cervical spondylosis lumbar radiculopathy s p cataract repair s p lue fx repair depression h o chf tte ef mildly dil la small asd w l r flow mild lvh near akinesis distal ventricle mildly hypokinetic basal anterior septal and inferolatral walls mild global rv free wall hypokinesis trace ar mr tr mild mpulmonary artery systolic hypertension social history retired math professor married husband is health care proxy etoh pt has h home health aid and ambulates with a walker family history non contributory physical exam exam tc tm pc pr bpc bpr s s resp l nc gen elderly female alert oriented to person and place nad heent anicteric pale conjunctiva omm slightly dry op clear neck supple no lad jvp cm cardiac rrr soft s s ii vi sm at apex pulm scatterred wheezes bilaterally bronchial breath sounds at left base abd moderately distended nabs soft nt ext le to mid calf bilaterally warm dp bilaterally pertinent results wbc rbc hgb hct mcv mch mchc rdw neuts bands lymphs monos eos basos plt count pt ptt inr pt glucose urea n creat sodium potassium hemolyzed chloride total co ck cpk ck mb ekg nsr at bpm nl axis lae prwp twi in i avl v v no change from prior micro ucx k e coli levo bcx ngtd fecal cx no salmonella shigella e coli h c diff cancelled mucus blood contamination c diff toxin b pending radiology cxr increased lll and lingular opacity head ct chronic microvascular changes atrophy ct abd layering dependent gallstones no free air fluid thickening beginning in mid transverse colon and extending distally inflammation in rectosigmoid colon c w recurrent diverticulitis brief hospital course a f with hx of cad s p cabg crf dm admitted with abdominal pain brbpr found to have extensive colitis infectious vs ischemic and recurrent rectosigmoid diverticulitis abdominal pain brbpr this was most likely related to known diverticulitis colitis distal colitis was most likely secondary to infectious etiologies ischemic colitis was felt to be less likely despite the patient s known cardiovascular disease given the distribution of inflammation on ct surgery was consulted who do not feel surgical intervention was required there was no indication for urgent colonoscopy given acute colitis diverticulitis the patient will require a colonoscopy as an outpatient once her acute illness has resolved her abdominal exam was closely monitored and remained benign at time of discharge her diarrhea resolved prior to discharge her hematocrit remained stable at following transfusion unit of prbc in the icu prior to transfer to the floor e coli campylobactor salmonella shigella stool cultures were negative c diff toxin was negative x unable to produce additional stool samples and c diff toxin b assay was pending at time of discharge she was continued on levofloxacin metronidazole and will complete a day course for presumed infectious colitis her diet was advanced and at time of discharge she was tolerating a regular diet if her diarrhea resumes following completion of antibiotics stool samples should be obtained for c diff testing pneumonia lll lingular infiltrate noted on cxr following admission this may have been related to aspiration in the setting of nausea vomiting prior to admission although this may also have represented a community acquired pneumonia as mentioned above she was continued on levofloxacin metronidazole and will complete a day course which will cover both aspiration pneumonia and infectious colitis blood loss anemia the patient s hematocrit remained stable at following u prbc transfusion a m iron studies were not consistent with iron deficiency and vit b folate were not deficient the patient s hematocrit should be monitored as an outpatient to ensure stability and as mentioned above she will need an outpatient colonoscopy once her diverticulitis colitis has resolved hypotension the patient s hypotension on admission was most likely secondary to volume depletion given it rapidly normalized with iv fluid resuscitation random cortisol obtain in the icu was not suggestive of adrenal insufficiency at the time of discharge the patient s blood pressure remained stable on anti hypertensives required increase of lisinopril to mg daily acute on chronic renal failure creatinine improved to from on admission with hydration the acute renal failure was most likely related to volume depletion dehydration in setting of colitis although the differential diagnosis includes atn in setting of hypotension coronary artery disease initially held asa in the setting of gi bleed however this was resumed at discharge her statin was continued throughout hospital stay and ace inhibitor and beta blocker were resumed once she was hemodynamically stable there were no ischemic changes on ekg to suggest active myocardial ischemia h o congestive heart failure ef the patient was euvolemic at time of discharge and had been restarted on ace inhibitor and furosemide her fluid status will need to be closely monitored as an outpatient to ensure stability and she should follow up with cardiology as an outpatient at the discretion of her pcp type ii diabetes her glyburide was intially held given poor po intake however this along with her home dose of was resumed at time of discharge stroke induced seizures the patient was continued on her home dose of valproic acid code full medications on admission aspirin mg qd atorvastatin mg qd olanzapine mg and qhs divalproex mg atenolol mg d lisinopril mg qd glyburide mg qd units humulin qam lasix mg qd prilosec mg qd discharge medications divalproex mg tablet delayed release e c sig one tablet delayed release e c po bid times a day albuterol mcg actuation aerosol sig puff inhalation every six hours as needed for shortness of breath or wheezing disp mdi refills atrovent mcg actuation aerosol sig two puff inhalation every six hours as needed for shortness of breath or wheezing disp mdi refills levofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills metronidazole mg tablet sig one tablet po tid times a day for days disp tablet s refills acetaminophen mg tablet sig tablets po q h every to hours as needed olanzapine mg tablet sig one tablet po twice a day as needed atenolol mg tablet sig one tablet po once a day lisinopril mg tablet sig one tablet po daily daily disp tablet s refills glyburide mg tablet sig one tablet po daily daily humulin units qam furosemide mg tablet sig one tablet po daily daily prilosec mg capsule delayed release e c sig one capsule delayed release e c po once a day aspirin mg tablet chewable sig one tablet chewable po once a day discharge disposition home with service facility homecare discharge diagnosis primary colitis diverticulitis pneumonia blood loss anemia secondary urinary tract infection type ii diabetes coronary artery disease hypertension hyperlipidemia discharge condition good discharge instructions please follow up with your primary care physician or go to the emergency room if you develop recurrence of diarrhea rectal bleeding abdominal pain or other symptoms that concern you your lisinopril has been increased to mg daily for better control of your blood pressure you will continue levofloxacin metronidazole for more days to treat your pneumonia and colitis followup instructions please follow up with your primary care physician at p m if you have recurrent diarrhea following discontinuation of antibiotics you should be tested for c diff colitis at time of discharge c diff toxin b is pending your primary care physician may consider referral to cardiology for further management of your coronary artery disease and dilated cardiomyopathy completed by [NEW_RECORD] admission date discharge date service medicine allergies penicillins attending chief complaint decreased po confusion major surgical or invasive procedure none history of present illness y o f with recent hospitalization d c for lll pneumonia and diverticulitis presented to ed after home caregiver po intake and confusion x hours after d c pt completed day course of levo flagyl day no abd pain cp fever or chills pt does report diarrhea over the last few days cannot quantify how many bms day vomited x no blood or coffee ground emesis sob baseline mentation good per husband and care giver per report in the pt was afebrile disoriented mildly hypoxic on ra on l nc ekg w no acute changes rec d ceftriaxone g azithromycin and vancomycin g pt was ready to be admitted to the floor but became hypotensive to the s and minimally responsive she responded well to l ivf with rise in sbp to s and improved mental status abg was on o lactate decreased from to past medical history dm type cad s p vessel cabg and pci to lima lad in carotid stenosis s p stent to l ica in atrial septal defect tia cva chronic kidney disease baseline cr stroke induced seizures htn hyperlipidemia cervical spondylosis lumbar radiculopathy depression chf ef mildly dil la small asd w l r flow mild lvh near akinesis distal ventricle mildly hypokinetic basal anterior septal and inferolatral walls mild global rv free wall hypokinesis trace ar mr tr mild pulmonary artery systolic hypertension psh s p cataract repair s p lue fx repair s p cabg social history retired math professor married and lives with husband is health care proxy denies present or past tobacco no etoh pt has h home health aid and states that she ambulates without a walker though previous notes indicate she is wheelchair bound and needs a walker for assistance states that does all of her own cooking son phone nurse family history non contributory physical exam tc l nc gen lying in bed in nad appropriate cooperative heent anicteric pale conjunctiva mm dry op clear neck supple no lad jvp cm cardiac rrr soft s s ii vi sm at apex pulm crackles on l side entire lung field posteriorly no crackles anteriorly r base clear no wheezes abd soft nt minimally distended bs ext no pitting edema warm dp bilaterally l calf scar from cabg intact to light touch neuro a ox to person not to city fact that in a hospital not to year month day cn ii xii intact 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 hct 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 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 cxr portable ap chest film was performed and compared with the portable ap chest film from the patient is status post median sternotomy and cabg cardiomegaly is present with no significant change in comparison to the previous study there is no evidence of pulmonary edema there is slight improvement in the left lower lobe consolidation and slight decrease in small left pleural effusion is also noted impression slight improvement in the left lower lobe pneumonia brief hospital course this is an y o female with pmh significant for depression chf cad s p recent admission for pna now presenting with confusion poor po intake mental status changes likely multifactorial infection dehydration renal failure back to baseline per husband and family after gentle hydration she also appears depressed and will benefit from a psychiatry consult at rehab likely underlying dementia as well no underlying signs of infection given negative cultures she should continue to follow with behavioral neurology as well hypotension briefly hypotensive on admission to s sbp this resolved rapidly with gentle hydration this hypotension was likely to dehydration and her lactate also normalized with fluids her anti hypertensives were restarted and her bp is stable in the s s pneumonia covered transiently for possible hospital acquired with zosyn urine legionella pending never produced sputum for culture as no sign of infectious process zosyn d c ed after days cxr on showed resolving pna acute renal failure likely prerenal in setting of decreased po intake infection resolved back to baseline with gently hydration with cr chf ef of was monitored off medications for first days restarted on bb and acei once creatinine normalized and bps climbed to s no current symptoms of volume overload continue strict i o s and daily weights and she may need lasix prn depending on symptoms she was on mg of lasix daily at home cad as above transiently held acei and bb restarted before leaving icu stable no active symptoms no evidence of acute ischemic issues monitored on tele with no evidence of arrhythmias hx cva seizures contued depakote for seizure ppx as per outpt regimen no active symptoms dm held glyburide in setting of renal failure as is renally cleared and could precipitate hypoglycemia also as she is eating less would continue insulin sliding until she is eating more and sugars are stable continue diabetic diet depression on sertraline and olanzapine due to oversedation olanzapine was d c d on she needs a psychiatric evaluation at rehab as she appears more depressed and her poor po intake may be secondary to that anemia baseline secondary to acd stable hct benefit from checking spep upep in future as outpatient to r o other processes medications on admission aspirin mg po qday prilosec mg po qday lasix mg po qday lisinopril mg po qday atenolol mg po qday olanzapine mg po bid atrovent inh albuterol inh divalproex mg glyburide mg day insulin u u day based on sliding scale zoloft mg day discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily ipratropium bromide mcg actuation aerosol sig two puff inhalation qid times a day albuterol mcg actuation aerosol sig puffs inhalation q h every hours as needed sertraline mg tablet sig tablet po daily daily divalproex mg tablet delayed release e c sig one tablet delayed release e c po bid times a day insulin regular human unit ml solution sig as directed injection asdir as directed see attached flow sheet 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 metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po daily daily lisinopril mg tablet sig one tablet po daily daily discharge disposition extended care facility of discharge diagnosis primary mental status changes brief hypotension due to dehydration resolving pneumonia secondayr diarrhea resolved currently c diff negative x chf ef cad h o cva seizures niddm arf resolved baseline cr discharge condition stable l discharge instructions please continue with all medications as directed strict i o and weights daily goal i o even may need lasix prn to reach goal or depending on symptoms shortness of breath hypoxia peripheral edema etc low salt diet less than g daily if symptoms of shortness of breath chest pain dizziness lightheadededness severe nausea vomiting diarrhea or any other concerning symptoms occur please see your pcp immediately or come to the ed followup instructions please see your pcp weeks after discharge from rehab completed by [NEW_RECORD] admission date discharge date service medicine allergies penicillins attending chief complaint fever and diarrhea major surgical or invasive procedure none history of present illness yo f with h o dementia cad s p cabg dm seizure disorder hyperntension who presented to ed with diarrhea and fever she was admitted to in and treated for pneumonia she was discharged to rehab at and was discharged from to home on wednesday she is helped by a home health aide pt is demented and could not provide any history she denies all complaints including abd pain chest pain sob dysuria per her aid and husband over the telephone they say that she has had diarrhea since wed episodes on day of admission with mucous and traces of blood x one day they also note she had nausea and vomited x on day of admission ne hemetemesis they do not believe she had abd pain they are not sure if she was recently on antibiotics and per the d c summary was not sent out on antibiotics but only treated for a few days during that hospitalization per the home nurse she has been declining over the past weeks she said that it would not be unusual for to not realize she was in the er past medical history dm type cad s p vessel cabg and pci to lima lad in carotid stenosis s p stent to l ica in atrial septal defect tia cva chronic kidney disease baseline cr stroke induced seizures htn hyperlipidemia cervical spondylosis lumbar radiculopathy depression chf ef mildly dil la small asd w l r flow mild lvh near akinesis distal ventricle mildly hypokinetic basal anterior septal and inferolatral walls mild global rv free wall hypokinesis trace ar mr tr mild pulmonary artery systolic hypertension psh s p cataract repair s p lue fx repair s p cabg social history sh retired math professor married and lives at with husband is primary hcp and son is secondary hcp denies present or past tobacco no etoh pt has h home health aid per health aid she is wheelchair bound son phone nurse family history non contributory non contributory physical exam pe ra genl pleasantly demented heent perl eomi op clear no lad cv rrr systolic murmur lungs cta with crackles at bases abd soft nt nd bs no hsm ext trace edema pedal pulses neuro awake oriented to self only follwed some simple commands moves all extremities pertinent results abd ct marked wall thickening of the rectosigmoid colon surrounded by fat stranding suspicious for infectious versus inflammatory colitis the abnormality is in similar area compared to the prior study therefore chronicity of the finding is uncertain clinical correlation is recommended multiple small gallstones 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 hypochr normal anisocy poiklo normal macrocy normal microcy normal polychr normal am blood plt smr normal plt ct am blood glucose urean creat na k cl hco angap am blood tsh pm blood k brief hospital course yo f with dementia cad cva and seizure d o admitted with diarrhea x days and fever pts floor course was notable for elevated wbc with left shift low grade fever initially she was made npo and found to be c diff ct abd showed rectosigmoid thickening with fat stranding given ns a cc hr over the course of the day with little uop overnight on the patient triggered for low bp at pm vs were given cc bolus with improvement in bp another trigger called at am on hr doppler l uop cc hrs po vanco was added surgery was consulted and recommended transfer to the icu for closer monitoring in the icu renal was consulted a renal ultrasound showed no significant abnormalities but ascites a kub showed c difficile but no toxic megacolon and a uretherogram showed atn the patient was given mg iv lasix in the unit and diuresed well she was continued on iv lasix until her creat came back down to baseline of in addition after fluid recusitation pt became anasarcic which improved with diuresis pt should continue lasix mg po for approximately weeks or until her edema resolved her creat and potassium should be followed while she is on this dose of lasix after addition of po vancomycin and aggressive ivf pt s bp stablitized nutrition was maintained with tpn while pt still nauseous diet advanced slowly and pt tolerated this well pt should receive full week course of abx picc line placed for iv flagyl for additional days of treatment pt was found to be anemic with guiac neg stools prior to placement of recal tube pt had trace amounts of bright red blood after recal tube removed which resolved iron studies were normal baseline hct is pt is on epogen pt dropped hct to during admission and was transfused one unit prbc with appropriate response pt should have hct rechecked in days cva seizure d o pt was continued on her depakote per outpt dose depakote level can also be checked in days dm while pt npo she was maintained on insulin sliding scale glyburide restarted after pt tolerating po psych per son pt has been diagnosed with depression and schitzoaffective d o cont zoloft htn pt switched to iv lopressor while npo and started back on po lopressor once tolerating po will change to po lopressor instead of toprol xl as outpatient as metoprolol can be crushed fen pt was on tpn until able to tolerate po diet pt can have only nector thickened liquids and ground solids meds should be crushed when able and pt should be assisted to eat with aspiration precautions code patient is a full code per son this was discussed with the family medications on admission glyburide depakote toprol xl mg daily asa mg daily zoloft mg qd albuterol ih atrovent ih riss pantoprazole discharge disposition extended care facility of discharge diagnosis c diff colitis dementia atn anemia hypertentiosn discharge condition stable discharge instructions please return to the hospital if you develop chest pain shortness of breath diarrhea severe nausea vomiting fevers or any other concerning symptoms followup instructions please follow up with dr in weeks,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""service"", ""CCU"", ""chief complaint"", ""status post"", ""left internal carotid artery angioplasty and stenting"", ""history of present illness"", ""word finding difficulty"", ""carotid doppler"", ""stenosis of left carotid artery"", ""stenosis of right carotid artery""],
""Medications"": [""mucormyst"", ""dopamine""]
}"
200,admission date discharge date date of birth sex m service orthopaedics allergies patient recorded as having no known allergies to drugs attending chief complaint crush injury major surgical or invasive procedure fem bypass graft repair of gastrocnemius gracilis tear rle fasciotomies orif right patella history of present illness the patient is a year old male who presented to ed via the trauma service by medlfight pt was involved in a construction accident at his work where he was pinned between a moving truck and a stationary truck he was medflighted in secondary to a pulseless extremity past medical history none social history construction worker family history nc physical exam upon discharge avss nad a o cta rrr s nt nd bs rle incisions c d i fhl at g s silt dp pt brisk cap refill brief hospital course the patient was admitted to the trauma service he was emergently taken to the operating room with the vascular service for repair of his popliteal artery injury he tolerated the procedure well he was extubated and brought to the tsicu for close monitoring on pod his compartments were closely monitored he developed increased swelling and some diminished sensation over toes vascular surgery then took him back to the operating room for rle fasciotomies he tolerated the procedure well he was extubated and brought to the recovery room in stable condition post operatively he was transferred to the vascular service once stable in the pacu he was transferred to the floor on the floor he did well his pain was well controlled he was seen by social work for emotional support he was transfused units prbc s on for post op anemia on he was brought back to the operating room for orif of his right patella with orthopedics he tolerated the procedure well he was extubated and brought to the recovery room in stable condition once stable in the pacu he was transferred to the floor on the floor he did well he was seen by physical therapy and progressed well he was also seen by chronic pain service to help control his post operative pain his labs and vitals remained stable his pain was well controlled his hospital course was otherwise without incident he is being discharged today to rehab in stable condition discharge medications acetaminophen mg tablet sig tablets po q h every to hours as needed calcium carbonate mg tablet chewable sig one tablet chewable 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 bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po bid times a day as needed ferrous sulfate mg tablet sig one tablet po daily daily enoxaparin mg ml syringe sig one mg syringe subcutaneous q h every hours for weeks simethicone mg tablet chewable sig tablet chewable po qid times a day as needed tizanidine mg tablet sig one tablet po tid times a day gabapentin mg capsule sig one capsule po tid times a day hydromorphone mg tablet sig tablets po q h every to hours as needed discharge disposition extended care facility me discharge diagnosis right popliteal artery injury right patella fracture right lateral femoral condyle fracture right lateral tibial plateau fracture post operative anemia discharge condition stable discharge instructions please keep incision clean and dry dry sterile dressing daily as needed if you notice any increased redness swelling drainage temperature or shortness of breathe please md or report to the emergency room please take all medications as prescribed you need to take the lovenox shots to prevent blood clots you may resume any normal home medication please follow up as below call with any questions physical therapy wbat rom as tol treatments frequency dry sterile dressing daily followup instructions please follow up with dr at the orthopedic clinic clinic in weeks call to make that appointment please follow up with dr at the vascular clinic in weeks call to make that appointment completed by,{}
79126,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint cardiomyopathy and heart failure major surgical or invasive procedure pacer defibrillator generator change attempted lead placement mini left thoracotomy with lv epicardial lead placement history of present illness this year old black male with significant non ischemic cardiomyopathy who underwent icd implant in he has nyha class ii congestive heart failure with an ef of the patient was hospitalized in for a chf exacerbation treated with intravenous diuretics the patient reports a moderate limitation with physical activity and a low energy level the patient reports shortness of breath with mild exertion relieved with rest the patient denies lightheadedness palpitations pre syncope syncope or chest pain the patient denies rest symptoms recent interrogation of his device revealed that he had episodes of non sustained vt no episodes of sustained vt and no therapies were delivered the optivol index was noted to be high implying ongoing heart failure it was decided to proceed with upgrading his current device to a biv icd past medical history non ischemic cardionyopathy s p gastric bypass hypertension gout obstructive sleep apnea social history married and retired police officer he denies tobacco or illicit drug use upon questioning the patient has an extensive h o alcohol use he admits to being a heavy social drinker family history grandmother with cad but no premature cad in family mother with cancer sister with dm physical exam admission pulse resp o sat not recorded on room air b p height feet inches wt lbs general skin dry x intact x 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 neuro grossly intact pulses femoral right left dp right left pt left radial right left carotid bruit none right left 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 urean creat na k 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 urean creat na k cl hco angap am blood alt ast ld ldh alkphos amylase totbili am blood lipase am blood albumin am blood hba c am blood type art temp po pco ph caltco base xs echo echocardiography report tte complete done at pm final referring physician information cardiac electrophysiology status inpatient dob age years m hgt in bp mm hg wgt lb hr bpm bsa m m indication coronary artery disease left ventricular function right ventricular function shortness of breath icd codes test information date time at interpret md md test type tte complete son bzymek rdcs doppler full doppler and color doppler test location west echo lab contrast none tech quality adequate tape w machine other 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 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 ratio e e aortic valve peak velocity m sec m sec aortic valve peak gradient mm hg mm hg aortic valve lvot vti aortic valve lvot diam cm aortic valve valve area cm cm mitral valve e wave m sec mitral valve e wave deceleration time ms ms tricuspid valve peak velocity m sec tr gradient ra pasp mm hg mm hg pulmonic valve peak velocity m sec m sec findings this study was compared to the prior study of left atrium dilated la right atrium interatrial septum mildly dilated ra a catheter or pacing wire is seen in the ra left ventricle normal lv wall thickness dilated lv cavity suboptimal technical quality a focal lv wall motion abnormality cannot be fully excluded depressed lvef right ventricle mildly dilated rv cavity cannot assess regional rv systolic function aorta normal aortic diameter at the sinus level normal ascending aorta diameter aortic valve normal aortic valve leaflets no as no ar mitral valve mildly thickened mitral valve leaflets mild mitral annular calcification mild thickening of mitral valve chordae trivial mr tricuspid valve normal tricuspid valve leaflets with trivial tr borderline pa systolic hypertension pulmonic valve pulmonary artery pulmonic valve not well seen pericardium trivial physiologic pericardial effusion no echocardiographic signs of tamponade general comments suboptimal image quality poor subcostal views suboptimal image quality body habitus the rhythm appears to be a v paced regional left ventricular wall motion n normal h hypokinetic a akinetic d dyskinetic conclusions the left atrium is dilated left ventricular wall thicknesses are normal the left ventricular cavity is dilated due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded lv systolic function appears depressed but images are suboptimal for assessment of wall motion the right ventricular cavity is mildly dilated with grossly preserved contractility but views are suboptimal the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve leaflets are mildly thickened trivial mitral regurgitation is seen there is borderline pulmonary artery systolic hypertension there is a trivial physiologic pericardial effusion there are no echocardiographic signs of tamponade compared with the prior study images reviewed of left ventricular systolic function appears more vigorous in the setting of tachycardia electronically signed by md interpreting physician brief hospital course mr was admitted to the on for placement of an epicardial lead he was worked up in the usual preoperative manner and was ready for surgery on the generator was upgraded but attempts at transvenous lead placement were unsuccessful by the electrophysiology service on he was taken to the operating room where he underwent a left minithoracotomy with placement of epicardial ventricular leads please see operative note for details postoperatively he went to the post anesthesia care unit he developed epigastric pain and a surgery consult was obtained no acute surgical issues were found beyond colonic ileus and he was transferred to the cardiac surgery intensive care unit for monitoring his creatinine rose to antigas medications and promotility agents were given narcotics were stopped and he improved attempts at gastric and rectal tube placement were unsuccessful there was no stomach distention his ct was removed he was mobilized and over two days the ileus resolved flatus passed and his diet was advanced from clears to regular heart healthy as he was hydrated urine output picked up and his creatinine normalized to his baseline of he was placed back on his preoperative medications and transferred to the floor by post operative day he was ready for discharge to home he was tolerating a regular diet ambulating and moving his bowels wounds were clean and healing well arrangements were made for follow up and instructions discussed with him medications on admission calcium carbonate mg daily tamsulosin mg po daily spironalactone mg daily crestor mg daily prilosec mg daily lasix mg daily finasteride mg daily allopurinol mg daily asa mg daily coreg mg tid 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 spironolactone 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 rosuvastatin mg tablet sig two tablet po qhs once a day at bedtime disp tablet s refills tamsulosin mg capsule sust release hr sig one capsule sust release hr po hs at bedtime disp capsule sust release hr s refills finasteride mg tablet sig one tablet po daily daily disp tablet s refills allopurinol mg tablet sig one tablet po daily daily disp tablet s refills carvedilol mg tablet sig one tablet po tid times a day disp tablet s refills omeprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily furosemide mg tablet sig one tablet po daily daily acetaminophen mg tablet sig two tablet po q h every hours as needed for pain fever calcium carbonate mg tablet chewable sig one tablet chewable po daily daily discharge disposition home with service facility vna discharge diagnosis attempted placement pacemaker leads left thoracotomy and placement of ventricular leads for biventricular pacemeker defifrillator non ischemic cardiomyopathy s p virtuoso dual chamber icd hypertension sleep apnea chronic renal insufficiency s p gastric bypass surgery gout 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 no lotions creams or powders to incision until it has healed please shower daily no bathing or swimming for month no lifting greater then pounds for weeks from date of surgery no driving for month or while taking narcotics for pain call with any questions or concerns followup instructions dr in month surgeon dr in weeks dr in weeks completed by [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint initiation of milrinone major surgical or invasive procedure right heart catheterization history of present illness yo m history of idiopathic dilated cardiomyopathy with moderately dilated left ventricle last ef now with mr tr and resultant pulmonary hypertension nyha class iii heart failure presenting for milrinone initiation per dr last clinic note dated the patient has had progressive and marked reduction in his functional capacity over the last few months over this period of time the patient has developed pulmonary hypertension his most recent echo in demonstrated tricuspid regurgitation pressure gradient of mmhg indicating a pulmonary artery systolic pressure of mmhg to mmhg currently he is unable to walk more than a few yeards or a few stairs without dyspnea he also complains of orthopnea paroxysmal nocturnal dyspnea and occasional lightheadedness his symptoms were thought to be representative of nyha class iii symptoms weight in clinic on was pounds which is not far from what has been considered in the past to be his dry weight it was felt that the patient was doing poorly at this time now with orthopnea paroxysmal nocturnal dyspnea and dyspnea during ordinary activities of daily living echo was performed in clinic showing left ventricle is more dilated and there has been a substantial further reduction of ejection fraction lvef in addition his mitral regurgitation is markedly increased lasix apparently made him lightheaded and it was discontinued recently patient underwent right heart cath before admission results baseline pcwp mean pa mixed veinous p co ci unit transpulmonary gradient co l post milrinone mcg kg min with large amount of ectopy pcwp mean pa mixed veinous p co ci unit post milrinone mcg kg min pcwp mean pa mixed veinous p co ci unit gastric bypass years ago cholecystectomy non ischemic cardiomyopathy ef dual chamber icd placement for primary prevention of sudden cardiac death in the setting of nonsustained vt and class iii heart failure hypertension gout obstructive sleep apnea last seen by dr on for osa follow up he utilizes an adapt sv machine his pressure was change to expiratory pressure of and pressure support and diabetes ckd evaluated by renal baseline creatinine hyperlipidemia past medical history gastric bypass years ago cholecystectomy non ischemic cardiomyopathy ef dual chamber icd placement for primary prevention of sudden cardiac death in the setting of nonsustained vt and class iii heart failure hypertension gout obstructive sleep apnea last seen by dr on for osa follow up he utilizes an adapt sv machine his pressure was change to expiratory pressure of and pressure support and diabetes ckd evaluated by renal baseline creatinine hyperlipidemia social history married and retired police officer he cares for his and year old grandchildren he denies tobacco or illicit drug use history of extensive etoh use however he has cut back last alcoholic drink month ago family history grandmother with cad but no premature cad in family mother with cancer sister with dm physical exam admission weight kg vs ra general nad oriented x mood affect appropriate heent moist mucus membranes neck supple with flat jvp cardiac rrr with normal s s occasional pvcs no murmurs rubs gallops lungs resp were unlabored no accessory muscle use ctab no crackles wheezes or rhonchi abdomen soft ntnd no hsm or tenderness extremities no edema skin no stasis dermatitis ulcers scars or xanthomas pertinent results echo left ventricular cavity size is moderately dilated there is severe global left ventricular hypokinesis lvef overall left ventricular systolic function is severely depressed lvef the right ventricular cavity is mildly dilated with normal free wall contractility the mitral valve leaflets are mildly thickened there is no mitral valve prolapse mild to moderate mitral regurgitation is seen compared with the prior study images reviewed of right ventricular function is more vigorous the severity of mitral and tricuspid regurgitation is reduced left ventricular ejection fraction appears slightly improved and cavity size is smaller echo the left atrium is moderately dilated left ventricular wall thicknesses are normal the left ventricular cavity is severely dilated there is severe global left ventricular hypokinesis lvef the estimated cardiac index is depressed l min m tissue doppler imaging suggests an increased left ventricular filling pressure pcwp mmhg the right ventricular free wall thickness is normal the right ventricular cavity is dilated with borderline normal free wall function 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 an eccentric posteriorly directed jet of at least moderate to severe mitral regurgitation is seen due to the eccentric nature of the regurgitant jet its severity may be significantly underestimated coanda effect the left ventricular inflow pattern suggests a restrictive filling abnormality with elevated left atrial pressure moderate tricuspid regurgitation is seen due to acoustic shadowing the severity of tricuspid regurgitation may be significantly underestimated there is moderate pulmonary artery systolic hypertension significant pulmonic regurgitation is seen the end diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension there is no pericardial effusion compared with the findings of the prior study images reviewed of the left ventricle is more dilated and there has been a substantial further reduction of ejection fraction mitral regurgitation is markedly increased am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap am blood ck mb ctropnt am blood calcium phos mg brief hospital course yo m history of idiopathic dilated cardiomyopathy with moderately dilated left ventricle last ef now with mr tr and resultant pulmonary hypertension nyha class iii heart failure presenting for milrinone initiation started on milrinone in cath lab with excellent response milrinone initiation he has had significantly worsening functional status and lvef to over the last few months he underwent right heart cath showing elevated wedge and pa pressures he was started on milrinone during right heart catheterization with impressive response wedge and pa pressures both dropped by almost half cardiac index doubled milrinone was decreased from mcg kg min to mcg kg min due to ectopy he was admitted to the ccu to monitor infusion he continued to have some ectopy and tachycardia carvedilol was restarted at an increased dose of mg he was on coreg mg daily at home this helped to control his heart rate and ectopy a repeat echo the following day showed increased rv and lv squeeze the swan catheter was pulled and his milrinone was continued via picc line he was transferred to the floor he had occasional episodes of hypotension to the s and s intermittently throughout his hospital stay the carvedilol was switched to metoprolol to avoid the hypotension he was also felt to be dry so the torsemide was stopped his valsartan was also decreased to mg daily he continued to have occasional dizziness and was advised to avoid standing up too quickly chf htn lvef of as above this improved to about with repeat echo his anti hypertensives were titrated as above he was discharged home on metoprolol succ mg daily valsartan mg daily aspirin mg rosuvastatin mg daily and eplerenone mg daily he was provided a prescription for torsemide to take if he had weight gain osa uses a cpap machine at home his o sats were monitored in house dm continued glipizide mg daily gout continued allopurinol mg daily bph continued finasteride and tamsulosin daily transitional issues patient is being discharged off diuretics with a prescription for prn torsemide if at follow up he appears volume overloaded then restart torsemide mg daily medications on admission allopurinol mg tablet daily calcitriol mcg weekly carvedilol coreg cr mg daily eplerenone mg daily finasteride mg daily folic acid mg daily furosemide mg daily glipizide mg tablet daily omeprazole mg rosuvastatin crestor mg daily tamsulosin flomax mg daily valsartan diovan mg tablet daily aspirin mg daily calcium carbonate vitamin d mg mg unit cholecalciferol vitamin d unit daily cyanocobalamin vitamin b mcg daily mvi discharge medications milrinone in d w mcg ml piggyback sig mcg kg min intravenous infusion continuous infusion disp bag refills allopurinol mg tablet sig one tablet po daily daily calcitriol mcg capsule sig one capsule po once a week eplerenone mg tablet sig one tablet po daily daily 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 finasteride mg tablet sig one tablet po daily daily folic acid mg tablet sig one tablet po daily daily glipizide mg tablet sig tablet po daily daily rosuvastatin mg tablet sig one tablet po once a day omeprazole mg capsule delayed release e c sig one capsule delayed release e c po bid times a day valsartan mg tablet sig tablets po daily daily disp tablet s refills aspirin mg tablet chewable sig one tablet chewable po daily daily calcium carbonate mg calcium mg tablet chewable sig one tablet chewable po daily daily cyanocobalamin vitamin b mcg tablet sig one tablet po daily daily cholecalciferol vitamin d unit tablet sig one tablet po once a day tamsulosin mg capsule ext release hr sig one capsule ext release hr po hs at bedtime torsemide mg tablet sig one tablet po once a day as needed for weight gain 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 discharge disposition home with service facility critical care systems discharge diagnosis acute on chronic systolic congestive heart failure hypotension acute on chronic kidney injury discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you had trouble breathing and an echocardiogram showed that your heart function was very poor you were admitted to start a medicine called milrinone that you will have infused continuously into your iv weigh yourself every morning call dr if weight goes up more than pounds in day or pounds in days we made the following changes to your medicines start milrinone to help your heart pump better decrease valsartan to mg daily stop taking furosemide take torsemide if you notice your weight is increasing stop taking carvedilol take metoprolol instead to lower your heart rate and help your heart pump better followup instructions name a address nd fl phone appointment wednesday pm department cardiac services when monday at am with dr building sc clinical ctr campus east best parking garage department nutrition phone a message was left for an outpatient nutritionist to schedule an appt with you in the next few weeks they should be contacting you at home please call the number next week if you do not hear from them department west clinic when wednesday at am with m d building de building complex campus west best parking garage,"{
""Diagnoses"": [""cardiomyopathy"", ""heart failure"", ""nyha class ii congestive heart failure""],
""Medications"": [""intravenous diuretics""]
}"
62791,admission date discharge date date of birth sex m service medicine allergies lisinopril attending chief complaint gib major surgical or invasive procedure egd history of present illness yom with h o likely copd ckd anemia prostate ca who is called out of micu green after presenting with weeks of epigastric pain for which he was taking otc pain meds nsaids tylenol and then saw his pcp and was given stool softeners days later he had black diarrhea episodes the last episode of which was symptomatic with lh dizziness diaphoresis abdominal pain he went to the ed where he was hemodynamically stable and hct seen to drop from at the end of to cr was also up from apparent baseline he got a ct abd without iv contrast that showed stranding around pancreatic head cannot r o pancreatitis with peripancreatic soft tissue nodule opacity at l base could be atelectasis nonspecific rll small nodular opacity inflammatory recommend mo f u diverticulosis pt was admitted to micu green for monitoring and for scope which happened today he was seen to have gastritis a single cratered cm ulcer in the duodenal proximal bulb with mild oozing with significant erythema surrounding and edema a gold probe was successfully applied for hemostasis recommendations were for continued ppi check hpylori and it was felt likely due to nsaid s but given the inflammation the possibility of malignancy either duodenum or eroding into the duodenum couldn t be excluded so plan a repeat egd in wks he was also given u prbc s yesterday on interview in spanish in the icu pt denies pain sob cp abdominal pain nausea vomiting or any other symptoms is in jolly spirits and just finished his meal past medical history copd asthma chronic respiratory symptoms follwed previously with dr in now at ckd prostate ca dx intermediate high grade by seen by dr and dr at htn hl anemia source gi osteoporosis s p thyroid surgery followed at chronic knee pain s p l knee surgery and cortisone injections h o pna social history originally from retired military officer then office jobs came to us spanish speaking only he lives with his daughter and his wife whose memory is failing has six children no h o etoh use smoked cigarettes day for yrs then quit family history unknown mother and father has two sisters and six kids without any history of lung disease in the family negative for prostate cancer physical exam p l nc l jolly pleasant well appearing m in no distress spanish speaking sitting at bedside chair eomi no icterus mouth moist normal appearing lungs ctab no w c r r good air movement rrr without m g or adventitious sounds abd rotund without ttp soft bs ble without edema warm no cyanosis cn intact mood affect appropriate and conversant moving all extremities 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 hct am blood hct 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 neuts lymphs monos eos baso am blood neuts lymphs monos eos baso pm blood pt ptt inr pt 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 lipase am blood lipase am blood calcium phos mg am blood calcium phos mg pm blood calcium phos mg am blood glucose lactate pm blood lactate pm blood lactate pm serology blood added to specimen v final report helicobacter pylori antibody test final negative by eia reference range negative ct abd pelvis impression mild stranding about the pancreatic head cannot exclude acute pancreatitis correlation with lipase is recommended finding change in wet read was discussed with ed resident at p m by dr by phone on peripancreatic small soft tissue node opacity at the left lung base could be atelectasis cannot exclude pneumonia correlate clinically nonspecific small nodular opacity at the right lung base could be inflammatory if clinical concern consider six month followup cholelithiasis diverticulosis however no evidence of acute diverticulitis mild loss of l vertebral body height of uncertain chronicity likely degenerative correlate with pain nonspecific stranding at the dome of the urinary bladder anteriorly could be urachal remnant attention on next followup coronary artery calcification brief hospital course yom with h o likely copd ckd anemia prostate ca who presents with hct drop from bleeding duodenal ulcer possibly due to nsaid use now s p egd and gold probe therapy bleeding duodenal ulcer he was transfused u prbc s in micu and had egd which visualized the ulcer and gold probe was applied to achieve hemostasis hct s were stable thereafter for days hemodynamics were stable suspected due to nsaid use but its endoscopic appearance on egd was also worrisome for malignancy so pt will need close f u after acute therapy to re egd him this was imparted to the pt the family the pt s pcp and the fellow who performed the first egd his hct s were trended post procedure and were stable for days hpylori was negative but was pending by discharge the pt and family were instructed to touch base with his pcp to follow up the results of this he was also instructed several times to avoid nsaid s pancreatitis his initial lipase was normal but when repeated later the same day was elevated to x uln he also appears to have peripancreatic stranding concerning for a pancreatitis suspect there was peri pancreatic inflammation from the ulcer and perhaps some duodenal ulcer penetrance however also concerning for malignancy during egd and symptoms will need to be followed up regardless he was eating full meals having bowel movements no abdominal pain abdomen exam soft without ttp so even if pancreatitis not particularly clinically worrisome ckd pt was above his cr baseline on admission but back baseline by discharge rll nodular opacity low wbc count no reported coughs no fevers to suggest pna prior smoking history will need f u as outpt with repeat imaging in mos follow up the pt s pcp fellow performing the egd inpatient service attending were all emailed to close the loop regarding need for repeat egd inability to make follow up appointments given the holidays and need for f u h pylori in addition will need lung nodules followed up in mos medications on admission albuterol sulfate proair hfa mcg hfa aerosol inhaler to puffs s inhaled every four hours as needed for cough shortness of breath or wheezing ergocalciferol vitamin d prescribed by other provider pt from dr endocinology unit capsule capsule s by mouth q st th day each mo fluticasone salmeterol advair diskus visit reconciliation mcg mcg dose disk with device one inhalation s inhaled twice a day levothyroxine visit reconciliation mcg tablet one tablet s by mouth once a day as needed for in the morning on an empty stomach losartan mg tablet tablet s by mouth once a day zoledronic acid zometa prescribed by other provider endocrinology mg ml solution annual medications otc acetaminophen mg tablet one tablet s by mouth three times a day aspirin prescribed by other provider mg tablet delayed release e c tablet s by mouth daily bisacodyl mg tablet delayed release e c tablet s by mouth once a day as needed for constipation docusate sodium colace mg capsule capsule s by mouth twice a day stool softener discharge medications albuterol sulfate mcg actuation hfa aerosol inhaler sig inhalation inhalation every hours as needed for nausea ergocalciferol vitamin d unit capsule sig one capsule po on the first and th of every month per dr in endocrinology fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day levothyroxine mcg tablet sig one tablet po daily daily in the morning on an empty stomach losartan mg tablet sig one tablet po once a day zometa mg ml solution sig one intravenous every year per dr in endocrinology aspirin mg tablet effervescent sig one tablet effervescent po once a day colace mg capsule sig one capsule po twice a day as needed for constipation stool softener continue taking this if you were taking it before admission bisacodyl mg tablet sig one tablet po once a day as needed for constipation stool softener continue taking this if you were taking it before admission acetaminophen mg tablet sig two tablet po q h every hours as needed for pain pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours this is an acid suppressing medication for your stomach disp tablet delayed release e c s refills discharge disposition home discharge diagnosis bleeding duodenal ulcer discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions mr it was a pleasure taking care of you at the you were admitted with abdominal pain and black stools and found to have a drop in your blood level from to you had and egd endoscopy which visualized a bleeding ulcer in your duodenum this was fixed during the procedure and your blood levels were stable afterwards as we discussed you will need to have a repeat egd in weeks to make sure it is ok this has been scheduled as below as we also discussed the blood test for a bacteria in your stomach called h pylori is also pending but this can be followed up with dr if it is positive you will need antibiotics the following changes were made to your medication regimen start pantoprazole mg twice a day this is an acid suppressing medication for your stomach you should discuss this new medication change with your doctors followup instructions as we discussed we were unable to schedule a follow up appointment for you because it is the day after however i called the office and told them to call you with an appointment i have also emailed your primary care doctor to let him know to get in touch you will need to see your pcp within the next weeks if you do not hear from him please call to schedule an appointment you will also need to see a gi doctor in follow up but the same situation as above we were unable to schedule an appointment but the doctors have notified if you do not hear from them in the next few days please call to schedule an appointment however the appointment for the repeat egd was able to be scheduled as below department digestive disease center when monday at am with md building building complex campus east best parking main garage department endo suites when monday at am you also had this appointment previously scheduled department radiology when tuesday at am with ultrasound building cc clinical center campus west best parking garage completed by,{}
22997,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint pt fell struck head and siezed major surgical or invasive procedure none history of present illness pt was s p fall and after fall had a siezure past medical history afib aflutter htn cva with subsequent siezures social history etoh physical exam on discharge heent atraumatic perrl eomi neck cervical collar in place chest ctab cardiac irregular rhythm rate of approx abd soft nt nd bs ext no edema 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 calcium phos mg pm blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap pm blood ck cpk amylase am blood albumin calcium phos mg pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg am blood type art po pco ph calhco base xs brief hospital course after his fall and siezure pt was admitted to trauma surgery was found to have a question of widening of atlantooccipital joint so was put in a cervical collar during his stay the patient was also noted to have an irregular heart rate that would occasionally increase to the but then decrease to the patient remained completely assymptomatic during these episodes cardiology was consulted and lopressor was increased up to a dose of tid with his pressures tolerating this dose at on d c pt continued to have transient episodes of tachycardia but was always asymptomatic during these episodes and these episodes always subsided within minutes these findings were discussed with in house cardiology and his primary care physician who were all comfortable with his discharge and close follow up with his primary care physician note the patient had a mild level of underlying dementia which precluded him from going home alone and was discharged with a friend radiology positive findings ct neck impression no fractures apparent malalignment of c ring and dens is probably due to patient positioning although rotatory subluxation cannot be excluded on the basis of this study medications on admission pt non compliant on coumadin atenolol lisinopril discharge medications metoprolol tartrate mg tablet sig one tablet po tid times a day disp tablet s refills aspirin mg tablet sig one tablet po daily daily disp tablet s refills phenytoin sodium extended mg capsule sig two capsule po q h every hours disp capsule s refills discharge disposition home discharge diagnosis fall resulting in cervical ligamentous injury a fib discharge condition stable discharge instructions follow up with you primary care physician collar at all times take medications as perscribed followup instructions follow up with your dr on thursday at pm they will call to move up appointment if there are cancellations wear cervical collar for a total of wks discuss setting up an orthopaedics appointment with primary care physician for collar removal,"{
""Diagnoses"": [""afib"", ""ahflut"", ""htn"", ""cva"", ""siezures"", ""widening of atlantooccipital joint""],
""Medications"": [""cervical collar"", ""ethanol"", ""acetmnp"", ""bnzodzp"", ""barbitr"", ""tricycl"", ""amylase"", ""calcium phos"", ""pm blood asa"", ""pm blood glucose"", ""pm blood inr"", ""pm blood ptt"", ""pm blood ck"", ""pm blood cpk""]
}"
1538,admission date discharge date date of birth sex m service psu chief complaint the patient has a congenital right thumb abnormality presenting for toe to thumb transplant history of present illness the patient is a year old male who was born with congenital right thumb abnormality who presents to the plastic surgical service for a toe to thumb transplant past medical history hypertension decreased hearing congenital thumb abnormality history of alcohol abuse history of psoriasis past surgical history significant for a right ear procedure medications percocet atacand chlorthalidone atenolol nortriptyline methotrexate allergies the patient has no known drug allergies family history noncontributory social history noncontributory physical examination the patient was afebrile vital signs stable in no apparent distress alert and oriented times head was atraumatic normocephalic and anicteric neck was soft and supple with no masses chest was clear to auscultation bilaterally heart has regular rate and rhythm abdomen was benign on extremity exam the patient has a deformed nonfunctional right thumb with moderate sensation and moderate movement summary of hospital course the patient is a year old man who presents to the plastic surgical hand service for toe to thumb free flap transplant on the patient went to the or on that date for said procedure for more detailed account please see operative report postoperatively the patient was transferred to the csru for close monitoring of toe to thumb transplants the patient was taken to the or on for amputation of right thumb with preservation of ulnar vascular structures resection neuroma and soft tissue contouring of the right index finger and cmc arthroplasty of the right thumb with resection of osteophytes and degenerative joint disease postoperatively the patient did well following this procedure and was taken back to the or on for right great toe to right thumb microvascular transfer in addition flexor tendon transfer of flexor digitorum superficialis from the right long finger to the flexor pollicis longus of the right thumb completion of cmc arthroplasty of the right thumb using orthosphere in addition of local flap closure at the right foot donor site and intrinsic muscle transfer to the right thumb at the flexor pollicis brevis and abductor pollicis brevis and resection of alloderm implantation the dorsal and radial aspect of the right thumb for more detailed account of this procedure please operative reports postoperatively the patient was transferred to the csru for close monitoring of new thumb immediately afterwards on postoperative day and the patient noticed significant bluish discoloration and swelling of the thumb the patient was taken back to the or on for reexploration of the right thumb with revisions of the arterial anastomosis and revision of the venous anastomosis at the wrist in addition placement of alloderm approximately x cm and catheter injection of tpa all under the microscope postoperatively the patient was transferred back to the csru for continued monitoring and the patient s clinical texture did not improve the patient was then taken back to the or again for reexploration of the right toe to thumb graft with the revision of the arterial anastomosis exploration of the vein evacuation of hematoma replacement of the alloderm x square patch all under the microscope for more details account please see operative reports postoperatively the patient was transferred to the csru for close monitoring where the patient was placed on iv heparin with the therapeutic range between and and was watched closely for compromise of the transferred thumb the patient remained intubated throughout his course of take backs to the or and was extubated on postoperative day number and on postoperative day respectively from the initial toe to thumb transfer and take backs for revisions the patient remained on iv heparin and was placed on leech therapy to the thumb leech q h for bluish discoloration the patient remained on this therapy for the following several weeks with slowly improving color of the thumb as well as slowly improving swelling eventually the patient was taken back to the or on for split thickness skin graft to the right hand and split thickness skin graft to the right foot postoperatively the patient did very well also then the patient was eventually transferred out of the csru on to the floor approximately on postoperative day number following the split thickness skin graft dressing was taken down days postprocedure and the right foot graft had a percent take while the right hand graft had percent take after the dressing was taken down on the right wrist skin graft and seen that it had percent take the graft was debrided with normal saline wet to dry dressing changes were begun b i d in addition on the patient was discontinued on leech therapy following a brief wean as well as discontinued on heparin therapy on the night following these therapeutic clinic changes the patient noticed some increased discoloration and the patient was placed on q leech therapy p r n for increased bluish discoloration the patient was also started on coumadin mg p o q h s with the therapeutic inr between and not to exceed days of treatment on the patient was finally deemed well enough to go home bluish discoloration of the thumb had vastly increased the patient was receiving dressing changes to the right wrist with good results skin graft was getting xeroform dressings q day also with good results the patient was deemed well enough to go home will be discharged with supply of emergency leeches for application to the thumb for dramatic increase in bluish discoloration per patient in addition the patient would be going with coumadin q h s to be followed by dr colleague in discharge disposition to home with a vna discharge diagnoses congenital right thumb disease hypertension the patient is to follow up with dr colleague in in plastic surgery for right thumb evaluation right wrist wound evaluation right foot skin graft evaluation and inr checks discharge medications all pervious medications as well as coumadin mg p o q h s with therapeutic inr between and discharge condition stable dictated by medquist d t job,"{
""Diagnoses"": [""congenital right thumb abnormality"", ""toe to thumb transplant""],
""Medications"": [""percocet"", ""atacand"", ""chlorthalidone"", ""atenolol"", ""nortriptyline"", ""methotrexate""]
}"
46820,admission date discharge date date of birth sex f service medicine allergies no allergies adrs on file attending chief complaint altered mental status hypoxemic respiratory distress major surgical or invasive procedure left sided thoracentesis endotracheal intubation trauma central line placed history of present illness ms is a f with history etoh cirrhosis who was initially transferred from hospital with altered mental status at the osh labs notable for wbc of tbil of a ct torso without iv contrast was performed and showed a large left pleural effusion with white out of the left lung ascites and diffuse wall thickening of the terminal ileum and right colon and was tranferred to for further care initially in the ed vs l nasal cannula a diagnostic para revealed wbc with polys ua was mildly positive she was given gram of ceftriaxone for sbp and to cover for a uti also got l ns cxr showing white out of the left lung with shift of mediastinal structures to the right blood urine and peritoneal cultures were sent the patient was seen by transplant surgery and was thought that she had sbp vs secondary bacterial peritonitis was continued on ceftriaxone overnight the patient pulled out one of her ivs and started bleeding out of her iv lines she then started having respiratory distress during this episode she was placed on right side at which point she desatted to undetectable on lnc with on nrb for approximately min code blue was called for emergent intubation which was done with etomidate and succinycholine without any complications she was subsequently transferred to ccu under micu team for further evaluation and management on arrival to the unit the patient was intubated and sedated past medical history etoh cirrhosis c b esophageal varices etoh abuse hld htn depression axiety social history per report from osh patient denies drinking since last family history nc physical exam admission physical exam general confused somnolent but arousable and able to follow conmmands heent nc at perrla eomi icteric sclera dry mucous membranse neck supple no thyromegaly no jvd no carotid bruits lungs patient is poorly cooperative with exam right sides breath sounds intact with fine crackles at the bases left sided breath sounds diminished throughout lheart rrr s s sem loudeset at rusb with radiation at the base no radiation to axilla abdomen distended non tender to deep palpation no spider angiomata no caput madusa extremities wwp pitting edema to the knees skin no rashes or lesions lymph no cervical axillary or inguinal lad neuro awake aaox name only astrixes discharge physical exam expired pertinent results admission labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood neuts bands lymphs monos eos baso am blood pt ptt inr pt am blood fibrino am blood glucose urean creat na k cl hco angap am blood alt ast alkphos totbili am blood lipase am blood albumin am blood calcium phos mg am blood hbsag negative hbsab negative hbcab negative hav ab negative am blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg am blood hcv ab negative am blood glucose na k cl calhco am blood lactate am blood freeca icu labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt pm blood fibrino am blood fibrino am blood fdp am blood fibrino pm blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos totbili dirbili indbili pm blood d dimer pm blood type art temp rates tidal v peep fio po pco ph caltco base xs intubat intubated vent controlled am pleural wbc rbc hct fl polys lymphs monos macro am pleural totprot glucose ld ldh amylase albumin less than am ascites wbc rbc polys lymphs monos macroph am ascites ld ldh albumin less than micro blood cultures no growth to date peritoneal fluid culture and gram stain negative pleural fluid culture no growth to date imaging echo left atrium normal la and ra cavity sizes right atrium interatrial septum no asd by d or color doppler the ivc was not visualized the ra pressure could not be estimated left ventricle wall thickness and cavity dimensions were obtained from d images normal lv cavity size normal regional lv systolic function hyperdynamic lvef no resting lvot gradient right ventricle normal rv chamber size and free wall motion normal rv free wall thickness aorta normal aortic diameter at the sinus level focal calcifications in aortic root normal descending aorta diameter aortic valve aortic valve leaflets moderately thickened aortic valve leaflets mild as area cm trace ar mitral valve mildly thickened mitral valve leaflets moderate mitral annular calcification trivial mr tricuspid valve normal tricuspid valve leaflets mild tr moderate pa systolic hypertension pulmonic valve pulmonary artery pulmonic valve not well seen pericardium no pericardial effusion general comments suboptimal image quality poor parasternal views suboptimal image quality poor apical views suboptimal image quality ventilator resting tachycardia hr bpm ascites conclusions the left atrium and right atrium are normal in cavity size the left ventricular cavity size is normal normal global and regional left ventricular systolic function right ventricular chamber size and free wall motion are normal the right ventricular free wall thickness is normal the number of aortic valve leaflets cannot be determined the aortic valve leaflets are moderately thickened there is mild aortic valve stenosis valve area cm no aortic regurgitation seen there is moderate pulmonary artery systolic hypertension there is no pericardial effusion impression suboptimal image quality normal left ventricular caivty size with mildly thickened inferolateral wall and preserved global and regional biventricular systolic function mild aortic stenosis although in the setting of vigorous left ventricular systolic function its severity may be somewhat overestimated at least moderate pulmonary artery systolic hypertension cxr history feeding tube placement findings in comparison with the earlier study of this date there has been placement of a feeding tube that extends to the distal stomach complete opacification of the left hemithorax is again seen consistent with a large pleural effusion and collapse of the underlying left lung large opacification in the right upper abdomen most likely represents a laminated gallstone cxr am indication hypoxic respiratory failure orogastric tube placement findings as compared to the previous radiograph there is a massive change the patient has been intubated the tip of the endotracheal tube is located cm above the carina an additional nasogastric tube has been inserted the course of the tube is unremarkable the tip of the tube is not visualized on the image there is unchanged complete opacification of the left hemithorax however massive alveolar opacities in the entire right hemithorax have newly appeared these opacities could reflect bleeding pneumonia or acute pulmonary edema there is mild to moderate volume loss of the right hemithorax cxr pm history new og tube placed impression ap chest compared to through a m nasogastric tube passes into the upper stomach and out of view with the chin down the et tube ending no less than cm from the carina is standard placement right jugular introducer ends in the upper svc nasogastric tube ends in the region of the pylorus severe bilateral pulmonary consolidation worse in the right lung has not improved the lung volumes are slightly better at least small bilateral pleural effusions are present increased on the left since the earlier examination heart size is normal mediastinal veins are dilated i would have urged an upright chest radiograph to exclude the possibility of an anteriorly collected pneumothorax in the supine patient but chest radiograph performed a m available at the time of this review was performed with the patient in semi erect and showed left pneumothorax is unlikely cxr reason for examination followup of the patient with diffuse axonal hemorrhage ap radiograph of the chest was compared to prior study obtained the same day earlier as well as several prior studies dating back to the left lung is grossly unremarkable within the limitations of the study technique although several pulmonary nodules are suspected and should be further evaluated with dedicated cross sectional imaging since on the prior ct torso from the entire left lung was collapsed due to large amount of pleural effusion on the right there is slight improvement since yesterday of the extensive consolidation but with still present multifocal nodular opacities although overall the extent of the consolidation appears to be gradually improving the et tube tip is cm above the carina the ng tube tip is in the stomach the right internal jugular line tip is at the level of superior svc continued surveillance with radiographs is recommended brief hospital course ms is a year old female with alcoholic cirrhosis initially presenting with altered mental status then developed respiratory failure and found to have hepatic hydrothorax on imaging and abdominal sepsis as paracentesis with evidence of spontaneous bacterial peritonitis sbp hospital course by problem hypoxemic respiratory failure on the floor the patient was found to have large left sided pleural effusion likely hepatic hydrothorax given her underlying cirrhosis during the hospital stay the patient had an acute desaturation that did not respond to nonrebreather therapy and ultimately required intubation the etiology of this acute hypoxia is unclear but her were suggestive of pleural effusion but also an alveolar process this alveolar process cleared up within a few hours making diffuse alveolar hemorrhage or transfusion related lung injury a more likely cause of her acute hypoxemia versus ards or an aspiration pna the patient was initially on fio and of peep in order to maintain her oxygenation she also underwent a left sided thoracentesis with removal of l of fluid and an additional l over the next two days to a drainage bag the pleural fluid was transudative and had negative cytology however did not wean off the ventilator completely and her family decided to make her cmo and terminally extubate her as per her living will sepsis due to sbp the patient had a diagnostic paracentesis done in the ed consistent with sbp her ct abdomen showed edema of the bowel wall which could be ischemia or infection however this bowel wall edema in the setting of an elevated lactate secondary peritonitis was also on the differential and the patient was being followed by transplant surgery before she decompensated she was getting ceftriaxone gram daily after decompensation she was broadly covered with vancomycin pip tazo metronidazole and this was continued until she was made cmo the patient s living will stated that she would not want antibiotics decreased hematocrit the day the patient was intubated she also was found to have a crit drop from to a trauma line was placed and the patient was volume resucitated once stabilized an egd was done that showed no bleeding into the gi tract it was thought that the crit drop may have gone into diffuse alveolar hemorrhage as discussed above disseminate intravascular coagulopathy dic her sepsis developed into dic with a low fibrinogen and continually rising tbili and inr she was treated with ffp for the thoracentesis and cryoglobulin to keep fibrinogen her platelets stayed above without transfusion altered mental status ams patient initially presented with ams this was thought opssibly related to hepatic encephalopathy vs sepsis her toxicology screens were negative the patient was initially on ceftriaxone for sbp treatment and once she decompensated her antibiotic coverage was broadened as above she was also continued on lactulose rifaxamin while in the hospital titrating to bms daily she was given albumin on the first and third day of sbp treatment acute kidney injury her creatinine increased and her urine output decreased to near anuria during the first day after hypoxemic respiratory failure her creatinine was slowly improving when she was made cmo alcoholic cirrhosis the patient was continued on lactulose rifaxamin for encephalopathy and sbp treatment as discussed above hepatology team was following with her and her hepatitis serologies were negative she had reportedly been sober since the hyponatremia likley hypervolemic hyponatremia in the setting of cirrhosis urine na fena medications on admission lasix omeprazole metoprolol quinalapril triamterene spironolactone discharge medications expired discharge disposition expired discharge diagnosis expired discharge condition expired discharge instructions expired followup instructions expired,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""service"", ""medicine"", ""allergies"", ""no allergies"", ""ADRs on file"", ""attending chief complaint"", ""altered mental status"", ""hypoxemic respiratory distress"", ""major surgical or invasive procedure"", ""left sided thoracentesis"", ""endotracheal intubation"", ""trauma"", ""central line placed"", ""history of present illness"", ""MS is a F with history of ETOH cirrhosis"", ""who was initially transferred from hospital with altered mental status""],
""Medications"": [""ceftriaxone"", ""gram of ceftriaxone"", ""SBP"", ""to cover for a UTI""]
}"
17535,admission date discharge date date of birth sex m service history of present illness the patient is a year old man who was transferred from for evaluation of weakness and numbness for the past hours the patient works as a limo driver to the state of and is a physically demanding job last wednesday prior to admission the patient contracted a flulike illness and then experienced malaise and general body weakness over the next few days over the weekend prior to admission the patient continued to have this flulike illness with diarrhea present on the monday hours prior to admission the patient called in sick to work because of the flu like illness and at p m noticed that his legs were stiff and tired he went out for a beer with his friends and from to noticed that he could not get out of his chair after repeated attempts to get out of the chair that were unsuccessful the patient called ems and was transferred to the patient was tentatively diagnosed with guillain syndrome as they noticed the pattern of ascending weakness and transferred him to the for further workup the patient did report that he felt sensory changes relating to ankles spreading down to his toes hours prior to admission after he had taken a nap on monday these sensory changes were unchanged on his presentation to the when i first came in to evaluate the patient he provided the history above but rejected my questions many times and stated that he did not seek admission at this time after being cleared by psychiatry as competent the patient agreed to being admitted to the hospital for further workup physical examination the patient s temperature was f blood pressure heart rate respiratory rate on initial physical examination the patient had pertinent positives as follows the patient was in mild respiratory distress neck was supple with no midline tenderness no lymphadenopathy lungs showed moderately low total volume and were clear to auscultation bilaterally cardiovascular exam was regular rate and rhythm with no murmurs gallops or rubs extremities showed good peripheral pulses and no edema abdomen was soft and nontender on rectal examination the patient had stool in the vault with good rectal tone on back there was no tenderness on neurologic examination mental status the patient was awake alert oriented cooperative fluent following commands on cranial nerve examination gaze was midline pupils were equal and reactive to light and accommodation extraocular muscles are intact the patient had full facial strength and sensation uvula palate were midline on motor examination the patient had strength in the upper extremity and lower extremity the patient had a the iliopsoas at the quadriceps knee flexors dorsiflexors of foot and plantar flexors of the foot on sensory exam strength position sense and pin prick were impaired from the ankle down to the toes bilaterally in a stocking distribution on reflex examination notably the patient was areflexic in both upper and lower extremities toes were downgoing bilaterally on coordination exam the patient finger nose finger were not ataxic the patient was too weak to perform heel to shin without bias laboratory data the patient had nif of on vital capacity on one to two liters screening complete blood count showed white blood cell count normal chem ck liver function tests lumbar puncture showed three white blood cells zero red blood cells total protein of and glucose of gram stain was negative cultures are pending which turned out to be negative chest x ray showed a left lower lobe pneumonia emg obtained on was consistent with acute generalized acquired demyelinating sensory motor polyradicular neuropathy consistent with guillain syndrome acute inflammatory demyelinating polyneuropathy the patient had negative cytology on lumbar puncture hospital course the patient was immediately admitted to the intensive care unit with emergent management of respiratory status as the patient s nif was concerning a negative the patient was monitored in the intensive care unit for hours and subsequent q h nifs and forced vital capacities demonstrated the patient was stable from a respiratory point of view his strength in his upper extremities was unchanged for hours and his lower extremities his exam was unchanged for hours the patient was then transferred to the general medical floor on the transfer the patient was covered with ceftriaxone for a left lower lobe pneumonia on the general medical floor the patient s weakness from day four through day of hospitalization continued to involve his upper extremities as the patient had serial motor exams documented at his bedside on a work sheet motor exams demonstrated that the patient developed distal greater than proximal weakness in a at finger flexors and finger extensors distally and at triceps and deltoids proximally on day seven of admission the patient also developed a facial diplegia involving frontalis ovicularsorus and ocular muscles vigilant pulmonary monitoring was continued on the general medical floor and the patient s nif had forced vital capacities remained stable at an average of and the the patient was also noted to be diaphoretic during this time of admission and had several blood pressure drops and falls consistent with the autonomic debility seen in guillain syndrome the patient s blood pressure was treated with captopril mg p o three times a day and hydralazine mg intravenous p r n only for systolic blood pressures greater than the patient was also maintained on heparin subcutaneous and meticulous nursing care to prevent ulcers and deep vein thrombosis in his lower extremities which are weak and bed bound plasmaphoresis was started in the intensive care unit and five treatments were given through the patient s course on the general medical floor because of the development of the facial diplegia and new upper extremity weakness the patient immediately received five treatments of intravenous immunoglobulin over the next five days from hospital day to the patient s motor exam remains stable over this time and on day of hospital admission the patient s motor exam dramatically improved as his lower extremities were and the patient s upper extremities also improved to a distally the patient s facial diplegia was unchanged at this time the patient had several speech and swallow evaluations and it was determined that the patient was able to tolerate food although it did show small amounts of aspiration the patient was then prophylactically started on flagyl for aspiration pneumonia in addition to ceftriaxone and the patient completed day courses of each during the patient s time on the general medical floor he developed diffuse sensory polyneuropathy with diffuse loss to pin prick and soft touch bilaterally the patient was maintained on gabapentin mg p o three times a day for the polyneuropathy the patient was also maintained on famotidine mg p o twice a day the patient s social situation was complicated as he needed mass health free care and placement with a rehabilitation facility social workers on the neurology team worked diligently to arrange for the patient to have his first choice and priorities met while taking care of administrative issues related to the patient s insurance on the general medical floor nifs and fvcs through were stable with fvcs of and nifs of to the patient s last chest x ray on showed residual infiltrates at the site of left lower posterior segments of consolidation suggesting resolving pneumonia the patient is now having an improving neurologic exam with residual sensory deficits and facial diplegia this dictation will be addended prior to discharge with discharge medications and orders m d dictated by medquist d t job [NEW_RECORD] name unit no admission date discharge date date of birth sex m service addendum hospital course after the patient s motor examination improved to involve the upper and lower extremities to the range and the patient s facial diplegia improved such that the patient was able to smile symmetrically on both sides although there was still limited movement of the orbicularis auris the patient s sensory deficits continued to involve patchy pin prick loss in his upper and lower extremities and he continued to have neuropathic type pain in his lower extremities for which he was being treated with gabapentin mg p o three times a day from a cardiovascular point of view the patient had several episodes of bradycardia with two second pauses when the patient was sleeping during the day or night the cardiology electrophysiology service was curbsided about the pauses and on their recommendation serial electrocardiograms were performed which showed no pr interval prolongation and the pauses were not associated with any blood pressure changes on their recommendation there was atropine at bedside provided throughout the admission since these episodes occur only when the patient was sleeping and not awake and not associated with any pr interval prolongation there was no intervention necessary at this time bradycardia and pauses never occurred when the patient was awake prior to discharge the patient continued to work with physical therapy on a daily basis and was able to walk with a walker prior to placement in rehabilitation facility autonomic dysfunction the patient s autonomic dysfunction related to the guillain syndrome improved after up until the time of discharge he was no longer orthostatic when getting up from a supine position and the patient s hypertension had diminished there was one occasion during which the patient demanded to be let go from the hospital and was threatening to leave against medical advice however psychiatry consultation came by and deemed the patient to be incompetent at the time for making his own medical decisions psychiatry consultation continued to follow the patient and he never had any more episodes of such nature prior to discharge to rehabilitation facility the patient s white blood cell count remained stable as did his chemistries prior to discharge condition on discharge stable discharge status to rehabilitation facility medications on discharge lipitor mg p o once daily aspirin mg p o once daily zyprexa mg p o twice a day gabapentin mg p o three times a day captopril mg p o three times a day famotidine mg p o twice a day thiamine mg p o once daily multivitamin one capsule p o once daily folic acid one capsule p o once daily heparin units subcutaneous q hours for deep vein thrombosis prophylaxis stool softener p r n follow up the patient will follow up with dr in neurology clinic the patient will also follow up with primary care physician who will be provided for him at his request prior to discharge to rehabilitation facility the patient was to follow up with his primary care physician in compliant fashion and was instructed to do so m d dictated by medquist d t job,"{
""Diagnoses"": [""Guillain-Barré syndrome""],
""Medications"": [""None""]
}"
23633,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint shortness of breath syncope major surgical or invasive procedure aortic valve replacement with millimeter ce pericardial tissue valve history of present illness this is a year old male with known aortic stenosis since he has been followed by serial echocardiograms and has been asymptomatic until this past year when he began to experience progressive fatigue shortness of breath and dyspnea on exertion he also experienced a syncopal episode cardiac catheterization in confirmed moderate to severe aortic stenosis with a valve area of cm angiography showed no significant coronary artery disease with only a lesion in the first diagonal artery his most recent echo from revealed an aortic valve area of cm with peak and mean gradients of and mmhg there was mild to moderte aortic insufficiency and only trace mitral regurgitation past medical history aortic stenosis hypertension chronic renal insufficiency copd anemia gerd bph depression asthma diverticular disease hiatal hernia hemorrhoids appendectomy bilateral cataract surgery skin cancer s p appendectomy social history married retired lives in at least a pack year history of tobacco quit years ago family history no prematue coronary disease father died at age of rheumatic heart disease physical exam vitals bp hr general elderly male in no acute distress heent oropharynx benign neck supple no jvd heart regular rate normal s s systolic murmur lungs decreased right base o w clear delayed expiration no wheeze abdomen soft nontender normoactive bowel sounds ext warm trace edema pulses distally neuro alert and oriented normal gait but slow upper extremity tremors noted no focal deficits noted 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 am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood pt ptt inr pt am blood pt ptt inr pt 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 urine color yellow appear clear sp pm urine blood lg nitrite neg protein neg glucose neg ketone tr bilirub neg urobiln neg ph leuks neg 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 cxr comparison made to prior study of there are small bilateral pleural effusions the lungs are otherwise clear mild cardiac enlargement is present and is unchanged from the prior study mri mra head diffusion images demonstrate no evidence of acute infarct there is no evidence of midline shift mass effect or hydrocephalus seen mild changes of small vessel disease are noted in the white matter there is mild to moderate brain atrophy seen impression no evidence of acute infarct mra of the head the head mra is somewhat limited by motion the mra demonstrates no evidence of vascular occlusion or high grade stenosis in the arteries of anterior or posterior circulation impression slightly motion limited normal mra of the head brief hospital course mr was admitted on the following day he underwent an aortic valve replacement with a millimeter pericardial tissue valve surgery was uneventful and he transferred to the csru for invasive monitoring within hours he was extubated and awoke neurologically intact he was successfully weaned from inotropic support and transferred to the sdu on postoperative day one he remained somewhat hypotensive with a low hematocrit dropping as low as he was concomitantly noted to have an acute decline in renal function with creatinine peaking to on postoperative day five over several days he received several units of packed red blood cells with an appropriate response in blood pressure and hematocrit his renal function slowly improved due to worsening tremulousness of his upper extremities which was noted preop along with gait disturbance and hallucinations the neurology service was consulted a brain mri mra was essentially normal a full work up as an outpatient was recommended and follow up appointments were scheduled he was also noted to have thrombocytopenia an hit assay was checked which was negative by time of discharge his platelet count had normalized he also continued to have bilateral expiratory wheezes post operatively and required nebulizer treatments mr had a run of atrial fibrillation on pod and amiodarone and lopressor were started with conversion to normal sinus rhythm despite him being rather stable he was not able to achieve a level status at pod on post op day his foley was re inserted for a post void residual of roughly liter flomax and proscar were started and he should attempt another voiding trial at rehab bactrim was started for prophylactic foley coverage and follow up should be made with a urologist if retention continues the occupational therapy and physical therapy service worked with mr daily he continued to make steady progress and was discharged to on postoperative day fourteen he will follow up with dr his cardiologist his primary care physician neurology service and the urology service as an outpatient medications on admission depakote zyprexa qam aricept qam remeron qpm flomax qd effexor proscar qd discharge medications docusate sodium mg capsule sig one capsule po bid times a day aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily divalproex sodium mg tablet delayed release e c sig one tablet delayed release e c po bid times a day disp tablet delayed release e c s refills olanzapine mg tablet sig one tablet po daily daily disp tablet s refills donepezil mg tablet sig two tablet po qam once a day in the morning disp tablet s refills tamsulosin mg capsule sust release hr sig one capsule sust release hr po hs at bedtime disp capsule sust release hr s refills mirtazapine mg tablet sig three tablet po hs at bedtime disp tablet s refills venlafaxine mg tablet sig four tablet po bid times a day disp tablet s refills finasteride mg tablet sig one tablet po daily daily disp tablet s refills ferrous gluconate mg tablet sig one tablet po daily daily disp tablet s refills ascorbic acid mg tablet sig one tablet po bid times a day disp tablet s refills metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet s refills amiodarone mg tablet sig two tablet po bid times a day take mg x day for until than mg x day for week than mg x day thereafter 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 daily daily for days disp capsule sustained release s refills percocet mg tablet sig tablets po every hours as needed for pain disp tablet s refills albuterol mcg actuation aerosol sig one inhalation every four hours as needed for shortness of breath or wheezing combivent mcg actuation aerosol sig two inhalation four times a day sulfamethazine powder sig one tablet miscell daily daily discharge disposition extended care facility hospital of islands discharge diagnosis aortic stenosis s p aortic valve replacement tissue valve on post operative atrial fibrillation hypertension chronic renal insufficiency chronic obstructive pulmonary disease anemia gastroesophageal refulx disease benign prostatic hypertophy depression asthma diverticular disease tremor hiatal hernia discharge condition good discharge instructions can take shower wash incision with soap and water and gently pat dry do not apply any lotions creams ointments or powders until wound has healed do not take baths or swim until wound has healed call office if you notice any redness or drainage from incision fever or weight gain more than pounds in one day or five in one week no lifting more then pounds for weeks or driving for month bactrim for foley coverage void trial at rehab if fails void trial please schedule appointment with urologist discontinue bactrim when foley out amiodarone until then mg twice daily for week then mg once daily thereafter until seen by cardiologist lasix and potassium should be taken as directed for week then stopped unless otherwise directed by a physician monitor electrolytes while on lasix and replete as needed call with any questions or concerns followup instructions dr in weeks dr or dr cardiologist in weeks dr pcp in weeks please call providers for appointmnets provider m d phone date time provider md phone date time completed by,"{
""Diagnoses"": [""cardiothoracic"", ""aortic stenosis"", ""hypertension"", ""chronic renal insufficiency"", ""COPD"", ""anemia"", ""GERD"", ""BPH"", ""depression"", ""asthma"", ""diverticular disease"", ""hiatal hernia"", ""hemorrhoids"", ""appendectomy"", ""bilateral cataract surgery""],
""Medications"": [""mmilimeter ce pericardial tissue valve"", ""angiography"", ""cardiac catheterization"", ""only a lesion in the first diagonal artery""]
}"
90238,admission date discharge date date of birth sex m service neurosurgery allergies no known allergies adverse drug reactions attending chief complaint s p mechanical fall major surgical or invasive procedure none history of present illness called by ed to see this pt s p fall for occipital hemorrhage ed resident explains that pt was sweeping out the back of his pick up truck and he was a witnessed fall off of the truck striking his head he was with loc he stood up and then was able to walk up two flights to his apt unassisted he then was seen coming out of the bathroom and fell again not striking his head at this time there is also report of a witnessed seizure he was brought to hospital there he was combative and after ct results they decided to intubate him for transport to for neurosurgical eval per report the wife states he is on an hiv cocktail and a medication for gerd she does not know the names and is not here in the ed at this time past medical history hiv hep c ivda social history married history of ivda heroin use within hrs of admit family history nc physical exam o t af bp was sys at osh hr r o sats intubated gen wd thin male intubated with ogt in place hard collar in place with soft restraints in place mae to lab draws heent pupils right eye with subconjunctival hemorrhage pupils midposition conjugate gaze no nystagmus or gaze preference no hemotymapnum no csf rhinorrhea possible battle sign early vs pressure from collar raccoon eyes with minimal swelling blood to scalp in occipital region minimal no step off neck in hard collar neuro intubated off sedation possibly still post ictal grimace to noxious no eo no commands extensor postures to le s without stim with stim he does not localize he does withdraw his extremity equally without focal weakness he does withdraw his lowers to noxious he also has some spontaneous le movement knee bending no clonus pertinent results ct maxface multiple nasal bone fractures with opacification of the ethmoidal air cells right frontal pneumocephalus while no discrete right frontal bone fracture is seen an occult fracture is not excluded left occipital fracture again seen extending to the level of the jugular foramen as noted on the concurrent head ct internal jugular vein injury can not be excluded and can be further evaluated for on mrv ctv ct head left occipital fracture extending through the left occipital condyle and extending to the level of the left jugular foramen cannot exclude an internal jugular vein injury which could be further evaluated with mrv ctv if necessary there is also a small left occipital extra axial focus of hemorrhage at the level of the bony fracture additionally there is a small right frontal subdural hematoma and small left parafalcine subdural hematoma there are also foci of right frontal hyperdensity which are likely foci of subarachnoid hemorrhage versus small contusions small right pneumocephalus of unknown etiology an occult frontal bone fracture is not excluded left nasal bone fractures ct torso endotracheal tube is located at less than cm from the carina and withdrawing repositioning of this tube is recommended findings and recommendation had been discussed with dr on nasogastric tube distal tip at the gastroesophageal junction and further advancement is recommended so that it is well within the stomach finding and recommendation had been discussed with dr on bilateral dependent atelectasis with possible aspiration no evidence of acute traumatic injury in the chest abdomen or pelvis brief hospital course patient was admitted to surgical icu after beign trasnferred from an osh where he was intubated and placed cervical collar after a fall he remained stable in the icu overngiht and scans of his head face sinus mandible and torsos were obtained he was found to have multiple nasal fractures and an occipital bone fracture in addition to his intracranial blood on the mornign of he was deemed fit for extubation and it was noted after conversation with his wife that he had within at least the last hours if not more recently used heroin as a result the icu placed him on methadone for withdrawl prophylaxis pt had a repeat ct that evening which showed stable parafacline sdh and r frontal contusions he was extubated without incident on he was transferred to floor in stable condition social work was consulted on due to active heroin abuse however patient refused to meet with social work he also refused the option of methadone clinic initially stating that he wasn t allowed back to the clinic and subsequently stating that it wouldn t help his addiction it was explained to him that without adequate followup in methadone clinic or with a specialist he would not be given a prescription for methadone he intitially entertained the option of a suboxone treatment program but then refused based on his hiv medication status he became increasingly agitated and demanded to be discharged as soon as possible at the time of discharge the patient is afebrile vss and neurologically stable patient s pain is well controlled and the patient is tolerating a good oral diet he was cleared by pt for discharge home in stable condition and will follow up accordingly medications on admission kaletra lopinavir ritonavir mg two tabs po bid epzicom abacavir sulfate lamivudine mg po qhs omeprazole mg po hs amitriptyline hcl mg tabs po hs prn discharge medications acetaminophen mg tablet sig two tablet po q h every hours as needed for pain fever lopinavir ritonavir mg tablet sig two tablet po bid times a day abacavir mg tablet sig one tablet po qhs once a day at bedtime lamivudine mg tablet sig two tablet po qhs once a day at bedtime omeprazole mg capsule delayed release e c sig one capsule delayed release e c po qhs once a day at bedtime levetiracetam mg tablet sig one tablet po bid times a day nicotine mg hr patch hr sig one patch hr transdermal daily daily disp patch hr s refills oxycodone acetaminophen mg tablet sig tablets po every hours as needed for pain disp tablet s refills discharge disposition home discharge diagnosis frontal contusion sdh seizure left cerebellar contusion nasal bone fracture left occipital bone fracture substance abuse discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge 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 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 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 you refused discussion with social work during this admission and refused the option of a methadone clinic and suboxone center at this time please contact your pcp or mental health services at at should you wish to pursue these options at a later time md completed by,"{
""Diagnoses"": [""occipital hemorrhage"", ""seizure""],
""Medications"": [""hiv cocktail"", ""gerd medication""]
}"
32516,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint exertional chest pain major surgical or invasive procedure off pump cabgx left internal mammary left anterior descending artery vein graft diagonal artery vein graft posterior descending artery cardiac catheterization history of present illness cc yo hispanic man admitted to holding area from exercise lab due to ekg changes and chest pain during outpt ett today hpi information obtained from pt with assistance of interpreter services this yo man with no known prior hx cad reports overall good health approximately months ago he noted the onset of chest pressure associated with physical activity he also had periods of doe both with and without chest pressure he works as a janitor initially symptoms were infrequent and relieved by rest over the past month he has had episodes of chest pain per week symptoms relieved by rest he was referred for ett today by pcp dr he completed min of a modified protocol stopped due to symptoms of chest pressure and fatigue ekg showed mm st segment horizontal down sloping in the inferolateral leads there were t wave inversions leads v v noted during the recovery phase nuc imaging revealed nl lv size mild systolic dysfunction and distal anterior hk past medical history htn hyperlipidemia headaches social history employed custodian lives with his son his son is not able to help with discharge to home due to work schedule no current tobacco quit years ago or etoh use family history noncontributory physical exam appears comfortable stating no further episodes of chest pain vs tele sr s bp s lungs cta ant lat heart rrr mrg abd nt bs pv fems no bruits dps bilaterally no no variocosties 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 am blood pt ptt inr pt pm blood plt ct pm blood pt inr pt am blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos amylase totbili pm blood vitb pm blood hba c pm blood triglyc hdl chol hd ldlcalc radiology final report chest pa lat pm chest pa lat reason evaluate ptx medical condition year old man s p cabg reason for this examination evaluate ptx cxr two films history status post cabg findings sternotomy noted there are small bilateral pleural effusions and thickening of the fissures the bibasilar atelectasis shows considerable improvement compared to the previous examination of no heart failure conclusion status post cabg improving bilateral pleural effusions and bibasilar atelectasis dr approved tue pm cardiology report echo study date of report not finalized preliminary report patient test information indication abnormal ecg aortic valve disease coronary artery disease left ventricular function mitral valve disease valvular heart disease status inpatient date time at test tee complete doppler full doppler and color doppler contrast none tape number aw test location anesthesia west or cardiac technical quality adequate referring doctor dr measurements left ventricle ejection fraction to nl interpretation findings off pump cabg left atrium normal la size no spontaneous echo contrast or thrombus in the body of the laa right atrium interatrial septum normal ra size a catheter or pacing wire is seen in the ra dynamic interatrial septum no asd or pfo by d color doppler or saline contrast with maneuvers left ventricle normal lv wall thickness and cavity size moderately depressed lvef lv wall motion regional lv wall motion abnormalities include basal anterior hypo mid anterior hypo basal anteroseptal hypo mid anteroseptal hypo basal inferoseptal hypo mid inferoseptal hypo basal inferior hypo mid inferior hypo basal inferolateral hypo mid inferolateral hypo basal anterolateral hypo mid anterolateral hypo anterior apex hypo septal apex hypo inferior apex hypo lateral apex hypo apex hypo right ventricle mildly dilated rv cavity normal rv systolic function aorta normal ascending aorta diameter normal descending aorta diameter simple atheroma in descending aorta aortic valve three aortic valve leaflets mildly thickened aortic valve leaflets no as no ar mitral valve mildly thickened mitral valve leaflets mild mitral annular calcification mild thickening of mitral valve chordae physiologic mr within normal limits tricuspid valve normal tricuspid valve leaflets with trivial tr pulmonic valve pulmonary artery normal pulmonic valve leaflets with physiologic pr pericardium no 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 suboptimal image quality poor echo windows conclusions 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 atrial septal defect or patent foramen ovale is seen by d color doppler or saline contrast with maneuvers left ventricular wall thicknesses and cavity size are normal overall left ventricular systolic function is moderately depressed lvef xx the right ventricular cavity is mildly dilated right ventricular systolic function is normal 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 no aortic regurgitation is seen the mitral valve leaflets are mildly thickened physiologic mitral regurgitation is seen within normal limits there is no pericardial effusion physician cardiology report ecg study date of pm sinus rhythm with ventricular premature beat low limb lead qrs voltage is non specific modest right precordial lead anterior t wave changes are non specific and unstable baseline makes assessment difficult clinical correlation is suggested compared to the previous tracing of sinus bradycardia is absent ventricular ectopy and precordial t wave changes are now seen read by w intervals axes rate pr qrs qt qtc p qrs t brief hospital course mr was admitted to the on for further management of his angina and positive stress test he underwent a cardiac catheterization which revealed severe three vessel coronary artery disease given these findings the cardiac surgical service was consulted for surgical mananagement mr was worked up in the usual preoperative manner on mr was taken to the operating room where he underwent off pump coronary artery bypass grafting to three vessels please see operative note for details postoperatively he was taken to the cardiac surgical intensive care unit for monitoring on postoperative day one mr neurologically intact and was extubated aspirin beta blockade and his statin were resumed plavix was started as his surgery was performed off pump and should be continued for three months on postoperative day two he 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 continued to progress and was ready for discharge to rehab on pod medications on admission medications as per pharmacy patient unable to identify meds states takes pills a day aspirin mg daily atenolol mg daily hctz mg daily tylenol daily for headache prazosin mg daily pt thinks this was stopped unable to verify discharge medications oxygen oxygen l nc wean to room air for sats 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 docusate sodium mg capsule sig one capsule po bid times a day oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain ranitidine hcl mg tablet sig one tablet po daily daily clopidogrel mg tablet sig one tablet po daily daily for months furosemide mg tablet sig one tablet po once a day lisinopril mg tablet sig tablet po daily daily metoprolol succinate mg tablet sustained release hr sig tablet sustained release hrs po daily daily hydrochlorothiazide mg tablet sig one tablet po once a day discharge disposition extended care facility home discharge diagnosis cad s p off pump cabg systolic heart failure ef hyperlipidemia htn headaches discharge condition good 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 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 dr cardiologist pcp after discharge from rehab md completed by,"{
""Diagnoses"": [""cardiothoracic"", ""exertional chest pain""],
""Medications"": [""off pump cabgx"", ""left internal mammary artery vein graft"", ""diagonal artery vein graft"", ""posterior descending artery"", ""cardiac catheterization""]
}"
99260,admission date discharge date date of birth sex m service emergency allergies patient recorded as having no known allergies to drugs attending chief complaint hyperglycemia major surgical or invasive procedure g tube placement cvl intubation picc line history of present illness the patinet is a year old male with a history of t dm diagnosed at age w insulin pumps placed for the first time in the last month who presented to an osh with altered mental status the patient is currently intubated and unresponsive so most information is gained from the medical record the patinet had been feeling unwell over the last few days with decreased energy nausea vomiting the patient was found by his daughters boyfriend on the day of presentation in respiratory distress and altered mental status and was brought to an osh ed for further manegment on arrival to the osh hr bp dyspneic with kussmal breathing lab work up revealed a k of sodium of creatinine of and glucose of he had an anion gap of an abp was checked with a ph of the patinet develped hrs in the s bps in the s he was given amps of nahco insulin gtt at which was uptitrated to and calcium gluconate his ua was for moderate ketones a r sc line was placed without complications the patinet was intubated for airway protection and respiratory distress he was given l of ns the patient was transfered to for further care on arrival to our ed initial vs on the vent his insulin was reduced to units hr he was given an addition l of ns the patient was given vanc zosyn but no blood cultures were sent he blood sugars persisted in the s he was admitted to the micu for further manemement past medical history dm hbga c on htn cri cr of dchf hl social history patient is a former smoker quit many years ago works as a diesal mechanic has children family history nc physical exam tmax c f tcurrent c f hr bpm bp mmhg rr insp min spo heart rhythm sr sinus rhythm wgt current kg admission kg height inch ventilator mode mmv psv autoflow vt set ml vt spontaneous ml ps cmh o rr set rr spontaneous peep cmh o fio rsbi pip cmh o spo gen trach in place winces to pain in le only cv rr no mrg pulm coarse breath sounds abd benign abdomen g tube in place lap incisions well healing no bleeding erythema or oozing no guarding or rebound peripheral vascular right radial pulse not assessed left radial pulse not assessed right dp pulse not assessed left dp pulse not assessed skin not assessed neurologic responds to pain winces pupils mm with some response to light eyes moving in same direction as head movement no spontaneous movement of extremities pertinent results admission 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 fibrino am blood ret aut am blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos totbili am blood lipase am blood calcium phos mg pm blood caltibc ferritn trf am blood triglyc am blood osmolal am blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg am blood type art po pco ph caltco base xs am blood glucose greater th lactate k discharge am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood plt ct am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos totbili am blood calcium phos mg pm blood type temp rates peep po pco ph caltco base xs intubat intubated pm blood lactate cxr ap supine chest radiograph tracheostomy tube with its tip cm above the carina and a right picc with its tip in the upper svc are unchanged the nasogastric tube has been removed the lungs are clear without effusion consolidation or pneumothorax heart size is normal impression no acute cardiopulmonary process tte 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 the aortic root is mildly dilated at the sinus level the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation no masses or vegetations are seen on the aortic valve the mitral valve appears structurally normal with trivial mitral regurgitation there is no mitral valve prolapse no mass or vegetation is seen on the mitral valve the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression no obvious vegetations seen mri head impression multifocal subacute infarction configuration and distribution favor hypoxic ischemic insult such as sustained during acute hypotension cardiac arrest given gyriform configuration the embolic etiology is felt less likely however remains a differential consideration no evidence of mass effect edema herniation or hemorrhage pansinusitis ct head impression bitemporal regions of low attenuation not significantly changed since ct appearance is non specific and further evaluation with mr preferably with contrast if feasible is recommended to exclude acute infectious inflammatory process such as cerebritis encephalitis or ischemic causes vs chronic encphalomalacia perhaps related to old contusions persistent opacification of paranasal sinuses ct abd pelvis impression indistinct and hazy borders of the pancreas most compatible with acute pancreatitis pancreatic necrosis and other complication cannot be evaluated on the current study due to lack of iv contrast extensive subcutaneous edema consistent with anasarca colonic diverticulosis apparent descending colon wall thickening may be secondary under distention third spacing and or colitis bilateral small pleural effusions with adjacent associated atelectasis superinfection can not be excluded brief hospital course the patient is a year old male with a history of dm with a recent insulin pump placement cri cr who presented in respiratory distress and altered mental status found to have profound hyperglycemia and metabolic acidosis dka patient presented with profound dka with acidemia to for an unknown period of time the precipitant was unclear but he did have pancreatitis with an elevated lipase his dka resolved with aggressive ivfs and an insulin drip anoxic brain injury he was intubated for lethargy in the setting of dka and was comatose off sedation early on during his hospital course an lp was performed that did show pleocytosis and he was empirically treated with vanc zosyn an mri was also performed and had findings consistent with anoxic brain injury nuero was consulted and felt that the anoxic injury was likely related to prolonged acidemia in the setting of dka a review of the osh records also demonstrated intervals lasting minutes in which the patient had systolic bps in the s though he was never asystolic his family initially planned to withdraw care given the patient s preferences prior to illness and his poor prognosis but on he withdrew to painful stimuli on his legs and ears given this finding they decided to proceed with tracheostomy and peg though they understood that despite these findings his prognosis was still very poor respiratory failure the patient was intubated in the setting of lethargy he received tracheostomy on and peg as described above he had periods of apnea and therefore required mmv he did not tolerate trach collar for long periods of time pancreatitis he had an elevated lipase thought to be secondary to dka a non contrast abdominal ct scan demonstrated findings consistent with acute pancreatitis but necrosis could not be visualized because of the lack of contrast which was not used because of surgery was consulted and felt that there were no acute surgical interventions indicated fevers he continued to spike fevers throughout his hospital stay cultures were consistently negative and he received broad spectrum antibiotics for meningitis we felt his fevers were most likely central neurologic in origin patient finished a day course of vancomycin and cefepime on acute on chronic kidney injury he had in the setting of hypovolemia and dka and this improved with ivfs renal was consulted and recommended continued diuresis given his l positive fluid balance a lasix drip was initiated and he diuresed well and was transitioned to lasix boluses he subsequently had worsening and renal re evaluated felt to have prerenal etiology given diuresis on top of atn he was given ns for day with no improvement the patient should have his renal function assessed daily and may eventually require renal replacement therapy based on overall improvement prognosis and plan of care defer to rehab team hypernatremia patient noted to have hypernatremia with average sodium concentration near at time of discharge patient required frequent free water flushes and will require ongoing monitoring given patients inability to express thirst on control fluid intake please obtain daily sodiums and replete free water based on daily deficit anemia he has anemia of chronic inflammation and was transfused u prbc on there was no evidence of active bleeding he will need to have his hematocrit checked weekly contact next of c h brother son ter medications on admission ramipril mg take capsule mg by oral route every day zestril mg time per day simvastatin mg time per day viagra mg as directed before sexual intercourse furosemide mg take tablet mg by oral route times every day aspirin mg take tablet mg by oral route every day avapro mg take tabs d discharge medications chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane times a day acetaminophen mg tablet sig one tablet po q h every hours as needed for fever labetalol mg tablet sig tablets po tid times a day white petrolatum mineral oil ointment sig one appl ophthalmic prn as needed as needed for dry eyes heparin porcine unit ml solution sig u injection tid times a day famotidine mg tablet sig one tablet po q h every hours senna mg tablet sig one tablet po bid times a day as needed for bm docusate sodium mg ml liquid sig one po bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for thrush sodium chloride flush ml iv prn line flush temporary central access icu flush with ml normal saline daily and prn 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 lantus unit ml solution sig twenty four u subcutaneous qam insulin regular human unit ml insulin pen sig per sliding scale subcutaneous every six hours u u u u u u u md discharge disposition extended care facility discharge diagnosis diabetic ketoacidosis diffuse brain injury meningitis encephalitis acute on chronic renal failure hypernatermia anemia discharge condition poor mental status does not withdraw to pain no purposeful movements discharge instructions it was a pleasure taking care of you in the hospital you were admitted to the hospital because of elevated sugars and severe acidosis you required intubation and had a prolonged admission in the icu you had fevers and were treated for an infection with antibiotics for days you were evaluated by neurology and it is unclear the level of neurologic improvement you will have please see discharge summary for full hospital course followup instructions you will need renal follow up regarding your acute on chronic renal failure [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 seizure altered mental status major surgical or invasive procedure lumbar puncture history of present illness history obtained from hcp and neuro notes y o m with pmhx of type i dm htn ckd and dka c b hypoxic brain injury who had a witnessed generalized tonic clonic seizure today this morning which lasted approximately minute per report he was then noted to be postictal and yawning but he was moving all extremities at the time and bs was the rehab team cannot tell if there was a gaze deviation or bowel incontinence he did not receive any meds brother reports that at baseline the patient is able to converse and comprehend but has difficulty with naming at baseline patient is able to walk with assist using a belt and a person following with a wheelchair has recently been able to walk up stairs per patient s brother hcp pt s blood glucose levels have been fluctuating recently and he reportedly had an episode of hypoglycemia yesterday with a glucose poc of because the patient missed a meal brother saw patient last night at which time he was able to discuss his children and his retirement pt had a uti last week which was treated with ceftriaxone last dose hours ago of note he has had a foley in since admission to the nh hcp reported that he has had recurrent infections while at rehab and recently treated for cdiff stopped abx for cdiff on initial vs on arrival to the ed t bp rr sats l nc given new onset seizure and mental status changes pt was given ativan mg iv and there were multiple unsuccessful attempts at lumbar puncture head ct did not show any acute changes from baseline neuro was consulted and pt was empirically treated with ceftriaxone grams vancomycin gram ampicillin grams acyclovir gram pt was given ivf but this was stopped after cxr showed increased pulm edema on arrival to the micu pt was somnolent but arousable to stimuli pt would shout out in clear language to stop and says but otherwise he does not follow commands of note he falls to sleep and exhibits cheynes breathing family provided additional ros pt has been c o chills at night but denies fevers good appetite some diarrhea recent uti no significant cough or shortness of breath improving with swallow function advanced to regular diet approx wks ago no nausea or vomiting past medical history dm since age insulin pump requiring hba c on hypertension diastolic heart failure hyerplipidemia ckd cr of h o acute pancreatitis h o dka with associated hypoxic brain injury and prolonged icu stay requiring trach peg now weaned from trach but peg in place social history used to work as an mechanic but had to stop working when he lost driver s license after repeated episodes of hypoglycemia not married pt has been living at rehab since admission in family history non contributory physical exam pe bp hr rr sats on ra gen lying in bed somnolent but arousable not following commands and reports pain when touched anywhere heent nc at dry mucosa neck supple cv rrr nl s and s no murmurs gallops rubs lung not compliant with exam but subtle inspiratory crackles at bases bilaterally abd soft mildly ttp diffusely no rebound guarding nabs lower ext no edema warm good dpulses rue warm erythematous edematous pertinent results labs at 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 pm blood alt ast ld ldh alkphos totbili am blood calcium phos mg am blood osmolal am blood tsh am blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg am blood lactate csf fluid analysis wbc rbc polys lymphs monos totprot glucose ld ldh herpes simplex virus pcr pending micro data bcx pending ucx negative csf hsv pcr negative csf cryptococcal antigen negative gram stain final no pmns no microorganisms fluid culture preliminary no growth fungal culture preliminary no fungus isolated viral culture preliminary c diff negative ucx negative imaging studies ecg sinus rhythm borderline prolonged upper limits of normal qtc interval is non specific otherwise tracing is within normal limits clinical correlation is suggested since the previous tracing of the rate is slower and low amplitude t wave changes have decreased intervals axes rate pr qrs qt qtc p qrs t ct head no acute intracranial process unchanged old infarctions cxr mild chf left retrocardiac opacity most likely representing atelectasis pneumonia cannot be excluded abd x ray no evidence of bowel obstruction no free intraperitoneal air eeg abnormal portable eeg due to the slow and disorganized background and frequent bursts of generalized slowing these findings indicate a widespread encephalopathy affecting both cortical and subcortical structures there were some sharp features before the generalized slowing but they were not simple spike or sharp and slow wave complexes and they appeared repetitively for only a few seconds at a time the tracing cannot rule out the occurrence of seizures at other times but the bursts of slowing and even sharp waves appeared more likely related to the encephalopathy if clinical suspicion for seizures persists a repeat tracing or longer monitoring could be helpful there were no areas of persistent focal slowing but encephalopathies may obscure focal findings renal u s echogenic kidneys suggesting underlying medical renal disease there is no nephrolithiasis hydronephrosis or renal mass lesion right ue u s no right upper extremity dvt brief hospital course seizure altered mental status neuro exam was generally non focal aside from right sided and lower extremity weakness which had reportedly been stable since his hypoxic brain injury several months ago he was empirically treated with vanc ceftriaxone ampicillin and acyclovir for possible meningitis lp was eventually obtained after an initially unsuccesful attempt csf was not concerning for infection and antibiotics antivirals were discontinued neuro was consulted and recommended starting keppra in the micu his toxic metabolic work up revealed a mildly elevated tsh and normal free t infectious workup was unrevealing pt was initially continued on empiric metronidazole for possible c diff given his history of recurrent cdiff recent abx course and elevated wbc count but this was discontinued when his toxin assay came back negative eeg was performed and showed findings likely related to encephalopathy mental status was improved by day of admission and pt was called out to the floor he did not have any further seizures and his mental status improved to his baseline mental status from prior to the seizure according to his brothers will follow up with neurology as an outpatient acute on chronic renal failure pt has ckd with baseline creatinine of and presented with a creatinine of and a hemoconcentrated cbc his creatinine had a variable result to volume repletion but eventually improved to nephrology was consulted a family meeting was held between the patient brothers and the renal service during which the brothers were told that hemodialysis may not have a significant benefit in the patient s quality of life the family may consider seeing a local nephrologist to further discuss the risks benefits of hemodialysis diastolic chf the patient was generally euvolemic during the hospitalization he was intermittently given iv fluids to treat his and did not have significant edema oxygen desaturation or other signs of significant volume overload despite holding diuretics his respiratory status was stable he was continued on hydralazine amlodipine and labetalol for bp control typei dm pt with h o labile bs and severe episode of dka complicated by hypoxic brain injury of note his bs after the seizure was though his family had been feeding him his meals and the day prior to admission his bs was due to missing a meal given the lability of his blood sugars the patient was given tube feeds at a low rate and his initial insulin regimen was conservative to avoid repeat episodes of hypoglycemia upon transfer to the floor though his blood sugars were somewhat labile especially after the re introduction of a diet he was seen by who recommended adding bedtime glargine and his fingersticks were subsequently better controlled his insulin doses will likely have to be adjusted further as his oral diet and tube feeds are adjusted obstructive sleep apnea the patient underwent a sleep study as recommended by the neurology service the neurology attending planned to evaluate the sleep study the patient was recommended to sleep on his side fen the patient was given tube feeds on he was seen by speech and swallow therapy he was written for a regular diet which he tolerated but did not have sufficient po intake to warrant discontinuation of his tube feeds code the patient was full code for the duration of the hospitalization as confirmed with the health care proxy c h medications on admission miconazole tp ranitidine mg amlodipine mg daily heparin u sc tid insulin humolog ss labetalol mg tid calcium acetate mg nitroglycerin patch lasix mg lantus units daily metolazone mg daily hydralazine mg q hr tylenol percocet prn discharge medications miconazole nitrate powder sig one appl topical tid times a day as needed for axilla ranitidine hcl mg tablet sig one tablet po twice a day heparin porcine unit ml solution sig units injection tid times a day amlodipine mg tablet sig two tablet po daily daily labetalol mg tablet sig three tablet po tid times a day insulin glargine unit ml solution sig eighteen units subcutaneous qam insulin glargine unit ml solution sig eight units subcutaneous at bedtime levetiracetam mg tablet sig one tablet po bid times a day hydralazine mg tablet sig two tablet po q h every hours insulin lispro subcutaneous discharge disposition extended care facility discharge diagnosis primary seizure acute on chronic kidney injury diabetes mellitus secondary history of hypoxic brain injury hypertension diastolic heart failure hyerplipidemia discharge condition mental status confused always level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions mr you were admitted with a seizure you were found to be hypogylcemic low blood sugar and this was treated you had a lumbar puncture to evaluate for an infection in your spinal fluid the lumbar puncture results did not show infection you had worsening kidney function which is now stable your diabetes was difficult to control but your blood sugars are now more stable you have had some swelling of your right arm but your ultrasound was negative for a blood clot we made the following changes to your medications started levetiracetam mg tabs one tab by mouth twice daily changed your insulin regimen please see the attached sheet for your new regimen followup instructions please follow up with your primary care doctor after you are discharged from rehab department neurology when wednesday at pm with drs building sc clinical ctr campus east best parking garage,"{
""Diagnoses"": [""Hyperglycemia"", ""Major surgical or invasive procedure"", ""CVL intubation"", ""Picc line"", ""History of present illness""],
""Medications"": [""Nahco insulin"", ""Gtt"", ""Amps"", ""Calcium gluconate"", ""Ua for moderate ketones""]
}"
19545,admission date discharge date date of birth sex m service nb history of present illness is the former kg product of a and weeks gestation pregnancy born to a year old g p woman prenatal screens blood type o antibody negative rpr nonreactive rubella immune hepatitis b surface antigen negative group beta strep status unknown complications the pregnancy was complicated by maternal fibroids and unstoppable preterm labor delivery the infant was born by spontaneous vaginal delivery with apgar scores of at one minute and at five minutes he received blow by oxygen in the delivery room because of persistent cyanosis he was admitted to the neonatal intensive care unit for treatment of prematurity and respiratory distress physical examination upon admission to the neonatal intensive care unit weight kilograms th to th percentile length cm th percentile head circumference cm th percentile general a nondysmorphic slightly preterm male with respiratory distress manifested by grunting flaring and retractions head ears eyes nose and throat examination molding of the head palate intact red reflex present bilaterally neck supple without masses skin pink and ruddy chest lungs with shallow respirations grunting and intercostal retractions cardiovascular a regular rate and rhythm a grade systolic murmur at the left sternal border femoral pulses bilaterally abdomen soft with active bowel sounds no masses or distention gu normal male with testes descended bilaterally musculoskeletal clavicles intact hips stable spine normal neuro good tone with normal suck and gag reflexes hospital course by systems including pertinent laboratory data respiratory was placed on continuous positive airway pressure upon admission to the neonatal intensive care unit his maximum oxygen requirement was oxygen he was extubated to nasal cannula on day of life and remained on nasal cannula through he remained in room air thereafter a chest x ray was consistent with retained fetal lung fluid cardiovascular the murmur noted on admission resolved within hours he has maintained normal blood pressures and heart rates fluids electrolytes nutrition was initially n p o and treated with intravenous fluids enteral feeds were started on day of life and gradually advanced to full volume he is currently on mm or e and his weight prior to discharge was grams infectious disease due to respiratory distress and prematurity he was evaluated for sepsis the white blood cell count was benign a blood culture was obtained prior to starting ampicillin and gentamicin the blood culture was negativ at hours and the antibiotics were discontinued hematological hematocrit at birth was he did not receive any transfusions of blood products gastrointestinal peak serum bilirubin occurred on day of life total mg dl over mg dl direct he was not treated with phototherapy his last bilirubin level was on neurology has maintained a normal neurological exam during admission and there are no neurological concerns at the time of discharge sensory hearing screening passed prior to discharge circumcision immunizations hepatitis b given on discharge disposition f u at pediatrics dr on vna to visit home day post discharge discharge diagnoses prematurity at and weeks gestation respiratory distress secondary to retained fetal lung fluid suspicion for sepsis ruled out hyperbilirubinemia dictated by medquist d t job,{}
30236,admission date discharge date date of birth sex f service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint esophagel perforation major surgical or invasive procedure right thoracotomy repair of esophageal perforation with intercostal muscle flap history of present illness mrs is a year old female with known common bile duct strictures who for the past five months has been undergoing ercp with biliary stent placement endoscopy was performed for the purposes of ercp and a perforation was incurred in the posterolateral left portion of the esophagus cm from the incisors the thorascic team was notified and the patient was taken emergently to the operating room for repair of this perforation past medical history common bile duct strictures anemia constipation osteoporosis psh several ercps and biliary stenting since social history lives alone denies tobacco or etoh family history non contributory physical exam vs t hr sr bp sats ra general no apparent distress card rrr normal s s no murmur gallop or rub resp decreased breath sounds throughout gi bowels sounds positive abdomen soft non tender non distended extr warm no edema incision right thoracotomy site clean dry intact no erythema neuro non focal pertinent results wbc rbc hgb hct plt ct wbc rbc hgb hct plt ct urean creat na k cl hco angap glucose urean creat na k cl hco alt ast alkphos amylase totbili cxr status post esophageal repair as compared to the previous examination there is no relevant change small left sided pleural effusion retrocardiac atelectasis and small right sided pleural effusion the previously inserted drain has been removed after is esophageal repair there is no evidence of pneumothorax ugi sgl contrast w kub clip barium esophagram evaluation of the distal esophagus was achieved via administration of water soluble contrast material followed by thin barium there is no extravasation of contrast from the esophagus contrast material passed freely through the distal esophagus into the stomach which filled and emptied normally minimal holdup of barium within the esophagus occurred impressions no contrast extravasation to indicate leak retrocardiac opacity likely atelectasis dedicated chest radiograph recommended brief hospital course mrs was admitted for ercp a perforation was incurred in the posterolateral left portion of the esophagus cm from the incisors she was referred to thoracic surgery and underwent esophagogastroduodenoscopy right thoracotomy primary repair of esophageal perforation intercostal muscle flap and a flexible bronchoscopy she tolerated the procedure she was monitored in the sicu overnight and transferred to the floor on pod she had an bupivacaine epidural was placed by the acute pain service for better pain control she continue on the dilaudid pca she had a right chest tube jp drain and ng in place on pod the ng was removed a barium swallow revealed no esophageal leak which she was then started on a clear liquid diet the chest tube was removed on pod the jp drain remained she was seen by physical therapy who recommended rehab on pod the epidural was removed and she was converted to po pain medication with good control the foley was removed and she voided without difficulty on pod the jp was removed she was followed by the gi service throughout her stay on pod she was started on a day course of triple therapy for h pylori her diet was advanced to a soft dysphagia which she tolerated she continued to make steady progress and was discharged to rehab she will follow up with dr and gi as an outpatient medications on admission calcium carbonate naproxyn evista mirilax discharge medications raloxifene mg tablet one tablet po daily oxycodone acetaminophen mg ml solution five ml po q h every hours as needed for pain ibuprofen mg ml suspension ten ml po q h every hours as needed for mild pain prevacid solutab mg tablet rapid dissolve dr one tablet rapid dissolve dr once a day docusate sodium mg ml liquid ten ml po bid times a day magnesium hydroxide mg ml suspension thirty ml po q h every hours as needed amoxicillin mg tablet chewable four tablet chewable po bid times a day for days lansoprazole mg tablet rapid dissolve dr one tablet rapid dissolve dr po bid times a day for days clarithromycin mg tablet one tablet po bid times a day for days crush all meds miralax powder one po once a day discharge disposition extended care facility healthcare center discharge diagnosis common bile duct strictures anemia constipation osteoporosis psh several ercps and biliary stenting since discharge condition deconditioned discharge instructions call dr office if experience fever or chills increased shortness of breath or chest pain difficulty or painfull swallowing nausea vomiting incision monitor for discharge or increased redness chest tube site cover site with a bandaid until healed complete day course of antibiotics for h pylori through followup instructions follow up with dr at am on the clinical center report to the radiology department for a chest x ray minutes before your appointment completed by,{}
28165,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint hypotension major surgical or invasive procedure intubation mechanical ventilation picc placement history of present illness mr is a y o m well known to the micu team with h o afib on coumadin dementia dm chf recent right hemiarthroplasty of the hip who presented to and osh after being found unresponsive and hypotensive in the setting of oxycodone at nh before admission pt was being treated for c diff with positive assay noted at nh weeks pta had a course of po flagyl but still had diarrhea so was changed to po vanc at osh ct abd showed pan colitis pt was stabilized with ivf digoxin for a fib and transfered to at bicmc surgery evaluated and felt the collitis to be most likely infectious pt was hypotensive in the ed so went to the micu in the micu po vanc was continued and po flagyl was added for c diff bp stabilized to basline of sbp with fluid resuscitation no pressors were required all cultures negative since admission c diff assay has been negative here but he has continued to have diarrhea he was transferred to the floor with stable vs on the floor he has had a worsening polyarticular gout flare he was restarted on his home colchicine and probenacid with little relief of symptoms rheumatology was consulted and recommended a steroid taper but the floor team decided to hold off on this in the setting of infection ua was positive after transfer and cipro was started empirically on the afternoon after transfer he triggered for low urine output this was felt to be due to hypovolemia and he was given l of ns because of concern for hypernatremia by pm he had made cc urine since midnight he was then hypotensive to mid s systolic at that time he was afebrile and it was felt that hypotension was still most likely due to hypovolemia he received cc ns with good effect sbp to s following this he became febrile to bp returned to mid s systolic continue to have very poor urine output blood pressure and urine output did not respond to a further l of ns mental status grossly the same although patient has baseline dementia was unable to swallow pills however which is reportedly new on repeat exam patient was felt to have mild guarding although he denied pain he did not have rebound tenderness cxr did not show free air given possibility of urosepsis with resistant organism cipro was broadened to zosyn with volume resuscitation patient began to get more edematous in lower extremities and scrotum he continued to breathe comfortably on room air however o saturation went from to on arrival he was unable to give additional details of history he denies cp sob orthopnea pnd cough abdominal pain n v he does complain of joint pain and stiffness in his arms especially past medical history atrial fibrillation diabetes mellitus chf ef with mr and tr dementia parkinson s disease htn ra gout s p open appy remote s p r total hip weeks ago social history married living at nursing home since hip surgery family history non contributory physical exam vs on ra gen nad lying in bed at rest heent perrl anicteric mm sl dry cv irreg irreg no m r g lungs few crackles at left base otherwise clear abd bs soft ntnd no rebound or guarding ext warm le edema warm erythematous mcps of both hands erythematous warm toes on b feet with tenderness to palpation c w podagra tenderness warmth and erythema of bilateral tibial tuberosities neuro a ox to person moving all extremities but with pain on rom following commands back stage i ii sacral decubitus ulcers pertinent results admission labs mcv neuts bands lymphs monos eos pt ptt inr alt ast alk phos bili alb ca phos mg lactate microbiology blood culture x negative c diff negative c diff negative c diff negative ucx contaminated blood culture negative blood culture x negative stool o p negative ucx yeast k pm urine source catheter final report urine culture final escherichia coli organisms ml presumptive identification yeast organisms ml sensitivities mic expressed in mcg ml escherichia coli ampicillin r ampicillin sulbactam i cefazolin s cefepime s ceftazidime s ceftriaxone s cefuroxime s ciprofloxacin r gentamicin s meropenem s nitrofurantoin i piperacillin r piperacillin tazo s tobramycin s trimethoprim sulfa s pm stool consistency soft source stool final report fecal culture final no salmonella or shigella found campylobacter culture final no campylobacter found ova parasites final no ova and parasites seen many polymorphonuclear leukocytes few rbc s this test does not reliably detect cryptosporidium cyclospora or microsporidium while most cases of giardia are detected by routine o p the giardia antigen test may enhance detection when organisms are rare clostridium difficile toxin assay final feces negative for c difficile toxin by eia reference range negative studies chest portable ap portable ap chest radiograph compared to previous study obtained the same day earlier at the right internal jugular line tip is in the distal svc the mild cardiomegaly is unchanged there is interval improvement in perihilar interstitial prominence and bibasilar opacities suggesting resolution of mild pulmonary edema there is no pleural effusion or pneumothorax abdomen supine only findings please note the detection of free air on a supine abdominal radiograph is limited no gross abdominal free air is noted there are several mildly distended air filled loops of small bowel in the left and mid abdomen air is noted throughout the colon and rectum as well there are mild to moderate degenerative changes involving the lumbar sacral spine the patient is status post right femoral hip prosthesis impression limited examination for the assessment of free air unremarkable bowel gas pattern ekg baseline artifact irregular rhythm probably atrial fibrillation although baseline artifact makes assessment difficult ventricular premature beats low qrs voltage delayed r wave progression with late precordial qrs transition is non specific but cannot exclude prior septal myocardial infarction diffuse non specific st t wave abnormalities clinical correlation is suggested no previous tracing available for comparison portable tte complete done the left atrium is elongated no left atrial mass thrombus seen best excluded by transesophageal echocardiography left ventricular wall thicknesses and cavity size are normal due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded overall left ventricular systolic function is low normal lvef 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 are mildly thickened there is no aortic valve stenosis no aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild to moderate mitral regurgitation is seen moderate tricuspid regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion impression low normal left ventricular systolic function mild moderate mitral regurgitation moderate tricuspid regurgitation pulmonary artery systolic hypertension dilated thoracic aorta chest portable ap chest ap cardiac mediastinal and hilar contours are stable pulmonary vasculature is within normal limits there are bilateral lower lobe opacities new since the previous exam right ij cvl has been removed no definite pleural effusions are seen impression new bilateral lower lobe consolidations which may represent atelectasis or aspiration portable abdomen findings single portable supine abdominal view obtained and compared to the prior study from one mildly dilated colonic segment is observed there is one air filled small bowel segment which does not appear to be dilated a small amount of air is seen in the rectum there is limited evaluation of the bowel gas pattern incidental note is made of a bipolar prosthesis in the right impression limited evaluation of the bowel gas pattern portable abdomen findings single supine view of the abdomen is obtained air is seen in numerous non dilated loops of small bowel there is no evidence of colonic dilatation there is no supine radiographic evidence of free intraperitoneal air impression limited study no evidence of megacolon ct abdomen w contrast ct pelvis w contrast impression no evidence of active inflammatory process in the abdomen sigmoid wall thickening likely secondary to chronic diverticulosis moderate bilateral pleural effusions and adjacent passive atelectasis as well as airspace opacities noted at the lung bases as detailed above question of thrombus within the superior vena cava recommend clinical correlation as to the presence of a prior line insertion nonobstructing right renal stone portable abdomen impression limited study no evidence of megacolon chest portable ap impression subtle increase in right upper lobe opacity attention to this area on followup is recommended to exclude a developing pneumonia otherwise unchanged radiographic appearance of the chest ct head w o contrast impression no acute intracranial hemorrhage or edema chest portable ap the nasogastric tube is in unchanged position in the interval an extensive right sided pleural effusion has newly occurred as a consequence subtle right sided suprabasal areas of atelectasis are seen in the right upper lobe there is a subtle area of peribronchial opacities with sparse air bronchograms this area could correspond to pneumonia unchanged effusion related blunting of the left costophrenic sinus subtle areas of atelectasis are seen in the left basal lung brief hospital course sepsis on the morning of the patient was noted to be increasingly altered mental status abgs showed acidosis the patient was continued on pressors ct head showed no acute intracranial process repeat abg continued to show severe acidosis and he acutely became bradycardic and hypotensive full resuscitation efforts were initiated but the family decided to make him dnr dni mr shortly thereafter c diff colitis associated diarrhea the patient was admitted with hypotension and on exam appeared warm consistent with a distributive shock picture echocardiogram showed preservation of ejection fraction with mild pulmonary hypertension noted he was treated for severe c diff with iv flagyl and po vanco serial c diff a toxins were sent here and were negative his referring hospital telephoned with a positive c diff assay shortly after arrival he was fluid resuscitated aggressively but maintained low urine output surgery was consulted initially and later reconsulted but no surgical indication was met he had difficulty tolerating tube feeds initially but this later improved with time however later during his course he became hypotensive and pressors were initiated failure to thrive despite being treated adequately for severe c diff to best of ability the patient s mental status continued to decline oliguric renal failure the patient was oliguric during most of admission and this was at first thought likely a combination of poor retention of intravascular volume given marked hypoalbuminemia with albumin of g dl he was given ivf boluses as well as albumin challenge but only became severely anasarcic later it was thought that his oliguria was appropriate for his nutritional status urinary tract infection the patient had positive u a and was treated with cipro initially and then expanded to zosyn when he again became hypotensive u a grew e coli and yeast and he completed a day course with ceftriaxone based on sensitivities and fluconazole gout flare the patient s anti gout meds were held when he was initially strictly npo for severe c diff unfortunately he developed a gouty flare he was placed on a prednisone taper and restarted on colchicine and probenecid rheumatology was consulted and followed the patient in house mental status the patient s mental status deteriorated over the admission his baseline advanced dementia was exacerbated by acute delirium of illness he had no focal neurologic findings on exam to suggest ischemic or intracranial process he had several metabolic derangements with diarrhea that were treated including hyponatremia medications on admission medications at home lasix daily enablex daily atenolol iron daily colace daily exelon remeron hs starting for week then mg hs vanco q started riss colchicine probenecid tid coumadin daily on hold prilosec ativan mg tid prn mom prn tylenol prn lanta prn oxycodone mg q h prn dulcolax prn acidophilus tabs ensure pudding medications on transfer to icu acetaminophen prn ciprofloxacin mg po q h d colchicine mg digoxin mg po daily flagyl mg po tid miconazole powder pantoprazole mg piperacillin tazobactam grams iv q h received dose am probenacide mg po bid vancomycin mg po q h warfarin mg discharge medications none discharge disposition discharge diagnosis primary diagnosis sepsis c difficile colitis oliguric renal failure urinary tract infection gout flare dementia altered mental status discharge condition discharge instructions none followup instructions none md completed by,"{
""Diagnoses"": [""hypotension"", ""major surgical or invasive procedure"", ""intubation"", ""mechanical ventilation"", ""picc placement"", ""history of present illness"", ""MR is a YO/M"", ""well known to the MICU team with HF/AFIB on Coumadin"", ""dementia"", ""DM"", ""CHF"", ""recent right hemiarthroplasty of the hip""],
""Medications"": [""oxycodone"", ""Coumadin"", "" Flagyl"", ""Vanc"", ""Digoxin""]
}"
4472,admission date discharge date date of birth sex service history of present illness this is an year old female with a past medical history of hypertension and parkinson s disease status post fall three weeks prior to admission the patient had been complaining of low back pain since the fall and numbness in the saddle distribution she had been experiencing bowel and bladder incontinence for eight days prior to admission the patient had the shingles three weeks prior to admission the patient states initially that they thought the pain and numbness were related to that ambulation had diminished from her baseline shuffling gait to an inability to ambulate at all secondary to the pain magnetic resonance scan revealed l compression fracture with retropulsed segment compressing the spinal cord the patient neurologically at the time of admission had a right tremor in her upper extremity at rest the patient was awake alert pupils were reactive the patient responded appropriately to verbal stimuli the patient s sensory level was localized to l distribution the patient had positive rectal tone upper extremities were throughout both left and right lower extremities the patient was in both right and left ip s plantars were three out of five bilaterally dorsiflexion was and extensor hallucis longus were the patient had increased tone in bilateral lower extremities reflexes were bilateral knee jerks the patient had received some sedation prior to her examination hospital course the patient was admitted to the floor for possible operating room on the patient was seen by cardiology regarding preoperative evaluation the patient was considered a low to moderate risk for spine surgery the patient was measured for a tslo brace on for postoperative the patient s neurologic examination improved since admission secondary to increased alertness the patient was able to maintain her lower extremities against gravity and was throughout lower extremities the patient underwent l vertebroplasty t to l fusion with titanium plates and screws on operating room was unremarkable estimated blood loss was cc the patient was transferred to the surgical intensive care unit postoperatively the patient was cardiovascularly stable postoperatively neurologic examination was unchanged lower extremity strength postoperatively the patient was extubated on without difficulty the patient was transfused one unit of packed red blood cells on for a hematocrit of the patient was started on subcutaneous heparin the patient was transferred to the floor on central line was discontinued on the patient is out of bed with physical therapy the patient continues to improve lower extremity dopplers were done on secondary to left thigh swelling and warmth dopplers were negative the patient was discharged to rehabilitation on with instructions to follow up in the office with dr in one month the patient was discharged on the following medications discharge medications metoprolol mg p o twice a day hydralazine mg p o three times a day diltiazem mg p o four times a day percocet one to two tablets p o every four to six hours prn atorvistatin mg p o q day mirapax mg p o four times a day carbidopa levodopa mg tablets p o four times a day paroxetine mg p o q day the patient was neurologically stable at the time of discharge m d dictated by medquist d t job,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""service history of present illness"", ""post-fall""],
""Medications"": [""shingles"", ""hypertension"", ""parkinson's disease"", ""bowel and bladder incontinence"", ""spinal cord compression""]
}"
23847,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint esrd major surgical or invasive procedure living related renal transplant history of present illness mr is a year old gentleman with end stage renal disease and significant cardiac history after an extensive workup and extensive discussion of the risks and benefits of the transplant he strongly desired to proceed with a living related renal transplant past medical history cad s p acute anterior mi with cabg at ischemic cardiomyopathy tte ef with global hk mr tr pulm htn htn dmii last a c crf creatinine slowly rising over past few years anemia thrombocytopenia social history former tobacco use quit runs two restaurants has children social etoh twice a month family history his mother has diabetes his father died of stomach cancer maternal gf died at age of likely mi physical exam on discharge ra rrr ctab soft appropriate tenderness incision c d i with staples in place no edema brief hospital course this patient was admitted for his surgery and prepared consented as per standard there were no intra op complications please see operative report for details the patient was taken to the icu post operatively and started on a nitro gtt to maintain sbp and pa pressures he was transfered to the floor on pod after swan removal once he was stable from a cardiac point of view his home medications were resumed and he was ambulating his pain was moderately controlled on pod pca was stopped and he was started on asa the pt received mg of atg he experienced some indigestion during the day with an ekg that was unremarkable he received mmf and fk in the post operative period as per standard on pod he received unit prbc for postoperative anemia hct he was otherwise well pod he did well and was able to be discharged to home in the am of pod he will follow up in the clinic tomorrow for lab draw and levels medications on admission coreg asa lipitor avandia erytropoeitin phoslo lasix lisinopril discharge medications trimethoprim sulfamethoxazole mg tablet sig one tablet po daily daily disp tablet s refills valganciclovir mg tablet sig two tablet po daily daily disp tablet s refills nystatin unit ml suspension sig five ml po qid times a day disp ml refills colace mg capsule sig one capsule po twice a day disp capsule s refills carvedilol mg tablet sig one tablet po bid times a day disp tablet s refills isosorbide dinitrate mg tablet sig one tablet po tid times a day disp tablet s refills senna mg tablet sig one tablet po bid times a day disp tablet s refills hydrocodone acetaminophen mg tablet sig one tablet po q h every to hours as needed 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 mycophenolate mofetil mg tablet sig one tablet po qid times a day disp tablet s refills pantoprazole 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 tacrolimus mg capsule sig four capsule po q h every hours disp capsule s refills discharge disposition home discharge diagnosis esrd esrd discharge condition good good discharge instructions call dr if fevers chills nausea vomiting inability to take medications decreased urine output weight gain lbs in a day edema incision redness bleeding drainage adhere to gm sodium diet prograf dose may be adjusted based on laboratory levels chrazn will contact you if there are changes followup instructions please follow up in clinic tomorrow mon for labs provider md phone date time provider transplant social work date time provider md phone date time follow up with your cardiologist at as soon as possible [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 anemia fever dyspnea major surgical or invasive procedure arterial line history of present illness year old male with cad s p cabg and lvef dmii pulmonary mucor and esrd s p lrrt from son who presented on with hrs of fevers body aches and cough seen in nephrology transplant clinic on and noted to have hct recently but baseline hct and cr of recent baseline given his new anemia ebv parvo b were sent and remain pending from in the er he was tachycardic and sbp dropped to he received ns l hr s and his temp spiked at he then became sob with ivf but sats remained stable ekg was without ischemic changes he was admitted to the micu for further w u management past medical history esrd dm htn post cabg atn s p lrrt from son mucormycosis pulmonary infection when neutropenic from high dose immunosuppression for lrrt cad s p acute anterior mi v cabg at in ischemic cardiomyopathy with tte showing ef with severe global hypokinesis mr tr htn dmii last hba c anemia thrombocytopenia sinusitis right inguinal hernia repair post transplant social history indian man from emigrated years ago studied electrical engineering at currently on leave from work he has healthy children the oldest son is years old and donated his kidney former tobacco use quit runs two restaurants has children social etoh twice a month family history father died at age from colon cancer mother is alive has had diabetes x years sister and children are healthy otherwise no family history his mother has diabetes his father died of stomach cancer maternal gf died at age of likely mi physical exam vitals general appearance heent cor lung abd ext neuro pertinent results pm lactate pm glucose urea n creat sodium potassium chloride total co anion gap pm lipase pm ck mb ctropnt pm wbc rbc hgb hct mcv mch mchc rdw pm neuts bands lymphs monos eos basos pm hypochrom normal anisocyt poikilocy macrocyt microcyt polychrom ovalocyt schistocy occasional teardrop occasional pm plt smr low plt count am glucose am urea n creat sodium potassium chloride total co anion gap am alt sgpt ast sgot tot bili am albumin calcium phosphate am fk am urine hours random creat tot prot prot crea am wbc rbc hgb hct mcv mch mchc rdw am plt count am urine color yellow appear clear sp am urine rbc wbc bacteria none yeast none epi brief hospital course he received units of prbcs had an a line was placed his prograf was continued but given his anemia his mmf was initially held his mmf was restarted yesterday and his hydrocort was discontinued he was given ml of kayexylate today for a k of repeat k currently pending id was consulted who agreed with above recommendations they are concerned for a possible klebsiella pna he is being called out to the service for continued management mr is a year old male with cad s p cabg esrd s p living donor transplant in with post op course complicated by mucor pulmonary infection and acute rejection in admitted with pneumonia bacteremia anemia pneumonia e coli bacteremia on chest xray he has rml rll infiltrate with e coli bacteremia he was initially admitted to the micu given fever and hypotension he was also treated with hydrocort iv q given his relative hypotension on admission although his blood pressure did respond to ivf he was improving on iv antibiotics initially treated with cefepime azithromycin and vancomycin once blood cultures returned his vancomycin and azithromycin were discontinued and he was transferred to the floor on ceftriaxone he also has known mucor pulmonary infection but this appears stable on posiconazole dfa legionella were negative he was discharged with picc and vna to continue ceftriaxone for one more week last dose then start ciprofloxacin for one week to complete week course of antibiotics he will f u with dr as an outpatient anemia likely esrd guaiac negative in the ed hemolysis labs negative he has been transfused u prbc over the course of his admission with good response in hct parvo and ebv were negative his mmf was initially held on admission due to his anemia however was restarted prior to transfer to the floor his severe anemia likely due to chronic kidney disease he was continued on procrit k mwf pulmonary mucormycosis medication compliance has been an issue in the past no active issues on this admission he was continued on qid dosing of posaconazole esrd s p transplantation with rejection since rejection thought patient stopping posiconazole and subsequent decrease in immunosupression levels creatinine currently stable at current baseline his fk levels were followed daily with goal of he was continued on mmf bactrim ss and valgancyclovir type i dm he was continued on his home dose of glargine units qhs hiss cad s p cabg no acute issues he was continued on atorvastatin asa and carvedilol chronic systolic heart failure echo from showed ef of slightly improved c w hyperlipidemia cont lipitor htn stable continue carvedilol code status full medications on admission trimethoprim sulfamethoxazole mg po daily pantoprazole mg tablet one tablet po q h atorvastatin mg one tablet po daily mycophenolate mofetil mg one tablet po bid folic acid mg tablet po daily valganciclovir mg po x week we carvedilol mg po bid posaconazole mg po qid with meals tacrolimus mg po q h asa daily procrit k recently increased from k weekly florinef mg po daily calcium vitamin d discharge medications ceftriaxone dextrose iso osm gram ml piggyback sig one gram intravenous q h every hours for days disp gram refills heparin lock flush porcine unit ml syringe sig two ml intravenous once a day for days ml ns followed by ml of units ml heparin units heparin each lumen daily disp qs qs refills sodium chloride syringe sig ten ml injection daily daily as needed for days ml ns followed by ml of units ml heparin units heparin each lumen daily disp qs ml s refills midline care per protocol ciprofloxacin mg tablet sig one tablet po q h every hours for days do not start this medication until monday once you finish the iv antibiotics disp tablet s refills pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours atorvastatin mg tablet sig one tablet po once a day mycophenolate mofetil mg tablet sig one tablet po bid times a day folic acid mg tablet sig one tablet po daily daily sodium bicarbonate mg tablet sig one tablet po twice a day disp tablet s refills tacrolimus mg capsule sig one capsule po q h every hours fludrocortisone mg tablet sig one tablet po daily daily os cal d mg unit tablet sig one tablet po once a day posaconazole mg ml suspension sig two hundred mg po qid times a day disp mg refills valganciclovir mg tablet sig one tablet po every other day every other day disp tablet s refills trimethoprim sulfamethoxazole mg tablet sig one tablet po daily daily ferrous sulfate mg mg iron tablet sig one tablet po daily daily insulin glargine unit ml solution sig ten units subcutaneous at bedtime aspirin mg tablet delayed release e c sig one tablet delayed release e c po once a day epoetin alfa injection carvedilol mg tablet sig one tablet po twice a day disp tablet s refills discharge disposition home with service facility critical care systems discharge diagnosis primary diagnoses pneumonia bacteremia anemia secondary end stage renal disease due to diabetes hypertension post cabg acute tubular necrosis status post renal transplant from son complicated by chronic rejection mucormycosis pulmonary infection when neutropenic from high dose immunosuppression for renal transplant coronary artery disease status post acute anterior myocardial infarction cabg congestive heart failure with ef hypertension type diabetes thrombocytopenia sinusitis right inguinal hernia repair post transplant discharge condition afebrile vital signs stable discharge instructions you were admitted to the hospital because you were having fever and cough you were found to have a pneumonia in your right lung you also had bacteria in your blood which likely came from the pneumonia you were treated with intravenous antibiotics and your symptoms improved you will continue intravenous ceftriaxone for six days and then take ciprofloxacin orally to complete a day course in addition you had a low red blood cell count on admission you were transfused units of blood total during your admission your blood count has remained stable please contact a physician if you experience fevers chills chest pain shortness of breath increased cough or any other concerning symptoms please take your medications as prescribed you should take ceftriaxone gram intravenously once daily for six days you should then take ciprofloxacin orally to complete a total day course of antibiotics the first dose of ciprofloxacin will be you should continue posaconazole indefinitely you were started on sodium bicarbonate because of low levels in your blood your epoeitin dose was increased as an outpatient and you should continue as per previous for you heart failure weigh yourself every morning md if weight lbs adhere to gm sodium diet no fluid restriction followup instructions you had the following appointments scheduled provider md phone date time please keep your already scheduled appointments provider md phone date time provider md phone date time md,"{
""Diagnoses"": [""ESRD"", ""Major surgical or invasive procedure"", ""Living related renal transplant"", ""Cardiac history"", ""Acute anterior MI with CABG"", ""Ischemic cardiomyopathy"", ""TTE ef with global HK"", ""MR tr pulm"", ""Htn"", ""DMII"", ""Anemia"", ""Thrombocytopenia""],
""Medications"": [""None known""]
}"
74805,admission date discharge date date of birth sex f service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint increasing chest tightness and sob major surgical or invasive procedure aortic valve replacement history of present illness mrs is a year old lady with worsening symptoms of chest tightness shortness of breath related to documented critical aortic stenosis by catheterization and echocardiography presenting for aortic valve replacement her coronary arteries were normal by cardiac catheterization past medical history ef cr wt k pmh rhd as htn djd spine lumbar cervical tia skin ca psh tonsillectomy c section x bilat varicose vein stripping d c excision skin ca lesion social history retired teacher non smoker lives w husband etoh one drink day family history mother died age rhf father died age ruptured aneursym physical exam general well appearing robust female vs sr ra heent unremarkable chest sternal incision clean dry and intact sternum stable cor rrr s s abd soft nt nd bs extrem pedal edema bilat 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 pt ptt inr pt pm blood pt ptt inr pt am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap echocardiography report complete done at pm 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 avr 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 inferolateral thickness cm cm left ventricle ejection fraction to left ventricle peak resting lvot gradient mm hg mm hg aorta ascending cm cm aorta descending thoracic cm cm aortic valve peak velocity m sec m sec aortic valve peak gradient mm hg mm hg aortic valve mean gradient mm hg aortic valve valve area cm cm mitral valve peak velocity m sec mitral valve pressure half time ms mitral valve mva p t cm findings right atrium interatrial septum no spontaneous echo contrast in the body of the ra no mass or thrombus in the ra or raa no asd by d or color doppler left ventricle mild symmetric lvh with normal cavity size mild symmetric lvh mildly depressed lvef no vsd lv wall motion regional left ventricular wall motion findings as shown below remaining lv segments contract normally right ventricle normal rv chamber size and free wall motion aorta normal diameter of aorta at the sinus ascending and arch levels normal ascending aorta diameter simple atheroma in ascending aorta normal descending aorta diameter simple atheroma in descending aorta aortic valve severely thickened deformed aortic valve leaflets severe as aova cm mild ar mitral valve mildly thickened mitral valve leaflets mild mr tricuspid valve normal tricuspid valve leaflets mild tr pulmonic valve pulmonary artery pulmonic valve not visualized no ps physiologic pr pericardium no 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 regional left ventricular wall motion n normal h hypokinetic a akinetic d dyskinetic conclusions pre cpb no spontaneous echo contrast is seen in the body of the right atrium no mass or thrombus is seen in the right or left atrium or left atrial appendage no atrial septal defect is seen by d or color doppler there is mild symmetric left ventricular hypertrophy with normal cavity size overall left ventricular systolic function is mildly depressed lvef there is no ventricular septal defect the remaining left ventricular segments contract normally right ventricular chamber size and free wall motion are normal the diameters of aorta of the descending ascending and arch levels are normal there are simple atheroma in the descending thoracic aorta the aortic valve leaflets are severely thickened deformed there is severe aortic valve stenosis area cm mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen there is no pericardial effusion post cpb aortic prosthesis in place no ai no perivalvular leak seen av mean gradient mm hg ascending and descending thoracic aorta free of dissection no new mitral regugitation i certify that i was present for this procedure in compliance with hcfa regulations electronically signed by md interpreting physician brief hospital course pt was admitted and taken to the or for aortic valve replacement with a mm mosaic porcine tissue valve for critical aortic stenosis see operative notes for details pt was admitted to the cvicu for post operative invasive hemodynamic monitoring pt was extubated on pod transferred from the icu to the telemetry unit for ongoing post operative care on pod she was rec ing lopressor and diuresis on the eve pod mrs developed afib and was started on amiodarone gtt she converted to sr and after completion of iv amiodarone was started on a po regimen atrial fibrillation recurred and the patient was started on coumadin of note pt was borderline hyponatremic on admit which persisted throughout her hospital stay the lowest na was and the highest was she was placed on a free water restriction she progressed well and was ready for d c home on pod medications on admission benicar folate tramadol pidoxicam soma mvi vite fish oil caltrate d lasix q days asa amoxicillin gm prn discharge medications docusate sodium mg capsule sig one capsule po bid times a day for months disp capsule s refills 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 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 acetaminophen mg tablet sig two tablet po q h every hours as needed 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 amiodarone mg tablet sig two tablet po bid times a day mg x day x days then mg x day x days then mg day until further instructed disp tablet s refills metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet s refills tramadol mg tablet sig one tablet po q h every hours as needed disp tablet s refills carisoprodol mg tablet sig one tablet po bid times a day disp tablet s refills piroxicam mg capsule sig one capsule po once a day disp capsule s refills furosemide mg tablet sig two tablet po once a day for weeks disp tablet s refills potassium chloride meq tab sust rel particle crystal sig one tab sust rel particle crystal po twice a day for weeks disp tab sust rel particle crystal s refills warfarin mg tablet sig one tablet po once a day dr to dose for goal inr dose will change disp tablet s refills discharge disposition home with service facility vna of southeastern mass discharge diagnosis s p aortic valve replacement discharge condition good discharge instructions shower daily no baths or swimming no driving for weeks and off all narcotics no lifting more than pounds for weeks no lotions creams or powders to incisions report any fever greater than report any redness of or drainage from incisions report any weight gain greater than pounds a day or pounds a week take all medications as directed followup instructions dr in weeks wound clinic in weeks dr in weeks dr in weeks please call for appointments vna will draw inr on with results to dr completed by,"{
""Diagnoses"": [""cardiothoracic"", ""aortic stenosis"", ""critical aortic stenosis""],
""Medications"": [""none known""]
}"
27072,admission date discharge date date of birth sex f service medicine allergies crestor attending chief complaint hypertensive urgency major surgical or invasive procedure none history of present illness y f with hx diastolic hf with baseline cr of htn cad stenosis of om no stents dm presenting with bp in the setting of inability to take meds for days n v n v started days ago last solid meal days ago and has not been taking meds for past days usually applies clonidine patch on sunday but reports that she didn t take a shower on sunday nfw and therefore never put on her patch she doesn t remember ever taking her old patch off but states that it must have come off at some point mild abd pain none now no diarrhea or constipation last bm yesterday seen today at heart failure clinic sent here for sbp she denies fever chills uri symptoms diarrhea sick contacts in the ed she had mild chest pressure when she arrived which resolved now after treating bp ekg was negative trop but not up from baseline and ck mb negative they were unable to get iv access so an ej was placed no ha dizziness visual changes on presentation her bp was treated with labetalol mg iv x then a nitro gtt her sbp remained in the s head ct was obtained due to the isolated nausea vomiting no ich seen at time of transfer she continues to report nausea and slight headache worsened since getting ntg in ed ros negative for fevers chills cough uri dysuria hematuria melena brbpr rash past medical history cad stent in cri baseline cr diastolic chf htn anemia dm peripheral neuropathy social history denies tobbacco denies alcohol denies ivdu family history mother with htn and denies fh of dm cad physical exam vitals t hr bp rr ra gen middle aged female sleeping awakens easily appears uncomfortable heent perrla eomi sclera anicteric op clear mmm no lad no jvd rej iv in place cv regular nl s s syst ii vi murmor at rusb pulm ctab anteriorly no r r w abd soft obese nontender nondistended bs ext warm no pedal edema dp s bilaterally neuro alert oriented x cn ii xii grossly intact pertinent results pm glucose urea n creat sodium potassium chloride total co anion gap pm ck mb ctropnt pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count pm pt ptt inr pt studies r heart cath resting hemodynamic measurements by right heart catheterization demonstrated elevated left and right heart pressures with a mean pcwp of mmhg rvedp of mmhg and ra of mmhg the pulmonary artery systolic pressure was significantly elevated with a mean of mmhg the calculated fick c i was preserved at l min m final diagnosis severe biventricular diastolic dysfunction severe primary pulmonary hypertension tte the left atrium is moderately dilated there is moderate symmetric left ventricular hypertrophy the left ventricular cavity size is normal regional left ventricular wall motion is normal left ventricular systolic function is hyperdynamic ef tissue doppler imaging suggests an increased left ventricular filling pressure pcwp mmhg transmitral doppler and tissue velocity imaging are consistent with grade ii moderate lv diastolic dysfunction 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 no aortic regurgitation is seen the mitral valve leaflets are mildly thickened the tricuspid valve leaflets are mildly thickened there is moderate pulmonary artery systolic hypertension there is a small pericardial effusion there are no echocardiographic signs of tamponade compared with the prior study images reviewed of the degree of tricuspid regurgitation underestimated on prior study and pulmonary hypertension detected have decreased these constellation of diastolic heart failure lvh thickened valves large atria and pericardial effusion are suggestive not diagnostic of cardiac amyloidosis cxr no radiographic evidence of pneumonia or chf head ct no acute intracranial hemorrhage ekg nsr at bpm evidence of atrial enlargement l axis deviation minimal criteria for lvh normal intervals ekg nsr at bpm lad atrial enlargement lvh strain pattern with st elevation in v through v brief hospital course this is a year old woman with h o of diastolic chf and diabetes who presented with hypertensive emergency and was transferred to icu on nitroprusside gtt hypertensive emergency urgency thought most likely to stopping antihypyertensives including clonidine patch and inability to take oral pills due to nausea vomiting patient has severe htn likely worsened by and is on a drug regimen as an outpatient associated symptoms of headache and chest pain with strain pattern on ekg were concerning for htn emergency she was admitted to icu ruled out for mi required nitro drip on transfer to the floor she was able to tolerate po s and was restarted on her home regimen with good effect by discharge day the trend had shown that the one time of day when blood pressure above goal was shortly after waking pt was told to take her carvedilol very soon after awakening rather than waiting an hour and a half as she had been doing pt states she sleeps until am every morning nausea vomiting resolved with addition of reglan pt was warned of side effects and discharged on one week supply told to follow up with pcp as she may only require this for one week if nausea and vomitting were due to virus if due to developing gastroparesis may need indefinitely chronic diastolic dysfunction at dry weight currently lbs and without evidence of volume overload chronic kidney disease creatinine at baseline by discharge anemia at baseline of attributed to no evidence of acute bleed at this time medications on admission diovan mg coreg mg clonidine mg h patch qsun amlodipine mg qday lasix mg neurontin po qday zetia mg qday vitamin d u qday lantus units qhs asa mg qday feso mg qday discharge medications aspirin mg tablet chewable sig one tablet chewable po daily daily clonidine mg hr patch weekly sig one patch weekly transdermal qwed every wednesday amlodipine mg tablet sig two tablet po daily daily carvedilol mg tablet sig two tablet po bid times a day valsartan mg tablet sig one tablet po bid times a day metoclopramide mg tablet sig one tablet po tid w meals for weeks disp tablet s refills hydrochlorothiazide mg capsule sig one capsule po daily daily lasix mg in the morning and mg in the eveming discharge disposition home discharge diagnosis hypertensive emergency nausea discharge condition stable discharge instructions weigh yourself every morning md if weight lbs adhere to gm sodium diet please be sure to take the same blood pressure medications you were taking prior to admission but make a point to take the carvedilol as soon as you wake up in the morning followup instructions please follow up with your primary care doctor within one week you will be given enough of the anti nausea medication to last one week md completed by,"{
""Diagnoses"": [""hypertensive urgency"", ""major surgical or invasive procedure"", ""history of present illness"", ""diastolic HF"", ""cad stenosis"", ""om stenosis"", ""DM""],
""Medications"": [""clonidine"", ""labetalol"", ""nitro"", ""none""]
}"
32015,admission date discharge date service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint confusion agitation major surgical or invasive procedure none history of present illness m with cad and pafib presented from home with ms change he sustained a mechanical fall in and was discharged from to rehab on at that time notes already suggests that he had some confusion i talked to the daughter this evening and she reports that he was intermittently confused at rehab as well the family took the patient home five days ago and then brought him to the ed for ongoing and worsening confusion and agitation in the ed a ct head was ordered but he was unable to cooperate so he was sedated and intubated for the study he was obtunded after the study and was tranferred to the micu because there was difficulty extubating him in the micu there was a concern for acute stroke since his pupils were noted to be unequal the stroke team was called and mri mra was done that did not show acute stroke apparently his unequal pupils are not new the cause of his mental status change was unclear the thought at this time is toxic metabolic which neuro agrees with there was a question of seizure in the micu but eeg was unrevealing lp was done and did not show infection currently he is still agitated and the daughter notes a waxing and course past medical history past medical history per omr coronary artery disease had imi s p ptca of rca and lcx pafib not on anticoag hypertension seizure disorder last yrs ago systolic chf with ef on echo in glaucoma glucose intolerance social history denies etoh tobacco illicit drug or herbal medication use native of lives with his wife family history non contributory physical exam physical exam vs ra gen agitated trying to climb out of bed moans intermittently in creole heent left pupil mm fixed right mm fixed op clear mmm neck no jvd no carotid bruits resp mild crackles at bases bilaterally no wheezes rhonchi 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 warm good pulses skin no rashes no jaundice neuro limited left pupil mm fixed right mm fixed moves all extremities bilaterally spontaneously pertinent results admission labs am plt count am neuts lymphs monos eos basos am wbc rbc hgb hct mcv mch mchc rdw am asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg am phenytoin am ck mb ctropnt am lipase am alt sgpt ast sgot ck cpk alk phos amylase tot bili am estgfr using this am glucose urea n creat sodium potassium chloride total co anion gap pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg pm urine color yellow appear clear sp pm urine bnzodzpn neg barbitrt neg opiates neg cocaine neg amphetmn neg mthdone neg pm urine hours random last set of labs obtained on wbc rbc hgb hct mcv mch mchc rdw plt ct pt ptt inr glucose urean creat na k cl hco micro urine culture negative urine culture mrsa csf no organisms three sets and two sets on blood cultures no growth to date pertinent studies ct head w o contrast impression no evidence of acute intracranial hemorrhage mr head w o contrast mra brain w o contrast am brain mri there is no acute infarct identified there is no midline shift mass effect or hydrocephalus there is moderate ventriculomegaly and prominence of sulci including prominence of temporal which has increased since the previous mri of these findings would indicate brain and medial temporal atrophy there are mild to moderate changes of small vessel disease in the periventricular white matter no evidence of chronic blood products identified in the brain impression no evidence of acute infarct moderate brain and medial temporal atrophy the medial temporal atrophy has progressed since the previous mri mra of the neck neck mra demonstrates normal flow signal in the carotid and vertebral arteries the right vertebral artery origin is not well seen due to technical reasons otherwise both vertebral and carotid arteries demonstrate normal flow signal on fat suppressed images no evidence of fat suppression is seen impression normal mra of the neck mra of the head head mra demonstrates normal flow signal within the arteries of anterior and posterior circulation no evidence of vascular occlusion or stenosis is seen the left posterior cerebral artery is fetal in origin a normal variation distal left vertebral artery is small in size which is a normal variation slight narrowing in the distal left vertebral artery on post contrast images could not be confirmed on d images of the head and could be artifactual impression normal mra of the head video oropharyngeal swallow pm oropharyngeal video fluoroscopic swallow an oropharyngeal swallow evaluation was performed in conjunction with the speech and swallow pathology division this demonstrated mild to moderately reduced bolus formation and control with premature spillage consistently noted once swallow was initiated laryngeal elevation valve closure and epiglottic deflection were within functional limits no episodes of penetration or aspiration were noted chest portable ap pm findings in comparison with study of the endotracheal tube has been removed there is again opacification at the left base consistent with pleural effusion and underlying atelectasis the possibility of aspiration pneumonia cannot be excluded without a lateral view the right lung is essentially clear with mild atelectatic changes at the bases brief hospital course m creole only speaking admitted for confusion and found to have mrsa uti and pneumonia patient was initially admitted to the micu after being intubated and sedated for agitation as in hpi briefly he was delirious and required intubation for airway protection and to undergo imaging studies and lp safely he was initially difficult to ween and eventually was weened and transferred to the floor hospital course outlined by problem below delirium agitation the patient was admitted in a severely confused and agitated state he had an extensive workup for delirium all of which was unrevealing ct head was negative mri mra head was negative eeg was abnormal due to toxic metabolic encephalopathy likely infection metabolic but workup was initially negative lumbar puncture was negative and csf culture was negative he was transferred to the floor where he was still severely agitated nightly repeat ua was positive for mrsa uti and cxr showed left sided atelectasis vs pneumonia he was placed on vanco levo for uti and aspiration pneumonia coverage after antibiotics were started his delirium dramatically improved but he was still moderately agitated he required soft restraints for agitation and protection of the patient himself and for the staff he was hitting and scratching staff and pulling out foley and ivs making the delirium worse is the fact that he can speak clearly for a few sentences and then will speak nonsensical language and shout in the air he is legally blind in both eyes and hard of hearing hears best out of left ear per his family s report this is the best mental status they have witnessed from the patient in the last year however his baseline end stage dementia remained a family meeting decided that the patient would become comfort measures only cmo hcp is his son with no gastric tube for feeding pain control prn and completion of antibiotic treatment for his infections see below for details under code status he responds well to zyprexa mg qam and mg qpm standing zyprexa iv im prn and or haldol iv prn geriatric consult assessed the patient and recommended these medications for the patient nutrition patient has minimal oral intake and needs help with eating and drinking he occasionally expectorates out his food and drink and he cannot take po pills reliably he expectorates out pills or crushed pills but will take pills once every day or few days speech and swallow consult performed bedside assessment and video swallow and recommended thin liquids and pureed consistency video swallow showed normal swallowing ability and was unremarkable he may eat any foods that he would like but he does not have drive to eat and drink family understands aspiration risk but wants to focus on comfort care at this point diffuse body pain no etiology could be found for the patient s diffuse body pain he was given morphine iv prn tylenol g prn with no change in patient s report of diffuse body pain workup was unrevealing inferior myocardial ischemia the patient had new t wave inversions in leads ii iii avf on with sec pauses on telemetry he had moderately severe bradycardia and hypotension during this event cardiology was consulted and the decision was made to medically manage the patient and not do invasive workup he was maintained on asa metoprolol systolic chf chronic has ef on echo from currently euvolemic has tr and mr as well not on acei given bp and issue with low oral intake paroxismal afib he was rate controlled on metoprolol and anticoagulation was on asa pr no coumadin given fall risk bilateral eye pain blindness the patient was assessed by ophthalmology consult who recommended glaucoma and prophylactic erythromycin eyedrops for the patient seizure disorder continued po phenytoin at baseline no seizures while in house sacral decubitus ulcer stage ii continue care per protocol inr inr elevated to likely secondary to vit k deficiency from antibiotic use he has pafib and thus was not given vitamin k dnr dni cmo family meetings including the hcp concluded that dnr dni cmo was the appropriate goal of care for the patient ethics consult recommended that the decision for cmo not be changed for the patient and for the patient to be maintained in comfort inhouse with encouragement of po intake but no artificial means of nutrition palliative care recommended that the patient not be re hospitalized unless his mental status clears further from currently his current mental status baseline is apparently much better than it has been over the past months to year per the patient s hcp and family the patient s family agrees with these recommendations medications on admission medications on admission aspirin mg daily calcium cholecalciferol twice a day furosemide mg po once a day atorvastatin mg tdaily metoprolol tartrate po bid hexavitamin po daily daily pantoprazole mg once a day phenytoin sodium extended mg tid docusate sodium mg po bid cosopt r eye alphagan r eye xalata b eye erythromycin ointment both eyes discharge medications dorzolamide timolol drops sig one drop ophthalmic times a day brimonidine drops sig one drop ophthalmic q h every hours aspirin mg suppository sig one suppository rectal daily daily metoprolol tartrate mg tablet sig tablet po tid times a day phenytoin mg ml suspension sig one hundred mg po tid times a day olanzapine mg tablet rapid dissolve sig tablet rapid dissolve po qam once a day in the morning olanzapine mg tablet rapid dissolve sig one tablet rapid dissolve po qhs once a day at bedtime thiamine hcl mg tablet sig one tablet po daily daily erythromycin mg g ointment sig in ophthalmic qid times a day polyvinyl alcohol drops sig drops ophthalmic prn as needed discharge disposition extended care facility manor nursing center in discharge diagnosis primary diagnosis mrsa uti pneumonia aspiration dementia delirium inferior mi sacral decubitus ulcer stage secondary diagnosis cad s p imi paroxysmal atrial fibrillation not on anticoagulation hypertension seizure disorder last yrs ago systolic chronic chf with ef glaucoma glucose intolerance discharge condition vital signs are stable eating meal every days drinking one small cup of water or juice every days baseline mental status is responsive to voice and minimal stimulus with opening eyes or moaning withdraws all extremities to noxious stimulus occasionally communicates with creole interpreter but rarely forms complete thoughts discharge instructions admitted for delirium agitation found to have mrsa uti and aspiration pneumonia both treated complicated by acute myocardial infarction now discharged to rehab please call the patient s primary care physician with questions patient s family wants patient to be dnr dni and cmo they do not want him rehospitalized they do not want peg tube for feeding they want to keep him comfortable and allow him to eat or not eat based on his wishes followup instructions provider m d phone date time md completed by,"{
""Diagnoses"": [""Confusion"", ""Agitation"", ""Major surgical or invasive procedure"", ""Toxic metabolic""],
""Medications"": [""Medicine"", ""Allergies""]
}"
15607,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint thoracoabdominal gunshot wound major surgical or invasive procedure exploratory laparotomy diaphragmatic repair gastric repair splenectomy history of present illness m s p l ant chest gsw p w hemoptx diaphragmatic gastric splenic injuries pt had hypotension in ed large resusitation with prbcs and iv fluid past medical history etoh abuse unknown liver problem social history tobacco ppd h o iv heroin family history non contributory physical exam heent no abnormalities noted cv rrr no mrg resp lungs cta b l bs on l r at bases abd soft nt nd no masses ext edema b l pertinent results admission labs pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood pt ptt inr pt pm blood fibrino pm blood glucose urean creat na k cl hco angap pm blood amylase pm blood lipase pm blood calcium phos mg pm blood asa neg ethanol acetmnp neg bnzodzp neg barbitr neg tricycl neg pm blood type art po pco ph caltco base xs intubat intubated vent controlled pm blood glucose lactate na k cl calhco radiology chest cta gsw to l chest producing moderate tension ptx and penetration of the l ant and post hemidiaphragm no evidence of vascular injury or trauma to the abdominal visceral organs consolidation along the posterior l lung c w contusion and small hematoma chronic diverticula w o evidence of diverticulitis cxr post op subsegmental atelectasis of rul unchanged position of bullet cxr lll consolidation contusion is persistent left sided bowel loops are higher in position compared to r hemidiaphragm l hemidiaphragm paresis or possible herniation is suspected ct a p micro blood mrsa catheter tip mrsa blood mrsa sputum coag staph and gram rods wound brief hospital course patient was intubated at the osh chest tube placed in ed with ml out had hypotension to s units prbcs given as well as l ivns the patient was admitted to the tsicu and then taken to the or for ex lap repair of his diaphragm and stomach and splenectomy he recieved post splenectomy vaccinations pod the patient was extubated he began to show signs of alcohol withdrawl and was placed on a ciwa scale with ativan pod cipro and flagyl prophylactic abx were d ced continued to use large amounts of ativan for control of etoh withdrawl wbc elevated to ngt was d ced pod the patient became febrile and had decreased mental status vancomycin was started the site of the patient s central line looked red and pus was expressed the line was removed and sent for culture that grew mrsa blood cultures also grew mrsa a new central line was placed pod left chest tube drained ml and was taken out pod the patient was transferred to the floor tolerating po diet and making good urine output pod the patient ambulated there was severe difficulty with iv access and an external jugular iv was finally obtained his ativan was decreased pod the patient was noted to have increased erythema around the wound probing of the wound demonstrated hematoma and the skin staples were opened to allow drainage the patient was afebrile but wbc count increased to a ct scan of his abdomen and pelvis was preformed to look for signs of intra abdominal infection abscess the ct showed a large fluid collection in the area where the bullet penetrated his diaphragm from the ct it was difficult to assess if the fluid collection was in the lung or abdomen pod the fluid collection was drained by radiology under ultrasound guidence and a pigtail catheter left in place cc of serosanguinous fluid was removed and the fluid was sent for culture a wound vac dressing was placed over the abdominal incision wound cultures showed no growth wound erythema improved greatly pod the patient remained afebrile there was cc drainage from the pigtail catheter wbc peaked at the patient continued to tolerate a regular diet and his o saturation continued to improve pod a cxr showed stable moderate effusion pod tpa was added to the pigtail catheter and the patient was slowly rotated every min to maximize area involved over the subsequent hours the patient s jp drain put out cc of serosanguinous fluid the vac dressing was changed wbc down to pod a second dose of tpa was inserted into the pigtail catheter the patient remained afebrile but his wbc again increased to surveillence blood cultures showed resolution of mrsa bacteremia pod repeat ct scan showed persistent small to moderate left pleural effusion collected posteriorly might be layering persistent subpulmonic organized hematoma in the region of a left basal pleural drain because of the small size and location of these collections respectively sampling would require imaging guidance persistent consolidation basal segments left lower lobe without obvious explanation other than adjacent pleural restriction and splinting mediastinal adenopathy probably reactive opened upper abdominal wound no associated fluid collection in the levels imaged possible cellulitis retained bullet and bone fragments left posterior chest wall and adjacent pleural or extrapleural space attending discussion regarding thoracic involvement and it was decided that nothing needed to be done at the present time however follow up with thoracics was advised vaccuum dressing changed jp removed at bedside post pull cxr showed no ptx last dose of vancomycin given vaccuum dressing changed patient cleared for discharge with services and vac changes medications on admission klonipin vicodin paxil discharge medications fentanyl mcg hr patch hr sig one patch hr transdermal q h every hours disp patch hr s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills aspirin mg tablet sig one tablet po daily daily paroxetine hcl mg tablet sig one tablet po daily daily clonazepam mg tablet sig one tablet po bid times a day oxycodone mg tablet sig one tablet po q h every to hours as needed for breakthrough pain disp tablet s refills nicotine mg hr patch hr sig one patch hr transdermal daily daily disp patch hr s refills bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed disp tablet delayed release e c s refills pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours for days disp tablet delayed release e c s refills magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed for constipation disp ml s refills discharge disposition home with service facility health care discharge diagnosis diaphragmatic injury s p repair gastric injury s p repair splenic injury s p splenectomy thoracoabdominal gunshot wound discharge condition good discharge instructions it is very important that you rest and take good care of yourself for the next few weeks the wound on your abdomen needs special care the vaccuum dressing will need to be looked at daily and changed every three days you must be carefuel not to trip over teh tuing or to adjust it yourself visiting nurses will come to your house to help you with this if you develop worsening pain or redness at the wound site fevers above pus like drainage nausea or vomiting that won t stop difficulty breathing chest pain or any other concerning symptom please call dr office or come to the er right away followup instructions please follow up with dr in week call for an appointment,"{
""Diagnoses"": [""thoracoabdominal gunshot wound"", ""major surgical or invasive procedure"", ""exploratory laparotomy"", ""diaphragmatic repair"", ""gastric repair"", ""splenectomy""],
""Medications"": [""prbcs"", ""iv fluid"", ""heroin"", ""ethanol"", ""acetaminophen"", ""barbiturates"", ""tricyclics"", ""pm blood type"", ""art"", ""po"", ""pco"", ""caltco"", ""base"", ""ints"", ""lactate""]
}"
7950,admission date discharge date date of birth sex m service trauma history of present illness this is a year old male pedestrian struck by a car unknown loss of consciousness but the patient does not recall the event there was major damage to the vehicle in the emergency department the patient had gcs of with stable vitals the patient was intubated secondary to agitation for airway protection past medical history premature birth with biventricular shunts for grade intraventricular hemorrhage at birth left occipital encephalomalacia bronchopulmonary dysplasia status post pericardial drainage as a baby for fluid in the pericardial sac right retinal detachment with placement of an artificial right eye medications on admission ventolin allergies latex penicillin vancomycin physical examination on admission temperature pulse blood pressure general the patient was an obese male agitated prior to intubation left eye pupil was reactive right eye glass prosthetic eye chest clear to auscultation with decreased breath sounds on the left heart regular rate and rhythm abdomen soft nontender nondistended extremities left knee with deformity pulses were dopplerable bilaterally back no stepoffs or deformities abis were bilaterally labs white count crit electrolytes all normal abg normal head ct showed a chronic subdural bleed on the left with a possible acute component on the left side a ct torso showed sacral fracture c through t and t through spinous process fractures bilateral pulmonary contusions ct of his l spine was negative mri of his c spine was negative the patient also had an echo done on hospital day showing no pericardial effusion and normal lv function hospital course neurosurgery was consulted for subdural hemorrhage and ortho was consulted for management of his spine fractures and his extremity deformity the patient was placed in the icu with frequent neuro checks and repeat cat scans serially the patient s cat scan was followed with no significant change the patient s left lower extremity was reduced and splinted with ortho the patient was difficult to wean from the ventilator and a pulmonary consult was obtained given that the patient had a history of bronchopulmonary dysplasia on the patient went to the operating room for repair of his pcl tear on the left knee the patient was placed in bilateral knee immobilizers the patient was finally weaned from the ventilator and extubated on for dvt prophylaxis the patient had a temporary ivc filter placed after several serial head cat scans noted stable likely chronic subdural hematoma the patient s filter was removed on and the patient was started on lovenox for dvt prophylaxis the patient was transferred to the floor on the patient was agitated on the floor and required ativan for anxiety the patient was discharged to rehab in good condition discharge diagnoses left knee posterior ligament tear right knee ligamentous injury subdural hematoma pulmonary contusions sacral fracture c through c and t through spinous process fractures follow up the patient is to follow up with dr in weeks follow up with dr in weeks follow up with trauma clinic only as needed the patient will need an outpatient mri for definitive management of the right knee injury the patient is to remain nonweightbearing on both lower extremities on the left secondary to the pcl tear and on the right secondary to the sacral fracture finally the patient was further evaluated by the spine service on and it was determined that the patient did not need to remain in a c collar with thoracic extension any longer discharge medications albuterol puffs q h prn clonidine mg patch q weekly transdermal docusate mg bisacodyl tablets mg po qd prn percocet mg po q h ativan mg po q h prn anxiety and agitation lovenox mg po bid famotidine mg po bid m d dictated by medquist d t job,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""m"", ""service"", ""trauma history"", ""of present illness""],
""Medications"": [""ventolin"", ""allergies"", ""latex"", ""penicillin"", ""vancomycin""]
}"
21190,admission date discharge date date of birth sex m service neonatology history of present illness baby is an gram product of a and week spontaneous dichorionic tri amniotic triplet gestation estimated date of confinement was born to a year old gravida v para mother with the following maternal laboratory studies ab positive antibody negative rpr nonreactive rubella immune hepatitis b negative gbs unknown mom s maternal history is significant for a spontaneous abortion in at weeks gestational age with a cerclage week iufd secondary to pprom at weeks at women s and infant s hospital mom also has maternal history of hypothyroidism treated with levoxyl this pregnancy was complicated by preterm labor at weeks mom was admitted to treated with betamethasone and magnesium sulfate and placed on bed rest mother developed separation of symphysis pubis and was put in traction a cesarean section was scheduled because of maternal indication there was no fever before delivery rupture of membranes occurred at delivery there was no increased fetal heart rate mom was not treated with antibiotics prior to delivery this infant emerged vertex presentation active and well appearing there was a nuchal cord times one which was quickly reduced apgar scores were and at one and five minutes he was taken to the neonatal intensive care unit for further management physical examination birth weight grams length cm head circumference cm temperature heart rate respiratory rate saturations to in room air blood pressure was to general preterm male in radiant warmer no apparent distress head eyes ears nose and throat afof oropharynx clear palate intact neck supple no crepitus respiratory lungs clear to auscultation bilaterally good air entry no retractions cardiac regular rate and rhythm s and s normal no murmur on examination abdomen soft nondistended normoactive bowel sounds no masses no hepatosplenomegaly extremities well perfused femoral pulses plus bilaterally spine normal no sacral dimpling no hip click on examination anus patent genitourinary normal premature male testes descended bilaterally neurologic spontaneous movement of all four extremities appropriate tone on examination suck grasp palmar plantar reflexes intact hospital course respiratory this patient was stable on room air at the time of delivery and remained on room air for the remainder of his hospital course he had no signs of respiratory distress no apnea of prematurity throughout his hospitalization cardiovascular this patient was cardiovascularly stable throughout his hospital course fluids electrolytes and nutrition patient was placed on intravenous fluids of d w at cc per kg per day on day of life number one on day of life number two enteral feeds were started of breast milk or special care kc per ounce by day of life three the patient was advanced to full feeds of breast milk or special care kc per ounce at cc per kg per day with no signs of intolerance gastrointestinal the patient s bilirubin within the first hours was on bilirubin was at which time phototherapy was initiated she is currently on single phototherapy at time of trasnfer infectious disease due to lack of maternal risk factors for infection no cbc blood cultures antibiotics were obtained on this child neurologic the patient had stable neurologic examinations and was normal neurologically throughout his hospital course sensory the patient will receive a hearing screen prior to transfer ophthalmology the patient does not qualify for an ophthalmologic examination condition on discharge stable discharge diagnoses hospital in name of pediatrician dr care recommendations feeds at discharge include breast milk or special care kilocalories per ounce p o ad lib minimum cc per kg per day po pg medications none car seat position screening will not be performed prior to discharge state newborn screen sent on day of life number three no immunizations administered throughout this hospitalization discharge diagnoses prematurity at and weeks gestational age immature feeding hyperbilirubinemia reviewed by dictated by medquist d t job,"{
""Diagnoses"": [""Neonatology"", ""History of Present Illness"", ""Baby is an Gram Product of a and Week""],
""Medications"": [""Betamethasone"", ""Magnesium Sulfate"", ""Levoxyl""]
}"
2164,admission date discharge date date of birth sex f service bl gen history of present illness the patient is a year old woman with extreme obesity and a current body weight of lbs and volume mass in excess of she is closely evaluated by dr clinic for gastric bypass surgery she has been on numerous diet programs in the past without significant long term weight reduction she has had high cholesterol in the past otherwise no other significant medical problems allergies no known drug allergies medications she is not taking any medications she was recently on meridia for weight reduction however this was discontinued past surgical history she has no past surgical history physical examination she is a young morbidly obese woman with no acute distress her sclerae were anicteric her oropharynx clear without lesions neck exam showed no lymphadenopathy her lungs were clear to auscultation bilaterally her cardiac exam showed regular rate and rhythm without murmurs abdomen was obese soft nondistended nontender bilateral extremities showed no edema laboratory data her ekg was normal sinus rhythm at a rate of lab tests had essentially normal cbc urinalysis coagulation studies chemistries electrolytes serum lipid profile with the exception of an elevated cholesterol of and ldl of recent abdominal ultrasound revealed no gallstones hospital course the patient presented on for a rouxen y gastrojejunostomy gastric bypass surgery the patient did well postoperatively on postoperative day one she developed a low grade fever most likely due to atelectasis with aggressive chest pulmonary toilet the patient s fever subsided she was tolerating a stage i diet on postoperative day two she began tolerating stage ii diet on postoperative day three she was discharged home in stable condition tolerating stage iii diet while in the hospital the patient had sinus tachycardic which was unchanged from her preoperative ekg discharge diagnosis status post gastric bypass rouxen y gastrojejunostomy discharge medications roxicet elixir to milligrams po q four to six hours prn pain zantac elixir milligrams po bid actigall milligrams po bid vitamin b milligram po q day discharge instructions the patient is to follow up with dr in his clinic in two weeks follow up with nutrition for nutritional consult the patient should follow up with primary care physician for evaluation of apparent hypertension m d dictated by medquist d t job [NEW_RECORD] name c unit no admission date discharge date date of birth sex f service blue general surgery service on postoperative day patient developed low urine output became tachycardic and felt a low grade temperature decision was made to do a gastrografin or an upper gi series which showed a leak at the site of her gastric bypass anastomosis decision was made to take the patient to the operating room for repair of this leak on the evening of that same night postoperatively the patient was admitted to the sicu intubated the patient did well at the time of surgery the patient was started on levaquin flagyl and fluconazole the patient remained hemodynamically stable she continued to have low grade temperatures however she was extubated on postoperative day one and transferred to the floor on postoperative day after her anastomotic leak during this time the patient was having good urine output a chest x ray was obtained which revealed atelectasis or revealed infiltrates and left pleural effusion the patient was also started on tpn given that with her previous anastomotic leak she was going to be required to be kept npo during her hospital stay as well as on discharge home the patient had occasional episodes of shortness of breath which were resolved with albuterol and pulmonary toilet and she was maintaining good oxygen saturation her vital signs remained stable patient was started on tube feeds and tolerated them well on postoperative day the patient developed some left lower quadrant pain and generalized malaise and with a low grade temperature of and o saturation of on room air on liters the decision was made to get a ct scan to evaluate and rule out an abscess given her white blood cell count had bumped to ct scan showed no evidence of an abscess and patient s symptoms resolved as well as her shortness of breath with pulmonary toilet she with physical therapy began ambulating repeat chest x ray revealed continued left pleural effusion and so the decision was made on postoperative day eight the patient had ultrasound guided aspiration of pleural fluid which greatly improved the patient s symptoms the patient remained afebrile the vital signs are stable and over the course of the next two hospital days with physical therapy the patient was ambulating on her own and she was eventually discharged home in stable condition discharge diagnosis status post gastric bypass surgery status post repair of anastomotic leak status post resolving left pleural effusion and left lower lobe pneumonia the patient was discharged home tolerating tube feeds with a g tube in place as well as a j p drain she will follow up with dr in his office m d dictated by medquist d t job,"{
""Diagnoses"": [""Extreme obesity"", ""High cholesterol""],
""Medications"": [""Meridia""]
}"
17024,admission date discharge date date of birth sex m service medicine allergies bactrim ds dapsone delavirdine abacavir sulfate amoxicillin attending chief complaint nausea vomiting fever fatigue major surgical or invasive procedure right subclavian line placement history of present illness mr is a year old man with hiv on haart cd count of and cad who presented to the ed with nausea vomiting diarrhea weakness fevers chills pruritis and abdominal pain patient had a dental visit today and took antibiotic prophylaxis amoxicillin shortly after he developed symptoms of nausea vomiting diarrhea fever chills in the ed his initial temperature was with hr of bp o sat ra abdominal ct showed no diverticulitis or appendicitis while in the ed he developed a temperature of with hr of bp o sat lactate was patient received ceftriaxone gm vancomycin and flagyl after liters of normal saline his bp was temp hr he had several episodes of watery diarrhea lp was performed which showed no signs of infection he was started on the sepsis protocol and received a total of l of ns with cc of urine output patient was started on levophed and it was titrated to mcg kg min for a bp of with a map cvp was svo in the icu he initially required pressors to maintain his blood pressure but his hemodynamics quickly stabilized so that he did not require pressors or iv fluids on he was afebrile with stable vitals on po levofloxacin and he was transferred to the medical floor on transfer he endorsed continued fatigue and nausea but felt subjectively much better and specifically denied fevers chills sweats chest pain dyspnea abdominal pain or dysuria past medical history hiv cd count of coronary artery disease status post st elevation mi in with stenting of the lad dyslipidemia peptic ulcer disease low back pain gastritis history of abnormal lfts with repeat normal lfts depression pertinent cardiac studies cardiac cath final diagnosis one vessel coronary artery disease normal ventricular function patent lad stent focal stenosis is the mid pda that upon review did not appear significantly worse than on his previous catheterization of echo ef e a the left atrium is normal in size left ventricular wall thicknesses and cavity size are normal there is mild regional left ventricular systolic dysfunction with focal hypokinesis of the distal inferior wall and distal half of the anterior septum and apex the remaining segments contract well right ventricular chamber size and free wall motion are normal the aortic root is mildly dilated the aortic valve leaflets are mildly thickened but not stenotic there is no aortic regurgitation the mitral valve appears structurally normal with trivial mitral regurgitation there is no mitral valve prolapse the estimated pulmonary artery systolic pressure is normal there is no pericardial effusion social history previously from moved to the states after high school lives in and works as a social worker with the homeless denies tobacco or ivdu drinks etoh occasionally family history maternal uncle w mi at age father w mi in his s and another uncle with a recent myocardial infarction physical exam vs t hr bp rr o sat ra gen ill appearing comfortable lying in bed in nad heent perrl eomi sclera anicteric mmm neck no lad jvd or thyromegly cv rrr with sem at lusb lungs crackles at the left base abd soft distended non tender active bs no hepatosplenomegly rectal guaic negative per ed ext no clubbing cyanosis or edema no rash pertinent results labs wbc hct plt na k cl hco bun cr glucose ca mg ph lactate trend csf wbc poly lymph mono rbc tp glucose microbiology blood clx ngtd urine clx no growth csf no micro organisms no pmns negative culture stool c difficile negative salmonella shigella campylobacter o p negative abd pelvic ct no evidence of appendicitis bowel obstruction or free air diverticulosis of the sigmoid and descending colon without evidence of diverticulitis cxr opacity at the left lung base brief hospital course mr is a year old man with hiv cad and htn who presented with nausea vomting diarrhea weakness fevers chills pruritis and abdominal pain he initially required pressors and iv fluids to support his blood pressure sirs his presentation with fever tachycardia hypotension and an elevated lactate was thought to be consistent with sirs the etiology of his sirs was unclear as his infectious workup was largely negative with the exception of a potential lll pneumonia it was thought that this was most likely due to an anaphylactic reaction to amoxicillin as on further questioning he endorsed pruritis facial erythema edema and that these symptoms felt quite similar to an anaphylactic exposure to bactrim he had several years ago regardless of the etiology he quickly improved in terms of hemodynamics and lactate level he was continued on levofloxacin and given a prescription to complete a seven day course to finish on abdominal pain diarrhea vomiting this was thought to be part of his sirs process and generally improved during his hospitalization a ct scan was negative for an infectious or inflammatory process he still complained of slight nausea at discharge and was given a prescription for compazine to use as needed hiv he was continued on his haart regimena and will follow up with dr cad htn his anti hypertensives were initially held due to his hypotension at discharge his blood pressure was stable in the range at discharge he was restarted on atenolol at mg daily he has a follow up appointment in on and at this time he should have his blood pressure checked and medications adjusted if needed he was previously taking metoprolol mg and lisinopril mg he was continued on his aspirin hyperlipidemia he was restarted on his pravastatin at discharge medications on admission androgel mg apply to shoulders every day as instructed aspirin mg one tablet s by mouth daily folic acid mg one mg every day fosamprenavir mg take two pills twice a day with food kaletra capsules twice a day with food lisinopril mg mg every day loratadine mg tablet s by mouth once a day lorazepam mg take pill as needed for insomnia metoprolol tartrate mg mg every day patanol drops to each eye twice a day pravastatin sodium mg take one pill at night rhinocort aqua sprays to each nostril once a day tenofovir mg take one pill a day with food tricor mg one tablet by mouth every day zantac mg one tablet at bedtime discharge medications aspirin mg tablet sig one tablet po daily daily disp tablet s refills fosamprenavir mg tablet sig two tablet po q h every hours disp tablet s refills lopinavir ritonavir mg capsule sig four cap po bid times a day disp cap s refills tenofovir disoproxil fumarate mg tablet sig one tablet po daily daily disp tablet s refills levofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills oxycodone acetaminophen mg tablet sig tablets po q h every to hours as needed for headache for days disp tablet s refills pravastatin mg tablet sig one tablet po once a day disp tablet s refills patanol drops sig drops ophthalmic twice a day drops in each eye disp bottle refills atenolol mg tablet sig one tablet po once a day disp tablet s refills androgel mg gel in packet sig one packet transdermal once a day disp packets refills folic acid mg tablet sig one tablet po once a day disp tablet s refills loratadine mg tablet sig one tablet po once a day disp tablet s refills tricor mg tablet sig one tablet po once a day disp tablet s refills compazine mg tablet sig one tablet po every eight hours as needed for nausea for weeks disp tablet s refills discharge disposition home discharge diagnosis primary diagnosis sirs amoxicillin anaphylaxis secondary diagnoses hiv coronary artery disease hypertension hypercholesterolemia discharge condition stable discharge instructions please take all medications as perscribed please refrain from using amoxicillin as you may have an allergy please keep all follow up appointments keep yourself well hydrated to prevent your headache from becoming worse please come to the emergency room with any fevers chills nausea vomiting shortness of breath palpitations throat swelling followup instructions provider m d date time provider am please have your bp checked at this visit and have your blood pressure medications adjusted as necessary until this visit please only take atenolol for your blood pressure provider am completed by [NEW_RECORD] admission date discharge date date of birth sex m service cardiothoracic allergies bactrim ds dapsone delavirdine abacavir sulfate amoxicillin attending chief complaint chest pain major surgical or invasive procedure off pump coronary artery bypass graft x lima lad svg rca svg ramus rad art diag svg ramus history of present illness yo m with h o coronary artery disease s p pci who presented with chest pain past medical history hiv cd count of coronary artery disease status post st elevation mi in with stenting of the lad dyslipidemia peptic ulcer disease low back pain gastritis history of abnormal lfts with repeat normal lfts depression social history previously from moved to the states after high school lives in and works as a social worker with the homeless denies tobacco or ivdu drinks etoh occasionally family history maternal uncle w mi at age father w mi in his s and another uncle with a recent myocardial infarction physical exam on l nad rrr no m r r lungs ctab abd soft nt nd no c c e pulses t o pertinent results cath coronary angiography in this right dominant system demonstrated three vessel coronary artery disease the lmca was a long vessel with mild plaquing and proximal and distal lesions the lad had a ostial tubular lesion the lad and the diagonal were calcified the lad after the takeoff of d had a stenosis with timi flow a previously large d was totally occluded with distal filling via lcx collaterals and in stent restenosis the lcx had minimal luminal irregularities and supplied the atrial branch om lpl s proximal stenosis at lpl and collaterals to the rpda the ramus has an ostial and proximal then lesions with diffuse plaquing multiple distal branches are noted the rca has a proximal stenosis and a mid stenosis with haziness suggestive of thrombus with timi flow distally the rpda has a mid lesion at major sidebranches follwed by a stenosi revealed minimally elevated left sided filling pressures with lvedp of mmhg left ventriculography revealed no mitral regurgitation the lvef was calculated to be with posterobasal inferior and anterolateral hypokinesis and inferoapical akinesis echo pre procedure the left atrium is mildly 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 the left ventricular cavity size is normal regional left ventricular wall motion is normal overall left ventricular systolic function is normal lvef right ventricular chamber size and free wall motion are normal 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 there is no aortic valve stenosis no aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen there is no pericardial effusion post off pump bypass wall motion and lv function unchanged aortic contours preserved mitral regurgitation appears trace to mild remaining exam unchanged all findings discussed with surgeons at the time of the exam cxr stable small to moderate right apical pneumothorax persistent bibasilar atelectasis slight improved aeration of the left lung base 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 hct plt ct pm blood pt ptt inr pt am blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap brief hospital course mr was admitted following being ruled in for nstemi he underwent a cardiac catheterization on which showed severe three vessel coronary artery disease he was referred for surgical revascularization on he was brought to the operating room where he underwent an off pump coronary artery bypass graft x please see operative report for details following surgery he was transferred to the csru for invasive monitoring in stable condition later on op he was weaned from sedation awoke neurologically intact and extubated he was started on imdur for his radial artery graft and his drips were weaned on post op day one he was started on beta blockers and diuretics and gently diuresed towards his pre op weight later on post op day one he was transferred to sdu for further care on post op day three his epicardial pacing wires and chest tubes removed chest x ray following removal of chest tubes revealed a small apical pneumothorax chest x ray the following day showed the pneumothorax to have decreased in size post operatively he worked with physical therapy for strength and mobility he appeared to be doing well on post op day four and was discharged home with vna services and the appropriate follow up appointments medications on admission asa atenolol protonix pravastatin gemfibrozil kaletra tabs lexiva viread discharge medications docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills ranitidine hcl mg tablet sig one tablet po bid times a day disp tablet s refills atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills isosorbide mononitrate mg tablet sustained release hr sig one tablet sustained release hr po daily daily disp tablet sustained release hr 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 fosamprenavir mg tablet sig two tablet po q h every hours lopinavir ritonavir mg tablet sig one tablet po bid times a day tenofovir disoproxil fumarate mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day disp tablet s refills discharge disposition home with service facility homecare discharge diagnosis coronary artery disease s p coronary artery bypass graft x pmh hiv cd count of coronary artery disease status post st elevation mi in with stenting of the lad dyslipidemia peptic ulcer disease low back pain gastritis history of abnormal lfts with repeat normal lfts depression 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 or driving until follow up qith surgeon followup instructions dr weeks dr weeks dr weeks already scheduled appointments provider m d date time provider suite gi rooms date time provider md phone date time md completed by,"{
""Diagnoses"": [""nausea"", ""vomiting"", ""diarrhea"", ""fever"", ""chills"", ""pruritis"", ""abdominal pain""],
""Medications"": [""amoxicillin"", ""ceftriaxone"", ""vancomycin"", ""flagyl"", ""levophed""]
}"
89334,admission date discharge date date of birth sex f service cardiothoracic allergies shellfish peanut attending chief complaint angioedema major surgical or invasive procedure intubation history of present illness year old female with history of shellfish nut allergies and asthma presenting to ed with difficulty speaking and breathing with a swollen tongue she woke up at am with sob tongue and throat swelling and took diphenhydramine without relief she then knocked on her roommate s door asking her to call ems due to inability to catch her breath and swollen tongue reporting that her symptoms worsened over a few hours she was given epipen in field without effect satting on arrival by ems she did eat strawberries yesterday but has no known reaction to them in the past no fevers chills medication changes or drug use speaking to her boyfriend and sister she also has asthma with albuterol prn and has not been hospitalized for this before she is originally from the democratic republic of the grew up in and now studies business at she has had upper lip swelling since she was very young with occasional hives on her extremities as well as swollen feet upon waking up in the morning she has never had any tongue swelling in the past the swelling she does have usually resolves in a day and she was given a medication for it unknown type upon arrival to the ed there was concern for angioedema and she was intubated for airway protection after receiving benadryl famotidine epinephrine and methylpredinsolone anesthesia and surgery called and fiberoptic nasal intubation performed with ett pre medication with glycopyrrolate nebulized lidocaine and racemic epinephrine started on propofol and fentanyl ogt and ett confirmed by cxr tachycardia improved past medical history asthma idiopathic swelling of her lips prior work up social history non smoker social drinker no drug use student at studying management internship at pathfinder s international mother lives in brothers in father in sister in as a consultant family history asthma cad and htn in her father younger sister passed away at age from cancer but not sure physical exam admisison exam vitals t bp p r o on ac general intubated sedated breathing well on vent heent sclera anicteric perrl firm and swolleng tongue and lips unable to visualize anywhere in the mouth much less the oropharynx neck supple jvp not elevated no lad but swollen submandibular region cv regular rate and rhythm normal s s no murmurs rubs gallops lungs clear to auscultation bilaterally no wheezes rales rhonchi abdomen soft non tender non distended bowel sounds present no organomegaly gu foley in place ext warm well perfused pulses no clubbing cyanosis or edema neuro not awake enough to follow commands arouses to voice nonfocal exam discharge exam vs t bp p r o room air gen pleasant woman sitting comfortably on hospital bed in nad heent sclera anicteric perrl lips non edematous oropharynx clear without lesions neck supple jvp not elevated no lad or swelling of neck no stridor cv regular rate and rhythm normal s s no murmurs rubs gallops lungs clear to auscultation bilaterally no wheezes rales rhonchi abdomen soft non tender non distended bowel sounds present no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema neuro cn ii xii grossly intact strength in upper and lower extremities sensation intact to light touch pertinent results admission labs 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 pt ptt inr pt am blood esr am blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos totbili am blood totprot albumin globuln am blood hbsag negative hbsab positive hbcab negative hav ab negative am blood pep no specific abnormalities seen am blood c c discharge labs 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 alt ast alkphos totbili am blood calcium phos mg iron am blood caltibc ferritn trf labs pending at discharge am blood hgb a pnd hgb s pnd hgb c pnd pm blood cryoglb pnd am blood c inhibitor pnd micro monospot final negative by latex agglutination pm mrsa screen final no mrsa isolated pm urine culture final citrobacter koseri organisms ml sensitivities mic expressed in mcg ml citrobacter koseri cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s nitrofurantoin i tobramycin s trimethoprim sulfa s pm blood culture x no growth to date pm bronchoalveolar lavage gram stain final per x field polymorphonuclear leukocytes per x field multiple organisms consistent with oropharyngeal flora respiratory culture preliminary organisms ml commensal respiratory flora staph aureus coag organisms ml am urine culture final no growth imaging cxr frontal view of the chest demonstrates an et tube approximately cm from the carina and should be repositioned withdraw approximately cm bilateral low lung volumes are noted with mild crowdingof bronchovascular markings cardiac silhouette appears accentuated by low lung volumes there is no focal consolidation pleural effusion or pneumothorax cxr compared to the study from two days prior the heart size is mildly larger but there is no focal infiltrate or effusion et tube and ng tube are unchanged brief hospital course year old female with history of atopy and asthma admitted with angioedema of the tongue and throat requiring nasal intubation angioedema on presentation to the ed the patient underwent nasotracheal intubation for airway protection in the setting of epinephrine refractory edema of her lips tongue and throat she was given a dose of solumedrol and started on prednisone daily she was also started on iv benedryl fexofenadine famotidine and albuterol nebs she began a course of augmentin given the risk of bacterial sinus infection with nasotracheal intubation edema improved and the patient was transitioned to oropharyngeal intubation she underwent bronchoscopy that appeared benign for workup of her edema the patient was evaluated by allergy c and c levels c esterase inhibitor function and level cu index fcer antibody spep esr hepatitis serologies lfts and cryoglobulins were sent c esterase inhibitor function cryoglobulins and cu index pending at discharge the remainder of tests returned normal her presentation is most consistent with angioedema an allergic component no known exposure to allergens though she is quite atopic and it is possible that she is having a reaction to an as yet unknown allergen however she did not respond to high dose epinephrine and there were no eosinophils on her differential making allergy unlikely with further improvement in edema the patient was extubated stridor resolved the patient was advanced to a regular diet and was discharged home on a day prednisone taper starting at mg daily she will also complete a day course of augmentin days remaining at discharge the patient was provided prescriptions for diphenhydramine and an epipen in case of future episodes she will follow up with dr in allergy upon discharge asthma chronic with no contribution to admission lungs remained clear to auscultation throughout admission the patient was continued on albuterol prn positive urine culture the patient had a urine culture sent on admission in the absence of symptoms that grew colonies of citrobacter foley catheter was removed and repeat u a and urine culture were benign the patient was not treated for uti anemia the patient was admitted with a mild likely chronic anemia ferritin consistent with likely iron deficiency anemia given the patient s background hemoglobin electrophoresis sent for possible sickle cell trait results pending at discharge transitional issues patient provided number to establish care with a pcp patient to follow up with dr in allergy on discharge hemoglobin electrophoresis c esterase inhibitor function cryoglobulins and cu index pending at discharge medications on admission diphenhydramine prn albuterol prn discharge medications amoxicillin clavulanic acid mg po q h day rx amoxicillin pot clavulanate mg mg tablet s by mouth every hours disp tablet refills prednisone mg po daily duration days take tablets on day tablets on day tablets on day tablets on day tablet on day tablet on day tapered dose down rx prednisone mg tablet s by mouth see below disp tablet refills diphenhydramine mg po q h prn swelling epipen nf epinephrine mg ml injection once inject into arm or thigh if no improvement within minutes inject a second pen rx epinephrine epipen mg ml inject into thigh with symptoms if no improvement within minutes inject a second pen disp syringe refills albuterol inhaler puff ih q h prn sob rx albuterol sulfate mcg puff inhaled every six hours disp inhaler refills discharge disposition home discharge diagnosis angioedema 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 because you were having lip swelling and difficulty breathing you ultimately needed intubation with a breathing tube you were given steroids and supportive medications and your swelling improved with the breathing tube subsequently taken new medications prednisone mg x days mg x days mg x days augmentin tablet every hours for more days epipen inject into thigh with symptoms of throat tightness inability to breath well hives followup instructions you will be set up with a new primary care doctor called dr her office will call you to set up the appointment the office number is you also need to follow up with an allergist called dr her office will call you to set up an appointment if you have not heard from dr or dr office by tuesday please call them to set up the appointments,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""f"", ""service"", ""cardiothoracic"", ""allergies"", ""shellfish"", ""peanut"", ""intubation"", ""history of present illness"", ""year old"", ""female"", ""with history of shellfish nut allergies and asthma""],
""Medications"": [""diphenhydramine"", ""Epipen"", ""albuterol"", ""prn""]
}"
7095,admission date discharge date date of birth sex m service med chief complaint anemia history of present illness a year old man with the extensive past medical history significant for diabetes chronic kidney disease hypertension and peripheral vascular disease presented to the nephrology clinic on with increasing fatigue and lower extremity edema blood work done at that time revealed a hematocrit of in a setting of inr of he was triaged in the emergency room for further work up on further questioning the patient denies any melena hematochezia or bleeding of any kind or bruising nasogastric lavage done in the emergency room was positive for coffee grounds he was transfused with units of red blood cells in the emergency room after which he was transferred to the intensive care unit in the intensive care unit his coagulopathy was reversed with vitamin k and fresh frozen plasma and he was further transfused to a stable hematocrit endoscopy done revealed gastritis with lots of blood in the stomach granularity and nodular lesion in the duodenum which possibly could be the source of his bleeding he was eventually transferred out to the floor after a stable hematocrit on the floor he was initiated by dialysis by the renal team past medical history diabetes mellitus chronic kidney disease stage complicated by hyperkalemia volume overload secondary hypoparathyroidism and anemia ulcerative colitis right adrenal adenoma gout history of prostate cancer status post prostatectomy remote history of nephrolithiasis hypertension hyperkalemia peripheral vascular disease with carotid stenosis infrarenal abdominal aortic aneurysm deep venous thrombosis iron deficiency anemia and adrenal nodule allergies no known drug allergies social history quit smoking at age retired as a chemical mixer from a leather tannery no alcohol or illicit drug use lives at home with his wife and family family history brother had liver cancer father and mother had cerebrovascular accidents paternal grandfather rectal cancer physical examination on arrival to the floor vital signs blood pressure heart rate temperature patient appeared in no acute distress head and neck examination showed perrl moist mucous membranes no elevated jugular venous distension no cervical lymphadenopathy supraclavicular lymphadenopathy heart and lungs normal abdomen soft nontender nondistended no palpable masses extremities showed absent dorsalis pedis and posterior tibial pulses bilaterally right lower extremity revealed bluish discoloration of the toes patient reports this to be present for the past months on neurological examination the patient was intact neurologically of note in the intensive care unit streaks of blood were noted on the glove with black colored stools on rectal examination with erythema and maceration of the skin around the rectum pertinent laboratory data x ray and other tests cbc on admission hematocrit on discharge on admission white count on discharge platelets at discharge coagulation panel on admission inr is pt ptt coagulation panel at discharge was normal reticulocyte count bun and creatinine at admission and respectively at discharge and respectively after the last laboratory on the day of discharge the patient was dialyzed liver function tests normal troponin calcium phosphorus magnesium total protein albumin a c parathyroid levels hepatitis panel negative lactate normal urinalysis revealed rbcs blood cultures done negative at discharge at the time of discharge helicobacter pylori serology negative at the time of discharge urine culture contaminated specimen specimen obtained during esophagogastroduodenoscopy biopsy revealed hyperplasia of gastric pit refer to mr for details chest x ray on admission revealed no acute cardiopulmonary process electrocardiogram revealed sinus rhythm with first degree av block right bundle branch block unchanged from prior electrocardiograms procedures performed esophagogastroduodenoscopy and infusion of dialysis summary of hospital course acute blood loss anemia from upper gastrointestinal bleeding after the correction of coagulopathy and transfusion of units of packed red blood cells the patient had an esophagogastroduodenoscopy that revealed the above findings and a biopsy was done that revealed the above findings during the rest of the hospital course his hematocrit remained stable he was started on pantoprazole to be taken times a day the patient is scheduled for a repeat upper endoscopy as indicated below it is suggested that he also get a colonoscopy at that same time the colonoscopy was scheduled on the same day as the endoscopy gastrin levels were sent and are pending at the time of discharge will defer to the primary care provider to follow up on the gastrin levels coumadin was stopped as the patient had completed about months of anticoagulation therapy for a deep venous thrombosis he was initiated on aspirin he was advised to refrain from using non steroidal anti inflammatory medications as well as alcohol and caffeine chronic kidney disease stage dialysis was initiated at this time under the guidance of nephrology he was started on renagel and nephro caps epogen will be administered x a week during dialysis outpatient follow up was arranged by social work for patient to get continued dialysis as indicated below on tuesdays thursday and saturdays peripheral vascular disease the patient was started on aspirin and then warfarin was stopped vascular surgery attending who follows the patient in clinic dr was attempted to be contact however he was traveling and could not be contact the vascular consulting was contact who recommended that given the chronicity of the problem it is best if the patient follow up with dr for the possibility of an angiogram now that he is on dialysis hypertension he was continued on his medications during the hospitalization after he was out of the intensive care unit blood pressure remained stable leukocytosis an infection work up remained negative likely reactive gout allopurinol was continued type diabetes mellitus he was continued on glipizide on his home dose with the insulin sliding scale and the a c was less than deep venous thrombosis warfarin as above was stopped the patient was placed on aspirin and encouraged ambulation the patient will require deep venous thrombosis prophylaxis while immobile for example if he has further hospitalizations or perioperatively the patient also has abdominal aortic aneurysm and adrenal nodular as well as carotid stenosis on multiple radiological studies done in our system these should be followed up as per the discretion of the primary care provider condition on discharge stable discharged to home patient discharge instructions the patient was discharged with the following instructions please follow with your primary care doctor or return to the hospital if you have fevers chills chest pain dizziness or any other symptom concerning to you make an appointment as instructed below with dr in the next week you should blood work done at that time for hematocrit also discuss with dr about getting another urine test to look for blood as the urine test during the hospitalization reveals some blood you are scheduled for an upper endoscopy and as a colonoscopy as well please contact your primary care doctor for the preparation of the colonoscopy please attend the dialysis sessions as instructed you should not take coumadin as this may make you bleed for the ulcer avoid taking ibuprofen motrin advil or any such medications without consulting your primary care doctor you are started on a coated aspirin and please take as instructed recommended follow up nephrology dr on at a m dr date and time of the appointment at a m gastrointestinal endoscopy suite room at the on at a m for esophagogastroduodenoscopy and colonoscopy dr please contact your primary doctor tion for the preparation for colonoscopy dialysis on at p m at please call dr to make a follow up appointment in the next week for further management of the vascular disease in your legs major surgical or invasive procedures esophagogastroduodenoscopy and infusion of dialysis discharge medications atorvastatin mg p o daily calcium carbonate mg tablets x a day sevelamer mg tablets tablets x a day nephro caps capsule daily lansoprazole mg senna tablets x a day glipizide mg daily allopurinol mg daily lidocaine and prilocaine cream topically as directed minutes prior to dialysis to the av graft metoprolol mg p o b i d nifedipine mg sustained release tablets tables to be taken daily aspirin mg extended coated release tablets once daily discharge diagnoses acute blood loss anemia upper gastrointestinal bleeding chronic kidney disease stage initiation of dialysis peripheral vascular disease secondary diagnosis hypertension gout history of deep venous thrombosis diabetes mellitus poorly controlled with complications abdominal aortic aneurysm adrenal nodule carotid stenosis md 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 hypotension major surgical or invasive procedure pacemaker placement history of present illness year old male with dm esrd on hd via lue av fistula placed s p multiple stenoses and angioplasties with angioplasty who is undergoing iv antibiotic therapy cefazolin at hd for mssa bacteremia of unclear duration and source he was at hd today for his regular visit and was noted to have hypotension his pulse was then checked and found to be low and his dialysis was cut short by hours and he was transferred to er for further evaluation upon presentation pt denied complaints but was noted to be in complete heart block with a wide complex escape rhythm rbbb pattern at bpm known to have second degree av block on ekg prior bp was and rr with sats pacer pads were placed carotid sinus massage and exercise were performed with no prominent effect on av nodal conduction he was noted to have wcb that was likely in the his bundle as a pacemaker was recommended id was consulted due to recent infection bacteremia a tee was performed and did not reveal any vegetations he was afebrile with negative blood cx s since maintained on abx at dialysis went for ppm placement today and was complicated by very difficult to access anatomy in holding area post procedure pt delirius and confused needed a team of ten people to keep control of him glucose was on one measurement repeat was he started the procedure with a glucose of he had been npo all day awaiting the procedure he remained confused even after and was admitted to ccu for monitoring past medical history diabetes mellitus chronic kidney disease stage on hd mwf ulcerative colitis no flares x years right adrenal adenoma gout history of prostate cancer status post prostatectomy remote history of nephrolithiasis hypertension peripheral vascular disease s p left dp bypass carotid stenosis infrarenal abdominal aortic aneurysm deep venous thrombosis in iron deficiency anemia recent episode of aphasia which resolved tia social history quit smoking at age retired as a chemical mixer from a leather tannery no alcohol or illicit drug use lives at home with his wife and family family history brother had liver cancer father and mother had cerebrovascular accidents paternal grandfather rectal cancer physical exam pe t hr bp rr ra neuro perrla a x cvs hsm heard best at apex r chest dressing over pacemaker c d i lungs cta b abd bs soft nt nd ext wwp trace edema pulses dopplerable pertinent results pm glucose urea n creat sodium potassium chloride total co anion gap pm alt sgpt ast sgot alk phos tot bili pm calcium phosphate magnesium pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm pt ptt inr pt am glucose k echo no spontaneous echo contrast or thrombus is seen in the body of the left atrium left atrial appendage or the body of the right atrium right atrial appendage right atrial appendage ejection velocity is good cm s no atrial septal defect is seen by d or color doppler with mild global free wall hypokinesis there are complex mm atheroma in the aortic arch there are complex mm atheroma in the descending thoracic aorta the aortic valve leaflets are mildly thickened no masses or vegetations are seen on the aortic valve no aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mass or vegetation is seen on the mitral valve mild to moderate mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened there is at least mild pulmonary artery systolic hypertension no vegetation mass is seen on the pulmonic valve there is no pericardial effusion impression no valvular vegetations or peri valvular abcesses seen mild to moderate mitral regurgitation mildly depressed left ventricular and moderately depressed right ventricular systolic function complex plaque in descending aorta and aortic arch mild pulmonary hypertension cxr impression evidence for mild vascular congestion and very small pleural effusions cardiomegaly a transvenous pacemaker in place brief hospital course yo m w pmhx of htn dm and esrd on hd who was known to have second degree av block on prior ekg noted on admission to have deteriorated to complete heart block altered mental status his course post pm placement was complicated by delirium in the setting of hypoglycemia to he received an amp of d with improvement of his gfs to the s he was delirious initially on the floor and per discussions with his spouse he is confused at baseline in addition to the hypoglycemia he may have been particularly sensitive to sedating medications and there may be some metabolic component given his esrd although his electrolytes were not markedly abnormal his gfs were checked every hours he received repeated reorientation and benzodiazepines were avoided his sensorium continued to improve complete heart block s p pacemaker he had a ddd pacemaker placed set at he was appropriately v paced on telemetry and subsequent ekg he received a cxr the day following his procedure showing that the leads were appropriately positioned ep interoggation post procedure showed the pacemaker was working appropriately he was instricted to wear a slight to immobilize his right arm for several weeks post procedure a plan was made for him to follow up with the device clinic within one week of discharge he needs a new cardiologist and the phone number for the cardiology clinic was given to him to set up an appointment esrd on hd he has esrd on hemodialysis mwf due to his episode of hypotension his friday hemodialysis session was terminated prematurely and he only received half of his dialysis he was discussed with our renal team and was not found to be grossly volume overloaded nor were the electrolytes particularly abnormal dialysis was deferred to his next scheduled session on monday mssa bacteremia undergoing iv antibiotic therapy cefazolin at hd for mssa bacteremia of unclear duration and source at this point he is days into his course he should complete the course of cefazolin decided by his nephrologists at dialysis htn he was normotensive this hospitalization his antihypertensive regimen with metoprolol and lisinopril was continued carotid stenosis infrarenal aaa pvd he was continued on asa simvastatin lisinopril medications on admission albuterol sulfate puffs qid prn calcium acetate mg capsule sig two capsule po tidac clopidogrel mg po q day fluticasone salmeterol mcg dose lasix mg po bid glipizide mg er po bid lisinopril mg po q day metoprolol tartrate mg tablet po q day ranitidine hcl mg po q day silver sulfadiazine cream sig q day simvastatin mg tablet po q hs aspirin mg po q day folic acid mg po q day b complex vitamin c folic acid mg capsule po q day cefazolin at hd discharge medications albuterol sulfate mcg actuation hfa aerosol inhaler sig puffs inhalation q h every hours as needed for sob calcium acetate mg capsule sig two capsule po tid w meals times a day with meals clopidogrel mg tablet sig one tablet po 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 bid times a day ranitidine hcl mg tablet sig one tablet po daily daily simvastatin mg tablet sig one tablet po daily daily aspirin mg tablet sig one tablet po daily daily folic acid mg tablet sig one tablet po daily daily b complex vitamin c folic acid mg capsule sig one cap po daily daily silver sulfadiazine cream sig one appl topical daily daily as needed for apply to foot wounds cefazolin gram recon soln sig two grams iv injection hd protocol hd protochol glipizide mg tablet extended rel hr sig one tablet extended rel hr po once a day disp tablet extended rel hr s refills lisinopril mg tablet sig one tablet po once a day metoprolol tartrate mg tablet sig one tablet po once a day discharge disposition home discharge diagnosis primary complete heart block s p pacemaker placement secondary end stage renal disease diabetes discharge condition alert and oriented to person place and time mildly confused discharge instructions you were admitted to the hospital because you had dropped your blood pressure during dialysis you were found to have complete heart block on ekg a condition where the of your heart do not communicate electrically for this reason you had to have a pacemaker placed you were disoriented after the procedure because your blood sugar was low however this has been corrected some of the sedating medications may take some time to wear off so you may be a little confused intitially please see your doctor if you still feel confused after a couple of days the following changes were made to your medications decrease glipizide to mg once a day it is very important that you do not engage in any stretching or lifting using your right arm please keep the pacemaker area dry for week please limit movement of your right arm and wear the arm sling for six weeks followup instructions provider clinic please follow up within one week of discharge the number to call to make your appointment is you need a new cardiologist please call cardiology at to set up an appointment provider 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 medicine allergies cefazolin attending chief complaint desaturation and change in mental status major surgical or invasive procedure none history of present illness this is a year old man with dm ii esrd on hd via lue av fistula aaa carotid disease mssa bacteremia of unclear source recently admitted for hypotension and complete heart block treated with a permanent pacemaker patient now returns to with aletered mental status and hypoxemia was at his usual hd session when o sat was noted to be ra was reportedly having labored breathing complained of an odd feeling in his stomach patient was only kg over dry weight so only small amount of fluid removed during hypoxemic episode patient initially required l nc became increasinly confused and changed to nrb hd session was completed and about l fluid was removed by report from the family patient was recently hospitalized at and discharged day before admission for hypotension with demand ischemia according to family patient has been confused intermittently for several months in the ed initial vs were t hr bp rr o on nrb patient sleepy but appropriate no jvd but accessory muscle use taking deep full breaths no murmur gallop belly was soft but patient complained of abdominal pain lle erythema w o tenderness ekg sinus tachycardia w atrial sensing and v pacing patient got aspirin for troponin elevation and haldol mg iv x for agitation past medical history recent permanent pacemaker for chb ongoing mssa bacteremia diabetes mellitus last a c chronic kidney disease stage on hd mwf ulcerative colitis no flares x years right adrenal adenoma gout history of prostate cancer status post prostatectomy remote history of nephrolithiasis hypertension peripheral vascular disease s p left dp bypass carotid stenosis infrarenal abdominal aortic aneurysm deep venous thrombosis in iron deficiency anemia recent episode of aphasia which resolved tia prostate cancer s p prostatectomy pulmonary hypertension uses home oxygen of l nc normally sats as per family social history quit smoking at age retired as a chemical mixer from a leather tannery no alcohol or illicit drug use lives at home with his wife and family family history brother had liver cancer father and mother had cvas paternal grandfather had rectal cancer physical exam vitals t bp p r o on l general alert oriented no acute distress heent sclera slightly icteric mmm oropharynx clear neck supple no jvp appreciated lungs clear bilaterally with decreased sounds at bases cv regular rate and rhythm normal s s no murmurs rubs gallops abdomen distended bs tympanic no organomegally appreciate but difficult exam ext edema bilaterally left second toe is bandaged bandage is clean dry and intact scar on left shin skin warm and dry psych appropriate neuro alert to person and place tired during interview pertinent results labs on admission am plt smr very low plt count am neuts lymphs monos eos basos am wbc rbc hgb hct mcv mch mchc rdw am asa neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg am haptoglob ferritin am ck mb notdone probnp greater th am ctropnt am lipase am alt sgpt ast sgot ld ldh ck cpk alk phos tot bili am estgfr using this am glucose urea n creat sodium potassium chloride total co anion gap am pt ptt inr pt pm lactate pm po pco ph total co base xs pm urine hyaline pm urine rbc wbc bacteria none yeast none epi pm urine blood neg nitrite neg protein glucose ketone neg bilirubin neg urobilngn neg ph leuk neg pm urine color yellow appear clear sp pm urine bnzodzpn neg barbitrt neg opiates neg cocaine neg amphetmn neg mthdone neg pm urine hours random chloride pm ethanol neg pm ck mb notdone ctropnt pm ck cpk non contrast head ct non contrast head ct please note that evaluation is significantly limited by head motion within that limitation there is no intracranial hemorrhage mass effect edema shift of normally midline structures or major vascular territorial infarction the white matter differentiation is preserved a mm hyperdense lesion at the foramen of appears stable as compared to prior exams consistent with a colloid cyst this appeared relatively less conspicuous on certain prior exams prominent ventricles are essentially stable without evidence of acute hydrocephalus sulci are prominent compatible with age related involutional change there is extensive subcortical and periventricular white matter hypoattenuation consistent with small vessel ischemic disease unchanged a hypodense focus is noted in the right lentiform nucleus consistent with lacune versus prominent perivascular space within significant limitation by motion artifacts paranasal sinuses and mastoid air cells appear relatively aerated impression no evidence of acute intracranial hemorrhage stable mm colloid cyst and stable appearance of prominent ventricle without evidence of hydrocephalus extensive small vessel ischemic disease and age related involutional change ct impression no evidence of central pulmonary embolism limited evaluation of the more peripheral pulmonary vasculature due to patient respiratory motion overall stable appearance of a fusiform aaa since continues to measure cm in diameter no evidence of current rupture extensive atherosclerotic vascular disease with two penetrating thoracic aortic ulcers one of which is increased in size as compared to two mm right middle lobe pulmonary nodular opacities are of uncertain chronicity without prior chest studies to compare month followup is recommended to document resolution or stability right lung base linear densities are unchanged since most consistent with chronic fibrotic changes nonspecific mediastinal and axillary lymphadenopathy perihepatic and perisplenic ascites nodular liver contour suggests cirrhosis gynecomastia heterogeneous appearing thyroid with a possible subcentimeter nodule and punctate calcification on the left findings could be further evaluated on nonemergent ultrasound nonspecific mild stable pancreatic ductal dilatation no obstructive or mass lesion identified atrophic kidneys consistent with history of end stage renal disease unchanged occlusion of the left renal artery unchanged since echo the left atrium is moderately dilated no atrial septal defect is seen by d or color doppler there is mild symmetric left ventricular hypertrophy the left ventricular cavity is mildly dilated there is moderate global left ventricular hypokinesis lvef the right ventricular cavity is moderately dilated with mild global free wall hypokinesis 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 mildly thickened mild to moderate mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened moderate to severe tricuspid regurgitation is seen there is severe pulmonary artery systolic hypertension there is no pericardial effusion right upper quadrant ultrasound impression gallbladder wall edema without gallbladder wall stones sludge or sign these findings are nonspecific and could be related to third spacing versus renal failure however in the appropriate clinical setting acalculous cholecystitis is not entirely excluded therefore at this time a hida scan is recommended for further evaluation if clinical suspicion warrants trace ascites mild splenomegaly brief hospital course this is a year old man w cad aaa mssa bacteremia and pulmonary hypertension who presents with confusion and hypoxemia altered mental status patient has a history of dementia for several months as per family members patient s mental status waxed and waned throughout admission especially during dialysis sessions patient is alert and oriented and consistently answers correctly when asked about person place time and events however his behavior is sometimes inappropriate and he is not always sure of his surroundings at one point he thought he was in a bakery likely mr has some underlying dementia with superimposed delirium in the setting of frequent hospitalizations and medicalizations also possible that there are metabolic derrangements in the setting of frequent dialysis all offending medications were discontinued such as ranitidine efforts were made to orient patient and discontinue unnecessary tethers patient will follow up with geriatrics as an outpatient for neuro psychiatric testing he was given low dose haldol mg as needed for agitation of note mr was given mg of haldol in the icu and was unarousable for hours hypoxia pulmonary hypertension mr was initially admitted because of hypoxia o sats in the s during a dialysis session however during admission mr had no problems with oxygenation he was satting on room air on discharge dyssynchrony on echo as per echocardiogram performed during admission there is dyssynchrony between native heart beat and pacemaker electrophysiology was consulted who made some changes to pacemaker setting with moderate effect mr will follow up with general cardiology in weeks cad troponin elevation mr had a troponin elevation on admission however troponin was lower than on admission the week before at troponin was likely patient had a missed mi or troponin leak in setting of hypotension prior to arrival at patient was continued on asa plavix metoprolol and statin throughout admission patient had no ecg changes to suggest ischemia and no new chest pain mr will follow up with cardiology in weeks thrombocytopenia patient had a rapidly dropping platelet count ever since being started on cefazolin for mssa bacteremia in early cefazolin was held and platelet count went up mr was switched to nafcillin with good effect but antibiotic was finally changed to vancomycin as this can be easily administered at dialysis patient will continue on vancomycin given at dialysis through patient had no signs or symptoms of bleeding throughout admission patient s platelet count should be re checked in days at rehab mssa bacteremia patient with mssa bacteremia found on recent admission in source was never identified but thought to be from infected fistula extensive work up completed on previous admission mr did not have a fever or elevated white count during hospitalziation patient will continue on vancomycin through he will follow up with id specialists diabetes patient s oral medications were held during admission and he was started on an insulin sliding scale his oral medications can be restarted upon discharge itching likely from uremia patient was continued on sarna cream as needed hallucinations family states that patient has been complaining of bugs crawling on his skin and over his sheets hallucinations have been increasing in frequency can consider delerium vs body dementia diagnosis as an outpatient patient was given low dose haldol as needed for agitation can be changed to an anti psychotic with fewer extrapyramidal side effects if body is suspected and will follow up with geriatrics as an outpatient esrd on hd patient will continue on dialysis monday wednesdays and fridays patient will receive vancomycin at dialysis through or unless directed otherwise by infectious disease medications on admission albuterol sulfate mcg actuation hfa aerosol inhaler sig puffs inhalation q h every hours as needed for sob calcium acetate mg capsule sig two capsule po tid w meals times a day with meals clopidogrel mg tablet sig one tablet po daily fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day furosemide mg tablet sig one tablet po bid ranitidine hcl mg tablet sig one tablet po daily simvastatin mg tablet sig one tablet po daily aspirin mg tablet sig one tablet po daily daily folic acid mg tablet sig one tablet po daily daily b complex vitamin c folic acid mg capsule sig one cap po daily silver sulfadiazine cream sig one appl topical daily daily as needed for apply to foot wounds cefazolin gram recon soln sig two grams iv injection hd protocol hd protochol glipizide mg tablet extended rel hr sig one tablet extended rel hr po once a day disp tablet extended rel hr s refills lisinopril mg tablet sig one tablet po once a day metoprolol tartrate mg tablet sig one tablet po daily discharge medications albuterol sulfate mg ml solution for nebulization sig one inhalation q h every hours calcium acetate mg capsule sig two capsule po tid w meals times a day with meals clopidogrel mg tablet sig one tablet po 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 bid times a day simvastatin 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 folic acid mg tablet sig one tablet po daily daily metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po daily daily disp tablet sustained release hr s refills vancomycin mg recon soln sig one recon soln intravenous hd protocol hd protochol lisinopril mg tablet sig two tablet po daily daily glipizide mg tablet extended rel hr sig one tablet extended rel hr po once a day silver sulfadiazine cream sig one topical once a day b complex vitamin c folic acid mg capsule sig one capsule po once a day discharge disposition extended care facility rehab discharge diagnosis primary hypoxia resolved thrombocytopenia mssa bacteremia delirium secondary esrd on hd htn hyperlipidemia dementia discharge condition mental status confused sometimes level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr it was a pleasure taking care of you on this admission you came to the hospital because of low oxygen levels at dialysis you were initially admitted to the intensive care unit but you were transferred to the general medical wards when your levels normalized you were found to have low platelets and your cefazolin was switched to vancomycin you will continue this antibiotic through your platelt count should be rechecked in days the electrophysiologists made some changes to your pacemaker you should follow up with cardiology in weeks the following changes were made to your medications stop taking cefazolin start taking vancomycin as directed by your dialysis center start taking toprol xl mg once a day stop taking metoprolol mg once a day stop taking ranitidine this may have been making your platelets low please take all of your medications as prescribed please keep all of your follow up followup instructions department gerontology when tuesday at am with md building lm bldg campus west best parking garage department cardiac services when friday at pm with md building campus east best parking garage department advanced vasc care cnt when thursday at am with md building ma campus off campus best parking free parking on site infectious disease a lm bldg basement id west sb md [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies cefazolin attending chief complaint hypotension major surgical or invasive procedure right internal jugular central venous catheter insertion history of present illness year old male with a history of known cm aaa and penetrating thoracic aortic ulcerations chf with ef dm esrd on hd mwf via lue av fistula carotid disease chronic dyspnea on lnc previous mssa bacteremia presents from dialysis with hypotension pt here from dialysis after full run with c o bright red blood from rectum on toilet paper denies abd pain cp sob lightheadedness or dizziness in dialysis of note patient admitted from for similar presenation after dialysis he had a ct scan at that point which ruled out aaa rupture he was initially on dopamine but once it was determined that thigh bps were higher than arms he was quickly weaned off it was ultimately thought that bps low from intravascular depletion after dialysis he had an episode of somnolent and delirium after receiving ativan during this admission he was also intubated on admission after reaction while getting blood and vancomycin while hypertensive so thought to have flash pulm edema this resolved quickly he was guaic positive previously in the ed initial vitals were l triggered for bps to s bolus prior to transfer hr paced l n c v paced to prior brwn stool guaiac positive cbc hct stable pt sbps s int then dropped to s trigger x but asymptomatic cautious ivf cc fluids x asictes thought chf in past rij placed in ed for levofed on bps now mentating ok doesn t urinate a lot upon arrival to the icu patient was asking for food but was otherwise without complaints his sbps in thighs showed sbps in s and levofed was immediately shut off there was noticeable difference in upper ext bps by mmhg lower which had been reported previously he reported not feeling well in the months prior but no recent changes in symptoms since recent hospital discharge reports having occasional episodes of spots bright red blood in toilet but no profuse bleeding denied cp sob cough fever dizziness n v d but did endorse abdomen more distended review of systems per hpi denies fever chills night sweats recent weight loss or gain denies headache sinus tenderness rhinorrhea or congestion denied cough shortness of breath denied chest pain or tightness palpitations denied nausea vomiting diarrhea or constipation no recent change in bowel or bladder habits no dysuria denied arthralgias or myalgias past medical history htn dm esrd on hd mwf pvd carotid stenosis infrarenal aaa dvt dementia uc quiet x years r adrenal adenoma gout prostate ca kidney stones fe deficiency anemia aphasic episode cva psh pm pacemaker sensia sedr s p l bk dp w rgsvg s p lue avf s p mult angioplasties s p prostatectomy l ureteral stent social history quit smoking at age retired as a chemical mixer from a leather tannery no alcohol or illicit drug use family history brother had liver cancer father and mother had cvas paternal grandfather had rectal cancer physical exam vs temp bp hr rr o sat l gen pleasant comfortable nad heent perrl eomi anicteric mmm op without lesions no supraclavicular or cervical lymphadenopathy jvd difficult to appreciate with line no carotid bruits no thyromegaly or thyroid nodules resp crackles at left bases no wheezes or rhonchi cv rr s and s wnl sem best heard at lusb no r g abd distended with ascites b s soft ttp in llq no masses or hepatosplenomegaly appreciated no rebound or guarding ext no c c edema to b l knees left nd toe s p amputation dp dopplerable b l skin no jaundice no splinters erythema in b l legs c w venous stasis changes neuro aaox cn ii xii intact strength throughout no sensory deficits to light touch appreciated no pass pointing on finger to nose dtr s patellar and biceps pertinent results admission labs 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 ck mb pm blood glucose na k cl calhco discharge labs pm blood hct microbiology blood culture no growth to date at time of discharge mrsa screen pending at time of discharge ekg vpaced at bpm unchanged from prior imaging cxr portable ap again seen is a pacemaker with dual leads seen projecting in the right atrium and right ventricle the degree of enlargement of the cardiac silhouette is unchanged there is haziness of the pulmonary vasculature suggesting mild failure there are no pleural effusions there is trace atelectasis seen in the left lower lobe impression mild pulmonary edema brief hospital course year old male with a cm aaa and penetrating thoracic aortic ulcerations chf with ef dm esrd on hd mwf via lue av fistula carotid disease chronic dyspnea on lnc previous mssa bacteremia presents from dialysis with hypotension hypotension hypertension the patient was initially thought to be hypotensive with blood pressures in his right arm as low as the s he was never symptomatic in the emergency department he was treated with iv fluids additoinally a central venous catheter was placed in the ed norepinephrine and the patient was transferred to the micu in the micu prior records were reviewed including the partially completed discharge summary from the patient s admission for asymptomatic hypotension after dialysis during this prior admission it was determined that the blood pressures in his right upper extremity were significantly different by points from his right thigh pressures and it was recommended that blood pressures be checked in the patient s thigh based on this information the patient s right thigh pressure was checked and was found to be in the s norepinephrine was shut off with improvement in the patient s right thigh pressure to the s as before the patient had a significant difference between his his right arm and thigh blood pressures antihypertensives were initially held but the right thigh blood pressure rose to the s during ultrafiltration on lisinopril and metoprolol were restarted with improvement in the patient s right blood pressure to the s the patient was never symptomatic consideration was given to whether the patient s arm thigh blood pressure difference might be a sign of acute aortic pathology the same concern was raised during the patient s admission during which ct angiography of the chest from showed extensive but stable aortic atherosclerotic disease and cta of the abdomen and pelvis showing the patient s known abdominal aortic aneurysm without evidence of leak or rupture the patient s arm thigh blood pressure difference was discussed with the vascular team who cared for the patient during his prior admission they concluded that it was very difficult to determine the patient s true aortic blood pressure which was probably somewhere in between the blood pressures that were being measured in the patient s arm and thigh they thought the patient s arm pressure was probably more accurate but that it might not be completely accurate given the patient s extensive peripheral vascular disease and the fact that he was hypotensive in the right arm but asymptomatic at the time of discharge the patient s right thigh blood pressure was in the s and his right arm blood pressure was in the s with a pediatric cuff the patient was discharged without any medication changes with instructions to follow up with his vascular surgeon and his primary care physician for further management of his hypertension leukocytosis wbc count was elevated to on admission but the patient had no fever or focal signs of infection cxr showed some atelectasis but no infiltrate the patient s oxygen requirement remained at his baseline of l the patient refused to be catheterized for urinalysis and culture a blood culture showed no growth to date at the time of discharge right red blood per rectum the patient s hematocrit remained stable during his admission however the nurses noted a very small amount of blood in the commode after the patient used it the patient s stool was brown but guaiac positive the reported that he occasionally saw blood on his toilet paper at home the nurses were not certain if the bleeding was coming from the patient s gi or gu tract but the patient refused urinalysis for further evaluation of this the patient was instructed to follow up with his primary care doctor for further evaluation of the bleeding anemia chronic hct stable likely related to chronic kidney disease chronic blood loss no concern for acute bleeding the patient was instructed to follow up with his primary care doctor regarding the bleeding thrombocytopenia platelet count at baseline esrd the patient is dialyzed on a mwf schedule and also receives ultrafiltration on saturdays he received ultrafiltration on he continued phoslo and b complex vitamins ascites tapped on previous admission with saag c w portal hypertension likely related to chf peripheral vascular disease followed by vascular surgery as outpatient for toe amputation the wounds appeared clean dry and intact aspirin plavix and simvastatin were continued the patient was instructed to follow up with vascular surgery dm on glipizide at home the patient was monitored on an insulin sliding scale while in house and was discharged on his home dose of glipizide transitional issues pcp for bright red blood on toilet paper the patient may also require further evaluation with colonoscopy vascular surgery follow up for recent toe amputation vascular surgery and pcp for bp difference and further management of hypertension the patient should undergo arterial ultrasound of his right upper extremity to evaluate for peripheral vascular disease although he is unlikely a candidate for intervention unless he develops symptoms important info for all providers mr has very significant peripheral vascular disease and bp varies very widely in each limb labs pending at time of discharge blood culture mrsa screen medications on admission medications at home discharge summary aspirin mg tablet sig one tablet po daily daily clopidogrel mg tablet sig one tablet po daily daily metoprolol succinate mg tablet extended release hr sig one and a half tablet extended release hrs po once a day lisinopril mg tablet sig one tablet po once a day please hold on days of dialysis wednesday friday simvastatin mg tablet sig one tablet po daily daily disp tablet s refills phoslo mg capsule sig two capsule po three times a day with meals glipizide mg tablet extended rel hr sig one tablet extended rel hr po twice a day folic acid mg tablet sig one tablet po once a day 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 b complex vitamin c folic acid mg capsule sig one cap po daily daily disp cap s refills discharge disposition home discharge diagnosis primary peripheral vascular disease hypertension hypotension secondary end stage renal disease discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you came to the hospital with low blood pressure it was determined that there is a difference between the blood pressure in your arm and the blood pressure in your thigh please discuss this with your vascular surgeon dr when you see him this week please also discuss this discrepancy with your primary care physician you got some iv fluids in the emergency department and were treated with ultrafiltration on you had a small amount of blood in your urine or stool but your blood counts were stable there are no changes to your medications weigh yourself every morning md if weight goes up more than lbs followup instructions call your primary care doctor to arrange to be seen within the next week for further management of your blood pressure talk to your primary care doctor about the blood that you have had in your stool and possibly your urine department hemodialysis when at am department cardiac services when friday at am with md building campus east best parking garage md [NEW_RECORD] admission date discharge date date of birth sex m service surgery allergies cefazolin attending chief complaint left lower extremity pain left lower extremity gangrene major surgical or invasive procedure left below knee amputation history of present illness year old male with a history of pvd s p left bk popliteal to dp with rgsvg s p lue avf s p multiple angioplasties htn dm esrd on dialysis m w f presenting with gangrene of his left st and th toes patient has a recent history of frequent minor accidental trauma to left st toe with poor healing and progression of gangrene the patient presented to on with an unroofed left toe blood blister and left fourth toe gangrene and lle angiography was done at that time it was later decided to proceed with a bka on admission patient denied cp sob f c gi or gu complaints past medical history esrd on hd mwf pvd cad chf ef dm cm infrarenal aaa penetrating thoracic aortic ulcerations mssa bacteremia carotid stenosis htn dvt dementia uc r adrenal adenoma gout prostate ca nephrolithiasis fe deficiency anemia cva aphasic episode pulmonary htn l o at home pm pacemaker sensia sedr l below knee popliteal to dorsalis pedis bypass with reversed saphenous vein multiple lle angios balloon angioplasty l peroneal l nd toe amputation cabg av fistula multiple angioplasties of fistula pm prostatectomy l ureteral stent social history quit smoking at age retired as a chemical mixer from a leather tannery no alcohol or illicit drug use family history brother liver cancer father mother cva paternal grandfather rectal cancer physical exam vss heent normocephalic atraumatic eomi perrl nares clear mucous membranes moist neck supple without lymphadenopathy cvs regular rate and rhythm without murmurs rubs or gallops s and s resp clear to auscultation bilaterally without adventitious sounds no wheezing rhonchi or crackles abd soft non tender non distended with normoactive bowel sounds no masses or peritoneal signs extr s p left bka rle warm and dry dopplerable r dp pt incision incision without drainage mild erythema of amputation site dressing c d i 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 glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap blood culture no growth pathology leg right below knee amputation a gangrene b severe atherosclerosis c resection margins appear viable upper endoscopy nodularity and atrophy of mucosa in the whole stomach biopsy multiple nodules were noted at the apex of the duodenal bulb biopsy no obvious source of gi bleeding was noted otherwise normal egd to third part of the duodenum colonoscopy large pedunculated polyp in the sigmoid colon not removed given recent gi bleed biopsy injection diverticulosis of the sigmoid colon and descending colon the ic valve appeared thickened and nodular dark stool was noted upon intubation of terminal ileum solid and liquid stool was found at several regions of the colon precluding optimal visualization otherwise normal colonoscopy to cecum and terminal ileum brief hospital course mr was admitted on with left lower extremity gangrene he agreed to have an elective below knee amputation pre operatively he was consented a cxr ekg labs and type and cross were obtained he started a day course of vancomycin ciprofloxicin and metronidazole he was prepped and brought to the operating room for surgery intra operatively he was closely monitored and remained hemodynamically stable he tolerated the procedure well please see the operative report on for further details post operatively he was extubated and transferred to the pacu for further stabilization and monitoring due to persistent hypotension with sbps in the s he was started on a levophed drip and then transferred to the icu for management while on pressors his diet was advanced once he was weaned from levophed and maintaining a map above he was transferred to the vicu for further recovery while in the vicu he recieved monitored care when stable his arterial line was discontinued pt followed the patient he was then transferred to floor status on the floor he remained hemodynamically stable with his pain controlled he received hemodialysis per his outpatient regimen throughout his stay his vancomycin was admiinstered during hd he was followed by physical therapy he was restarted on his home po medications he continued to make steady progress on the patient was noted to have a dark guiac positive stool he was changed to ppi and his hematocrit was watched closely on his hematocrit had fallen from two days prior to a gi consult was obtained and they recommended upper and lower endoscopy which was performed on after achieving a bowel prep revealing the aforementioned findings in the pertinent results section biopsies were taken which were pending diagnosis at the time of discharge no active bleeding source was found the patient is advised to follow up with dr at gastroenterology as well as with his pcp for further management of his gi nodules and polyp for the remainder of his hospitalization the patient s hematocrit remained fairly stable it is expected that it may drift slightly and this is to be expected he was discharged on pod to a rehabilitation facility in stable condition tolerating a regular diet and with good pain control he was advised to follow up with dr of vascular surgery dr of gastroenterology and his pcp medications on admission toprolxr simvastatin albuterol sulfate mcg fluticasone salmeterol glipizide lisinopril not on hd days calcium acetate tid gabapentin omeprazole triphrocaps sucralfate gm before meals hydrocodone discharge medications omeprazole mg capsule delayed release e c sig two capsule delayed release e c po daily daily fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q h every hours as needed for wheeze simvastatin mg tablet sig one tablet po daily daily gabapentin mg capsule sig one capsule po daily daily aspirin mg tablet sig one tablet po daily daily acetaminophen mg tablet sig one tablet po every six hours as needed for pain disp tablet s refills oxycodone mg tablet sig one tablet po q h every hours as needed for pain disp tablet s refills senna mg tablet sig one tablet po bid times a day as needed for constipation disp tablet s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills b complex vitamin c folic acid mg capsule sig one cap po daily daily metronidazole mg tablet sig one tablet po tid times a day for days disp tablet s refills ciprofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills metoprolol succinate mg tablet extended release hr sig tablet extended release hrs po daily daily lisinopril mg tablet sig two tablet po on non hd days vancomycin in d w gram ml piggyback sig one iv sliding scale per hd protocol intravenous hd protocol for days to be administered during hemodialysis per protocol until disp refills nephrocaps mg capsule sig one capsule po once a day glipizide mg tablet sig tablet po twice a day calcium acetate mg capsule sig one capsule po three times a day sucralfate gram tablet sig one tablet po before meals discharge disposition extended care facility discharge diagnosis peripheral vascular disease left lower extremity gangrene discharge condition mental status clear and coherent level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair activity per rehabilitation regimen discharge instructions this information is designed as a guideline to assist you in a speedy recovery from your surgery please follow these guidelines unless your physician has specifically instructed you otherwise please call our office nurse if you have any questions dial if you have any medical emergency activity there are restrictions on activity on the side of your amputation you are non weight bearing until cleared by your surgeon you should keep this amputation site elevated when resting you may use the other leg to assist in transferring and pivots but try not to exert to much pressure on the amputation site when transferring and or pivoting please keep knee immobilizer on at all times to help keep the amputation site straight no driving until cleared by your surgeon exercise follow the recommendations of the rehabilitation facility limit strenuous activity for weeks do not drive a car unless cleared by your surgeon try to keep leg elevated when able bathing showering you may shower no bathing soaking a dressing may cover your amputation site and this should be left in place for three days remove it after this time and wash your incision s gently with soap and water you will have staples which are usually removed in weeks this will be done by the surgeon on your follow up appointment wound care sutures staples an appointment will be made for you to return for staple removal if sutures are removed the doctor may or may not place pieces of tape called steri strips over the incision these will stay on about a week and you may shower with them on if these do not fall off after days you may peel them off with warm water and soap in the shower avoid taking a tub bath swimming or soaking in a hot tub for four weeks after surgery medications unless told otherwise you should resume taking all of the medications you were taking before surgery you will be given a new for pain medication which can be taken every three to four hours only if necessary remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet check with your physician if you have fluid restrictions if you feel that you are constipated do not strain at the toilet you may use over the counter metamucil or milk of magnesia appetite suppression may occur this will improve with time eat small balanced meals throughout the day cautions no smoking we know you ve heard this before but it really is an important step to your recovery smoking causes narrowing of your blood vessels which in turn decreases circulation if you smoke you will need to stop as soon as possible ask your nurse or doctor for information on smoking cessation avoid pressure to your amputation site no strenuous activity for weeks after surgery diet there are no special restrictions on your diet postoperatively poor appetite is expected for several weeks and small frequent meals may be preferred for people with vascular problems we would recommend a cholesterol lowering diet follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood additionally some people see a reduction in serum cholesterol by reducing dietary cholesterol since a reduction in dietary cholesterol is not harmful we suggest that most people reduce dietary fat saturated fat and cholesterol to decrease total cholesterol and ldl low density lipoprotein the bad cholesterol exercise will increase your hdl high density lipoprotein the good cholesterol and with your doctor s permission is typically recommended you may be self referred or get a referral from your doctor if you are overweight you need to think about starting a weight management program your health and its improvement depend on it we know that making changes in your lifestyle will not be easy and it will require a whole new set of habits and a new attitude if interested you can may be self referred or can get a referral from your doctor if you have diabetes and would like additional guidance you may request a referral from your doctor follow up appointment be sure to keep your medical the key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have things like high blood pressure diabetes and high cholesterol are major villains to the blood vessels don t let them go untreated please call the office on the first working day after your discharge from the hospital to schedule a follow up visit this should be scheduled on the calendar for seven to fourteen days after discharge normal office hours are through friday please feel free to call the office with any other concerns or questions that might arise followup instructions please call dr office for a follow up appointment please call dr at gastroenterology for a follow up appointment in weeks please call your primary care physician for visit in about week completed by,"{
""Diagnoses"": [""Anemia"", ""History of Present Illness"", ""Peripheral Vascular Disease"", ""Chronic Kidney Disease"", ""Hypertension"", ""Coagulopathy"", ""Gastritis"", ""Nodular Lesion in Duodenum""],
""Medications"": [""Red Blood Cells"", ""Vitamin K"", ""Fresh Frozen Plasma""]
}"
18291,admission date discharge date date of birth sex f service neurosurgery history of present illness the patient is a year old female with a history of diabetes mellitus end stage renal disease on hemodialysis and hypertension who was found unresponsive on her floor on the patient was last seen awake and talking the previous night the patient was intubated in the field and brought in at blood pressure on admission was to to pulse to on initial examination the patient was unresponsive to voice the patient was intubated the patient showed decerebrate posturing to sternal rub face symmetric pupils mm fixed positive ocr no blink decreased tone throughout head ct revealed subarachnoid hemorrhage large right basal ganglia bleed and extension into the ventricles with evidence of hydrocephalus and a cm midline shift the patient the same day on underwent a right frontal intraventricular drain placement the patient continued to be monitored in an intensive care unit setting on the patient had evidence of brain stem compression with a left cranial nerve iii palsy this was explained to the family on on neurological examination the patient had no pupillary response to light no ocr no corneals no gag reflux with ett movement no cold cholurics bilaterally no withdraw to pain in any extremities no posturing or movement with sternal rub neurological no brain stem reflexes were elicited and given the lack of response this is consistent with brain death the patient was reexamined later that day and again fulfilled brain death criteria this was discussed with the family and the family made the decision to withdraw the patient off life support and off the ventilator the ventilator was shut off in the evening of and the patient was declared dead at p m m d dictated by medquist d t job,"{
""Diagnoses"": [""history of present illness"", ""subarachnoid hemorrhage"", ""large right basal ganglia bleed"", ""extension into the ventricles"", ""hydrocephalus"", ""midline shift""],
""Medications"": [""hemodialysis"", ""hypertension"", ""intubation"", ""ventricular drain placement""]
}"
23628,unit no admission date discharge date date of birth sex m service nb reason for admission prematurity weeks gestation maternal history baby boy was to year old g p mother with prenatal screen a antibody negative hbsag negative rprnr rubella immune gbs unknown pregnancy was complicated by twin gestation dichorionic diamniotic maternal pih pre eclampsia increased bp proteinuria and visual changes and gestational diabetes mellitus requiring insulin in addition maternal medical history is notable for crohn s disease polycystic ovarian disease and endometriosis due to pre eclampsia in the mother she proceeded for elective cesarean section after a course of betamethasone delivery the baby was by elective cesarean section there were no perinatal risk factors fever prolonged rupture of membrane or chorioamnionitis the baby was in good condition requiring no resuscitation apgar s and at and minutes respectively physical examination on admission weight th percentile length cm percentile head circumference cm th percentile gen non dysmorphic pink alert heent intact palate and clavicle neck supple respiratory mild intermittent grunting no flaring or retractions cardiovascular regular rate and rhythm no murmur abdomen soft bowel sounds present genitourinary normal male genitalia b l testes descended patent anus extremities spine normal hips stable skin cm regular brown nevus on the back neurological active alert tone normal symmetrical movements summary of hospital course by systems respiratory baby boy had very mild respiratory distress at the time of birth which rapidly resolved he continued to breath in room air throughout the hospital stay he had no significant apnea of prematurity cardiovascular no concerns fluid electrolyte and nutrition he was initially commenced on intravenous fluid d w feeds were started on the first day of life and he was on full feeds by day of life feeds were further advanced to a maximum of ml kg day of pe for better weight gain at the time of discharge he is on ad lib p o feeds of e taking approximately to mls kg day weight at discharge g gi he had no significant gastrointestinal problems was noted to have mild candidiasis of the diaper area the day before discharge that is responding well to topical miconazole therapy he received phototherapy for physiological jaundice exaggerated by prematurity maximum bilirubin was mg dl on day of life hematology he did not require any blood transfusion during hospital stay infectious disease he had no episodes of suspected or proven sepsis neurology normal sensory he has passed his newborn hearing screen ophthalmology he does not fulfill criteria for rop screening psychosocial no concerns condition on discharge well discharge disposition home primary care pediatrician dr m d pediatrics telephone care and recommendation feeds on discharge ad lib p o e feeds monitor weight gain to stop topical miconazole after days course medications miconazole powder topical to diaper area times a day with diaper change started car seat positioning screen passed state newborn screening status normal immunizations hepatitis b was given on immunizations recommended synagis rsv prophylaxis should be considered from through for infants who meet any of the following criteria at less than weeks at and weeks with of the following day care during rsv season smoker in the household neuromuscular disease airway abnormalities or school age siblings or with chronic lung disease influenza immunization is recommended early in fall for all infants once they reach months of age before this age and for the first months of the childs life immunization against influenza is recommended for household contacts and out of home caregivers follow up recommended with primary care physician to days following discharge discharge diagnosis prematurity weeks gestation twin of twin pregnancy reviewed by dictated by medquist d t job,"{
""Diagnoses"": [""prematurity"", ""gestational diabetes mellitus"", ""hypertension"", ""proteinuria"", ""visual changes""],
""Medications"": [""betamethasone"", ""insulin""]
}"
26048,admission date discharge date date of birth sex f service medicine allergies nsaids attending chief complaint pain with swallowing hoarse voice admitted after ent saw epiglottitis on laryngoscopy major surgical or invasive procedure none history of present illness yo f w recent diverticulitis p w dysphagia x d pt had otherwise been completely healthy until mid when developed abdominal pain and diarrhea she was hospitlaized in where had been living for several months there she had a negative c diff and ct abd pelvis showed diverticulitis she was treated with amox clavulnate since then to finish a week course since then she has had near resolution of the abdominal pain and diarrhea days ago she developed acute sore throat it progressively got worse until she was seen in the ed where monospot was sent and was negative and given the number for outpt ent where she was seen laryngoscopy showed epiglottitis she was sent to the for direct admission and then ent suggested she be admitted to the icu for continuous o sat monitoring past medical history diverticulitis recently chronic back pain secondary to spondylosis arthritis s p appendectomy cholecystectomy tonsillectomy tubal ligation gerd social history no sick contacts history of tobacco quit at age occasional etoh no ivdu lives with husband has children teaches one class at was at working on a book independent adl s family history no dm cad htn mgm and pgf with colon ca fathre died secondary to aortic aneurysm physical exam t bp p rr o ra gen well nourished pleasant heent perrl eomi mmm erythematous posterior op cv rrr normal s s pulm cta no stridor no wheeze abd nabs s nd nt extr no c c e dp neuro aaox nonfocal pertinent results pm plt count pm neuts lymphs monos eos basos pm wbc rbc hgb hct mcv mch mchc rdw pm calcium phosphate magnesium pm glucose urea n creat sodium potassium chloride total co anion gap brief hospital course ms is a year old female with recent diverticulitis presenting with five days of dysphagia she was admitted after an urgent visit to ent in which laryngoscopy showed epiglottitis she was initally treated with iv unasyn however given concern that she may have developed epiglotitis while on augmentin was being treated with augmentin for diverticulitis her antibiotics were switched to ceftriaxone and clindamycin on this regimen she had improvement of her symptoms and she was transferred to the floor on on the floor she developed llq pain similar to her diverticulitis pain ct scan was done on showing thickening of the sigmoid colon with fat stranding surgery consulted and felt imaging and the physical exam were both consistent with diverticulis clindamycin and ceftriaxone were stopped did recieve doses in afternoon on and levo flagyl were started on ampicillin was added later that day as well dose x she was also given a single dose of fluconazole for vaginitis and started on nystatin s s for oral thrush on she complained of increased swelling in her throat after evaluation by house doctor ent was called to re evaluate there exam showed increased swelling and pus in the posterior oropharynx her o sat dropped to on ra which returned to on l she was given g of vancomycin and started on decadron mg iv q h she was transferred to the for continuous o monitoring in the patient did well with o sat l abx were switched to augmentin for epiglottitis flagyl for diverticulitis and decadron patient was then transferred to f for continuous o monitoring on the floor the patient received continuous o sat monitoring after ent saw her the morning of noting improvement of her epiglottitis the decadron was discontinued she was monitored for the rest of the day and her o sats were steady at on room air the patient s diarrhea improved throughout the admission and by the time she was transferred to the floor she flet no abdominal pain she was given vaccinations for both h flu and pneumococcus while inpatient she was discharged on augmenting mg po bid for days flagyl mg po tid for days and a total course of days of fluconazole she was given phone numbers to make follow up appointments with dr surgery dr ent and dr primary care medications on admission amox clav x percocet prn lidocaine viscous ibuprofen estring discharge medications pramoxine mineral oil zinc ointment sig one appl rectal times a day as needed disp bottle refills pantoprazole 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 amoxicillin pot clavulanate mg tablet sig one tablet po bid times a day for days disp tablet s refills fluconazole mg tablet sig one tablet po q h every hours for days disp tablet s refills metronidazole mg tablet sig one tablet po tid times a day for days disp tablet s refills discharge disposition home discharge diagnosis epiglottitis diverticulitis infection discharge condition stable satting well on room air tolerating po discharge instructions please take all of your medications as instructed if you experience a sore throat difficulty swallowing pain swallowing fever difficulty breathing or any other concerning symptoms please seek medical advice immediately followup instructions please set up an appointment with dr for ent follow up provider surgical assoc a sb date time provider md phone date time provider md phone date time provider suite gi rooms date time,"{
""Diagnoses"": [""epiglottitis"", ""diverticulitis"", ""acute sore throat""],
""Medications"": [""amox clavulnate"", ""number for outpt ent""]
}"
26421,admission date discharge date date of birth sex m service chief complaint confusion and hypoxia history of present illness this is a year old african american male with a history of mild mental retardation depression psychosis asthma and restrictive lung disease on a home oxygen requirement of three liters he presented from home after feeling confused this morning at baseline mr pulmonary disease leaves him with a chronic nonproductive cough and limits him from walking any length of time or climbing stairs he was in his usual state of health until the morning of admission when he awoke and felt confused and lethargic he was unable to eat his breakfast which he states demonstrates a major deviation from baseline according to his mentor he has had episodes of confusion where he is unable to recall the day of the week this has been happening intermittently over the course of the week prior to admission upon arrival to the emergency department his oxygen saturation was percent on three liters oxygen at the time of this interview he denied worsening shortness of breath and in fact says that this is a good day for his breathing he also denies increase in the severity of his cough from baseline chest pain pleuritic chest pain headache nausea vomiting diarrhea melena bright red blood per rectum abdominal pain dysuria fever chills night sweats or unexplained loss of weight the patient has had a medication change in the past couple of weeks his outpatient psychiatrist dr discontinued his paxil and risperidone and started him on zyprexa mg q p m instead mr has a known mixed restrictive obstructive lung disease of unknown etiology and is followed by the pulmonary team at in particular by m d his baseline chest x ray shows an interstitial pattern with a patchy infiltrate on the left lower lobe he has a history of multiple presentations to this hospital with symptoms of shortness of breath confusion and chest x rays that show an interstitial pattern he has been treated empirically multiple times for pneumonia and asthma flares he was intubated once in at which time he had a pneumonia with empyema past medical history his past medical history is significant for restrictive lung disease with his last pulmonary function test on with an fev of liters percent of predicted and an fvc of liters which is percent of predicted his tlc is percent of predicted and dlco percent of predicted as reported on his oxygen saturations tend to run approximately percent in room air it decreases to percent in room air with exercise he is followed by dr of the pulmonary service it is unclear of the exact nature of his disease it may be a complicated picture including an interstitial lung process of unknown etiology as well as obstructive sleep apnea asthma and possibly a neuromuscular disorder as well the patient has a history of methicillin resistant staphylococcus aureus and pneumonia he had a last empyema which required thoracotomy and decortication in he was intubated and required hospitalization in the medical intensive care unit at that time he also has a history of hypertension the patient had an electrocardiogram in which showed a right ventricular dilation he has a history of depression with psychosis the patient is noted to have a self inflicted abdominal wound where he stabbed himself in the stomach in it was apparently after his father had passed away he was admitted for psychiatric hospitalization in with auditory hallucinations and again in with a hypomanic episode he has a history of mild mental retardation history of gastrointestinal bleed from internal hemorrhoids total left hip replacement status post septic arthritis of that hip hernia repair cervical stenosis of c with bilateral hand weakness he has a history of obstructive sleep apnea which was confirmed by a sleep study prior to admission he has a history of corneal ulcer status post right corneal transplant he has stasis dermatitis on bilateral lower extremities followed by dermatology with negative in the past medications his medications on admission included albuterol two puffs q i d flovent two puffs b i d singular ten puffs p o q h s serevent two puffs t i d mg p o b i d cardura mg p o q h s monopril mg p o q day lasix mg p o q day neurontin mg p o q a m mg p o q h s zyprexa mg p o q p m tylenol mg p o q i d p r n detrol mg p o q day prednisolone acetate eye drops one drop to both eyes t i d allergies the patient is allergic diltiazem and lactose family history his father died of a myocardial infarction at age mother died of cancer the patient also reports asthma in his sister social history the patient has attended special needs classes through the ninth grade and worked in hospitals as a housekeeper he is currently in a mentor program and lives with a family and attends the center five days per week he has a caseworker whose name is he states he has a number of friends at the senior center program and denies drug and alcohol use now and in the past physical examination temperature on admission was blood pressure pulse respiratory rate oxygen saturation percent on three liters oxygen nasal cannula generally he was awake and alert breathing comfortably pleasant oriented to place and cooperative with exam heent exam revealed pupils are equal round and reactive to light extraocular movements intact oropharynx clear moist mucous membranes his neck had no jugular venous distention and was supple with full range of motion his lungs revealed some inspiratory crackles left greater than right and decreased lung sounds at the right base cardiovascular exam revealed a regular rate and rhythm slightly tachycardiac normal s and s no murmurs rubs or gallops appreciated his abdomen had a large midline scar positive bowel sounds soft and obese nontender and nondistended his extremities had evidence of chronic stasis dermatitis no edema or cyanosis and his neurological exam was nonfocal laboratory data on admission his white count was hematocrit platelets sodium potassium chloride bicarbonate bun creatinine glucose ck mb troponin of less than alt ast alkaline phosphatase total bilirubin theophylline his urinalysis was unremarkable chest x ray shows slight left ventricular enlargement right pleural effusion and a lower lobe infiltrate possibly consistent with consolidation his electrocardiogram showed normal sinus rhythm at beats per minute with a normal axis and some new t wave inversions changed from prior electrocardiogram in leads v v hospital course briefly this is a year old male with severe asthma obstructive sleep apnea restrictive lung disease and a psychiatric history with a recent psychiatric medication change who presented with episodes of confusion lethargy and hypercarbia problem pulmonary the patient was admitted with confusion and elevated bicarbonate his pulmonary picture was likely multifactorial he has a history of obstructive sleep apnea confirmed by a sleep study as well as both severe restrictive lung disease of unknown etiology and asthma the patient also has a history of multiple elevated ck enzymes in the past thought to be from a muscle source as well as a markedly abnormal emg which raised the concern of a neuromuscular component to his hypercapnia the patient is followed by dr from neurology of note his vital capacity decreases percent when he lies flat compared to sitting upright at the time of admission the patient was on three liters of oxygen via nasal cannula chronically at home which he started several months ago however the patient had refused bi pap because he did not tolerate it at the time of his initial presentation the patient had an oxygen saturation in the high s and described his breathing as comfortable because of the concern about a possible left lower lobe infiltrate on his chest x ray a fever and a cough the patient was treated with a seven day course of levofloxacin initially during his hospitalization he was not on bi pap and had multiple episodes at night where he would desaturate into the s when lying flat on his three liters of oxygen he is a carbon dioxide retainer and one night after his oxygen was increased to ten liters per minute because of his desaturation the patient became somnolent and confused he was briefly transferred to the medical intensive care unit for observation and placed on bi pap with resolution of his confusion and somnolence the patient was then continued on bi pap at night which he tolerated very well initially during the remainder of his hospitalization the patient also had a high resolution chest ct to rule out pulmonary embolism which showed no evidence of pulmonary embolism he was continued on his metered dose inhalers and theophylline and had no evidence of worsening of his asthma throughout his hospital course he also had no evidence of congestive heart failure on exam and was not felt to have congestive heart failure as a contributing factor to his hypoxia he was scheduled for a muscle biopsy to further evaluate his possible neuromuscular disease but the patient had become increasingly psychotic by that time and was unable to consent for the procedure during the last five days of his admission he remained stable from a pulmonary point of view on his home three liters of oxygen he did however start to refuse his bi pap at night as he became more agitated and paranoid although he did not have evidence of desaturation at night after he had completed a course of levofloxacin problem cardiovascular mr has no known history of coronary artery disease and has had no signs or symptoms of congestive heart failure while at his electrocardiogram in the emergency department however did show some evidence of right heart strain as well as some t wave inversions in leads v v that were not present on a prior electrocardiogram he was ruled out for myocardial infarction with multiple enzymes which were notable however for the fact that his cks were elevated although his mb fractions were quite low again indicating possible chronic myositis the patient had no episodes of chest pain throughout his hospitalization his electrocardiogram was rechecked several times and was stable without any changes from the electrocardiogram done in the emergency department he had a transthoracic echocardiogram done during admission which showed an ejection fraction of percent it also showed some evidence of right ventricular hypokinesis consistent with pressure overload and revealed some underlying pulmonary hypertension problem gastrointestinal the patient was noted to have mildly elevated liver function tests during his admission but he did not complain of any gastrointestinal symptoms of abdominal pain a right upper quadrant ultrasound was obtained which showed no evidence of gallstones or biliary obstruction but did show mildly dilated common bile duct if his liver function tests remain elevated in the future he can get an mrcp as an outpatient problem psychiatric this patient has mild mental retardation as a baseline as well as an extensive psychiatric history including manic depression with psychotic episodes two weeks prior to admission his paxil and risperidone were discontinued by his outpatient psychiatrist and he was started on zyprexa mg p o q p m it was given at p m to minimize morning sleepiness on the day of admission the patient seemed alert and calm and was very pleasant and answered questions appropriately his mental status declined over several days into his hospital course when he was febrile and had become acutely hypercarbic secondary to being on ten liters of oxygen which caused him to retain carbon dioxide he was felt at that time to be delirious secondary to his metabolic issues his thyroid function was normal his b had recently been checked and was also normal as were his electrolytes a head ct was done which showed no evidence of intracranial pathology he was treated with bi pap briefly in the medical intensive care unit and had resolution of his hypercapnia and resolution of his mental status as well he was transferred back to the floor however he was felt to be still more confused and less alert in the mornings compared to the afternoons his evening dose of neurontin was decreased to mg q p m he was then evaluated by psychiatry who thought at that time that his mental status issues were still largely metabolic in nature his zyprexa was decreased to mg q p m down from mg p o q p m to try to improve his confusion in the morning after his zyprexa was decreased he began to be more agitated paced around his room muttered to himself and hallucinated he would speak to people who were not present and began to act very hypervigilant fearful and somewhat paranoid psychiatry again came to evaluate him and his zyprexa dose was then increased to mg p o q p m the last several days of his hospital course were significant in that the patient remained medically stable however he continued to have evidence of increasing psychosis he began to refuse his bi pap again at night and became very distrustful at times alternating with times when he would not want to be left alone it was felt that his medical issues were stable and that his problem was becoming psychiatric and that he would benefit from transfer to an inpatient psychiatric facility problem fluids electrolytes and nutrition the patient had a slightly elevated potassium on admission and was treated with kayexalate in the emergency room his potassium remained stable throughout the rest of his hospital course he was continued on a lactose free diet problem renal his creatinine was on admission which was increased over baseline of but it returned to baseline of with good oral intake of fluids during his hospital course discharge status discharge to hospital for inpatient psychiatric treatment discharge condition stable discharge medications albuterol two puffs q i d flovent two puffs b i d singular mg p o q h s serevent two puffs b i d mg p o b i d cardura mg p o q h s monopril mg p o q day lasix mg p o q day neurontin mg p o q a m mg p o q h s zyprexa mg p o q h s at p m tylenol p r n detrol mg p o q day haldol mg p o intramuscularly q hours p r n agitation prednisolone acetate eye drops one drop to both eyes t i d oxygen three liters nasal cannula all the time do not exceed three liters bi pap at night for obstructive sleep apnea discharge diagnosis restrictive lung disease asthma obstructive sleep apnea carbon dioxide retention methicillin resistant staphylococcus aureus precautions hypertension depression with psychosis mild mental retardation neuromuscular disease of unclear etiology corneal ulcers cervical stenosis dr dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service history of present illness briefly the patient is a year old male with a history of mental retardation psychosis restrictive obstructive lung disease obstructive sleep apnea on home bipap with poor compliance who initially presented to the emergency department with hypersomnolence in the emergency department he was not complaining of chest pain shortness of breath nausea vomiting diaphoresis or edema he had recently recovered one week before from a upper respiratory infection with day course of doxycycline in the emergency room the patient was arousable but very groggy with an arterial blood gases of the patient then dropped his blood pressure to and was subsequently intubated for hypercarbia in the medicine intensive care unit the patient was started on a prednisone taper albuterol and atrovent nebulizers bipap at night the patient did rule out for myocardial infarction he was extubated hours after admission and started on full face bipap he was also started on vancomycin and flagyl which was then discontinued in favor of levofloxacin mg q d for a probable pneumonia and left lower lobe infiltrate on chest x ray the patient has a past medical history of mental retardation asthma with fev of fec of dlco depression chronic obstructive pulmonary disease with also restrictive features of lung disease and multiple admits and multiple intubations hypertension ejection fraction of greater than by a echocardiogram obstructive sleep apnea total hip replacement methicillin resistant staphylococcus aureus positive and a corneal ulcer medications on admission albuterol puffs q i d flovent puffs b i d singulair puffs p o q h s serevent puffs t i d mg p o b i d cardura mg p o q h s monopril mg p o q d lasix mg p o q d neurontin mg p o q am mg p o q h s zyprexa mg p o q pm tylenol mg p o q i d prn detrol mg p o q d prednisolone acetate eyedrops one drop in both eyes t i d allergies diltiazem and lactulose family history father died of an myocardial infarction at age mother died of cancer the patient also reports asthma in his sister social history the patient has a case worker he currently lives with a mentor in an adult home he attends classes at the center five days a week physical examination examination on transfer to the floor revealed temperature blood pressure heartrate respiratory rate saturation on face mask general alert and oriented times three in no acute distress head eyes ears nose and throat showed extraocular movements intact pupils equal round and reactive to light and accommodation no jugulovenous distension bilateral erythema with slight discharge in both eyes neck no jugulovenous distension no lymphadenopathy chest left basilar crackles right bronchial breathsounds heart regular rate and rhythm s and s with no rubs gallops or murmurs abdomen distended nontender normoactive with no hepatosplenomegaly extremities no edema or cyanosis neurological asymmetric muscle weakness with strength in the right quadriceps strength in the left biceps laboratory data laboratory data on transfer to the floor revealed sodium potassium chloride bicarbonate bun creatinine glucose calcium phosphorus magnesium arterial blood gases complete blood count white blood count hematocrit platelets the chest x ray showed bilateral effusion patchy atelectasis urinalysis was negative for infection electrocardiogram showed tachycardia a sinus right axis deviation right atrial hypertrophy and t wave inversions in the lateral leads echocardiogram showed normal ejection fraction right ventricular hypertrophy left ventricular hypertrophy tricuspid regurgitation and mild pulmonary hypertension hospital course while on the floor pulmonary the patient was admitted with increased carbon dioxide and hypersomnolence with hypercapnic respiratory failure on the floor he was weaned from face mask to nasal cannula with saturations of to on liters the patient was thought to have his hypercarbic respiratory failure because of his combination of obstructive restrictive pulmonary disease and his obstructive sleep apnea with noncompliance of his bipap which he could not tolerate it is thought his obesity contributes to his restrictive disease the patient also had a cough which resolved over the course of his floor stay the patient was treated for empiric pneumonia with levaquin mg q d the patient was put on a prednisone taper starting at mg q d times three days and decreasing to mg p o q d and will subsequently be tapered down with etc the patient was put on bipap at night but could not tolerate this the patient should follow up with dr in the pulmonary clinic at two to three weeks after discharge from his pulmonary rehabilitation for evaluation for question of tracheostomy placement to deliver the bipap his carbon dioxide upon discharge was as well cardiology the patient has some evidence of right ventricular changes with his lung disease these are right axis deviation on his electrocardiogram right atrial hypertrophy on the electrocardiogram and chest x ray chronic venous stasis and mild pulmonary hypertension on echocardiogram it is unclear what precipitated the patient s episode of hypotension in the emergency room he ruled out for myocardial infarction and sepsis was unlikely the plan from a cardiac standpoint was to try to treat his obstructive sleep apnea to improve his right ventricular function and to continue his cardiac medications of the lisinopril mg p o q d and his furosemide mg p o q d for likely some degree of right sided failure infectious disease the patient was treated for presumptive pneumonia with his examination findings of left lower lobe crackles and his effusion on chest x ray he was treated with levaquin mg q d he was continued on this for today the patient is also methicillin resistant staphylococcus aureus positive and was placed on isolation precautions while on the genitourinary the patient also had intermittent hematuria for the first two days while on the floor he had a foley catheter in place which was removed and the hematuria resolved promptly psychiatric the patient has a history of severe depression and psychosis it has been mentioned that this may have been related to his steroid treatment although this is unclear was continued on his neurontin and olanzapine and was written for prn ativan for agitation which he did not receive there were no active issues in his depression or psychosis during this stay conjunctivitis the patient had a history of corneal ulcer but also had conjunctivitis which was likely due to oxygen toxicity from his face mask which was sitting loosely he was continued on his prednisolone acetate eyedrops and also added erythromycin eyedrops to this fluids electrolytes and nutrition the patient continued to take a p o diet while on the floor and did not have any electrolyte abnormalities with the exception of his persistently raised yet stable bicarbonate level the patient s baseline bicarbonate level is low s high s prophylaxis the patient was maintained on p o protonix for gastrointestinal prophylaxis and was allowed to be out of bed code status the patient is full code condition on discharge good disposition the patient will be discharged to a pulmonary rehabilitation facility discharge medications levaquin mg p o q d prednisone taper mg p o q d first dose on and will continue on that for three days then mg p o q d times three days mg p o q d times three days prednisone taper and then will stop albuterol to puffs inhaled q prn metered dose inhaler albuterol nebulizer solution nebulizer inhaled prn q hours epitropion nebulizers nebulizer inhaled q hours prn epitropion bromide metered dose inhaler puff inhaled q hours olanzapine mg p o b i d gabapentin mg p o b i d furosemide mg p o q d prednisolone acetate drop t i d salmeterol puffs b i d multilucast mg p o q d lisinopril mg p o q d detrol mg p o q d cardura mg p o q h s mg p o b i d pantoprazole mg p o q hours the patient was not tolerating his nasal cpap and will not be continued on that until pending an evaluation by dr the patient will be maintained on nasal cannula to keep his oxygen saturations greater than and less than the patient was discharged to dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service addendum the patient will be discharged to discharge medications the patient s levaquin was discontinued on to complete a ten day course for presumed pneumonia the patient is on his last day of prednisone mg by mouth x days and the patient should begin prednisone mg by mouth x days on and then move to mg by mouth x days and then stop the prednisone taper theophylline was also added on the this was theophylline mg by mouth twice a day the patient has an appointment with dr and this appointment should be in two weeks after discharge on discharge the patient s laboratories were a sodium of potassium chloride bicarbonate bun creatinine glucose white blood count hematocrit platelets calcium phosphorus magnesium condition at discharge good discharge status discharged to discharge diagnosis hypercapnic respiratory failure obstructive sleep apnea restrictive pulmonary disease from inclusion body myositis and obesity m d dictated by medquist d t job cc [NEW_RECORD] admission date discharge date date of birth sex m service chief complaint hypoxia change in mental status history of present illness this is a year old man with a history of mental retardation congestive obstructive pulmonary disease restrictive lung disease with known co retention obstructive sleep apnea who was discharged from the on after admit for hypoxemia which improved with liters of o by nasal cannula patient was discharged at that time without intervention on the date of admission the patient was noted to have increasing lethargy and also noted to have body twitching which he has had on previous admission as well on admission the patient was afebrile and had o sat of on liters he seemed increasingly weak and lethargic and had incontinence of bowel and bladder which was new for him the patient was sent to the emergency department for evaluation somewhere between the emergency department and the ambulance the patient was placed on nonrebreather in the emergency department he was noted to be lethargic and arterial blood gas done which was this improved and the patient was decreased to a face mask once the patient became slightly less lethargic he had a productive cough for several days he says he was coughing up food particles on occasion but had difficulty clearing secretions at time denied any fever or chills did have some dyspnea in the emergency department he was given levo flagyl and ceftriaxone for questionable left lower lobe infiltrate and intravenous solu medrol in case of congestive obstructive pulmonary disease care he is admitted to the vicu past medical history mild mental retardation congestive obstructive pulmonary disease status post intubation in for hypercarbia secondary to increased oxygen by nonrebreather the patient is on liters of home o asthma obstructive sleep apnea the patient does not tolerate bipap depression with psychosis osteoarthritis status post right total hip replacement methicillin resistant staphylococcus aureus empyema in corneal ulcer status post transplant bilateral arteritis question of myositis biopsy on consistent with myopathic changes but without definitive diagnosis the patient has been on steroids on cervical stenosis hypertension self inflicted abdominal wound stabbing history of septic arthritis with total hip replacement benign prostatic hypertrophy allergies diltiazem dust eggs and lactose medications pred forte od qid albuterol atrovent nebulizer prednisone taper as mg po q day cardura mg po q day monopril mg po q day detrol mg po q day singulair mg po q day multivitamin tums serevent inhaler two puffs zyrtec mg po q day iron sulfate mg po q day neurontin mg po bid zyprexa mg po bid social history the patient is living at the his sister is the health care proxy smoking history physical examination on face mask general breathing comfortably in no acute distress heent extraocular muscles are intact mucous membranes are moist oropharynx is clear neck no jugular venous distention lungs poor air movement no wheezes rales or rhonchi decreased breath sounds at the right base cardiovascular regular rate and rhythm no murmurs rubs or gallops abdomen is soft nontender nondistended positive bowel sounds extremities dusky skin discoloration bilateral lower extremity edema dorsalis pedis pulses bilaterally neurologic is alert and oriented times three cranial nerves ii through xii are intact laboratories white blood cells hematocrit bicarb chest x ray poor study but question of left lower lobe pneumonia pulmonary function tests on demonstrated a fvc of fev of fev fvc of chest ct scan in demonstrated enlarged pulmonary artery bibasilar atelectasis ground glass opacities in bilateral upper mid lung zones hilar adenopathy bronchiectasis in the left lower lobe hospital course hypoxia the patient was admitted to the micu for question of left lower lobe pneumonia versus congestive obstructive pulmonary disease exacerbation patient s o sats remained stable for the patient and he was quickly titrated down from his face mask to his nasal cannula of liters as the patient was at his baseline oxygen requirements it was not felt to be a congestive obstructive pulmonary disease exacerbation patient has been started on higher dose of prednisone in the micu but when he was transferred to the floor the patient was placed back on his taper of mg po q day the patient was maintained on levaquin mg po q day to complete a seven day course for a question of a left lower lobe infiltrate due to the patient s poor ability to comply with x rays this could not be further evaluated patient s myopathic disease likely contributes to his difficulty breathing and inability to clear hypercarbia the patient was transferred out of the micu on hospital day one and did very well he was at his baseline and ready to return to the myopathy i discussed the case with dr the patient s neurologist who said the patient s myopathy was of unclear etiology and had nonspecific biopsy results no further workup was planned as the patient has not had good results from steroid use steroids were being tapered this plan was continued as inpatient the patient will continue his outpatient steroid taper at star of swallowing the patient was questioned to have aspiration stating that he was coughing up food particles bedside swallow evaluation was performed which did not reveal any signs of aspiration the slight decrease in clearing of secretions may be related to his myopathy a video swallow was not performed as there was self limited utility iritis corneal ulcer as patient has missed several outpatient appointments with his ophthalmologist dr the patient was sent to clinic from the floor dr was unavailable but he was seen by another ophthalmologist examination revealed no evidence for iritis corneal transplant doing well no evidence for corneal ulcer artificial tears was recommended qid for keratitis follow up with dr in one month discharge condition stable discharge status the patient will be discharged to star of with followup in one month with dr discharge medications predforte od qid albuterol atrovent nebulizer prednisone taper as mg po q day cardura mg po q day monopril mg po q day detrol mg po q day singulair mg po q day multivitamin tums serevent inhaler two puffs zyrtec mg po q day iron sulfate mg po q day neurontin mg po bid zyprexa mg po bid levaquin mg to complete seven day course currently day artificial tears ou qid dictated by medquist d t job,"{
""Diagnoses"": [""Confusion"", ""Hypoxia"", ""Asthma"", ""Restrictive lung disease"", ""Mental retardation"", ""Depression"", ""Psychosis""],
""Medications"": [""Oxygen""]
}"
10425,admission date discharge date date of birth sex m service narrative summary the patient was admitted to the hospital pretransplantation for possible pancreatic transplantation the pancreatic transplantation was aborted due to aberrancy with abnormal anatomy in the donor organ the patient mr was then informed that the donor organ was unsuitable and therefore for this reason he was discharged home in stable condition status post potential pancreatic transplant dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service admitting diagnosis type diabetes mellitus called in for a possible pancreas transplant history of present illness the patient is a year old male status post living unrelated kidney transplant for end stage renal disease secondary to type diabetes he had a baseline creatinine of he experienced increase in creatinine in needle biopsy positive for acr with foci of mild endotheliitis he was treated with okt creatinine decreased to he was placed on prograf and rapamune without steroids on he called to report mouth sores rapamune dose was lowered to mg for a level of his mouth sores improved last creatinine and bun on were stress test performed for complaints of fatigue and chest pain fair functional exercise capacity borderline ischemic ekg bp responds to exercise stress echo no d echocardiogenic evidence of ischemia ejection fraction greater than the patient has been doing very well and no chest pain not actively taking blood pressure medications no lower extremity edema no abdominal pain no fevers no chills no nausea vomiting no change in urine or bowel movements eating well without problems past medical history end stage renal disease secondary to type diabetes living unrelated kidney transplant acr treated with okt x days history of anemia history of syncope history of asthma celiac sprue tia in history of hypotension history of atrial fibrillation h pylori history of psoriasis history of osteoarthritis cardiac catheterization history of murmur allergies captopril and iron meds on admission aspirin mg once daily lantus units once daily sertraline mg once daily bactrim ss once daily asacol mg once daily alendronate mg q week plavix once daily humalog ss prograf b i d rapamune mg once daily past surgical history left av wrist fistula status post cardiac catheterization with right coronary stent left cataract removed from eye right cataract removed living unrelated kidney transplant status post t and a status post deviated septum surgery status post cholecystectomy status post bladder tumor excision social history married with child electrical engineer no alcohol no tobacco family history noncontributory physical exam patient awake alert sitting up in bed in no acute distress temperature heart rate bp respirations on room air weight kg heent atraumatic normocephalic eyes pupils equal round react to light eoms are full mouth tongue midline no exudates neck supple no palpable nodes no thyromegaly no carotid bruits bilaterally full range of motion lungs clear to a and p bilaterally cv regular rate and rhythm a systolic ejection murmur of ii vi abdomen positive bowel sounds well healed left lower quadrant incision soft nontender no organomegaly extremities no c c e pulses at and dp groin pulses bilaterally neurologic cranial nerves ii through xii intact motor bilaterally labs on admission hematocrit platelets pt inr ptt ast alt alkaline phosphatase amylase total bilirubin ekg shows normal sinus rhythm no st changes chest x ray compared to continued to be clear no acute pulmonary process hospital course on the patient was waiting for the donor but the donor s organ was not acceptable for this patient the patient was discharged on the patient did return on for potential transplant compared to there was no change in his physical exam no fevers no chills no abdominal pain no swelling to lower extremities no cough no chest pain the patient went to surgery on for pancreas transplant y graft to left lower quadrant and bowel anastomosis performed by dr and there were no complications the patient was stable and went to recovery room please see detailed documentation of the operative note in the computer the patient went to the regular floor postoperatively the patient was placed on thymo mmf and fk was consulted on for blood sugar control and had continued to follow him while he was a patient in the hospital the patient continued on fk atg mmf simulect blood sugars have decreased significantly the patient had an ng tube placed the patient was n p o taking meds p o and clamping ng tube the patient had a jp drain in place which was draining sanguineous fluids labs have been stable the patient was placed on a pca postoperatively for pain control foley was removed on on the patient had an acute hematocrit drop on hematocrit was and this slowly decreased to to to that day so it was decided to get a ct abdomen with iv contrast as well as a ct pelvis the findings demonstrated that there was nothing to explain the significant hematocrit drop postoperative changes around the new pancreas and bowel anastomosis findings were discussed with dr the patient continued to do well with this blood sugars pca was discontinued postoperatively the patient had atelectasis bilaterally but no signs of acute infiltrate from a chest x ray that was done on the patient s hematocrit continued to drop requiring packed red blood cell transfusions and ffp for an inr of on the patient continued to have jp intact but has had bloody output from drain pt and ot were consulted he continued to be afebrile vital signs stable on the patient was brought to the or for abdominal washout with removal of pancreatic hematoma the old incision was opened and a significant amount of old blood and hematoma were present please see or note for detailed information about the procedure that was done on on labs were the following wbc hematocrit platelets pt ptt inr the patient continued to be on tacrolimus and rapamycin during this hospitalization on the patient had a ct abdomen status post washout and complained of abdominal pain diarrhea and elevated white blood cell count ct abdomen and pelvis demonstrated no evidence of small bowel obstruction or drainable fluid collection abdomen interval slight increase in amount of free fluid in the abdomen and pleural effusions after abdominal irrigation the patient had jp drains as well as jp drains after the washout surgery the patient continued to need intermittent transfusions for a low hematocrit the patient was restarted on aspirin and plavix the patient continued to see physical therapy and occupational therapy on the patient had picc line placement for parenteral nutrition on the patient had a lower extremity ultrasound for right lower extremity edema demonstrating no evidence of deep venous thrombosis throughout his hospitalization the patient has been making good urine output the patient had a low grade temperature on with diarrhea and was cultured for that temperature a swab culture that was finalized demonstrated that there was staph coag negative all of his multiple stool cultures have been sent off which have been unremarkable no growth no fungus no microbacteria on the patient had a dobbhoff tube placed under fluoroscopy tpn was switched to tube feeds and the reason behind that was that the diarrhea may be due to the actual tpn on around o clock in the evening the patient had dyspnea without any reason an abg was obtained demonstrating a ph po pco bicarbonate the patient was transferred to sicu just for close monitoring ct obtained cta was obtained to rule out pe ct chest with cta was performed demonstrating bibasilar atelectasis or consolidations with effusions no evidence of a pulmonary embolism the renal team continued to see patient while patient was hospitalized making excellent recommendations on the patient was transferred from the icu to the regular floor since he was stable the patient had repeat gases on and his ph was po co bicarbonate he did have cardiac enzymes obtained which were all unremarkable and so the patient was transferred to far very somnolent very low energy psychiatry came to see patient and felt that he should continue on his antidepressant medication which was zoloft at the present dose and had recommended giving him a trial of ritalin which they recommended starting at mg in the morning they felt that while he is at rehab he should be followed by psychiatrist there the patient continues to do well although very somnolent but awake and ambulating with physical and occupational therapy he has been afebrile vital signs stable his labs have been stable too he continues on tube feeds and he is on rapamycin and tacrolimus for immune suppression medications he has no swelling no lower extremity edema his wounds continues to be clean dry and intact he has good bowel sounds he has mild atelectasis at both bases so the patient is going to go to rehab continue on antibiotics for weeks and continue fluconazole for weeks discharge medications tylenol q h p r n albuterol nebs q h p r n anzemet iv q h p r n fludrocortisone acetate b i d heparin units subcutaneous t i d insulin sliding scale loperamide hcl mg b i d lopressor b i d flagyl mg t i d miconazole powder application tp t i d nystatin oral suspension ml p o q i d percocet p o q h p r n protonix q zosyn iv q for weeks it will be discontinued on zoloft mg p o once daily sirolimus mg once daily bactrim ss tab once daily tacrolimus possibly will leave on mg b i d valganciclovir hcl once daily ritalin mg q a m follow up the patient is going to be following up with dr on at a m at the bldg transplant office on the th fl telephone and also mr is going to follow up with dr on at a m she is also in the bldg transplant office on the th fl telephone and also patient is going to follow up with dr on at a m in bldg th fl the patient should follow up with psychiatrist while patient is at rehab the patient or staff at the rehab facility should call transplant surgery immediately if there are any fevers chills nausea vomiting inability to take medications decreased urine output increased glucose redness bleeding from incision or any questions he should have labs q monday and thursday for cbc chem calcium phosphorus ast total bilirubin lipase amylase urinalysis and a prograf and a rapamycin level results should be faxed to transplant office no driving while taking medications take showers but no heavy lifting for the past days the patient s tacrolimus level has been ranging from to the last one was on which was rapamycin levels the last one was on and it was they have been ranging from to the patient is currently on rapamycin mg once daily so levels are pending for today and the discharge medications may change according to the levels final diagnoses type insulin dependent diabetes mellitus status post pancreas transplant second surgery was washout of the abdomen on dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service surgery allergies captopril iron prednisone attending chief complaint massive gi bleed major surgical or invasive procedure exploratory laparotomy with ligation of arterial inflow to pancreatic allograft small bowel resection bilateral chest tube placement and removal of percutaneously placed right common iliac balloon exploratory laparotomy with enteroenterostomy and abdominal wall closure placement of a x mm balloon expandable covered stent in the right common iliac artery post pyloric feeding tube placement history of present illness yo m pmh kidney t p pancreas t p cad s p rca stent who presents with gi bleeding the pt was in his usual state of health until the morning before admission when he became nauseas and began to vomit and then had loose bm shortly after the bowel movement he felt weak laid down and was called while on the floor he had a large volume bloody stool per his wife he had not complained of fevers chills abdominal pain or any other symptoms prior to this sequence of events he has no prior history of either upper or lower gi bleeding he was initially transported to the ed and noted to have brbpr he wouldn t tolerate ng lavage sbp initially and went to s with fluid bolus he received unit of irradiated prbcs on ecg at noted to have anterior lateral st depressions that improved after transfusion he was admitted to the micu and went to ir for angiography he had appeared to stop bleeding approximately minutes prior to angiography and no bleeding was discovered at the time of the procedure he was brought back to the micu and continued to be monitored he was on levophed overnight and received rbc ffp and platelet transfusion large volume hematochezia then ensued at approximately am on and the massive transfusion protocol was activated by dr he is being actively transfused at the time of this note ng lavage was performed by drs and with return of brb this had been done earlier by the micu attending overnight with return of bile and water gi has been emergently consulted for egd past medical history past medical history diabetes with esrd osteoarthritis celiac sprue cardiac cath s p stent placement in tia in afib htn history of microsporidiosis past surgical history s p lurt now with cri pak with acute rejection episode treated with okt h o peripancreatic hematoma s p washout exploratory laparotomy with ligation of arterial inflow to pancreatic allograft small bowel resection bilateral chest tube placement and removal of percutaneously placed right common iliac balloon exploratory laparotomy with enteroenterostomy and abdominal wall closure placement of a x mm balloon expandable covered stent in the right common iliac artery post pyloric feeding tube placement social history lives with his wife etoh tobacco or illicit drug use family history father with bleeding stomach ulcer physical exam hr bp rr on vent spo gen intubated sedated heent ngt in place no blood in mouth cv rrr no m g r pulm clear to auscultation b l no w r r abd increasing distension of the abdomen massive brbpr ext le cool becoming somewhat mottled laboratory cbc cbc actively being transfused imaging and sma angiography without mesenteric bleed 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 am blood hct am 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 am blood alt ast ld ldh alkphos totbili am blood triglyc am blood tsh am blood t t am blood tacrofk brief hospital course yo m with h o lurt and pancreas failed after kidney presented to the ed with massive gi bleed concerning for fistula between pancreatic allograft and bowel he was sent emergently to ir for localization of bleed mesenteric angiogram did not reveal any extravasation several hours later he experienced another massive gi bleed and was taken back for angiography that demonstrated likely fistula from the artery in the pancreatic allograft to the small bowel the balloon was inflated in the right common iliac artery to achieve control he experienced hypovolemia as well as compartment syndrome and coded acls protocol was initiated with resuscitation he required emergent exploratory laparotomy in radiology with ligation of arterial inflow to pancreatic allograft small bowel resection bilateral chest tube placement and removal of percutaneously placed right common iliac balloon surgeon was dr see operative note for complete details postop he was taken intubated to the sicu chest tubes remained to water seal without pneumothorax noted on cxr insulin drip was started on he was taken to the or by dr for exploratory laparotomy with enteroenterostomy and abdominal wall closure postop he returned to the sicu intubated on a bronchoscopy was done for mucus plugs bal was negative he received broad spectrum antibiotic coverage a lasix drip was started for massive edema on he was extubated with chest tubes remaining to water seal lasix drip continued on interventional radiology placed a right common iliac artery covered stent over the arterio jejunal fistula a post pyloric tube was also placed by radiology radiology removed the bilateral groin sheaths without incident on bilateral ct s were removed with post cxr demonstrating a tiny l apical ptx that resolved spontaneously plavix mg was initiated trophic trophic tube feeds were started and advanced to goal free water flushes were given for hypernatremia on units of prbc were given for a hct of hct remained stable on vanco and zosyn were started for empiric pneumonia coverage cxr showed bilateral perihilar right greater than left and bibasilar left greater than right opacities and bilateral pleural effusions lasix drip was continued for generalized edema ng tube was removed and diet was advanced to a dm diet insulin drip continued aspirin was restarted oxycodone was given for pain control he developed a metabolic alkalosis and lasix drip was held diamox was given x urine output remained adequate on he was pancultured for leukocytosis blood and urine cultures remained negative cxr showed improved pleural effusions cmv and bk viral loads were sent and returned negative on he self d c d the feeding tube and was experiencing nausea and bilious emesis kub did not show signs of obstruction on a ct scan with po contrast demonstrated partial sbo dilated bowel proximal to anastomosis and decompressed bowel distally positive contrast in colon he was kept npo and was started on tpn ng continued with bilious output on hct was and he was transfused with u rbc bms appeared bloody he also experienced mental status changes and decreased movement of lle head ct demonstrated no evidence of territorial infarction or hemorrhage of note on lenis were done for r l leg swelling no dvt was seen on prbc were given for hct of with increase to where he stabilized mental status improved ng was removed on he was transferred out of the sicu diet was slowly advanced and tpn continued insulin drip was converted to glargine and regular sliding scale he experienced frequent non bloody stools stool was sent for c diff and was negative x a postpyloric feeding tube was placed on for insufficient kcals isosource was started with goal of cc hr identified by the dietician tpn was stopped on insulin was adjusted pt was consulted and worked with him daily initially noting orthostasis and patient complaints of dizziness these signs and symptoms improved with improved mobility pt recommended rehab due to deconditioning from long hospitalization the day of discharge patient is tolerating scant amounts of a regular diet and receiving tube feeds patient is alert and oriented midline incision is clean dry and intact with steri strips vital signs are stable insulin basal dose and sliding scale were adjusted to lantus units in am units in pm patient is pending discharge to rehab medications on admission calcitonin intranasally clopidogrel plavix doxercalciferol mcg leflunomide levothyroxine omeprazole prednisone sertraline bactrim tacrolimus valsartan aspirin multivitamin discharge medications prednisone mg tablet sig one tablet po daily daily sertraline mg tablet sig three tablet po daily daily clopidogrel mg tablet sig one tablet po daily daily insulin regular human subcutaneous doxercalciferol mcg capsule sig one capsule po daily daily leflunomide mg tablet sig four tablet po daily tablet s ipratropium albuterol mcg actuation aerosol sig puffs inhalation q h every hours as needed for shortness of breath or wheezing heparin porcine unit ml solution sig one injection times a day levothyroxine mcg tablet sig one tablet po daily daily omeprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day oxycodone mg tablet sig one tablet po q h every hours as needed for pain metoprolol tartrate mg tablet sig one tablet po bid times a day amlodipine mg tablet sig one tablet po daily daily aspirin mg tablet chewable sig one tablet chewable po daily daily tacrolimus mg capsule sig four capsule po q h every hours follow up drug levels for dose adjustment bactrim mg tablet sig one tablet po once a day discharge disposition extended care facility northeast discharge diagnosis pancreatic duodenal bleed partial sbo dm h o renal transplant 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 will be discharged to rehab you will continue on the tube feeds and will have blood draws twice weekly please call the tranplant office if you have any of the warning signs listed below followup instructions provider md phone date time [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies captopril prednisone infed attending chief complaint abdominal pain major surgical or invasive procedure nephrostomy tube placement central venous catheterization placement history of present illness pt is a yo with history of lurt in and pancreas after kidney transplant in complicated by rejection and subsequently a transplant pancreatic artery small bowel fistula and massive gi bleed in necessitating explantation of the pancreas and r iliac covered stent patient awoke with sudden onset sharp rlq pain awakening him from sleep overnight which radiates to his back he also has non bloody non bilious vomiting associated with the pain denies hematuria hematochezia chest pain shortness of breath or dysuria he had a colonoscopy one week ago to evaluate the etiology of weeks of diarrhea which was unrevealing in the ed initial vs ra patient had ua without evidence of uti ct abdomen and pelvis showing mod severe hydronephrosis and hydroureter of the r native kidney w perinephric stranding w o obvious stones transplant surgery saw patient in ed and felt pt had pyelonephritis on right native kidney recommended admission to medicine for antibiotics and percutaneous nephrostomy tube by ir in the ed patient spiked fever to received l ns tylenol mg po x and unasyn g iv x he also got mg iv morphine he took his long acting insulin last night and was not eating so he was started on d ns in the ed for downtrending fingerstick vitals on transfer are l currently pt complains of rlq abdominal pain he is sleepy and falls asleep during interview he denies chest pain shortness of breath on floor he was noted to be hypoxic at in the am to on l he triggered for that and at that time his bp was fine he was broadened to zosyn however later his bp dropped to s doppler he subsequently got l fluid past medical history celiac sprue depression diabetes s p failed pancreas transplant renal failure s p lurt diabetic retinopathy oa osteoporosis diabetic neuropathy cad hx tia hx afib psh tonsillectomy removal bladder tumor lap chole b l cataracts lurt pak ex lap pancreatic graft explantation sbr bl chest tubes abdominal closure social history lives with his wife etoh tobacco or illicit drug use family history father with bleeding stomach ulcer physical exam vs temp f bp hr r on l improved to on l general sleepy but arousable to voice a ox appears uncomfortable heent perrla eomi sclerae anicteric mmm neck supple no thyromegaly no lad heart tachy s s av fistula heard throughout the precordium lungs tachypnic bibasilar crackles abdomen nabs mildly distended soft moderate rlq tenderness to deep palpation no rebound tenderness or guarding back right sided cva tenderness extremities wwp no c c e skin no rashes or lesions lymph no cervical axillary or inguinal lad neuro awake a ox cns ii xii grossly intact pertinent results labs on admission pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count pm glucose urea n creat sodium potassium chloride total co anion gap pm lactate pm ck cpk pm ck mb ctropnt pm urine color yellow appear clear sp pm urine blood neg nitrite neg protein glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg pm urine rbc wbc bacteria none yeast none epi pm urine hyaline pm urine mucous rare cxr findings removal of central venous catheter and nasogastric tube stable cardiomediastinal contours mild pulmonary vascular congestion accompanied by interstitial edema and a small amount of fluid within the minor fissure patchy bibasilar retrocardiac opacities are present and likely reflect atelectasis ct abdomen pelvis new moderate to severe hydronephrosis and hydroureter of the native right kidney dilated ureter can be seen to the level of small soft tissue density at the site of previously removed pancreas transplant locule of gas within the right lower quadrant may be within a tethered loop of small bowel or a contained locule of intra abdominal gas a small gas fluid collection cannot be entirely excluded or potentially fistulization if clinically indicated a repeat ct with oral and or iv contrast or enhancement may be considered liver us impression normal appearance of the liver parenchyma no focal lesions pulsatility in the main portal vein is suggestive of right heart dysfunction tte the left atrium is normal in size there is mild symmetric left ventricular hypertrophy the left ventricular cavity size is normal overall left ventricular systolic function is normal lvef the right ventricular free wall is hypertrophied right ventricular chamber size is normal with normal free wall contractility the aortic root is mildly dilated at the sinus level the aortic valve leaflets are mildly thickened the noncoronary cusp is moderately thickened and displays reduced systolic excursion there is a minimally increased gradient consistent with minimal aortic valve stenosis the mitral valve leaflets are mildly thickened there is borderline mild posterior leaflet mitral valve prolapse mild mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened the estimated pulmonary artery systolic pressure is normal there is no pericardial effusion renal transplant us left lower quadrant renal transplant without hydronephrosis perinephritic fluid is present although may be confounded by presence of a small ascites as seen on prior ultrasound dated intraparenchymal arterial resistive indices of previously in thickened bladder wall may be accentuated by underdistension nephrostogram impression complete obstruction at the mid right native ureter microbiology c difficile toxin pcr negative pm blood culture final report blood culture routine final klebsiella pneumoniae final sensitivities cefazolin interpretative criteria are based on a dosage regimen of g every h piperacillin tazobactam sensitivity testing performed by sensitivities mic expressed in mcg ml klebsiella pneumoniae ampicillin sulbactam s cefazolin s cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s piperacillin tazo s tobramycin i trimethoprim sulfa r aerobic bottle gram stain final reported to and read back by dr am gram negative rod s anaerobic bottle gram stain final gram negative rod s blood cultures no growth to date cmv viral load final cmv dna not detected am urine source kidney gram stain add on requested by fax per dr on at am urine gram stain unspun final per x field polymorphonuclear leukocytes or per x field gram negative rod s fluid culture final klebsiella pneumoniae organisms ml cefazolin interpretative criteria are based on a dosage regimen of g every h piperacillin tazobactam sensitivity testing available on request sensitivities mic expressed in mcg ml klebsiella pneumoniae ampicillin sulbactam s cefazolin s cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s nitrofurantoin s tobramycin i trimethoprim sulfa r anaerobic culture final no anaerobes isolated fungal culture final no yeast isolated acid fast culture preliminary viral culture preliminary no virus isolated c diff toxin microsporidia stain final no microsporidium seen cyclospora stain final no cyclospora seen fecal culture final no salmonella or shigella found no enteric gram negative rods found campylobacter culture preliminary ova parasites final no ova and parasites seen this test does not reliably detect cryptosporidium cyclospora or microsporidium while most cases of giardia are detected by routine o p the giardia antigen test may enhance detection when organisms are rare cryptosporidium giardia dfa final no cryptosporidium or giardia seen clostridium difficile toxin a b test final feces negative for c difficile toxin a b by eia reference range negative brief hospital course this is a year old with pmh of lurt in and pancreas after kidney transplant in who presented with rlq abd pain n v diarrhea and found to have urosepsis with a dilated hydroureter of the native right kidney which drained frank pus septic shock patient presented with acute onset rlq abdominal pain and was found to have hydronephrosis and hyrodureter of his native right kidney without evidence of obstruction transplant surgery evaluated him and recommended percutaneous nephrostomy which drained frank pus he was covered for pyelonephritis with vanco zosyn cipro given his fever and fat stranding seen around his native right kidney he was narrowed to just ceftriaxone when his blood and urine cultures grew out pansensitive klebsiella subsequent blood cultures were negative his blood pressure was initially supported on levophed which was quickly weaned off maps were kept above and cvps between id was consulted and recommended continuation of ceftriaxone for a total of days from his first negative blood culture last dose with transition to oral ciprofloxacin mg until definitive procedure is completed respiratory failure likely secondary to sepsis and resultant leaky capiliaries he was intubated on arrival and vented via ardsnet protocol to support his respiratory distress he was extubated within hours oxygen saturations remained stable on room air pyelonephritis as above the patient was initially treated with broad spectrum antibiotics for pyelonephritis of his native r kidney a nephrostomy tube was placed by ir attempts were made to place a ureteral stent but were unsuccessful the patient will ultimately need embolization of the renal artery or a nephrectomy of the native kidney his nephrostomy tube will need to stay in place until a definitive procedure is completed he will follow up with transplant surgery as an outpatient regarding this procedure acute on chronic kidney injury esrd s p lurt baseline creatinine is around s p renal transplant his creatinine peaked at in the setting of sepsis likely prerenal vs atn creatine was improving to upon transfer to the floor creatinine continued to trend downward and was on discharge transplant nephrology was consulted and his home tacrolimus prednisone doxercalciferol and bactrim prophylaxis were all continued his tacrolimus levels were running high in his home dose therefore his dose was decreased to mg with appropriate levels elevated transaminitis transaminitis to the s on admission likely secondary to the beginnings of shock liver transaminitis improved with ivfs pressors and improved blood pressures ruq u s showed normal appearance of the liver parenchyma with patent portal vasculature lfts trended downward and were normal at the time of discharge diarrhea patient noted a week history of diarrhea of unclear etiology stool studies were performed c diff was negative x cyclospora and microsporidium were negative salmonella and shigella were negative cryptosporidium and giardia were also negative the patient was started on loperamide coronary artery disease s p stenting held home asa plavix and simvastatin asa and simvastain were restarted but plavix was held at the time of discharge hypertension home diovan was held throughout the admission and at the time of discharge patient will follow up as an outpatient regarding restarting this medication thrombocytopenia platelets fell from peak of to upon transition to the floor possibly reflective of low grade dic in the setting of sepsis patients platelet count trended upward and were normal at the time of discharge anemia hct trended downward from to upon transition to the floor likely in the setting of fluid resuscitation hct remained labile but was relatively stable his ldh was elevated by haptoglobin and bilirubin were normal making hemolysis unlikely output from nephrostomy tube was bloody however only put out approxmately ml per day making this an unlikely source of hct drop diabetes mellitus continued home insulin regimen hypothyroidism continued home levothyroxine mcg daily depression continued home sertraline mg daily transitional issues blood cultures were pending at the time of discharge patient will follow up with transplant nephrology patient was full code throughout this hospitalization plavix stopped during this admission as patient had placed in and no coronary events since full dose asa continued medications on admission clopidogrel mg daily doxercalciferol mcg daily lantus in am in pm regular insulin sliding scale levothyroxine mcg daily pantoprazole mg daily prednisone mg daily sertraline mg daily simvastatin mg daily bactrim ss daily tacrolimus mg diovan mg daily aspirin mg daily ferrous sulfate mg daily mvi discharge disposition home with service facility vna discharge diagnosis primary diagnosis pyelonephrosis respiratory failure septic shock bacteremia secondary diabetes coronary artery disease celiac sprue 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 mr it was a pleasure participating in your care while you were admitted to as you know you were admitted because you were having abdominal pain it was ultimately determined that you had an infection in your kidney a drain was placed to drain the infection you were given antibiotics through the iv which you will need to continue for more days you will need to continue oral antibiotic pills until you are instructed to stop by your doctors you will also need to have a procedure in the future to solve this problem will therefore need to follow up with the surgeons to have this done we made the following changes to your medications stop plavix decrease tacolimus to mg twice a day start loperamide mg twice a day start ceftriaxone gram daily for more days start ciprofloxacin mg by mouth twice a day once you finish the iv antibiotics until instructed to stop by your doctor stop diovan and please measure your blood pressure at home if your blood pressure is more than call your primary care physician and restart this medication you should continue to take all other medications as instructed please feel free to call with any questions or concerns please check cbc with differential chemistry panel tacrolimus level lfts and coagulation studies on monday and fax results to renal transplant clinic at followup instructions name e address phone please call your primary care physician to book follow up appointment for your hospitalization you need to book an appointment within week of discharge department transplant center when tuesday at am with md building lm campus west best parking garage md [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies captopril prednisone infed attending chief complaint low hematocrit major surgical or invasive procedure right native kidney embolization history of present illness m h o lurt and pancreas after kidney transplant c b rejection with subsequent transplant pancreatic artery small bowel fistula and massive gi bleed requiring explantation of the pancreas and r iliac covered stent p w decreased hct in the setting of recent admission for urosepsis r sided pyelonephritis requiring r nephrostomy placement briefly he was hospitalized recently from to for urosepsis r sided pyelonephritis c b hypotension tachycardia requiring brief micu stay at the time of discharge hct was and ctx x d until was planned following discharge he reports recovering well endorsing only minimal lightheadedness and dyspnea on exertion both of which he attributed to the normal course of recovery his wife estimates cc serosanguinous nephrostomy output dauly he denies f c s chest pain abdominal pain or distention brprp melena hematochezia hematuria or back pain on routine outpatient monitoring he was found to have hct of this morning and sent to the ed in the ed he was afebrile with stable vs including hr and bp and downtrending hct of and guiac negative ekg was notable for persistent st depression accompanied by elevated tn to attributed by cardiology service to demand ischemia requiring no intervention following ivf resuscitation and administration of u prbc he was transferred to the floor where he remained hd stable and received a third unit prbc per renal transplant ir guided r renal artery embolization v r nephrectomy is planned for tomorrow for presumptive bleeding from the r native kidney review of systems negative except as noted above past medical history diabetes s p failed pancreas transplant renal failure s p lurt gi bleed from pancreas transplant related fistula celiac sprue depression diabetic retinopathy oa osteoporosis diabetic neuropathy cad hx tia hx afib psh tonsillectomy removal bladder tumor lap chole b l cataracts lurt pak ex lap pancreatic graft explantation sbr bl chest tubes abdominal closure social history lives with his wife etoh tobacco or illicit drug use family history noncontributory physical exam on admission vs afebrile ra general well appearing in nad heent perrla eomi sclerae anicteric mmm neck supple no thyromegaly no lad heart rrr s s iii vi sm throughout precordium longstanding per patient lungs ctab abdomen bs nt nd no guarding rebound llq ecchymoses insulin heparin use per patient extremities wwp no c c e back no cvat neuro awake a ox cns ii xii grossly intact tld r nephrostomy with cc sanguinous drainage rue picc line pertinent results admission labs hct bun cr c w baseline tnt ck mb lactate ua negative microbiology bcx x pending admission ekg nsr bpm stable st depressions in v v imaging ct abdomen pelvis w o contrast interval placement of a right sided nephrostomy tube without sequela of complication of placement no findings to explain the patient s point hematocrit drop interval development of very small bilateral pleural effusions multiple chronic changes unchanged including vascular calcifications pancreatic atrophy atrophy of the left kidney degenerative changes of the bony structures brief hospital course brief course low hematocrit likely bleed from r native kidney nephrostomy no other obvious source of bleeding in the absence of rp bleed on noncontrast abdominal ct negative hemolysis labs hct bumped appropriately from on admission to following u prbc remaining stable x and he underwent uncomplicated r native kidney embolization prior to transfer to the floor he remained hd stable throughout elevated tnt tnt of and ck mb of in the setting of persistent st depressions attributed by cardiology to demand ischemia with no procedural intervention required home asa mg and simvastatin mg continued given concern for nstemi in the setting of known cad with plans to resume home clopidogrel following r kidney embolization repeat tnt and ck mb downtrended appropriately without further ekg changes diabetes mellitus fsbg of with mild blurry vision at am on likely receipt of home glargine despite poor po intake with increase in fsbg to s s following amps dextrose and subsequently s on continuous d ns home glargine held with continuation of ss for glycemic coverage recent h o r sided pyelonephritis no e o persistent infection in the absence of fever hd instability or bacteremia planned course of ceftriaxone continued medications on admission clopidogrel mg daily held at last admission doxercalciferol mcg daily lantus in am in pm regular insulin sliding scale levothyroxine mcg daily pantoprazole mg daily prednisone mg daily sertraline mg daily simvastatin mg daily bactrim ss daily tacrolimus mg diovan mg daily held at last admission aspirin mg daily ferrous sulfate mg daily mvi discharge medications clopidogrel mg tablet sig one tablet po daily daily doxercalciferol mcg capsule sig one capsule po daily daily prednisone mg tablet sig one tablet po daily daily ferrous sulfate mg mg iron tablet sig one tablet po daily daily aspirin mg tablet sig one tablet po daily daily valsartan mg tablet sig one tablet po once a day simvastatin mg tablet sig one tablet po once a day tacrolimus mg capsule sig three capsule po q h every hours sulfamethoxazole trimethoprim mg tablet sig one tablet po daily daily multivitamin tablet sig one tablet po daily daily levothyroxine mcg tablet sig one tablet po daily daily sertraline mg tablet sig three tablet po daily daily pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours ciprofloxacin mg tablet sig one tablet po twice a day for weeks disp tablet s refills insulin glargine unit ml cartridge sig twenty units subcutaneous at bedtime apidra unit ml solution sig one injection subcutaneous per sliding scale discharge disposition home with service facility vna discharge diagnosis acute anemia due to kidney bleed h o renal transplant coronary artery disease insulin dependent diabetes mellitus discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you were admitted to because you were anemic we think this likely happened because of a bleed in your right kidney you had a procedure called an embolization of the artery to the kidney and the bleeding stopped you had low blood sugars at times during your hospitalization and your insulin glargine dose was decreased to units at bedtime no glargine in the morning please follow up with your primary care physician for continued titration of your insulin regimen please note the following changes to your medications stop iv ceftriaxone start ciprofloxacin mg twice daily by mouth take for weeks or until dr tells you to stop decrease insulin glargine lantus to units once daily at bedtime only no glargine in the morning restart plavix and follow up with your primary care physician or cardiologist regarding whether to stop this medication restart diovan for blood pressure we made no other changes to your medications while you were in the hospital please continue taking the rest of your medications as prescribed by your outpatient providers please see below for your currently scheduled appointments at you will have your nephrostomy tube removed by dr at your next appointment it has been a pleasure taking care of you and we wish you a speedy recovery followup instructions department transplant center when tuesday at am with md building lm campus west best parking garage department transplant center when tuesday at am with md building lm campus west best parking garage department transplant center when friday at am with md building lm campus west best parking garage md,"{
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""Medications"": [""creatinine"", ""okt"", ""prograf"", ""rapamune""]
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30864,admission date discharge date date of birth sex f service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint chest pain major surgical or invasive procedure cardiac catherization coronary artery bypass graft x left internal mammary artery p left anterior descending saphenous vein graft d left anterior descending saphenous vein graft y graft ramus ygraft obtuse marginal obtuse marginal history of present illness year old female who presented to pcp office with chest pain and shortness of breath she developed acute onset of substernal squeezing chest pain while she was walking up stairs at home past medical history angina diabetes mellitus type hypertension hyperlipidemia social history lives with spouse denies current tobacco pack year history quit years ago etoh occassional works as an administrative assistant for physician family history father angina mother heart failure brother hypertension physical exam general wdwn middle aged female in no acute distress heent ncat sclera anicteric perrla eomi neck supple full rom cv rr no m r g chest crackles way up bilat abd obese soft nt nd ext warm pulses pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood neuts lymphs monos eos baso am blood plt ct pm blood pt ptt inr pt pm blood pt ptt inr pt am blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap am blood alt ast ld ldh ck cpk alkphos totbili am blood mg pm blood calcium phos mg pm blood hba c am blood triglyc hdl chol hd ldlcalc chest portable ap pm chest portable ap reason s pct removal medical condition year old woman with reason for this examination s pct removal chest single view history status post chest tube removal findings the et tube swan ganz catheter mediastinal drains and chest tube have been removed there is bilateral lower lobe volume loss with infiltrate and consolidation the consolidation is left lower lobe greater than right lower lobe however the aeration of the lungs is improved compared to the film from the prior day dr approved sun pm cardiology report ecg study date of pm sinus rhythm mild p r interval prolongation borderline left atrial abnormality since the previous tracing earlier on the voltage in leads i and avl has diminished otherwise no change clinical correlation is suggested tracing read by a intervals axes rate pr qrs qt qtc p qrs t echocardiography report complete done at am preliminary referring physician information status inpatient dob age years f hgt in bp mm hg wgt lb hr bpm bsa m m indication intraop 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 siemens echocardiographic measurements results measurements normal range left atrium long axis dimension cm cm left atrium four chamber length cm cm left atrium peak pulm vein s m s left atrium peak pulm vein d m s left atrium peak pulm vein a m s m s 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 to left ventricle peak resting lvot gradient mm hg mm hg aorta annulus cm cm aorta sinus level cm cm aorta sinotubular ridge cm cm aorta ascending cm cm aorta arch cm cm aorta descending thoracic cm cm aortic valve peak velocity m sec m sec aortic valve peak gradient mm hg mm hg aortic valve mean gradient mm hg aortic valve valve area cm cm findings left atrium normal la size no mass thrombus in the laa right atrium interatrial septum normal interatrial septum no asd by d or color doppler left ventricle mild symmetric lvh normal lv cavity size mild global lv hypokinesis right ventricle normal rv chamber size and free wall motion mildly dilated rv cavity aorta normal aortic diameter at the sinus level focal calcifications in aortic root normal ascending aorta diameter no atheroma in ascending aorta normal aortic arch diameter complex mm atheroma in the aortic arch normal descending aorta diameter complex mm atheroma in the descending thoracic aorta aortic valve three aortic valve leaflets mildly thickened aortic valve leaflets no as no ar mitral valve mildly thickened mitral valve leaflets no ms mild mr tricuspid valve normal tricuspid valve leaflets mild tr pulmonic valve pulmonary artery normal pulmonic valve leaflets no 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 no tee related complications conclusions pre bypass the left atrium is normal in size no mass thrombus is seen in 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 there is mild global left ventricular hypokinesis lvef the apex is poorly seen but may be akinetic right ventricular chamber size and free wall motion are normal the right ventricular cavity is mildly dilated there is prmoinent focal calcification at the sintoubual junction which are isolated to that area and the sinus of valsalva to a lesser extent there are borderline complex mm atheroma in the distal aortic arch there are complex mm 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 no aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen post byass patient is a paced on no vasoactives i certify that i was present for this procedure in compliance with hcfa regulations interpretation assigned to md interpreting physician brief hospital course transferred in from for cardiac workup after ruling in for nstemi she underwent cardiac catherization which revealed three vessel coronary artery disease cardiac surgery was consulted and she underwent preoperative workup which revealed hgba c was consulted for glucose management she was gently diuresised as she awaited surgery on she was taken to the operating room and underwent a coronary artery bypass graft please see operative report for further details vancomycin was administered for periop antibiotics since she was in the hospital preoperatively she was transferred to the intensive care unit in stable condition in the first hours her sedation was weaned awoke neurologically intact and was extubated she continued to do well and was transferred to the floor she was started on beta blockers for rate control and lasix for diuresis physical therapy worked with her in regards to strength and mobility she continued to do well and was ready for discharge home with services on post operative day follow up with for diabetes management as an outpatient medications on admission avandia mg daily amlodipine mg daily pravastatin mg daily metformin mg twice a day glipizide mg daily discharge medications oxycodone acetaminophen mg tablet sig one tablet 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 ranitidine hcl mg tablet sig one tablet po once a day disp tablet s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills pravastatin mg tablet sig one tablet po daily daily disp tablet s refills insulin sliding scale insulin sc sliding scale breakfast lunch dinner bedtime humalog humalog humalog humalog glucose insulin dose insulin dose insulin dose insulin dose mg dl oz juice oz juice oz juice oz juice mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units insulin glargine unit ml solution sig thirty six units subcutaneous at bedtime disp qs qs refills insulin supplies syringes lancets and gluocmeter strips as directed qs month humalog unit ml solution sig see ss sliding scale subcutaneous four times a day please dose based on sliding scale and blood glucose level disp qs qs refills furosemide mg tablet sig one tablet po bid times a day for weeks disp tablet s refills potassium chloride meq tab sust rel particle crystal sig one tab sust rel particle crystal po bid times a day for weeks disp tab sust rel particle crystal s refills metoprolol tartrate mg tablet sig one tablet po tid times a day disp tablet s refills discharge disposition home with service facility vna of southeastern mass discharge diagnosis coronary artery disease s p cabg acute nstemi pulmonary edema angina diabetes mellitus type hypertension hyperlipidemia 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 blood glucose monitoring please do times a day and cover with sliding scale humalog goal if greater than x please follow up with clinic followup instructions please call to schedule appointments dr in week dr in weeks dr in weeks scheduled appointments diabetes follow clinica at diabetes educator needles at pm at clinic md completed by,"{
""Diagnoses"": [""cardiothoracic"", ""angina"", ""hypertension"", ""hyperlipidemia""],
""Medications"": [""aspirin"", ""metoprolol"", ""lisinopril"", ""atorvastatin""]
}"
66419,admission date discharge date date of birth sex m service surgery allergies no known allergies adverse drug reactions attending chief complaint status post crush injury by car major surgical or invasive procedure epidural catheter placement history of present illness mr is a year old male transferred from w chest injuries he was working under a car and apparently the malfunctioned and the car came down on him he was transferred to for further management of his injuries his gcs was upon arrival to the ed he noted mostly pain in his sides right worse than left with increased pain with inspiration he was initially evaluated in the trauma bay cxr showing multiple right sided rib fractures a small apical pneumothorax and subcutaneous emphysema past medical history thalassemia minor social history works as a mechanic pack per day smoking drinks socially family history noncontributory physical exam upon presentation to hr bp resp o sat normal constitutional uncomofortable heent normocephalic atraumatic pupils equal round and reactive to light extraocular muscles intact oropharynx within normal limits chest clear to auscultation crepitance anterior chest wall on r normal chest rise no evidence of flail cardiovascular regular rate and rhythm normal first and second heart sounds abdominal soft mild upper abd ttp extr back no cyanosis clubbing or edema skin no rash neuro speech fluent normal strength and sensation all ext psych normal mood normal mentation upon discharge vs avss o saturations ra general in no acute distress no increased work of breathing heent mucus membranes moist no perioral cyanosis nares clear trachea at midline cv regular rate rhythm no murmurs rubs gallops chest resolving crepitance to right anterior chest pulm bilateral breath sounds clear abd soft nontender nondistended msk warm well perfused 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 plt count 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 am blood glucose urean creat na k cl hco angap imaging osh ct torso chest no effusion small right pneumothorax and air over the right chest wall with fractures of the right st and nd ribs anteriorly small contusion adjacent to first rib fracture right st posteriorly and nondisplaced fracture or posterior right ribs left and posterolateral fractures nondisplaced no left pneumothorax or contusion bibasilar atelectasis vertebral bodies and sternum unremarkable no evidence of aortic or other mediastinal injury no solid organ injury no free fluid or air no pelvic or lumbar fractures osh ct head and c spine head no intra cranial hemorrhage or other acute process no fractures c spine no fracture or malalignment rib fractures as noted on concurrent torso cxr minimal opacification in the right apical region could reflect post traumatic bleeding several displaced rib fractures are seen on the left no evidence of acute vascular congestion or pneumonia cxr a small right pneumothorax is less conspicuous than before right subcutaneous emphysema has improved bilateral pleural effusions larger on the right side are unchanged right upper lobe atelectasis is stable right lower lobe opacity has increased due to increasing atelectasis the left lung is grossly clear besides the small pleural effusion with minimal adjacent atelectasis brief hospital course he was admitted to the acute care surgery team and transferred to the trauma icu for close monitoring of his respiratory status and pain management for his multiple rib fractures dilaudid pca was started with minimal effect on hd the acute pain service was consulted and an epidural catheter was placed for better pain control after placement of the epidural he was transferred to the regular nursing unit his epidural remained in place for days during this time toradol and neurontin were added the toradol was stopped after hours for concern over his low hematocrits serial hematocrits were followed and remained low but stable on hd the epidural was removed and he was noted with increased pain requiring several adjustments in his oral regimen including adding iv toradol back to his regimen and switching from oxycodone to dilaudid he continued to have moderate pain particularly with deep inspirationr or hiccups of new onset chronic pain service was consulted a this point to continue his current regimen with motrin and tylenol in addition to lidoderm patch he was noted with bilateral subcutaneous emphysema serial chest xrays were followed which showed resolving bilateral effusions and small anterior pneumothorax he was started on nebulizers and instructed on use of incentive spirometer he was evaluated by physical therapy and cleared for home once medically stable upon discharge he was afebrile maintaining o sats between on room air was ambulating and tolerating a regular diet medications on admission denies discharge medications acetaminophen mg tablet sig two tablet po q h every hours docusate sodium mg capsule sig one capsule po bid times a day senna mg tablet sig one tablet po bid times a day magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed for constipation bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for constipation hydromorphone mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills tramadol mg tablet sig one tablet po qid times a day disp tablet s refills gabapentin mg capsule sig one capsule po tid times a day disp capsule s refills lidoderm mg patch adhesive patch medicated sig one topical once a day for weeks apply to posterior right ribs hours on then hours off disp refills discharge disposition home discharge diagnosis s p crush injury rib fractures right anteriorly right posteriorly left posterolateral small right pneumothorax small right pulmonary contusion 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 after a crsh injury where you sustained multiple rib fractures on both sides you were monitored closley in the hopsital and evalauted by the pain specialisits who placed a special catheter into your back called an epidural in order to deliver medications in a manner that would help control your rib pain after this catheter was removed you were given oral pain medications and you will be discharged to home on these pain from rib fractures can cause you to take shallow breaths it is important that you use your incentive spirometer to take deep breaths every hour that you are awake coughing and deep breathing should be done at the end of your incentive spirometer excersises you should take your pain medication as directed to stay ahead of the pain otherwise you won t be able to take deep breaths if the pain medication is too sedating take half the dose and notify your physician pneumonia is a complication of rib fractures in order to decrease your risk you must use your incentive spirometer times every hour while awake this will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs you will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing symptomatic relief with ice packs or heating pads for short periods may ease the pain narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible do not smoke if your doctor allows non steroidal antiinflammatory drugs are very effective in controlling pain ie ibuprofen motrin advil aleve naprosyn but they have their own set of side effects so make sure your doctor approves return to the emergency room right away for any acute shortness of breath increased pain or crackling sensation around your ribs crepitus followup instructions department general surgery when monday at pm with acute care clinic building lm bldg campus west best parking garage you will need a chest x ray prior to this appointment please go to clinical center radiology minutes prior to your appointment completed by,"{
""Diagnoses"": [""Crush injury"", ""Multiple rib fractures"", ""Pneumothorax"", ""Subcutaneous emphysema""],
""Medications"": [""Oxygen"", ""Pain medication"", ""Antibiotics"", ""Pain medication"", ""Muscle relaxants""]
}"
30276,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint necrotizing fasciitis major surgical or invasive procedure radical debridement of soft tissues of left lower abdominal wall groin thigh and perineum debridement and primary closure with drains of necrotizing fasciitis of the perineum history of present illness pt is yo man with dm morbid obesity recurrent groin boils who presented to osh with l groin boil and fever per chart pt developed l groin boil days prior to presentation had small amt drainage days prior to presentation developed fever and l groin swelling redness on went to pcp office found glucose osh er t exam notable for severe erythema of l groin l hemiscrotum l medial thigh with pain on palpation wbc n l ct showed gas in l groin scrotum extending to fem sheath inguinal canal pt transferred to for emergent management of suspected necrotizing fasciitis past medical history dm htn morbid obesity hx boils in b groin spontaneous rupture social history tob yes etoh denies ivdu unknown family history noncontributory physical exam physical exam on initial evaluation general diaphoretic flushed tm at osh tc hr bp rr o sat on ra lungs cta b l heart tachycardic abdom bs soft obese extrem r groin well healed pits scabs l groin severe erythema cellulitis scrotum cm boil crepitus perineal involvement le no edema 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 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 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 pt ptt inr pt am blood pt ptt inr pt am blood plt ct am blood pt ptt inr pt am blood plt ct am blood pt ptt inr pt am blood plt ct am blood pt inr pt am blood plt ct am blood plt ct am blood pt ptt inr pt am blood plt ct am blood pt ptt inr pt am blood plt ct am blood plt ct am blood plt ct am blood plt ct am blood plt ct am blood pt inr pt am blood plt ct am blood plt ct am blood plt ct am blood plt ct 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 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 na k 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 vanco am blood vanco am blood vanco am blood vanco am blood type art po pco ph caltco base xs intubat intubated am blood type art po pco ph caltco base xs intubat intubated am blood type art temp rates tidal v peep fio po pco ph caltco base xs aado req o assist con intubat intubated am blood type art po pco ph caltco base xs pm blood type art po pco ph caltco base xs 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 am blood type art po pco ph caltco base xs pm blood type art po pco ph caltco base xs 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 am blood type art po pco ph caltco base xs pm blood type art po pco ph caltco base xs 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 am blood type art po pco ph caltco base xs pm blood type art po pco ph caltco base xs 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 am blood type art temp rates tidal v peep fio o flow po pco ph caltco base xs intubat intubated vent spontaneou pm blood type art temp rates tidal v peep fio o flow po pco ph caltco base xs intubat intubated vent spontaneou comment ps cm pm blood type art temp rates tidal v peep fio o flow po pco ph caltco base xs intubat intubated vent spontaneou pm blood type art temp po pco ph caltco base xs intubat intubated am blood type art po pco ph caltco base xs pm blood type art temp rates tidal v peep fio po pco ph caltco base xs intubat intubated vent spontaneou am blood type art po pco ph caltco base xs pm blood type art po pco ph caltco base xs pm blood type art po pco ph caltco base xs pm blood type art temp peep po pco ph caltco base xs intubat intubated vent spontaneou am urine blood mod nitrite neg protein tr glucose ketone tr bilirub neg urobiln neg ph leuks neg am urine blood lg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks neg am urine blood sm nitrite neg protein tr glucose neg ketone neg bilirub neg urobiln neg ph leuks neg am tissue site groin right final report gram stain final per x field polymorphonuclear leukocytes per x field gram positive cocci in pairs per x field gram negative rod s smear reviewed results confirmed tissue final reported by phone to pm on due to mixed bacterial types an abbreviated workup is performed p aeruginosa s aureus and beta strep are reported if present susceptibility will be performed on p aeruginosa and s aureus if sparse growth or greater additional work up per dr this is a corrected report reported by phone to dr at pm enterococcus sp heavy growth beta streptococcus group b heavy growth staphylococcus coagulase negative sparse growth viridans streptococci heavy growth previously reported as probable enterococcus sensitivities mic expressed in mcg ml enterococcus sp ampicillin s penicillin g s vancomycin s anaerobic culture final mixed bacterial flora culture screened for b fragilis c perfringens and c septicum none isolated am swab site groin left final report gram stain final per x field polymorphonuclear leukocytes per x field gram positive cocci in pairs and chains per x field gram negative rod s wound culture final due to mixed bacterial types an abbreviated workup is performed p aeruginosa s aureus and beta strep are reported if present susceptibility will be performed on p aeruginosa and s aureus if sparse growth or greater beta streptococcus group b heavy growth anaerobic culture final mixed bacterial flora culture screened for b fragilis c perfringens and c septicum none isolated pathology examination specimen submitted left groin tissue procedure date tissue received report date diagnosed by dr axg diagnosis left groin tissue soft tissue with extensive necrosis and purulent exudate consistent with necrotizing fasciitis clinical necrotizing fascitis left groin gross the specimen is received fresh in one container marked with the patient s name j the medical record number and left groin tissue it consists of one fragmented piece of skin and attached subcutaneous tissue measuring x x cm multiple surgical incisions have already been made to the specimen the subcutaneous tissue has a brown color with copious amounts of purulent exudate the specimen is represented in a c am urine site catheter source catheter final report urine culture final no growth am blood culture source venipuncture final report blood culture routine final no growth am sputum source endotracheal final report gram stain final pmns and epithelial cells x field no microorganisms seen respiratory culture final no growth pm bronchoalveolar lavage final report gram stain final per x field polymorphonuclear leukocytes no microorganisms seen respiratory culture final no growth cfu ml pm bronchoalveolar lavage right final report gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final no growth cfu ml am stool consistency soft source stool final report clostridium difficile toxin a b test final feces negative for c difficile toxin a b by eia reference range negative pm catheter tip iv source right sc triple lumen final report wound culture final no significant growth brief hospital course is a year old gentleman with poorly controlled type ii diabetes and morbid obesity who was referred to for treatment and management of suspected necrotizing soft tissue infection of left abdominal wall groin thigh and perineum during his admission he underwent radical debridement of soft tissues of left lower abdominal wall groin thigh and perineum and subsequently debridement and primary closure with drains of necrotizing fasciitis of the perineum postoperatively he was admitted to the icu for supportive management the patient was transferred to the surgical floor on when stable id post operatively the infectious disease service was consulted the patient was started on broad spectrum iv antibiotics vancomycin clindamycin and piperacillin tazobactam the antibiotic regimen was tailored based on tissue culture results and per the recommendations of the infectious disease service the patient was eventually discharged home on a day course of po metronidazole at the time of discharge the patient was afebrile and the wbc count was within normal limits pulmonary post operatively the patient was maintained on mechanical ventilation the post op course was complicated by a collapsed right upper lung lobe found on post op chest x ray repositioning of the endotracheal tube and repeat imaging showed improved aeration of the right upper lobe on the patient underwent a bronchoscopy for episodes of oxygen desaturation and increased respiratory secretions sputum and bronchoalveolar cultures were negative the patient was weaned from mechanical ventilation on cv the patient s volume status was monitored closely in the icu with a central line and an arterial line resuscitative fluid was given as needed when necessary a norepinephrine drip was used to support the patient s blood pressure vital signs were routinely monitored as per icu and floor protocol neuro post operatively the patient received propofol and benzodiazepines for sedation as needed in the icu pain was adequately controlled with fentanyl and dilaudid iv with good effect when tolerating oral intake the patient was transitioned to oral pain medications gi gu the patient was given gastric ulcer prophylaxis his diet was advanced when appropriate which was tolerated well the patient was also started on a bowel regimen to encourage bowel movement cultures for c difficile toxin were negative the foley was removed prior to transfer from the icu to the surgical floor intake and output were closely monitored skin after initial operative debridement the patient s groin wound was treated with wet to dry dressings wound care was transitioned to vac dressings the wound was eventually closed with large vertical mattress sutures approximately over a suction drainage the patient was discharged with the drain in place he was given written and verbal instructions regarding proper drain and wound care in addition during admission a stage decubitis ulcer was found by nursing it resolved with proper wound care endocrine the patient s blood sugar levels were closely monitored throughout the admission the patient s diabetes medication regimen was tailored based on diabetes consult recommendations an iv insulin drip was used to control blood sugar levels when a subcutaneous insulin sliding scale was inadequate dvt prophylaxis the patient received subcutaneous heparin during this stay and was encouraged to get up and ambulate as early as possible at the time of discharge the patient was doing well afebrile with stable vital signs tolerating a regular diet voiding without assistance and pain was well controlled on po medications medications on admission per admission note linisopril metformin insulin discharge medications miconazole nitrate powder sig one appl topical tid times a day disp qsf qsf refills metronidazole mg tablet sig one tablet po tid times a day for days disp tablet s refills lisinopril mg tablet sig one tablet po daily daily disp tablet s refills insulin lispro unit ml solution sig sliding scale subcutaneous four times a day disp qs refills insulin glargine unit ml solution sig fifty units subcutaneous once a day disp qs refills insulin syringe ml x syringe sig one miscellaneous four times a day disp syringes refills lancets misc sig one miscellaneous four times a day disp refills one touch ultra kit sig one miscellaneous four times a day disp refills onetouch blood glucose testing strip sig one four times a day disp refills oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for weeks disp tablet s refills colace mg capsule sig one capsule po once a day as needed for constipation for weeks disp capsule s refills discharge disposition home discharge diagnosis necrotizing fasciitis of the groin scrotum discharge condition stable tolerating po intake pain controlled discharge instructions general please continue to change your groin dressings at home as you did in the hospital you may continue to use the miconazole powder for moisture in the groin you should continue to take your antibiotic for days 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 see blood or dark black material when you vomit or have a bowel movement 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 avoid lifting objects lbs until your follow up appointment with the surgeon avoid driving or operating heavy machinery while taking pain medications 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 and take any new meds as ordered continue to ambulate several times per day jp drain care please look at the site every day for signs of infection increased redness swelling odor yellow or bloody discharge fever maintain the bulb deflated to provide adequate suction note color consistency and amount of fluid in drain call doctor if amount increases significantly or changes in character be sure to empty the drain frequently you may shower wash area gently with warm soapy water maintain the site clean dry and intact avoid swimming baths hot tubs do not submerge yourself in water keep drain attached safely to body to prevent pulling followup instructions please follow up in the trauma clinic with dr in week you will need to call to schedule an appointment please follow up in the clinic in weeks you will need to call to schedule an appointment,"{
""Diagnoses"": [""necrotizing fasciitis""],
""Medications"": [""antibiotics"", ""pain management medication""]
}"
12399,admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint icd firing major surgical or invasive procedure ablation history of present illness f w hx apical hocm gradient mm hg w hx sustained vt and s p icd placement presents for treatment for refractory vt pt dx d w hcm years ago and did well until when she developed pvcs and was started on toprol which she did not tolerate fatigue on she presented w nausea and sweating and was found to be in hemodynamically stable vt she was treated w icd per osh records she had a cardiac catheterization that revelaed no coronary disease but tortuous vessels s p icd placement she did well for days when she was shocked times for vt per osh records and treated w iv amio and then switched to sotalol which caused her increased fatigue on she had shocks from her icd and then given lidocaine gtt and increased sotalol dose per osh recs she has apical hocm w peak gradient mm hg also her shocks have been appropriate for vt and they tend to be triggered by single pvc she is being transferred to for treatment of refractory vt past medical history hcm dx social history glasses of wine day no smoking no illicit drug use family history no family history of heart disease physical exam t bp hr rr o sat gen nad heent normocephalic atraumatic perrl eomi mmm no oral ulcers cv rrr nl s s no murmurs lungs ctab abd soft nontender nondistended bowel sounds present ext warm no cyanosis no edema pedal pulses present neuro alert and oriented x cn ii xii intact moving all extremities pertinent results echo the left atrium is elongated there is symmetric left ventricular hypertrophy there may be an apical left ventricular aneurysm apex not fully visualized overall left ventricular systolic function is mildly depressed the left ventricle is heavily trabeculated and meets borderline criteria for noncompaction right ventricular chamber size and free wall motion are normal the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve leaflets are structurally normal mild mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened there is mild pulmonary artery systolic hypertension there is a trivial physiologic pericardial effusion ekg atrial sensed ventricular paced possible left ventricular hypertrophy anterior t wave changes may be due to myocardial ischemia clinical correlation is suggested echo there is isolated distal left ventricular hypertrophy with an apical aneurysm c w apical hypertrophic cm variant no masses or thrombi are seen in the left ventricle an ablation catheter is seen within the lv apex lv systolic function appears depressed right ventricular chamber size and free wall motion are normal there is no pericardial effusion compared with the prior study images reviewed of an ablation catheter is now seen in the lv apex echo there is isolated apical left ventricular hypertrophy there is an apical left ventricular aneurysm overall left ventricular systolic function is probably normal lvef an apical intracavitary gradient is identified there is no ventricular septal defect right ventricular chamber size and free wall motion are normal there is no aortic valve stenosis no aortic regurgitation is seen the mitral valve leaflets are structurally normal there is no systolic anterior motion of the mitral valve leaflets mild mitral regurgitation is seen there is no pericardial effusion compared with the prior study images reviewed of no major change labs 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 pt ptt inr pt pm blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap pm blood calcium phos mg pm blood calcium phos mg brief hospital course a p f w hx apical hocm gradient mm hg w hx sustained vt and s p icd placement presents for treatment for refractory vt and ep study planned for rhythm hemodynamically stable vtach s p icd placement she has hcm and apical thickening across lv she is s p icd placement with episodes of icd firing currently having some nsvt that is asymptomatic ep study without inducible vt eps with inducible nsvt at apical isthmus and plan for ablation eps showed a small area of inducible vt that was ablated after ablation she was started on metoprolol and flecainide flecainide was titrated up to mg po bid and the patient tolerated the patient continued to have short runs of asymptomatic nsvt plan for discharge with exercise test on flecanide she will also need anticoagulation s p ablation and f u with device clinic her qrs was ms on discharge pump pt w apical hcm and gradient of mm hg no murmur on exam provocable goal is to keep her slightly positive to help decrease her obstruction echo with symmetric lv hypertrophy psych psychiatry evaluated patient yesterday assess that patient has acute disorder ptsd from icd firing per psych recs xanax d c d because short acting and klonopin started encourage relaxation full code medications on admission alprazolam mg po tid and mg qhs lidocaine mg min iv infusion metoprolol mg po bid mexiletine mg po tid multivitamin discharge medications outpatient lab work check on tuesday inr check chem send results to dr phone outpatient lab work or inr check have results fowarded to dr office hexavitamin tablet sig one cap po daily daily warfarin mg tablet sig tablets po at bedtime disp tablet s refills metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet s refills clonazepam mg tablet sig tablet po bid times a day as needed this medication will make you sleepy do not drive or operate heavy machinery while taking this medication disp tablet s refills flecainide mg tablet sig tablets po q h every hours disp tablet s refills discharge disposition home discharge diagnosis icd firing hcm v tach discharge condition good ambulatory respiratory status stable discharge instructions please take all medications as directed continue to take flecainide mg by mouth twice daily and metoprolol mg by mouth twice daily as directed also continue to take coumadin as directed you will need to have your inr level checked on a regular basis you should have your next inr blood work checked on tuesday have the results fowarded to dr office please go to all of your follow up appointments if you develop shortness of breath chest pain icd firing or any other symptoms that concern you call dr office and have the ep fellow on call paged followup instructions follow up appointment with dr on phone provider exercise lab phone date time device clinic appointment for device check and carelink enrollment phone follow up inr check and have the results forwarded to dr go to on the cardiology floor for inr checks on and ep nurse rn will follow up inr results,{}
56343,admission date discharge date date of birth sex f service medicine allergies morphine attending chief complaint hospitalist admit note patient name dob pcp transferring facility transferring physician contact transferring floor n contact cc major surgical or invasive procedure ercp history of present illness yo f with htn skin melanoma in and skin squamous cell cancer in who developed new onset jaundice and nausea at osh t bili and direct bili ast alt ap inr ct showed a x x cm cystic lesion with calcification at the head of pancreas cbd and pd were dilated she had mild respiratory distress and cxr showed lll infiltrate for which she was started on ampicillin she was given vitk and unit of ffp due to coagulopathy inr improved to she underwent ercp with dr yesterday under general anesthesia cannulation of cbd was not successful only pd was cannulated patient with increasing bili today needing transfer for repeat ercp per report vitals prior to transfer tx tc bp hr rr o sat l min o per transferring physician patient with no respiratory symptoms after ercp despite o requirement pt reports that that she developed week of nausea vomiting fever up to abdominal distention and day of dark urine prior to admission to osh reports that symptoms were intermittent but worsened on sat prior to admit pt reports she was diagnosed with a uti on fri and started on cipro she reports intermittent chills weight loss of lbs over months in addition pt reports intermittent diarrhea non bloody over last few months pt denies new foods travel sick contacts abdominal pain constipation melena brbpr cp sob palpitations uri cough rash paresthesias weakness dysuria headache but does report chronic intermittent dizziness pt reports decreased appetite and po intake x week past medical history appendectomy hysterectomy tonsillectomy removal of skin cancer and melanoma formerly had htn formerly hl hypothyroidism social history pt lives at home alone but multiple family members nearby to help ambulates with a cane occasionally former smoker quit yrs ago former alcoholic quit years ago denies drug use family history mother died at arthritis cancer dad alcoholic physical exam gen lying in bed jaundiced nad vitals t bp hr rr sat on l heent nc at eomi icterus dry mm neck supple thyromegaly jvd to earlobe chest b l crackles heart rrr m r g abd bs soft mildly tender softly distended no guarding or rebound back non tender no cva tenderness ext no c c e pulses skin multiple areas of scaring hypo and hyperpigementation l shin with sutures from recent resection c d i neuro aaox cn intact motor x sensation intact to lt no tremor psych calm cooperative pertinent results labs t bili and direct bili ast alt ap inr imaging ct showed a x x cm cystic lesion with calcification at the head of pancreas ercp cbd and pd were dilated cxr lll infiltrate ercp cystic neoplasia of pancreas unable to access bile duct ekg nsr q iii twi iii avf ct abd pelvis severe ventilation of the intereim bilary ducts as well as the main pancreatitic duct multiloculated cystic lesion in the head of the pancreas associated with small punctate calcifications that can be related to a pancreatic neoplasia like serous cystadenoma of the pancreas suboptimal evaluation due to the lack of iv contrast ercp or mrcp is recommended for further eval mild free fluid in pelvis diverticulosis without diverticulitis b l cortical renal cysts ruq u s marked intrahepatic and extrahepatic biliary ductal dilatation of etiology cxr streaky lll infiltrate otherwise no significant acute finding wbc hct plt inr ap tbili direct bun ca creat gluc lip ast alt tsh brief hospital course yo f with htn skin melanoma in and skin squamous cell cancer in who developed new onset jaundice nausea with vomiting and was found to have a cystic pancreatic mass at osh cmo patient was made comfort measure after discussion with family palliative care saw patient and it was decided that she would go home with hospice care she was comfortable at the time of discharge she was sent home on oxycodone zofran promethazine compazine ativan for symptom management patient medications were reviewed and non palliative medications were removed from regimen we called the pcp couple of times during this stay and were only able to reach his answering machine we left messages with the new changes in care goals and with numbers for him to contact us family very involved has also said that they will be in touch with her pcp as well she will continue to have her foley and oxygen with n as needed at home which hospice can provide bile duct obstruction with obstructive jaundice cystic pancreatic head lesion etiology of patients symptoms abdominal distention nausea jaundice is likely related to obstruction from pancreatic head mass ddx includes malignancy vs cyst pt does have h o skin cancer but unlikely to metastasize to pancreas pt may also have stricture or stones she had an ercp with cm by mm wallflex fully covered biliary stent which was successfully placed with large amounts of mucin which drained patient presented with nausea and continued to have nausea intermittently throughout stay have increased regimen as above to control nausea able to tolerate po meds gingerale and some soft foods hypoxia lll infiltrate pt thought to have pna at osh cxr found streaky lll infiltrate pt does have a leukocytosis but denies cough on exam pt with elevated jvp crackles more c w volume overload pt does have suspicion of malignancy and will consider if continued hypoxia will continue to cover for suspected pna including atypicals with levofloxacin to end on able to tolerate po so will go home with po regimen transient bacteremia s p ercp will treat with flagyl in addition to levoflox as above for total of wk course to end on have been tolerating po as well h o skin cancer squamous cell melanoma stable will f u outpt if necessary but cmo at this point afib patient found to have atrial fibrillation to procedure which has resolved and has not recurred no need for any anticoagulation especially given goals of care hypothyroidism will continue home levothyroxine as it might help patient feel better more energetic code dnr dni cmo d w patient in presence of hcp medications on admission levothyroxine mcg daily hctz not on prior to admit mvi prochlorperazine cipro mg inpatient she is on ampicillin gm q hours and prn albuterol allergy morphine discharge medications levothyroxine mcg tablet sig one tablet po daily daily ativan mg tablet sig one tablet po every hours as needed for nausea disp tablet s refills albuterol sulfate mg ml solution for nebulization sig one inhalation q h every hours as needed for sob wheezing metronidazole mg tablet sig one tablet po q h every hours for days end date disp tablet s refills levofloxacin mg tablet sig one tablet po q h every hours for days last day disp tablet s refills prochlorperazine mg suppository sig one suppository rectal q h every hours as needed for nausea disp suppository s refills promethazine mg tablet sig two tablet po q h every hours as needed for nausea disp tablet s refills ondansetron mg tablet rapid dissolve sig one tablet rapid dissolve po q h every hours as needed for nausea disp tablet rapid dissolve s refills oxycodone mg ml concentrate sig mg po q h prn as needed for pain and shortness of breath disp ml refills discharge disposition home with service facility vna of central discharge diagnosis pancreatic head mass bile duct obstruction hyperbilirubinemia hypoxia pneumonia htn benign discharge condition mental status confused sometimes level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions you were admitted for further work up of a blockage noted in your bile ducts and a mass that was seen in your pancreas you underwent a procedure called an ercp that showed significant blockage of your biliary system there was a stent placed which relieved the blockage you were also continued on antibiotics for a pneumonia and prophylaxis after ercp which you will continue until you had significant nausea during your hospitalization you will be sent on on many different medications for your nausea medication changes start oxycodone liquid mg ml mg po q h for pain and shortness of breath sl start ativan mg q h as needed for anxiety and shortness of breath continue flagyl q h until continue levofloxacin mg every day until continue prochlorperazine mg twice a day as needed for nausea continue promethazine mg tablet every hours as needed for nausea continue zofran mg every day as needed for nausea please take all of your medications as prescribed and follow up with the appointments below followup instructions please follow up with your pcp at after discharge md completed by,"{
""Diagnoses"": [""jaundice"", ""nausea"", ""vomiting"", ""fever"", ""abdominal distention""],
""Medications"": [""morphine"", ""ampicillin"", ""vitk"", ""ffp"", ""inr"", ""aprin"", ""tc bp"", ""hr"", ""rr"", ""o2""]
}"
27697,admission date discharge date date of birth sex m service medicine allergies penicillins trileptal sulfa sulfonamides attending chief complaint s p fall major surgical or invasive procedure none history of present illness yo man with hx bipolar htn chronic neck back pain here from micu after p w fall and hypotension recently discharged from psych after inpt stay for hyponatremia hyperkalemia diarrhea then depression he was in usoh with only new meds of seroquel wellbutrin until day of admission he was walking off the bus and tripped he hit posterior head but had no loc denied any fevers photophobia cp sob palpitations abd pain he came to ed vss initially head ct neg creatinine bl potassium received insulin and l ivf then developed hypotension with sbp s to sent to the icu in icu bp stabilized with additional l creatinine improved hct dropped from to ob neg even while hypotensive he was assymptomatic cxr cx neg to date no infectious source thought to be atenolol in setting of arf valsartan and pain meds causing hypotension random cortisol was notably the patient has q month steroid injections in ankles for pain control he has never taken oral or iv steroids he has no change in skin color he reports fatigue depressive sx ros and currently no fevers chills ha vision changes cp sob has been compliant with medications reports neck and right shoulder pain s p fall reports bilat ankle pain which is chronic past medical history chronic renal failure bl creatinine hypertension hyperlipidemia mitral regurgitation mgus diverticulosis adenocarcinoma of the prostate s p radical prostatectomy depression bipolar disorder chronic pain cervical lumbar spine disease chronic headaches peptic ulcer disease tremors internal hemmorrhoids cervical osteoarthritis history of bilateral degenerative joint disease glaucoma palpitations with a holter monitor showing sinus tachycardia and occasional premature ventricular contractions but otherwise negative in status post lumbar fusion h o fainting spells med related s p tonsillectomy adenoidectomy recent admission for hyponatremia hyperkalemia diarrhea fatigue source unclear social history grew up in lives in with his partner of years no tobacco no etoh received a ba and then an ms in philosophy from he taught at the college level for years worked as contracts specialist for for about years family history father alcoholic died of metastatic melanoma at mother mother died of chf and cad at age with first mi at physical exam vs ra i o ml ml gen aao x fatigued easily arousable nad able to ambulate without dizziness pos right foot pain with ambulation orthostatics neg heent mm dry jvp flat op clear cards rrr nl s s no mgr lungs clear abd bs nt nd no organomeg ext no edema or rashes no darkening of skin noted neuro cn ii xii intact strength upper right ex prox otherwise full bilat intact romberg neg gait with narrow steps ob negative pertinent results ekg nsr nl axis intervals j point inferiorly twf avl unchanged more pronounced t waves from prev labs hct baseline creatinine bl hepatic enzymes normal venous lactate ck ckmb mbi neg trop urine and serum tox neg random cortisol stim time cortisol at minutes wbc n l m e plt hct retic egd gastritis diverticulosis of the whole colon polyps in the ascending colon grade internal external hemorrhoids polyp in the sigmoid colon head ct no evidence of intracranial hemorrhage cxr no failure no pneumonia brief hospital course hypotension thought to be related to two factors hypovolemia from recent diarrheal illness and medication effect from multiple anti hypertensives as well as decreased clearance of atenolol due to acute on chronic renal failure patients was volume resucitated and anti hypertensives as well as narcotics were held and his sbp nadir was increased eventually to upon discharge his diovan was restarted at half of his home dose mg home dose was mg his norvasc was held normally takes mg po daily and his hctz was also started at half of his home dose mg po bid of oxycontin rather than his normal dose of mg po bid his atenolol was held a decision was made to defer beginning a low dose toprol xl in the outpatient setting and uptitrating as needed adrenal insufficiency was ruled out with stim from at time and a cortisol of at time minutes arf acute on chronic renal failure likely due to pre renal causes as patient had a diarrheal illness for days which resolved a few days prior to admission and his renal failure improved with liters of fluid resuscitation back to his baseline patient will follow up with his renal doctor within days of his discharge anemia slightly worse than previous retic in the high s and stable upon discharge iron studies b folate normal month ago and guiac negative would likely benefit from beginning epo therapy the patient should discuss this during his appointment with his nephrologist fall per patient his fall was completely mechanical his ankle pain caused his instability he was not using his cane at the time per pt he should use his cane at all times from this point forward he has chronic ankle pain from previous trauma and is scheduled for surgical correction in roughly week pain medications were decreased to oxycontin mg po bid from mg po bid patient s pain was well controlled on this regimen he should uptitrate as outpatient with his pcp as his blood pressure allows if his pain worsens cardiac trop peak at likely insignificant in setting of renal failure ruled out for mi depression suicidal post discharge from psych facility patient no longer feels suicidal continued wellbutrin hyperkalemia this was in the setting of his acute renal failure it resolved and was stable upon discharge he was placed on half of his home dose of hctz mg po daily he will have his labs checked on by vna k bun cr and have these results called to his pcp medications on admission rosuvastatin mg tablet sig one tablet po daily valsartan mg tablet sig two tablet po daily daily gabapentin mg capsule sig one capsule po tid oxycodone mg tablet sustained release hr oxycodone mg tablet po q h as needed atenolol mg tablet sig tablets po daily primidone mg tablet sig tablet po hs quetiapine mg po tid as needed for anxiety wellbutrin sr daily discharge medications gabapentin mg capsule sig one capsule po tid times a day quetiapine mg tablet sig one tablet po q h every hours as needed for anxiety primidone mg tablet sig tablet po hs at bedtime bupropion mg tablet sustained release sig one tablet sustained release po qam once a day in the morning zolpidem mg tablet sig one tablet po hs at bedtime as needed rosuvastatin mg tablet sig one tablet po once a day oxycodone mg tablet sustained release hr sig one tablet sustained release hr po q h every hours oxycodone mg tablet sig one tablet po q h every hours as needed tylenol mg tablet sig tablets po every hours as needed for pain please do not exceed grams of tylenol per day valsartan mg tablet sig one tablet po twice a day disp tablet s refills hydrochlorothiazide mg tablet sig one tablet po once a day disp tablet s refills discharge disposition home with service facility vna discharge diagnosis primary diagnosis mechanical fall hypotension acute renal failure secondary diagnosis chronic renal failure discharge condition stable bp well controlled discharge instructions you were admitted for a fall related to your ankle pain you were found to have a very low blood pressure thought to be related to your medications as well as your worsening renal function one of your medications atenolol is cleared by your kidney and built up in your system when your kidney function worsened please call your doctor or go to the emergency room if your ankle pain worsens if you feel lightheaded have chest pain shortness of breath or any other concerning symptoms followup instructions please follow up with your renal kidney doctors weeks of your discharge they can check labs and help determine if you need a medication called erythropoetin or epo for your anemia associated with your kidney dysfunction also please follow up with your primary care physician weeks of your discharge you have the following appointments rm preadmission testing date time md phone date time drs and phone date time [NEW_RECORD] name unit no admission date discharge date date of birth sex m service medicine allergies penicillins trileptal sulfa sulfonamides attending addendum addendum to discharge summary on patient also had an spep and upep sent these results were pending upon discharge discharge disposition home with service facility vna md completed by,"{
""Diagnoses"": [""admission for hyponatremia"", ""hyponatremia"", ""hypotension"", ""SBP <90 mmHg"", ""hypotensive emergency"", ""ARF"", ""valsartan"", ""pain meds causing hypotension""],
""Medications"": [""seroquel"", ""wellbutrin"", ""atenolol"", ""cortisol"", ""steroid injections""]
}"
28224,admission date discharge date date of birth sex f service neurology allergies patient recorded as having no known allergies to drugs attending chief complaint confusion headaches major surgical or invasive procedure s p peg tube placement history of present illness patient is a yo woman with pmh of alzheimer s disease colon ca who has had a rapid decline in her cognition she is followed by dr from neurology for her dementia according to her husband and her daughter she has had an acceleration in her decline over the last months there was some concern that this might be secondary to the xeloda and these were stopped about months ago since that time she has coninued to decline and over the last days she has had a particularly rapid decline in speech confusion and gait her speech is much more limited and she has trouble expressing herself meaningfully this was particularly worse today her gait is more unsteady over the last few days but she can still walk unassisted this prompted imaging although there is no ct in our system her husband says that she had a ct somewhere that showed concern for bleeding an mri here was abnormal with extensive white matter hyperintensities the patient is unable to give any account as to why she is here she has no complaints or pain the patient s family does not note any focal weakness she complained of a headache this morning but now denies this and has not complained of headaches any other days this week she denies any neck stiffness ros ha as above no neck pain no cough no fevers chills nausea vomitting diarrhea past medical history alzheimer s disease colon cancer no known mets of chemo agents xeloda and for months now hypercholest tah bso yr hypothyroid social history she has stayed at home raising a number of her grandchildren she quit smoking about ten years ago after smoking one pack per day she drinks alcohol only very rarely family history her mother developed disease in her early s her father died at a young age from an accident physical exam t bp hr rr o sat ra gen lying in bed nad smiling heent nc at moist oral mucosa neck no tenderness to palpation normal rom supple no carotid or vertebral bruit back no point tenderness or erythema cv rrr nl s and s no murmurs gallops rubs lung clear to auscultation bilaterally abd bs soft nontender ext no edema neurologic examination mental status awake and alert cooperative with majority of exam inappropriately laughing or smiling on occasion oriented to self and husband but does not recognize her daughter and does not know month year or place her husband feels that the disorientation to place and year is likely baseline but no knowing her daughter might be new she is fluent to about words and has some spontaneous speech which is gramatically correct and somewhat appropriate to the situation she follows simple step commands midline but mixes left right commands and cannot do two step commands she names watch but not parts she cannot read without her glasses she repeats a simple sentence she does not have unilateral neglect mild grasp cranial nerves pupils equally round and reactive to light to mm bilaterally could not cooperate with fundoscopy visual fields are full to threat extraocular movements intact bilaterally no nystagmus sensation intact v v facial movement symmetric palate elevation symmetrical trapezius normal bilaterally tongue midline movements intact motor normal bulk bilaterally tone normal no observed myoclonus or tremor no pronator drift no asterixis was full strength in the triceps bicpes ips df and pf but could otherwise not test formally sensation intact to light touch and cold could not cooperate with dss testing reflexes and symmetric throughout ue knees ankles crossed adductors bilaterally toes mute bilaterally coordination reaches for my finger without ataxia but cannot test more specifically gait moderate based mildly unsteady romberg not attempted pertinent results pm albumin pm phenytoin pm ck cpk pm ck mb notdone ctropnt pm urine color yellow appear clear sp pm urine blood neg nitrite neg protein neg glucose neg ketone bilirubin neg urobilngn neg ph leuk neg pm pt ptt inr pt pm glucose urea n creat sodium potassium chloride total co anion gap pm alt sgpt ast sgot alk phos tot bili pm lipase pm ck mb ctropnt pm calcium phosphate magnesium pm tsh pm free t pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count am blood pt ptt inr pt am blood pt ptt inr pt am blood phenyto pm urine color yellow appear cloudy sp pm urine blood lg nitrite pos protein glucose neg ketone bilirub neg urobiln neg ph leuks mod pm urine rbc wbc bacteri many yeast none epi urine culture final mixed bacterial flora colony types consistent with skin and or genital contamination non contrast ct head impression evaluation slightly limited by motion artifact cm rounded focus of right frontal hyperdensity is most consistent with parenchymal hemorrhage though no definite underlying lesion was seen on mri from that assessment was incomplete without intravenous contrast and this focus of hemorrhage may be associated with an underlying lesion relatively symmetric distribution of white matter disease with subcortical involvement is more consistent with extensive chronic small vessel ischemic change perhaps of binswanger type likely with focal areas of chronic infarction than an unusual edema pattern related to occult metastatic disease non contrast head ct impression no interval change in the right frontal intraparenchymal hemorrhage with associated edema extensive periventricular and subcortical white matter low attenuation which likely reflects extensive chronic small vessel ischemic changes however foci of metastatic disease cannot be excluded mri head impression markedly limited study due to patient motion x cm intraparenchymal hemorrhage of the right frontoparietal lobe as before there is a central area of t hyperintensity within the hematoma which may represent blood versus enhancement a followup study after the resolution of the hematoma can be obtained to assess for any underlying lesions eeg impression this is an abnormal portable eeg due to the disorganized low voltage and slow background consistent with a mild encephalopathy and suggestive of dysfunction of bilateral subcortical or deeper midline structures medications metabolic disturbances and infection are among the common causes of encephalopathy but there are others there were no areas of prominent focal slowing although encephalopathic patterns can sometimes obscure focal findings there were no clearly epileptiform features and no electrographic seizure activity was noted cxr findings portable chest radiograph is reviewed without comparison cardiomediastinal contours are unremarkable pulmonary vascularity is normal lungs are grossly clear though note is made of slight elevation of the left hemidiaphragm there is no pleural effusion or pneumothorax impression no acute intrathoracic process brief hospital course a non contrast ct of the head in the emergency room showed a x cm right frontal intraparenchymal hemorrhage while in the emergency room the patient had a witnessed generalized tonic clonic seizure and was loaded with dilantin then ultimately started on mg tid for maintenance post ictal confusional state was noted the patient was admitted to the neurologic icu for further evaluation and management her blood pressure was closely watched with a goal map less than she underwent repeat imaging on including an mri of the head which showed a stable right frontal hemorrhage and again raised concern for amyloid angiopathy she remained encephalopathic which was attributed to both underlying illness and medication effect an eeg confirmed her persistent encephalopathic state but no subclinical seizures or epileptiform changes were seen on the patient was determined to be stable for transfer to the floors for further management the patient failed multiple swallowing evaluations attributed to her impaired level of alertness and attentiveness she was maintained npo but the family did not want a nasogastric tube placed due to concerns for discomfort over the next days the patient continued to remain encephalopathic she was generally hypertensive and standing iv metoprolol was titrated upward she did not follow commands or interact with those around her on the staff and family held a meeting regarding the direction of her care her outpatient neurologist dr was among those present the family expressed concern that she seemed to continue to decline even after arrival at after an extensive discussion her husband expressed a strong desire to proceed with peg placement in an effort to see how his wife might do in the coming weeks and months of supportive care at this time the patient s inr was rising after evaluation this was thought to be due to subcutaneous heparin which was subsequently discontinued the patient was given fresh frozen plasma to reverse her inr prior to peg placement by interventional radiology however the patient developed a transfusion reaction in response with swollen eyes and hives noted she was given benadryl with good effect and remained hemodynamically stable peg placement was delayed but did occur on tube feeds and medications were initiated through the peg tube later that day the patient was noted to have cloudy urine and a urinalysis suggestive of a urinary tract infection remained afebrile with normal wbc she was started on a day course of antibiotic ciprofloxacin based on her mri scans there was concern for the possibility of amyloid angiitis that could be responsive to high dose steroids however after extensive discussion it was decided not to pursue a trial of steroids given possible risks associated with steroid treatment and the difficulty in assessing possible response to treatment the patient remained stable with her encephalopathy over the final days of her stay the patient was generally awake with eyes open occasionally attending to her environment there was no spontaneous coherent speech though the patient occasionally smiled she was deemed stable for discharge to rehabilitation on medications on admission all nkda meds aricept daily lipitor daily citalopram levoxyl mcg daily memantine discharge medications famotidine mg tablet sig one tablet po twice a day donepezil mg tablet sig two tablet po hs at bedtime atorvastatin mg tablet sig one tablet po daily daily citalopram mg tablet sig one tablet po daily daily memantine mg tablet sig two tablet po twice a day acetaminophen mg tablet sig tablets po q h every hours as needed for fever or pain senna mg tablet sig one tablet po bid times a day as needed for constipation miconazole nitrate mg g combo pack sig one combo pack vaginal hs at bedtime for days phenytoin mg ml suspension sig one po tid times a day please dose so that patient receives mg tid levothyroxine mcg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig one tablet po bid times a day ciprofloxacin mg tablet sig one tablet po q h every hours for days docusate sodium mg ml liquid sig one po bid times a day discharge disposition extended care facility nursing home discharge diagnosis right frontal intracerebral hemorrhage discharge condition stable awake intermittently alert not speaking or following commands weakly moving all four extremities right side more than left discharge instructions please administer the medications as prescribed and have the patient follow up with appointments as scheduled if the patient experiences any new worsening or concerning symptoms such as increasng somnolence or weakness please contact the patient s neurologist dr at or bring the patient to the nearest emergency room for further evaluation followup instructions neurology follow up provider m d phone date time md,"{
""Diagnoses"": [""Alzheimer's disease"", ""Dementia""],
""Medications"": [""Xeloda""]
}"
61051,admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint dyspnea hoarseness and cough major surgical or invasive procedure bronchoscopy x tracheal y stent placement pigtail catheter placement right for pleural effusion intubation re intubated after attempted extubation chest tube placement right for pneumothorax radiation therapy x chemotherapy x days lumbar puncture history of present illness year old female pack year smoker with dyspnea hoarseness and cough x month admitted to sicu after found to have large mediastinal mass today found to be poorly differentiated carcinoma suspected small cell on initial evaluation patient was found to have mm opening of distal trachea secondary to external compression from mediastinal mass rul mass rul collapse and clinical findings consistent with svc sydrome y stent was placed that evening in addition to pigtail catheter for right sided effusion patient remained intubated following surgery on paralytics due to low lying et tube and small volume bleeding after endobronchial biopsy on extubated was attempted patient was reintubated within minutes due to neurological unresponsiveness hypoxia o saturation s and hemodynamic instability she was found to have a right pneumothorax which improved with subsequent placement of chest tube patient was also noted to have pericardial effusion given absence of physiologic tamponade cardiology decided against pericardiocentesis hospital course also complicated by hyponatremia on admission na attributed to siadh and improved with fluid restriction na also with hypotension sbp s following reintubation on given hyperkalemia hyponatremia adrenal insufficiency was suspected evaluated by endocrine team who recommended stress dose steroids pending further evaluation of etiology of hypotension also with non anion gap metabolic acidosis transient hypothermia t of unknown etiology per report patient has done well today she remains intubated on pressure support given the above pathology results patient is transferred to the medical icu for radiation therapy on arrival to the medical icu patient is intubated sedated and unable to provide history past medical history hypertension s p cerebral sneurysm repair x gerd social history per review of records pack year history family history unable to obtain physical exam on admission ps general intubated sedated not responsive to verbal stimuli swelling of head neck and upper extremities wasting of lower extremities skin mottled at arms and superior to nipple line telangiectasias on chest wall heent temporal wasting pupils symmetric minimal reactivity to light sclerae anicetric scleral edema dry mucous membranes neck large unable to appreciate neck veins secondary to swelling right anterior chain palpable lymph node chest right chest tube pigtail catheter in place lungs upper airway noise by anterior ausculation few expiratory wheezes diffusely breath sounds appreciable in all lung fields cv tachycardic regular rhythm pronounced s at apex i vi early systolic murmur at left llsb unable to assess pulsus paradoxus given quiet korsakoff sounds abdomen hypoactive bowel sounds soft non distended gu foley ext right dp left dp appreciated with doppler no lower extremity edema upper extremity nonpitting edema pertinent results on admission wbc rbc hgb hct mcv mch mchc rdw plt ct glucose urean creat na k cl hco angap alt ast ld ldh alkphos totbili cortsol hgb calchct o sat imaging ct chest without contrast large mediastinal mass causes narrowing of the right pulmonary artery superior vena cava and trachea and occlusion of the pulmonary artery supplying the right upper lobe in addition to the right upper lobe bronchus these findings are most concerning for a primary lung carcinoma right upper lobe collapse with nonenhancing lung parenchyma tumor involvement cannot be excluded atelectasis of the right lower and middle lobe large right pleural effusion tracheal mass tissue pathology immunohistochemical studies show that tumor cells are positively stained by ttf and ck they are negative for ck chromogranin and synaptophysin the tumor shows areas of necrosis extensive apoptosis and focal lymphatic vascular invasion some areas the tumor cell size approaching that of a small cell carcinoma but much of the tumor has larger nuclei overall the tumor probably fits into the spectrum of a small cell carcinoma of lung pleural fluid cytology rare groups of epithelioid cells too few to characterize further by immunohistochemistry mesothelial cells stain for calretinin and wt epithelial markers cea and b are negative rare cells are highlighted by ttf however these cells are not cytologically atypical and may represent non specific reactivity ekg sinus tachycardia low qrs voltage in limb leads no previous tracing available for comparison echo the left atrium and right atrium are normal in cavity size there is mild symmetric left ventricular hypertrophy with normal cavity size and regional global systolic function lvef right ventricular chamber size and free wall motion are normal 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 small to moderate sized primarily anterior pericardial effusion without right ventricular diastolic collapse impression suboptimal image quality mild moderate primarily anterior pericardial effusion mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function if clinically indicated a follow up study is suggested ct chest abdomen pelvis with and without contrast vascular findings unchanged from narrowing of svc and left brachiocephalic vein by large mediastinal mass the svc is narrowed to approximately mm over a region extending cm in craniocaudal dimension indirect evidence of right brachiocephalic vein occlusion likely complete unchanged narrowing of right pulmonary artery splayed but patent aortic arch branches interval decrease in large right pleural effusion with small anterior pneumothorax right chest tube terminating at apex no interval change in large infiltrative hypoattenuating right hilar mediastinal mass no evidence of metastases in the abdomen or pelvis slightly bulky left adrenal gland without discrete nodule or mass anasarca and small amount of peritoneal fluid collecting in the pelvis likely related to edema interval tracheal stenting with improved caliber of airway echo compared with the prior study images reviewed of the size of the pericardial effusion is unchanged with no signs of tamponade the left ventricle seems to be underfilled ct head within limits of this modality no evidence of enhancing mass or edema to suggest metastatic disease status post bilateral frontal craniotomy and probable aneurysm clipping with encephalomalacic changes in the right frontotemporal and left temporal lobes no evidence of acute hemorrhage or infarct probable chronic bifrontal subdural hygromas with minimal mass effect on the subjacent frontal gyri these may relate to the extensive remote surgery ct head performed due to worsened mental status unchanged examination from recent exam of status post bilateral frontal craniotomies with aneurysm clipping and encephalomalcia as described above no evidence of acute hemorrhage or infarct renal us mildly echogenic kidneys consistent with medical renal disease there is no evidence of hydronephrosis stone or mass the left kidney remains atrophic and lobulated similar to ct chest w o contrast to evaluate tumor s p xrt and chemo for future xrt sessions right anterior pneumothorax has resolved mixed response of the tumor to radiotherapy with a decrease of the central component of the tumor and a mixed response of the peripheral tumor components the peripheral consolidations in the right upper lobe have overall decreased in size however a new cavitary lesion has formed measuring x mm the peripheral consolidations in the right lower lobe and left lower lobe have increased in size number and density and may be part of post obstructive post radiotherapy post infectious or acute inflammatory changes lymphangio carcinomatosis in the right upper lobe there is new small right pleural effusion and increased moderate left pleural effusion left adrenal gland mass is only partially visualized in this study eeg markedly abnormal portable eeg due to the very disorganized and slow background rhythms this suggests a widespread and moderately severe encephalopathy in both cortical and subcortical structures medications metabolic disturbances and infection are among the most common causes although there were fleeting asymmetries there was no reliable area of focal slowing encephalopathies may obscure focal findings there are some sharp features but no clearly epileptiform abnormalities and no electrographic seizures leni no dvt echo final read pending micro pleural fluid gram stain final per x field polymorphonuclear leukocytes no microorganisms seen fluid culture final no growth anaerobic culture final no growth acid fast smear final no afb seen on direct smear acid fast culture preliminary pending cytology atypical cells non specific findings bal gram stain final per x field polymorphonuclear leukocytes per x field gram negative rod s per x field budding yeast with pseudohyphae respiratory culture preliminary fungal culture preliminary csf gram stain final no polymorphonuclear leukocytes seen no microorganisms seen fluid culture preliminary no growth cytology no malignant cells c diff negative blood cx ngtd blooc cx pending bronchoscopy lots of necrotic tissue noted ett tube dislodged between stent and tracheal wall repositioned during bronch brief hospital course course f with likely small cell carcinoma complicated by svc syndrome airway compromise requiring y stent pericardial effusion resolved pleural effusion and pneumothorax and electrolytes disturbances admitted to for radiation decompression therapy and chemotherapy pt developed respiratory failure and renal failure hypoxic respiratory failure pt was initially transferred from sicu to on cpap ps she developed increasing respiratory failure and was changed to ac mode in the she underwent xrt x and then chemotherapy for days increased hypoxia may have been due to pneumothorax which resolved pleural effusions atelectasis possible vap tumor compression during hypoxic episodes pt underwent bronchoscopy twice both times of which demonstrated the ett lodged between tracheal wall and stent pt s saturation improved with repositioning respiratory status also complicated by possible underlying copd given smoking history with possible air stacking trapping pt was started on vancomycin cefepime and ciprofloxacin started for day course for vap vanco was later held as the level was elevated in the setting of renal failure patient s family decided to persue comfort only care on and she was terminally extubated patient expired minutes later from respiratory failure and asystole secondary to lung cancer altered mental status pt had decline in mental status over time she initially withdrew from noxious stimuli but later was less responsive ams continued despite sedation being off ams most likely due to toxic metabolic syndrome in setting of uremia and multi system organ failure differential also included seizure given hx of cerebral aneurysm repair on anti epileptics presumably prophylactically although eeg did not demonstrate focal abnormalities lp did not demonstrate infection or spread of malignancy ct head negative for acute process small cell lung carcinoma per pathology the tumor probably fits into the spectrum of a small cell carcinoma of lung given associated svc syndrome prognosis poor ct head pelvis negative for metastases pt underwent days of chemotherapy and sessions of xrt initially xrt was clinical emergency normal and pathologic tissue was likely treated necrotic tissue noted on bronchoscopy pt was to undergo formal tissue planning session on to better delineate area of radiation however family decided to persue comfort only care on acute renal failure in setting of chemo with carboplatin urine casts consistent with atn uric acid and electrolytes elevated d post chemotherapy concerning for tumor lysis syndrome the next therapeutic step was dialysis as patient became oliguric despite volume overload but the family wished for comfort only care given dismal prognosis of her lung cancer metabolic acidosis originally thought to be non gap metabolic acidosis due to hypoaldosteronism and type iv rta with low albumin however this is a gap metabolic acidosis most likely due to uremia unable to increase rr to compensate due to concern for auto peeping in setting of possible copd goal ph is on pt s acidosis worsened with ph despite adjusting ett placement and decreasing rr to reduce auto peep pt s acidosis worsened bicarbonate was given tachycardia hypotension pt with tachycardia to s and episodes of hypotension to sbp low s pt with new a fib on telemetry and ekg ddx includes possible enlarging pericardial effusion tamponade but pulsus paradoxus was normal and echo was unchanged from prior no pneumothorax seen on cxr unable to assess for pe by cta as pt in renal failure and vq would not be helpful in setting of other lung pathology leni s negative for dvt pe likely given malignancy and prolonged bed rest but unable to do cta given renal failure and vq scan not helpful in setting of lung changes even if it had been positive heme onc recommended against anti coagulation in setting of possible tumor necrosis hemorrhage pt remained tachycardic to s despite numerous fluid boluses electrolyte disturbances pt developed hypernatremia on most likley due to dehydration with free water deficit of l started on d w pt had hyponatremia and hyperkalemia on admission both resolved unclear etiology of electrolyte disturbances on admission hyponatremia thought to be secondary to possible adrenal insufficency now discarded or possibly siadh low una does not exclude siadh renal recommended rechecking urine lytes with saline load whcih was not done in setting of pt s other medical issues hyperkalemia originally attributed to hypoaldosteronism and type iv rta but unlikely per endocrine because of low urine sodium svc syndrome incomplete occlusion of svc near complete occlusion of brachiocephalic veins clinically identified by upper extremity and facial swelling plethora and mottled skin also with scleral edema unable to assess jugular venous distension given considerable swelling seen in appoximately cases of sslc improved edema on exam compared to admission svc syndrome occurred after y stent placed possible that tumor pushing into trachea shifted to compress svc after stent placement she underwent radiation therapy and chemotherapy for decompression pleural effusion s p right pigtail catheter placement removed ldh effusion serum exudate by light s criteria greatest concern for malignant effusion however cytology was nonspecific cultures of fluid all preliminary negative pneumothorax developed pneumothorax in setting of re intubation that resolved after chest tube placement pericardial effusion suspected by cardiology to be malignant effusion felt not to be large enough for percutaneous drainage ekg without signs of electrical alternans but does have low voltages repeat echo done in setting of hypotension demonstrated no change in pericardial effusion sinus pause on telemetry pt had episodes of sinus pauses on tele night of with turning to right side occurred again again with re positioning metoprolol was held and glucagon given in case this was due to beta blocker toxicity but pauses decreased in frequency and duration on their own without intervention cardiology consulted who felt it was vagally mediated have been due to ett tube displacement pressing on carotid when pt was turned leukopenia thrombocytopenia most likely due to chemotherapy and no improvement in counts on neupogen she was repeatedly pan cultured with negative results anemia normocytic and likely due to anemia of chronic disease given malignancy hemolysis labs were negative s p cerebral aneurysm repair history of cerebral aneurysm repair with a number of chronic changes on head ct her antiepileptic medications were continued medications on admission home medications metoprolol omeprazole levetiracetam carbatrol medications on transfer to furosemide mg iv once duration doses carbamazepine mg po qpm carbamazepine mg po qam artificial tears preserv free drop both eyes prn dry eyes potassium phosphate iv sliding scale insulin sc sliding scale insulin regular unit iv once dextrose gm iv once duration doses propofol mcg kg min iv drip titrate to moderate heavy sedation chlorhexidine gluconate oral rinse ml oral hydrocortisone na succ mg iv q h nicotine patch mg td daily levetiracetam mg iv bid magnesium sulfate iv sliding scale calcium gluconate iv sliding scale potassium chloride iv sliding scale albuterol ipratropium puff ih q h pantoprazole mg iv q h heparin unit sc tid fentanyl citrate mcg iv q h prn sedation discharge medications expired discharge disposition expired discharge diagnosis expired discharge condition expired discharge instructions expired followup instructions expired md,"{
""Diagnoses"": [""Dyspnea"", ""Hoarseness"", ""Cough"", ""Poorly differentiated carcinoma"", ""Suspected small cell""],
""Medications"": [""Medicine"", ""Allergies"", ""Intubation"", ""Reintubation"", ""Paralytics"", ""Endobronchial biopsy""]
}"
9058,admission date discharge date date of birth sex f service cardiothoracic allergies zoloft tetracyclines prozac paxil attending chief complaint shortness of breath major surgical or invasive procedure cardiac catheterization cartotid stent to picc line insertion coronary artery bypass graft x lima to lad svg to diag svg to om svg to rca aortic valve replacement mm st mechanical mitral valve replacement mm st mechanical aortic root enlargement with pericardial patch history of present illness y o f w hx of htn and pvd was in her usoh on sunday night until she woke up at midnight severely sob she was intubated in the filed and brought to upon intubation they noted pink frothy sputum coming from the ett at the icu her bp was controlled and she was diuresed with lasix she was extubated on monday she had a cta to r o pe which demonstrated only interstitial opacities c w chf no pe she had a tte which showed mr ar and an akinetic anterior wall her initial ecg upon arrival yest am showed depressions in ii iii avf with mm ste in v by this am her ecg showed deep twi in i avl ii and v her cardiac enzymes showed ck with mb trop from yest at am to am to pm she was then transferred from osh to for cardiac cath and further care past medical history hypertension hypercholesterolemia peripheral vascular disease varicose veins congestive heart failure congenital hip dysplasia with chronic low back pain s p appendectomy s p cholecystectomy s p left finger reattached s p stents to left leg and angioplasty to right leg s p left hip replacement social history patient is married with one grown daughter previously worked as a medical assistant ppd smoking since age quit no alcohol drug abuse family history father with diabetes and cva in his late s mother with mi at age physical exam t bp p r ra gen alert and oriented pleasant female in nad heent pupils mm and minimally reactive eomi sclerae anicteric mmm no op lesions neck supple bilateral carotid bruits jvd not elevated lungs minimal bibasilar crackles dullness to percussion at bilateral bases cv rrr normal s s no m r g abd soft nt nd normoactive bowel sounds ext no edema dp bilaterally neuro cn ii xii intact maew pertinent results cath vd the lmca had diffuse stenosis the lad had had diffuse proximal disease without critical lesions the distal lad was intramyocardial with the distal d being the predominant vessel to the apex the lcx was a non dominant vessel with stenosis in its origin the rca was a dominant vessel with stenosis at its origin cnis significant plaque with bilateral carotid stenosis of note the plaque extends fairly high in both cervical internal carotid arteries echo pre bypass preserved biventricular systolic function the intrinsic lv systolic function may be depressed given the degree of mitral regurgitation overall lvef thickened mitral leaflets at commisures no prolapse or flail segments reflecting a probable rheumatic disease in origin there is shortened chordae and a thickened subvalvular apparatus there is mild mitral stenosis with moderate to severe mitral regurgitation the regurgitant jet is mostly central with a vena contracta of cm and mitral annulus of mm and a dilated left atrium thickened aortic leaflets especially at commissures with a mild aortic stenosis and a central regurgitant jet c w with moderate aortic regurgitation there is no flow reversal of flow in the thoracic aorta mild tricuspid and pulmonic regurgitation post bypass suboptimal images due to double mechanical valves a mechanical prosthesis is seen in the native mitral position stable and functioning well and regurgitant jets are typical for the type of prosthesis no mitral stenosis is appreciated mean gradient of mm hg a mechanical prosthesis is seen in the native aortic position stable and functioning well and the regurgitant jets are typical of the prosthesis with a mean gradient of mm hg cxr bilateral pleural effusions worse on the left than the right there is interval worsening of the left sided pleural effusion bibasilar atelectasis 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 pt ptt inr pt am blood pt ptt inr pt pm blood pt ptt inr pt am blood pt ptt inr pt 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 urine blood lg nitrite neg protein tr glucose neg ketone neg bilirub neg urobiln ph leuks mod am urine rbc wbc bacteri many yeast none epi pm urine rbc wbc bacteri many yeast none epi pm urine rbc wbc bacteri occ yeast none epi brief hospital course ms was transferred from osh to and underwent cardiac cath on which revealed severe vessel disease also on this day she underwent an echo which revealed moderate mr pre operative work up was performed which first revealed a uti she was treated with appropriate antibiotics and then definitive once cultures were completed she also underwent a carotid ultrasound which revealed bilateral stenosis on she underwent stenting of her please see procedure note on she underwent picc line placement for definitive iv therapy please see procedure note over the next several days she was medically managed and treated for her uti her operation was cancelled several times due to her uti she was finally cleared for surgery and on she was brought to the operating room where she underwent a coronary artery bypass graft x aortic valve replacement and mitral valve replacement please see operative report for surgical details she tolerated the procedure well and was transferred to the csru for invasive monitoring in stable condition she remained intubated and on pressors through post op day one she also required multiple transfusions for bleeding and low hct by post op day two pressors were weaned and she now required labetalol for hypertension this was slowly weaned off and she was then started on beta blockers and diuretics she was gently diuresed towards her pre op weight and beta blocker was titrated for maximum hr and bp control she was weaned from sedation awoke neurologically intact and was extubated also on this day her chest tubes were removed she was started on coumadin d t mechanical valves with a heparin bridge until inr therapeutic epicardial pacing wires were removed on post op day three and she was transferred to the sdu on post op day three her inr dramatically rose to over and coumadin was stopped she was treated with ffp and over the next several days her inr trended down and she was again titrated with coumadin for a goal inr on post op day six amiodarone was started for episode of atrial fibrillation she was ready for discharge on medications on admission medications at home plavix toprol lisinopril oxycontin mg tid oxycodone mg prn aspirin protonix medications on transfer lasix iv x oxycontin mg tid toporol mg qd protonix mg qd plavix mg qd aspirin mg qd reglan prn lopressor iv x labetalol mg iv x nitropaste inch dilaudid prn lipitor mg qd lisinopril mg qd lovenox 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 simvastatin mg tablet sig one tablet po daily daily disp tablet s refills clopidogrel mg tablet sig one tablet po daily daily disp tablet s refills ferrous gluconate mg tablet sig one tablet po daily daily disp tablet s refills ascorbic acid mg tablet sig one tablet po bid times a day disp tablet s refills hydromorphone mg tablet sig one tablet po q h every hours as needed disp tablet s refills lisinopril mg tablet sig one tablet po daily daily disp tablet s refills pantoprazole 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 metoprolol tartrate mg tablet sig two tablet po bid times a day disp tablet s refills warfarin mg tablet sig one tablet po daily daily mg alternating with mg mg today check inr with results to dr disp tablet s refills furosemide mg tablet sig one tablet po bid times a day for weeks disp tablet s refills potassium chloride meq capsule sustained release sig four capsule sustained release po bid times a day for weeks disp capsule sustained release s refills amiodarone mg tablet sig two tablet po bid times a day x days then qd x days then qd ongoing disp tablet s refills discharge disposition home with service facility discharge diagnosis coronary artery disease s p coronary artery bypass graft x aortic insufficiency s p aortic valve replacement mitral regurgitation s p mitral valve replacement pmh hypertension hypercholesterolemia peripheral vascular disease varicose veins congestive heart failure chronic low back pain s p appendectomy s p cholecystectomy s p left finger reattached s p stents to left leg and angioplasty to right leg s p left hip replacement discharge condition good discharge instructions take shower wash incisions and pat dry do not take bath do not apply lotions creams or ointments to incisions do not drive for month do not lift more than pounds for months if you develop a fever notice redness or drainage from incision please contact office immediately call to schedule all follow up appointments followup instructions dr in weeks dr in weeks dr in weeks and for coumadin follow up md completed by [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies zoloft tetracyclines prozac paxil attending chief complaint claudication major surgical or invasive procedure catheterization r ij central venous line placement history of present illness year old female with pmh of cad s p cabgx htn hyperlipidemia s p mvr and avr and severe pvd who presents from home the day of admission for heparinization prior to a planned intervention for worsening claudication ms has had severe claudication in the past and underwent a r sfa atherectomy and angioplasty in and stenting of the l sfa total occlusion in she then underwent a cabg x and mvr and avr in over the early winter months she remained asymptomatic from claudication likely secondary to decreased exertion approximately months ago she started to notice r leg pain in the back of her calf with walking it then progressed to be rest pain then her l leg began to ache it progressed to the point where both posterior calves ache when walking the length of a hallway she is forced to stop and rest for a few minutes before being able to continue walking she also has pains in the back of her calves at rest like her legs are falling asleep at night despite the fact that her r leg started first and that her r leg appears worse by recent abis her l leg is more painful to her and feels tired all the time she denies having any swelling in her feet above her baseline her lle has been slightly swollen ever since her cabg or a cold foot her feet remain warm and well perfused there had been a planned intervention at the end of which she was admitted for however her mother passed away and she was unable to undergo the intervention she was admitted for heparinization in anticipation of an intervention planned for wednesday she last took coumadin on friday night days pta and her inr today at home was cardiac review of systems is notable for absence of chest pain dyspnea on exertion paroxysmal nocturnal dyspnea orthopnea ankle edema palpitations syncope or presyncope 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 other than chronic hip back pain cough hemoptysis black stools or red stools she denies recent fevers chills or rigors she does endorse exertional calf pain l r all of the other review of systems were negative past medical history hypertension hyperlipidemia peripheral vascular disease status post bilateral lower extremity sfa revascularization by dr most recently in abis right decreasing to with exercise left decreasing to with exercise impression left iliofemoral arterial disease right sfa disease possible left sfa disease bilateral infrapopliteal arterial disease right sfa atherectomy and angioplasty dr abis as below cardiomyopathy admission to with chf cardiomyopathy ef etiology unclear repeat echo ef history of coronary artery disease status post cabg x and avr mvr in under the care of dr asymptomatic bilateral carotid artery disease status post stent under the care of dr prior to cardiac surgery in congenital hip dysplasia status post left total hip replacement chronic back pain hyperlipidemia status post appendectomy status post cholecystectomy social history the patient is married and has a year old daughter she lives in she used to work as a nursing assistant in alf but had to retire due to back hip pain has recently been working in retail but that is on hold until she completes cardiac rehab smoked ppd x years quit at age occasional etoh family history mother cad hypercholesterolemia mi in s breast cancer fater dm cva siblings healthy physical exam vs t bp hr rr sats on ra gen thin 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 no jvd carotid bruit on r cv rr mechanical s and 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 palpated no abdominial bruits appreciated bs throughout ext no c c l le is slightly more swollen than r per pt is her baseline since cabg skin diffuse erythematous rash over extremities shoulders bilaterally per pt is sun tanning damage pulses on palpation right carotid femoral popliteal dp absent pt left carotid femoral popliteal dp pt absent pertinent results labwork on admission wbc hct mcv plt ct pt ptt inr pt glucose urean creat na k cl hco angap calcium phos mg labwork on discharge 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 ld ldh alkphos totbili am blood calcium phos mg am blood triglyc hdl chol hd ldlcalc ecg study date of pm sinus bradycardia right bundle branch block prolonged q tc interval st t wave changes may be in part primary these findings are nonspecific but clinical correlation is suggested since previous tracing of st t wave abnormalities decreased ct abdomen pelvis impression moderate sized extraperitoneal hematoma in pelvis extending mostly into the space of retzius with small retroperitoneal extension anterior to right psoas muscle this is contiguous with stranding in the right groin small pleural effusion which demonstrates high hounsfield units greater than expected of simple pleural fluid hemothorax cannot be excluded tiny amount of blood anterior to liver likely hematoma about newly placed right superficial femoral artery stent this study was performed without iv contrast if there is concern for pseudoaneurysm or extravasation about the stent femoral vascular ultrasound is recommended difficult crossmatch diagnosis assessment and recommendations ms has a new diagnosis of allo antibodies to the e and k antigens the e and k antigens are members of the rhesus and antigen blood groups respectively both of these antibodies are capable of mediating hemolytic transfusion reactions in the future blood transfusions for this patient should be restricted to abo and crossmatch compatible red cells that are negative for both e and k antigens approximately of abo compatible blood will be negative for both of these antigens a wallet card and letter stating the above will be sent to the patient peripheral atheterization final diagnosis right lower extremity pvd as evidenced by moderate diffuse disease of the cfa and total occlusion of the sfa with distal flow preservation via the pfa left lower extremity pvd as evidenced by origin stenosis involving the sfa and pfa successful silverhawk atherectomy of the left sfa pfa origin successful rescue pta of the pfa origin le u s impression no evidence of dvt cm predominantly hypoechoic collection around left sfa stent which may represent hematoma or seroma however clinical correlation is required ct abdomen pelvis impression large extraperitoneal hematoma in the pelvis which compared to prior ct from appears slightly increased in size small bilateral pleural effusions with adjacent compressive atelectasis cxr right jugular line tip projects over the lower svc no pneumothorax small right pleural effusion unchanged heart size moderately enlarged but stable lungs grossly clear ecg study date of am sinus rhythm left atrial abnormality right bundle branch block q waves in lead iii unsupported by q waves in leads ii or avf compared to the previous tracing of st segment depressions are no longer present in leads v v brief hospital course year old female with history of cad s p cabg mvr and avr and severe pvd who presented for heparinization prior to intervention for worsening claudication the patient received intervention to left sfa and pfa the procedure was complicated by retroperitoneal bleed peripheral vascular disease the patient has severe bilateral lower extremity pvd per abi in the patient underwent peripheral catheterization with intervention to left sfa and pfa with report as above the patient s inr was prior to procedure and the patient was given ffp the plan was for subsequent right sided intervention during this admission but the procedure was complicated by retroperitoneal bleed as below the patient was continued on aspirin the patient was started on plavix and pravastatin the patient will follow up with dr retroperitoneal bleed the patient complained of increased back pain above baseline after the procedure the patient s hematocrit was noted to have dropped from to and ct abdomen showed extraperitoneal retroperitoneal hemorrhage the patient was transfused a total of three units packed red blood cells repeat ct abdomen showed a small increase in the size of the hemorrhage but was otherwise stable the patient was followed by vascular surgery but did not require intervention anticoagulation was resumed for avr mvr after the patient s hematocrit was stable x hours the patient s hematocrit was stable in the mid s on discharge cardiovascular a coronary artery disease the patient has known cad and is s p cabg x in there was no evidence of active ischemia during hospitalization the patient was discharged on aspirin statin beta blocker and inhibitor the patient was placed on plavix for her peripheral stents b rhythm the patient remained on normal sinus rhythm the patient was continued on a beta blocker c pump last ejection fraction pre cabg was the patient likely has an element of diastolic heart failure the patient had one episode of flash pulmonary edema in the setting of receiving ivf for hydration in the context of continued nausea vomiting she responded to furosemide mg iv x and put out cc urine to this with resolution of symptoms the patient was continued on beta blocker and inhibitor status post avr and mvr the patient is on coumadin as an outpatient and was admitted for heparinization prior to her schedule procedure the patient was off of all anticoagulation briefly in the setting of the retroperitoneal bleed but was re started on heparin and coumadin once her hematocrit was stable and discharged with a therapeutic inr hyperlipidemia zocor was discontinued due to lft abnormalities the patient s lfts were stable and she was started on pravastatin during this admission the patient s liver function tests should be rechecked as an outpatient hypertension the patient s blood pressure was quite labile from systolics to when nauseated and vomiting the patient s anti hypertensive regimen was titrated during admission and the patient was discharged on her home regimen back pain the patient was continued on oxycontin mg tid initially then reduced to mg for concern for sedation the patient needed very little as needed pain medication on the reduced dose nausea vomiting the patient had severe nausea vomiting for six days after catheterization and has a history of nausea vomiting after catheterization or surgery she responded to compazine ativan anzemet as needed and was tolerating a regular diet prior to discharge urinary tract infection the patient had a positive urinalysis and urine culture was positive for e coli pan sensitive per the patient s husband the patient has had urinary tract infections in the past with foley catheterization the patient was give bactrim to complete a seven day course medications on admission lisinopril mg po qd protonix mg po qd metoprolol mg po bid aspirin mg po qd coumadin mg as directed oxycontin mg po tid oxycodone mg po prn for breakthrough pain discharge disposition home with service facility vna of greater discharge diagnosis primary peripheral vascular disease retroperitoneal bleed hypertension anticoagulated for avr mvr constipation urinary tract infection secondary coronary artery disease status post cabg in congenital hip dysplasia status post left total hip replacement chronic back pain status post appendectomy status post cholecystectomy discharge condition hemodynamically stable ambulatory discharge instructions you were admitted for a catheterization for your peripheral vascular disease you had a retroperitoneal bleed after your catheterization but your hematocrit has been stable for several days several of your medications were changed during your hospital course you were started on plavix it is very important that you take this medication every day to prevent clots in the stent it is very important that you also continue your aspirin you should take only mg of coumadin daily and continue to check your inr at home you were started on pravastatin to lower your cholesterol you were started on bactrim an antibiotic for a urinary tract infection continue taking this medication for five more days your oxycontin was decreased to mg twice daily please take colace senna and bisacodyl as needed for constipation please seek medical attention immediately if you develop chest pain shortness of breath fever or other concerning symptoms please schedule your follow up appointments as below followup instructions please call to make a follow up appointment with dr within the next week please call to make a follow up appointment with your primary care physician within the next two weeks [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies zoloft tetracyclines prozac paxil darvocet a attending chief complaint admit for cath major surgical or invasive procedure cardiac and lower extemity catheterization with relook history of present illness ms is a year old woman with history of cabg mechanical avr and mvr hx of severe pvd s p pta s being referred for both cardiac and rle angiography on wednesday she has a history of prior retroperitoneal bleed with last cath she had had a long history of symtoms of claudication with ambulation she has had le angiography in the past that has demonstrated several le blockages she states that at baseline she can typically walk approximately one block before she has to rest she stated that a few days ago she had experienced some dull chest pain at rest that lasted a few minutes it was not associated with any sob nausea or diaphoresis on patient taken for le and coronary angiography patient had a complicated procedure that led to her transfer to the ccu during the cath patient developed a lcfa dissection the lcfa was ballooned using an approach from the right patient also was found to have a proximal rca lesion that was stented using a bms she was also found to have a lmca lesion that was not intervened upon several hours post intervention patient complained of pain in lle and was unable to move her foot patient s foot was cold and did not have any pulses she was taken for re look and was found to have an embolus in the popliteal artery patient had an embolectomy and a stent placed in the popliteal artery she was started on a heparin gtt and was taken to the ccu for back pain delirium nausea she recieved pain meds lorazepam and now feels better she dropped her oxygen satutations and her cxr showed possible pulm edema and got furosemide mg iv x at am to which she has diuresed well pt is now transferred back to floor patient denies any nausea vomiting diarrhea cp past medical history cardiac risk factors diabetes dyslipidemia hypertension cardiac history cabg in anatomy as follows left internal mammary artery to left anterior descending artery saphenous vein grafts to right coronary artery saphenous vein grafts to obtuse marginal artery saphenous vein grafts to diagonal artery aortic valve replacement mm st mechanical mitral valve replacement mm st mechanical aortic root enlargement with pericardial patch percutaneous coronary intervention silverhawk atherectomy of the left sfa pfa origin on pta was performed on the pfa origin on acculink stent in on protege stent in the l sfa on atherectomy and angioplasty of rsfa on other past history hypertension hyperlipidemia peripheral disease status post bilateral lower extremity sfa revascularization by dr abis and on the right and left respectively remaining stable with exercise she has triphasic waveforms throughout with exception of monophasic right dp her pvrs are maintained at bilaterally at the metatarsal level duplex results reveal elevated velocities at proximal aspect of stents bilaterally and cm sec respectively consistent with narrowing abis right decreasing to with exercise left decreasing to with exercise impression left iliofemoral arterial disease right sfa disease possible left sfa disease bilateral infrapopliteal arterial disease right sfa atherectomy and angioplasty dr abis as below coronary artery disease status post cabg x in under the care of dr rheumatic heart disease with ar and mr s p avr mvr in cardiomyopathy admission to with chf cardiomyopathy ef etiology unclear repeat echo ef asymptomatic bilateral carotid artery disease status post stent under the care of dr prior to cardiac surgery in congenital hip dysplasia status post left total hip replacement chronic back pain status post appendectomy status post cholecystectomy social history the patient is married and has a year old daughter she lives in she used to work as a nursing assistant in alf but had to retire due to back hip pain has recently been working in retail but that is on hold until she completes cardiac rehab smoked ppd x years quit at age occasional etoh family history mother cad hypercholesterolemia mi in s breast cancer fater dm cva siblings healthy physical exam vs ra gen oriented x mood affect appropriate heent perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthalesma neck no jvp cv rr loud s load s with iv vi sem no thrills lifts no s or s chest resp were unlabored no accessory muscle use ctab no crackles wheezes or rhonchi abd soft ntnd no hsm or tenderness ext no c c e no inguinal hematomas bilaterally no bruit on r l femoral soft bruit ble warm well perfused skin no stasis dermatitis ulcers scars or xanthomas pulses right dp pt left dp pt pertinent results c cath comments the right femoral artery sheath ws exchanged for a french short sheath an omniflush catheter was advanced over an angled glide wire over the to the lcfa angiography revealed a patent cfa with the previous dissection site widely patent the lsfa stent was widely patent and the left popliteal artery was occluded and reconstituted aftet approximately mm the at and pt were patent to the foot we planned to export the thrombus from the left popliteal artery and laser if needed a french sheath was advanced over the to the contralateral sfa the lesion was crossed with an angled glide wire and then a spartacore wire a spider filter was used for distal protection thrombectomy was preformed with the export cathether with retrieval of thrombus but little improvment angiographically atherectomy with a mm laser at was preformed without return of flow the lesion was then dilated with a x mm amphirion balloon a x mm zilver stent was deployed in the left popliteal artery and was post dilated with a x mm amphirion balloon final angiography revealed no residual stenosis in the stent and no dissection the dp had a distal cut off though the pt was widely patent right femoral arteriotomy site was closed with a french angioseal device final diagnosis acute limb ischemia successful thrombectomy laser atherectomy pta and stenting of the left popliteal artery c cath comments coronary angiography in this right dominant system revealed the lmca had a proximal tubular lesion with flow into the lcx and competitive flow into the lad the lad was patent with competitive flow to the diagonal and lad from a patent graft the lcx was a non dominant vessel with moderate diffuse disease there is tenting of a small om from the occluded svg graft the rca was a dominant vessel with origin lesion arterial conduit angiography revealed the lima lad graft to be widely patent venous conduit angiography revealed the svg rca svg om and svg diag grafts to be occluded this was confirmed by supravalvular aortography supravalvular aortography confirmed occlusion of the svg rca svg om and svg diag grafts upon access in the lcfa dissection was noted with preserved flow the eia had moderate diffuse disease proximal to the previous sfa stent the reia had a tubular lesion with the rsfa having a proximal lesion above the previous stent limited resting hemodynamics revealed severe arterial systolic hypertension with sbp mmhg we first palnned to fix the right external iliac artery we exchanged the left cfa sheath for a french balken sheath the lesion was crossed with a steel core wire to the right popliteal artery a x mm protege stent was deployed in the reia and was post dilated with a x mm admiral balloon we then advanced a x mm angiosculpt balloon to the proximal rsfa and dilated the lesion at moderate pressure final angiography revealed no residual stenosis in the stent and a residual in the sfa we then turned our attention to the right coronary artery successful ptca and stenting of the ostial rca with a x mm vision bms which was deployed at atm final angiography revealed no residual stenosis in the stent no dissection and timi iii flow see ptca comments we then turned our attention to the lcfa dissection we accessed t he rcfa and placed a french balken sheath to the contralateral lcia a angled glide wire was left in the l sfa angiography confirned a retrograde dissection the left cfa was closed with a french mynx device but flow diminished the and the lcfa were t hen dilated with a x admiral balloon to atms final angiography revealed a residual a contained dissection with preserved flow final diagnosis native three vessel cad patent lima lad occluded svg rca svg diag and svg om grafts dissection in lcfa with preserved flow moderate diffuse disease in tubular stenosis in reia and stenosis in r sfa severe systemic arterial systolic hypertension successful stenting of the reia and pta of the rsfa successful ptca and stenting of the ostial rca successful pta of teh lcfa dissection successful closure of lcfa access site with mynx closure device kub impression incompletely visualized abdomen however visualized portion appears normal indistinct left lung base better characterized on accompanying chest radiograph femoral u s impression no evidence of hematoma pseudoaneurysm or av fistula no son evidence of foreign object in the right common femoral artery a possible angioseal device is seen in the superficial tissues superficial to the right cfa am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood hct 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 am blood plt ct am blood pt ptt inr pt am blood plt ct am blood pt ptt inr pt am blood caltibc hapto ferritn trf am blood triglyc hdl chol hd ldlcalc brief hospital course year old woman with history of cabg mechanical avr and mvr hx of severe pvd s p pta s s p bms to prox rca and lcfa dissection with reia and l popliteal stenting cad patient is s p cabg with triple vessel disease and with lower extremity disese cp free but coronaries were looked during the procedure patient was found to have a tight left main that was supplying a diagonal likely d that was not intervened upon the lmca had a proximal tubular lesion with flow into the lcx and competitive flow into the lad that was patent the rca was a dominant vessel with origin lesion that was successfully stented with bms the lmca was not intervened upon continue asa bb statin continue i continue plavix mg daily pvd stable during the cath patient developed a lcfa dissection the lcfa was ballooned using an approach from the right several hours post intervention patient complained of pain in lle and was unable to move her foot patient s foot was cold and did not have any pulses she was taken for re look and was found to have an embolus in the popliteal artery patient had an embolectomy and a stent placed in the popliteal artery she was started on a heparin gtt and was taken to the ccu for back pain delirium nausea patient recovered after one night in the ccu patient has a soft l femoral bruit that was likely from the dissection and was confirmed by ultrasound there was no evidence of av fistula patient s ble are warm with pulses present pump patient is euvolemic on exam she has a history of av and mvr and has been on coumadin at home patient was started on a heparin drip and warfarin was held prior to procedure on discharge patient s inr was with goal patient is to follow up with pcp for inr check cont coumadin mg follow inr as outpatient rhythm nsr monitor on tele hyperlipidemia continue pravastain medications on admission plavix mg daiy hctz mg daily hydromorphone mg qid ipratropium bromide qid lisinopril mg daily lopressor mg omeprazole mg daily oxycontin mg pravastain mg daily coumadin mg day asa mg daily discharge medications metoprolol tartrate mg tablet sig two tablet po bid times a day clopidogrel mg tablet sig one tablet po daily daily pravastatin mg tablet sig two tablet po daily daily lisinopril mg tablet sig one tablet po daily daily omeprazole mg capsule delayed release e c sig one capsule delayed release e c po bid times a day ferrous sulfate mg mg iron tablet sig one tablet po tid times a day disp tablet s refills oxycodone mg tablet sustained release hr sig two tablet sustained release hr po q h every hours hydrochlorothiazide mg capsule sig one capsule po daily daily warfarin mg tablet sig one tablet po once daily at pm please adjust according to your inr ipratropium bromide mcg actuation aerosol sig one inhalation twice a day aspirin mg tablet delayed release e c sig one tablet delayed release e c po once a day disp tablet delayed release e c s refills discharge disposition home discharge diagnosis primary coronary artery disease peripheral disease hypertension discharge condition afebrile vitals stable discharge instructions you were hospitalized because you needed to have a lower extremity and cardiac catheterization you had a stent placed in your proximal right coronary artery and another placed in an artery in your right and left lower extremities please continue to take plavix your dose of aspirin has been increased to mg daily your inr is on discharge please continue to adjust your coumadin dose based on your home inr machine please make an appointment to see dr and to have your inr officially checked on wednesday please call dr office to make an appointment to see him in weeks you were also found to be anemic please continue to take iron supplements please consider having a screening colonoscopy as an outpatient followup instructions please call dr office to make an appointment within week please tell his office that you need your inr checked on wednesday his number is please call dr office to make a follow up appointment his number is completed by,"{
""Diagnoses"": [""Cardiothoracic"", ""Allergies"", ""Zoloft"", ""Tetracyclines"", ""Prozac"", ""Paxil""],
""Medications"": [""Lasix"", ""TTE"", ""CTA"", ""ECG"", ""Cardiac Enzymes""]
}"
16302,admission date discharge date date of birth sex f service neurology allergies dilantin tegretol gold salts attending chief complaint ha and visual field cut at neurology clinic major surgical or invasive procedure ventricular drain placement mri history of present illness year old rh woman with h o protein c defficiency and venous sinus thrombosis was recently discharged on lovenox and reportedly was doing fine initially sister and mother at bedside report that she first started comlaining of headache days ago also complained that she couldn t see characters on the right side of the tv she presented today in neurology clinic for follow up where she complained of headache and was noted to have a right field cut on exam patient is inattentive aphasic and perseverating so unable to give a coherent history other than talking about her headache describes the headache as hurts on the top of my head and reports that its worse when she s lying down in bed complains of nausea but started vomitting only after coming to ed according to sister and mother the patient was looking better this am and was only complaining of feeling terrible and her headache was more attentive and able to express herself was discharged on lovenox rather than coumadin reportedly because the thrombus was not responding to coumadin for further details of initial presentation on please see admission note from that date patient unable to give coherent ros past medical history cortical venous thrombosis and associated stroke had presented with l leg clumsiness slurred speech headaches on coumadin therapy since venous sagittal sinus thrombosis with associated venous infarcts on neurology service had presented with left sided weakness seizures since during pregnancy with several seizure types including staring focal lue sz and complex partial with secondary generalization headaches on ppx with verapamil protein c deficiency gestational dm juvenile rheumatoid arthritis social history lives with son has boyfriend tob no etoh no drugs currently disabled family history aternal and paternal grandparents with strokes per old notes physical exam t hr bp rr ra general appearance looks somnolent pale and has emesis basin in hand heent moist mucus membranes clear oropharynx neck supple no bruits heart regular rate and rhythm no murmurs lungs clear to auscultation bilaterally abdomen soft nontender bs extremities warm well perfused skull spine neck movements are full and not painful to palpation in the paraspinal soft tissues mental status the patient is somnolent but awakens to voice and can stay awake for conversation during parts of the exam and at other times falls asleep in exam able to follow some simple commands but not all unable to follow complex commands and inattentive throughout exam oriented to person but names as hospital and cannot say date appears unable to convey her thoughts questions and perseverates frequently no dysarthria memory unable to be tested as inattentive cranial nerves the visual fields show right homonymous hemianopsia although testing accurately was difficult given her inattentiveness patient not able to cooperate with fundoscopic exam but portions of disc visualized did not appear crisp eye movements are normal with no nystagmus pupils react equally to light both directly and consensually sensation on the face is intact to light touch bilat no drpp and muscles of facial expression intact bilaterally hearing is intact to voice the palate elevates in the midline the tongue protrudes in the midline and is of normal appearance gag is intact motor system strength was full and equal in deltoids triceps biceps full and equal in ips quads dorsiflexors and plantar flexors weakness bilaterally in hamstrings tone was increased in right lower extremity just slightly normal otherwise reflexes the tendon reflexes are at biceps triceps and br bilaterally at left patella and on left ankles bilaterally the plantar reflexes are flexor sensory sensation is intact to lt equal in extremities no ext to dss could not test other modalities due to inattentiveness and problems with comprehension coordination there is no ataxia on fnf and could not assess hs gait deferred for now pertinent results pm urine color yellow appear clear sp pm glucose urea n creat sodium potassium chloride total co anion gap pm ck cpk pm ctropnt pm ck mb notdone pm calcium phosphate magnesium pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm pt ptt inr pt pm lmwh greater th head ct large hemorrhage within previous edematous region in the left temporal occipital portion of the brain as well as intraventricular hemorrhage in the setting of a known hypercoagulable state an infarct probably of venous origin with hemorrhagic transformation is suspected with neoplastic disease a secondary diagnostic consideration brief hospital course neurologically was not reversed with any agents and did not receive any blood products hob was elevated and initially was hyperventilated received several doses mannitol over first hours and then was weaned off on day systolic pressures controlled with rtc metoprolol and prn labetolol metoprolol with goal sbp around and map to be less than over the first several hours of admission mental status waxed and wained in the late hours of was reportedly more somnolent had the ventricular drain placed at around on based on her worsening clincal exam was placed contralaterally on right without complication went into respiratory distress shortly after vent drain placement and was emergently intubated follow up cts over the next hours showed increaseing hemorrhage and mass effect scans eventually stablilized and she remained intubated eventually without propofol and an exam showing spontaneous left sided movements but unresponsiveness around days pupils were unequal with left mm larger than right and sluggish also had bilaterally upgoing toes temporarily around left toe was noted to be down going on plantar response and pupils were noted to be equal and brisk bilaterally she was given cefazolin iv daily for cns vent drain infection prophylaxis also received days of mg tpa to vent drain to prevent clotting off of drain additional ipsilateral drain was consdiered and discussed with neurosurgery but thought not to be indicated icps were initially around s for first hours but came down to after vent drain adjusment in the first hours vent drain output was initially low but increased to cc day on day of the vent drain plan on was to increase icp to around and use tpa to try and lyse the intraventricular clot on the left side received seizure prophylaxis with topamax which was increased from to gabapentin was also increased to tid all anticoagulation was held initially eventually received prophylactic doses of heparin u sc tid starting became more arousable and with more left sided spontaneous movemnts on with ct scan essentially unchanged from to cts essentially unchanged except for some small edema mannitol restarted at grams iv q icp goal changed from to on with hope that ventricular tpa administration will break hematoma in contralateral ventricle on day of vent drain tubing replaced at bedside by neurosurg evd was ultimately discontinued on eeg performed with some spike sharp wave activity in right frontal region but no clear epileptiform activity but correlating with head and shoulder shaking she will continue on topamax and gabapentin at current doses cardiovascular ruled out for mi pressures controlled with metoprolol verapamil mg ng q as well as prn iv doses of labetolol and metoprolol was on telemetry had pneumoboots throughout the admission had negative dopplers for dvts on m she had episode of supraventricular tachycardia to s converted by cardiology via adenosine mg iv x one and then transiently on diltiazem diltiazem ultimately discontinued per cardiology recommendations and metoprolol discontinued after patient persistently normotensive transthoracic echocardiogram was unrevealing respiratory intubated for respiratory distress within hours of admission developed fevers around day and sputum sample showed multiple organisms with cultures pending at this time was started on levaquin cxr on looked clear was to be extubated but waiting for vent drain to be replaced so extubated she underwent tracheostomy placement on with downsizing of trach on a cuffless trach was placed on however patient was unable to use passy muir valve ent was consulted at found a large granuloma in the airway likely secondary to intubation she will see dr of ent for follow up as an outpatient ent would like her on proton pump inhibitor for reflux treatment gi was started on tube feeds around hours after intubation and tolerated gi prophylaxis with famotidine peg was placed on she should continue on proton pump inhibitor therapy until ent follow up reglan started for nausea out of concern for motility issues liver function tests and abdominal imaging were unremarkable endocrine received riss with qid accuchecks had some borderline hyponatremia off and on which was just managed with fluid restriction renal stable infectious disesae received levaquin for suspected pneumonia and was on prophylactic cephazolin for vent drain blood cultures were negative times and urine negative x continued to be febrile on levaquin and cephazolin so id consulted on and recommended d c cefazolin and start vanco gm iv q in addition to the levaquin continued to pan culture including csf and stool studies with cdiff but no clear infectious source id agrees that fever and white count can be as a result of the ich itself she also underwent a course of acyclovir for vesicular appearing lesions on her buttocks in setting of hsv direct antigen positivity but hsv csf pcr returned negative so acyclovir discontinued hematology protein c defficiency hematology consulted day and agreed with holding any further anticoagulation but not reversing initially was initially given no heparin did not receive any reversing agents factor a level returned which is supratherapeutic hematology recommended that anticoagulation could be reconsidered after the hemorrhage had been stable at least days prophylactic doses of heaprin sc started also mg doses of tpa given for several days through ventricular drain initially to prevent clotting of drain and later with the intention of lysis of the intraventricular hematoma heparin gtt was restarted on it was discontinued on in setting of therapeutic inr while on couamadin goal inr will be on coumadin she was also anemic at times during this admission underwent transfusion of one unit on iron was low and supplementation was started psych patient started on valium and celexa for depression and anxiety medications on admission gabapentin mg capsule sig three capsule po tid times a day atorvastatin mg tablet sig one tablet po daily daily enoxaparin mg ml syringe sig one subcutaneous times a day disp syringes refills indomethacin mg capsule sig one capsule po bid times a day topamax mg tablet sig one tablet po twice a day verapamil mg tablet sustained release sig one tablet sustained release po once a day glycerin solution sig one oz po tid times a day did not take yet today discharge medications atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills docusate sodium mg ml liquid sig one po bid times a day disp refills topiramate mg tablet sig two tablet po bid times a day disp tablet s refills ipratropium bromide mcg actuation aerosol sig two puff inhalation q h every to hours as needed disp inhaler refills bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po bid times a day as needed disp tablet delayed release e c s refills ferrous sulfate mg ml liquid sig one po daily daily disp refills acetaminophen mg tablet sig tablets po q h every to hours as needed citalopram mg tablet sig one tablet po daily daily zinc oxide cod liver oil ointment sig one appl topical prn as needed diazepam mg tablet sig one tablet po qhs once a day at bedtime diazepam mg tablet sig tablet po q h every hours as needed for anxiety dolasetron mg ml solution sig mg intravenous q h every hours as needed warfarin mg tablet sig two tablet po hs at bedtime goal inr is polyvinyl alcohol povidone dropperette sig drops ophthalmic prn as needed gabapentin mg ml solution sig mg po tid times a day lansoprazole mg susp delayed release for recon sig thirty mg po bid times a day lidocaine hcl gel sig one appl mucous membrane prn as needed metoclopramide mg tablet sig ten tablet po qid times a day magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed mineral oil hydrophil petrolat ointment sig one appl topical tid times a day as needed for dry skin oxycodone acetaminophen mg ml solution sig five ml po q h every hours as needed for pain discharge disposition extended care facility rehab center discharge diagnosis intracranial hemorrhage history of sinus venous thrombosis protein c deficiency discharge condition fair making improvements in function and mobility ambulating well with assistance and following commands unable to speek secondary to trach discharge instructions please return to ed or call ems if significant changes in level of function new weakness sensory changes or if headache and nausea vomiting develop follow up with appointments as below followup instructions m d phone date time m d phone date time dr from ent at monday at at in ma call with questions,"{
""Diagnoses"": [""neurology"", ""allergies"", ""dilantin"", ""tegretol"", ""gold salts"", ""ventricular drain placement"", ""mri"", ""protein c deficiency"", ""venous sinus thrombosis""],
""Medications"": [""lovenox""]
}"
26381,admission date discharge date date of birth sex m service neurosurgery admission diagnosis aneurysmal subarachnoid hemorrhage history of present illness the patient is a year old right handed gentleman who was found confused at home after not showing up for work he was found on at home by a co worker reportedly at home he was agitated and confused but awake and responsive reportedly he then became less responsive and was brought to the emergency department at an outside hospital a computed tomography scan there showed a subarachnoid hemorrhage he was noted to decompensate he was then intubated on he was transferred to where he was found to have an anterior communicating artery aneurysm the aneurysm was coiled on he also received a ventricular drain for prominent hydrocephalus in the emergency department in the emergency department he was noted to have a variable level of consciousness with a fluctuating mental status examination at times he would follow commands while at others he would be more somnolent subsequent to his coiling he was transferred to the intensive care unit for close neurologic monitoring there he developed atrial fibrillation requiring amiodarone subsequently he became febrile and the ventricular drain was removed he received a spinal tap showing blood cells and red blood cells he was then placed on vancomycin and ceftazidime for macrobacterial coverage subsequent cultures were negative by he was more responsive during his stay in the intensive care unit he slowly became more awake and alert he began moving all four extremities and following commands more regularly on he had his first lumbar puncture for hydrocephalus the opening pressure was approximately cc of cerebrospinal fluid was removed leaving a closing pressure of cm of water subsequently he also received a video swallow which he passed the nasogastric tube was then removed and he was started on a by mouth diet he received several subsequent lumbar punctures to relieve increasing cerebrospinal fluid neurologically he remained intact even with elevated opening pressures the notion of inserting a ventriculoperitoneal shunt was debated but given his improving neurologic function it was ultimately cancelled on there was an incident report where he became agitated and hit a nurse in the nose he was placed on four point restraints and then transferred to a vale bed for a short duration he subsequently calmed down and has been compliant since he has not needed a vale bed for the last several days on mini mental state testing he scored a he was subsequently seen by the neurobehavioral team for a consultation and was placed on haldol and ativan as needed past medical history nothing of note medications on admission current medications included insulin sliding scale subcutaneous heparin albuterol ipratropium bromide famotidine mg by mouth twice per day amiodarone mg by mouth once per day hydromorphone mg intravenously q h as needed trazodone mg by mouth q h s as needed haloperidol mg by mouth three times per day benztropine mesylate mg by mouth once per day haldol mg by mouth q h as needed allergies brief summary of hospital course his subsequent stay on the has been uneventful and he has gradually improved he currently ambulates well independently with supervision physical examination on discharge on examination he was afebrile his blood pressure was heart rate was and his respiratory rate was he was alert cooperative and polite he was oriented to hospital but not to time he had fluent speech wit normal comprehension but some difficulty recalling the names of people he was able to read and write a sentence able to perform months backward to then he had full visual fields without extinction full extraocular movements facial symmetry and normal tongue protrusion in the midline his motor examination was normal throughout he displayed no drift asterixis or tremor his reflexes were brisk and symmetric throughout he had normal sensation to light touch and pinprick throughout his cardiovascular examination was normal he had clear lung fields his abdomen was soft and nontender he had good distal pulses with no peripheral edema medications on discharge his discharge medications included insulin sliding scale subcutaneous heparin albuterol ipratropium bromide famotidine mg by mouth twice per day amiodarone mg by mouth once per day hydromorphone mg intravenously q h as needed trazodone mg by mouth q h s as needed haloperidol mg by mouth three times per day benztropine mesylate mg by mouth once per day haldol mg by mouth q h as needed condition at discharge condition on transfer was stable discharge disposition he is currently stable for transport to rehabilitation m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service neurosurgery history of present illness mr is a year old gentleman who presented in with a ruptured large anterior communicating artery aneurysm and underwent endovascular coil embolization he tolerated some post treatment and vasospasm successfully he returned for six month follow up of his aneurysm and had a repeat angiogram at this time this did show interval presence of residual filling of an inferior pointing proximal portion of the aneurysm which was felt to require additional treatment allergies he has no known drug allergies medications at time of admission hydrochlorothiazide mg q d aspirin mg q d plavix mg q d prior surgical history includes only the above mentioned brain aneurysm coiling physical examination at time of admission inches weight pounds blood pressure heart rate is o sat is hospital course he was admitted and brought to the angiography suite on he underwent coiling of the residual aneurysm he tolerated this procedure well postoperatively systolic blood pressure was kept between and he had frequent neuro checks later on in the postoperative day he did develop atrial fibrillation his vital signs were stable with heart rate to blood pressure to to respirations o sat to he had no complaints of pain headache chest pain shortness of breath or dizziness dorsalis pedis pulses were felt post procedure and he had no hematoma at the groin site a left sheath did remain in place and he received prophylactic antibiotics he was neurologically intact and appeared to be the sheath was removed without incident on the second hospital day the patient continued taking plavix and aspirin he continued to have frequent neuro checks and tight blood pressure control his atrial fibrillation did spontaneously resolve he advanced his activity and his diet and continued to be neurologically intact disposition discharged to home discharge instructions follow up with dr in clinic in one month s time he was also advised to follow up with his primary care provider for the history of atrial fibrillation discharge medications aspirin mg q d plavix mg q d hydrochlorothiazide mg one p o q d metoprolol mg tablets p o b i d percocet p r n discharge diagnoses aneurysm procedure coiling of aneurysm discharge condition good and neurologically intact m d dictated by medquist d t job [NEW_RECORD] name unit no admission date discharge date date of birth sex m service neurosurgery his discharge medications do not include plavix and aspirin and he will follow up with dr in two weeks time he will also follow up with his primary doctor regarding his episode of atrial fibrillation m d dictated by medquist d t job cclist,"{
""Diagnoses"": [""Aneurysmal subarachnoid hemorrhage"", ""Anterior communicating artery aneurysm""],
""Medications"": [""Amiodarone""]
}"
89854,admission date discharge date date of birth sex f service medicine allergies aspirin nsaids non steroidal anti inflammatory drug ambien penicillins attending chief complaint hypotension major surgical or invasive procedure none history of present illness history of present illness f with hx of copd on l home o pulm htn and transferred from bidn and admitted to the micu for hypotension and sob concerning for cardiogenic shock pt presented to bidn ed with dehydration and per report has been having poor po intake over the last few weeks due to low appetite and was found to be hypotensive to as low as the s systolically with cr of from prior baseline of she was otherwise asymptomatic and this was assessed as severe dehydration and was given l of fluid without response to blood pressure patient was started on dopamine became tachycardic to s without much improvement in blood pressure he was switched to phenylephrine and patient was transferred for further workup arrived to our ed without central access of note patient has noticed dark stools for the last days but denies bright red blood per rectum and was guaiac positive at osh ed with crit of down from prior baseline of high s ua negative ucx and bcx sent she also describes some nausea and a pound unintentional weight loss in the last month she otherwise denies fevers chills chest pain abdominal pain vomiting diarrhea urinary symptoms or localized numbness weakness or tingling ed course in the ed initial vitals were t hr bp rr svo l nrb bp s in the s systolically on neosyneprhine cvl rij placed started on norepinephrine with good response given stress dose hydrocort cxr with b l pleural effusions and fluid overload bnp cvp ekg with new q waves trop of osh wbc plt inr cr lactete bedside echo with good squeeze per report cardiology consulted and saw patient in ed discovered that weeks ago she had moderate chest pressure that woke her from sleep nights in a row for which she did not seek medical care reviewed her ekg which demonstrated nsr na ni new inferior q waves late transition with anterior q waves and anterolateral st and t changes consistent with old mi recs for plavix load high dose atorva serial enzymes urgent bedside tte and intervention as soon as possible or in case of mechanical complication on arrival to the micu patient s vs afebrile l nrb patient feels comfortable and is pleasant but sob she confirms the above history past medical history copd on l nc baseline hypothyroidism asthma htn pulmonary hypertension c b le edema h o svt social history social history retired anesthesiologist she lives in with a roommate she is independent in her adls iadls she is a remote smoker who quit years ago she drinks alcohol drinks daily she has no history of drug abuse family history family history non contributory physical exam afebrile l nrb general alert oriented no acute distress heent sclera anicteric mmm oropharynx clear eomi perrl neck supple jvp not elevated no lad cv regular rate and rhythm normal s s no murmurs rubs gallops lungs clear to auscultation bilaterally no wheezes rales ronchi abdomen soft non distended bowel sounds present no organomegaly no tenderness to palpation no rebound or guarding gu no foley ext warm well perfused pulses no clubbing cyanosis or edema neuro cnii xii intact strength upper lower extremities grossly normal sensation reflexes bilaterally gait deferred pertinent results on admission 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 neuts bands lymphs monos eos baso atyps metas myelos am blood neuts lymphs monos eos baso pm blood hypochr anisocy normal poiklo normal macrocy microcy normal polychr normal target occasional stipple occasional am blood plt ct am blood pt ptt inr pt pm blood plt smr high plt ct pm blood pt ptt inr pt am blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap am blood alt ast ld ldh ck cpk alkphos totbili pm blood alt ast alkphos totbili pm blood lipase am blood ck mb ctropnt pm blood ctropnt pm blood probnp am blood albumin calcium phos mg pm blood albumin calcium phos mg am blood type po pco ph caltco base xs pm blood type central ve po pco ph caltco base xs intubat not intuba am blood lactate pm blood lactate pm blood lactate am mrsa screen source nasal swab mrsa screen pending chest portable ap study date of pm impression opacification of the lower lungs greater on the right than left probably reflecting pleural effusions and associated atelectasis although an infectious process is hard to exclude regular lung markings and architecture suggesting there may be emphysema portable tte focused views done at am final conclusions poor image quality due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded overall left ventricular systolic function is probably preserved lvef no masses or thrombi are seen in the left ventricle there is no ventricular septal defect rv with normal free wall contractility the aortic valve leaflets appear structurally normal with good leaflet excursion the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen there is no pericardial effusion ekg nsr na ni q waves in ii iii twi s in i v v poor r wave progression brief hospital course assessment and plan f with hx of copd htn pulm htn and remote smoking hx admitted to the micu with gib evidence of recent inferior mi pneumonia and hypotension septic shock requiring pressor support pneumonia septic shock hypoxia patient presented with hypoxia and left lower lobe consolidation she was started on broad spectrum antibiotics and pressors for blood pressure support sputum cultures grew staph aureus which had been appropriately covered by vancomycin however she continued to require pressors and continued to clinically deteriorate multiple discussion were held regarding goals of care initially the goal was to wean her off pressors so that she could go home with hospice however she was not able to be weaned off she was then made cmo and her pressors and antibiotics were stopped she was started on morphine drip for comfort and she passed away shortly after recent inferior mi c b cardiogenic shock she had evidence of a new inferior mi on her ekg because of her hypotension it was initially thought that she had a component of cardiogenic shock an echo was performed which showed preserved lvef in conjunction with low central venous pressure makes cardiogenic shock highly unlikely concern for ugib patient s hematocrit on admission was lower than previous baseline she was trasnfused two units prbc in the setting of hypotension and concern for active gib however her hct remained stable gi was consulted who felt that she was not having gi bleeding and that further intervention was not waranted medications on admission medications pt unsure of her meds per recent outpatient note symbicort puff twice a day thyroxine mcg daily atenolol mg daily detrol mg daily tramadol mg daily ativan mg prn sleep furosemide mg daily discharge medications expired discharge disposition expired discharge diagnosis expired discharge condition expired discharge instructions expired followup instructions expired md completed by,"{
""Diagnoses"": [""hypotension"", ""severe dehydration"", ""cardiogenic shock""],
""Medications"": [""dopamine"", ""phenylephrine""]
}"
5140,admission date discharge date date of birth sex m service ct surgery history of present illness briefly this is a year old gentleman who is a psychiatrist who has had increasing shortness of breath and dyspnea on exertion for the past year he has been followed by a cardiologist who noted mitral valve prolapse and an echocardiogram done during workup showed mitral regurgitation and normal ejection fraction past medical history raynaud s disease mitral valve prolapse exercise induced asthma gastroesophageal reflux disease depression benign prostatic hypertrophy osteoporosis status post appendectomy status post right lower extremity vein ligation and stripping osteomyelitis of the left hip medications on admission lexapro omeprazole ativan p r n amoxicillin for dental procedures allergies sulfa drugs physical examination he was afebrile with stable vital signs his lungs were clear his heart was regular however he had a significant iii vi holosystolic murmur heard best at the apex abdomen is soft nontender nondistended bowel sounds are present his extremities are warm and well perfused he had good radial palpable pulses throughout laboratory data his laboratories were all within normal limits hospital course the patient was taken to the operating room on for a mitral valve repair with an annuloplasty the patient did well postoperatively and was transferred to the csru he was weaned from his ventilator and extubated he continued to do well and was planned on transferring to the floor he was off all pressors at that time he was transferred to the floor postoperatively where he continued to improve physical therapy was consulted for evaluation of his function and he did well with physical therapy and was cleared by physical therapy standpoint to go home he continued to do well however he had a slow rhythm and required av pacing for multiple days throughout his hospital stay he was able to be slowly weaned off his av pacing on he did not require any further av pacing and on his wires were removed he continued to do well his laboratories were all within normal limits on the patient was discharged home tolerating regular diet he was started on lopressor mg p o twice a day for beta blockade he did have some mild orthostatic changes with the lower dose however it improved through his hospital stay and therefore it was decided that he would continue on his beta blockade for now it could be decided whether or not his beta blockade should be continued medications on discharge aspirin mg p o once daily percocet one to two tablets p o q hours p r n colace mg p o twice a day protonix mg p o once daily lopressor mg p o twice a day discharge status he is discharged to home condition on discharge stable discharge diagnoses mitral valve regurgitation now status post mitral valve repair exercise induced asthma gastroesophageal reflux disease depression history of pneumonia benign prostatic hypertrophy osteoporosis status post appendectomy status post right leg vein stripping status post left hip osteomyelitis fop the patient is discharged to home in stable condition and instructed to follow up with his primary care physician in one to two weeks and instructed to follow up with his cardiologist in three to four weeks and is to follow up with cardiothoracic surgery in four to six weeks he was also instructed to call with any questions to dr office the patient was discharged home in stable condition m d dictated by medquist d t job,"{
""Diagnoses"": [""Mitral valve prolapse"", ""Mitral regurgitation"", ""Raynaud's disease"", ""Exercise-induced asthma"", ""Gastroesophageal reflux disease"", ""Depression"", ""Benign prostatic hypertrophy"", ""Osteoporosis"", ""Status post appendectomy"", ""Status post right lower extremity vein ligation and stripping"", ""Osteomyelitis of the left hip""],
""Medications"": [""Lexapro"", ""Omeprazole"", ""Ativan"", ""P.R.N. Amoxicillin"", ""Allergies: Sulfa drugs""]
}"
72225,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint s p moter vehicle accident major surgical or invasive procedure tracheostomy percutaneous g tube halo placement bilateral chest tubes placed history of present illness yo man who was transferred by from on after being involved in a motor vehicle accident he was the driver of a car that reportedly rolled over and collided with a tree it is unclear as to whether he had his seat belt on or whether he had any loss of consciousness there was a prolonged extrication process by the ems he was transferred here after it was found that he had multiple rib fractures cervical spine fracture c widened mediastinum and a possible head bleed sdh sah he was then intubated and given prbc ffp and ivf for resuscitation prior to transfer he was alert upon arrival to however he became hypotensive upon arrival here and his mental status slowly declined he was found to have the following injuries cspine unstable l occipital condyle fx c lat mass fx c type iii dens fx c tp fx all disruption at c prelim read l vertebral artery injury at c tspine fx t anterior endplate fx sternal fracture comminuted manubrium multiple ant r rib fractures l ant nd rib fx l left dr dislocation l wrist fracture was reduced hematoma l thigh and neck hematoma lacerations to face these lacerations were sutured past medical history pmhx seizure disorder pshx b l hip lap hernia repair social history she said he rarely drives anymore and when he does he follows his own set of rules he refuses to allow any passengers in the car he won t drive if he s stressed or not feeling well because he knows these things can mean he might have a seizure he s very careful but he still shouldn t have been driving at all he s only been driving lately because my mother has been in the hospital the last few days reports her mother fell three days ago and fx d her collar bone she is currently admitted at she is pt s hcp and believes there is paperwork back at pt s home she will attempt to bring in a copy of the hcp family history nc physical exam o t bp hr rr o sats vent gen wd wn comfortable nad heent l periobital eccymosis l facial lac and laceration under chin pupils perrl eoms not tested neck in c collar extrem cool however equal sensation neuro mental status awake and alert cooperative with exam normal affect orientation oriented to person place and date motor grasps and wiggles toes on commands unable to fully assess strength at this time however spontaneous movement of all extremities sensation intact to light touch propioception not tested toes downgoing bilaterally rectal exam diminished tone pertinent results pm 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 hct plt ct pm blood hct pm blood hct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood hct pm blood hct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood hct 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 pm blood pt ptt inr pt pm blood fibrino pm blood fibrino 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 pm blood ck cpk am blood ck cpk pm blood ck mb mb indx ctropnt am blood ck mb ctropnt am blood ck mb ctropnt pm blood calcium phos mg am blood calcium phos mg pm blood calcium phos mg am blood vanco am blood vanco pm blood valproa am blood valproa am blood valproa pm blood type art po pco ph caltco base xs am blood type art po pco ph caltco base xs am blood type art po pco ph caltco base xs pm blood type art po pco ph caltco base xs pm blood glucose lactate na k cl calhco final report ct c spine technique contiguous axial imaging was performed through the cervical spine without iv contrast administration sagittal and coronal reformats were generated comparison ct head history year old man post motor vehicle collision findings there is a comminuted fracture through the c body a type dens fracture with a vertically oriented fracture noted extending into the left lateral mass of c there is disruption of the anterior and posterior cortices of the mid aspect of the dens with retropulsion of bony fragments posteriorly into the spinal canal b there is a fracture through the left lateral mass of c extending to the transverse process there is a minimally displaced fracture through the left occipital condyle b there is anterior widening of the intervertebral disc space between c and c there is a minimally displaced fracture of the anterior superior endplate of t b there is significant prevertebral soft tissue swelling particularly at c through c there is an extra axial hematoma extending from the clivus inferiorly to approximately the c level this extra axial hematoma causes indentation of the anterior thecal sac but no clear evidence for cord compression mri is more sensitive for evaluation of the intrathecal sac and spinal cord posterior disc osteophyte complexes with resulting canal narrowing are present particularly at c c c c and c c the endotracheal tube tip terminates at t vertebral body there is a sternal fracture with widening of the mid sternum of approximately mm a mediastinal hematoma is present and likely the result of this sternal fracture however evaluation of the aorta and great vessels is incomplete without iv contrast administration there are small retropulsed bone fragments posterior to the sternal fracture bilateral second anterior rib fractures are also seen and the partially visualized lung apices demonstrate dependent atelectatic changes no pneumothorax was visualized subcutaneous gas in the right neck soft tissues is associated with soft tissue swelling and possible hematoma which may be due to a site of laceration as there is overlying bandage material there is a minimally displaced fracture of the left transverse process of c multilevel degenerative changes with facet arthropathy are present the patient is intubated and an orogastric tube is present nasopharygeal secretions are likely due to recent intubation impression type odontoid fracture with a vertical fracture through the left lateral mass of c disruption of the anterior and posterior cortex of the dens with slight posterior dens angulation there are posterior and anterior hematomas at the site of dens fracture the posterior hematoma is an extra axial hematoma within the spinal cord extending from the clivus to approximately c causing thecal sac indentation mri would be recommended for better evaluation of the cord and thecal sac anterior widening of the intervertebral disc space between c and c concerning for anterior longitudinal ligamentous disruption mri again is recommended for further evaluation of ligamentous injury anteriorly minimally displaced fracture of the superior anterior endplate of t sternal fracture with widening with associated medistinal hematoma small osseous fractures are seen posterior to the sternal fracture bilateral second anterior rib fractures no pneumothorax minimally displaced fractures of the left occipital condyle and left c lateral mass extending into the transverse process minimally displaced fracture of the transverse process of c mediastinal hematoma is likely a result of the sternal and rib fractures however evaluation of the great vessels and aorta with ct angiography is recommended to exclude acute vascular injury within the chest findings were discussed via telephone with dr shortly after completion of the study on the study and the report were reviewed by the staff radiologist dr dr approved wed pm final report head ct contiguous axial imaging was performed through the brain without iv contrast administration sagittal and coronal reformats were prepared comparison none available in pacs history year old man with motor vehicle accident with intubation findings no evidence for hemorrhage edema mass effect or acute territorial infarction there is prominence of the ventricles and sulci related to age related parenchymal loss periventricular white matter hypodensities are present likely the sequela of small vessel ischemic changes lacunar infarcts and calcifications are present in the right basal ganglia bilateral carotid siphons are calcified overall white matter differentiation is well preserved there is mucosal thickening of the bilateral ethmoid air spaces worse on the right maxillary sinuses and mastoid air cells remain well aerated frontal sinuses are clear there is incompletely assessed and visualized a fracture of the left aspect of the c arch better evaluated on accompanying ct of c spine as well as the left occipital condyle secretions within the nasopharynx are likely related to recent intubation impression no acute intracranial pathology identified age related atrophy incompletely evaluated fracture of left side of c and left occipital condyle please refer to ct of c spine performed on the same day for full evaluation the study and the report were reviewed by the staff radiologist dr dr approved wed am final report indication fall with right hand swelling comparison none three views of the right hand there is cortical irregularity involving the base of the third metacarpal which may either be subacute or chronic additionally post surgical changes are noted involving the third pip joint with a spacer device noted an ossific density which is well corticated is seen posterior to the carpal bones on the lateral view which could represent an old triquetral fracture vascular calcifications are noted impression cortical irregularity involving the base of the third metacarpal which could represent a subacute or chronic fracture but clinical correlation is recommended to better determine the acuity of this finding post surgical changes involving the third pip joint well corticated ossific density dorsal to the carpal bones likely represents an old triquetral fracture final report cta neck indication year old male post mvc with cervical spine fractures evaluate for vertebral artery dissection comparison ct cervical spine performed on technique mdct axial images of the neck were obtained following administration of cc of optiray intravenously per neck cta protocol coronal and sagittal mips and d volume rendered images were obtained on a separate workstation cta neck there is a focal contour irregularity and deformity of the left vertebral artery at the level of c best seen on series image and concerning for vascular injury and pseudoaneurysm formation likely produced by fracture fragments of the lateral masses of c and c the remainder of the carotid and vertebral arteries and their major branches are patent with no evidence of stenosis there is no evidence of aneurysm formation multiple cervical spine fractures are evaluated and described in detail on the separate dedicated ct cervical spine the fractures include comminuted fracture through the c body with retropulsion extending sagittally into the left lateral mass of c and through the left lateral mass of c extending to the transverse process left occipital condyle fracture additionally there is a superior anterior endplate avulsion fracture of t as well as fracture of the left anterior tubercle of c and acute fracture of the t right lamina and base of that transverse process incidentally noted are bilateral cervical ribs the patient is intubated there are air fluid levels in maxillary sphenoid sinuses bilaterally there is opacification of most of the ethmoid air cells mastoid air cells are pneumatized and well aerated fluid is seen in the nasal cavity there are bilateral pleural effuions mediastinal stranding consistent with hematoma interlobular septal thickening could be related to volume overload impression findings concerning for left vertebral artery injury and pseudoaneurysm formation at c level which could be due to compression of the vessel between the fracture fragment of left c and lateral masses multiple cervical and thoracic spinal fractures as detailed above bilateral hyperattenuating pleural effusions and mediastinal hematoma interlobular septal thickening which could be secondary to volume overload comment the findings of possible vascular injury and pseudoaneurysm formation involving the distal left vertebral artery were discussed with dr on at p m the study and the report were reviewed by the staff radiologist dr dr approved wed pm final report chest history bilateral pleural effusions and rib fracture one portable view comparison with positioning is suboptimal but there appears to be interval increase in bilateral pleural effusions increased density in the underlying lungs is consistent with compressive atelectasis or consolidation the lower heart borders are indistinct mediastinal structures appear otherwise unchanged a tracheostomy tube has been inserted a nasogastric tube is no longer identified impression limited study demonstrating evidence for increased pleural fluid and underlying atelectasis or consolidation tracheostomy tube in place dr approved sun pm m radiology report chest portable ap study date of am tsicu am chest portable ap clip reason interval changes medical condition year old man with trach reason for this examination interval changes final report ap chest history tracheostomy assess changes impression ap chest compared to through previously widened mediastinum has remained normal in caliber over the past several days left lower lobe atelectasis and small right pleural effusion persist no appreciable pneumothorax apical pleural drains in place side port of the right chest tube is extrathoracic but the only subcutaneous emphysema is on the other side heart size normal spinal fractures are not assessed by this examination tracheostomy tube in standard placement final report history year old man status post motor vehicle collision with posterior stroke evaluate for evolution or hydro mid line shift cta head contiguous axial imaging was performed through the brain without iv contrast administration subsequently after uneventful administration of cc of optiray contiguous helical imaging was performed from the aortic arch through the skull vertex multiplanar reformats curved reformats and volume rendered imaging was performed on a separate workstation comparison ct head ct neck ct c spine cta head there is evolution of infarct involving the left cerebellum and left medulla without new areas of infarction identified evaluation of the supratentorial brain is somewhat limited by streak artifact from external fixation hardware no areas of hemorrhage or acute territorial infarction are present the ventricles and sulci are mildly prominent but stable in size there is no shift of normally midline structures there is near complete opacification of bilateral maxillary sphenoid frontal and ethmoid sinuses partial opacification of bilateral maxillary sinuses is present these findings are unchanged there is unchanged comminuted fracture of the cervical spine involving the type odontoid fracture and fractured left lateral mass of c and skull base these findings are better described on prior ct imaging pooled secretions are present in the pharynx cta head there is incidental note of a left fetal pca otherwise the vasculature within the circle of appears unremarkable without aneurysm dissection occlusion or stenosis cta neck there is a stable appearance to dissection involving the left v segment there is pseudoaneurysm at the left v v segment which is stable in appearance compared to previous examination no evidence for occlusive thrombus within the left vertebral artery there is calcification at bilateral ica bifurcation no flow limiting stenosis the distal left internal carotid artery measures mm the distal right internal carotid artery measures mm multiple stable thoracic fractures including fracture of the sternum and bilateral nd anterior ribs are present there is bilateral atelectasis with small pleural effusions bilateral chest tubes are in place with their tips in bilateral lung apices patient is status post tracheostomy again with pooled secretion seen in the pharynx impression evolving infarction of the left cerebellum and left mid brain stable appearance to the ventricles without midline shift stable left v dissection and left v v pseudoaneurysm without evidence for occlusive thrombus no acute infarct or hemorrhage stable appearance to multiple spinal and thoracic fractures calcification in bilateral internal carotid artery bifurcations without flow limiting stenosis bilateral atelectasis with small pleural effusions patient is status post tracheostomy with pooled secretion seen in the pharynx the study and the report were reviewed by the staff radiologist dr dr approved tue pm final report history fracture trauma three radiographs of the left wrist again demonstrate a minimally displaced intra articular fracture of the distal radius avulsion of the ulnar styloid is again noted overall mineralization is normal diagnostic quality is markedly limited by overlying casting material atherosclerotic calcifications are seen in the regional soft tissues the scapholunate interval is widened measuring at least mm impression distal radius and ulna fractures similar to that seen previously widening of the scaphol unate interval representing injury of the scapholunate ligament dr approved mon pm micro ucx no growth blood cx no growth bal per x field gram negative rod s per x field gram positive cocci in pairs and clusters imaging cxr widened mediastinum ct head no acute pathology age related atrophy incompletely evaluated fracture of c ct cspine comminuted type odontoid fx with vertical fracture through the l lat mass of c ant and post hematomas at dens fx ant widening of disc space b w c c all disruption minimally displaced fx of the l occipital condyle and l c lateral mass extending into the tp minimally displaced fracture of c tp cta neck wet read was no injury however paged by radiologist at on overread is l vert injury at c c trauma and neurosurgery aware recommend neurology consult final read findings concerning for left vertebral artery injury and pseudoaneurysm formation at c level which could be due to compression of the vessel between the fracture fragment of left c and lateral masses cta torso wet read no acute aortic injury extravasation evident mediastinal blood not significantly changed new bilaterally symmetric pleural effusion with attenuation suggesting some sanguinous component communuted fracture of the manubrium multiple anterior right rib fractures left t anterior rib fracture compression deformities of t and t vertebral bodies t compression fx anterior t without compression no evidence of bleeding in abdomen or pelvis ct t spine wet read acute fx avulsion of anterior superior t endplate and right t lamina extending to base of the tp chronic mild anterior compression deformity of t and ct l spine wet read no fx mri cspine new left pica cva involving l inf cerebellum and l lateral medulla likely dissection of l distal v v and possibly v segments of l vertebral arteries type odontoid fx with anterior epidural hematoma and prevertebral soft tissue swelling c c intradiscal injury soft tissue chance fracture with disruption of the all c c endplate hyperintensity concerning for intradiscal injury however possibly is change left c lat mass fx ct chest pending my read increasing bilat pleural eff wet read slight interval increase in the size of the bilateral pleural effusion since the prior exam there has been an interval decrease in the attenuation of the bilateral pleural effusions consistent with evolving bilateral hemothoraces interval decrease in the amount of mediastinal hematoma persistent bibasilar atelectasis consolidation new pneumoperitoneum which is presumably secondary to the interval g tube placement however clinical correlation is recommended the comminuted sternomanubrial fracture bilateral rib fractures nondisplaced left proximal clavicular fracture and t through thoracic vertebral body fractures are unchanged c spine lateral odontoid fracture better seen on recent mri cta neck evolving infarction of the left cerebellum and left mid brain stable appearance to the ventricles without midline shift stable left v dissection and left v v pseudoaneurysm without evidence for occlusive thrombus no acute infarct or hemorrhage stable appearance to multiple spinal and thoracic fractures calcification in bilateral internal carotid artery bifurcations without flow limiting stenosis bilateral atelectasis with small pleural effusions patient is status post tracheostomy with pooled secretion seen in the pharynx brief hospital course mr was admitted to the emergency room s p trauma he was noted to be with multiple lacerations and sternal hematomas his pressure began to drop quickly in the ed and there was concern for internal bleeding his mental status was also waxing and so the decision was made to intubate all of his ct scans of the chest were essentially negative for large bleeding pathology but there was concern for widened mediastinum on his portable xr in the ed overnight on he was persistantly hypotensive and tachycardic he received a total of u prbcs and u ffp due to a significant hct drop to overnight that night his l wrist was reduced from its dislocated position the morning of his torso was rescanned and his facial lacerations were sutured he received another units prbc over the next hours for persistantly low hct mri c spine was significant for a displaced c fracture and cta was questionable for a vertebral artery dissection he was too unstable to start on antiplatelet agents and his hct was trended and supportive care initiated in the sicu he was continued on the ventilator with aggressive fluid therapy his head was re scanned and positive for a pica stroke on he was stable for trach peg ivc filter and halo placement he tolerated the procedure well he was noted to be with rapid afib and treated with diltiazem gtt on he received another unit of blood and his diltiazem drip was changed to metoprolol po which he tolerated well repeat ct chest was stable with bilateral pleural effusions on it was felt that his effusions necessitated bilateral chest tubes and these were placed on the left side cc initially was released and the right side with cc he spiked a fever to and bal was positive for likely aspiration pna and he was started on vanc zosyn between and the patient worked with pt to get out of bed and received more units of prbc for downtrending hct his chest tubes were placed to waterseal and ultimately d c ed on from then on he remained stable on the ventilator and worked to get oob with pt he continued on antibiotics and remained afebrile with normal blood pressure and adequate urine output his repeat head cts were stable and no hydrocephalus seen he was started on asa for stroke prophylaxis with recommendations from the stroke team discharge medications lamotrigine mg tablet sig one tablet po q am crushed through ng levetiracetam mg tablet sig one tablet po bid times a day docusate sodium mg ml liquid sig ten ml po bid times a day magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed for constipation metoprolol tartrate mg tablet sig tablet po tid times a day aspirin mg tablet chewable sig one tablet chewable po daily daily heparin porcine unit ml solution sig one injection tid times a day valproic acid as sodium salt mg ml syrup sig five ml po q h every hours insulin regular human unit ml solution sig one injection asdir as directed sliding scale lamotrigine mg tablet sig five tablet po q pm crushed through jtube famotidine mg tablet sig one tablet po q h every hours oxycodone acetaminophen mg ml solution sig mls po q h every hours as needed for pain senna mg tablet sig one tablet po bid times a day as needed for constipation zosyn gram recon soln sig one g dose intravenous every eight hours for days vancomycin mg recon soln sig one intravenous every eight hours for days discharge disposition extended care facility rehab discharge diagnosis unstable cervical spine fracture c type iii l vertebral artery injury at c with mild dissection pica stroke tspine fx t anterior endplate fx sternal fracture comminuted manubrium multiple ant r rib fractures l ant nd rib fx l left distal radius fx dislocation l wrist fracture was reduced and splinted hematoma l thigh and neck hematoma descending into retrosternal area lacerations to face lacerations were sutured by plastic surgery discharge condition stable on ventilator and in halo being treated actively for aspiration pneumonia discharge instructions you were evaluated in the hospital for multiple injuries after a car accident you are being discharged to an extended care facility where your injuries will be further managed and you will undergo acute rehabilitation for your injuries you will be on a ventilator with a slow wean towards normal breathing you should also wear your halo vest at all times to minimize movement of your unstable neck fracture you are also being treated for aspiration pneumonia on broad spectrum antibiotics these should be narrowed once bacterial sensitivities arise should you experience any of the following please call your doctors return to the emergency room chest pain tightness or shortness of breath abdominal pain significant vomiting or nausea fever weakness numbness speech difficulty anything else that concerns you followup instructions please call neurosurgery dr for follow up of your cervical spine fracture in weeks remind them that you need ap and lateral plain films of your cervical spine prior to follow up please call neurology md for follow up in weeks regarding your stroke please call orthopaedic trauma np for a follow up appointment in weeks please call general surgery trauma clinic for followup in weeks indicate to them that you will likely need a chest xray for your appointment it is very important that you follow up with your primary care doctor neurologist to have your seizure medications adjusted to their normal doses or adjusted new doses completed by,"{
""Diagnoses"": [""Multiple rib fractures"", ""Cervical spine fracture"", ""Widened mediastinum"", ""Possible head bleed"", ""Cranial fracture"", ""Spinal fracture"", ""Vertebral artery injury"", ""Disruption of C1 preliminary read"", ""Disruption of C2 vertebral artery""],
""Medications"": [""PrBC FFP"", ""IVF"", ""Intubation""]
}"
10417,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint transferred for hypoxia and bronchoscopy major surgical or invasive procedure intubation pulmonary artery catheter placement history of present illness y o male with a history of angioimmunoblastic t cell lymphoma s p cycles of chop chemotherapy diagnosed in on with increasing hypoxia on ra orthopnea decreasing appetite increasing weakness and increasing abdominal girth he was thought to be in decompensated chf with pulmonary edema and ascites and underwent aggressive diuresis with no improvement in his symptoms on admission he was started on azithromycin and ceftriaxone for community acquired pneumonia per report he was not febrile thru out his hospital stay he was evaluated by infectious disease given his lack of improvment who recommended vancomycin for mrsa infection bactrim for pcp pna cefepime for gn coverage and gatifloxacin for atypical pna his wbc trended downward however his oxygen requirment continued to increase he underwent ct chest abdomen pelvis which demonstrated extensive hilar mediastinal retroperitoneal iliac and inguinal adenopathy a cm left perihilar mass and and mm nodule in left lung near the descending aorta right sided pleural effusion small bilateral renal calculi with no obstructive changes he underwent ct neck which revealed stable ln dz in neck and ln enlargement in mediastinum he underwent echo with normal ef and was evaluated by cardiology who felt his symptoms were consistent with chf his hospital course was complicated by the development of acute renal failure with a cr of and agitation requiring haldol and supratherapeutic inr worsening of his rapid afib with rvr to the s for which he was started on diltiazem there were also rate related st depressions reported he underwent diagnostic paracentesis which revealed atypical cells on cytology and wbc rbc with neutropil concerning for sbp he was transferred to for bronch past medical history angioimmunoblastic t cell lymphoma s p cycles of chop diagnosed in late due to symptoms of night sweats weight loss and bulky adenopathy in the neck copd with fev fvc predicted fev fvc tlc predicted atrial fibrillation coronary artery disease diabetes mellitus cri nephrolithiasis chf ef variable reported social history retired and lives with his wife previously smoked ppd no etoh or ivda originally from family history mother died of trauma father died of old age physical exam pe on nrb fm hr afib gen alert agitated chronically ill appearing male heent eomi sclera non icteric neck jvp at cm at degrees neg hjr pulm diffuse ronchi b l l r no wheezes cv irreg irreg variable s no murmurs abd distended not tense no pain except mild pain at l sided paracentesis site no erythema or pus at this area fluid wave no caput no spider angiomas no hsm ext trace b l le edema to ankles neuro able to respond to yes no questions and follow simple commands but speech is mostly incoherent pt is mildly agitated pulling at lines currently in soft ue restraints primary language is portugese but able to communicate in english at baseline per son s report pertinent results lab trends at osh wbc cr micro data cdiff negative blood cx ngtd ua wnl ekg atrial fibrillation at admission labs fibrinoge pt ptt inr pt plt count wbc rbc hgb hct mcv digoxin vanco cortisol tsh caltibc haptoglob ferritin trf albumin calcium phosphate magnesium uric acid iron lipase alt sgpt ast sgot ld ldh alk phos amylase tot bili glucose urea n creat sodium potassium chloride total co anion gap freeca lactate radiologic studies cxr there are diffuse bilateral opacities and this is a cardiomegaly consistent with chf however a multifocal pneumonia cannot be excluded micro data bal gram stain final per x field polymorphonuclear leukocytes per x field budding yeast with pseudohyphae respiratory culture final ml oropharyngeal flora yeast organisms ml staph aureus coag ml legionella culture preliminary no legionella isolated immunofluorescent test for pneumocystis carinii final pneumocystis carinii not seen acid fast smear preliminary no afb seen on direct smear brief hospital course y o male with progressive pulmonary decline unresponsive to diuresis and broad spectrum antibiotics and new onset of ascites concerning for rapidly progressive metastatic lymphoma and new acute renal failure intubated emergently for refractory hypoxemia on w prolonged icu stay c b vent assoc mrsa pna periods of rapid afib drug rash and diffuculty weaning off ventilator hypoxemic respiratory failure sirs emergently intubated on admission to the icu for refractory hypoxemia the cause of his respiratory failure was unclear however infectious etiology was felt to be high given his immunosuppressed state from his t cell lymphoma he was covered broadly with ceftriaxone azithromycin bactrim vancomycin and voriconazole was on vanco ctx azithro vori x days on zosyn for increased fever and secretions day course bronchoscopy bal was performed and was negative for afb pcp or bacterial microorganisms induced sputum was also negative he was continued empirically on antibiotics given his clinical decline with sepsis physiology tumor burden with lymphangitic spread was also considered as a potential etiology of his respiratory distress but was felt less likely given the stable appearance of his tumor on imaging studies cta was negative for pe as a potential source he had a tracheotomy tube placed on and was slowly weaned off the ventilator weaning was complicated by large amount of bleeding from tracheostomy while on heparin and by large amounts of secretions leading to mucous plugging heparin was d ced to bleeding from tracheostomy course was further complicated by mrsa tracheobronchitis treated with vancomycin expected to complete day course he improved greatly with decreased secretions with vancomycin recent speech consult for passey muir valve patient was able to tolerate for short periods of time approximately seconds secretions currently able to tolerate longer periods of time currently patient with o sats on face mask current respiratory treatments include vancomycin gm q hr day albuterol q hr it is hoped that in the next week or so he will have the trach removed and return to breathing from his oral airway hypotension hypotension felt to be septic in etiology given its distributive nature svr was found to be low in s by pulmonary artery cath with normal cardiac output he was treated with broad spectrum antibiotics as outlined above in addition he was started on pressors with neosynephrine however he remained persistently hypotensive with decreasing svr s therefore vasopressin was added to his regimen subsequently his map s increased with steady uop cc hr he was also noted to have initial evidence of low grade dic with increasing pt ptt and decreasing fibrinogen and platelets therefore he was started on activated protein c his fibrinogen levels subsequently improved with stable coags and platelets he did not require cryoprecipitate or ffp transfusions in addition he had no noted bleeding complications w apc currently he is normotensive with bp s s s s without use of pressors given improvement of hypotension with antibiotic treatment likely etiology was sepsis ascites cytology from outside hospital consistent with lymphoma and sbp started on ceftriaxone for sbp repeat ultrasound showed loculated abdominal ascites not felt to be ammenable to paracentesis therefore he was monitored clinically without further intervention repeat ultrasound showed small amount of ascites unable to place peg given ascites he is currently with slightly distended non firm non tender abdomen on ciprofloxacin mg x wk for sbp prophylaxis mental status patient with episodes of delirium since admission to icu most commonly in morning then becomes more lucid later in day possibly to lack of sleep infection medications or combination haldol initially tried but d ced to increased qtc zyprexa and versed were also tried but were found to be ineffective in treating his delirium ativan mg was effective in assisting the patient to sleep and patient has not had delirium since this time he is currently awake and alert oriented to being in but remains slightly confused when asked if he knows what type of building he is in he is portugeuse speaking and therefore interviewed with help of an interpreter lymphoma initially presented with hypocalcemia hyperphosphatemia and acute renal failure concern for suspected tumor lysis treated with ivf allopurinol and close monitoring of electrolytes he was felt to be too sick for chemotherapy during his stay pt s outpt onc will follow him once discharged cont acyclovir for prophylaxis acute renal failure initially pt had elevation of bun cr which resolved with fluid resuscitation cr stabilized at afib loaded with digoxin and continued on mg daily initially on heparin but discontinued because of large amount of bleeding from trach site restarted with tpn units good rate control with mg digoxin qd metoprolol mg q hr attempted anticoagulation with heparin drip and coumadin however had extensive bloody secretions and anticoagulation was subsequently stopped plan for coumadin once start po as pt was not able to take po medications metoprolol was d c d prior to discharge to rehab once he is able to take po s this medication may be restarted should he have rapid ventricular rates pulmonary hypertension an echo on showed severe pulmonary htn associated with mitral regurgitation it was unclear whether this could be due to the mr pulmonary emboli he was initially started on heparin but this was discontinued given large amounts of bleeding from the trach site furthermore mr was felt to be more likely the cause of the pulmonary hypertension fen pt had post pyloric feeding tube inserted twice both of which he pulled out while in episodes of confusion delirium he failed a bedside swallowing study and we were unable to place a peg ascites as a result he was started on tpn for nutrition it is expected that pt will only require the trach mask for approx one more week at which time the trach will be removed and hopefully he will be able to eat again rash and eosinophilia rash started after starting multiple antibiotics biopsy performed felt to be drug rash associated with antibiotics most likely ceftriaxone improved on steroids cad pt was treated with beta blocker and asa hydralazine for afterload reduction was initiated at low doses but d c d before discharge since pt could not take po medications and iv hydral could not be dosed at rehab pt should be started on an ace i once he can tolerate po s again anemia stable hct pt previously with bleeding from trach when on heparin now stopped no evidence of bleeding anticoag was primarily for afib continue to monitor hct dm iss humalin dose calculated out and based on carbs in tube feeds and glargine calculated based on basal metabolic rate currently pt is receiving insulin in tpn once this is stopped and he is able to eat he should be restarted on glargine approximately units in urine changed foley but repeat culture has yeast no antifungal treatment for now latest ua with occ yeast and wbcs ppx heparin stopped because of bloody secretions restarted in tpn access pt pulled out tlc and a line currently has piv and picc for access full code communication wife son pcp onc medical medications on admission allopurinol qd dilt colace lasix gatafloxacin qd insulin ss solumedrol q hours metoprolol tid bactrim ml iv q hours iv q hours albuterol atrovent prn morphine prn discharge medications albuterol mcg actuation aerosol sig puffs inhalation q h every hours as needed bisacodyl mg suppository sig one suppository rectal daily daily as needed acetaminophen mg tablet sig tablets po q h every to hours as needed camphor menthol lotion sig one appl topical qid times a day as needed lactulose g ml syrup sig thirty ml po q h every hours as needed senna mg ml syrup sig one po bid times a day albuterol ipratropium mcg actuation aerosol sig puffs inhalation q h every hours aspirin mg suppository sig one suppository rectal daily daily digoxin mcg ml solution sig one mg injection daily daily diphenhydramine hcl mg ml solution sig one injection q h every hours as needed vancomycin in dextrose g ml piggyback sig one g intravenous q h every hours for days total days through ciprofloxacin in d w mg ml piggyback sig one mg intravenous x week sa please give on saturdays pantoprazole sodium mg recon soln sig one recon soln intravenous q h every hours lorazepam mg ml syringe sig one mg injection hs at bedtime as needed bacitracin zinc unit g ointment sig one appl topical qid times a day as needed for neck sore insulin regular human unit ml solution sig as directed units injection qachs for fsbs units for fsbs units for fsbs units for fsbs units for fsbs units for fsbs units for fsbs units for fsbs notify m d discharge disposition extended care facility rehab discharge diagnosis community aquired pneumonia sepsis requiring long intubation tracheobronchitis sbp s p arf with cr increase to resolved with fluid rescusitation afib currently well controlled with digoxin metoprolol angioimmunoblastic t cell lymphoma s p x cycles chop dx in ascites lymphoma dm cad anemia copd discharge condition patient in fair good condition on discharge main issues include tracheostomy on trach mask to achieve good ventilation tpn for nutrition ascites lymphoma discharge instructions come to hospital if fever increased respiratory distress any other concerns followup instructions follow up with oncologist dr medical center follow up with pcp [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies vancomycin cefepime attending chief complaint transferred from rehab for fever hypotension and recurrent pneumonias x month major surgical or invasive procedure intubation history of present illness pt is a yo male with angioimmunoblastic t cell lymphoma diagnosed s p cycles of chop chemotherapy atrial fibrillation copd cad s p mi dm who presented to the ed from rehab with fever and hypotension pt had been discharged from to rehab on after presenting from osh in with increasing hypoxia orthopnea weakness and increasing abdominal girth necessitating admission he remained in the icu for weeks with complicated hospital course he was thought to be in decompensated chf but did not improve with adequate diuresis he was covered broadly for pneumonia with ceftriaxone azithromycin bactrim vancomycin and voriconazole was on vanco ctx azithro vori x days on zosyn for increased fever and secretions day course bronchoscopy bal was performed and was negative for afb pcp or bacterial microorganisms pt was trached and was able to be weaned off of the ventilator after many weeks intubated but complicated by mrsa tracheobronchitis treated with vanc and acute renal failure with peak cr additionally paracentesis at osh prior to transfer was consistent with both malignancy and sbp and pt was treated with ceftriaxone pt was discharged to rehab on pt presented to the ed today with reported bp in the s temperature to at rehab vs in ed were t hr bp rr o l per ed resident pt was placed horizontally for central line and pressure fell to systolic he was unable to maintain secretion in ed given levaquin iv x flagyl mg x decadron iv x linezolid mg iv x past month with recurrent febrile pnas mrsa chlamydia s p numerous abx treatments including doxycycline and linezolid last dose and treatment for c diff on treated with flagyl past medical history angioimmunoblastic t cell lymphoma s p cycles of chop diagnosed in late due to symptoms of night sweats weight loss and bulky adenopathy in the neck copd with fev fvc predicted fev fvc tlc predicted atrial fibrillation coronary artery disease diabetes mellitus cri nephrolithiasis chf ef variable reported social history retired and lives with his wife previously smoked ppd no etoh or ivda originally from family history mother died of trauma father died of old age physical exam vs bp hr t sat on gen portuguese speaking male sedated intubated responsive to verbal stimuli heent left subclavian line in place c d i no appreciable jvd cv distant hs muffled by ventilator s s irregularly irregular lungs coarse rhonchi b l anterior fields abd soft nt mild distension bs normoactive no appreciable organomegaly ext cold extremities no c c e symmetric pulses 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 plt ct pm blood fdp pm blood glucose urean creat na k cl hco angap pm blood alt ast ck cpk alkphos totbili pm blood albumin calcium phos mg pm blood type art temp tidal v peep fio po pco ph calhco base xs aado req o pm blood type art temp tidal v po pco ph calhco base xs intubat intubated vent controlled pm blood type art temp rates tidal v peep fio po pco ph calhco base xs assist con intubat intubated brief hospital course patient was admitted to the intubated on levophed for pressor support with diagnosis of sepsis cxr showed bilateral infiltrates and overall respiratory demise with wbc of given complicated medical history recent hopsitalization months and several respiratory infections mrsa tracheobronchitis chlamydia pneumonia patient was started on linezolid meropenem and ciprofloxacin for broad spectrum antibiotics coverage voriconazole was added to regimen later in the morning given severity of condition activated protein c was considered however patient had inr of and given risks of bleeding apc was not administered patient remained stable on pressor overnight diltiazem drip was started for control of atrial fibrillation as patient was tachcardic to s hr was under control and patient remained stable on diltiazem drip and levophed drip that was weaned off by the morning insulin drip was started for tight glucose control in the morning patient went into rapid atrial fibrilation that did not respond to lopressor iv mg x esmolol drip was started patient became hypotensive to s requiring aggressive fluid resuscitation esmolol and diltiazem drips were discontinued patient underwent electrical cardioversion phenylephrine drip was started for hypotension patient continued to be in pressure demise and vasopressin was added patient also became hypoxic requiring increase in ventilator settings abg showed ph of patient s condition continued to deteriorate and required continued use of dual pressors and high ventilator settings and patient expired later the next morning due to overwhelming sepsis and multi organ failure medications on admission kcl meq ibuprofen prn riss procrit u sc qweekly warfarin mg po qd cardizem mg po bid asa ec mg po qd lopressor po tid lasix mg po bid flagyl tid nd course started protonix mg po qd colace mg po qd discharge medications patient expired discharge disposition expired discharge diagnosis sepsis respiratory failure pneumonia atrial fibrillation hypotension discharge condition deceased completed by [NEW_RECORD] name h unit no admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending addendum please check digoxin level in days target level please relay level to nursing home md on call to adjust digoxin level as necessary and recheck digoxin accordingly discharge disposition extended care facility rehab md completed by,{}
29617,admission date discharge date service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint admitted after fall in bathroom with rib fractures and hemothorax major surgical or invasive procedure blood transfusions vitamin k and ffp chest tube insertion epidural catheter placement history of present illness year old male was evaluated at an outside hospital after a fall in the bathroom at his rehab facility and was discharged back to rehab that same day hematocrit check at rehab was so pt returned to outside hospital got unit packed rbcs vitamin k and ffp and was transferred to past medical history chf atrial fibrillation with pacemaker dm htn chronic uti chronic renal failure social history was recuperating at health care center at time of admission son lives in area family history non contributory physical exam afebrile vital signs stable gen no distress alert and oriented x cv rrr resp bibasilar crackles abd soft non tender non distended bowel sounds ext warm and well perfused pertinent results pm urine rbc wbc bacteria many yeast none epi pm urine blood mod nitrite neg protein tr glucose neg ketone neg bilirubin mod urobilngn neg ph leuk mod pm pt ptt inr pt pm wbc rbc hgb hct mcv mch mchc rdw am hct am gluc bun creatinine sodium potassium chloride hco anion gap ekg sinus tachycardia left bundle branch block cxr extensive right sided rib fractures multiple in more than one place highly suggestive of a flail chest there is also a posteriorly layering pneumothorax cxr interval removal of right sided chest tube with development of small apical pneumothorax no significant residual effusion the heart remains mildly enlarged without evidence for overhydration there is also a hazy area of opacity in the left upper lobe which could be resolving contusion injury however this should be followed to resolution no change to previously seen rib fractures cxr stable small apical pneumothorax f u right lower lobe opacity likely pulmonary contusion with future films brief hospital course he was admitted to the trauma service with right sided rib fractures a hematocrit of and inr a chest tube was placed and returned cc of blood from the thorax he was initially admitted to the trauma icu for monitoring his hematocrit improved after transfer of units rbcs vit k and ffp on urinalysis revealed a uti for which he was treated with days of ciprofloxacin his hematocrit subsequently remained stable and gradually increased to on because of his rib fractures the acute pain service was consulted for epidural analgesia the epidural catheter was placed and remained for several days he was later transitioned to oral narcotics and the epidural was removed his pain adequately controlled on tylenol tramadol and oxycodone prn he is on a bowel regimen pt was previously anticoagulated for atrial fibrillation because of his recent fall and hemothorax and increased risk of similar subsequent events given pt s age and relative instability would recommend not restarting coumadin for anticoagulation in spite of pt score of physical therapy was consulted and have recommended rehab after acute hospital stay medications on admission coumadin digoxin mg qd accupril mg qd humalog u tid lantus u qhs glucophage mg colace atenolol mg qd lasix qd discharge medications digoxin mcg tablet sig one tablet po daily daily atenolol mg tablet sig one tablet po daily daily heparin porcine unit ml solution sig one injection tid times a day senna mg tablet sig two tablet po hs at bedtime docusate sodium 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 magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed for constipation acetaminophen mg tablet sig two tablet po q h every hours furosemide mg tablet sig one tablet po bid times a day tablet s oxycodone mg tablet sig one tablet po q h every hours as needed for pain tramadol mg tablet sig tablet po q h every hours as needed for pain metformin mg tablet sig one tablet po bid times a day insulin nph regular human subcutaneous discharge disposition extended care facility health care center discharge diagnosis right rib fractures and hemothorax secondary to fall from standing discharge condition stable meeting discharge criteria afebrile vital signs stable eating regular diet pain controlled on oral meds indwelling foley discharge instructions it is important that you continue to cough deep breathe and use the incentive spirometer every hour that you are awake to prevent pneumonia that is often a complication associated with rib fractures followup instructions call dr office to schedule a follow up appointment in weeks at follow up with a urologist to evaluate your urinary retention and history of urinary tract infections after discharge from rehab follow up with your pcp after discharge from rehab,{}
27690,admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint hematuria and suprapubic vaginal pain major surgical or invasive procedure none history of present illness yo russian only speaking f w a presents with a week history of suprapubic pain and symptoms of uterine prolapse she has had these symptoms once in the past about a year ago she states that she feels vaginal tissue protrude from her vagina when she is walking and she has a suprapubic and vaginal pain when this happens she states that there is a recession back into her vaginal canal when she lies down and this relieves the symptoms she has had a history of c b htn anemia and recently x days hematuria she has had hematuria x days light pink urine no dysuria no suprapubic pain when she is urinating no incrase in urinary frequency no change in urinary urgency no fevers or night sweats chronic history of chills which she attributes to her anemia no weight changes she recieves her care at home in visting family here in has refused prospect of hd in past adamantly and today discusses that she realizes the risk of refusing hd when it may become a necessity risks including death no ha no visual changes weakness or numbness past medical history polycystic kidney disease cr on eval by renal at that time started on phos binder followed in w reportedlly worsening renal function but cr unknown htn on unk russian med dormatec hematuria in past year ago attributed to cyst rupture social history lives in in the currently not working non smoker never did and occ etoh family contacts children phone family history uncle w father deceased in maternal aunt w cva physical exam vs bp hr rr ra gen nad aox heent jvp roughly cm mmm op clear cardiac harsh holosystolic murmur apex radiates to axilla rrr pulm slight rales in lll otherwise clear abd soft bulging flanks bs bilateral large palpable kidneys no hepatomegaly or splenomegaly mild distention gu external genetalia normal no prolapsed tissue on external exam bimanual exam reveals no adnexal masses and normal uterus ext pedal edema to mid shins neuro cn intact normal distal motor in all extremities perrl pertinent results renal u s innumerable renal cysts consistent with polycystic kidney disease admission labs wbc bands pmns lymphs hct plt ptt inr lactate glucose bun cr na k cl bicarb discharge labs na k cl bicarb bun cr glucose ca mg phos wbc hct plt alt ast ap ldh t bili alb u a spec lg blood protein trace glucose and mod leuks rbc wbc many bacteria no yeast urine cr urine na t prot urine prot cr brief hospital course ckd secondary to patient has a history of worsening renal function and does not have renal follow up she was seen by renal inpatient who initially recommended treating her acidosis with a bicarb drip and then transitioning to po bicarb discharged on level teaspoon of baking soda per day she had no indication for emergent dialysis she had some signs of uremia including insomnia and decreased appetite but was not encephalopathic and had no uncontrolled bleeding she was close to euvolemic possibly slightly volume overloaded she had a good urine output and had some light pink urine likely due to her baseline possibly related to a cyst rupture she had some recent nsaid use we had her hold her nsaids and recommended that she not use them as an outpatient she was set up with follow up for renal and should be closely monitored multiple physicians had repeated conversations with the patient through a translator regarding the issue of dialysis for the long term the patient was adamantly against dialysis at this time even though there was the possibility that she could die if she denied dialysis when she emergently needed it she understood these risks upon discharge she seemed to be more amenable to conversation regarding dialysis and has been having much encouragement from her daughter in this issue hypocalcemia secondary hypoparathyroidism has renal follow up anemia normocytic not iron deficient tibc decreased ferritin elevated likely epo deficiency per renal they will follow in clinic and initiate erythropoeitin injections htn started on norvasc and lopressor for htn control medications on admission iron supplements calcium daily ibuprofen russian antihypertensive which she uses prn when home bp is elevated ends up being qod dosing discharge medications calcium acetate mg capsule sig two capsule po tid w meals times a day with meals disp capsule s refills ferrous sulfate mg tablet sig one tablet po daily daily disp tablet s refills prochlorperazine mg tablet sig one tablet po q h every hours as needed disp tablet s refills amlodipine mg tablet sig one tablet po daily daily disp tablet s refills toprol xl mg tablet sustained release hr sig one tablet sustained release hr po once a day disp tablet sustained release hr s refills sodium bicarbonate powder sig as directed po once a day please take baking soda level teaspoon fill heaping teaspoon then run your finger over the top to level the powder off take with glass of water disp qs refills trazodone mg tablet sig tablet po at bedtime as needed for insomnia for weeks disp tablet s refills discharge disposition home discharge diagnosis primary diagnosis polycystic kidney disease with chronic renal failure uterine prolapse discharge condition stable acidemia resolved discharge instructions you have been admitted for uterine prolapse as well as acidic blood as a result of your polycystic kidney disease which has caused your kidney failure the acidity was corrected and you are being sent out on something to control it you should take teaspoon of baking soda sodium bicarbonate per day fill up the tea spoon and then run your finger over it so the teaspoon is level at the top please continue your other medications that you have been prescribed and please follow up with nephrology kidney doctors and gynecology you should return to the emergency room if you have chest pain shortness of breath palpitations increased blood in your urine fevers or chills or any other symptoms that concern you as far as diet avoid bananas oranges and tomatoes please also note the potassium content of your meals and do not eat foods that have a lot of potassium such as the three listed above please limit protein intake to grams daily followup instructions please call the following numbers to make follow up appointments kidney doctors please make an appointment for within weeks of your discharge from the hospital ask for an appointment with dr at you need to have an appointment within weeks gynecologist for uterine prolapse please schedule an appointment with gynecology outpatient within weeks of your discharge from the hospital [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint anemia hypocalcemia major surgical or invasive procedure tunneled catheter line hemodialysis history of present illness this is a yo f from the russian speaking only with a past medical history of polcystic kidney ds with esrd followed by dr creatinine of late htn who was sent to the ed from renal clinic after she was found to have a hct of baseline symptomatic with dyspnea on exertion a creatinine of bicarb of and corrected calcium of she was guaiac negative in the emergency department her vitals were t hr bp rr o sats room air she was found to also have elevated pancreatic enzymes and was sent for ruq u s renal saw the patient in the ed and plan to place tunnelled cath in am and initiate hd she also received g ca gluconate and unit of prbc s she was found to have a uti and was given dose of ciprofloxacin vbg with ph of and was initiated on na bicarb ros she admits to progressive worsening of fatigue worst over last year n v about week ago and ruq pain for days although has had right flank pain for a while beginning of chills constipation back pain chronic ha past medical history polycystic kidney disease creatinine evaluated by renal at that time started on phos binder refused hd in the past and on most recent admission h o ag non gap acidosis h o of kidney stone hematuria attributed to cyst rupture htn anemia attributed to renal failure uterine prolapse social history lives in in the here about month visiting family denies past or current tobacco illicit drug use occasional etoh never heavy family history uncle w father deceased in maternal aunt w cva physical exam vs temp bp hr rr o sat ra gen pale tired appearing yo f no acute distress heent perrl eomi anicteric pale conjunctiva mm dry op without lesions neck no supraclavicular or cervical lymphadenopathy no jvd no goiter palpated resp cta b l with good air movement throughout cv rr s and s wnl iii vi sem heard throughout the precordium best at lusb radiates to carotids abd soft nd bs tender to palpation along the right flank no rebound guarding mild ttp across epigastrium ext pitting edema to knees no c c warm good pulses skin no rashes no jaundice neuro aaox cn ii xii intact strength throughout no sensory deficits to light touch appreciated dtr s patellar and biceps resting tremor no asterixis pertinent results ekg st degree av block compared with prior from there is no significant change imaging cxr impression superior mediastinal widening may be due to a thyroid goiter tortuous vessels or lymphadenopathy further evaluation starting with a dedicated pa and lateral chest radiograph are recommended abd u s impression normal gallbladder with no evidence of cholecystitis massive polycystic kidneys with no definite evidence of hydronephrosis though evaluation is very limited no ascites identified am pt ptt inr pt am neuts bands lymphs monos eos basos am wbc rbc hgb hct mcv mch mchc rdw am pth am caltibc haptoglob ferritin trf am tot prot albumin globulin calcium phosphate magnesium am iron am tot prot am lipase am alt sgpt ast sgot alk phos amylase tot bili dir bili indir bil am urea n creat sodium potassium chloride total co anion gap pm urine rbc wbc bacteria few yeast none epi pm urine blood lg nitrite neg protein glucose tr ketone neg bilirubin neg urobilngn neg ph leuk tr pm hgb calchct impression superior mediastinal widening not seen on current study no tracheal displacement or impression to suggest goiter or lymphadenopathy no acute cardiopulmonary process brief hospital course imp yo f with polcystic kidney disease and esrd presenting with anemia acute on chronic renal failure hypocalcemia and abdominal pain hopsital course by problem acute on chronic renal failure the patient was initially admitted to the micu with progessive worsening of esrd secondary to as described above she had significant metabolic acidosis the renal service was involved and recommended the placement of a tunnelled line to initiate hd on the line was placed and dialysis was initiated the patient s acid base status normalized with several session of hd and the patient was set up for an out patient hd schedule anemia this was felt to be secondary to her known esrd her hematocrit improved significantly with the initiation of epopgen at dialysis dyspnea on exertion the patient s rogressive fatigue and dyspnea on exertion felt most likely to be secondary to marked anemia from esrd a chest x ray showed no evidence of pneumonia her symptoms resolved with improvement of her hematocrit abdominal discomfort the patient had mild right lateral abdominal pain ruq u s and ct abdomen and pelvis were unremarkable for any acute process her symptoms were felt to most likely br secondary to her at the time of dicharge her symptoms had largely resolved uti the patient was placed on ciprofloxacin with a planned course of ten days to be completed as an out patient htn as an out patient she was on toprol and norvasc her norvasc was discontinued and lisinopril was initiated given potential vascular benefits f e n the patient was placed on a renal low sodium diet ppx the patient was place on pneumoboots code status full consent signed through russian interpreter communication daughter medications on admission iron supplements calcium acetate amlodipine mg qdaily compazine prn toprol xl sodium bicarbonate powder trazadone mg qhs discharge medications calcium acetate mg capsule sig two capsule po tid w meals times a day with meals disp capsule s refills ciprofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po daily daily b complex vitamin c folic acid mg capsule sig one cap po daily daily disp cap s refills lisinopril mg tablet sig one tablet po daily daily disp tablet s refills trazodone mg tablet sig tablet po at bedtime as needed for insomnia discharge disposition home discharge diagnosis acute on chronic renal failure polycystic kidney disease discharge condition good stable on current dialysis schedule discharge instructions you were admitted for acute on chronic renal failure you underwent placement of a tunnel catheter to initiate dialysis you underwent several dialysis sessions and tolerated them well you will go to dialysis as an outpatient if you develop fever chills pain redness at the site of the tunnel catheter shortness of breath chest pain abdominal pain nausea vomiting or diarrhea burning on urination leg swelling please contact your doctor or go to the emergency room please take you medications as prescribed and follow up with the appointments below followup instructions you should return to for dialysis on thursday and saturday on both days you should report to the building at am this is where you received in patient dialysis dr office will make arrangements for further out patient dialysis at another site if you have any questions you may contact his office at you should follow up with your primary care physician in the next weeks her phone number is provider md phone date time,"{
""Diagnoses"": [""Hematuria"", ""Uterine prolapse"", ""Anemia"", ""Chills""],
""Medications"": [""HD""]
}"
7051,admission date discharge date date of birth sex f service medicine history of present illness the patient is a year old female with a history of asthma times four years with a history of intubation in presenting with asthma flare on the night prior to admission the patient started feeling shortness of breath she reported increased cough productive of yellow sputum with small blood streaking no recent exposure to allergens or sick contacts she came to the emergency department saturating in room air she received continuous nebulizer and solu medrol mg intravenously she was speaking only in one word sentences peak flow was at only with a baseline of the patient was admitted to the medical intensive care unit for further management asthma diagnosed in intubated once most recent pulmonary function tests with fev of predicted fvc of frequently requires po steroids gastroesophageal reflux disease migraines status post ectopic pregnancy with tubal ligation status post effusion secondary to trauma medications on admission robitussin albuterol nebulizer tums mg p o t i d atrovent two puffs t i d omeprazole mg p o q d salmeterol two puffs t i d hydrocortisone topical q i d beclomethasone two puffs b i d nedocromil two puffs b i d fluticasone inhaler two puffs b i d mg p o b i d montelukase mg q d allergies no known drug allergies social history the patient is married the patient denies etoh and quit tobacco four to five years ago physical examination on admission vital signs reveal pulse blood pressure respiratory rate pulse oximetry on nebulizer mask in general the patient is dyspneic using accessory muscles head eyes ears nose and throat examination mucous membranes are dry the neck examination is supple cardiovascular is tachycardia with no murmurs the lung examination revealed prolonged expiratory with inspiratory and expiratory wheezes abdominal examination is obese nontender nondistended positive bowel sounds extremities no cyanosis clubbing or edema neurologic examination the patient is alert and oriented times three cooperative strength in all four extremities laboratory data on admission laboratory values were significant for a white count of with a polys no bands lymphocytes arterial blood gases on admission was with a pco of and a po of on face mask chest x ray on admission showed no evidence of pneumonia hospital course the patient was admitted to the medical intensive care unit for further management she was intubated on the third hospital day due to increasing pco she was a slow wean from the ventilator remaining intubated for eleven days in the interim she was started on levaquin for a presumed development of pneumonia she was also started on a course of ampicillin for a enterococcal urinary tract infection which was diagnosed during her medical intensive care unit stay she was successfully extubated on the thirteenth hospital day and transferred to the floor upon arrival to the floor she maintained adequate saturation on nasal cannula and later in room air however it was noted status post extubation that the patient had profound upper and lower extremity weakness her weakness was presumed to be secondary to steroid myopathy she did receive propofol and high dose course of intravenous solu medrol upon admission which was tapered down to a course of prednisone mg q d with plan for taper upon discharge despite the strong suspicion for steroid myopathy a neurology consultation was called to rule out any more dangerous causes of her extremity weakness an emg was done which showed only diffuse myopathy and no evidence of denervation magnetic resonance scan of the cervical and high thoracic spine showed chronic changes consistent with cervical spondylosis as well as a shallow disc protrusion and multiple foraminal narrowing she was discharged to on the twentieth hospital day condition on discharge the patient was discharged to rehabilitation in stable condition follow up she will follow up with her new pcp at discharge medications nystatin swish and swallow ml p o q i d serevent two puffs b i d combivent two puffs q i d p r n albuterol atrovent nebulizer q hours p r n prednisone mg p o q d with plans for slow taper mg per week down to mg p o q d pending further assessment lisinopril mg p o q d lasix mg p o q d flovent four puffs b i d colace mg p o b i d levofloxacin mg p o q d with plans for discontinuation on protonix mg p o q d hydrocortisone topical b i d dulcolax mg p o q d p r n montelukase mg p o q d nedocromil two puffs b i d discharge diagnoses status asthmaticus steroid myopathy m d dictated by medquist d t job cclist [NEW_RECORD] admission date discharge date date of birth sex f service med allergies patient recorded as having no known allergies to drugs attending chief complaint wheezing sob major surgical or invasive procedure intubated extubated history of present illness y o female with adult onset asthma s p previous intubations and tracheostomies and copd on chronic l home o osa admitted initially to on with shortness of breath and increased wheezing chest tightness pt had reported that she had progressively worsening wheezing sob x wks and had been requiring more frequent alb nebs at home initially denied any f c n v abd pain d c or any other associated symptoms home peak flows are initially in ed was as low as improved only to after albuterol neb in pt was given combivent nebs x solumedrol mg iv x heliox therapy x min in pt was continued on solumedrol mg iv q h combivent nebs had occasional desats to while coughing vomiting also started on course of azithromycin x days on evening of became more tachypneic and hypercarbic with pco at on abg intubated for resp distress and increased work in breathing pt was then extubated without difficulty with rsbi she still experienced occasional desats to at night last desat but since has improved with frequent nebs and continued high dose solumedrol pt transferred to medicine floor for further management currently feeling well no complaints denies any shortness of breath chest pain nausea or vomiting abd pain dysuria no f c diarrhea yesterday loose watery but no bms today also ros for cough productive with whitish yellow sputum but pt states this is unchanged for the last week past medical history adult onset asthma s p previous intubations and tracheostomies for prolonged weans copd on chronic home o l osa not currently using cpap at home gerd htn dm social history denies etoh use former smoker ppd x yrs quit no ivda currently on disability for asthma family history noncontributory physical exam t bp p r sat l nc gen pleasant obese female a o x lying comfortably nad heent perrl eomi op clear with mmm no sinus tenderness neck supple nt no lad pulm decreased bs throughout with prolonged exp phase few scattered wheezes no rales cv rrr no m r g abd s nt obese bs ext edema nonpitting dp pulses bilaterally pertinent results pm plt count pm neuts lymphs monos eos basos pm wbc rbc hgb hct mcv mch mchc rdw pm glucose urea n creat sodium potassium chloride total co anion gap labs on transfer central line tip cx pending 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 type art po pco ph calhco base xs brief hospital course a p y o female with adult onset asthma and copd on chronic home o admitted to for status asthmaticus s p intubation and extubated now improved after steroids and nebs tx transferred to medicine floor for further management status asthmaticus now appears improved s p extubation satting in mid s on l nc still has been maintained on steroid taper since admission with solumedrol mg iv tid micu notes have mentioned will wean steroids but not weaned as of yet pf per micu resident checked last night and was not far off pt s baseline since pt has arrived so late to floor and already has received solumedrol dose for today pt switched to po steroids mg po prednisone will give week taper cont with frequent alb atrovent nebs q standing cont with flovent salmeterol inhalers per outpt doses likely co retainer given prev abg so will monitor o sats carefully goal low s peak flow f u with dr leukocytosis wbc almost doubled now decreasing unclear etiology pt has remained afebrile central line pulled in and sent for culture now growth will also check c diff given hospital stay previous azithromycin use h o recent diarrhea pt has now not had any diarrhea no other focal signs of infection will cx if spikes check cbc with diff and follow fever curve pt has not been febrile no more diarrhea therefore leukocytosis likely stress of intubation extubation and steroids dm qid fs riss and fixed doses probably will have decreased insulin requirement with taper of steroids htn titrate up lisinopril gerd cont protonix fen dm diet ppx sc heparin bowel regimen access piv code full confirmed in dispo to home will d w cm re potential for rehab pt consult obtained and no home pt required clinic appts with dr and in clinic medications on admission albuterol nebs prn advair atrovent ih puffs lisinopril qd calcium supplements mg po qd insulin units qam units q pm riss protonix mg po qd discharge medications salmeterol xinafoate mcg dose disk with device sig one disk with device inhalation q h every hours disp disk with device s refills montelukast sodium mg tablet sig one tablet po qd once a day disp tablet s refills fluticasone propionate mcg actuation aerosol sig four puff inhalation times a day disp qs 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 ipratropium bromide solution sig one inhalation q h every hours disp qs refills albuterol sulfate solution sig one inhalation q h every hours disp qs refills lisinopril mg tablet sig one tablet po qd once a day disp tablet s refills prednisone mg tablet sig three tablet po qd once a day for days disp tablet s refills prednisone mg tablet sig two tablet po once a day for days disp tablet s refills prednisone mg tablet sig one tablet po once a day for days disp tablet s refills prednisone mg tablet sig one tablet po once a day for days disp tablet s refills insulin unit ml suspension sig thirty u subcutaneous qam for months u qam disp qs refills insulin unit ml suspension sig twenty u subcutaneous at bedtime for months u qhs disp qs refills discharge disposition home with service discharge diagnosis status asthmaticus discharge condition good discharge instructions please monitor your respiratory status if any increase work of breathing cough or weakness please call your doctor or go to the er followup instructions dr at at am in bldg on in rehab services dr at clinic at pm completed by [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint shortness of breath major surgical or invasive procedure cpap history of present illness f with adult onset asthma status post prior intubations with prolonged wean and chronic obstructive pulmonary disease copd l home o no home steroids obstructive sleep apnea admitted to icu for copd exacerbation this is her second hospitalization this year for respiratory distress and she requires home oxygen l per nasal cannula but not daily steroid therapy the patient complained of shortness of breath and dyspnea on exertion for one week with acute deterioration on date of admission she also had cough productive of sputum at her baseline she has occasional shortness of breath walking around the house and waking up short of breath is a routine thing she uses her albuterol inhaler or nebulizer therapy daily and denies medical non compliance no ill contacts recent uri or allergic trigger she has seasonal allergies and eczema denied pets at home she denied fever or chills she had no increased lower extremity edema orthopnea or paroxysmal nocturnal dyspnia and no dvt risk factors in the ed the patient was treated with combivent nebs solumedrol mg iv x heliox and eventually placed on non invasive positive pressure ventilation nippv arterial blood gas in the ed was the same therapy was continued in the icu over the day prior to transfer to the medicine floor on the patient tolerated weaning from nippv heliox to nc spaced out nebs every hrs changed from iv to oral steroid therapy and tolerated an oral diet abg day of transfer in the icu cxr was clear without evidence of pneumonia edema or effusion sputum gram stain and culture was negative past medical history adult onset asthma s p prior intubations and prolonged weans chronic obstructive pulmonary disease home o l nc fev obstructive sleep apnea cpap at home gastroesophageal reflux disease hypertension diabetes diastolic congestive heart failure per transthoracic echocardiogram e a eczema seasonal allergies social history denies alcohol and illicit drug use former smoker of ppd x yrs quit currently on disability for asthma since family history asthma diabetes physical exam t bp p r sat l nc gen pleasant obese female sitting in chair comfortably nad heent perrl eomi op clear with mmm no sinus tenderness neck supple nt no lad no jvd pulm prolonged exp phase fair air movement scattered exp wheezes throughout no rales cv rrr s s no m r g abd s nt obese bs ext edema nonpitting dp pulses bilaterally neuro aox cn intact no focal weakness or sensory deficit no dysarthria pertinent results labs ed icu course cbc 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 lymphs monos eos baso chem lytes 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 calcium phos mg pm blood mg pm blood cholest am blood calcium phos mg am blood calcium phos mg lipids pm blood triglyc hdl chol hd ldlcalc abg am blood type art temp po pco ph am blood type art po pco ph lactate micro pm sputum site expectorated gram stain final pmns and epithelial cells x field gram stain of this specimen indicates contamination withoropharyngeal secretions and invalidates results respiratory culture final no predominance of these respiratory pathogens s pneumoniae h influenzae and m catarrhalis cxr chest portable ap pm the cardiac size is normal no failure is seen the lung fields are clear the right costophrenic angle is not included on the film no failure no infiltrates no significant change since prior film chest portable ap am the cardiac and mediastinal silhouettes appear stable there are no focal pulmonary opacities pleural effusions or evidence of pneumothorax slight prominence of the right cardiphrenic angle probably represents a combination of lung markings and a prominent fat pad the osseous structures are unremarkable no evidence of pneumonia ecg am sinus tachycardia st changes are nonspecific since previous tracing st changes noted intervals axes rate pr qrs qt qtc p qrs t brief hospital course year old female with adult onset asthma and copd on chronic home o admitted to icu copd exacerbation and treated for days with mask ventilation steroids antibiotics and bronchodilators her respiratory status improved and she was transferred to the medicine floor for further management presentation with respiratory distress the patient has long history of prior tobacco abuse and developed a copd flare while on home oxygen with an unknown trigger she likely has a component of carbon dioxide retention considering her increased carbon dioxide on arterial blood gases her respiratory status improved during her icu course which included solumedrol tid she was transferred to the medicine floor for continued monitoring and therapy medications included flovent albuterol inh atrovent inh atrovent nebs q h and albuterol nebs she has been afebrile without leukocytosis recent illness or significant sputum production chest x ray showed no evidence of pneumonia or chf and sputum culture was negative her clinical exam was significant for scattered expiratory wheezing and prolonged expiratory phase at discharge her pulmonary exam improved significantly and she lacked wheezing ambulatory and resting oxygen saturations were appropriate at approximately at her home regimen of l nasal cannula oxygen supplementation she will finish a week taper course of oral steroids and week course of oral levoquin that will end obstructive sleep apnea she refused nightly cpap several nights her home regimen is mm per home regimen diastolic chf the patient s cxr was without significant effusions and did not improve after lasix mg iv given in the ed it s unlikely a component of her presenting respiratory distress this admission her home regimen including lisinopril mg daily and aspirin was continued diabetes her diabetes was well controlled on riss and nph twice daily gerd protonix was continued the patient was discharged in good condition eating a diabetic cardiac healthy diet and ambulating well she will follow up with pcp and will dr in the clinic within the next weeks medications on admission salmeterol mcg ipratroprium inh q hrs albuterol inh q hrs mg daily flovent mcg inh fluticasone mcg p inh protonix mg daily lisinopril mg daily riss insulin u qam and u qpm furosemide mg daily aspirin mg daily discharge medications levofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills montelukast sodium mg tablet sig one tablet po daily daily fluticasone propionate mcg actuation aerosol sig four puff inhalation times a day pantoprazole sodium mg tablet delayed release e c sig one tablet delayed release e c po q h every hours lisinopril mg tablet sig two tablet po daily daily fluticasone propionate mcg actuation aerosol spray sig four nasal twice a day aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily albuterol sulfate solution sig one inhalation q h every to hours as needed for shortness of breath or wheezing ipratropium bromide solution sig one inhalation every hours as needed for shortness of breath or wheezing ipratropium bromide mcg actuation aerosol sig one puff inhalation every six hours albuterol mcg actuation aerosol sig one puff inhalation every four hours as needed dextromethorphan guaifenesin mg ml syrup sig mls po q h every hours as needed insulin unit ml suspension sig thirty units subcutaneous qam disp qs refills insulin unit ml suspension sig eighteen units subcutaneous qpm disp qs refills strip sig one glucose testing strips four times a day disp qs refills diabetic supplies miscellan kit sig one diabetic syringes and needles miscell xd disp qs refills prednisone mg tablet sig three tablet po once a day for days take and disp tablet s refills prednisone mg tablet sig two tablet po once a day for days take through disp tablet s refills prednisone mg tablet sig one tablet po once a day for days take through disp tablet s refills prednisone mg tablet sig two tablet po once a day for days take through disp tablet s refills diabetic inch needles dispense xd qs to month refills insulin regular human unit ml cartridge sig one injection four times a day as needed for elevated blood glucose as directed per sliding scale disp refills discharge disposition home discharge diagnosis primary adult onset asthma chronic obstructive pulmonary disease obstructive sleep apnea secondary gastroesophageal reflux disease hypertension diabetes diastolic congestive heart failure eczema seasonal allergies discharge condition good in usual state of health breathing at baseline comfort level and oxygen saturation without wheezing without distress ambulating with good oxygen saturation eating oral diet discharge instructions please monitor your respiratory status if any increase work of breathing cough or weakness please call your doctor or go to the er please take all medications as prescribed and use your cpap machine at home follow up with your doctor appointments listed below finish all of your antibiotic levofloxacin finish your prescription for prednisone with a dose that will be tapered slowly over the next few weeks followup instructions provider m d where rehab services dyspnea phone date time provider md where phone date time [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint respiratory distress major surgical or invasive procedure intubation history of present illness hpi yo f with adult onset asthma status several prior intubations with prolonged wean severe obstructive lung disease copd l home o no home steroids obstructive sleep apnea who was found in respiratory distress satting ra and was intubated in the field on since that time patient has been at hospital at pts abg was on ac at fio the pt remained intubated and was placed on iv solumedrol nebs and levofloxacin she has been occasionally febrile to and was noted to have a vaginal and thick nasal discharge both of which were sent for culture ekg on admission was abnormal with sinus tach and st depressions in lat and inf leads a d dimer was also elevated at the time to patient was ruled out by negative sets of enzymes the team attempted to extubate patient day prior to transfer on and removed the et tube patient struggled and was wheezy for a few hours and was re intubated with a et tube on day of transfer patient s family requested transfer to her rsbi prior to transfer was on tp her abg was on fio prior to transfer her last abg was on ac rr peep fio volumes o was weaned down to of note throughout admission at patient s bicarb was elevated at thought to be due to chronic respiratory acidosis past medical history adult onset asthma s p multiple prior intubations and prolonged weans chronic obstructive pulmonary disease home o l nc fev obstructive sleep apnea cpap at home gastroesophageal reflux disease hypertension diabetes tte with ef mr e a eczema seasonal allergies spirometry actual pred pred actual pred chg fvc fev mmf fev fvc marked obstructive ventilatory defect social history denies alcohol and illicit drug use former smoker of ppd x yrs quit currently on disability for asthma since family history asthma diabetes physical exam vitals t bp hr sat r gen overweight aaf lying in bed intubated sleepy heent perrl muddy sclerae conjunctivae anicteric nares patent white plaque on middle of tongue neck no jvd no lad cv rrr nl s s no m r g lungs diffuse mild end expiratory wheezes ab soft ntnd nabs extrem no c c e wwp full dp pt pulses neuro responds to only some commands sleepy pertinent results chest portable ap pm chest portable ap reason please eval for infiltrate medical condition year old woman with copd asthma intubated for respiratory failure reason for this examination please eval for infiltrate history copd and asthma intubated for respiratory failure comparison chest ap semi upright portable view the endotracheal tube terminates at least cm above the carina the nasogastric tube is poorly visualized beyond the mid esophagus secondary to technique and it is not certain whether it reaches the stomach the lungs appear clear there is no pulmonary edema or pleural effusion cardiac and mediastinal contours are unchanged and within normal limits impression satisfactory endotracheal tube position suboptimally evaluated nasogastric tube position pm type art po pco ph total co base xs pm k pm o sat pm alt sgpt ast sgot alk phos tot bili 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 urine color green appear slhazy sp pm urine blood lge nitrite neg protein glucose neg ketone tr bilirubin neg urobilngn ph leuk sm pm urine rbc wbc bacteria few yeast none epi pm urine mucous occ brief hospital course a p yo f with reactive and severe obstructive lung dx status several prior intubations with prolonged wean and trach l home o no home steroids obstructive sleep apnea who was found in hypoxic hypercarbic respiratory distress the pt is transferred from osh after failure to wean from the vent now extubated and doing well on l nc in the micu she was treated as follows hypoxic hypercarbic resp distress the patient has a history of reactive airway disease with severe obstructive lung disease and obstructive sleep apean she was transferred to after failure to wean from ventilator this was thought to be secondary to bronchospasm she was maintained on a ventilator for one day after admission and was successfully weaned from the ventilator without difficulty she was continued on nebulizers and a steroid taper she was empiracally started on levofloxacin for a copd exacerbation to complete a day course fever leukocytosis unclear etiology afebrile so far upon transfer elevated wbc likely due to steroids has borderline dirty ua probably covered by levaquin urine cx pending f u urine blood and sputum cultures bv pt has had foul smelling vaginal discharge and is being treated with flagyl mg iv bid x days day htn continue lisinopril dm pt has been on in the past keeping on ssi for now continue ssi qid fs anemia pts baseline hct in was hct now with mcv iron studies c w anemia of chronic disease gerd continue lansoprazole communication dr intern at daughter once called out to the floor the patient did well she was successfully weaned to her home o dose of l w out problem and maintained sats on this level she tolerated ambulation w out significant desaturations or subjective sob she continued on her levaquin and flagyl for a copd flare and bv respectively she also continued on steroids and was d c home on a steroid taper w close f u with dr and her pcp medications on admission meds on transfer albuterol aspirin beclomethasone docusate fluconazole hsq iss ipratropium bromide lansoprazole levofloxacin lisinopril lidocaine jelly lorazepam metronidazole montelukast prednisone discharge medications aspirin mg tablet chewable sig one tablet chewable po daily daily lisinopril mg tablet sig two tablet po daily daily montelukast mg tablet sig one tablet po daily daily metronidazole mg tablet sig one tablet po bid times a day for days disp tablet s refills levofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills fluticasone mcg actuation aerosol sig four sprays inhalation twice a day protonix mg tablet delayed release e c sig one tablet delayed release e c po once a day albuterol mcg actuation aerosol sig puff inhalation four times a day as needed for shortness of breath or wheezing atrovent mcg actuation aerosol sig one puff inhalation four times a day disp inhaler refills prednisone mg tablet sig five tablet po once a day for days disp tablet s refills prednisone mg tablet sig four tablet po once a day for days please start after you finish your course of mg disp tablet s refills prednisone mg tablet sig three tablet po once a day for days please start after you finish your course of mg disp tablet s refills prednisone mg tablet sig two tablet po once a day for days please start after you finish your course of mg disp tablet s refills prednisone mg tablet sig one tablet po once a day for days please start after you finish your course of mg disp tablet s refills prednisone mg tablet sig tablet po once a day for days please start after you finish your course of mg disp tablet s refills guaifenesin mg ml syrup sig mls po q h every hours as needed calcium carbonate mg tablet chewable sig one tablet chewable po tid w meals times a day with meals disp tablet chewable s refills cholecalciferol vitamin d unit tablet sig one tablet po daily daily disp tablet s refills insulin nph regular human rec unit ml suspension sig thirty unit subcutaneous qam insulin nph regular human rec unit ml suspension sig eighteen units subcutaneous once a day discharge disposition home discharge diagnosis primary copd flare asthma exacerbation secondary bacterial vaginiosis osa gerd htn dm discharge condition stable on home o level ambulatory and able to feed self discharge instructions please keep your follow up appointments please take your medications as directed please call your pcp or return to the er for chest pain shortness of breath fever to dizziness fainting other concerning symptoms followup instructions provider md phone date time provider breathing test phone date time provider m d phone date time completed by,"{
""Diagnoses"": [""asthma"", ""intubation"", ""pulmonary function tests"", ""gastroesophageal reflux disease"", ""migraines"", ""status post ectopic pregnancy"", ""status post effusion secondary to trauma""],
""Medications"": [""robitussin"", ""albuterol"", ""tums"", ""omeprazole"", ""hydrocortisone"", ""beclomethasone""]
}"
20312,admission date discharge date date of birth sex m service history of present illness patient is a year old african american male with a history of insulin dependent diabetes hypertension and hepatitis b who presented on with dehydration hyperglycemia and hyperkalemia the patient had developed nausea vomiting diarrhea and nonproductive cough approximately to days previous he denied any fevers chills dyspnea chest pain headache focal weakness visual change rashes or arthralgias he admitted to loose stools without hematochezia his abdominal pain was diffuse and described as crampy the patient denied any unusual ingestion sick contacts or recent travel initially denied any recent alcohol or drug use however his history had subsequently followed heavy alcohol of beer and scotch over the day weekend on presentation to the emergency department the patient was found to be tachycardic hyperglycemia and hyperkalemic a right femoral line was placed his initial bicarbonate was less than and he had a blood ph of and an anion gap of his potassium was and a blood sugar was on arrival patient received kayexalate sodium bicarbonate and insulin drip and calcium gluconate as well as intravenous fluids ceftriaxone flagyl and zantac in the emergency department he was subsequently transferred to the medical intensive care unit past medical history diabetes mellitus insulin dependent although adult onset hypertension bilateral glaucoma burns to the bilateral upper extremities hepatitis b history of lacunar infarcts history of a positive ppd and echocardiogram in showing mild aortic insufficiency medications on admission ambien mg po q h s enteric coated aspirin mg po q d univasc mg po q d nph insulin units subcutaneous q a m timolol eye drops to both eyes one drip t i d trusopt eye drops to both eyes one drop t i d xalatan eye drops one drop to each eye q h s tylenol tablet po q hours prn and prilosec mg q d allergies question of codeine although patient does take tylenol without problem making this unlikely family history coronary artery disease in both brother and sister social history the patient is married with children he is on disability he has a pack year history of smoking and quit years ago he works in a liquor store physical examination temperature of blood pressure pulse of respiratory rate was he was on nonrebreather mask general very thin frail male sitting upright in mild distress head eyes ears nose and throat normocephalic atraumatic pupils equal round and reactive to light his pupils were myotic extraocular movements were intact oropharynx was clear he had dry mucous membranes no lymphadenopathy the jugular venous pressure was flat his trachea was midline his lung exam was clear to auscultation bilaterally heart revealed tachycardic normal s s no s a laterally displaced point of maximal impulse and no murmurs rubs or gallops abdomen was soft and diffusely tender nondistended there was normal active bowel sounds there was no hepatosplenomegaly there was no rebound or guarding his back revealed mild left cva tenderness extremities revealed poor skin turgor it was cool pulses were intact there was trace edema dry eczema was noted laterally there are multiple burns and surgical scars noted on his upper extremities neurological patient was alert and oriented times three otherwise nonfocal gross motor exam he had guaiac positive stool labs on admission included a white count of hematocrit of platelets he had an mcv of his sodium was although this corrected to given his glucose of his potassium was chloride of bicarbonate of less than bun of and creatinine of an arterial blood gas in the medical intensive care unit showed a ph of pc of and a p of on nonrebreather his lactate was lfts alt of ast alkaline phosphatase t bilirubin ck of albumin of globulin of protein of serum tox and a urine tox were both negative a urinalysis showed greater than glucose greater than ketones his chest x ray showed no acute infiltrates or effusions there is no cardiomegaly an nasogastric tube was well placed a kub showed no evidence of obstruction or free air electrocardiogram showed sinus tachycardia with left axis deviation left interventricular conduction delay there was normal r wave progression peak t waves across the precordium with elevated j point in v v and v hospital course the patient was admitted to the medical intensive care unit he received an insulin glucose tolerance test with fingerstick blood sugars q hour he also received intravenous hydration with normal saline at cc an hour for two liters he had serial chem done every six hours to correct his electrolytes including calcium magnesium and phosphorus in addition his cardiac enzymes were cycled to rule out ischemia as it was initially unclear what was the initial trigger to his dka by the second day of his admission his anion gap had closed and since insulin gtt had been discontinued he was placed on a nph units prior to discontinuing the insulin gtt he was also given four units of regular insulin as well before the drip was stopped on the second day blood cultures did in fact also came back gram positive for cocci in the blood this was felt likely secondary to the femoral line insertion he was treated empirically with a dose of vancomycin and the femoral line was ultimately pulled a left subclavian line was placed under sterile conditions in its place after the femoral line was pulled patient was subsequently transferred to the medical floor for observation as well as to receive diabetic education from the teaching nurse on the floor his stay was remarkable only for a drop in his hematocrit to a low of given his history of guaiac positive stools it was felt that this was most likely related to this he did in fact receive two units of packed red blood cells and will need follow up after discharge in addition his blood pressure was under suboptimal control on the floor with it ranging anywhere between and systolic therefore his univasc was titrated up during his admission with moderate effect on his blood pressure the patient subsequently felt much better and appeared well he was tolerating food without any problem was subsequently discharged to follow up with dr nurse discharge medications univasc mg po q d nph insulin units subcutaneous q a m units subcutaneous q p m prilosec mg po q d enteric coated aspirin mg po q d ambien mg po q h s timolol eye drops both eyes one drop t i d trusopt eye drops both eyes t i d xalatan eye drops to each eye q h s discharge diagnosis alcohol induced nausea vomiting with subsequent diabetic ketoacidosis m d dictated by m d medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service neurology allergies codeine codeine anhydrous ambien attending chief complaint code stroke altered mental status major surgical or invasive procedure mri eeg history of present illness the pt is a year old gentleman who presented with alteration in mental status the pt was unable to offer a history at the time of my encounter therefore the following history is per the primary team ems and the medical record per ems the pt was last seen well by his wife at am before going to bed last night i e hours prior to presentation this morning at approximately am his wife found him in bed not responding to her and thrashing around she called ems on their arrival they found the pt to be unresponsive with eyes deviated to the right and pinpoint given history of diabetes mellitus fingersticks were performed and were and he was given mg of iv ativan without effect he was subsequently brought to the ed for further evaluation at the time of my initial encounter the pt was in the midst of intubation therefore a detailed nihss could not be performed see brief examination below he was subsequently sedated and paralyzed unfortunately further obscuring the examination the pt was unable to offer a review of systems past medical history hypertension diabetes mellitus on insulin insulin regimen nph q am ss with hga c chronic renal failure baseline creatinine peripheral neuropathy glaucoma hepatitis b sag neg sab cab hepatitis c hcv vl k genotype ib anemia baseline hct h o chest pain no cad on angiography substance abuse none since h o osteomyelitis h o back pain legally blind h o ppd conversion erectile dysfunction h o mva with extensive injuries requiring skin graft social history social history is significant for the absence of current tobacco use quit in packs week for yrs there is no h o of alcohol abuse no ivdu although crack abuse till s patient is married with children lives with wife retired family history no cad in family h o cancer physical exam vitals t f p r bp sao general lying in bed with eyes closed intubated heent nc at mmm neck no carotid bruits appreciated no nuchal rigidity pulmonary lungs with transmitted sounds bilaterally cardiac rrr nl s s no m r g noted abdomen soft nt nd normoactive bowel sounds extremities no c c e bilaterally radial dp pulses bilaterally skin no rashes noted multiple healed scars over abdomen and legs neurologic initial examination just prior to intubation and sedation mental status does not open eyes to verbal or noxious stimuli no verbal output does not follow commands cranial nerves perrl to mm and briskly reactive eyes were initially deviated to the right on reexamination approximately minutes later eomi to oculocephalic maneuver corneal reflex and nasal tickle present bilaterally no overt facial asymmetry gag reflex intact motor normal bulk throughout could not assess tone was seen to move all extremities antigravity in a semi purposeful manner during line placement before he was chemically paralyzed no overt adventitious movements were noted sensory could not assess prior to intubation sedation and administration of paralytics dtrs could not assess prior to intubation sedation and administration of paralytics plantar response was mute bilaterally pertinent results am wbc rbc hgb hct mcv mch mchc rdw am urine bnzodzpn neg barbitrt neg opiates neg cocaine neg amphetmn neg mthdone neg am ctropnt am ck mb am alt sgpt ast sgot ck cpk alk phos amylase tot bili am phenytoin brief hospital course neurologic patient was initially admitted to the neuro intensive care unit for close observation considerations for patient s etiology of mental status change were multiple and included seizure hypertensive encephalopathy metabolic infectious toxic medication substance withdrawl stroke a head ct scan did not demonstrate evidence of bleed or evolving infarct mri was negative for infarct but showed extensive small vessel disease presumably from poorly controlled hypertension as seizure was high on the differential patient had bedside eeg monitoring which showed moderate enceohpalopathy on and on a second seizure was witnessed and captured with eeg showing no epileptiform acitivity and relatively normal background in the emergency room he received grams of iv phenytoin in addition to total of mg iv lorazepam in ed and was continued on dilantin then increased to lfts were slightly elevated on but normal on and again very mildly elevated ammonia level was withing normal limits and then repeated for continued encephalopathy but continued to be normal tsh was normal csf studies were sent to r o cns infection and patient had normal results with no growth and negative hsv pcr a second set of mri cts was obtained to make sure that patient had not developed any interval neurological process that could be affecting his mental status and these studies were normal the pateint s delerium began to clear some after he was placed in a windowside bed and forced into a more regular day night sleep schedule with daytime stimulation cardiac wise he was followed on telemetry no arythmia noted hypertension was previously poorly controlled at home on lisinopril catapress amlodipine and hydralazine lisinopril was increased from to amlodipine continued at daily hydralazine continued at q hrs catapress increased from to lopressor was started and eventually titrated up to mg tid cardiac enzymes were negative at admission pulmonary patient self extubated and tolerated well endocrine patient s home doses of nph insulin initially held as he was intubated and not receiving nutrition was maintained on a regular insulin sliding scale when tube feeds started he had home dose of nph qam qpm restarted nph titrated up as patient s blood sugars continued to be elevated consult called and patient was started on lantus with humalogue sliding scale renal has history of chronic renal insufficiency creatinine was on admission and corrected to baseline level of within hours the patient was found to be retaining urine during the admission he was catheterized at discharge he was being treated for a uti and foley was discharged he will need a post void residual checked after transfer to assure that he is not retaining urine should he become aggitated or in pain urinary retention needs to be ruled out inectious disease cxr was negative for pneumonia ua was negative but urine cultures grew beta strep was started on bactrim initially and then changed to clindamycin based on sensitivities stool studies showed no cdiff csf studies also sent and negative cultures and hsv pcr he had one uti treated with ciprofolxacin and then a second uti developed before discharge he was started on cipro and vanc to which the organisms were sensitive gi lfts slightly elevated then normal again mildly elevated with ast less elevated than prior but lipase again similarly elevated with no clear reason patient s abnominal exam at this time normal with no tenderness and normal bowel sounds patient had normal bowel movements and no diarrhea or tube feeding residuals then passed swallow eval and started diabetic diet fen was hypernatremic so replenishing free water deficit of l plus insensible losses with cc hr of d ns for total of l prophyllactically received sc heparin pneumoboots ppi medications on admission per recent discharge summary clonidine mg hr weekly aspirin mg po daily omeprazole mg po once a day lisinopril mg po daily amlodipine mg po daily insulin nph insulin units in the morning units qhs atorvastatin mg po daily oxycodone acetaminophen mg po q h as needed pilocarpine hcl drops one drop ophthalmic q h dorzolamide timolol one drop ophthalmic daily latanoprost drops one drop ophthalmic hs hydralazine mg po q h isosorbide dinitrate mg po tid discharge disposition extended care facility discharge diagnosis hypertensive encephalopathy discharge condition good patient becoming more oriented daily discharge instructions follow up as below do not drink or use drugs take medications as directed rehab please note that the patient has history of urinary retention please check a post void residual tonight to assure that the patient is not retaining if in the future there is aggitation or pain please consider that he may be retaining urine please also place the patient in a window adjacent bed his delerium seems to improve significantly if he is forced into a regular wake sleep schedule by daytime stimulation followup instructions after discharge from rehabiliation please call your m to arrange neurologist provider md phone date time of building provider m d phone date time [NEW_RECORD] admission date discharge date date of birth sex m service urology allergies codeine codeine anhyd ambien attending chief complaint bph major surgical or invasive procedure turp history of present illness m with multiple medical problems and bph past medical history vascular dementia htn cva diabetes dvt late s p filter ckd baseline cr around peripheral neuropathy glaucoma with legal blindness skin grafts on b ue burns from automobile fire in hepatitis b and c anemia baseline hct history of alcohol and cocaine use a history of osteomyelitis left hip replacement joint infection erectile dysfunction social history currently lives with his wife who is the primary care taker previously was a construction worker retired years ago daughter lives nearby he was a smoker pack year quit years ago in the past h o etoh and cocaine abuse no etoh use since no cocaine use since family history non contributory physical exam avss nad abd soft nt nd pertinent results pm glucose urea n creat sodium potassium chloride total co anion gap pm wbc rbc hgb hct mcv mch mchc rdw brief hospital course patient underwent a bipolar turp on please see operative report for further details he was extubated in the or but then reintubated due to tachypnea and poor respiratory effort he was transferred to the icu for overnight monitoring icu course he was transferred to the icu following reported respiratory distress following an elective turp requiring reintubation while in the icu his home anti hypertensives other than lisinopril were restarted no anticoagulants were given due to concern of questionable prolonged pr interval on tele lead ekg was done which was slightly concerning for a questionable st elevation in v v cardio fellow was contact who felt it was most likely repolarization and was not concerned appears old compared to ekg from he had cath in which showed normal coronaries the next day of icu stay he was extubated and we restarted lantus lasix lisinopril and called out to urology the cbi was clamped at am on pod and clear urine was noted inthe foley line without clots the foley was removed and he was voiding without difficulty and his pain was well controlled he was tolerating a regular diet at discharge patient s pain well controlled with oral pain medications tolerating regular diet ambulating without assistance and voiding without difficulty he is given explicit instructions to call dr for follow up medications on admission amlodipine mg tablet sig two tablet po daily daily atorvastatin mg tablet sig one tablet po once a day clonidine mg hr patch weekly sig one patch weekly transdermal qfri every friday donepezil mg tablet sig one tablet po once a day isosorbide dinitrate mg tablet sig one tablet po tid times a day lisinopril mg tablet sig one tablet po daily daily aspirin mg tablet chewable sig one tablet chewable po daily daily cyanocobalamin vitamin b mcg tablet sig two tablet po daily daily pilocarpine hcl drops sig one drop ophthalmic q h every hours docusate sodium mg capsule sig one capsule po bid times a day nitroglycerin mg tablet sublingual sig one sublingual as directed every minutes up to times for chest pain call if chest pain continues insulin glargine unit ml solution sig units subcutaneous at bedtime insulin lispro unit ml cartridge sig as directed subcutaneous as directed please use as previously prescribed lumigan drops sig one drops ophthalmic as directed drop both eyes at bedtime clotrimazole betamethasone cream sig one cream topical as directed apply to affected areas twice a day cosopt drops sig one ophthalmic as directed drop both eyes three times a day terbinafine cream sig as directed topical apply to affected area twice a day hydralazine mg tablet sig three tablet po three times a day lasix mg daily discharge medications acetaminophen mg tablet sig two tablet po q h every hours as needed for fever pain dorzolamide timolol drops sig one drop ophthalmic tid times a day donepezil mg tablet sig one tablet po hs at bedtime pilocarpine hcl drops sig one drop ophthalmic q h every hours docusate sodium mg capsule sig one capsule po bid times a day hydralazine mg tablet sig two tablet po tid times a day amlodipine mg tablet sig two tablet po daily daily latanoprost drops sig one drop ophthalmic hs at bedtime isosorbide dinitrate mg tablet sig one tablet po tid times a day atorvastatin mg tablet sig one tablet po daily daily oxycodone mg tablet sig tablet po every hours as needed for pain disp tablet s refills lisinopril mg tablet sig one tablet po daily daily furosemide mg tablet sig one tablet po daily daily discharge disposition home with service facility homecare discharge diagnosis bph discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions no vigorous physical activity for weeks expect to see occasional blood in your urine and to experience urgency and frequecy over the next month tylenol should be your first line pain medication a narcotic pain medication has been prescribed for breakthough pain replace tylenol with narcotic pain medication max daily tylenol dose is gm note that narcotic pain medication also contains tylenol acetaminophen do not drive or drink alcohol while taking narcotics colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication discontinue if loose stool or diarrhea develops resume all of your home medications except for aspirin resume aspirin on monday resume all of your home medications but please avoid aspirin advil for one week if you have fevers f vomiting severe abdominal pain or inability to urinate call your doctor or go to the nearest emergency room followup instructions call dr office for follow up and if you have any questions page dr at completed by [NEW_RECORD] name l unit no admission date discharge date date of birth sex m service neurology allergies codeine codeine anhydrous ambien attending addendum added pyridium mg tid for days for bladder pain from uti pertinent results am urine blood mod nitrite neg protein glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg am alt sgpt ast sgot ck cpk alk phos amylase tot bili am glucose lactate na k cl tco am wbc rbc hgb hct mcv mch mchc rdw wbc csf ul performed at west stat lab rbc csf ul clear and colorless performed at west stat lab polys cell differential performed at west stat lab lymphs monocytes hsv pcr negative rpr negative mri brain many of the images are degraded by patient motion within this limitation there appears to be redemonstration of the high t signal largely within the periventricular white matter of both cerebral hemispheres as well as within the pons these abnormalities have been previously characterized as chronic small vessel infarcts there does not appear to be any new major vascular territorial infarct identified including no abnormal signal on the diffusion weighted scans the high resolution imaging of the hippocampal regions does not demonstrate overt hippocampal asymmetry or abnormal signal in this locale within the limits of the motion degraded contrast enhanced scans no definite pathological enhancement in the brain is appreciated eeg this hour eeg telemetry captured one pushbutton activation for unclear symptoms there was no electrographic change on eeg seen in association with this activation no electrographic seizures or interictal epileptiform discharges were seen although much of the recording was contaminated by electrode artifact the background did reach a normal alpha frequency maximum discharge disposition extended care facility md completed by [NEW_RECORD] name l unit no admission date discharge date date of birth sex m service neurology allergies codeine codeine anhydrous ambien attending addendum see portions below chief complaint aggitation hypertensive to sbp in setting of hypertension refusal to take po major surgical or invasive procedure no new surgical invasive procedure see attatched d c summary for invasive procedures of initial admission history of present illness the patient is a yo man dm htn extensive small vessel disease blind cri neuropathy who is sent back from rehab to which he was discharged earlier today reason was that he seemed confused and punched staff as well as for sbp of upon his prior admission he was found in bed thrashing around he was brought to the ed where ativan did not resolve his symptoms and was loaded on pht considerations for patient s etiology of mental status change were multiple and included seizure sec generalized hypertensive encephalopathy metabolic infectious toxic medication substance withdrawl stroke a head ct scan did not demonstrate evidence of bleed or evolving infarct mrix was negative for infarct but showed extensive small vessel disease presumably from poorly controlled hypertension there were no interval changes bedside eeg monitoring showed moderate enceohpalopathy on and whereas on a second seizure was witnessed and captured with eeg showing no epileptiform acitivity and relatively normal background lfts were slightly elevated ammonia level was within normal limits tsh was normal csf profile was normal with no growth and negative hsv pcr the patient s delerium began to clear some after he was placed in a windowside bed and forced into a more regular day night sleep schedule with daytime stimulation he was somewhat agitated after his foley was d c ed prior to d c but calmed down later after transfer to rehab he apparently was confused and combatative tried to punch staff and apparently seeing things in his room rehab staff though one picc in one arm would not be sufficient for access especially as he refused to take meds their note says that they will accept pt with better bp control spb was while agitated after return back to the floor the pt was directed to without permission from ed attending sent up via ed triage nurses without notification of the team on the floor the first thing the pt mentions is that he is terrified ros denies pain detailed ros not possible past medical history hypertension diabetes mellitus on insulin insulin regimen nph q am ss with hga c chronic renal failure baseline creatinine peripheral neuropathy glaucoma hepatitis b sag neg sab cab hepatitis c hcv vl k genotype ib anemia baseline hct h o chest pain no cad on angiography substance abuse none since h o osteomyelitis h o back pain legally blind h o ppd conversion erectile dysfunction h o mva with extensive injuries requiring skin graft social history discharge summary social history signed pm social history is significant for the absence of current tobacco use quit in packs week for yrs there is no h o of alcohol abuse no ivdu although crack abuse till s patient is married with children lives with wife retired family history no cad in family h o cancer physical exam vitals t hr bp rr so ra gen nad heent mmm neck no lad no carotid bruits limited rom no brudz lungs clear to auscultation bilaterally heart regular rate and rhythm normal s and s abdomen normal bowel sounds soft nontender nondistended extremities multiple skin scars from grafts mental status awake and alert able to say name age does not know where he is able to follow simple midline and appendicular commands cranial nerves ii poor vision pupils pinpoint iii iv vi extraocular movements intact when asking him to move to r and l no ptosis v facial sensation intact to light touch vii facial movement symmetrical viii hearing intact to voice ix palate elevates in midline xii tongue protrudes in midline sternocleidomastoid and trapezius normal bilaterally motor system normal bulk rigidity in both ue tone increased in both le mild tremor in ue able to hold arms and legs antigravity rather symmetrically reflexes b t br pa pl right left toes mute bilaterally sensory system intact to lt in all s coordination no dysmetria per observation gait deferred pertinent results pm urine color yellow appear clear sp pm urine blood tr nitrite neg protein glucose neg ketone neg bilirub neg urobiln neg ph leuks mod pm urine blood tr nitrite neg protein glucose neg ketone neg bilirub neg urobiln neg ph leuks mod 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 calcium phos mg pm urine source catheter final report urine culture final enterococcus sp organisms ml escherichia coli organisms ml presumptive identification trimethoprim sulfa sensitivity testing confirmed by sensitivities mic expressed in mcg ml enterococcus sp escherichia coli ampicillin s s ampicillin sulbactam s cefazolin s cefepime s ceftazidime s ceftriaxone s cefuroxime s ciprofloxacin s gentamicin s imipenem s meropenem s nitrofurantoin s s piperacillin s piperacillin tazo s tetracycline r tobramycin s trimethoprim sulfa s vancomycin s pm urine source catheter final report urine culture final no growth brief hospital course addendum to patient s return from rehab see attatched d c summary for course from neuro the patient returned from rehab within several hours of discharge with report that he had been aggitated and combative hypertensive to sbp and refusing to take po medications on arrival he reported that he was terrified and thought that he was going to die there he had a non focal neurological exam that continued to show some delerium but no acute changes from discharge he was able to be re oriented and was soon normotensive and again agreeing to take po he did not at any time during this re admission require sedation restraints or bed side sitter he has continued to show some mild to moderate encephalopathy with a waxing pattern but this continues to clear slowly his sleep pattern continues to be very disrupted despite great efforts to normalize him by getting him out of bed every morning and trying to stimulate him currently he is oriented to hospital and but continues to be confused and perseverative otherwise this is an improvement from re admission at which time he was more disoriented to the extent that he did not know where he was for further work up he had an abg which was relatively normal crp which was and esr which is pending a serum tox screen was negative he also had a repeat ua on readmission which showed continued uti the uti is being treated and the urine culture was negative as he has not had any events strongly suggestive for seizure and has had multiple eegs without any epileptiform activity his keppra was discontinued completely had previously been tapering down and was down to cvs mr reported some chest pain on sunday he was unable to give a clear description an was answering yes to pain in all other areas of his body as well he was unsure if he had any symptomatic sob or chest pressure but his vital signs were stable a stat ekg was unchanged from recent ekgs and serial ck troponins were negative x he did not experience any further chest pain this admission his hypertension was mostly well controlled with one sbp of on on monday his hydralazine was changed from iv to po equivalenr of po q hrs and on his losartan was increased from to daily resp no respiratory issues this admission gi no gi issues this admission mr has been taking adequate pos this admission but does require assistance with meals as he is legally blind he has been taking all medications po and has not required any ng at any time this re admission his previously elevated lfts and amylase lipase have normalized and he has been continued on lantoprazole for gi prophylaxis id mr was transferred on vancomycin and ciprofloxacin for enterobacter and e coli growing in a urine culture on re admission his ua was positive but the urine culture has not grown anything to date based on the previous positive urine culture he was switched from vanc cipro to ampicillin gm iv q to which the enterobacter and ecoli were sensitive he will finish his last day of ampicillin on in pm which will complete a seven day course for the uti mr has been afebrile and has a normal white count there are no other id issues endo mr has dm and was re admitted on lantus units qhs along with insulin sliding scale this was modified on by the diabetes consult service who increased is suppertime insulin coverage on the sliding scale on he had a low am sugar of and his lantus was decreased from to based on recs this may require further titration as his diet and po intake vary renal mr suffers from chronic renal insufficiency and it is unclear what his prior baseline creatinine was his initial admission creatinine was and he has corrected to a current creatinine of he has had no other renal issues this admission urology the patient had urinary retention on in the setting of a uti that was mid treatment he currently has a foley in place which should be disctontinued tomorrow evening when he has completed his day course of ampicillin heme mr has had some anemia this admission with a hct ranging his hct was within this same range on an admission last year guiacs were performed and were negative iron studies did not show iron defficiency anemia but his mcv was borderline elevated which could be secondary to his history of etoh abuse ppx mr received ativan per ciwa for prophylaxis against etoh withdrawl during the first week of admission but he did not require any ativan after that he has received lantoprazole for gi prophylaxis he is also on heparin sc for dvt prophylaxis he received a coures of dilantin and then keppra for seizure prophylaxis but this was discontinued after serial negative eegs and no events medications on admission acetaminophen mg pr q h prn pain insulin sc per insulin flowsheet amlodipine mg po ng daily hold for sbp hr latanoprost ophth soln drop both eyes hs aspirin mg po ng daily lansoprazole oral disintegrating tab mg po ng bisacodyl mg po pr prn until stools levetiracetam mg po ng ciprofloxacin hcl mg po q h lisinopril mg po ng daily hold for sbp clonidine tts patch ptch td qsat losartan potassium mg po daily hold for sbp cyanocobalamin mcg po daily magnesium sulfate gm ml sw iv prn value dextrose gm iv prn blood sugar metoprolol mg po ng tid hold for sbp hr dorzolamide timolol ophth drop both eyes daily nystatin oral suspension ml po qid prn thrush enalaprilat mg iv q hours prn sbp phenazopyridine hcl mg po tid duration days folic acid mg po daily pilocarpine drop both eyes q h heparin unit sc tid thiamine hcl mg po ng daily hydralazine mg iv q h hold for sbp vancomycin mg iv q h discharge medications latanoprost drops one drop ophthalmic hs at bedtime clonidine mg hr patch weekly one patch weekly transdermal qsat every saturday dorzolamide timolol drops one drop ophthalmic daily daily heparin porcine unit ml solution one injection tid times a day pilocarpine hcl drops one drop ophthalmic q h every hours bisacodyl mg tablet delayed release e c two tablet delayed release e c po bid times a day as needed acetaminophen mg suppository one suppository rectal q h every to hours as needed for pain folic acid mg tablet one tablet po daily daily aspirin mg tablet one tablet po daily daily thiamine hcl mg tablet one tablet po daily daily metoprolol tartrate mg tablet three tablet po tid times a day lisinopril mg tablet two tablet po daily daily amlodipine mg tablet two tablet po daily daily lansoprazole mg tablet rapid dissolve dr one tablet rapid dissolve dr po bid times a day losartan mg tablet two tablet po daily daily hold for sbp disp tablet s refills cyanocobalamin mcg tablet two tablet po daily daily nystatin unit ml suspension five ml po qid times a day as needed for thrush insulin glargine unit ml solution seven units subcutaneous at bedtime to be titrated based on his daily sugars insulin regular human unit ml solution one units per sliding scale injection four times a day per insulin sliding scare with qid accuchecks enalaprilat mg ml injectable one intravenous q hours prn as needed for sbp dextrose in water d w syringe one intravenous prn as needed as needed for blood sugar hydralazine mg tablet three tablet po every six hours hold for sbp ampicillin sodium g piggyback one intravenous every twelve hours for days last dose to be pm to complete day antibiotic course for ecoli and enterobacter in urine both amp sensitive discharge disposition extended care facility discharge diagnosis hypertensive encephalopathy discharge condition good patient becoming more oriented daily discharge instructions follow up as below do not drink or use drugs take medications as directed for please note that the patient is legally blind and can get disoriented when moved he may require re orienting and reassurance multiple times his delerium and level of alertness waxes and wanes he is most often very somnolent in the early morning and he is typically more aggitated or confused in the afternoons in the last days here he has not required any sedation restraint or sitter he is usually easily comforted and re oriented he has also transiently refused po intake for short periods hr but is usually amenable to taking po later if re approached gently please note that the patient has history of urinary retention if in the future there is aggitation or non specific pain please consider that he may be retaining urine and check a post void residual please also place the patient in a window adjacent bed his delerium seems to improve significantly if he is forced into a regular wake sleep schedule by daytime stimulation he has a disordered wake sleep schedule at baseline per wife and maintaining a normal sleep wake cycle in house has been difficult but has led to sifnigicant improvement followup instructions after discharge from rehabiliation please call your pcp m to arrange follow up he is aware of your hospital course to date neurologist provider md phone date time of building provider m d phone date time md completed by [NEW_RECORD] name l unit no admission date discharge date date of birth sex m service urology allergies codeine codeine anhyd ambien attending addendum prior to d c rn voiced concern that patient did not seem at usual baseline activity level versus preop pt was asked to evaluate the patient and felt he was not in fact returned to baseline he was kept in house overnight for repeat eval session with pt after which he was deemed fit for d c home with vna and home physical therapy to further rehabilitate him otherwise he spent an unremarkable night without events complaints fever or other symptoms at time of d c voiding pain controlled tolerating usual diet will f u with dr and clinic and vna pt at home as above discharge disposition home with service facility homecare md completed by,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""m"", ""service history of present illness"", ""patient is a year old"", ""African American male"", ""history of insulin dependent diabetes"", ""hypertension"", ""hepatitis B"", ""dehydration"", ""hyperglycemia"", ""hyperkalemia"", ""nausea"", ""vomiting"", ""diarrhea"", ""nonproductive cough""],
""Medications"": [""kayexalate"", ""sodium bicarbonate"", ""insulin drip"", ""calcium gluconate"", ""intravenous fluid""]
}"
13812,admission date discharge date service micu green history of present illness the patient is an year old female with recent admission to with right empyema treated by chest tube and thrombolytic therapy to pleural space subsequently transferred to rehab on for a cardiac rehab after empyema therapy and diuresis for congestive heart failure community acquired pneumonia with ceftriaxone and azithromycin of note during admission had four units of packed red blood cells transfused while on heparin per report this was a retroperitoneal bleed although we do not have paperwork documenting this today at rehab the patient had melanotic stools times two and inr of and was given fresh frozen platelets and subcutaneous vitamin k nasogastric lavage showed scant coffee grounds the patient was hemodynamically stable and transferred to past medical history rheumatic heart disease with mitral stenosis cm squared valve area increased left atrial size diastolic dysfunction chronic obstructive pulmonary disease pulmonary hypertension atrial fibrillation degenerative joint disease tah bso myelodysplastic syndrome with anemia on erythropoietin macular degeneration current medications piperacillin tazobactam social history retired electrolysis teacher widow of years no children she quit tobacco years ago after a thirty five pack year smoking history family is quite involved health care proxy is dr grand niece s husband next of is brother physical examination temperature blood pressure pulse respiratory rate oxygen saturation on liters nasal cannula pupils sluggish conjunctiva and sclera normal mucous membranes are moist head normocephalic atraumatic neck supple kyphosis noted no cervical lymphadenopathy point of maximal impulse of heart palpated clear s distant s no gallops systolic murmur out of no friction rub respirations symmetric with normal effort bronchial breath sounds in bases as well as fine crackles no pleural rub abdomen obese with normal bowel sounds soft to palpation no tympany no masses liver and spleen within normal limits radial pulses without clubbing or cyanosis and normal capillary refill skin warm and dry oriented to person place and time responding to verbal stimuli attentive unable to stand normal motor tone with diffuse decrease in strength laboratory data sodium potassium chloride bicarbonate bun creatinine glucose inr ptt white blood cell count hematocrit platelets hospital course the patient had a gastrointestinal bleed in the setting of warfarin anticoagulation for atrial fibrillation warfarin was held the patient was given vitamin k and fresh frozen platelets at the outside institution she was given b i d protonix gi was consulted and felt clinical picture was supportive of upper gi or right colonic bleed in the setting of coagulopathy recommended continued correction of coagulopathy and hemodynamic support with proton pump inhibitor no esophagogastroduodenoscopy or colonoscopy as the patient was clinically unstable the patient was continued on her cardiac medications and nebulizers at p m on the patient became increasingly lethargic and had a blood gas with a ph of pco po on shovel mask the patient was started on noninvasive positive pressure ventilation with partial improvement in respiratory acidosis and hypoxia diuresis was performed with intravenous furosemide with sluggish response despite this therapy the patient was felt to be in a situation where endotracheal intubation would be required to maintain her respiratory status the health care proxy dr and the patient s brother were contact and both affirmed that the patient wished to avoid mechanical ventilatory support defibrillation and cardiopulmonary resuscitation after appropriate time to allow the patient s family to consult with the patient was maintained on noninvasive positive pressure ventilation the health care proxy affirmed the wishes of the family that the patient would not want further invasive measures and the patient s status was changed to comfort measures only at a m on sentinel ativan and an intravenous morphine sulfate drip were given for comfort noninvasive positive pressure ventilation was discontinued the patient expired secondary to respiratory arrest at a m condition on discharge expired discharge diagnoses respiratory arrest gastrointestinal bleed family notified post mortem examination declined by brother medical examiner notification m d dictated by medquist d t job,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""service"", ""micu"", ""green"", ""history of present illness"", ""community acquired pneumonia"", ""ceftriaxone"", ""azithromycin"", ""retroperitoneal bleed"", ""melanotic stools"", ""inr"", ""fresh frozen platelets"", ""subcutaneous vitamin k"", ""nasogastric lavage"", ""scant coffee grounds""],
""Medications"": [""packed red blood cells"", ""heparin"", ""fresh frozen platelets"", ""subcutaneous vitamin k"", ""piperacillin"", ""tazobactam""]
}"
76477,admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint elective admission for tracheal stent major surgical or invasive procedure pericardiocentesis pulmonary stenting history of present illness mr is a yom with h o hyperlipidemia s p pacemaker hep c to ivdu yrs prior and untreated h o ptx alcohol abuse and smoking p w sclca s p cycles etop cisplatin large mediastinal masses with critical obstruction to the lul who was admitted for elective stent placement and is being transferred to the ccu for pericardial effusion with early tamponade physiology per the outside report he had progressive cough and voice changes over the past few months and reports trouble with both solids and liquids he has had weight loss of approximately lbs during this time as well biopsy of his left upper lung mass was consistent with small cell lung cancer in ct brain with contrast was negative for mets pet scan showed b l subcarinal nodes but no more distant disease he was recently noted to have very bulky with lul collapse and partial occlusion of the left pulmonary artery patient presented for direct admit for stent placement but ct scan showed pericardial effusion and pulsus was reportedly measured on the floor to be cardiology fellow was called for evaluation bedside echo showed rv collapse with signs of tamponade transfer to ccu for monitoring with plan for pericardiocentesis in am on review of systems s 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 s he denies recent fevers chills or rigors s 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 chest pain dyspnea on exertion paroxysmal nocturnal dyspnea orthopnea ankle edema palpitations syncope or presyncope past medical history sclc sclca diagnosed had etoposide carboplatin with th cycle given good tolerance and rt done showed regression in most areas reduction in mass persistent subtotal central occlusion of lul bronchus reduction in constriction of pulmonary artery to the lul and reduction in central adenopathy reexpansion of lul last chemo pet showed reduction in all areas no new areas hemoptysis of teaspoon cc brb ct scan noted for new infiltrate showing encasement of artery to lul and subtotal occlusion of the bronchus to the lul smoking was continued at this point ppd bronchoscopy by dr was suspiciuous for tumor continued worsening of hoarseness paroxysmal cough left anterior chest dsicomfort increased dyspnea no other pain or headache no addtional bleed ct increasing central adenopathy narrowing of left mainstem bronchus to of the right bronchus complete obliteration of the lul bronchus with collapse of lul with compromise of left pulmonary artery bronchus to lll lingular were compromised started on etoposide and carboplatin cycles progressive disease noted has a pericardial effusion continued to be symptomatic dyspnea no dysphagia continued anorexia presented for paliative treatment hyperlipidemia pacemaker h o hep c untreated ivdu yrs ago spontaneous ptx cigarette addiction significant alcohol intake tendon repair th finger on the right hand social history drinks daily smoke ppd or more till started a nicotine patch married to working hr days family history father died in s emphysema mother dies in s natural causes sister yrs sister yrs has two grown children physical exam vs t bp hr rr o sat ra pulsus general nad oriented x depressed mood 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 chest device in place in l upper chest cardiac muffled heart sounds rr normal s s no m r g no thrills lifts no s or s lungs diffuse expiratory rhonchi with decreased bs at l apex abdomen soft ntnd no hsm or tenderness extremities trace pitting edema b l skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid femoral popliteal dp pt left carotid femoral popliteal dp pt 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 alt ast ld ldh alkphos totbili pm blood albumin calcium phos mg 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 alt ast alkphos totbili am blood calcium phos mg studies portable tte focused views done at pm conclusions overall left ventricular systolic function is normal lvef the right ventricular cavity is unusually small with normal free wall contractility the mitral valve leaflets are mildly thickened there is a moderate to large sized pericardial effusion no right ventricular diastolic collapse is seen there is brief right atrial diastolic collapse impression moderate to large pericardial effusion located mostly at the lv apex and lv inferolateral wall there is relatively little fluid overlying the right ventricular free wall apical approach to pericardiocentesis likely better no frank echo evidence of tamponade although both ventricles are small and patient is tachycardic cardiac cath study date of final diagnosis successful pericardiocentesis with cc of serosanguinous fluid removed with access obtained under echocardiographic guidance and pericardial drainage bag secured and sutured into position refer to comments section monitor drainage with plan for removal of drain in hours chest portable ap study date of pm findings the patient is intubated the tip of the endotracheal tube projects cm above the carina massive volume loss in the left lung due to fibrosis and consolidations subsequent elevation of the left hemidiaphragm a central airway stent is visible no pathological changes in the right lung portable tte focused views done at pm conclusions overall left ventricular systolic function is normal lvef right ventricular chamber size and free wall motion are normal there is no pericardial effusion there are no echocardiographic signs of tamponade impression prior to tap moderate to large circumferential pericardial effusion is seen post tap there is minimal fluid with normal biventricular function brief hospital course yo m with metastatic sclc admitted for tracheal stent placement found to have pericardial effusion with concern for early tamponade physiology on tte hemodynamically stable now pericardial effusion he presented with reported shortness of breath he had a pulsus paradoxus of he had questionable tamponade physiology on echo he was hemodynamically stable however needed to drain the effusion prior to bronchial stenting in the ccu his pulsus was less than ten he was taken to the cath lab on and had cc s a drain was kept overnight with drainage overnight after multiple hours of no output the drain was pulled a post procedure echo showed minimal effusion and echo the following day showed minimal increase from post procedure after minimal output from the drain his pulsus remained less than ten after the procedure small cell lung ca he is undergoing palliative measures as an outpatient he was admitted for elective tracheal stenting after pericardiocentesis he was taken for bronchial stenting they did not observe there to be any purulence posterior to the obstruction however there was extensive invasion and necrosis from tumor including into the he was very sedated after the procedure and required intubation overnight for airway protection post procedurally there were minimal secretions suctioned the morning after the procedure he was extubated successfully he was well oxygenated sats in the high s throughout his stay transaminitis be chronic untreated hcv infection given concomitant elevated inr and low albumin also possibly a component of alcoholic cirrhosis hepatitis though ast not significantly more elevated than alt metastatic disease also on the differential unclear etiology while an inpatient and could be worked up as an outpatient leukocytosis wbc elevated with left shift his wbcs increased post procedurally to treatment was started with levaquin for postobstructive pneumonia his wbcs trended down to at discharge follow up mr has a few pending labs that will need to be followed up by his primary care physician or service and faxed to his pcp blood cultures no growth to date respiratory culture no growth to date broncoalveolar lavage fluid cultures no growth to date medications on admission megace es mg prn atenolol mg qd aspirin prn mucinex mg prn guaiatussin ac prn discharge disposition home with service facility angels visiting nurse discharge diagnosis primary left main bronchus obstruction small cell lung cancer pericardial effusion secondary hld alcoholism hepatitis c discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions mr it was a pleasure taking part in your care you were admitted to have a procedure called a pulmonary stenting this was to open the airway to your left lung on admission you were found to have fluid surrounding your heart which was causing mild shortness of breath you had a procedure called a pericardiocentesis the cardiologists drained the fluid from around your heart and the pulmonologists took you for the stenting you tolerated the procedure well you required intubation a breathing tube overnight to help you rest and breath you were extubated the following day and did very well on discharge you were doing well and your breathing was improved however you may need oxygen at home to help you breathe better a visiting nursing service will evaluate you for this at home you should continue to take antibiotics for a total day course for what we believe may be a pneumonia we have made the following changes to your medications start levofloxacin mg daily until stop atenolol and aspirin until advised to restart by your physicians start percocet at night as needed for pain it is important that you do not drive while taking a sedating medication like this please use a different over the counter pain reliever if followup instructions please call to schedule follow up with your primary care doctor you will be contact by interventional pulmonology for outpatient follow up in the next weeks please call your oncologist for follow up completed by [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint hemoptysis major surgical or invasive procedure ir angiogram with stent placement rigid bronchoscopy history of present illness yo male diagnosed with small cell lung cancer s p chemo and radiation therapy with increasing tumor burden and left main obstruction s p left mainstem stent placement presenting today with submassive hemoptysis patient was recently admitted for elective rigid bronchocscopy found to have pulsus and had pericardiocentesis for pericardial effusion with tamponade patient then had left main stem stent placed via ip and discharged on per wife patient was doing well following discharge today just after eating breakfast patient s wife who is providing history heard patient coughing in kitchen wife then found patient had coughed up bright red blood covering plate with coffee mug half filled with blood patient then asked wife to call patient had some lightheadedness no syncope no other symptoms patient was then transferred to osh where patient received cc ns at osh and tylenol for headache and was then transferred to ed given recent history in the ed vitals were l nc he felt well although continues to cough teaspoons to tablespoons of bright red blood and clots he denied dyspnea fever chills or chest pain at baseline on liters supplemental o requirements unchanged patient went to the or from ed for rigid bronchoscopy and cauterization with apc in or patient received lr cc propofol midazolam mg fentanyl mcg phenylephrine and rocuronium bronch showed left main stem medial wall is completely eroded unclear if changed from prior bronch lll patent but with tumor burden distal to stent lul remains collapsed fresh clot was noted at carina no signs of active hemorrhage patient was then transferred to icu for further management and angiography possible embolization vs vascular stent patient arrived in icu inubated and sedated history provided by wife past medical history sclc sclca diagnosed had etoposide carboplatin with th cycle given good tolerance and rt done showed regression in most areas reduction in mass persistent subtotal central occlusion of lul bronchus reduction in constriction of pulmonary artery to the lul and reduction in central adenopathy reexpansion of lul last chemo pet showed reduction in all areas no new areas hemoptysis of teaspoon cc brb ct scan noted for new infiltrate showing encasement of artery to lul and subtotal occlusion of the bronchus to the lul smoking was continued at this point ppd bronchoscopy by dr was suspiciuous for tumor continued worsening of hoarseness paroxysmal cough left anterior chest dsicomfort increased dyspnea no other pain or headache no addtional bleed ct increasing central adenopathy narrowing of left mainstem bronchus to of the right bronchus complete obliteration of the lul bronchus with collapse of lul with compromise of left pulmonary artery bronchus to lll lingular were compromised started on etoposide and carboplatin cycles progressive disease noted has a pericardial effusion continued to be symptomatic dyspnea no dysphagia continued anorexia presented for paliative treatment hyperlipidemia pacemaker h o hep c untreated ivdu yrs ago spontaneous ptx cigarette addiction significant alcohol intake tendon repair th finger on the right hand social history drinks daily smoke ppd or more till started a nicotine patch married to working hr days family history father died in s emphysema mother dies in s natural causes sister yrs sister yrs has two grown children physical exam gen comfortable nad intubated and sedated heent perrl eomi anicteric mmm op without lesions no supraclavicular or cervical lymphadenopathy no jvd no carotid bruits no thyromegaly or thyroid nodules resp cta b l dimished breath sounds in left axillae 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 skin no rashes no jaundice no splinters neuro pupils mm minimally responsive to light but react equally pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap cxr there is an endotracheal tube whose distal tip is cm above the carina a left sided tracheal stent is again seen and without complications pacemaker wires are seen there is again seen volume loss on the left with increased density within the left upper lobe this is unchanged the right lung is clear no pneumothoraces are present no pneumomediastinum is identified overall there has been no change brief hospital course mr is a yom with hld hcv ivdu sclc complicated by left main stem obstruction and recent pericardial tamponade presenting with hemoptysis now s p ir stending of pa hemoptysis patient admitted intubated he underwent rigid bronchoscopy with no intervention performed as well as ir angiogram with placement on the first night of admission hct stable s p ir stenting of pa per discussion with ip and ir no further interventions possible at this time if patient rebleeds discussed overal situation with patient confirmed dnr dni status prior to discharge sclc scheduled for outpatient onc visit on with intent to begin palliative chemotherapy on post obstructive pneumonia patient had been discharged on course of levofloxacin for days completed yesterday no evidence of excessive sputum production on on code dnr dni medications on admission guiatuss ac mg ml liquid sig ten ml po prn cough levofloxacin mg tablet sig one tablet po q h days mucinex mg tablet sustained release q h prn cough megace es mg ml suspension sig five ml po tid with meals hydrocodone acetaminophen mg tablet sig tablets po qhs prn colace mg capsule sig one capsule po bid prn constipation home oxygen liters continuously pulse dose system discharge medications nicotine mg hr patch hr sig one patch transdermal once a day disp patches refills benzonatate mg capsule sig one capsule po three times a day disp capsule s refills tylenol codeine mg tablet sig one tablet po every six hours for days disp tablet s refills discharge disposition home with service facility angels at home discharge diagnosis primary small cell lung cancer hemoptysis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were transferred to due to an episode were your coughed up blood after being evaluated at another hospital you underwent a rigid bronchoscopy with stenting of your left pulmonary artery procedure where a camera takes a look into your lungs you completed a course of antibiotics for a pneumonia you have had no further episodes of coughing up blood you need to stop smoking given your oxygen at home and your bleeding risk please follow up closely with your previously scheduled appointments with your oncologist and pcp this week you need to stop smoking please discuss this with your primary doctor medication changes added nicotine patch to be applied to the skin daily added benzonatate to be taken for cough tylenol with codeine to be given for cough followup instructions please follow up with your oncologist and primary care doctor you stated you already had appointments with them this upcoming week your pcp is phone number,"{
""Diagnoses"": [""admission for tracheal stent"", ""major surgical or invasive procedure"", ""pericardiocentesis"", ""pulmonary stenting"", ""history of present illness"", ""MR is a YOM with HO hyperlipidemia"", ""SP pacemaker"", ""Hep C"", ""IVDU years prior and untreated"", ""HO PTX"", ""alcohol abuse and smoking"", ""PWS"", ""cycles"", ""etop"", ""cisplatin"", ""large mediastinal masses with critical obstruction to the LUL""],
""Medications"": [""none""]
}"
31547,admission date discharge date date of birth sex f service neurosurgery allergies patient recorded as having no known allergies to drugs attending chief complaint headache major surgical or invasive procedure none history of present illness y o female with a history of migraine headaches who developed a typical migraine headache on however the intensity of the pain was worse on this occasion and she noted left ptosis which has not happenend with a migraine over the past years according to the patient pain increased over the course of the week and this am she was observed by her parents to be talking to herself which is unusual for her she also experienced night sweats over the past several evenings this morning she rolled into a prone position on the floor became stiff and would not respond to questions from her family members for several minutes she is amnestic to this episode she was taken to an outside hospital where head ct revealed an acute hemorrhage along the falx and slightly shifted to the right in the frontal lobes approximately x cm in diameter no significant midline shift is noted neurosurgery was consulted past medical history migraine ha followed by dr new onset in ct scan negative referral neurologist considered but not done b c self resolved in this episode of two years was approx in sync with menopauze the headaches would be pounding and excruciating midfrontal in always the same spot followed by back of the neck pain n v photo phon fobia rx percocet x year but lasting up to a week completely off from work normal functioning in between with only minor more stress related headaches which responded to otc meds depression adhd anxiety r arm and repair wisdowm teeth extraction at age intermittent exophoria esotropia as a child with the l eye turning inward with pain and fatigue social history school cirriculum director denies tobacco etoh or ivdu family history no migraines sister has headaches located behind the eyes which are attributed to allergies no severe carsickness in family physical exam o t bp hr r o sats ra gen wd wn comfortable nad slightly lethargic heent pupils bilaterally eoms intact except left th nerve palsy left ptosis as well neck supple lungs cta bilaterally cardiac rrr s s abd soft nt bs extrem warm and well perfused neuro mental status awake and alert cooperative with exam normal affect orientation oriented to person place and date recall objects at minutes language speech fluent with good comprehension and repetition naming intact no dysarthria or paraphasic errors 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 left th nerve palsy left ptosis 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 toes downgoing bilaterally coordination normal on finger nose finger rapid alternating movements heel to shin 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 pm blood pt ptt inr pt am blood pt ptt inr pt 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 am blood osmolal am blood osmolal am blood phenyto am blood phenyto am urine blood neg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks neg mri findings of concern for the presence of a complex solid and cystic mass within the region of the right frontal lobe judging from the complete extent of this mass including its hemorrhagic elements it is more likely intra than extra axial primary and metastatic etiololgies need to be considered and seem more likely than an extra axial lesion such as a meningioma ct torso no source of brain metastasis is identified somewhat distended gallbladder with some pericholecystic fluid there is evidence of periportal tracking would recommend correlation with clinical and laboratory factors to rule out cholecystitis cta right frontal mass which appears to have a few tiny vessels within the substance of the lesion but the majority of the anterior cerebral artery branches lie along the surface of the mass this study does not differentiate between an intra and extra axial mass as the origin of this lesion bone scan no evidence of osseous metastatic disease brief hospital course ms was admitted to the neurosurgery service for further evaluation she was started on dilantin for seizure prophylaxis an mri was done which showed a complex solid and cystic mass within the region of the right frontal lobe there was associated edema surrounding the mass she was therefore also treated with a mannitol taper and decadron over the following days she was evaluated by ct and bone scan for other possible primary tumors but these results were negative neurology was consulted to further evaluate the l lateral rectus palsy and recommended an lp as part of the work up the patient and family refused this and requested that it be done in the or surgery was recommended to the patient for tumor resection however the patient and family were not ready to make a decision therefore the were encouraged to get a second opinion the family agreed and sought this at the the patient was screened by pt and deemed clear to go home with services ms will therefore go home with her family and services and postpone surgery to pursue an outpatient second opinion first she and her family were counseled to return to the hospital should her headache worsen or should she develop new or worsening neurological symptoms she will continue on decadron and dilantin until cleared by her physician on discharge her neurological exam was only remarkable for a l lateral rectus palsy medications on admission vicodin percocet prn prozac concerta klonopin d c d in in winter takes sudafed for post nasal drip discharge medications acetaminophen mg tablet sig two tablet po q h every hours as needed tablet s bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed disp tablet delayed release e c s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills nystatin unit ml suspension sig five ml po qid times a day disp ml s refills phenytoin sodium extended mg capsule sig one capsule po tid times a day disp capsule s refills dexamethasone mg tablet sig one tablet po q h every hours disp tablet s refills pantoprazole 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 oxycodone mg tablet sig tablets po q h every hours as needed disp tablet s refills discharge disposition extended care facility discharge diagnosis brain mass discharge condition stable l lateral rectus palsy discharge instructions discharge instructions for brain masses take your pain medicine as prescribed exercise should be limited to walking no lifting straining excessive bending increase your intake of fluids and fiber as pain medicine narcotics can cause constipation unless directed by your doctor do not take any anti inflammatory medicines such as motrin aspirin advil ibuprofen etc if you have been prescribed an anti seizure medicine take it as prescribed and follow up with laboratory blood drawing as ordered clearance to drive and return to work will be addressed at your next office visit call your surgeon immediately if you experience any of the following new onset of tremors or seizures any confusion 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 any signs of infection at the wound site redness swelling tenderness drainage fever greater than or equal to f followup instructions please see dr for follow up if you so choose otherwise please follow up with your neurosurgeon [NEW_RECORD] name unit no admission date discharge date date of birth sex f service neurosurgery allergies shellfish derived attending addendum on attempted discharge on patient had vasovagal episode when ambulating to bathroom so her discharge was cancelled this occured again on the patient and family decided to stay and have her surgery done here on she underwent a right sided high frontal craniotomy for resection post operatively she was monitored in the icu for close neurological checks and blood pressure control on pod she was transferred to the neurosurgical floor and had an mri completed showing no residual tumor labs wbc crit dilantin neurologically the patient continued with th nerve palsy and difficulty with ambulation she was tolerating a regular diet and voiding without difficulty on the patient s urine culture sensitivities were finalized and she was found to have a uti she was started on bactrim prior to discharge she was seen by pt who felt she needed acute level rehab she was tapered off steroids she will have follow up in the brain tumor clinic discharge disposition extended care facility md completed by,"{
""Diagnoses"": [""migraine headache"", ""acute hemorrhage""],
""Medications"": [""none""]
}"
80722,admission date discharge date service medicine allergies no known allergies adverse drug reactions attending chief complaint dyspnea major surgical or invasive procedure none history of present illness mr is a y o m with pmh of low grade b cell non hodgkins lymphoma most recently treated in with rituxan and cad s p cabg and pacer who was biba from home after the sudden onset of sob pt states he first noticed the shortness of breath after he had been walking on his treadmill for about minutes he said he had to stop and didn t feel right he tried walking again after a short while and felt the same he says onset was relatively sudden over the course of minutes or so characterized by tightness cough and sob no cp pt states he noticed a similar feeling a few days earlier but it went away he has had a cough for approx week which was also noticed by home home nurse pat it is productive of mucus like saliva but not green or yellow in color he says he has felt congested during the past week since he began coughing no palpitations f c s or abdominal pain says his bm a little loose today but no other change in bowel movements ems was called and found the patient to be wheezing with a room air oxygen saturation he was also tachypneic in the s but began satting well on nrb no h o copd or pulm disease in the ed vitals were nrb ekg was done in ed which showed paced beats cxr showed pna in rll he was given levofloxacin in the ed for cap coverage lives at home and nebs he was ordered for cefepime but had not received it by the time of transfer to the floor so this was discontinued in favor of ctx azithro regimen starting in am stool guaiac negative on transfer ed vitals were vs l nrb on the floor the patient is comfortable and in no acute distress providing the above history pt expressed uncertainty with being treated by physicians he does not know and would like the most experienced doctor to perform any procedures that must be done to him past medical history non hodgkins lymphoma mesenteric axillary epitrochlear recurrence rituxin leukeran prednisone and radiation rituxin monotx for recurrence hl htn cad cabg x v pacer x yrs gerd bilat total hip replacment c b peripheral neuropathies anemia pt states he has long history of anemia that is always near borderline renal failure baseline cr social history married to his wife nd marriage previously worked in textiles sons daughter smokes ocassional etoh no other drug use lives at home and walks with a cane family history sisters deceased brother died unknown cancer history physical exam general alert oriented no acute distress heent sclera anicteric mmm oropharynx clear neck supple no lad lungs coarse crackles in rll but otherwise no crackles or wheezes frequent coughing during lung exam cv systolic murmur heard over entire precordium irregular rate with frequent early beats 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 neuro cn intact bilat decreased hearing on right pt wears hearing aid bilat but was not wearing aid on right at time of exam strength in ue and le bilat pertinent results labs on admission pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count pm glucose urea n creat sodium potassium chloride total co anion gap pm lactate imaging cxr cardiomegaly pulmonary edema small bilateral pleural effusions post diuresis chest radiograph recommended to exclude underlying pneumonia in the lower lobes cxr resolution of temporary severe chf episode with pulmonary congestion remaining right lower lobe infiltrate which ought to be followed no other new abnormalities echo the left atrium is moderately dilated no left atrial mass thrombus seen best excluded by transesophageal echocardiography there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded the ascending aorta is mildly dilated 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 no mitral valve prolapse moderate mitral regurgitation is seen due to acoustic shadowing the severity of mitral regurgitation may be significantly underestimated there is mild pulmonary artery systolic hypertension there is no pericardial effusion impression mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function moderate mitral regurgitation pulmonary artery hypertension mild aortic regurgitation brief hospital course pneumonia acute diastolic chf non hodgkins lymphoma cabg s p cabg hypertension mitral regurgitation pulmonary hypertension gerd chronic kidney disease stage iii anemia likely secondary to ckd admitted with acute onset of dyspnea likely multifactorial from right lower lobe pneumonia and chf as per his pneumonia he was covered empirically with antibiotics for presumed cap with ceftriaxone and azithromycin as per acute on chronic chf exacerbation etiology was unclear and may have been precipitated by underlying infection and catecholamine surge during exertion he was ruled out for acute ischemia with cardiac enzymes x echo showed biventricular hypertrophy and moderate mitral regurgitation patient s breathing responded well to diuresis with decrease in oxygen requirement and significant improvement in cxr given that he did not appear total body overloaded and that his creatine increased with initial diuresis opted not discharge him on standing diuretics he will see his pcp soon after for further evaluation medications on admission atorvastatin lipitor mg tablet tablet s by mouth daily felodipine prescribed by other provider mg tablet extended release hr tablet s by mouth metoprolol succinate prescribed by other provider mg tablet extended release hr tablet s by mouth daily omeprazole prescribed by other provider mg aspirin mg po daily discharge medications atorvastatin mg tablet sig one tablet po once a day felodipine mg tablet extended release hr sig one tablet extended release hr po once a day metoprolol succinate mg tablet extended release hr sig one tablet extended release hr po once a day omeprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily aspirin mg tablet sig one tablet po daily daily azithromycin mg tablet sig one tablet po once a day for days disp tablet s refills discharge disposition home with service facility homecare discharge diagnosis pneumonia unknown organism acute diastolic chf non hodgkins lymphoma cabg s p cabg hypertension mitral regurgitation pulmonary hypertension gerd chronic kidney disease stage iii anemia likely secondary to ckd 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 with shortness of breath likely the result of both pneumonia and congestive heart failure please continue the prescribed antibiotic completely the medication as prescribed no other changes were made to your medications followup instructions care connections,"{
""Diagnoses"": [""Low grade B-cell non-Hodgkin's lymphoma""],
""Medications"": [""Rituxan"", ""CAD s.p. cabg"", ""Pacer""]
}"
7440,admission date discharge date date of birth sex service history of present illness this is a year old man with end stage renal disease dementia hypertension type ii diabetes change in mental status five days prior to his admission at hemodialysis the patient was noted to have low grade fevers blood cultures were drawn and he was given vancomycin and gentamycin doses times one on arrival to the emergency room the patient was found to have a right lower lobe consolidation and he was given one dose of levaquin the patient was found to be in altered mental status subsequently his psychiatric medications were held his levofloxacin was started on hospital day number two for possible pneumonia by hospital day number three the patient became increasingly lethargic and febrile to at this time the patient became hypotensive his systolic blood pressures dropped to the s the patient s blood pressure responded to intravenous fluids and he was given vancomycin and flagyl on hospital day number four the patient again became hypotensive and was sent to the intensive care unit and given aggressive hydration in the intensive care unit the patient was given vancomycin and flagyl for suspected aspiration pneumonia at that time the patient also had increasing rigors and muscle tone thought to possibly be secondary to his psychiatric medications in the medical intensive care unit the patient was placed on pressors and intravenous fluids he was given vancomycin levofloxacin and flagyl a lumbar puncture was performed without evidence of infection once the blood pressure was stabilized the patient was transferred to the medicine floor past medical history hypertension end stage renal disease on hemodialysis arteriovenous fistula with a history of pseudoaneurysm status post repair in dementia gout questionable history of positive ppd history of methicillin resistant staphylococcus aureus anemia of chronic disease history of hospitalization for syncope and mental status changes dialysis allergies no known drug allergies medications risperdal mg p o three times a day phos low two tablets with medications remeron mg once a day zestril mg once a day hydralazine mg four times a day aspirin mg once a day imdur mg once a day nephro caps one tablet q day hytrin mg p o q h s colchicine mg p o q day allopurinol mg p o q day physical examination upon transfer temperature was t maximum was blood pressure was pulse respiratory rate oxygen saturation on four liters on general examination he is unresponsive to verbal stimuli he was lethargic but responded to pain cardiovascular neck examination revealed jugular venous distention of about cm cardiovascular distant heart sounds regular rate and rhythm pulmonary poor inspiratory effort abdomen was nontender nondistended positive bowel sounds no masses extremities the patient is in multi poultice boots for bed sore blisters on feet neurologic he is unresponsive decreased tone laboratory data sputum culture showed methicillin resistant staphylococcus aureus positive but consistent with oropharyngeal flora cerebrospinal fluid showed one white blood cell count total protein of glucose of ldh of white blood cell count was troponin t of tsh of all blood cultures were negative urine cultures were negative cerebrospinal fluid cultures negative hospital course mental status changes the patient was thought to have poor mental status secondary to his infection the patient during the earlier part of the hospital course had hyponatremia which was repleted cautiously with free water meningitis was ruled out by lumbar puncture his psychiatric medications were held as a potential cause for his change in mental status however as the patient s febrile illness subsided the patient s mental status increased by the end of the hospital stay the patient was able to verbally respond to questions the patient continued to have elevated fevers after his transfer from the intensive care unit initially the patient was on ceftriaxone and flagyl for antibiotics given the high likelihood of the patient s gram negative infection with the possibility of anaerobic infection from aspiration the patient was switched to cefepime and flagyl to also include pseudomonal coverage given that the patient had a methicillin resistant staphylococcus aureus positive sputum he was also continued on the vancomycin the patient s fever curve continued to improve and the patient became afebrile for over hours at this time the flagyl was discontinued to prevent the selection of vancomycin resistant to enterococcus the patient s blood pressure remained stable during his hospital course after medical intensive care unit transfer the patient became hypertensive and his antihypertensive medications were added gradually the patient continued hemodialysis on monday wednesday and friday the patient was given phosphate binders the patient had remained n p o for several days an nasogastric tube placement was attempted but was unsuccessful initial placement of nasogastric tube was pulled out by patient subsequently placement was unsuccessful after discussion with the family it was decided that the patient would be a candidate for percutaneous endoscopic gastrostomy placement to receive enteral nutrition the patient had percutaneous endoscopic gastrostomy placement by gastroenterology without complications and tube feeds were started several hours after placement of the tube the patient was evaluated by speech and swallow for possibility of aspiration a video swallow was performed which showed that food of all consistencies were aspirated down the trachea the patient was deemed unable to take p o and was made n p o in addition to prevent further complications from tube feeds the patient was kept upright at degrees during all times of tube feeds the patient had anemia of chronic disease the patient was given erythropoietin the patient was immobile and chronically in bed the patient began to develop bed sores the patient was placed in multi poultice boots for formation of new ulcers on the heels of both feet as well as a sacral ulcer grade one the patient was given first step air mattress and wounds were managed with wet to dry dressings daily the patient was turned twice a day to avoid formation of bed sores the patient never complained of chest pain however the patient s troponin t levels trended upwards despite this the patient s creatinine kinase and mb fractionation remained stable the patient s peak troponin t was the patient was given aspirin p r and intravenous beta blocker prior to his percutaneous endoscopic gastrostomy placement subsequent to percutaneous endoscopic gastrostomy placement the patient was given betablocker and aspirin via percutaneous endoscopic gastrostomy tube the patient s cardiac enzymes were monitored condition on discharge afebrile no hypoxia good discharge status to rehabilitation facility discharge diagnoses aspiration pneumonia ischemia end stage renal disease delirium dementia hypernatremia hypotension discharge medications aspirin mg once a day isosorbide mg once a day terazosin mg once a day colace liquid bisacodyl mg once a day subcutaneous heparin q eight hours allopurinol mg p o q day senna mg p o twice a day sovalimir mg p o three times a day bactroban ointment twice a day to scrotal sores isosorbide dinitrate mg p o three times a day lisinopril mg p o q day metoprolol mg p o twice a day acetaminophen flumotadine mg intravenous q hours cefepime mg intravenously once a day for seven days given after hemodialysis on monday wednesday and friday vancomycin one gram dosed by vancomycin levels daily for the next seven days if less than then give gram dose and repeat the dose the next day humalog sliding scale follow up plans the patient is to follow up with his primary care physician patient should get hemodialysis every monday wednesday and friday the patient should have cardiac enzymes white blood cell count and vancomycin levels followed on a regular basis the patient should have tube feedings nepro full strength with a goal rate of ml per hour grams of promod should be added to the tube feeds daily tube feeds should be flushaed with ml of water every four hours m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service addendum hospital course after placement of the patient s ng tube on he did well however it was noted that he had an increased white blood cell count to approximately this continued over several days and there was concern for a possible second source of pneumonia therefore the patient was not discharged as planned on blood cultures and urine cultures remained negative the patient continued with a severe aspiration pneumonia although chest x ray did not show any worsening of the pneumonia during this time the patient remained with only very low grade fevers of approximately he was continued on his cefepime and vancomycin as the white count remained elevated for several days infectious disease was consulted and they recommended the addition of flagyl for better coverage of anaerobes despite the addition of this third antibiotic the patient s white count remained elevated in the range he also however remained afebrile and did not show any clinical worsening of his hypoxemia or cough additionally the patient s mental status worsened and he was no longer communicative in correlation with this increasing white count repeat head ct was negative for any new changes it was felt that his waxing and mental status was most likely a combination of his underlying dementia as well as secondary to toxic metabolic process from his infection the patient s mental status did improve slightly by the day of discharge so that he was awake and would open his eyes but was not following simple commands or speaking communication was maintained with his daughter who was also his healthcare proxy throughout his hospitalization and it was decided that since he is currently stable and it seemed unlikely that he will show significant improvement from his current status given that little change had been seen over the last week he was sent to a skilled nursing facility for further care discussions with his daughter have been ongoing as to whether his code status should be changed to cmo and hospice care should be pursued currently he is still dnr dni and antibiotics and dialysis will be continued condition on discharge the patient is stable with a l oxygen requirement he also has significant dementia he opens his eyes to voice but does not communicate and does not follow commands well discharge status to nursing home discharge diagnosis aspiration pneumonia ischemia end stage renal disease on hemodialysis delirium dementia hypernatremia resolved hypotension resolved discharge medications please note that unless specified otherwise all medications are to go through the patient s g tube aspirin q d colace mg b i d bisacodyl mg p r n heparin u subcue q hours allopurinol q d senna tab b i d p r n mg t i d bactroban creme applied topically to scrotal ulcers isosorbide dinitrate mg t i d lisinopril mg q d metoprolol mg b i d tylenol p r n insulin sliding scale lansoprazole mg q d nephrocaps cap q d cefepime mg iv q d through give every day but on days of dialysis give after hemodialysis metronidazole t i d through follow up the patient is to follow up with his primary care physician weeks and he is to continue dialysis three days a week additionally his white count should be checked in approximately four days to ensure that it is stable m d dictated by medquist d t job,"{
""Diagnoses"": [""End Stage Renal Disease"", ""Dementia"", ""Hypertension"", ""Type II Diabetes"", ""Pneumonia""],
""Medications"": [""Vancomycin"", ""Gentamycin"", ""Levaquin"", ""Levofloxacin"", ""Flagyl"", ""Vancomycin""]
}"
21769,admission date discharge date service med history of present illness an year old male with a history of rectal cancer status post sigmoid colectomy in presents with melena and left foot cellulitis the patient states that he has been short of breath x weeks with worsening symptoms in this past week in his usual state of health he would walk his dogs times a day in the past week he stopped walking his dogs found that he cannot walk to his door nor walk up the stairs without feeling tired he also notes that his stools were darker than usual stools per day intermittent black for the past days but did not think much of it at this time he also developed redness and tenderness in his left middle toe he went to hospital for evaluation of his left foot cellulitis when the doctor noticed that he was short of breath cbc showed a hematocrit of positive for nausea dry heaves lightheadedness with positional change ethanol and generalized malaise negative for fever chills vomiting hematemesis epistaxis syncope brbpr history of xrt in the esophagus region history of pud history of gerd the patient decided that he wanted to be admitted to the center at this point emergency department course temperature degrees pulse blood pressure respiratory rate percent on room air and hematocrit rectal exam guaiac positive ng lavage coffee ground with cc lavage egd several nonbleeding erosions in body of stomach but duodenum esophagus within normal limits received units of packed red blood cells started on clindamycin mg x for cellulitis the patient was then transferred to the sicu sicu course t max pulse blood pressure respiratory rate of percent on room air hematocrit of to to was started on augmentin for cellulitis past medical history type diabetes hypertension gout rectal carcinoma status post sigmoid colectomy on chronic renal insufficiency status post appendectomy skin cancer asthma social history the patient lives at home alone drinks glasses of wine per day stopped smoking years ago allergies no known drug allergies medications lisinopril lasix q d flovent wellbutrin allopurinol aspirin glyburide units q a m units q p m metformin mg q d singulair q d prazosin tablet q d physical examination on initial exam patient had a t max of degrees pulse of blood pressure of respiratory rate of percent on room air the patient had diffuse wheezing with resolving left foot erythema the remainder of the exam was unremarkable laboratory data chem was significant for a bun of creatinine of which had decreased from calcium of with an albumin of hematocrit was initially at pt ptt and inr all within normal limits impression an year old male with a history of rectal carcinoma status post sigmoid colectomy admitted for upper gastrointestinal bleed and left foot cellulitis upper gastrointestinal bleed unclear source esophagogastroduodenoscopy revealed only erosion the patient was monitored by serial hematocrits units of blood was transfused in the ed the patient was started on clears and iv protonix b i d was given once hematocrit was stable greater than protonix was switched to p o and patient was restarted on his medications withholding aspirin cellulitis left toe erythema was improving once the patient was on the floor the patient was continued on augmentin for a day course cultures remained negative during this time frame discharge medications same as admission with the addition of augmentin mg tab q d for the remaining days protonix mg p o q d colace aspirin was withheld disposition to home discharge status the patient was ambulating mentating eating and drinking normally discharge diagnosis upper gastrointestinal bleed secondary to erosion within the stomach and duodenum discharge followup the patient was asked to follow up with his pcp within the week dictated by medquist d t job [NEW_RECORD] admission date discharge date service medicine allergies percocet tylenol attending chief complaint bloody emesis major surgical or invasive procedure debridement of right rd toe and excision of the distal phalanx picc line placed history of present illness history of present illness source patient who is tangential though oriented y o male with pmhx of atrial fibrillation on coumadin copd dm colon ca s p left colectomy and iron deficiency anemia who presents to the ed with a chief complaint of vomiting blood patient reports a history of days of antibiotics augmentin for a foot infection he had been experiencing foot pain for appoximately weeks prior to the initiation of antibioitics and for this he was taking advil every day he reports experiencing some dark stools throughout this time and on the day of presentation experienced an episode of hematemesis for which he presented to the ed he denies abdominal pain fevers chills chest pain shortness of breath palpitations he does also note some drops of blood in the toilet but no frank hematochezia in the ed initial vitals were t bp hr rr o ra hct was low at down from baseline of low s and inr was elevated to ng lavage showed coffee grounds which did not clear with ccs and rectal exam revealed black stool that was frankly guaiac positive gi was consulted and planned for egd once admitted patient was ordered for mg of vitamin k as well as units of ffp and prbcs patient s labs were also notable for acute on chronic renal failure with bun creatinine of creatinine up from baseline of in the setting of this acute renal failure troponin was elevated to without ischemic changes on ekg patient was thus admitted to the micu for further management of his severe anemia with renal failure and a troponin leak upon arrival to the icu patient was interactive and in no acute distress with stable vitals past medical history dm paroxysmal atrial fibrillation on anticoagulation cri baseline cr htn gout copd oa h o gib found to have gastritis ulcerations no active bleeding and angioectasia in colon h o hip fx s p orif im nail r hip l hip unclear etiology previously treated with regular transfusions now on procrit baseline h o pericardial effusion in setting of af with rvr chf pleural effusions s p turp for prostate enlargement and urinary retention h o sigmoid colon ca s p sigmoid colectomy right cheek scc s p skin graft diastolic chf social history patient denies tobacco or illicit drugs he reports occasional alcohol consumption family history nc physical exam on admission vitals t bp p r o ra general awake 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 rectal deferred as bed with frank melena ext warm well perfused pulses no clubbing cyanosis or edema pertinent results labs on admission am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap am blood pt ptt inr pt hct trend inr trend am blood glucose urean creat na k cl hco angap pm blood vanco urine cx negative pm swab source right foot final report gram stain final per x field polymorphonuclear leukocytes per x field gram positive cocci in pairs smear reviewed results confirmed wound culture final staph aureus coag moderate growth oxacillin resistant staphylococci must be reported as also resistant to other penicillins cephalosporins carbacephems carbapenems and beta lactamase inhibitor combinations rifampin should not be used alone for therapy corynebacterium species diphtheroids moderate growth sensitivities mic expressed in mcg ml staph aureus coag clindamycin r erythromycin r gentamicin s levofloxacin r oxacillin r rifampin s tetracycline s trimethoprim sulfa s vancomycin s anaerobic culture final no anaerobes isolated pm tissue rt rd toe final report gram stain final no polymorphonuclear leukocytes seen per x field gram positive cocci in pairs and clusters tissue final due to mixed bacterial types an abbreviated workup is performed p aeruginosa s aureus and beta strep are reported if present susceptibility will be performed on p aeruginosa and s aureus if sparse growth or greater staph aureus coag sparse growth sensitivities performed on culture s anaerobic culture final no anaerobes isolated acid fast smear final no acid fast bacilli seen on direct smear acid fast culture final no mycobacteria isolated fungal culture final no fungus isolated cxr single portable upright chest radiograph there are low lung volumes mediastinal and hilar contours are unchanged there is left basilar atelectasis there is no right effusion or pneumothorax pulmonary vasculature is normal osseous structures are grossly normal impression left basilar likely atelectasis x rays of right toes findings there is abnormal soft tissue swelling and ulceration in the distal aspect of the right third toe there appears to be exposed bone as well as gas at the distal tip of the third toe highly suspicious for osteomyelitis the cortical definition of the third distal to until is also irregular consistent with cortical destruction there is extensive osteopenia vascular calcifications are present there is cortical thickening along several of the metatarsal shafts likely chronic right third toe debridement acute osteomyelitis fundoscopic mucosa biopsy gastric fundic mucosa biopsy focal foveolar hyperplasia duplex dop abd pelvis limited abd ultrasound complete findings there is somewhat limited evaluation of the liver due to body habitus and inability to suspend respiration no intrahepatic biliary ductal dilatation is seen on dedicated doppler interrogation there is normal flow and waveforms within the portal and hepatic veins as questioned the proximal common duct measures mm in diameter there is significantly limited visualization of the pancreas there is limited visualization of theaorta the gallbladder is normal the right kidney is normal in size measuring cm containing a simple cm cyst at the lower pole the spleen is normal measuring cm the left kidney is normal in size measuring cm containing cysts one of which had a punctate wall calcification on doppler interrogation no images of the hepatic artery were obtained due to technical factors impression normal portal vein flow as questioned somewhat limited evaluation of the liver with no intra or extra hepatic biliary ductal dilatation bilateral renal cysts cxr one ap portable view comparison with the prior study lung volumes are somewhat low streaky density at the lung bases consistent with subsegmental atelectasis and possibly retrocardiac consolidation persists there is blunting of the left costophrenic sulcus consistent with a small effusion not apparent previously a picc line has been inserted on the left and terminates in the region of the mid superior vena cava impression evidence for small left pleural effusion picc line in place no other significant change brief hospital course assessment and plan mr is a year old male with history of gibs colon ca s p colectomy atrial fibrillation on coumadin and dm who presents with hct of hematemesis and melena in the setting of a supratherapeutic inr found to have avm s p clipping pt also s p right distal toe amuptation gib the patient presented to the ed with bloody emesis ng lavage showed coffee grounds which did not clear with ccs and rectal exam revealed black stool that was frankly guaiac positive on arrival in the ed gi was consulted and the pt received mg of vitamin k as well as units of ffp for inr of in the setting of being on amoxicillin clavulanate for his toe and his hct was he received units of blood in the icu and his hct increased to which was above his baseline of he was plaved on an iv ppi and his asa ccb and ace were held during his admission he required egds the first showed an area of eythema with an overlying clot in the fundus with question of avm below the clot was unable to be suctioned off a single red non bleeding angioexctasia was seen in the fundus and was thought to be the source of his bleeding given that his inr was supratherapeutic on admission three endoclips were placed the egd was also notable for varices at the gastroesophageal junction an esophageal ring and a small hiatal hernia his second egd was notable for a cm x cm area of localized nodularity of the mucosa of the fundus which was biopsied and showed focal foveolar hyperplasia and no evidence of malignancy the previously placed clips were present in the gastric junction and a dilated vein was noted at the ge junction he was discharged on a po ppi his calcium dose was increased and changed to calcitrol since it is better absorbed when taking protonix likely osteomyelitis of right middle toe during his admission he required debridement of right rd toe and excision of the distal phalanx tissue cx grew mrsa and corynebacterium the patient was started on vancomycin flagyl and cipro a picc line was placed and the patient was discharged with vna on long term vancomycin with last dose planned for he was discharged with lab checks cbc ast alt a ph tbili chem q friday as well as a vanco trough check on his wound was dressed with betadine dressing a special brace was obtained as patient needed to be able to ambulate and even do some stairs at home rehab was offered but patient declined for social reasons he was discharged on calcium and vitamin d a fib with rvr the patient had an episode of a fib with rvr on and received diltiazem iv x lopressor ivx and an additional dose of diltiazem mg po of note his diltiazem had been held earlier in the day his diltiazem dose was increased to mg daily which was his previous home dose his coumadin was restarted prior to discharge as his score was at the time of discharge his inr was subtherapeutic at he was discharged with plan for inr check on and to have this result faxed to his pcp iron deficiency anemia his hct was above his baseline of at the time of discharge he is being continued on his home iron supplementation he is on epogen at home acute renal failure on admission his creatinine was initially elevated to from baseline of the arf was likely secondary to inadequate renal perfusion secondary to blood loss his creatinine was at discharge htn he was discharged on his home lisinopril and ccb copd patient had intermittent wheezes in the beginning of his hospitalization he was treated with prn nebs albuterol prn for sob or wheeze was added to his home regimen of medications including ipratropium inh fluticasone inh and montelukast gout his allopurinol was renally dosed during his arf he was discharged on his home allopurinol his colchicine was discontinued as he was doing well off this medication psych his home dose of buproprion was continued dm he was discharged on his rosiglitazone and was maintained on a diabetic diet while in the hospital diastolic chf he lasix was originally held in the setting of decreased uop due to gi bleed and in the setting of arf he was discharged on his home lasix ppx pneumoboots sc heparin ppi po code full emergency contact and friends pt has no family medications on admission ipratropium albuterol lisinopril mg po qd montelukast mg po qd pantoprazole mg po qd rosiglitazone mg po qd coumadin mg po qd iron mg po qd mvi discharge medications bupropion hcl mg tablet sig one tablet po bid times a day disp tablet s refills fluticasone mcg actuation aerosol sig two puff inhalation times a day disp inhaler refills montelukast mg tablet sig one tablet po daily daily disp tablet s refills ferrous sulfate mg mg iron tablet sig one tablet po bid times a day disp tablet s refills warfarin mg tablet sig two tablet po once daily at pm disp tablet s refills pantoprazole 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 lisinopril mg tablet sig one tablet po daily daily disp tablet s refills vancomycin in dextrose gram ml piggyback sig one intravenous q h every hours for weeks last dose disp qs refills ipratropium albuterol mcg actuation aerosol sig two puff inhalation twice a day disp inh refills rosiglitazone mg tablet sig one tablet po once a day disp tablet s refills vitamin d unit tablet sig one tablet po once a day disp tablet s refills calcium citrate mg tablet sig two tablet po twice a day disp tablet s refills multivitamin tablet sig one tablet po once a day disp tablet s refills albuterol sulfate mcg actuation hfa aerosol inhaler sig inhalation every four hours as needed for shortness of breath or wheezing disp inhaler refills outpatient lab work please have the folllowing labs drawn every friday and have them faxed to your pcp at cbc ast alt a ph tbili chem furosemide mg tablet sig one tablet po once a day disp tablet s refills allopurinol mg tablet sig one tablet po once a day disp tablet s refills outpatient lab work inr check on friday and fax to dr at outpatient lab work check vancomycin trough on and fax to dr diltiazem hcl mg capsule sustained release sig one capsule sustained release po once a day disp capsule sustained release s refills epogen unit ml solution sig one ml sc injection once a week on fridays disp qs refills discharge disposition home with service facility homecare discharge diagnosis primary upper gi bleed toe osteomyelitis secodary dm paroxysmal atrial fibrillation on anticoagulation cri baseline cr htn gout copd oa h o gib found to have gastritis ulcerations no active bleeding and angioectasia in colon h o hip fx s p orif im nail r hip l hip unclear etiology previously treated with regular transfusions now on procrit baseline h o pericardial effusion in setting of af with rvr chf pleural effusions s p turp for prostate enlargement and urinary retention h o sigmoid colon ca s p sigmoid colectomy right cheek scc s p skin graft diastolic chf discharge condition stable on vancomycin iv for osteomyelitis inr subtherapeutic at discharge instructions you were admitted to the hospital for an upper gastrointestinal bleed a source of bleeding was found in your stomach and it was clipped you received blood transfusions and now your blood count is stable while in the hospital you were also found to have osteomyelitis in your toe which is an infection of the bone you were started on a long term iv antibiotic called vancomycin you stayed in the hospital for one day longer than expected because your heart was in atrial fibrillation and beating quickly we restarted your diltiazem at it s previous dose the following changes were made to your medications vancomycin was started for your osteomyelitis albuterol was added to be taken as needed for shortness of breath or wheeze colchicine was discontinued since you are doing well off of it your calcium dose was increased and changed to calcitrol since it is better absorbed when you are taking protonix no other changes were made to your medications you should take all medications as detailed on the attached sheets you should return to the emergency room if you develop any of the following vomiting of blood or coffee grounds like substance black tarry stools lightheadedness or palpitations chest pain shortness of breath persistent fever worsening pain or redness blackness around the toe followup instructions please call dr office and make an appointment for weeks from now for podiatry please call dr office and make a follow up appointment for sometime in the next weeks provider md phone date time provider md phone date time provider m d phone date time completed by [NEW_RECORD] admission date discharge date service medicine allergies percocet tylenol attending chief complaint progressive doe x days major surgical or invasive procedure picc line placement cpap history of present illness yom with h o afib not on coumadin and scc on the face s p resection who presents with three days of progressive doe he reports pink tinged frothy sputum as well as chills anorexia and rhinorrhea though he denies fever ha arhtralgias myalgias chest pain emesis and diarrhea he says he may have gained weight recently though was at the doctor on and seemed to be doing well he denies weight loss over the last several months he also told the ed he had increased urinary output in the ed vs were t bp hr in afib rr on nrb ra lnc on presentation he was given asa mg ibuprofen mg po and levofloxacin mg iv ceftriaxone g iv and vanco g iv for cap in the ed bp was initially in the s on admission but then dropped to it improved to the s with a ivf bolus he got a total of l betwen ivf and antibiotics blood cultures were sent abg was not done there was concern for an element of chf with a bnp though he was not diuresed in the ed because of the concern for infection on arrival to the icu t hr bp nrb initially there was concern for volume overload and he was given lasix mg iv he also had some hemoptysis past medical history dm paroxysmal atrial fibrillation on anticoagulation cri baseline cr htn gout copd oa h o gib found to have gastritis ulcerations no active bleeding and angioectasia in colon h o hip fx s p orif im nail r hip l hip unclear etiology previously treated with regular transfusions now on procrit baseline h o pericardial effusion in setting of af with rvr chf pleural effusions s p turp for prostate enlargement and urinary retention h o sigmoid colon ca s p sigmoid colectomy right cheek scc s p skin graft diastolic chf social history patient denies tobacco or illicit drugs he reports occasional alcohol consumption hcp report recent falls house with stairs between kitchen and bedroom speaks multiple languages family history nc physical exam vs on arrival to the icu t hr bp nrb general elderly comfortable but appears somewhat sob nad speaking in full sentences heent poor dentition op clear tacky mm lungs end exp wheezes on right throughout high pitched sounds rhonchi crackles throughout on left some use of scm for breathing cardio heart sounds difficult to hear over o and breath sounds difficult to assess jvd with surgical scars and scm use abd somewhat distended and obese but soft no fluid wave appreciated nt ext chronic woody changes of b l le to mid shin b l symmetric skin multiple sk s and ak s large area of skin graft post surgery on left fronto parietal foreheaad head ms left leg slightly shorter and externally rotated neuro aa ox speaking in full sentences conversant appropriate resting tremor in l r pertinent results admission cxr single upright frontal chest radiograph there is near complete opacification of the left hemithorax with some residual aeration noted in the upper lung air bronchogram is the mid lung suggests a component of air space consolidation with probable increased effusion the right hemithorax is normally aerated there is no pneumothorax no large pleural effusion is noted on the right the cardiomediastinal silhouette is incompletely assessed secondary to the left hemithorax opacification there is unchanged calcification in the aortic knob impression interval near complete opacification of the left hemithorax compatible with a large left sided pleural effusion and likely consolidation echo the left atrium is mildly dilated there is mild symmetric left ventricular hypertrophy with normal cavity size there is moderate global left ventricular hypokinesis lvef the right ventricular cavity is moderately dilated with mild global free wall hypokinesis the aortic valve leaflets are mildly thickened but aortic stenosis is not present trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen the pulmonary artery systolic pressure could not be determined there is a trivial physiologic pericardial effusion compared with the report of the prior study images unavailable for review of biventricular systolic function is now seen clinical implications the left ventricular ejection fraction is a threshold for which the patient may benefit from an acei or ct chest diffuse dense left lung consolidation and collapse with extensive airway occlusion likely due to infectious pneumonia and coexisting atelectasis from retained secretions correlation with bronchoscopy may be helpful to clear secretions and to exclude a fixed endoluminal lesion no definite hilar mass but assessment limited by absence of iv contrast focal consolidation in the right upper lobe also likely due to infection but attention to this area on follow up imaging recommended to ensure resolution coronary artery aortic valve and mitral annulus calcification gallstones cxr there is slight improvement of the left lung consolidation although significant amount of consolidation is still involving most of the left lung with some minimal sparing of the lateral portion of the left lower lobe the right upper lobe is entirely consolidated but the right lower lung appears to be relatively clear there is potentially present left pleural effusion there is no pneumothorax multiple abnormalities might be further evaluated by chest ct if clinically warranted cxr cardiomediastinal contours are unchanged with cardiac size top normal multifocal consolidations have continuously improved still they are greater on the right upper lobe and left lower lobe if any there is a small left pleural effusion there is no pneumothorax cxr left picc tip is in the proximal svc cardiomediastinal contours are obscured by the lung abnormalities multifocal consolidations are unchanged as does a left pleural effusion there are lower lung volumes there is no evident pneumothorax cxr history pneumonia to evaluate for change findings in comparison with the study of the patient has taken a somewhat better inspiration the degree of left perihilar opacification retrocardiac opacification and perihilar opacification on the right is similar there may be some increase in the right upper lobe opacification when compared to the prior study picc line position is unchanged negative blood cultures negative urine legionella feces positive for c difficile toxin by eia labs on day of discharge wbc rbc hgb hct mcv plt ct glucose urean creat na k cl hco angap brief hospital course mr is an yom with a pmh significant for afib not on coumadin and scc on the face s p resection who presented to the micu with complete white out of left lung unilateral pleural effusion this was thought to be due to a pneumonia given the unilateral nature of the effusion parapneumonic effusion as most likely diagnosis given smoking history and degree to which whole lung is affected post obstructive pna due to malignancy was considered as a possibility too less likely chf b c of left sided unilateral nature although the pt appeared to have element of volume overload with peripheral edema and response to lasix it seems of relatively short onset given that the patient had a normal peat pcp s office four days prior to admission per the pt blood and sputum cultures and urine legionella were negative ct and cxr s showed the significant effusion the patient refused vats surgery thoracentesis so no clear etiology was discovered he was treated broadly with antibiotics empirically and there was progressive albeit slow improvement in patient s oxygenation on l nc at discharge his physical exam and his chest x rays he was treated empirically with vancomycin cefepime azithromycin for hospital acquired pneumonia broad coverage on multiple occasions patient had sob increased rr and work of breathing spo decreased on those occasions lasix was tried in case chf was a component in addition to morphine haldol sparingly for anxiety confusion and nebs we found that talking anxiety was big contibutor to tried to control that with reassurance patient was placed on cpap on a few of these separate occasions and tolerated it well and was able to come back off of the cpap without repercussion goal spo in low s which is finally acheived with l nc and off cpap for several days prior to dishcarge chemical pneumonitis is likely a component of the dypnea as the pt s neighbor later reported that he had found no less than dozen raid bombs on the patient s bedroom floor which the patient had been setting off due to bugs on the floor likely visual hallucinations the pt completed days of methylprednisolone course copd asthma as patient will now be long term npo any non inhaled meds had to be d c d and he was sent out on fluticasone inh and prn nebs afib the pt went into afib went into rvr after his po meds including metoprolol were held ultimately scheduled iv metoprolol was begun with good rate control he required diltiazem drip at two different time points during his hospitalization one of those times his heart rate went into the bradycardic range on other occasions he would just become bradycardic without an obvious trigger but tolerated it without symptoms he was in sinus rhythm at discharge given fall risk history and questionable history of gi bleed patient was not anticoagulated he was originally on aspirin mg daily but in the setting of melena see below that was stopped this should be restarted melena patient had one large melanotic stool without cht drop or decompensation during his hospitaliation thoguht to be due to c diff infection we held aspirin which should be restarted as below his ppi was also increased to and should be restarted at qd on the agitation disorientaion patient quite classically sundowns but responds well to redirection and zydis tab if necessary he had apparently been having nightly visual hallucinations at home prior to this admission diabetes held home po meds used ssi not an active issue c difficile infection c diff positive started on flagyl morning of should continue until contact with the patient has friends who are and they were updated frequently code dnr dni palliative care was consulted suggested morphine for discomfort anxiety and consider zydis as needed also used very rarely during admission access picc double lumen nutrition started tpn through picc we watched electrolytes closely due to concern for refeeding syndrome given patient was not eating for many days prior difficulty swallowing concern for aspiration po pills converted to iv form and non essentials d c d medications on admission buproprion mg combivent puffs diltiazem mg qd epo sc qweek ferroud sulfate mg qd fluticasone lasix mg qd lisinopril mg qd montelukast mg qd mvi pantoprazole mg qd rosiglitazone mg qd discharge medications bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for constipation tablet delayed release e c s heparin porcine unit ml solution sig one injection tid times a day fluticasone mcg actuation aerosol sig two puff inhalation times a day insulin lispro unit ml solution sig see attached sliding scale unit subcutaneous asdir as directed see attached sliding scale ipratropium bromide solution sig one inhalation q h every hours albuterol sulfate mg ml solution for nebulization sig one inhalation every six hours morphine mg ml syringe sig one injection q h every hours as needed for pain metronidazole in nacl iso os mg ml piggyback sig one intravenous q h every hours d dc on for day course after planned completion of cefepime changed to iv as pt could not swallow pill pantoprazole mg recon soln sig one recon soln intravenous q h every hours metoprolol tartrate mg ml solution sig mg intravenous q h every hours albuterol sulfate mg ml solution for nebulization sig one treatment inhalation q h every hours as needed for wheezing sob ipratropium bromide solution sig one treatment inhalation q h every hours as needed for wheezing sob olanzapine mg tablet rapid dissolve sig tablet rapid dissolve po bid times a day as needed for agitation discharge disposition extended care facility discharge diagnosis primary pneumonia respiratory distress c dificile colitis atrial fibrillation secondary congestive heart failure type diabetes chronic renal insuffiency squamous cell cancer iron deficiency anemia discharge condition mental status confused majority of time especially when hypoxic difficult to understand speech hoarseness face mask generally alert and interactive out of bed with assistance to chair or wheelchair discharge instructions you were seen in the ed for difficulty breathing you had a very large pneumonia and required a large amount of respiratory support in the micu at medical center for several weeks in the icu to maintain your oxygenation levels overtime you improved with iv antbiotics and iv steroids while you were hospitalized you developed an antibiotic associated infection of the colon called clostridium dificile which you will need to take antibiotics for weeks after the treatment for your pneumonia is completed during your stay in the icu you became quite confused we think this is due to your pneumonia decreased oxygen levels in your blood and being in an unfamiliar location you can take a medication called zydis which disolves on your tongue when you get very confused or agiatated your heart was evaluated while you were hospitalized and you do have congestive heart failure because of your chf pleae weigh yourself every morning md if weight goes up more than lbs you were diuresed with iv lasix periodically during your hospitalization additionally your infection triggerred your heart to go into a rapid abnormal rhythm atrial fibrillation during your hospitalization this was treated with metoprolol iv new medications antibiotics metronidazole flagyl mg iv q h discontinue on for day course can be changed to po when patient is eating vancomycin mg iv q h start discontinue on for day course heart medications metoprolol tartrate mg iv q h hold for hr sbp patient can be started on metop mg po tid when taking po again zydis mg fast melt can be uptitrated to a max of mg for agitation heparin units subcutaneous tid for anticoagulation combivent nebulizer treatments changed pantoprazole mg po qday to pantoprazole iv mg can be changed to po when pt taking pos holding these medications in acute setting rosiglitazone mg qday buproprion mg lasix mg po qday ferrous sulfate mg po qday discontinued diltiazem mg po qday followup instructions please follow up with your primary care physician in weeks you will need to call for an appointment phone please see your cardiologist dr date time tuesday at pm location bldg ma phone md,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""service med history of present illness"", ""an year old male with a history of rectal cancer"", ""status post sigmoid colectomy"", ""in presents with melena and left foot cellulitis""],
""Medications"": [""none""]
}"
13093,admission date discharge date date of birth sex f service nb history baby girl twin was admitted at weeks gestation due to prematurity infant was born to a year old gravida para mother with prenatal screens blood type b positive antibody negative rpr nonreactive rubella immune hepatitis b surface antigen estimated date of delivery was pregnancy was notable for ivf dichorionic diamniotic twin gestation reduced from triplets advanced maternal age with normal fetal surveys x first trimester nuchal translucency and biochemical screening altered risk for trisomy slightly elevated in both babies family declined amniocentesis intermittent chronic vaginal bleeding thought to be marginal placenta previa versus chronic abruption appropriate intrauterine growth with ultrasounds at weeks and weeks gestational diabetes premature preterm rupture of membranes with twin a ruptured at week gestation confirmed with positive nitrazine and fern testing status post betamethasone x and beta complete on indication for delivery was bpp of out of for twin a on with decision to deliver the infant had apgars of and required some facial cpap in the delivery room physical examination on delivery weight grams which was th to th percentile length was cm which was th to th percentile head circumference was cm was th to th percentile physical examination at discharge was within normal limits with a small capillary hemangioma and a pps murmur which has a preliminarily negative cardiac work up weight at time of discharge is grams summary of hospital course by systems respiratory the baby was placed on cpap at time of birth and weaned to room air by week of age since that time the patient has not required any supplemental oxygen or ventilatory support patient was started on caffeine due to apnea of prematurity which was discontinued on and since that time patient has not had significant apneic or bradycardic spells cardiovascular patient never required vasopressive agents no signs or symptoms of patent ductus arteriosus patient developed an intermittent murmur during the first week of life thought to be peripheral pulmonic stenosis murmur initial cardiac work up on showed a normal chest x ray normal electrocardiogram and normal for extremity blood pressures the cardiology service at also reviewed the ekg and read the study as normal for age they recommended follow up as needed no further work up is indicated at this time fluid electrolytes and nutrition patient was initially started on parenteral nutrition with enteral feeds initiated on day of life these were increased until patient was on full enteral feeds by day of life after which time caloric concentration of feeds was increased to a maximum of kilocalories per ounce and after steady weight gain was decreased to kilocalories on at the time of discharge the infant is feeding kilocalories per ounce of similac formula by concentration to then plus kcals per ounce with corn oil gastrointestinal maximum bilirubin was on day of life patient is status post several days of phototherapy treatment and a rebound bilirubin of on day of life phototherapy was discontinued on day of life with rebound on the th of and a recheck on day of life showing a direct bilirubin of and a total bilirubin of hematology patient s initial cbc was unremarkable white count of hematocrit of and platelets of with polys and bands since that time patient has been placed on iron supplementation and hematocrit was with a reticulocyte count of on day of life infectious disease patient underwent days of ampicillin and gentamicin treatment after birth for presumed sepsis and rupture lumbar puncture to rule out meningitis was negative with white blood cells red blood cells glucose and protein level of gram stain was negative and culture was negative since that time patient has not undergone antibiotic therapy neurology head ultrasound was performed at week of age which showed a grade left sided ivh follow up week later on showing a resolving grade bleed on the left side versus choroid plexus cyst the one month ultrasound on showed no interval change per radiology given the lack of interval change as would be expected with an ivh with retrospective review of the films the left sided process likely represents a choroid plexus cyst rather than hemorrhage no follow up is necessary sensory audiology hearing screen was performed with automated auditory brain stem responses and was passed ophthalmology patient underwent ophthalmologic examination on which showed immature zone retinal development with follow up recommended in weeks condition on discharge stable discharge disposition home name of primary pediatrician dr at pediatrics care recommendations feeds at discharge p o ad lib similac kilocalorie per ounce formula medications ferrous sulfate mg ml concentration ml p o qday iron and vitamin d 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 international units daily until months corrected age follow up pediatrician within a few days of discharge vna referral made home care ei referral made to minute man ei program ophthamology dr am car seat position screening was performed today and passed state newborn screening sent on and no abnormal results reported immunizations received hepatitis b vaccine on immunizations recommended synagis rsv prophylaxis should be considered from through for infants to any meet any of the following 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 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 and home care givers this infant has not received 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 discharge diagnoses respiratory distress syndrome resolved apnea of prematurity resolved rule out sepsis resolved hyperbilirubinemia resolved grade interventricular hemorrhage versus choroid plexus cyst small hemangioma on skin overlying chest stable small umbilical hernia stable cardiac murmur consistent with peripheral pulmonic stenosis pps dictated by medquist d t job,"{
""Diagnoses"": [""prematurity"", ""infant born to a year old gravida para mother"", ""IVF"", ""dichorionic diamniotic twin gestation"", ""reduced from triplets""],
""Medications"": [""betamethasone"", ""nitrazine"", ""fern testing""]
}"
18962,admission date discharge date service surgery allergies penicillins a c e inhibitors avapro attending chief complaint nausea vomiting change of mental status major surgical or invasive procedure exploratory laparotomy and lysis of adhesions history of present illness pt admitted through er with day complaint of abd pain and worsening nausea and vomiting pt denied fever chills dysuria pt denies any similar episodes of abdominal pain brought to er from rehab for evaluation past medical history coronary artery disease status post myocardial infarction in diastolic congestive heart failure atrial fibrillation hypertension hypercholesterolemia gastroesophageal reflux disease esophageal stricture status post dilation hypothyroidism status post right hip fracture approximately years ago cerebrovascular accident approximately in peripheral vascular disease status post right femoral popliteal bypass status post hysterectomy bronchiectasis aspiration pna anxiety depression social history lives in the nursing home denies tobacco or alcohol family history non contributory physical exam physical exam on discharge gen elderly appearing woman wearing oxygen face mask respondiny appropriately and clearly to questions cv rrr pulm crackles on r side l clear abd soft nt well healing incision with staples no erythema induration or drainage ext cool clearly palpable pulses pertinent results am blood plt smr very high plt ct am blood pt ptt inr pt am blood pt ptt inr pt brief hospital course pt admitted through er for complaint of abd pain nausea and change in mental status concern was greatest for superior mesenteric artery syndrome versus small bowel obstruction based on pt s surgical history ct scan revealed a high grade obstruction free fluid and a transition point this situation was explained to the patient who verbalized good understanding and consented to the plan for operative management after a complete discussion of the risks and benefits and all her questions were answered initially pt s inr was and this was appropriately corrected with ffp pt underwent an exploratory laparotomy in which a strangulating band was lysed and the bowel was deemed healthy and viable she was transferred to the sicu post operatively to optimize her pulmonary status pt was extubated on without incident pt was restarted on her lasix as she began to exhibit signs of chf and was maintained on nitroglycerin drips for bp control pt did have occasional episodes of agitation but her mental status cleared her bp control was optimized and she was transferred to the floor on coumadin a chronic medication for her atrial fibrillation was restarted on her mental status continued to improve and her oral intake also improved pt continued to have occasional desaturations to the high s despite being on a facemask although this significantly improved with nebulizer treatments pt is likely to require home oxygen for some time a chest x ray from revealed no effusions or infiltrates on pt continued to do well and was deemed suitable for transfer back to rehab s medications on admission ipratropium bromide solution sig one inhaler inhalation q h every hours as needed fluticasone propionate mcg actuation aerosol sig two puff inhalation times a day nifedipine mg tablet sustained release sig one tablet sustained release po daily daily docusate sodium mg capsule sig one capsule po bid times a day simvastatin mg tablet sig one tablet po daily daily trazodone hcl mg tablet sig tablets po hs at bedtime gabapentin mg capsule sig one capsule po hs at bedtime lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily levothyroxine sodium mcg tablet sig one tablet po daily daily furosemide mg tablet sig one hundred mg po qam furosemide mg tablet sig one tablet po qpm atenolol tartrate mg tablet sig one tablet po bid times a day bupropion hcl mg tablet sustained release sig one tablet sustained release po bid times a day warfarin sodium mg tablet sig one tablet po once once this medication will be changed frequently based on your blood tests alprazolam mg tablet sig one tablet po tid times a day as needed discharge medications ipratropium bromide solution sig one inhaler inhalation q h every hours as needed fluticasone propionate mcg actuation aerosol sig two puff inhalation times a day nifedipine mg tablet sustained release sig one tablet sustained release po daily daily docusate sodium mg capsule sig one capsule po bid times a day simvastatin mg tablet sig one tablet po daily daily trazodone hcl mg tablet sig tablets po hs at bedtime gabapentin mg capsule sig one capsule po hs at bedtime lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily levothyroxine sodium mcg tablet sig one tablet po daily daily furosemide mg tablet sig one hundred mg po qam furosemide mg tablet sig one tablet po qpm metoprolol tartrate mg tablet sig one tablet po bid times a day bupropion hcl mg tablet sustained release sig one tablet sustained release po bid times a day warfarin sodium mg tablet sig one tablet po once once this medication will be changed frequently based on your blood tests alprazolam mg tablet sig one tablet po tid times a day as needed discharge disposition extended care facility for the aged discharge diagnosis small bowel obstruction discharge condition good discharge instructions please continue to take all prescribed medications please keep wound clean and dry staples will be removed at your follow up visit please continue to use oxygen therapy as needed consult md or return to er if you develop fevers chills nausea vomiting abd pain or other concerning symptoms followup instructions please see dr in week for follow up and removal of staples [NEW_RECORD] admission date discharge date service medicine allergies penicillins a c e inhibitors avapro attending chief complaint incarcerated hernia major surgical or invasive procedure none history of present illness yo f h o cad s p mi x diastolic chf htn hl hypothyroidism cva p w abdominal pain transferred to micu for respiratory depression pt was in her usoh until yesterday evening when found at senior life to be in abdominal pain with nausea and nbnb emesis pt was afebrile and vitals were stable transferred to for further evaluation in the ed vitals rr sat on o sbo on ct related to her ventral hernia patient was seen by surgery who manually reduced her hernia felt she is not a surgical candidate pt confirmed she was a dnr dni and did not want surgery even if it was offered cardiac enzymes were positive and pt was started on heparin gtt pt given zofran morphine mg total and dilaudid mg total levo flagyl aspirin pt transferred to the when the pt arrived on the floor pt was unresponsive breathing at a rate of breaths per minute satting ra pt supported initially with ambu bag pt given narcan mg x and became more reponsive sbp initially in the s but increased to the s after narcan given lopressor mg iv x lasix mg iv x sats recovered on nrb abg stat cxr with evidence of r sided infiltrate ekg junctional bradycardia qtc ste v twi v transferred to micu service for further monitoring past medical history atrial fib anticoagulated on coumadin serere scoliosis with chronic back pain cad s p mi in and diastolic chf htn hypercholesterolemia gerd esophageal stricture s p dilation hypothyroidism s p r hip fracture s p cva pvd s p right femoral popliteal bypass s p hysterectomy bronchiectasis aspiration pna anxiety depression left putaminal infarction s p sigmoid resection for benign adenoma s p cholecystectomy social history pt lives at senior life has two daughters who are very involved in her care first emergency contact and hcp is her daughter her phone number is no tobacco or etoh she had her pneumovax in and her flu vaccine on family history non contributory physical exam temp bp pulse resp o sat l nc gen somnolent answering questions heent per sluggishly rl anicteric mucous membranes dry neck jvp cm no cervical lymphadenopathy chest crackles at bases cv brady regular no murmurs abd soft mildly tender over hernia which is midline and reducible normoactive bowel sounds extr no edema dp pulses bilaterally neuro ox following commands skin no rash pertinent results pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts bands lymphs monos eos baso pm blood glucose urean creat na k cl hco angap am blood ck cpk ck mb mb indx ctropnt pm blood ck cpk pm blood ck mb mb indx ctropnt pm blood ck cpk ck mb mb indx ctropnt am blood ck cpk ck mb ctropnt ekg baseline artifact sinus bradycardia versus slow atrial fibrillation anterior st segment elevations are suggestive of myocardial infarction compared to the previous tracing st segment elevation is more prominent and rhythm has changed atrial flutter with conduction possible anterolateral myocardial infarction and acute inferior st t wave changes may be due to myocardial ischemia compared to the previous tracing of st segment elevations are more prominent in the lateral leads in the current tracing studies ct abdomen pelvis periumbilical hernia contains a small portion of small bowel with distention of bowel proximally and nondistention distally correlate clinically for suspicion of early small bowel obstruction at this site though the neck of the hernia appears somewhat narrow today it appeared wide on ct of and may be manually reducible no evidence of bowel ischemia chronic severe wedge compression fracture of t chronic bibasilar atelectasis diverticulosis without acute diverticulitis tte the left atrium is markedly dilated no left atrial mass thrombus seen best excluded by transesophageal echocardiography there is mild symmetric left ventricular hypertrophy with normal cavity size there is moderate regional left ventricular systolic dysfunction with severe hypokinesis akinesis of the distal half of the septum and anterior walls the apex is mildly aneurysmal and dyskinetic no left ventricular mass thrombus is seen 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 mild mitral regurgitation is seen there is mild pulmonary artery systolic hypertension significant pulmonic regurgitation is seen there is no pericardial effusion compared with the prior study images reviewed of the left ventricular wall motion anbormalities are new and c w interim ischemia infarction cxr cardiomegaly is stable there is bibasilar atelectasis with no definite evidence of pneumonia the pulmonary vasculature is within normal limits impression no definite acute cardiopulmonary disease cxr a single ap view of the chest is obtained on at hours and compared with the prior morning s radiograph again is seen prominence of the interstitial markings which may represent fluid overload or early edema small bilateral pleural effusions are present the patient has had a nasogastric tube placed with its tip not included on the current image but below the level of the diaphragm cxr in comparison with the study of the nasogastric tube has been removed otherwise little change in the enlargement of the cardiac silhouette and fluid overload or pulmonary edema and small bilateral pleural effusions brief hospital course the patient is a year old woman with h o cad diastolic chf htn and prior cva admitted with ventral hernia whose hospital course was complicated by micu stay for respiratory depression in the setting of narcotics as well as stemi which was medically managed ventral hernia sbo the patient was evaluated by the general surgery service while in the ed who manually reduced bowel the patient and her family declined surgical intervention and was deemed not a surgical candidate by surgery team she was treated supportively with an abdominal binder dr outpatient physician was contact re further recommendations for palliative management she will see ms as an outpatient for further follow up stemi the hospital course was complicated by stemi in the context of bp likely related to severe abdominal pain ekg showed anterior st elevations v and peak troponin on follow up echo showed akinesis of apex and dyskinesis hypokinesis of anterior septum per cardiology recommendations and patient family preferences the patient was treated with medical management as she is poor cath candidate she was treated with heparin gtt x hours and was continued on asa lopressor plavix and statin despite the akinesis of her apex she was not felt to be a candidate for anticoagulation the patient and her family are aware of the risk of mechanical complications of mi they are aware that a critical event might occur and discussions with palliative care are underway just prior to her discharge the patient was made comfort measures only her cardiac meds were adjusted accordingly and only the medications that might help prevent episodes of shortness of breath or further discomfort were continued the palliative care team at rehab have been made aware of this transition respiratory distress the patient was briefly transferred to the micu for respiratory depression most likely secondary to narcotic medications administered for abdominal pain she received narcan in the micu with significant improvement in breathing patient continues to have episodes of dyspnea most likely due to volume overload in setting of impaired pump function recent mi ddx also includes mechanical complications of mi although hemodynamics have been stable pe but was recently on heparin gtt pna has not developed fevers she has responded well to lasix nitropaste and morphine with significant improvement in her respiratory status lasix and morphine can be continued to keep her breathing comfortably delirium the patient experienced some delirium after being transferred from the micu delirium was felt to be multifactorial associated with hospital setting pain medications and hypernatremia she was continued on supportive treatment with removal of foley catheter and physical restraints benzodiazepines anticholinergics and sleeping medications were avoided she responded well to frequent reoorientation at the time of discharge she was alert and oriented to person time and place hypernatremia most likely due to free water deficit in setting of altered mental status as the patient has been made comfort measures only the medical team and the patient s family have decided not to follow her sodium level regularly or to contine iv fluids afib the patient was continued on home bb with good rate control the patient does not appear to have been on coumadin by rehab records despite chads score of coumadin was not started in house given concern for high fall risk in setting of delirium treatment with high dose aspirin was continued but stopped just before discharge when she was made comfort measures only hypothyroidism the patient was continued on synthroid at home dose chronic renal failure creatinine at baseline medications were renally dosed code comfort measures only medications on admission tylenol tramodol lasix mg daily toprol mg daily mirtazipine omeprazole mg daily kcl spironolactone xanax vit d wellbutrin levothyroxine mg daily allergies penicillins a c e inhibitors avapro discharge medications bisacodyl mg suppository sig one suppository rectal hs at bedtime as needed levothyroxine mcg tablet sig one tablet po daily daily lidocaine mg patch adhesive patch medicated sig one adhesive patch medicated topical q h every hours hours on hours off alprazolam mg tablet sig one tablet po tid times a day as needed for agitation furosemide mg tablet sig one tablet po bid times a day hydralazine mg tablet sig two tablet po q h every hours hold for sbp acetaminophen mg tablet sig tablets po every six hours as needed for pain wellbutrin sr mg tablet sustained release sig one tablet sustained release po once a day mirtazapine mg tablet sig one tablet po once a day omeprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day oxygen please provide l of oxygen by nasal cannula to support patient s o saturation and provide comfort morphine concentrate mg ml solution sig mg po q h as needed for pain or shortness of breath please titrate to patient s comfort but would start with low doses given that patient had episode of narcotic induced respiratory depression metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po once a day discharge disposition extended care facility for the aged ltc discharge diagnosis primary ventral hernia st elevation mi acute systolic heart failure respiratory failure likely narcotics secondary atrial fibrillation cad diastolic chf htn hypercholesterolemia bronchiectasis anxiety depression discharge condition patient had stable vital signs and was sat ing well on l of oxygen by nasal cannula she is comfort measures only discharge instructions you were admitted with abdominal pain that was due to a hernia you should continue wearing your abdominal binder to prevent further episodes of this during your hospital course you had a heart attack for which you should continue several medications as listed below you had difficulty breathing probably due to receiving a lot of pain medications which resolved in the icu please continue to take all of your medications as prescribed please attend all of your follow up appointments if you experience any fevers chills abdominal pain chest pain palpitations shortness of breath or any other concerning symptoms please contact your pcp or go to the er for further evaluation medication changes we changed your lasix from mg daily to mg twice a day we started the following medications to help your heart and to treat your pain hydralazine and lidocaine patch we stopped the following medications because it was unclear that you still need them your doctors rehab may choose to restart them maalox miacalcin calcium carbonate cholecalciferol spironolactone tramadol potassium followup instructions please follow up with your pcp within weeks of discharge to discuss your hospitalization phone please follow up with dr provider md phone date time completed by,{}
22813,admission date discharge date date of birth sex m service neonatology history of present illness was born at and weeks gestation to a year old gravida iv para now i woman mother s prenatal screens were blood type ab positive antibody negative rubella immune rpr nonreactive hepatitis surface antigen negative and group b strep unknown the mother s prenatal history is remarkable for systemic lupus erythematosus treated with prednisone and imuran possibly as late as seven weeks gestation her previous medical history is also remarkable for gastritis treated with pantoprazole the mother had spontaneous onset of labor rupture of membranes occurred at delivery she did receive intrapartum antibiotics the infant delivered via spontaneous vaginal delivery apgars were eight at one minute and nine at five minutes the birth weight was grams the birth length was cm the birth head circumference was cm all at approximately the th percentile for gestational age with the head circumference being less than the th percentile the admission physical examination reveals a vigorous mildly dysmorphic preterm small for gestational age infant anterior fontanel open and flat palate intact breath sounds are clear and equal heart was regular rate and rhythm grade i over vi systolic murmur abdomen soft no masses premature male external genitalia testes descended bilaterally patent anus no sacral anomalies clavicles intact stable hips age appropriate tone and reflexes he does have some mildly dysmorphic features he has a very prominent occipital protuberance inion depressed nasal bridge and shortened fingers hospital course respiratory status remained in room air he has comfortable respirations he has had no episodes of apnea or bradycardia cardiovascular status he has had an intermittent grade i over vi systolic ejection murmur heard at the left mid sternal border consistent with a flow murmur or peripheral pulmonic stenosis on examination he is pink and well perfused he has remained without cardiorespiratory signs or symptoms throughout his neonatal intensive care unit stay this should be investigated further if persistent fluids electrolytes and nutrition at the time of discharge his weight is grams his length is cm and head circumference is cm enteral feeds were begun on the day of delivery and advanced without difficulty to full volume feedings at the time of discharge he is taking formula calories per ounce calories per ounce made from concentration and two calories per ounce made from corn oil he is eating on an ad lib schedule with consistent weight gain gastrointestinal status he was treated with phototherapy for hyperbilirubinemia on day of life number two until day of life number three his peak bilirubin occurred on day of life number two and was total of and direct of hematology status last hematocrit on was he is receiving supplemental iron he has never received any blood product transfusions infectious disease he was started on ampicillin and gentamicin at the time of admission for sepsis risk factors the antibiotics were discontinued after hours when the infant was clinically well and the blood cultures were negative he remained off antibiotics since that time on he was started on nystatin ointment for a monilial diaper rash and continues on that at the time of discharge neurology head ultrasound on was completely within normal limits and head ultrasound on was within normal limits with the finding of a small choroidal plexus cyst he was evaluated by neurosurgery for the prominent inion and it was felt that it was not concerning and could be followed clinically without need for further neurosurgical involvement sensory audiology hearing screen was performed with automated auditory brain stem responses and he passed in both ears genetics was followed by dr of genetics he did have a normal karyotype of xy they would like to see him in the genetics clinic six to eight weeks after discharge telephone number is genitourinary the infant was circumcised on the area is healing nicely psychosocial parents have been very involved in the infant s care throughout his neonatal intensive care unit stay they have been followed by social worker beeper number occupational therapy has been followed by the neonatal intensive care unit occupational therapist for lower extremity dorsiflexion contractures and hip external rotation the mother has been trained in proper exercise for this and demonstrates good ability to do these exercises he will be followed by early intervention for this the infant is discharged in good condition to home with his parents primary pediatric care south health center telephone number recommendations feedings formula calories per ounce calories per ounce made from concentration calories per ounce from added corn oil on an ad lib schedule to maintain consistent growth the infant is discharged on two medications iron sulfate mg per ml ml p o daily nystatin ointment topically to diaper area four times daily state newborn screen was sent last on received his hepatitis b vaccine on recommended immunizations synagis rsv prophylaxis should be considered from to for infants who meet any of the following three criteria born at less than weeks born between 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 or with chronic lung disease 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 dr of genetics six to eight weeks after discharge telephone number early intervention of the bay cove early intervention telephone number care group telephone number discharge diagnoses prematurity at and weeks gestation small for gestational age sepsis ruled out intermittent murmur consistent with peripheral pulmonic stenosis status post hyperbilirubinemia of prematurity choroid plexus cyst monilial diaper rash mild dysmorphism prominent inion status post circumcision reviewed by dictated by medquist d t job,"{
""Diagnoses"": [""Systemic lupus erythematosus"", ""Gastritis"", ""Rupture of membranes""],
""Medications"": [""Prednisone"", ""Imuran"", ""Pantoprazole""]
}"
13113,unit no admission date discharge date date of birth sex f service neonatology history of present illness baby girl is the gram product of a and weeks gestation born to a year old g p now mother prenatal screens a positive antibody negative hepatitis surface antigen negative rpr nonreactive rubella immune gbs positive mother presented on day of delivery for routine follow up and was found to be severely hypertensive with proteinuria subsequent evaluation revealed mildly elevated liver function tests and mildly decreased platelets consistent with hellp syndrome prompting cesarean section delivery biophysical profile was out of mother was treated with hydralazine and magnesium prior to delivery and received one dose of penicillin hours prior to delivery there was no labor noted and membranes were intact at delivery of note this mother is in custody of her older sibling father of baby is involved and was present prior to the delivery at delivery the infant emerged vigorous and assigned apgars of and physical examination vital signs gram th to th percentile head circumference cm th to th percentile length cm th percentile general active warm dry premature infant in no distress responsive to examination heent fontanel soft and flat ears and nares normal palate intact positive red reflexes bilaterally neck supple no lesions chest moderately aerated clear no grunting flaring or retracting cardiovascular regular rate and rhythm no murmurs abdomen soft no hepatosplenomegaly quiet bowel sounds three vessel cord genitourinary normal female anus patent femoral pulses and symmetric hips stable back normal tone and activity appropriate for gestational age summary of hospital course by systems respiratory has been stable in room air throughout hospitalization she has not required any methylxanthines her last documented apnea bradycardia episode was on cardiovascular no issues fluids electrolytes and nutrition birth weight was she was started on enteral feedings on day of life full enteral feedings were achieved by day of life she is currently ad lib feeding taking in excess of cc per kg per day assuring good weight gain mom is breast feeding the infant is taking enfamil or breast milk calorie her discharge weight is gms gastrointestinal peak bilirubin was on day of life at she has not required any intervention infectious disease cbc and blood culture obtained on admission cbc was benign blood culture was negative at hours the infant has had no other issues with infectious disease hematology hematocrit on admission was the infant has not required any blood transfusions neurology the infant has been appropriate for gestational age audiology hearing screen was performed with automated auditory brain stem responses and the infant passed in both ears psychosocial this is a year old mother who is in custody of her older sister father of baby is involved mother is very competent with the patient s care condition on discharge stable discharge disposition to home name of primary pediatrician dr medical care inc telephone no fax no care recommendations continue ad lib feeding of enfamil calorie or breast milk calorie ad lib medications none car seat position screen the patient passed the infant car seat position screen test of minutes the state newborn screen the last state newborn screen was sent as per protocol and have been within normal limits immunizations received hepatitis b vaccine on discharge diagnosis premature infant mild apnea of prematurity sepsis evaluation m d dictated by medquist d t job,"{
""Diagnoses"": [""Hellp Syndrome"", ""Hypertension"", ""Proteinuria"", ""Liver Function Tests Abnormal"", ""Platelets Decreased""],
""Medications"": [""hydralazine"", ""magnesium"", ""penicillin""]
}"
71327,admission date discharge date service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint fever hypotension major surgical or invasive procedure none history of present illness yo male with a h o colon cancer s p colectomy melanoma s p excision cad s p mi w pci to lad htn presented to the ed following syncopal episode the patient remembers falling but says it happened so fast that he is not sure what happened per his son over the last three days he has become progressively more weak and last night was unable to dress himself or walk per the patient and his son he has had no fever cough nausea vomiting diarrhea dysuria rash headache chest pain or palpitations also deny recent weight loss constipation blood in stool or melena son said he had some sneezing days ago he last took his bp med ace yesterday morning no sick contacts in the ed initial vs were on ra the patients labs were remarkable for leukocytosis negative cardiac enzymes ua was negative for infection cxr was unremarkable ekg showed nsr with st depressions in ii v v v he received a l of ns and was awaiting a bed on the regular medicine floor however prior to transfer to the floor the patient sustained a fall from bed did not lose consciousness head and c spine ct showed no acute process he then spiked a temp to blood cultures were sent and the patient was given tylenol vanco oseltamivir ceftriaxone levofloxacin repeat wbc was down from to but had a new bandemia creatinine was stable at lactate was and second set of cardiac enzymes was negative dfa for flu were sent flu negative blood cultures pending repeat cxr showed no change his sbp dropped to the s and he received l fluid according to ed records his bp ranged to on transfer to the floor hr though per verbal report he did have one of systolic in the s has peripheral ivs coming to icu for hypotension on the floor the patient reports feeling well continues to deny any symptoms review of systems per hpi denies fever chills night sweats recent weight loss or gain denies headache sinus tenderness rhinorrhea or congestion denies cough shortness of breath or wheezing denies chest pain chest pressure palpitations or weakness denies nausea vomiting diarrhea constipation abdominal pain or changes in bowel habits denies dysuria frequency or urgency denies arthralgias or myalgias denies rashes or skin changes past medical history hypertension coronary artery disease with mi on s p stent to distal lad colon cancer s p right colectomy melanoma on bac s p wide excision social history the patient was born in then moved to and came to the us in the s he retired engineer he lives with his son and reports being independent in adls but having memory problems denies ever tobacco etoh drug use family history non contributory physical exam 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 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 ck cpk totbili pm blood ctropnt pm blood albumin calcium pm blood albumin calcium phos mg pm blood type art po pco ph caltco base xs comment green top am blood lactate labs on transfer from the icu am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts lymphs monos eos baso am blood hypochr anisocy normal poiklo normal macrocy normal microcy normal polychr normal am blood plt ct am blood glucose urean creat na k cl hco angap am blood alt pnd ast pnd ld ldh pnd ck cpk alkphos pnd totbili pnd pm blood ck cpk am blood ck mb ctropnt am blood albumin pnd calcium phos mg pm blood type art po pco ph caltco base xs pm blood lactate am blood culture venipuncture final report blood culture routine final fusobacterium nucleatum anaerobic bottle gram stain final gram negative rod s imaging radiology report cta chest w w o c recons non coronary study date of pm final report indication year old man with fever and hypotension history of colon cancer comparison technique pre and post contrast axial images were obtained through the chest post contrast images were obtained through the abdomen and pelvis multiplanar reformatted images were generated ct chest without and with iv contrast the pulmonary arterial tree is well opacified and there is no pulmonary embolus the thoracic aorta is normal in caliber without dissection pseudoaneurysm or acute abnormality mild atherosclerotic calcifications are noted at the aortic arch and coronary vessels the left common carotid artery and the right brachiocephalic artery arise from a common trunk off the aortic arch small lymph nodes in the mediastinum and hila do not meet size criteria for pathologic enlargement a precarinal node measures mm in short axis a right hilar lymph node measures mm in short axis the heart size is normal without pericardial effusion there are calcified right hilar and sub carinal nodes consistent with granulomatous disease the coronary arteries are heavily calcified in the lungs mild dependent atelectasis is noted bilaterally without consolidation or pleural effusion the tracheobronchial tree is patent to subsegmental levels there is posterior indentation of the proximal trachea suggestive of teacheal malacia ct abdomen with iv contrast in the caudate lobe of the liver a x cm hypodense lesion abuts the ivc and there is loss of the fat plane between the liver and ivc concerning for vascular invasion the lesion is predominantly hypodense with no peripheral enhancement demonstrating somewhat irregular margins additionally there are tiny hypodense lesions in the upper left lobe and anterior right lobe too small to characterize no other liver lesions are identified there is no intra or extra hepatic biliary ductal dilatation the gallbladder is unremarkable the pancreas demonstrates fatty replacement the spleen adrenal glands stomach and duodenum are unremarkable the kidneys enhance and excrete contrast symmetrically without hydronephrosis stones or worrisome renal masses the infrarenal abdominal aorta demonstrates a x cm fusiform dilatation there is mild atherosclerotic calcification major branches are patent there is no free air or free fluid in the abdomen there is no retroperitoneal or mesenteric lymphadenopathy by size criteria ct pelvis with iv contrast the patient has undergone prior right colectomy there is moderate diverticulosis involving the descending and sigmoid colon without diverticulitis the remaining loops of small and large bowel are unremarkable the urinary bladder contains a foley catheter and a small amount of air consistent with instrumentation there is no free fluid in the pelvis the prostate gland is unremarkable there is no pelvic or inguinal lymphadenopathy by size criteria osseous structures there is no fracture or worrisome bony lesion degenerative changes are present in the spine impression no pulmonary embolus or acute aortic abnormality clear lungs aside from mild atelectasis cm irregular hypodense lesion in the caudate lobe of the liver concerning for metastasis this closely abuts and may invade the adjacent ivc abscess is considered less likely given the absence of gas within the lesion and the absence of peripheral enhancement no acute bowel abnormality or intraperitoneal collection to suggest other source of infection diverticulosis without diverticulitis case was enetered into critical results reporting ct c spine w o contrast study date of am final report indication year old male status post fall comparison no prior study available for comparison technique contiguous axial images were obtained through the cervical spine no contrast was administered coronal and sagittal reformats were displayed findings c through c are visualized there is no acute fracture there is no prevertebral soft tissue swelling there is grade anterolisthesis of c on c age indeterminate without prior study available for comparison ct is not able to provide intrathecal detail comparable to mri there is extensive multilevel degenerative change with an endplate osteophyte formation and facet arthropathy at c c there is small disc osteophyte complex without canal narrowing or deformity of the thecal sac at c there is heterotopic bone along the inner surface of the right lamina which abuts the cord at c c there is mild central disc bulge without narrowing of the canal at c there is heterotopic bone along the right lamina which narrows the canal but does not abut the cord at c c there is disc osteophyte complex with mild narrowing of the canal but no compression of the thecal sac impression no acute fracture grade anterolisthesis of c on c age indeterminate without prior study available for comparison multilevel degenerative change as above may predispose the patient to cord injury in the setting of trauma if there is clinical concern and no contraindication mri may be obtained for further evaluation echocardiogram the left atrium is mildly dilated no atrial septal defect is seen by d or color doppler there is mild symmetric left ventricular hypertrophy with normal cavity size there is mild regional left ventricular systolic dysfunction with inferior and infero lateral hypokinesis 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 root is mildly dilated at the sinus level 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 no mitral valve prolapse the tricuspid valve leaflets are mildly thickened the pulmonary artery systolic pressure could not be determined there is no pericardial effusion compared with the report of the prior study images unavailable for review of no definite change mri abdomen findings there is a x cm mass within the caudate lobe which is hypointense on t weighted images and slightly hyperintense on t weighted images this lesion demonstrates heterogeneous enhancement on post contrast images with central nonenhancing regions likely representing necrosis there appears to be a small vessel running through this lesion image of series there are no other focal liver lesions and there is no intra or extra hepatic biliary dilatation the portal veins and hepatic veins are patent there are no pathologically enlarged lymph nodes by size criteria the gallbladder is decompressed and contains a stone the adrenal glands spleen and pancreas are normal there are bilateral renal parapelvic cysts the visualized portions of the gastrointestinal tract are unremarkable and there is no concerning bone marrow abnormality multiplanar d and d reformations and subtraction images provided multiple perspectives for the dynamic series impression enhancing mass within the caudate lobe highly suspicious for malignancy imaging features do not suggest abscess cholelithiasis brief hospital course year old man with history of cad colectomy for colon ca in melanoma htn who presents with fever and relative hypotension sepsis patient admitted initially to micu with fever and relative hypotension regarding infectious workup cxrx no evidence of pna dfa for flu was negative u a negative cardiac etiology of hypotension less likely as patient ruled out for mi and no signs of chf however at age could have as and vasodilation in the setting of fever pain could cause hypotension so echocardiogram was done no as see above initially patient was treated with broad spectrum antibiotics flagyl cefepime vancomycin he remained afebrile with resolving leukocytosis on this regimen his blood cultures eventually revealed fusobacterium and suspected source was necrosis within liver mass id team was consulted and followed throughout his hospital course transplant surgery dr followed the patient as well and discussed surgical options with the patient and his family it was their wish to decline surgery at this time given the patient s age comorbidities and multiple risks of the surgery he will complete a day course of antibiotics received iv flagyl cefepime inhouse to receive po augmentin to complete course syncope by history appears to have been vasovagal or micturition syncope but more likely poor cerebral perfusion due to hypotension as it occurred after taking his bp meds in the setting of likely sepsis no acute intracranial process no acute fracture on spine infectious workup was completed as above the patient was orthostatic intermittently throughout hospital course but this was responsive to fluids he was seen by physical therapy liver lesions identified on ct scan and confirmed on mri concerning for metestatic disease tumor markers revealed normal afp and cea no biopsy or surgical intervention was performed given treatment goals of patient avnrt during his stay in the micu the patient had new avnrt he was started on diltiazem with good effect and no further episodes of avnrt on the general medical floor over the course of a week acute on chronic renal failure cr elevated to on admission and trended down to with ivf hydration likely prerenal in the setting of poor po intake dehydration prior to hospitalization cad continued aspirin lipid panel was drawn and ldl was at goal so statin not started hypertension lisinopril uptitrated from mg to mg in the setting of persistent bp s of s s systolic and s diastolic this should be further titrated as an outpatient medications on admission zestril mg po daily asa mg po daily discharge medications aspirin mg tablet chewable sig one tablet chewable po daily daily diltiazem hcl mg capsule sust release hr sig one capsule sust release hr po once a day zestril mg tablet sig one tablet po once a day augmentin mg tablet sig one tablet po twice a day for days take through disp tablet s refills discharge disposition extended care facility for the aged discharge diagnosis primary diagnosis bacteremia sepsis liver mass avnrt syncope secondary diagnosis hypertension coronary artery disease s p colon cancer s p melanoma discharge condition mental status confused sometimes level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions you were admitted to on with low blood pressures and fevers we did blood cultures which showed a bloodstream infection you will need to take antibiotics when you leave the hospital for this infection until we also did imaging and found a mass in your liver we strongly suspect that this is a malignant tumor as we discussed with you and your family per your wishes we did not pursue any surgical options dr discussed this with you and your family the following changes have been made to your medications start taking augmentin through this is an antibiotic start taking diltiazem for your fast heart rate increase lisinopril to mg for your blood pressure followup instructions when monday name b location cardiology associates of greater address phone,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""service medicine"", ""allergies"", ""patient recorded as having no known allergies to drugs"", ""attending chief complaint"", ""fever"", ""hypotension"", ""major surgical or invasive procedure"", ""history of present illness"", ""yo male with a h o colon cancer"", ""s p colectomy"", ""melanoma"", ""s p excision"", ""cad s p mi"", ""w pci to lad"", ""htn""],
""Medications"": [""ace""]
}"
15249,admission date discharge date date of birth sex m service nb history is a weeks gestation male admitted from the delivery room for persistent grunting his mother is a year old g p now with the following prenatal screens o positive antibody negative rpr nonreactive rubella immune hepatitis b surface antigen negative gbs positive pregnancy was uncomplicated spontaneous rupture of membranes hours prior to delivery the patient received adequate intrapartum antibiotic prophylaxis there was no maternal fever was delivered by normal spontaneous vaginal delivery required only routine delivery room care but then developed intermittent tachypnea and persistent grunting flaring and retractions for which he was transferred to the neonatal intensive care unit at hours of age physical exam on admission weight gm th percentile head circumference cm length cm appropriate for gestational age vital signs respiratory rate heart rate blood pressure oxygen saturation percent on room air general nondysmorphic infant with overall appearance consistent with appropriate for gestational age heent anterior fontanel soft open and flat red reflex present bilaterally palate intact chest breath sounds clear but positive grunting flaring and retraction with increased grunting over time heart regular rate and rhythm without murmur plus peripheral pulses including femoral s skin pink and well perfused neuro alert and responsive with appropriate tone and strength hospital course by systems respiratory had an initial chest x ray consistent with mild respiratory distress syndrome he was initially placed on cpap from which he weaned by day of life he has since not had anymore respiratory distress was noted to have occasional desaturations and bradycardias associated with feeding most of these spells were self resolved they were overall attributed to his borderline prematurity and resolved by has not had any spells in the last days prior to discharge cardiovascular had a soft murmur discovered on day of life which was consistent with a pda murmur in subsequent days his murmur disappeared and has not been heard since fluid electrolytes and nutrition was initially maintained on iv fluids and then transitioned to oral feeds of breast milk or premature enfamil he has been feeding vigorously and is close to regaining his birthweight on the day prior to discharge he fed cc kg d with on demand feeds his weight at the time of discharge was kg head circumference cm and length cm heme developed some mild jaundice of prematurity for which he was treated with phototherapy from day of life his maximum bilirubin level was mg dl his rebound bilirubin level on day of life hour after discontinuing phototherapy was mg dl maternal blood type was o positive antibody negative initial hematocrit on admission was infectious disease had an initial sepsis work up because of his respiratory symptoms his initial white blood cell count was with percent neutrophils and percent bands treatment with ampicillin and gentamicin was administered for hours and discontinued at that point because cultures had remained negative surgical was circumcised on there were no complications sensory he passed the hearing screen was performed with automated auditory brain stem responses on condition on discharge stable the infant is stable on full feeds discharge disposition discharge to home primary care doctor md telephone number care recommendations breast feed or enfamil with iron po ad lib medications none car seat screening was successfully performed on repeat newborn screen was sent on initial results were normal immunizations hepatitis b vaccine was given on 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 follow up appointments should follow up with dr on discharge diagnoses prematurity at and week s gestational age mild respiratory distress syndrome resolved rule out sepsis resolved feeding dysmaturity of the premature resolved apnea of prematurity resolved hyperbilirubinemia of the premature resolved status post circumcision md dictated by medquist d t job,"{
""Diagnoses"": [""admission for persistent grunting"", ""intermittent tachypnea"", ""persistent grunting"", ""flaring and retractions""],
""Medications"": [""antibiotic prophylaxis"", ""oxygen saturation""]
}"
93631,admission date discharge date date of birth sex f service neurology allergies progestins estrogens attending chief complaint b l le numbness major surgical or invasive procedure none history of present illness ms is a y o right handed white woman with a pmh significant for depression anxiety and hyperlipidemia who presents with worsening b l upper and lower extremity sensory and motor defecits this all began last sunday week ago when she was gardening and felt a in her lower back there was no other associated symptoms at that time on monday she noted lower back and b l le stiffness on tuesday she noted intermittent numbness and tingling in her fingertips and feet b l this lasted all day on wednesday the numbness and tingling became continuous in duration and spread up her legs to the level of her knee she also began noticing strength problems on wednesday increased difficulty with raising legs and walking noted only minor weakness in the b l ue on wednesday she went to and osh and had a head ct and back x rays performed all were reportedly normal and she went home from the ed on thursday she went to her chiropractor for an adjustment of her back but did not feel any better and continued to have difficulty with ambulation she also had a bowel movement that evening she noted that the sensation did not feel normal when wiping she also says that the le numbness tingling had progressed up to her waist yesterday while brushing her teeth she began urinating on herself and did not notice she has since had no further issues with continence also yesterday she noted the onset of chest tightness describing the sensation of something sitting on her chest and making it harder for her to breathe though not to the point where it is difficult for her to take a breath that day she went back to the chriopractor for a different kind of adjustment while leaving she fell and subsequently her pcp was called and reccommedned an mri she went to the osh and had the mri performed and then went home she was called and told to come back to the hospital later that night after a neurologist believed she needed to be admitted she reports that the brain and lumbar spine mri was basically normal mri l spine with no focal disc protrusion and unremarkable conus she brought a copy of the images with her today the neurologist from the osh asked if she could be sent here for further evaluation and mangement she also notes that the numbness and tingling sensation has spread up to her lower abdomen no recent illnesses no recent vaccinations past medical history depression anxiety hyperlipidemia social history works in manufacturing and is also pca lives with boyfriend and son smokes pack cigarettes over days x years rare alcohol use occasional marijuana use no other illicit drug use family history mother with copd htn depression stroke father with heart disease and hepatits physical exam vitals t p r bp sao ra nif vc general awake cooperative nad heent nc at no scleral icterus noted dry mucus membranes neck supple no carotid bruits appreciated pulmonary lungs cta bilaterally cardiac rrr s s no murmurs abdomen soft tender to palpation along upper abdomen bs extremities no pitting edema skin no rashes noted neurologic mental status alert oriented x able to relate history without difficulty attentive able to name backwards able to calculate how many quarters in able to follow simple commands registration and recall at minutes no evidence of apraxia or neglect language speech is clear fluent non dysarhtric naming and repetiton intact no paraphasic errors cranial nerves i olfaction not tested ii perrl 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 rectal tone intact no pronator drift bilaterally no adventitious movements such as tremor noted no asterixis noted delt bic tri wre ffl fe io ip quad ham ta gastroc l r sensory light touch grossly intact except for diminshed sensation l inner thigh compared to r pinprick diminished up to knees in le b l and up to elbows on ue b l believe pinprick sensation further decreased on left compared to right no sensory level on torso normal pinprick on abdomen and thighs vibratory sense intact throughout but notes that the vibratory sense itself was weaker in lower extremity compared to upper extremity proprioception intact no extinction to dss dtrs tri pat ach l r plantar response was flexor bilaterally coordination no intention tremor no dysmetria on fnf unable to perform heel to shin due to le weakness on discharge b l facial weakness w nasal voice likely secondary to palatal weakness ue full strength le ip b l q b l h b l ta b l gastroc b l muted reflexes throughout pertinent results pm cerebrospinal fluid csf protein glucose pm cerebrospinal fluid csf wbc rbc polys lymphs monos pm glucose urea n creat sodium potassium chloride total co anion gap pm estgfr using this pm vit b folate pm urine hours random pm urine ucg negative pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count pm urine color yellow appear clear sp pm urine blood mod nitrite neg protein neg glucose neg ketone bilirubin neg urobilngn neg ph leuk neg pm urine rbc wbc bacteria rare yeast none epi brief hospital course ms was admitted to the service with a progressive lower extremity weakness and absent reflexes secondary to she had csf which showed a cytoalbuminologic dissociation and was started on a course of ivig for a total of days her weakness progressed in her lower extremities and she developed a nasal voice and bilateral facial weakness thought most likely to be secondary to cranial nerve involvement she also became tachycardic to the s for days which prompted a transfer to the icu for concern of autonomic involvement she was started on carvedilol and can continue on this medication until her pulse returns to baseline her clonidine was stopped as she required beta and there was concern for lower her blood pressure too rapidly there were no issues with breathing and she had vc l throughout admission she showed gradual improvement by the time of discharge with stronger facial muscles and increased strength in her lower extremities she can follow up in clinic with after her discharge from rehab and was given the clinic number uti the patient required a foley catheter as she was unable to feel when she was urinating she had a urinary tract infection noted overnight on and was started on oral ciprofloxacin for a day course and fluconazole for yeast infection medications on admission simvastatin lowest dose zovia ocp tegretol mg for depression clonidine mg tid discharge medications simvastatin mg tablet sig tablet po daily daily 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 bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for constipation fluconazole mg tablet sig one tablet po q h every hours as needed for vaginal yeast infection for days carvedilol mg tablet sig two tablet po tid times a day oxycodone mg tablet sig one tablet po q h every hours as needed for pain gabapentin mg capsule sig two capsule po tid times a day carbamazepine mg tablet sig one tablet po qam once a day in the morning carbamazepine mg tablet sig two tablet po daily carbamazepine mg tablet sig two tablet po qpm once a day in the evening ciprofloxacin mg tablet sig one tablet po q h every hours for days heparin porcine unit ml solution sig one ml injection tid times a day discharge disposition extended care facility rehab unit at discharge diagnosis syndrome complicated urinary tract infection 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 were admitted to the hospital for progressive weakness in your lower extremities and were found to have you were given a day course of ivig for treament of this condition you were briefly transferred to the icu for involvement of your autonomic nervous system and a fast heart rate your condition will improve gradually but you will require physical therapy and rehabilitation you also have foley catheter and need to be put on a course of antibiotics to treat this followup instructions will be transferred to rehab you can follow up in clinic with dr and phone after you are discharged from rehab please speak with to book an appointment completed by,"{
""Diagnoses"": [""Neurology""],
""Medications"": [""Progestins"", ""Estrogens""]
}"
32551,admission date discharge date date of birth sex m service neurosurgery allergies patient recorded as having no known allergies to drugs attending chief complaint intracranial hemorrhage major surgical or invasive procedure craniectomy and evacuation of intracerebral hemorrhage history of present illness yo male with no known pmh who presents with intracranial hemorrhage after fall of unclear etiology per ems reports patient was at a store and fell backwards and hit his head with proable loc the fall was not reportedly witnessed ems was called and en route to osh the patient reportedly had a minute generalized tonic clonic seizure treated with mg iv ativan at osh he reported had ct findings of subdural hematoma and parietal bone fracture he was then transferred to for neurosurgical evaluation ros patient reports no ha neck pain sob cp abdominal pain visual changes dysarthia dysphagia or diplopia past medical history unknown social history lives alone denies smoking history unclear etoh drug history family history deferred physical exam t bp hr r o sats gen wd wn comfortable nad heent pupils perrla eomi neck c collar on lungs cta bilaterally cardiac rrr s s abd soft nt bs extrem warm and well perfused mae without complaints of pain neuro mental status awake and alert cooperative with exam normal affect orientation oriented to person and woman s hospital reports date as despite prompting recall objects at minutes attention dow forwards but not backwards language speech fluent with good comprehension to follow midline and appendicular naming intact to hi frequency objects no dysarthria or paraphasic errors cranial nerves i not tested ii pupils equally round and reactive to light to mm bilaterally visual fields to threat intact iii iv vi extraocular movements intact bilaterally with primary and end gaze 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 has intention tremor bilaterally strength full power throughout both arms drift slightly with pronator drift sensation intact to light touch propioception pinprick reflexes b t br pa ac right left withdraws bilaterally coordination normal on finger finger movement gets confused when asked to do heel to shin has slow fingers taps pertinent results ct c spine no acute fracture or malalignment of the cervical spine mild retrolisthesis at the c level trop t comments ctropnt ctropnt ng ml suggests acute mi trauma agap estgfr click for details ck mb ca alt ap tbili alb ast ldh dbili tprot lip serum asa etoh acetmnphn benzo barb tricyc negative urine benzos barbs opiates cocaine amphet mthdne negative wbc hgb plts hct n l m e bas pt ptt inr ua neg nits and leu mod blood brief hospital course mr is year old male with an unknown past medical history who presented with intracerebral hemorrhage following a reported fall ct scan revealed extensive l frontal intraparenchymal hemorrhage with large subdural component he was admitted to the trauma icu service and on hd developed worsened mental status with ct evidence of midline cerebral shift he was taken emergently to the or for craniectomy and evacuation of the hemorrhage follow up ct scanning revealed improvement in midline shift the patient continued to have severely depressed mental status unable to follow verbal commands right upper and lower extremity hemiparesis with occasional spontaneous flexion of left upper and lower extremities the patient required appointment of a temporary guardian given his depressed mental status and inability to protect or maintain adequate upper airway patency the patient went for tracheostomy and peg placement at time of discharge to extended care facility the patient was tolerating trach mask and tube feedings from his extended care facility at care in he should follow up in neurosurgery clinic with dr in weeks with a repeat head ct scan medications on admission unknown discharge medications bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for constipation docusate sodium mg ml liquid sig one po bid times a day as needed for constipation metoprolol tartrate mg tablet sig tablets po tid times a day heparin porcine unit ml solution sig one injection times a day tube feedings per nutrition recommendations phenytoin mg ml suspension sig one po q h every hours therapeutic multivitamin liquid sig five ml po daily daily folic acid mg tablet sig one tablet po daily daily thiamine hcl mg tablet sig one tablet po daily daily senna mg tablet sig one tablet po bid times a day as needed for constipation famotidine mg tablet sig one tablet po bid times a day discharge disposition extended care facility discharge diagnosis intracerebral hemorrhage discharge condition fair neurologic exam stable discharge instructions admission for intracerebral hemorrhage alert physician or return to emergency department for depressed mental status fever or any other concerning symptoms followup instructions you have an appointment to see dr with neurosurgery in weeks with a follow up head ct scan md,"{
""Diagnoses"": [""intracranial hemorrhage"", ""craniectomy"", ""evacuation of intracerebral hemorrhage"", ""subdural hematoma"", ""parietal bone fracture""],
""Medications"": [""Ativan"", ""Mg iv"", "" unknown""]
}"
89165,admission date discharge date date of birth sex f service cardiothoracic allergies sulfa sulfonamides acyclovir and derivatives lasix attending chief complaint chest tightness major surgical or invasive procedure none history of present illness yo female s p des in cx who presented with chest tightness at got cathed and was found to have in stent thrombosis on pt was initially on neo gtt that was weaned off echo in the other hospital showed moderate mr and severe as pt is transferred to for further management past medical history past medical history lupus erythematosus lupus glomerulonephritis htn hypercholesterolemia coronary artery disease s p stent left circumflex gerd history shingles in the past diverticulitis with resection of the colon with later reconstruction right below the knee amputation a year secondary mrsa infection social history widowed lives with yo mother family history noncontributory physical exam physical exam afebrile pulse resp o sat b p right left height weight general skin dry x intact x 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 lle rle bka well healed edema varicosities none x neuro grossly intact pulses femoral right left dp right left pt left radial right left 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 pt ptt inr pt pm blood pt ptt inr pt am blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos amylase totbili echocardiography report portable tte 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 m indication aortic valve disease left ventricular function mitral valve disease myocardial infarction 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 vivid 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 systolic dimension cm left ventricle fractional shortening left ventricle ejection fraction 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 aorta arch cm cm aortic valve peak velocity m sec m sec aortic valve peak gradient mm hg mm hg aortic valve mean gradient mm hg aortic valve lvot pk vel m sec aortic valve lvot diam cm aortic valve valve area cm 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 right atrium interatrial septum normal ra size normal ivc diameter cm with decrease during respiration estimated ra pressure indeterminate left ventricle mild symmetric lvh normal lv cavity size mild regional lv systolic dysfunction mildly depressed lvef no resting lvot gradient right ventricle normal rv chamber size and free wall motion aorta normal aortic diameter at the sinus level normal aortic arch diameter no d or doppler evidence of distal arch coarctation aortic valve severely thickened deformed aortic valve leaflets moderate as area cm mild ar mitral valve mildly thickened mitral valve leaflets mild mitral annular calcification mild thickening of mitral valve chordae calcified tips of papillary muscles mild to moderate mr due to acoustic shadowing the severity of mr may be significantly underestimated lv inflow pattern c w restrictive filling abnormality with elevated la pressure tricuspid valve mildly thickened tricuspid valve leaflets mild tr normal pa systolic pressure pulmonic valve pulmonary artery pulmonic valve not visualized no ps physiologic pr pericardium no pericardial effusion general comments resting tachycardia hr bpm the rhythm appears to be atrial fibrillation regional left ventricular wall motion n normal h hypokinetic a akinetic d dyskinetic conclusions the left atrium is mildly dilated the right atrial pressure is indeterminate there is mild symmetric left ventricular hypertrophy the left ventricular cavity size is normal there is mild regional left ventricular systolic dysfunction with severe hypokinesis of the inferior inferolateral anterolateral and apical walls overall left ventricular systolic function is mildly depressed lvef 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 mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild to moderate mitral regurgitation is seen due to acoustic shadowing the severity of mitral regurgitation may be significantly underestimated the tricuspid valve leaflets are mildly thickened the estimated pulmonary artery systolic pressure is normal there is no pericardial effusion impression regional left ventricular systolic function consistent with coronary artery disease moderate aortic stenosis mild aortic regurgitation mild to moderate mitral regurgitation electronically signed by md interpreting physician caregroup is all rights reserved brief hospital course yo female s p drug eluding stenet in the circumflex who presented with chest tightness at osh got cathed and was found to have in stent thrombosis on an echocardiogram at the other hospital showed moderate mr and severe as pt was transferred to for further management and preoperative surgical evaluation and work up while an inpatient in anticipation of aortic and possible mitral valve replacement repair ms was seen by the dental service for her poor dentition it was determined that she would need dental extraction prior to surgery the day before her planned dental extraction her oral surgery was cancelled because she was noted to have a diffuse generalized rash with erythematous eruptions dermatology was consulted for further evaluation and management of the rash derm felt the rash was most consistent with a hypersensitvity type of reaction one could see with a drug reaction as a precaution a skin bx was performed bx findings were consistent with agep pustular drug eruption culprit was unspecified but possible suspects were likely lasix and cipro which were both discontinued her rash subsequently improved during the remainder of her hospitalization infectious disease was consulted for her leukocytosis and recommendations followed on ms was taken to the operating room for surgical extraction of teeth and which were infected caries nonrestorable teeth in preparation for heart surgery over the remaining course of her hospital admission ms was in and out of atrial fibrillation and was placed on heparin drip for anticoagulation as her leukocytosis and rash improved her nutritional status waned prior to her operative date her albumin level was dr discussed with ms the risks and potential wound healing complications with nutritional depletion it was agreed to get a nutrition evaluation and assessment to optimize ms status and reschedule her surgery for a later date to optimize her potential for postoperative recovery ms was discharged to home on after a nutritional consult was performed she was advised of follow up with dr at mwmc on to recheck her albumin level coags and to reschedule an operative date inr coumadin dosing follow up was arranged with mwmc ms was discharged on coumadin for her paroxysmal atrial fibrillation medications on admission medications at home mvi tab po daily norvasc mg po daily lipitor po daily protonix mg po daily prednisone mg daily tramadol prn asa mg po daily caltrate mg po daily actonel mg po q sunday atenolol mg am and mg qpm cozaar mg sodium bicarbonate 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 warfarin mg tablet sig goal inr tablets po goal inr please take mg and please have inr drawn with results to mwhc coumadin clinic for further dosing goal inr disp tablet s refills metoprolol tartrate mg tablet sig three tablet po twice a day disp tablet s refills amiodarone mg tablet sig one tablet po daily daily disp tablet s refills triamcinolone acetonide cream sig one appl topical times a day disp qs qs refills diphenhydramine hcl mg capsule sig one capsule po q h every hours as needed for itching disp capsule s refills prednisone mg tablet sig two tablet po daily daily disp tablet s refills pantoprazole 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 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 ultram mg tablet sig one tablet po every four hours as needed for pain disp tablet s refills caltrate mg mg tablet sig one tablet po once a day disp tablet s refills cozaar mg tablet sig one tablet po once a day disp tablet s refills outpatient work pt inr for coumadin dosing first draw and then as instructed by coumadin clinic results to coumadin clinic heart center outpatient work sma cbc albumin please have drawn results to mwhc attention dr fax discharge disposition home discharge diagnosis coronary artery disease with in stent thrombosis moderate aortic stenosis mild moderate mitral regurgitation lupus erythematosus lupus glomerulonephritis hypertension hypercholesterolemia coronary artery disease s p stent left circumflex gerd history shingles in the past diverticulitis with resection of the colon with later reconstruction right below the knee amputation a year secondary mrsa infection discharge condition good discharge instructions as per nutritional recommendations medication compliance followup instructions clinic appointment with dr on please call for appointment recheck albumin level urine analysis and cx coags being discharged on coumadin completed by,"{
""Diagnoses"": [""cardiothoracic"", ""in stent thrombosis"", ""lupus erythematosus"", ""lupus glomerulonephritis"", ""HTN"", ""hypercholesterolemia"", ""coronary artery disease"", ""MRSA infection""],
""Medications"": [""Neo-GTT"", ""echo"", ""stent"", ""lasix"", ""acyclovir and derivatives"", ""Gerd history"", ""Shingles in the past"", ""Diverticulitis with resection of the colon with later reconstruction"", ""Right below the knee amputation"", ""Secondary MRSa infection""]
}"
57110,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint chest pain major surgical or invasive procedure urgent coronary artery bypass grafting x left internal mammary artery graft to left anterior descending reverse saphenous vein graft to the marginal branch diagonal branch posterior descending artery history of present illness year old male with progressive chest pain over last three months and a prior abnormal ett notable for inferior ischemia referred for cardiac catheterization to further evaluate catherization showed right dominant lvef lmca ostial distal lad ostial proximal orgin d lcx mid rca proximal distal fills l r collaterals cardiac echocardiogram ef trace mr d rt lt he was referred for coronary revascularization past medical history coronary artery disease diabetes mellitus type hypertension dyslipidemia hypertriglycerides carotid stenosis left ica cll diagnosed colon polyps past surgical history left elbow surgery as child due to fx social history race caucasian last dental exam last week lives with spouse occupation retired assistant principal tobacco denies etoh denies family history non contributory physical exam pulse resp o sat b p right left height cm weight kg general no acute distress skin dry x intact bilateral inner albows with petechia l r healed scar left elbow heent perrla x eomi x neck supple x full rom x chest lungs clear bilaterally x anteriorly heart rrr x irregular murmur no abdomen soft x non distended x non tender x bowel sounds x no palpable masses extremities warm x edema none varicosities spider veins bilat lower extremities neuro alert and oriented x non focal pulses femoral right cath site left dp right doppler left doppler pt doppler left doppler radial right left carotid bruit right bruit left bruit pertinent results echo pre bypass the left atrium is dilated no spontaneous echo contrast or thrombus is seen in the body of the left atrium left atrial appendage or the body of the right atrium right atrial appendage there is mild symmetric left ventricular hypertrophy with normal cavity size and regional global systolic function lvef right ventricular chamber size and free wall motion are normal there are simple atheroma in the descending thoracic aorta the aortic valve leaflets are mildly thickened but aortic stenosis is not present trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened with posterior mitral leaflet thicknening there is no mitral valve prolapse there is no pericardial effusion dr was notified in person of the results on mr post bypass preserved biventricular systolic function intact thoracic aorta all other findings in relevance to valvular function and wall motions similar to prebypass lvef am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm wbc rbc hgb hct mcv mch mchc rdw am blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap 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 glucose urean creat na k cl hco angap brief hospital course mr is a year old male with worsening anginal symptoms who underwent catheterization that showed severe vessel disease he presented for urgent revascularization given his unstable symptoms on he underwent an urgent coronary artery bypass grafting x with a left internal mammary artery graft to left anterior descending reverse saphenous vein graft to the marginal branch diagonal branch posterior descending artery see operative note for full details he was extubated on post operative night after precedex was started for agitation he was weaned from neo synephrine on post operative night with stable hemodynamics after being volume resuscitated he initially had low urine output with creatinine bumping to which resolved by post operative day he also had hyperglycemia with blood glucose in the high s post operative day and which improved with resuming home doses of metformin and lantus chest tubes and pacing wires were removed per cardiac surgery protocols ophthalmology was consulted post operative day for the patient s complaints of bilateral floaters it was determined that there were no signs of hemorrhage or neovascularization bilaterally and it was thought that the floaters were likely debris from ppv prior laser it was recommended he follow up with dr as scheduled after discharge the patient initially had a first degree av block coming out of the operating room on post operative day he went into a rate controlled atrial fibrillation he was transferred to the step down unit on post operative day after blood sugars were better controlled and he was in a rate controlled atrial fibrillation at this time his lopressor was again titrated up and he was bolused with iv amiodarone and started on oral amiodarone as well as coumadin he is to be followed by his cardiologist as an outpatient to determine the necessity of continuing these medications once on the floor mr continued to progress well he was working with physical therapy to increase strength and endurance tolerating a full po diet and his incisions were healing well he was felt safe for discharge home with visiting nurse services on post operative day his inr goal for atrial fibrillation was and will be followed by dr for further instructions for coumadin dosing all follow up appointments were discussed and arranged medications on admission nkda medications prescription atenolol prescribed by other provider mg tablet tablet s by mouth twice a day insulin glargine lantus prescribed by other provider unit ml solution units every evening ketoconazole prescribed by other provider cream applied twice a day to arms lisinopril prescribed by other provider mg tablet tablet s by mouth every morning metformin prescribed by other provider mg tablet tablet s by mouth three times a day last dose evening pre cardiac catheterization per dr simvastatin prescribed by other provider mg tablet tablet s by mouth every evening tamsulosin flomax prescribed by other provider mg capsule sust release hr capsule s by mouth every morning triamcinolone acetonide prescribed by other provider ointment apply to arms twice a day medications otc aspirin prescribed by other provider mg tablet tablet s by mouth every evening cyanocobalamin vitamin b prescribed by other provider mcg tablet tablet s by mouth daily multivitamin prescribed by other provider tablet tablet s by mouth once a day omega fatty acids fish oil prescribed by other provider mg mg capsule capsule s by mouth three times a day discharge medications insulin glargine unit ml solution sig thirty seven units subcutaneous at bedtime ketoconazole cream sig one appl topical times a day lisinopril mg tablet sig one tablet po daily daily metformin mg tablet sig one tablet po three times a day resume metformin saturday morning simvastatin mg tablet sig one tablet po at bedtime tamsulosin mg capsule sust release hr sig one capsule sust release hr po daily daily triamcinolone acetonide ointment sig one appl topical times a day cyanocobalamin mcg tablet sig one tablet po once a day multivitamin tablet sig one tablet po daily daily fish oil mg capsule sig one capsule po three times a day docusate sodium mg capsule sig one capsule po bid times a day disp capsule 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 as needed for pain oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills amiodarone mg tablet sig two tablet po bid times a day mg x days then mg daily x month then mg daily until further instructed disp tablet s refills warfarin mg tablet sig one tablet po once once dose to change daily for goal inr dr to manage via coumadin clinic disp tablet s refills furosemide mg tablet sig one tablet po once a day for weeks disp tablet s refills potassium chloride meq tab sust rel particle crystal sig one tab sust rel particle crystal po once a day for weeks disp tab sust rel particle crystal s refills atenolol mg tablet sig one tablet po once a day disp tablet s refills lisinopril mg tablet sig one tablet po once a day disp tablet s refills outpatient lab work serial pt inr dx atrial fibrillation results to coumadin clinic for dr first draw discharge disposition home with service facility vna discharge diagnosis coronary disease with unstable angina discharge condition alert and oriented x nonfocal ambulating gait steady sternal pain managed with percocet prn 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 please call to schedule appointments surgeon dr in weeks at pm primary care dr in weeks cardiologist dr in weeks wound check appointment your nurse will schedule dr to follow coumadin inr dosing through coumadin clinic first inr draw with results to provider md phone date time completed by,"{
""Diagnoses"": [""cardiothoracic"", ""allergies"", ""chest pain"", ""coronary artery disease"", ""diabetes mellitus"", ""hypertension"", ""dyslipidemia"", ""hypertriglycerides"", ""carotid stenosis""],
""Medications"": [""none"", ""referenced for coronary revascularization""]
}"
74969,admission date discharge date date of birth sex m service neurology allergies patient recorded as having no known allergies to drugs attending chief complaint confusion dysarthria major surgical or invasive procedure none history of present illness the pt is a year old left handed man who presents with an episode of somnolence and dysarthria according to his wife the patient has been under a significant degree of stress recently as they recently were evicted from their apartment and have had to stay at a hotel week ago he had been sitting in a car outside the hotel drinking gin and grapefruit when he called the va mental health line apparently they asked him if he had a weapon and had any intention of hurting himself or others at which point his phone connection was lost concerned that he may be trying to harm himself they sent the police to get him and he was placed in the va psychiatric facility for a week apparently while he was there he had and accident and fell resulting in a meniscal tear of his right knee however he otherwise improved and was discharged home on his wife reports that on the way home they stopped at a friend s house and she notes that he seemed to have a slight degree of difficulty walking unsteady not staggering in one direction or the other but she and her friend were able to help him into the car after arriving home she notes that he immediately went to the kitchen and began gorging himself with food she went to bed and he joined her shortly thereafter she notes that he was coughing frequently and hour later was moving around as though he were uncomfortable and was complaining that he needed to get up to go to the bathroom she turned on the light to find him wedged between the bed and the wall and discovered he had vomited and also was incontinent of urine he got cleaned up and went back to bed only to repeat the same series of events hour later she did not report that he was confused between these episodes after the second episode she reports being concerned that he may have had a stroke but figured she would wait until the morning to see how he did the following morning she had to go to work early but told her children to keep a close eye on him she got a call from them later that morning reporting that he was trying to eat breakfast but seemed to be having difficulty primarily spilling the the cereal on himself rather than eating it he then went to lie down and shortly thereafter his children reported he was drooling on himself and they were unable to wake him up when he did wake up he was reportedly slurring his words they called ems who came and gave him narcan with minimal effect he was taken to where he had a le ultrasound with showed no dvt a nchct which was unremarkable and a r knee x ray which showed a non displaced medial femoral fracture and a normal cxr tox screen was positive for benzodiazepines no etoh noted neurologic exam at that time showed he follows very simple commands there is no nystagmus there is no evidence of a facial droop his muscle strength is bilaterally not very sure if there is any problem with proprioception or sensation to light touch since patient is not very cooperative at they were concerned that he may be having a stroke due to his change in mental status including facial drooping slurred speech muscle weakness and memory loss for the last hours though of note the exam specifically states no facial droop past medical history htn dm hx of l meniscal tear on gout depression alcohol abuse social history used to live in state recently moved to the area because my wife made me vet reports he currently works for homeland security drinks gallons of gin week reports his last drink was last week has smoked ppd for years no illicits family history mother died at age of cad father died at of unknown causes physical exam vitals t p r bp sao on 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 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 alert oriented to though initially refers to it as a city i swore i d never go to states a bad one in response to the question of year but can then answer able to relate history without difficulty though is slightly tangential 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 without difficulty speech was not dysarthric able to follow both midline and appendicular commands pt was able to register objects and recall at minutes 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 though has slightly decreased upgaze 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 no pronator drift bilaterally no adventitious movements such as tremor noted no asterixis noted delt bic tri wre ffl fe io ip quad ham ta edb l r limited by leg injury sensory no deficits to light touch temperature throughout reports decreased pinprick vibration and proprioception bilaterally to the knee no extinction to dss dtrs tri pat ach l r plantar response was flexor bilaterally coordination no intention tremor no dysdiadochokinesia noted no dysmetria on fnf bilaterally gait deferred given knee injury 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 alt ast alkphos totbili am blood calcium phos mg am blood vitb am blood hba c eag am blood tsh am blood asa neg ethanol neg acetmnp neg bnzodzp pos barbitr neg tricycl neg am urine color straw appear clear sp am urine blood sm nitrite neg protein tr glucose neg ketone neg bilirub neg urobiln neg ph leuks lg am urine rbc wbc bacteri mod yeast none epi am urine bnzodzp pos barbitr neg opiates neg cocaine neg amphetm neg mthdone neg rapid plasma reagin test final nonreactive reference range non reactive urine culture final mixed bacterial flora colony types consistent with skin and or genital contamination mra head neck no acute infarction or mass effect mra head patent major arteries without focal flow limiting stenosis or occlusion or aneurysm more than mm within the resolution of mra mra neck suboptimal and assessment of ica and vertebral arteries and carotid bifurcation is limited increased signal in the superior opthalmic veins on boths dies on axial flair sequence may relate to slow flow and fat sat technique consider clinical correlation and if necessary mr orbits brief hospital course yo rhm with h o htn dm p w confusion and dysarthria following episode of incontinence and vomiting with gait disturbance neuro patient was transferred from where he presented with above symptoms and there was concern for stroke based on exam however it remains unclear what if any his focal deficits were at the time noncontrast head ct was normal upon arrival to there was no focal findings on neurologic exam in the neuro icu his exam was notable only for being tangential however he was well oriented was able to concentrate on tasks cranial nerves were normal and no weakness was noted on exam his story was concerning for very serious alcoholism and depression with recent suicidal ideation although a toxic metabolic encephalopathy was on the differential the patient was much improved over the notes from outside hospital and he was transferred to the general service upon arrival to the floor his mental status appeared at his baseline neurologic exam was significant only for bilateral sensory deficits decreased light touch pinprick position and vibratory sensation bilaterally to knees mri and mra of the brain and neck was normal he was found to have urinary tract infection and was started on ciprofloxacin most likely explanation for episode prior to admission is multifactorial urinary tract infection likely caused altered mental status and urinary urgency it is also possible that patient had an unwitnessed seizure leading to vomiting incontinence followed by post ictal confusion the following morning patient had been an inpatient at the va for depression and etoh withdrawal up until the day of the event and had been receiving benzo s he may have had a withdrawal seizure from benzodiapenes while in the hospital the patient had no events or seizure like episodes there were no signs of withdrawal he underwent a workup for peripheral distal neuropathy which was negative tsh rpr b hba c possible etiologies includes diabetes and toxicity from etoh he should continue to follow with his pcp was seen by pt and did not require any services until his knee is addressed by orthopedics cv patient remained hypertensive throughout admission hr was sinus s patient was continued on his home doses of atenolol and valsartan he was started on amlodipine mg for improved bp control ortho patient was in the midst of outpatient workup for right knee injury meniscal tear and missed his mri appointment while in hospital patient underwent knee mri and will present these images to his outpatient orthopedic specialist at va id patient had positive ua c w uti ucx showed mult organisms c w contamination patient will complete day course of ciprofloxicin medications on admission asa mg atenolol mg daily celexa mg daily flexeril mg tid generally takes lasix mg daily glucophage mg naprosyn mg protonix mg daily potassium chloride meq trazodone mg daily reportedly not taking diovan mg daily discharge medications aspirin mg tablet chewable sig one tablet chewable po daily daily furosemide 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 citalopram mg tablet sig one tablet po once a day atenolol mg tablet sig one tablet po daily daily flexeril mg tablet sig one tablet po three times a day as needed for pain glucophage mg tablet sig one tablet po twice a day naprosyn mg tablet sig one tablet po twice a day potassium chloride meq packet sig three po once a day valsartan mg tablet sig one tablet po once a day ciprofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills amlodipine mg tablet sig two tablet po daily daily disp tablet s refills discharge disposition home discharge diagnosis encephalopathy secondary to urinary tract infection hypertension right knee injury discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent neurologic exam significant for bilateral decreased sensation to all modalities in distal lower extremities to knees discharge instructions it was a pleasure taking care of you you were admitted for confusion difficulty walking and speaking you may have had a seizure from benzodiazepene withdrawal you were also found to have a urinary tract infection which could have caused confusion you were treated with antibiotics which you will continue to take at home you had an mri of the brain which showed no stroke tumor or aneurysm for your leg numbness you were tested for a variety of common causes for nerve problems but all tests were normal you likely have nerve damage called neuropathy from your history of alcohol use and diabetes you also underwent an mri of the knee so you may begin getting orthopedic treatment for your injury as an outpatient please bring the disk to your orthopedics appointment you had high blood pressure and another medication was added the following changes were made to your medications take ciprofloxicin mg twice daily for more days start amlodipine mg daily for blood pressure followup instructions you should follow up with your primary care physician at va you should follow up with orthopedics at the va as planned you should take a disc with your mri images to this visit you should follow up with social work and psychiatry to address your alcohol and depression issues,"{
""Diagnoses"": [""confusion"", ""dysarthria"", ""meniscal tear""],
""Medications"": [""none""]
}"
45409,admission date discharge date service surgery allergies penicillins heparin agents aldactone aldomet actonel attending chief complaint trauma found down major surgical or invasive procedure none history of present illness y o m w cad s p pci lad and rca in pacemaker unclear indication htn hld oa who was initially transferred to on after syncope fall and pelvic fracture patient was found down at his nursing home patient reports sitting and watching tv then lost consciousness next thing he remembered was waking up at he reported no chest pain sob palpitation or dizziness prior to syncope at he was found to have pelvic fracture and sent to for further management en route he was reported to have vtach no strips available did not require intubation past medical history cad s p ptca lad and rca stent in diastolic dysfunction aotrtic scloersis pacemaker in st htn hyperlipidemia oa transverse colon carcinoma addison s gout djd social history former smoker quit years ago denies etoh no illicits family history no premature cad physical exam on arrival to temp afebrile hr bp resp o sat room air normal constitutional he is awake and collared heent extraocular muscles intact no c spine tenderness chest clear to auscultation without chest wall tenderness cardiovascular normal first and second heart sounds abdominal nontender gu flank foley catheter in place with clear urine extr back no edema neuro speech fluent and he can move both sides equally psych normal mentation pertinent results chest portable ap study date of pm impression no definite evidence of injury mild cardiomegaly convex contour to the right upper mediastinum indeterminate although most likely a normal variant however correlation of planned ct is recommended ct abdomen chest w o contrast study date of pm impression known comminuted left iliac fracture with associated increased left retroperitoneal hematoma thyroid nodules measuring up to cm on the right wedge compression deformity at t this is age indeterminate however there is no paraspinal hematoma to suggest acute fracture cardiovascular report ecg study date of am atrial bigeminy right bundle branch block with left anterior fascicular block intermittent atrial pacing left ventricular hypertrophy non specific st segment changes no previous tracing available for comparison echo the left atrium is mildly dilated there is moderate symmetric left ventricular hypertrophy the left ventricular cavity size is normal regional left ventricular wall motion is normal overall left ventricular systolic function is normal lvef tissue doppler imaging suggests an increased left ventricular filling pressure pcwp mmhg doppler parameters are most consistent with grade i mild left ventricular diastolic dysfunction right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is moderate pulmonary artery systolic hypertension there is no pericardial effusion impression moderate symmetric lvh with normal global and regional biventricular systolic function mild diastolic lv dysfunction with elevated filling pressures and moderate pulmonary hypertension no clinically significant valvular disease seen carotid series complete study date of pm conclusion less than stenosis bilateral internal carotid arteries labs on admission pm glucose na k cl tco pm urea n creat pm alt sgpt ast sgot ld ldh alk phos tot bili pm lipase pm ctropnt pm albumin pm asa neg ethanol neg acetmnphn bnzodzpn neg barbitrt neg tricyclic neg pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm plt count pm fibrinoge brief hospital course mr was admitted on under the acute care surgical service he was admitted to the trauma icu given reported episode of vtach on transfer and elevated troponin and hypotension his troponins were trended and peaked at and decreased to cardiology was consulted and recommended continued resuscitation he had a tte that showed normal ejection fracture and normal wall motion he was continued on metoprolol and home simvastatin his diet was advanced to regular which he tolerated well his hematocrits were checked serially due to his retroperitoneal bleed and pelvic fractures and remained stable his cr improved from to which is his baseline he was placed on his home dose of steroids for his adrenal insufficiency in terms of his msk injuries for his pelvic fracture orthopedic surgery was consulted and recommended non operative management he was to be weight bearing as tolerated in his lower extremities on he remained hemodynamically stable and was transferred to the floor on the floor his vital signs were routinely monitored he was noted to be persistently hypertensive and his morning dose of hydrocortisone was decreased from mg to mg his home clonidine and lisinopril was restarted and his blood pressure normalized otherwise his vital signs were within normal limits his hematocrit was trended and remained stable he required no further blood transfusions his home aspirin was resumed on he was also started on fondaparinux at that time for dvt prophylaxis pt with history of heparin allergy with plans to discontinue when pt is more mobile his i o s were monitored and he made adequate amounts of urine his creatinine returned to baseline at he was tolerating a regular diet and was started on bowel regimen for prophylaxis his pain level was routinely assessed he was started on an oral pain regimen with standing tylenol and prn low dose oxycodone and tramadol physical therapy was consulted who evaluated the patient and determined that he would benefit from ongoing physical therapy at rehab after discharge on mr is afebrile with stable vital signs he is being discharged to rehab to continue his recovery medications on admission alprazolam mg po bid atenolol mg po bid finasteride mg po daily folic acid mg po daily hydrocortisone mg po qpm hydrocortisone mg po qam simvastatin mg po daily venlafaxine mg po bid aspirin mg po daily clonidine mg po daily clonidine patch mg hr ptch td weekly lisinopril mg po daily methylphenidate ritalin sr mg po daily tamsulosin mg po hs ferrous sulfate mg po daily discharge medications acetaminophen mg po tid alprazolam mg po bid atenolol mg po bid docusate sodium mg po bid finasteride mg po daily folic acid mg po daily hydrocortisone mg po qpm hydrocortisone mg po qam oxycodone immediate release mg po q h prn pain hold fro increased sedation resp rate senna tab po bid prn constipation simvastatin mg po daily venlafaxine mg po bid aspirin mg po daily clonidine mg po daily clonidine patch mg hr ptch td weekly lisinopril mg po daily hold for sbp tamsulosin mg po hs ferrous sulfate mg po daily tramadol ultram mg po q h prn pain hold for increased sedation resp rate methylphenidate sr mg po daily fondaparinux sodium mg sc daily discharge disposition extended care facility at discharge diagnosis s p trauma found down injuries left iliac crest fracture left comminuted pubic ramus fracture retroperitoneal bleed acute blood loss anemia 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 were admitted to the hospital after a fall you were found to have a left hip fracture which also caused some bleeding and your required a short stay in the intensive care unit you blood levels are now stable the orthopedic surgeons were consulted for the fracture this who recommended nonoperative management with physical therapy and pain management you are now being discharged to rehab to continue this treatment there was some concern over the reason for your fall and whether or not it was a syncopal episode cardiology was consulted for evaluation of this who determined your pacemaker to be functioning normally and no evidence of cardiac event you should follow up with your primary care provider after discharge from rehab for ongoing evaluation followup instructions department orthopedics when tuesday at am with ortho xray scc building sc clinical ctr campus east best parking garage department orthopedics when tuesday at am with np building campus east best parking garage md completed by,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""service"", ""surgery"", ""allergies"", ""penicillins"", ""heparin"", ""agents"", ""aldactone"", ""aldomet"", ""actonel"", ""attending"", ""chief complaint"", ""trauma"", ""found down"", ""major surgical or invasive procedure"", ""history of present illness"", ""y o m w"", ""cad s p"", ""pci lad and rca"", ""in pacemaker"", ""unclear indication"", ""htn"", ""hld"", ""oa""],
""Medications"": [""pacemaker""]
}"
28948,admission date discharge date date of birth sex f service neurology allergies lisinopril diltiazem terazosin attending chief complaint bilateral le stiffness pain major surgical or invasive procedure none history of present illness yo woman with stiff person syndrome sps maintained on mg valium daily baclofen pump and skelaxin as well as diabetes hypertension hyponatremia presents with exacerbation of her stiffness at baseline she has contractures and is unable to ambulate she has had multiple presentations for sps most recently to the ed on she reports that she went to sleep last night at around p usual for her and awoke at pm at which time she thought it was am instead she took her morning valium dose had breakfast and went downstairs at which time she saw it was dark outside and realized it was night around pm she felt her legs never relaxed after that she went back to bed but was unable to sleep all night she got up at am her usual time and her legs hurt she was unable to get up off the toilet she eventually did by using her upper extremities over the course of the day these symptoms worsened and she was not even able to transfer since she was treated for an exacerbation the last time with an extra dose of valium mg she took that this morning between her usual am and noon doses for a total of mg before noon she continued to worsen and so presented to the ed she reports she feels almost the same as the last time she came to the ed perhaps not quite as severe ros is notable for constipation the day prior to presentation for which she took laxatives with resulting diarrhea this morning she also has not urinated since noon she has a history of urinary retention thought to be medication related she denies any fevers chills dysuria cough abdominal pain nausea vomiting past medical history stiff man syndrome diagnosed in symptoms began in when she presented with foot cramps she was diagnosed by csf and serum analysis she was first started on valium which initially helped she was then treated with ivig in and plasmaphereis in with last ivig in with minimal improvement started weekly rituxan and qowk cytoxan starting on and last dose on dm type hypertension disease s p thyroidectomy urinary retention migraines hyponatremia social history worked at as a lab technician for years currently on disability no tobacco occ etoh no drug use uses wheelchair for ambulation family history fhx per omr last d c summary mother died at with high blood pressure and sepsis due to home dialysis father died at of a stroke she has three sisters and in good health and two brothers and in good health she has no children physical exam pe vs t hr bp rr sao ra genl nad lying in bed heent ncat mmm op clear neck no carotid bruits cv rrr nl s s no m r g chest ctab abd soft ntnd bs ext warm and dry neurologic examination mental status awake and alert cooperative with exam normal affect oriented to person place and date attentive says backwards speech is fluent with normal comprehension and repetition naming intact no dysarthria intact registers recalls in minutes no right left confusion no evidence of neglect cranial nerves fundoscopic examination reveals sharp disc margins pupils equally round and reactive to light to mm bilaterally no rapd visual fields are full to confrontation extraocular movements intact bilaterally without nystagmus sensation intact v v facial movement symmetric though slightly less prominent nlf on left at rest hearing intact to finger rub bilaterally palate elevation symmetric sternocleidomastoid and trapezius full strength bilaterally tongue midline movements intact motor decreased bulk and tone in bue increased tone in ble with contractures at knees and ankles the left foot is everted no observed myoclonus asterixis or tremor no pronator drift tri we fe ff ip r l distally can extend at knees antigravity but not fully and this is weak can flex at knees can wiggle feet at ankles but not significantly dorsiflex due to contractures and can just wiggle toes sensation intact to light touch pinprick vibration and cold sensation throughout no extinction to dss reflexes in b l triceps unable to elicit o w in bue could not elicit in legs due to contractures but using hammer causes leg to flex at hip coordination finger nose finger finger to nose fine finger movements and normal gait does not walk pertinent results labs comments k hemolysis falsely elevates k ck ca mg p comments mg hemolysis falsely elevates mg n l m e bas br cxr chest pa and lateral heart size is normal hilar and mediastinal contours are normal lungs are clear without focal consolidation or pulmonary edema there is no pleural effusion again seen is an old fracture of the right distal clavicle with bony absorption of the distal fracture fragment additionally there is a chronic deformity of the left proximal humerus osseous structures are otherwise unremarkable the visualized upper abdomen reveals gas filled colon improved from brief hospital course ms was admitted to the neuro icu for treatment of her stiff person syndrome exacerbation with propofol she was initially treated with mcg kg min over minutes this was performed under continuous sao monitoring with anesthesiology at the bedside she did not require intubation however she did become apneic requiring bagging for minutes this produced no observable benefit she still reported stiffness and pain in her legs a higher dose was considered but as she had had significant sedation and no benefit from the first dose it was decided that the risks of a higher dose outweighed the benefit she demonstrated the ability to straight cath herself and was then discharged home as she maintained sufficient independence in transfers and toileting she noted that she frequently handles these issues as an outpatient and this was verified by her outpatient neurologist the plan will be to try xyrem as an outpatient to improve her ongoing stiffness her use of extra valium was discussed with her she understands that she should not use more than the prescribed amount without calling her neurologist or pcp although she was hyponatremic on admission this improved to normal on discharge she was continued on her other home medications for hypertension and diabetes medications on admission citalopram mg daily diazepam mg mg mg lantus units qam units qpm humalog sliding scale lactulose ml g ml prn levothyroxine mcg daily extra tab weekly diovan mg daily ambien cr mg qhs asa mg daily citracal d two tabs chromium mvi daily all lisinopril diltiazem terazosin discharge medications citalopram mg tablet sig tablet po daily daily diazepam mg tablet sig four tablet po qam and qnoon diazepam mg tablet sig five tablet po qpm once a day in the evening insulin glargine unit ml cartridge sig two units subcutaneous qam insulin glargine unit ml cartridge sig three units subcutaneous at bedtime insulin lispro unit ml cartridge sig as dir units subcutaneous every six hours as per prior sliding scale hexavitamin tablet sig one cap po daily daily aspirin mg tablet chewable sig one tablet chewable po daily daily zolpidem mg tablet multiphasic release sig one tablet multiphasic release po hs at bedtime valsartan mg tablet sig two tablet po daily daily levothyroxine mcg tablet sig one tablet po daily daily metaxalone mg tablet sig tablet po tid lactulose gram ml solution sig twenty ml po once a day as needed for constipation discharge disposition home with service facility vna discharge diagnosis primary stiff person syndrome secondary type diabetes mellitus hypertension disease s p thyroidectomy discharge condition stable condition neuro exam notable for severe rigidity and contractures in bilateral les preventing ambulation upper extremities with mild rigidity discharge instructions you have been treated with propofol for stiff person syndrome unfortunately it did not have the desired effect therefore you were discharged for further treatment as an outpatient please take all medications as directed and keep all follow up appointments if you have intolerable pain or worsened stiffness or if you have urinary retention and are unable to straight cath yourself please call your neurologist or go to the nearest hospital emergency department followup instructions you have the following appointments scheduled provider md phone date time neurology provider vaderhorst phone date time md completed by,"{
""Diagnoses"": [""Stiff Person Syndrome"", ""Sleep Disorder""],
""Medications"": [""Lisinopril"", ""Diltiazem"", ""Terazosin"", ""Valium"", ""Baclofen"", ""Skelaxin""]
}"
19709,admission date discharge date date of birth sex f service orthopaedics allergies azithromycin cefazolin vancomycin attending chief complaint motor vehicle collision major surgical or invasive procedure orif right tibia fibula fractures closed reduction right radial head fracture history of present illness the patient was an unrestrained driver in a high speed motor vehicle collision vs tree she was ejected approximately feet and arrived to the ed amnestic to the event a passenger in the same vehicle was found to have fixed dilated pupils and subsequently expired etoh past medical history low back disc herniation chronic back pain social history etoh denies smoking other drugs family history noncontributory physical exam p ra a ox perrla eomi small amount blood in oropharynx teeth intact midface stable tms clear nares w o blood fluid large approx cm cresentic head lac left parieto occipital trachea midline rrr cta bilaterally ruq tenderness soft nondistended pelvis stable sacral tenderness no other midline or paraspinous tenderness no deformity or step off no abrasions or ecchymoses to back right tib fib deformity abrasion right lateral knee abrasion left ankle deformity right elbow femoral dp pt radial pulses bilaterally guiac negative normal tone pertinent results pm urine rbc wbc bacteria occ yeast none epi pm urine blood lge nitrite neg protein glucose neg ketone neg bilirubin neg urobilngn neg ph leuk tr pm urine color yellow appear hazy sp pm fibrinoge pm pt ptt inr pt pm plt count pm wbc rbc hgb hct mcv mch mchc rdw pm urine bnzodzpn neg barbitrt neg opiates neg cocaine neg amphetmn neg mthdone neg pm asa neg ethanol acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg pm amylase pm urea n creat pm hgb calchct r elbow there is a slightly angulated fracture through the right radial neck there are no other fractures identified r tib fib two views of the femur and three views of the right tibia and fibula were obtained there are obliquely oriented displaced fractures through the distal right tibia and fibula with significant lateral and posterior displacement of the distal fracture fragments there are several small associated bony fragments a minimally displaced fracture is also noted through the proximal right fibula the femur demonstrates no evidence of fracture ct head neg ct cspine neg ct abd technique multidetector ct scanning of the chest abdomen and pelvis was performed following administration of cc of optiray contrast coronal and sagittal reformations were also obtained ct of the chest with intravenous contrast the heart pericardium and great vessels are within normal limits the airways are patent to the segmental level bilaterally there are patchy bilateral areas of parenchymal opacity best appreciated in the posterior aspects of the upper lobes as well as the lower lobes bilaterally consistent with contusions linear densities are also appreciated in the lower lobes bilaterally which could be consistent with atelectatic change there is no pneumothorax or effusion ct of the abdomen with intravenous contrast there is a linear defect through the right inferior and posterior aspect of the liver consistent with a laceration a tiny punctate focus of hyperdensity is appreciated along the medial aspect of this laceration within the liver parenchyma which is felt to be most consistent with a small vessel rather than active extravasation the remainder of the liver gallbladder spleen and pancreas are unremarkable the intra abdominal loops of large and small bowel are within normal limits there is a moderate amount of high density material in the right retroperitoneal region expanding the perirenal space with associated perirenal stranding the kidneys are otherwise within normal limits with symmetric nephrograms the adrenals are unremarkable there is no free air ct of the pelvis with intravenous contrast a foley is present within the nondistended bladder the distal ureters rectum uterus and adnexa are within normal limits there is no pathologic adenopathy bone windows there are no suspicious lytic or sclerotic lesions no fractures are identified ct reconstructions the above findings were confirmed with coronal and sagittal reformations impression liver laceration of the right posterior liver right sided perirenal retroperitoneal hematoma with preserved renal function pulmonary contusions cxr patchy opacities in bilateral lower lobes probably representing combination of contusion and atelectasis in this patient status post motor vehicle accident brief hospital course the patient was admitted to the trauma sicu on with the injuries listed above she remained hemodynamically stable on presentation and throughout her stay on hd she went to the or with orthopedics for orif right tib fib closed reduction right radial head on hd she was transferred to the floor her pain was initially controlled with a dilaudid pca she was still having persistent pain all over and acute pain service was consulted she was switched to oral oxycodone and percocet with adequate pain control during the rest of her stay on hd her hct had trended down to and she was transfused units prbc with appropriate increase of her hct her hct remained stable during the rest of her stay repeat ct of her abdomen showed improved perirenal hematoma improved liver laceration she was seen by pt ot and her activity advanced she was also seen by social work and psychiatry for occasionally voiced suicidal thoughts she was cleared by psychiatry although it was thought that she would benefit from continued evaluation by psychiatry at her rehab center and eventual outpatient psychiatry follow up she was seen by dr and he felt she was developing an eschar on her rt medial leg she was transfered to ortho and started on abx her wound over the next three days remain unchanged and she was accepted to she was starting to put more effort in to her ot of her rt elbow and was ready for transfer to rehab medications on admission percocet discharge medications acetaminophen mg tablet sig tablets po q h every to hours as needed trazodone mg tablet sig tablet po hs at bedtime as needed nicotine mg hr patch hr sig one patch hr transdermal 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 oxycodone acetaminophen mg tablet sig tablets po q h as needed for pain oxycodone mg tablet sig tablets po q h as needed for breakthrough pain bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed haloperidol lactate mg ml solution sig mg injection q h every hours as needed for agitation enoxaparin sodium mg ml syringe sig one subcutaneous q h every hours oxycodone mg tablet sustained release hr sig one tablet sustained release hr po q h every hours pantoprazole sodium mg tablet delayed release e c sig one tablet delayed release e c po q h every hours clindamycin phosphate mg ml solution sig one injection q h every hours till follow up with dr in one week discharge disposition extended care facility discharge diagnosis motor vehicle collision liver laceration perirenal hematoma right bilateral pulmonary contusions displaced distal right tibia and fibula fractures minimally displaced proximal right fibula fracture right radial neck fracture discharge condition fair discharge instructions keep your splints and casts clean and dry take the pain medication as prescribed as needed physical therapy activity activity as tolerated right lower extremity non weight bearing right upper extremity non weight bearing walker with arm support treatments frequency site r leg type surgical cleansing saline dressing gauze dry comment to remain in ao splint ortho team to do any dressing changes site r arm type other dressing other comment splint with sling ortho team to do any splint changes rt popiteal fossa leave open to iar followup instructions with orthopedics in week please call as soon as possible to schedule a follow up appointment md completed by,{}
1845,admission date discharge date date of birth sex m service history of present illness this is a year old male who was in his usual state of health until one year ago when he had a chest x ray on routine physical exam where a cm right apical nodule was seen the patient then had a chest ct which revealed a x cm dilation of the ascending thoracic aorta the patient also has a history of hypertension high cholesterol and glaucoma he underwent cardiac catheterization on which revealed a left ventricular ejection fraction of global mild hypokinesis markedly dilated ascending aorta with aortic regurgitation lmca normal left anterior descending with minor mid disease left circumflex with no significant disease right coronary artery proximal he was admitted for elective aortic root replacement past medical history hypertension high cholesterol glaucoma bilateral laser eye surgery renal calculi transurethral resection of prostate the patient is legally blind allergies no known drug allergies medications hydrochlorothiazide mg p o q d diamox mg p o b i d for glaucoma cholesterol medication of unknown name a number of eye drops including drop o s q p m alphagan drops o u q d social history no tobacco history or alcohol history the patient lives with wife and son family history unremarkable physical examination general the patient was in no acute distress vital signs he was afebrile vitals signs were stable heent normocephalic atraumatic extraocular movements intact nasopharynx clear very poor dentition neck supple full range of motion no lymphadenopathy no thyromegaly carotids bilaterally with a positive bruit lungs clear to auscultation bilaterally cardiovascular regular rate and rhythm without rubs or gallops there was a out of systolic ejection murmur abdomen positive bowel sounds soft and nontender no masses no hepatosplenomegaly extremities no clubbing cyanosis or edema pulses radial bilaterally femoral bilaterally popliteal bilaterally dorsalis pedis bilaterally neurological nonfocal hospital course the patient was admitted to the hospital on and taken to the operating room that same day mitral valve replacement with a mm ce piermount was performed as well as a supracoronary arch repair of the abdominal aortic aneurysm with a mm gel weave the patient was sent to the cardiothoracic surgical ischemic cardiomyopathy postoperatively with mediastinal tubes and pacing wires in place he received kefzol times four perioperatively in the intensive care unit the patient was extubated and trialed on cpap although he failed and had to be reintubated he had a burst of atrial fibrillation for which treated with beta blockers the patient was eventually extubated and his mediastinal tubes were removed his pacing wires were also removed he was transferred to the regular floor on he was doing well however the first day out he had a t max of although this improved with oxygen and incentive spirometry urinalysis was done which was negative physical therapy saw the patient who indicated a need for continued rehabilitation it was intended that the patient will be discharged home on the th however immediately prior to discharge the patient converted to rapid atrial fibrillation he was treated with lopressor and after a drop in his blood pressure he was then loaded on amiodarone an electrophysiology consult was obtained who indicated the need for of hearts on discharge the patient at that time was not anticoagulated the patient again was going to be discharged on however immediately prior to discharge he again had an episode of atrial fibrillation at that time his lopressor was increased and amiodarone was increased and the patient was digitalized he was also started on coumadin and given a heparin drip electrophysiology agreed with this plan he again will be discharged with of hearts and will be anticoagulated this time up the patient has remained in sinus rhythm for over hours the patient will likely be discharged tomorrow on he will be sent to a rehabilitation facility he is to follow up with dr in four weeks he is to follow up with his cardiologist dr in one month he is to follow up with in weeks the patient should avoid strenuous activity he should not drive until off pain medication he may shower although he should not take baths discharge medications heparin drip lopressor mg p o b i d coumadin dosed per daily inr checks mg p o q h s mg p o q amiodarone mg p o q d insulin sliding scale drops o u b i d drop o s q h s dorzolamide timolol drops o s q d dorzolamide timolol drop o d q d milk of magnesia ml p o q h s p r n constipation percocet tab p o q hours p r n pain ibuprofen mg p o q hours p r n tylenol mg p o q hours p r n enteric coated aspirin mg p o q d ranitidine mg p o b i d colace mg p o b i d m d dictated by medquist d t job,{}
78615,admission date discharge date date of birth sex m service neurosurgery allergies no known allergies adverse drug reactions attending chief complaint altered mental status major surgical or invasive procedure none history of present illness m with a hx of etoh abuse depression multiple falls who called this morning with vague complaints patient initially gave the incorrect address he gave his childhood address when ems arrived to patient s home he was ambulatory intoxicated per report the patient was combative at the outside hospital and was sedated and intubated in order to obtain a head ct for a suspected head bleed past medical history depression diverticular bleed in social history unemployed lives alone daughter lives nearby per daughter patient has been struggling with depression and etoh abuse since being unemployed he was in detox rehab about a year ago he has the hx of mixing his antidepressants w etoh and hx of falls family history nc physical exam gen l eye ecchymosis facial scratches intubated sedated initial neuro exam no eo no commands perrl mm r corneal bue attempts to localize ble triple flexion repeat neuro exam off sedation eo to loud voice mae lue purposeful squeezes hands bilaterally ble withdraws exam at time of discharge nonfocal neurologically intact alert and oriented to person place and date following commands fluent speech full strength in all extremities upon discharge alert oriented x understands reason for hopsital stay motor full ambulating in halls pertinent results ct head w o contrast stable right temporal intraparenchymal hemorrhage and subdural hematoma slight increase in intraventricular hemorrhage no significant midline shift no fracture identified ct head w o contrast stable appearance of right temporal intraparenchymal hemorrhage as well as intraventricular hemorrhage interval decrease in prominence of right cerebellar tentorium density brief hospital course y o m etoh and question of fall was taken to osh where he was combative and aggressive patient was intubated and sedated to obtain head ct head ct revealed r temporal iph and patient was transferred to for further neurosurgical intervention on examination without sedation patient eo to voice perrl bue purposeful and w d ble he was admitted to the icu for monitoring he was extubated and exam remained stable on repeat head ct was stable and cipro was started for a uti in afternoon patient became aggitated and pulled out his foley he was given ativan and on ciwa scale for possible dts dilantin level corrected was he was given a mg bolus of dilantin his level the following morning improved to and he remained on mg tid for days and then discontinued he was transferred from the icu to the stepdown unit and he continued to require ativan per the ciwa scale for his dt s his neurological exam at this time was eyes open following commands intermittently agitated and trying to get oob for patient safety he remained in restraints on he was more alert he was oriented to hospital city and month but not the year his hand and wrist restraints were dc d but he did require a posey as he was continually getting oob without the help of nursing and was increased fall risk he was started on po seroquel on and this was titrated to mg twice daily his mental status continued to improve and on he was more awake and oriented to self and year but not to place despite up titration of seroquel he continued to require restraints for agitated behavior and so geriatric medicine consult was called for recommendations on they recommended to wean the ativan to off over days as well as wean seroquel to off over days a full lab workup was obtained including b tsh lfts and these values were all within normal limits a u a was consistent with infection and he was started on a day course of ciprofloxacin to finish patient s mental status continued to clear and by the restraints were no longer needed to maintain patient safety he was seen in consultation by psychiatry who were very helpful with medication adjustment he was started on celexa qd usual dose mg qd but as he was without it for extended period of time this was introdeced at lower dose per his daughter he had also been on neurontin doxepin at bedtime and ativan mg these have not yet been resumed multiple attempts were made to contact his psychiatrist but calls have not been returned dr patient was oriented and expressing desire for to focus on addiction issues psychiatry recommended psychiatric consult at rehab pt and ot evaluated the patient and found him appropriate for rehab for cognitive needs he had follow up head ct on prior to discharge that showed resolution of all hemorrhage medications on admission celexa qd ativan mg neurontin doxepin hs discharge medications docusate sodium mg capsule sig one capsule po bid times a day olanzapine mg tablet rapid dissolve sig one tablet rapid dissolve po daily daily folic acid mg tablet sig one tablet po daily daily thiamine hcl mg tablet sig one tablet po daily daily multivitamin tablet sig one tablet po daily daily ciprofloxacin mg tablet sig two tablet po q h every hours last dose citalopram mg tablet sig one tablet po daily daily discharge disposition extended care facility discharge diagnosis right intraparenchymal hemorrhage delerium tremens discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions take medicine as prescribed followup instructions follow up appointment instructions please call dr office as needed for any questions but no formal follow up or cts are needed completed by,{}
58955,admission date discharge date service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint pneumonia major surgical or invasive procedure nippv history of present illness yo man with pmh of atrial fibrillation on coumadin cri and possible chf who presents from his home with fever and sob his home health aides called ems because they were concerned that he had been more sob he received mg iv lasix by ems en route to the ed in ed vs were nrb was tachypneic looked unconfortable exam showed diffuse coarse breath sounds he was put on cpap with improvement in rr and good tidal volumes of cc labs revealed wbc count with polys cri at baseline and lactate cxr revealed slight central vascular congestion without overt edema or consolidation with left base atelectasis and a small left pleural effusion however the ed was concerned for lll pna ekg showed atrial fibrillation without ischemic changes u a was clean urine outpt cc in ed from lasix but was given l ivf and tylenol for fever blood and urine cultures were drawn and the patient received ctx g and levofloxacin mg and was admitted to the icu most recent vs cpap access piv currently he appears comfortable and in nad he is follows basica commands and interacts appropriately but is not very communicative past medical history hypertension prostate ca afib chf depression social history lives at home alone has hour home health aides at baseline does not ambulate at all no etoh tobacco drugs family history nc physical exam vs t hr bp rr sat on gen elderly caucasian male nad comfortable a ox self heent ncat perrl sclera anicteric neck supple no lad jvp at cm at degrees cv irregularly irregular s s no m r g resp moderate air movement but not taking deep breaths volitionally no appreciable crackles abdomen soft ntnd bs ext b l le pitting edema dp pulses are bilaterally neuro a o x cn ii xii grossly intact motor both upper and lower extremities skin pink warm no rashes 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 pm blood pt ptt inr pt am blood type art po pco ph caltco base xs blooc cx pnd ucx pnd cxr impression slight central vascular congestion without overt edema or consolidation low lung volumes with left base atelectasis and a small left pleural effusion brief hospital course mr is a yo man with pmh of chf afib on coumadin who presents with fever and sob admitted for pna pna febrile to in the ed with lll infiltrate on cxr no hap risk factors started on broad coverage narrowed to levaquin on discharge started on nippv rapidly transitioned to nc and room air by the time of discharged sent home after nights hours afebrile to complete days of antibiosis with chest pt and incentive spirometry for poor secretion clearance hypoxemia likely multifactorial from pna contribution from acute chf exacerbation responded to brief nippv o by nc and aggressive pulm toilet discharged on room air acute chf diastolic echo from showed preserved ef current presentation cxr vigorous repsonse to iv lasix and improvement on cpap le edmea and mildly elevated jvp do suggest some component of volume overload chronic renal insufficiency at baseline renally dose medications afib restarted diltiazem taught caretakers to no crush the xr formulation dementia continue namenda h o prostate ca no active issues medications on admission atorvastatin mg daily aspirin mg tablet po daily warfarin mg daily diltiazem xt mg daily spectravite senior tab daily lasix mg po q m w f s namenda mg discharge medications levofloxacin mg tablet sig three tablet po q h every hours take one disp tablet s refills memantine mg tablet sig two tablet po bid times a day aspirin mg tablet chewable sig one tablet chewable po daily daily diltiazem hcl mg capsule sustained release sig one capsule sustained release po once a day do not crush this pill if you cannot give a whole pill then obtain prescription for immediate release diltiazem lasix mg tablet sig tablet po m w f s atorvastatin mg tablet sig tablet po once a day spectravite senior tablet sig one tablet po once a day do not take with antibiotics incentive spirometer use every waking hour for days or until breathing difficulties resolve take a deep breath in and blow out into the device holding your exhalation as long as possible do this times every hour coumadin mg tablet sig one tablet po once a day hold and then restart on wed discharge disposition home with service facility homecare discharge diagnosis primary community acquired pneumonia secondary dementia atrial fibrillation discharge condition activity status ambulatory requires assistance or aid walker or cane mental status confused always level of consciousness alert and interactive discharge instructions mr you were admitted with a pneumonia you did well and were treated effectively with antibiotics however your lungs are weak and unable to clear your phlegm with ease you were managed at first in the intensive care unit and later on the general floor where you continued to improve needing oxygen supplementation at first and none by the time of your discharge new medication levofloxacin continue until the th hold coumadin the antibiotics keep your inr high you will need to have your coumadin checked frequently restart on wednesday you should have your inr checked on wednesday we have also provided an incentive spirometer use as directed every hour or so followup instructions please follow up with b at pm you can have the inr checked as per usual do so on wednesday completed by [NEW_RECORD] admission date discharge date service medicine allergies no known allergies adverse drug reactions attending chief complaint sob major surgical or invasive procedure picc line placement history of present illness m with hx of afib hypertension dchf recent aspiration pneumonia being treated with levofloxacin and flagyl presenting from home with increasing sob since midnight increased secretions decreased mental status overnight patient has hr caregivers at home who called ems unclear if patient has been having fevers at home patient currently on levo flagyl course for aspiration pneumonia in the ed initial vs were t hr bp on l o patient was given a dose of vancomycin levofloxacin and metronidazole due to likely aspiration ekg showed afib rate with no ischemic changes cxr showed increase in pleural effusions and atelectasis bibasilar lactate not elevated at trop elevated at increased past his baseline he was given a dose of aspirin mg rectally bnp elevated to patient was trialed with bipap which he did not tolerate well due to altered mental status patient was initially not given any ivfs but bps started to drop to for which he was given cc bolus ivfs to which bp reponded patient is dnr dni and is being transfered to medical icu for further management ed staff had conversation with hcp in who understood that patient was not doing well vitals in ed prior to transfer are as follows hr afib rr on nrb in the icu patient appears comfortable on non rebreather he is able to squeeze hands to commands and answer some yes or no questions he denies pain past medical history atrial fibrillation on warfarin and diltiazem followed by dr possible diastolic chf echo in showed ef of chronic renal insufficiency baseline cr dementia moderate to severe prostate cancer pt has elected to have no work up or treatment hypertension hyperlipidemia heel pressure ulcers pneumonia hospitalized treated with levofloxacin probable aspiration of thin liquids social history occupation retired lawyer alumnus religion living situation lives in own apartment with hour care key relationships nephew and caretaker giver stress level average smoking etoh non smoker glass wine month functional baseline adls dependent iadls dependent on all iadls services at home hour caregiver assistive device and wheelchair family history nc physical exam admission exam vitals t bp p r o nrb general eyes closed but awakens to voice and able to answer some yes or no questions and squeeze hands to comman difficult to assess orientation no acute distress with nonrebreather heent sclera anicteric perrla difficult to assess oropharynx with nonrebreather at this time but mucus membranes appear moist neck supple jvp estimated cm lungs poor air movement bilaterally no crackles but decreased breath sounds at bases cv irregular rhythm with rapid rate s normal s s no murmurs appreciated at this rapid rate abdomen soft but mildly distended non tender bowel sounds present gu foley in place with minimal urine output at this time ext warm well perfused palpable pulses edema lower extremity edema also has upper extremity edema r forearm and hand greater than left nonstageable left heel ulcer pertinent results admission labs pm urea n creat sodium potassium chloride total co anion gap pm ck cpk pm ck mb mb indx ctropnt pm magnesium am urine rbc wbc bacteria few yeast none epi trans epi am po pco ph total co base xs comments green top am glucose urea n creat sodium potassium chloride total co anion gap am ck cpk am ctropnt am ck mb probnp am tot prot albumin globulin am wbc rbc hgb hct mcv mch mchc rdw am neuts lymphs monos eos basos chest portable ap study date of am mild interval increase in bilateral pleural effusions and associated basal atelectasis mild pulmonary vascular congestion ekg atrial fibrillation with rapid ventricular response there is a regularity which may represent atrial flutter low amplitude qrs voltage in the limb leads indeterminate qrs axis non specific lateral st t wave changes compared to the previous tracing of the venetricular response is now rapid qrs voltage in the precordial and limb leads is much lower clinical correlation is suggested leni impression no deep venous thrombosis in right lower extremity ueni impression no deep venous thrombosis in right upper extremity cxr picc portable ap chest radiograph was reviewed in comparison to left picc line tip is at the level of mid svc bilateral pleural effusions are large interstitial pulmonary edema is unchanged no definitive pneumothorax is noted on the current study mediastinal contours are stable the study and the report were reviewed by the staff radiologist tte the left atrium is moderately dilated the right atrium is moderately dilated there is mild symmetric left ventricular hypertrophy with normal cavity size there is mild regional left ventricular systolic dysfunction with mild septal hypokinesis the remaining segments contract normally lvef the right ventricular cavity is dilated with mild global free wall hypokinesis the ascending aorta is mildly dilated 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 no mitral valve prolapse there is mild pulmonary artery systolic hypertension there is no pericardial effusion cxr semi upright bedside radiograph of the chest the right costophrenic angle was beyond the field of view note is made of bilateral pleural effusions which appear unchanged these effusions as well as overlying basal subsegmental atelectasis result in partial obscuration of the cardiac silhouette which nevertheless appears minimally changed mediastinal and hilar contours are also unchanged with note again being made of atherosclerotic calcification along the aorta a left picc again is seen to terminate at the upper portion of the superior vena cava the study and the report were reviewed by the staff radiologist blood culture blood culture routine final inpatient blood culture blood culture routine final inpatient stool fecal culture final campylobacter culture final clostridium difficile toxin a b test final inpatient mrsa screen mrsa screen final inpatient blood culture blood culture routine final inpatient urine urine culture final emergency blood culture blood culture routine final emergency hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct source line picc source line picc source line picc source line picc source line picc source line picc source line picc source line picc source line picc differential neuts bands lymphs monos eos baso atyps metas basic coagulation pt ptt plt inr pt ptt plt ct inr pt source line picc source line picc source line picc source line picc source line picc source line picc source line picc source line picc source line picc source line picc source line picc source line picc source line picc source line picc source line picc source line picc source line picc lab use only source line picc chemistry renal glucose glucose urean creat na k cl hco angap source line picc source line picc source line picc source line picc source line picc source line picc source line picc source line picc source line picc chems te te added am moderately hemolyzed specimen if fasting normal provisional diabetes verified by replicate analysis hemolysis falsely elevates k notified at estimated gfr mdrd calculation estgfr using this source line picc using this patient s age gender and serum creatinine value of estimated gfr if non african american ml min m estimated gfr if african american ml min m for comparison mean gfr for age group is ml min m gfr chronic kidney disease gfr kidney failure enzymes bilirubin alt ast ld ldh ck cpk alkphos amylase totbili dirbili source line picc chems te te added am moderately hemolyzed specimen new reference interval as of upper limit th ile varies with ancestry and gender male female whites blacks asians hemolysis falsely elevates ck new reference interval as of upper limit th ile varies with ancestry and gender male female whites blacks asians cpk isoenzymes ck mb mb indx ctropnt probnp source line picc chems te te added am moderately hemolyzed specimen ctropnt ng ml suggests acute mi notified at ctropnt ng ml suggests acute mi reference values vary with age sex and renal function at prevalence ntprobnp values have neg pred value have pos pred value see online lab manual for more detailed information chemistry totprot albumin globuln calcium phos mg uricacd iron cholest source line picc lipid cholesterol cholest triglyc hdl chol hd ldlcalc ldlmeas source line picc ldl calc invalid if trig or non fasting sample pituitary tsh chems te te added am lab use only redhold hold blood gas blood gases type temp rates tidal v peep fio o flow po pco ph caltco base xs comment green top whole blood miscellaneous chemistry glucose lactate na k cl brief hospital course m with atrial fibrillation right sided chf dementia recent aspiration pneumonia who presented from home with increased shortness of breath and altered mental status respiratory distress shortness of breath and hypoxemia likely aspiration and flash pulmonary edema from diastolic heart failure and afib with rvr he was admitted to the icu and started on vanc cefepime and cipro he received flagyl as outpt which was not continued his o status rapidly improved and it was thought that he unlikely had hap given that he lives at home with hour care and did not show signs of infection vanc and cefepime were d c d and ciprofloxacin was continued for a day course in house given its uncertain indication and course for him prior to hospitalization he remained afebrile without signs of infection throughout the rest of his hospitalization o was weaned off on he received a speech and swallow evaluation that was largely unchanged from previous his aspiration diet was continued without changes see below for chf diastolic chf he was admitted with flash pulmonary edema with markedly elevated bnp in the setting of rapid atrial fibrillation he was also total body volume overloaded with pitting edema throughout he was on a minimal lasix regimen as an outpatient apparently because he had little to no edema but he was treated in the icu with iv lasix and this was continued as iv and po on transfer to the floor although he is listed to have chronic renal insufficiency his creatinine tolerated diuresis well with no elevation he had a repeat tte showing good ef hypertrophy and possibly new rwma see below for nstemi on discharge he required no o but he should continue diuresis with daily weights and urine output monitoring bb and acei were started during this admission altered mental status likely toxic metabolic etiology in setting of hypoxia in the setting of underlying dementia patient appears to be comfortable and responding well at this time neuro exam nonfocal in icu his mental status is now back to baseline with a oxperson and intermittently place or month leukocytosis pt did have temp of in ed which improved with pr aspirin he does have elevated wbc to likely all secondary to aspiration pneumonitis now less likely pneumonia pt did have loose stools on arrival to floor and has been on antibiotics recently though one of these antibiotics has been flagyl c diff toxin and stool culture were negative leukocytosis resolved and pt remained afebrile on the regular medical floor chronic renal insufficiency creatinine on presentation actually lower than baseline but urine output had been low since arrival to ed and icu likely in setting of fluid overload urine electrolytes on admission c w prerenal state his cr remained normal stable during admission atrial fibrillation his rate was relatively well controlled after days with iv metoprolol transitioned to po metoprolol he previously was not on metoprolol as outpt now much better controlled previously supratherapeutic on coumadin now therapeutic originally bridged with lovenox pt s inr was on day of discharge but this was likely due to coumadin being held days ago he will continue his coumadin and was recommended to have inr checked in days elevated troponins thought to be demand ischemia vs nstemi in setting of rvr cardiac enzymes trended downward already on asa statin added bb and acei as above s p lovenox bridge to coumadin he never complained of cp sob palpitions hyponatremia patient with na which is likely in setting of fluid overload resolved with diuresis right arm and leg swelling he was ruled out for dvt in the setting of initially r l extremity swelling his edema later more symmetrical on turning likely represents dependent edema along with full body anasarca dementia patient responding to commands appears close to baselilne now per his caretakers and family memantine was not on formulary and was held while inpt fen regular low sodium consistency pureed dysphagia nectar prethickened liquids may take meds crushed in applesauce precautions aspiration prophylaxis warfarin code dnr dni confirmed in ed with hcp medications on admission diltiazem e r mg daily warfarin mg po every other day furosemide mg q m w f sat aspirin mg daily levaquin flagyl memantine mg tablet atorvastatin mg tablet daily discharge medications lift for home use aspirin mg tablet sig one tablet po daily daily lisinopril mg tablet sig one tablet po daily daily metoprolol succinate mg tablet extended release hr sig one tablet extended release hr po once a day disp tablet extended release hr s refills warfarin mg tablet sig one tablet po x week mo we fr sa atorvastatin mg tablet sig tablet po daily daily memantine mg tablet sig one tablet po twice a day furosemide mg tablet sig one tablet po bid times a day disp tablet s refills miconazole nitrate powder sig one appl topical times a day disp qs qs refills outpatient lab work please have your inr pt and chem checked on please fax results to name b location cardiology associates of greater address phone fax discharge disposition home with service facility caretenders discharge diagnosis aspiration pneumonitis atrial fibrillation acute diastolic heart failure non st elevation myocardial infarction or demand ischemia toxic metabolic encephalopathy hyponatremia discharge condition mental status intermittently responsive to questions oriented to person and sometimes month level of consciousness intermittently responsive activity status out of bed with assist ambulatory with assist discharge instructions you were admitted with confusion and low oxygen levels due to an aspiration event fast heart rate and congestive heart failure we have treated your heart rate and gave you medication to remove some extra fluid you should continue to be monitored closely for your heart failure and your atrial fibrillation specifically your heart rate oxygen status fluid status inputs and outputs and weights should be monitored daily you were evaluated for swallowing and found to be at risk for aspiration it is important that you follow dietary recommendations below medication changes metoprolol for rate control of your atrial fibrillation diltiazem stopped increased lasix for diuresis to mg twice a day ace inhibitor for your heart failure and given possible injury to your heart increased aspirin dosing please take your medications as prescribed and keep your appointments below weigh yourself daily followup instructions name b location cardiology associates of greater address phone appointment thursday pm department gerontology when friday at am with md building lm bldg campus west best parking garage,"{
""Diagnoses"": [""pneumonia"", ""atrial fibrillation"", ""lll pna""],
""Medications"": [""lasix"", ""ivf"", ""tylenol"", ""levofloxacin"", ""ctx g""]
}"
74418,admission date discharge date service neurology allergies no known allergies adverse drug reactions attending chief complaint speech difficulty hemiparesis major surgical or invasive procedure none history of present illness ms was unable to speak earlier today according to family and is now sedated with olanzapine mg history obtained from family and review of medical records ms is a year old right handed woman with pmh significant for htn dmii moderate dementia and admission in for multiple rib fractures and small sah though no witnessed or reported trauma who presents with right sided weakness and aphasia she was brought to the ed yesterday with chest pain and was ruled out for mi she was discharged home yesterday evening her daughter in law noted at that time that when she went to use her walker she was able to use her left hand normally to put her hand on top of the walker but was unable to place her right hand on top of the walker as usual but was rather grabbing on to the walker lower down with her right hand and she seemed to have difficulty controlling her right arm she went home and did not sleep well overnight this morning her daughter with whom she lives noted that she was dragging her right foot when walking and was not using her right arm well her daughter in law then came over and saw that her right arm appeared further impaired than yesterday evening her family also noted that she was not able to say any words today they said words were just not coming out and they were unable to understand anything she was trying to say her daughter in law is unsure if she was able to comprehend anything but she says it did not appear she was paying attention to her family her family also notes that it appeared at times as if she was trying to catch something in the air it is unclear is she was having visual hallucinations she was brought into the ed for further evaluation in the ed she was very agitated and pulling at lines so received zyprexa mg x ros unable to obtain from patient as she was previously noted to be aphasic by family and is now sedated past medical history hypertension diabetes mellitus type moderate dementia osteopenia s p right distal radial fracture h o acute cholesystitis s p open cholecystectomy recent admission for multiple rib fractures and small sah family unaware of a fall small bowel tumor s p resection social history per omr lives with daughter attended school cannot read or write well smokes a pipe no etoh of note at baseline she is able to ambulate engage in limited conversation and is oriented to person family history per family no known family history of strokes or seizures physical exam admission physical exam vitals t p r bp sao ra general somnolent difficult to arouse had previously received olanzapine mg x heent nc at no scleral icterus noted no lesions noted in oropharynx neck supple pulmonary anterior lung fields cta b l cardiac rrr s s ii vi systolic murmur abdomen soft nondistended bs extremities warm well perfused neurologic no eye opening no commands commands were given in her native language by her family perrl mm pupils in midline she would resist doll s eyes maneuver so unable to assess blinks to threat on left but not on right face appears symmetric at rest she spontaneously moves left upper extremity more than right upper extremity though there is spontaneous movement on the left moves le spontaneously b l withdraws all exttremities to noxious stimuli briskly during noxious stimuli testing she did say devil in her native language which is first word family says they understood her say all day reflexes were and symmetric throughout she had a withdrawal response with plantar testing b l discharge physical exam vitals on ra gen lying in bed in nad heent op clear cv rrr pulm ctab abd soft nt nd peg in place with c d i dressing ext no edema neuro ms aaox with interpreter unable to follow commands except to open and close eyes with miming cn forced eye closure pupils tracks examiner motor maee to tickle bilaterally sensation intact to tickle as above coordination pt unable to cooperate gait deferred pertinent results admission 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 am blood neuts lymphs monos eos baso am blood plt ct pm blood pt ptt inr pt am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood alt ast alkphos totbili pm blood ck cpk am blood ck cpk am blood probnp am blood ctropnt am blood ck mb ctropnt am blood albumin calcium phos mg cholest am blood calcium phos mg am blood hba c eag am blood triglyc hdl chol hd ldlcalc 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 reports nchct findings there is a large left x parieto occipital intraparenchymal hemorrhage with surrounding edema and intraventricular extension into the left lateral ventricle and occipital there is no shift of midline structures or evidence of central herniation prominent ventricles and sulci are consistent with age related atrophy without evidence of hydrocephalus periventricular white matter hypoattenuation is compatible with chronic small vessel infarciton the basal cisterns are patent there is no fracture the visualized paranasal sinuses mastoid air cells and middle ear cavities are clear impression large cm left parieto occipital acute intraparenchymal hemorrhage with surrounding edema and intraventricular extension no evidence of central herniation cxr findings as compared to the previous radiograph the patient has received a dobbhoff catheter the tip of the catheter projects over the middle parts of the stomach the course of the catheter is unremarkable there is no evidence of complications notably no pneumothorax borderline size of the cardiac silhouette mild areas of atelectasis at the left and right lung bases no evidence of other parenchymal opacities notably no evidence of pneumonia cxr findings as compared to the previous radiograph the lung volumes have decreased there is mild fluid overload and a plate like atelectasis at the left lung bases that has minimally increased in extent the pre existing minimal left pleural effusion is unchanged unchanged course of the nasogastric tube no pneumothorax cxr findings comparison is made to previous study from the dobbhoff tube has been removed there has been placement of nasogastric tube whose tip and side port are well below the gastroesophageal junction in the distal body of the stomach however there is a loop in the distal nasogastric tube the cardiac silhouette and mediastinum is prominent but stable there is improvement of the atelectasis at the lung bases there remains low lung volumes there are no pneumothoraces brief hospital course yo rhf with htn dm moderate dementia with acute onset r sided weakness and facial droop and found to have large iph on nchct neurological exam is significant for fluctuating agitation drowsiness inattention inability to follow commands facial droop decreased spontaneous movement on the right etiology most likely amyloid angiopathy other causes include underlying vascular abnormalities eg avm localization of iph was not typical for hypertensive bleed icu course overnight patient was agitated with hypertension and tachycardia and received olanzepine she was given standing iv tylenol for presumed pain which made her drowsy and less agitated she did not demonstrate clinical seizure activity patient underwent repeat nchct which showed stable l parieto occipital hemorrhage and she was transfered to the floor for further monitoring and treatment floor the patient was transferred to the neurology floor from the icu in stable condition she as kept on contact precautions for prior staphylococcus aureus infection with one negative mrsa isolate on screening on this admission her blood pressure medications were uptitrated to maintain an sbp she was noted to have intermittent nonsustained vt which lessened after repleting electrolytes she was placed on low dose beta blocker therapy she was evaluated by pt ot speech she would not cooperate with speech therapy she was continued on tube feeds via ngt her family agreed to have a gastrostomy placed acs was consulted who recommended ir guided placement due to a prior abdominal surgery this was placed on without complication she was discharged to rehab once her restraints were able to be stopped for hours pending studies none transitional care issues please continue to titrate her blood pressure medications to maintain sbp please continue pt ot for maximal functional recovery please avoid long term antithrombotic medications such as aspirin or warfarin aha asa core measures for intracerebral hemorrhage dysphagia screening before any po intake x yes no dvt prophylaxis administered x yes no smoking cessation counseling given yes x no reason non smoker x unable to participate stroke education given x yes no assessment for rehabilitation x yes no medications on admission lisinopril mg daily calcium d mg units proair puffs q h prn senna mg qhs docusate mg tylenol mg tid discharge medications lisinopril mg tablet sig one tablet po once a day proair hfa mcg actuation hfa aerosol inhaler sig two puffs inhalation every six hours as needed for shortness of breath or wheezing docusate sodium mg tablet sig one tablet po bid times a day senna mg tablet sig one tablet po at bedtime calcium d mg mg unit tablet oral acetaminophen mg tablet sig one tablet po three times a day as needed for pain heparin porcine unit ml solution sig units injection tid times a day docusate sodium mg capsule sig one capsule po bid times a day metoprolol tartrate mg tablet sig one tablet po bid times a day discharge disposition extended care facility rehabilitation nursing center discharge diagnosis primary diagnosis intracerebral hemorrhage intraparenchymal amyloid angiopathy secondary diagnosis hypertension diabetes mellitus discharge condition mental status confused always level of consciousness lethargic but arousable activity status out of bed with assistance to chair or wheelchair neuro exam aaox chronic dementia moves all extremities spontaneously discharge instructions dear mrs you were hospitalized due to symptoms of speech difficulty and weakness resulting from an acute ischemic stroke a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot the brain is the part of your body that controls and directs all the other parts of your body so damage to the brain from being deprived of its blood supply can result in a variety of symptoms stroke can have many different causes so we assessed you for medical conditions that might raise your risk of having stroke in order to prevent future strokes we plan to modify those risk factors we are changing your medications as follows please do not take any blood thinners such as aspirin or warfarin we are increasing your lisinopril to mg one tablet daily for better blood pressure control we have started metoprolol tartrate to help control your blood pressure and heart rate we have started you on subcutaneous heparin three times a day to prevent dvts while you are at rehab we have started you on docusate mg twice a day to prevent constipation please take your other medications as prescribed please followup with neurology and your primary care physician as listed below if you experience any of the symptoms below please seek medical attention in particular since stroke can recur please pay attention to the sudden onset and persistence of these symptoms sudden partial or complete loss of vision sudden loss of the ability to speak words from your mouth sudden loss of the ability to understand others speaking to you sudden weakness of one side of the body sudden drooping of one side of the face sudden loss of sensation of one side of the body sudden difficulty pronouncing words slurring of speech sudden blurring or doubling of vision sudden onset of vertigo sensation of your environment spinning around you sudden clumsiness of the arm and leg on one side or sudden tendency to fall to one side left or right sudden severe headache accompanied by the inability to stay awake it was a pleasure providing you with care during this hospitalization followup instructions primary care provider md phone date time neurology provider md phone date time pm ma md,"{
""Diagnoses"": [""Neurology"", ""Allergies"", ""Adverse Drug Reactions"", ""Dementia"", ""Hypotension"", ""Depression"", ""Multiple Rib Fractures"", ""Small Subdural Hematoma""],
""Medications"": [""Olanzapine""]
}"
13858,admission date discharge date date of birth sex m history of present illness baby is a former g product of a week gestation pregnancy born to a year old gravida para woman whose pregnancy was apparently uncomplicated in this healthy woman the babies were born at hospital and transferred to the via transport team they were transferred to the because of beds inavailability at mother presented in labor on the morning of delivery breech presentation of twin a no sepsis risk factors noted on hospital records ultimately maternal serologies were o positive antibody negative rubella immune rapid plasma reagin nonreactive hepatitis b surface antigen negative and group b strep unknown in the delivery room the infant emerged with decreased tone and respiratory effort apgar scores of at minute and at minutes the infant was brought to the newborn nursery intubated for increased work of breathing upon arrival of the transport team the infant was given surfactant and antibiotics complete blood count and differential were obtained and blood cultures the baby initially was on with pressures as high as weaned during transport a chest x ray was consistent with respiratory distress syndrome endotracheal tube was in the right main stem the tube was repositioned by the transport team physical examination on presentation on admission examination at the the infant was pink active nondysmorphic birth weight was g th ile length cm th ile and head circumference cm th ile skin without lesions bilateral red reflexes a regular rate and rhythm normal first heart sounds and second heart sounds lungs were coarse and equal bilaterally the abdomen was benign normal extremities a nonfocal and age appropriate neurologic examination spine was intact no dimples hips were normal a patent anus hospital course by issue system respiratory issues on arrival on settings of and a rate of had a blood gas of the baby was weaned to ventilator settings over the course of the day of and a rate of and was on room air by day of life one the baby was transitioned to continuous positive airway pressure of cm on room air with a respiratory rate in the s to s he was transitioned to room air on day of life two and then developed a nasal cannula oxygen requirement currently he is on nasal cannula at less than cc with a respiratory rate of s to s mild subcostal retractions cardiovascular system the baby has had no cardiovascular instability baseline heart rate is s to s he has had a stable blood pressure with systolics in the to range diastolic pressures of to and means in the s to s he has no murmur fluids electrolytes nutrition issues the baby has a peripheral intravenous line and was initially nothing by mouth with maintenance intravenous fluids of cc per kilograms of d w maintenance electrolytes were added on day of life one and he currently is receiving d w with meq of sodium chloride per cc at cc per kilograms per day he had enteral feedings introduced on day of life one and is advancing to full enteral feeds he is currently at cc per kilograms of pe with iron advancing cc per kilograms b i d the mother is pumping the mother informed us that she had cold sores on her lips which are frequent for her and was advised to discard expressed breast milk until her mouth lesions heal the baby is voiding and stooling and had a last set of electrolytes on which revealed sodium was potassium was chloride was and bicarbonate was gastrointestinal issues the baby had a peak bilirubin on day of life four of with a direct component of on his bilirubin was phototherapy was just discontinued and we would advise getting a rebound bilirubin on hematologic issues the baby has not required any blood products during this admission his admission hematocrit here was infectious disease issues the baby was started on hours of ampicillin and gentamicin with an initial white blood cell count of polys bands and lymphocytes platelet count was at hours of age blood cultures sent here were negative and the baby was clinically improving so the antibiotics were discontinued neurologic issues the baby was appropriate for gestational age based on a gestational age of greater than weeks a head ultrasound was not advised unless there is clinical concern sensory issues audiology screening not done at the time of this dictation ophthalmologic issues eye examination not indicated based on gestational age of greater than weeks psychosocial issues mother was discharged from the hospital on arrangements were made for her to stay at at a hotel however the family decided not to come to the city and we discussed transport to today which they were pleased about they have received updates via telephone from the staff condition at transfer condition on transfer was stable discharge status to primary pediatrician name of primary pediatrician was unknown at the time of this dictation care recommendations continue advancing enteral feeds cc per kilograms per day with a goal of cc per kilograms per day enterally medications would consider beginning ferrous sulfate when achieves full feedings none at this time car seat screening prior to discharge a state newborn screen was sent on immunizations received none to date 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 born between and weeks 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 follow up appointments per routine with primary care physician scheduled at this time discharge diagnoses former week premature twin respiratory distress syndrome status post rule out sepsis with antibiotics hyperbilirubinemia reviewed by m d dictated by medquist d t job,"{
""Diagnoses"": [""birth asphyxia"", ""bronchopneumonia"", ""research syndrome""],
""Medications"": [""surfactant"", ""antibiotics"", ""pressors""]
}"
2548,admission date discharge date service medicine allergies naproxen attending chief complaint melena major surgical or invasive procedure esophagogastroduodenoscopy history of present illness f cad s p silent mi here w melena after course of nsaids usoh until three days prior to admission developed melena weakness gnawing discomfort in epigastrium no cp sob guaiac pos in pcp office and sent to ed found to have decrease in hct to from baseline given iv protonix and brought to unit for egd which revealed gastritis shallow ulcer but no active bleeding recommended iv ppi hct while in house npo overnight then f u scope in two months while on ppi past medical history htn hyperlipidemia cad s p silent mi osteoarthritis social history occasional alcohol does not smoke independent adls family history nc physical exam vs l general nad sleepy after scope heent eomi ommm neck supple no lad cardiovascular s s reg i vi systolic no rg lungs ctab abdomen soft nt nd active bowel sounds extremities warm no cce neuro sleepy but arousable pertinent results pm hct pm hct pm urine color straw appear clear sp pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk tr pm urine rbc wbc bacteria mod yeast none epi 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 macrocyt pm plt count pm pt ptt inr pt egd small hiatal hernia ulcer in the stomach body and antrum erythema friability congestion and erosion in the antrum and stomach body compatible with erosive gastritis erythema friability and congestion in the proximal bulb brief hospital course f with erosive gastritis likely nsaids gastritis noted to have shallow nonbleeding ulcers by egd continued on ppi initially found to have continued hct drop overnight and as such was kept in icu for further observation transfused two units and bumped appropriately no further episodes of melena and tolerated po diet with no difficulty counseled to avoid nsaids however allowed to continue taking asa for presumed secondary prevention of cad cad n tachycardia or demand ischemia noted during this admission fen npo initially then soft diet in am following scope discharged to home following observation and transfusion to return in weeks for followup endoscopy medications on admission atenolol lipitor lisinopril asa ibuprofen discharge medications pantoprazole 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 lipitor mg tablet sig one tablet po once a day lisinopril mg tablet sig one tablet po once a day atenolol oral aspirin mg tablet delayed release e c sig one tablet delayed release e c po once a day discharge disposition home discharge diagnosis gastritis melena blood loss anemia discharge condition patient had stable hct at discharge no further bleeding or melena discharge instructions please take your medications as prescribed please do not take any ibuprofen advil or motrin you may still take tylenol for pain please call your doctor or return to the er if you have chest pain shortness of breath dizziness black stools or bloody stools blood when you vomit or have other concerning symptoms followup instructions you should follow up to have an endoscopy in weeks you should follow up with your primary care doctor dr in weeks his phone number is,"{
""Diagnoses"": [""Melena"", ""Gastritis"", ""Shallow ulcer"", ""Hyperlipidemia"", ""Osteoarthritis"", ""Silent MI""],
""Medications"": [""Naproxen"", ""Protonix"", ""IV PPI"", ""IV HCT"", ""Ondansetron""]
}"
63686,admission date discharge date date of birth sex m service plastic allergies codeine vicodin attending chief complaint right arm pain major surgical or invasive procedure incision drainage irrigation debridement vac dressing placement right upper extremity right arm washout and i d vac dressing history of present illness yo m with h o drug use who presents with days of progressive arm pain and drainage he originally injected himself im in the right arm with percocet days ago he became febrile to and began noticing purulent discharge from the drainage site he self lanced this wound with a straight razor days prior to presentation he awoke this morning with severely increased arm pain swelling and new redness and is here seeking care he reports emesis today denies cp sob n d ed course patient febrile in significant pain cbc with elevated wbc bc pnd ct scan wet read with evidence of necrotizing fascitis throughout right forearm up to humeral epiphysis hyperdensity in medial aspect of upper arm consistent with needle end past medical history ivdu social history previous drug user cocaine injected denies drug use in past years previous etoh disabled married family history noncontributory physical exam nad a ox ctab rrr soft wwp rue vac in place distal pulses intact no erythema drainage pertinent results imaging data ct findings diffuse edema within the soft tissues of the forearm and upper arm with a soft tissue defect noted along the radial aspect of the mid forearm there is tracking soft tissue gas along the deep fascial intramuscular planes as well as edema which extends from the distal radius proximally to the level of the mid humerus findings are compatible with necrotizing fasciitis a linear metallic foreign body measuring approximately mm in length is embedded within the biceps muscle and is seen on series image and it is likely that this foreign body is not related to the acute process the bones appear unremarkable with normal bony mineralization and no cortical destruction or erosive changes to suggest osteomyelitis given that iv contrast was not administered the evaluation for fluid collections is limited impression extensive subcutaneous and deep fascial edema with gas tracking along the deep fascial planes compatible with necrotizing fasciitis the extent of involvement is detailed above though extends from the level of the distal humerus through the level of the distal radius small retained foreign body embedded within the biceps muscle as detailed no evidence of osteomyelitis brief hospital course the patient was admitted to the acute care surgical service on for evaluation and treatment of necrotizing fasciitis admission rue ct revealed subcutaneous and deep fascial edema with gas tracking along the deep fascial planes compatible with necrotizing fasciitis extending from the level of the distal humerus through the level of the distal radius with fevers to and leukocytosis to the patient underwent open debridement and vac dressing placement which went well without complication reader referred to the operative note for details the patient was hemodynamically stable following a second debridement procedure the patient returned to the operating room for split thickness skin graft placement with vac dressing by the plastics and reconstructive surgery service monitored and subsequently discharged id the patient s white blood count and fever curves were closely watched for signs of infection the patient was started empirically on vancoymcin zosyn and clindamycin wound care pt required two debridement procedures and vac dressing placement surgical sites were routinely monitored for signs of infection endocrine the patient s blood sugar was monitored throughout his stay insulin dosing was adjusted accordingly hematology the patient s complete blood count was examined routinely no transfusions were required pain was well controlled diet was progressively advanced as tolerated to a regular diet with good tolerance the patient voided without problem during this hospitalization the patient ambulated early and frequently was adherent with respiratory toilet and incentive spirometry and actively participated in the plan of care the patient received subcutaneous heparin and venodyne boots were used during this stay at the time of discharge the patient was doing well afebrile with stable vital signs the patient was tolerating a regular diet ambulating voiding without assistance and pain was well controlled the patient was discharged home with vna services for dressing changes the patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan medications on admission neurontin trileptil trazodone discharge medications percocet mg tablet sig tablets po every hours for weeks do not drive operate machinery or take tylenol while on this medication disp tablet s refills clindamycin hcl mg capsule sig capsules po every hours daily for weeks followed by twice daily for weeks for months mg po q for weeks followed by mg po bid for weeks disp capsule s refills discharge disposition home discharge diagnosis necrotizing soft tissue infection right forearm discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to the hopsital with a sever skin infection in your right arm the infection required several operations and use of special dressing devices you were seen and evlauted by infectious disease and were given intravenous antibiotics you should avoid injections of any substances into your bloodstream and skin if you have been prescribed narcotics for pain control these medications should be taken only as directed by mouth do not take illicit drugs drink alcohol drive or operate heavy machninery while on these types of medications followup instructions follow up with plastic surgery clinic in week call for an appointment completed by,"{
""Diagnoses"": [""Necrotizing fasciitis"", ""Right arm pain""],
""Medications"": [""Codeine"", ""Vicodin"", ""I.V. antibiotics""]
}"
73837,admission date discharge date date of birth sex f service medicine allergies penicillins flonase attending chief complaint shortness of breath major surgical or invasive procedure picc line placement foley catheter placement right and left cardiac catheterization with the placement of a stent pulmonary artery catheter history of present illness ms is a woman with a history of asthma and seasonal allergies who three weeks ago developed symptoms of a sinus infection this was associated with pronounced congestion and some asthma symptoms such as wheezing and shortness of breath shortly thereafter she also developed symptoms of acute gastroenteritis nausea vomiting nonbloody nonbilious diarrhea nonbloody she notes that she has had similar symptoms following past sinus infections she waited approximately week before visiting her pcp to discuss these symptoms she was started on a z pack for the sinus infection which she completed the diarrhea resolved shortly thereafter but she has continued to vomit once daily which is unusual for her recently she has experienced worsening sob such that she is unable to walk down stairs or from bedroom to bathroom without becoming sob at baseline she is sob with walking upstairs these episodes are often associated with wheezing typical of her asthma and chest pressure like an elephant sitting on my chest however she has had this same sensation with her asthma for years when she becomes sob she pushes on but then has recently started to become lightheaded after hearing that she may have had a past problem with her heart she recalls an episode weeks ago when she had right arm pain that was new and severe but short lived she often has aches pains on her right side since she has had multiple sports injuries on the right including rotator cuff repair for snowmobiling injury years ago however looking back she wonders if this pain could have been cardiac she occasionally has random sharp chest pains with lifting or moving heavy objects but has had these symptoms for years 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 she denies dysuria or other urinary symptoms she endorses ankle edema which she states is related to prednisone use and correlates with the amount that she takes also endorses aches and pains especially of the right side related to old sports injuries this includes grinding in the right knee finally has been recently having hot flashes and believes she is perimenopausal 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 palpitations syncope or presyncope past medical history asthma severe springtime allergies with rhinitis and wheezing obesity s p delayed laproscopic appendectomy age s p ear corrective surgeries age h o cervical dysplasia tubal ligation rotator cuff repair on r injury to c c nerve roots chronic pain exploratory laparoscopy years ago for abdominal pain thought to be related to scar tissue from appendectomy cysts on r ovary fracture of r metatarsal in high school social history currently unemployed worked as an accountant she has two boyfriends at the moment one of whom smokes like a chimney providing significant second hand smoke exposure she lives alone has significant stressors including related to sister s murder and the fact that a boyfriend died in bed while sleeping next to her has tattoos tobacco history cigarettes per day for many years heavier smoker in youth etoh occasionally last drink usually beers if drinking illicit drugs none family history mother has type ii diabetes and breast cancer years ago details of her father s family history cannot be obtained he went out for milk and never came back when she was very young she believes he is now deceased no known family history of early mi arrhythmia cardiomyopathies or sudden cardiac death physical exam general wdwn overweight caucasian woman 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 flat jvp cardiac pmi not palpable tachycardic 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 extremities le edema pitting to mid shin no femoral bruits skin no stasis dermatitis ulcers scars or xanthomas pulses right dp pt left dp pt pertinent results pm pt ptt inr pt pm plt count pm neuts lymphs monos eos basos pm wbc rbc hgb hct mcv mch mchc rdw pm albumin pm ck mb notdone probnp pm ctropnt pm lipase pm alt sgpt ast sgot ld ldh ck cpk alk phos amylase tot bili pm glucose urea n creat sodium potassium chloride total co anion gap pm urine hyaline pm urine rbc wbc bacteria many yeast none epi pm urine blood neg nitrite neg protein glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg pm urine color yellow appear clear sp pm ck mb notdone ctropnt pm ck cpk pm urine rbc wbc bacteria few yeast none epi pm urine blood neg nitrite neg protein glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg pm urine color yellow appear clear sp pfts actual pred pred fvc fev mmf fev fvc ekg sinus tachycardia rate intraventricular conduction delay with left bundle branch block pattern left atrial abnormality low voltage in the standard leads and in the lateral precordial leads no previous tracing available for comparison ekg compared to tracing there is no diagnostic interim change ekg compared to tracing the rate is slightly faster at beats per minute but there is no diagnostic interim change chest x ray ap portable chest at p m history tachycardia and shortness of breath comparison findings lung volumes are diminished no consolidation or edema is evident the mediastinum is unremarkable the cardiac silhouette is accentuated by multiple patient and technical factors but is likely normal no effusion or pneumothorax is seen the osseous structures are unremarkable impression no acute pulmonary process chest ct cta indication year old female with dyspnea and tachycardia and concern for pulmonary embolism technique mdct acquired axial images of the chest were obtained with iv contrast sagittal and coronal reconstructions were performed no comparison studies available findings the heart appears normal there is no evidence of pericardial effusion the aorta appears normal in caliber with no evidence of dissection there is no mediastinal or hilar lymphadenopathy the pulmonary arteries and major pulmonary segmental arteries branches are well opacified with no evidence of embolus there is relatively slow clearance of contrast from the right atrium and right ventricle with mild regurgitation of contrast into the portal venous system this finding is suggestive of high vascular resistance however the main pulmonary artery is not distended which does not advocate pulmonary hypertension there is no pneumothorax or pleural effusion there is variable attenuation of the lung parenchyma with multiple areas of air trapping consistent with small airway disease compatible with patient s history of asthma there are no focal areas of opacification or pulmonary nodules included views of the abdomen demonstrate a normal appearing liver spleen stomach pancreas bilateral adrenal glands and upper regions of the kidneys included portions of the bowel are unremarkable there are no acute fractures or suspicious osseous lesions impression no evidence of pulmonary embolism variable attenuation of the lung parenchyma with multiple areas of airtrapping consistent with small airway disease compatible with patient s history of asthma relatively slow clearance of contrast from the right atrium and right ventricle with mild regurgitation of contrast into the portal venous system is suggestive of high vascular resistance question capillary level however the lack of distention of the pulmonary artery does not suggest pulmonary hypertension the study and the report were reviewed by the staff radiologist echocardiogram the left atrium is mildly dilated left ventricular wall thicknesses are normal the left ventricular cavity is mildly dilated there is severe global left ventricular hypokinesis lvef with basal inferolateral segments contracting best the estimated cardiac index is depressed l min m there is a x cm left ventricular apical thrombus tissue doppler imaging suggests an increased left ventricular filling pressure pcwp mmhg there is no ventricular septal defect right ventricular chamber size is normal with borderline normal free wall function 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 regurgitation moderate mitral regurgitation is seen the left ventricular inflow pattern suggests a restrictive filling abnormality with elevated left atrial pressure moderate tricuspid regurgitation is seen there is moderate pulmonary artery systolic hypertension there is no pericardial effusion impression large apical left ventricular thrombus dilated left ventricle with severe global systolic dysfunction mild right ventricular systolic dysfunction moderate mitral and tricuspid regurgitation elevated filling pressures low cardiac output and moderate pulmonary hypertension ruq ultrasound findings the liver shows no focal or textural abnormality there is no biliary dilatation and the common duct measures cm the portal vein is patent with hepatopetal flow the gallbladder is normal without evidence of stones the pancreas and aorta are not well visualized due to overlying bowel the spleen is unremarkable and measures cm there is no hydronephrosis the right kidney measures cm and the left kidney measures cm impression no gallstones and no signs of cholecystitis lhc rhc coronary angiography in this right dominant system demonstrated two vessel disease the lmca had mild diffuse plaquing the lad had an ostial stenosis and a long mid vessel total occlusion after the first diagonal and septal branches the apical lad filled by left to left and right to left collaterals the lcx had an ostial stenosis and mild luminal irregularities to throughout the rca had mi nimal luminal irregularities throughout and a proximal stenosis with a mid vessel stenosis the rca supplied mdoest collaterals to the mid lad resting hemodynamics revealed elevated right and left sided filling pressures with an rvedp of mm hg and a pcwp of mm hg the cardiac index was depressed at l min m using measured oxygen consumption there was moderate to severe pulmonary arterial hypertension with a pasp of mm hg there was normal systemic arterial blood pressure successful ptca and placement of a x mm endeavor drug eluting stent in the proximal rca were performed final angiography showed normal flow no apparent dissection and a residual stenosis see ptca comments final diagnosis two vessel coronary artery disease severe pulmonary arterial hypretension severely elevated right and left sided filling pressures placement of a drug eluting stent in the proximal rca ekg sinus tachycardia with ventricular premature depolarizations and left bundle branch block compared to the previous tracing of heart rate is increased otherwise there is no diagnostic change ekg sinus tachycardia with left bundle branch block compared to the previous tracing there is no diagnostic change ekg sinus rhythm compared to the previous tracing heart rate is somewhat reduced otherwise there is no major change cardiac mri impression mildly increased left ventricular cavity size with global severe hypokinesis involving predominantly the mid distal anterior wall and the apex the lvef was severely depressed at there was cmr evidence of prior myocardial scarring infarction late gadolinium contrast enhanced cmr images demonstrated areas of hyperenhancement as described above low dose dobutamine images showed poor likelihood of functional recovery of the mid distal anterior wall and apex after mechanical revascularization normal right ventricular cavity size and systolic function the rvef was normal at moderate severe mitral and tricuspid regurgitation the indexed diameters of the ascending and descending thoracic aorta were normal the main pulmonary artery diameter index was normal atrial enlargement left ventricular thrombus brief hospital course the following issues were addressed during this admission acute systolic congestive heart failure secondary to ischemic cardiomyopathy likely ischemic cardiomyopathy given the patient s findings of cardiac catherization echocardiogram showed ejection fraction of only consistent with symptoms of peripheral hypoperfusion characterized by cyanosis and cool to the touch extremities shortness of breath diaphoresis and nausea are largely due to systolic heart failure there was initial suspicion for myocarditis given the patient s lack of history of cad as well as the setting of recent viral prodrome the elevated troponin to in the setting of normal renal function suggests a possible demand ischemic event over the course of the past few weeks which may have coincided with the development of the lbbb likely new this patient has had several prior surgeries at other hospitals and most likely had prior ekgs although there are none in our system on the patient triggered for marked nursing concern with bps of s s drenching sweats nausea and pronounced cyanosis of the lips tongue cheeks and feet metoprolol was stopped at that time and lasix gtt held coumadin was stopped patient received one dose in anticipation of need for possible catheterization in the future morning cortisol returned at several hours later the patient had a second episode this one associated with nausea and vomiting and hypotension to s s she was then transferred to the ccu for further management in the ccu milrinone was started at mg dosing and lasix gtt was continued at cc hr with good response in urine output over the initial hours and the lasix drip was discontinued with continued good urine output she was taken for cardiac catheterization on off of milrinone which revealed vd lad rca with des endeavor placement in the rca on rhc she was found to have elevated pcwp of mmhg and ci of using measured oxygen consumption the patient was started on aspirin statin and plavix electrophysiology was consulted for evaluation for icd vs ventricular pacer placement it was determined that the patient should be re evaluated in mos following medical optimization and discharge to determine if icd v placement was necessary she will follow up with ep in following catherization the patient was continued on lasix gtt for continued diuresis she was then transitioned to po lasix and spironolactone upon transfer back to the floor and weight remained stable at kg less than admission weight left ventricular thrombus most likely developed in the setting of highly impaired cardiac output noted at the apex of the left ventricle on echocardiogram see report patient was started on a heparin drip for anticoagulation with plan to bridge to coumadin however coumadin was held after one dose given concern over the need for possible cardiac catheterization to rule out coronary disease as a contributing factor to systolic chf following cardiac catherization coumadin was restarted she was discharged on lovenox with plans to have inr checked on inr was at discharge hyperglycemia glucose on admission labs was found to be elevated to so qid fingersticks with humalog sliding scale were initiated hemoglobin a c returned at suggesting chronic hyperglycemia this may have been due to patient s prednisone use however glucose levels remained elevated typically s s she was seen by consult team who recommended starting glipizide mg po bid patient will require outpatient follow up for possible new diabetes mellitus for now she will follow up with dr of primary care if she requires or requests a separate endocrinologist she is not interested at this time she has contact information for the diabetes center where she could request to follow with dr consulting fellow elevated lfts given patient s history of nausea and vomiting for several weeks lfts and amylase lipase were sent and returned elevated as above right upper quadrant ultrasound was performed and showed no abnormality total bilirubin alkaline phosphatase and ldh normalized within a few days of admission while ast and alt remained mildly elevated this was felt to be secondary to most likely passive hepatic congestion due to right heart failure with possible contribution from underlying nash given patient s body habitus hepatitis a and b serology returned negative asthma suspect that some of patient s asthma symptoms in the recent past were actually due to congestive heart failure ischemic heart disease prednisone stopped by the patient days prior to admission was not restarted she was continued on the equivalent of her home medications during the admission xopenex was given by nebulizer she had no symptoms of wheezing throughout this admission medications on admission azithromycin mg tablet tablet s by mouth once a day take today course completed cyclobenzaprine mg tablet tablet s by mouth hs as needed muscle spasm may cause drowsiness hydrocodone acetaminophen mg mg tablet tablet s by mouth three times a day as needed for pain levalbuterol tartrate xopenex hfa prescribed by other provider dosage uncertain oxycodone acetaminophen percocet mg mg tablet tablet s by mouth up to qid for severe pain no driving prednisone mg tablet tablet s by mouth once a day sertraline zoloft not taking as prescribed mg tablet tablet s by mouth once a day temazepam mg capsule capsule s by mouth hs as needed for insomnia calcium carbonate vitamin d caltrate plus vitamin d otc mg unit tablet tablet s by mouth twice a day symbicort spiriva discharge medications lovenox mg ml syringe sig one syringe subcutaneous twice a day until inr becomes therapeutic most likely within week disp syringe refills cyclobenzaprine mg tablet sig one tablet po tid times a day as needed for muscle spasm temazepam mg capsule sig one capsule po hs at bedtime as needed for insomnia cetirizine mg tablet sig tablet po daily prn as needed for congestion hydrocodone acetaminophen mg tablet sig one tablet po q h every hours as needed for pain lisinopril mg tablet sig 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 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 warfarin mg tablet sig one tablet po once daily at pm disp tablet s refills furosemide mg tablet sig one tablet po daily daily disp tablet s refills spironolactone mg tablet sig one tablet po daily daily disp tablet s refills carvedilol mg tablet sig one tablet po bid times a day disp tablet s refills glipizide mg tablet sig one tablet po bid times a day disp tablet s refills xopenex inhalation caltrate plus vitamin d mg unit tablet sig one tablet po once a day spiriva with handihaler mcg capsule w inhalation device sig one inhalation once a day outpatient lab work please draw potassium bun creatinine and inr results should be faxed to dr at and dr at date dr at blood glucose monitor kit kit sig one kit miscellaneous once a day please provide patient with glucometer and test strips disp glucometer refills symbicort inhalation discharge disposition home discharge diagnosis primary ischemic cardiomyopathy acute systolic heart failure asthma hypertension uncontrolled diabetes mellitus without complication secondary asthma chronic shoulder pain discharge condition good able to ambulate short distances hemodynamically stable weight at discharge kg lbs discharge instructions you were admitted to with a complaint of worsening shortness of breath an ekg and blood tests suggested that you may have had a minor heart attack in the past but that you were not having a heart attack at the time of your admission an echocardiogram showed that the cause of your shortness of breath was heart failure your heart was not pumping blood effectively to your tissues in addition the echocardiom showed that you have a blood clot in your heart you received iv heparin a blood thinner to reduce this clot and prevent its re formation you were found to have low blood pressure and poor urinary output so you were taken to the cardiac intensive care unit where you received special medications to maintain your blood pressure while removing excess fluid from your system approximately pounds of excess fluid were removed you also underwent cardiac catheterization which showed diffuse coronary artery disease a stent was placed into one of your coronary arteries in the future you will need to take blood thinning medication at least until the clot in the heart resolves you will also need to take several other medications to maximize the function of your heart these medications will likely require adjustment over time and you should continue to follow the recommendations of your treating physicians additionally you were found to have elevated blood sugar during this admission blood tests show that you meet criteria for diagnosis with diabetes mellitus type ii in your case the prednisone that you were taking may have caused the elevated blood sugars this problem may correct itself now that you have stopped taking the prednisone for now you should continue to follow up with dr who will monitor your bloodwork and you should avoid food that are high in simple carbohydrates such as sugars or products made with white flour we will give you a prescription for a glucometer which you should take to your pharmacy please ask for instruction in how to use it bring your glucometer to your appointment with dr to discuss its use we recommend that you weigh yourself every morning and call your doctor if your weight goes up by more than lbs all in one day or over the course of a few days a rapid increase in weight is most likely due to excess fluid and a change in weight may be the first sign when you have too much excess fluid in your system you are likely to experience the same symptoms of shortness of breath and lightheadedness that you had when you came in please adhere to gm of sodium per day diet this will help to prevent fluid from building up in your system we recommend that you read product labels to determine which foods are high in sodium foods to avoid include deli meats processed soups cheese or cottage cheese pasta sauce or anything that is pickled in addition you should attempt to limit your fluid intake to to liters per day we have made the following changes to your medication regimen stop taking prednisone begin taking aspirin mg by mouth daily this medication will help to prevent complications related to your stent or to further coronary artery disease begin taking clopidogrel plavix mg by mouth daily this medication will help to prevent complications related to your stent begin taking carvedilol mg by mouth twice daily this medication will help to reduce the work that the heart needs to do to pump begin taking atorvastatin lipitor mg by mouth daily this medication will help to control your cholesterol to prevent complications from further coronary artery disease begin taking spironolactone mg by mouth daily this medication will help to prevent excess fluid build up and futher complicatins from heart failure begin taking furosemide lasix mg by mouth daily this medication will help to prevent excess fluid build up begin taking lisinopril mg by mouth daily this medication will help to protect your kidney function and prevent further complications from your heart failure begin taking enoxaparin sodium lovenox mg injection twice daily this medication is a rapid acting blood thinner to treat the blood clot in your heart that may be used until your inr reaches a therapeutic value from the warfarin begin taking warfarin coumadin mg by mouth daily this medication is an oral blood thinner to treat the blood clot in your heart you will have to have your blood checked regularly while you are taking this medication begin taking glypizide mg by mouth twice daily this medication will help to control your blood sugars check your blood sugar using your glucometer twice daily including first thing in the morning record the values and bring the recordings to your follow up appointments it may not be necessary to check your blood sugar this often in the future if you have a value less than mg dl you should drink some juice eat crackers or both if you feel lightheaded or dizzy or otherwise mentally sluggish you should consider checking your blood sugar as this may be a symptom of low blood sugar you will also need to arrange to have your blood drawn on this can be done in the same building as dr office either in his office or downstairs in the phlebotomy lab you should bring the prescription for labwork with you on that day afterward changes may be made to your warfarin lasix or spironolactone medications please follow up as directed below followup instructions cardiology dr phone date time building electrophysiology dr phone date time building primary care dr phone date time pm please discuss monitoring your blood sugar with dr you should bring your glucometer and a record of your blood sugars to his office bloodwork date morning place office same building where dr works you will have your potassium kidney function and inr checked changes to your medications may be required diabetes center dr if in the future you would like a separate endocrinologist to manage your diabetes please call this number to arrange for an appointment dr can follow you for now completed by,"{
""Diagnoses"": [""sinus infection"", ""acute gastroenteritis""],
""Medications"": [""Z-pack"", ""Flovent"", ""Flonase"", ""Penicillins""]
}"
95574,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 renal failure acute liver failure major surgical or invasive procedure hemodialysis history of present illness hpi mr is a y o m transferred from with new onset acute renal failure cr ck and elevated lfts last thursday days prior to admission the patient was involved in a bike accident with extensive bruising to his legs and arms he also admitted to injecting cocaine that night he had days of nausea vomiting vomiting up to times daily generalized muscle pain malaise myalgias weakness denies tick bites or recent sickness endorses subjective fever and dark urine reports recent hiv negative six months ago at osh ct abd pelvis reportedly without stones and free fluid in the ed initial vs t bp hr rr ra labs were drawn in the ed significant for microcytic anemia of thrombocytopenia alt ast ldh bili hyponatremia bun cr ag ck mb abg abdominal u s performed and pa and lateral cxr completed ekg showed nsr at pt was given fentanyl iv x zofran mg iv x and morphine mg iv x l ns given smear was also sent to for tick borne diseases renal was consulted and suggested aggressive volume repletion with normal saline bcx x sent currently the patient is reporting diffuse pain everywhere and is nauseas ros denies fever chills night sweats headache vision changes rhinorrhea congestion sore throat cough shortness of breath chest pain abdominal pain nausea vomiting diarrhea constipation brbpr melena hematochezia dysuria hematuria past medical history endocarditis secondary to ivda complicated by empyema treated with abx and thoracotomy social history drug use cocaine last use days prior to admission heroin use in the past alcohol use drinks pack daily smoking ppd lives by himself construction worker family history mother and father are both healthy physical exam vitals t bp hr rr sat ra general awake alert nad heent no sclericterus mmm no lad cardiac rrr systolic murmur loudest at llsb lung cta b l abdomen soft diffusely tender no rebound ext no edema ecchymoses on thighs bilaterally neuro moving all extremities without difficulty sensation intact in all extremities bilaterally derm abrasions over forehead knuckles pertinent results on admission negative parasite smear ck mb mbi ca mg phos alt ast ap ldh tbili dbili uric acid hapto hbsag negative hbs ab positive hbc ab negative hcv ab negative hiv antibody neg microbiology blood culture x pending studies ekg nsr at bpm nl intervals peaked ts in v v no st changes ct head impression no evidence of acute intracranial abnormalities abdominal ultrasound wet read diffusely echogenic kidneys bilaterally nonspecific and can be seen with medical renal disease hypoechoic focus in the mid pole of the right kidney with a thin septation while findings could represent a prominent pyramid septated cyst is also a possibility recommend further evaluation with a renal protocol mri or ct on a non emergent basis osh ct abd pelvis w o contrast no urinary tract stones no free fluid in the abdomen and pelvis linear strands of atelectasis at l lung base liver without focal defects or dilated bile ducts no hydronephrosis mild perinephric stranding bilaterally no bowel obstruction appendix normal cxr impression mild vascular engorgement slightly increased opacities in the left upper lobe could reflect mild edema or may reflect early consolidation brief hospital course patient was admitted to the icu on for new onset acute renal failure cr of and ck of and with elevated transaminases as well rhabdomyolysis patient initially presented with highly elevated ck and etiology of rhabdomyolosis considered as a sequelae of recent bike accident and concaine use the possibility of compartment syndrome was considered however physical exam was not c w this diagnosis also on differential was hiv given his risk factors and erlichiosis given that he is from but parasite smear at osh negative and pt does not recall tick bite pt was given aggressive fluid repletion initially with ns and then with ns c amps bicarb pt s bicarb was followed to ensure that metabolic acidosis was not entirely corrected as metabolic acidosis is protective for hypocalcemic seizures both by raising seizure threshold and by decreasing the fraction of calcium bound to albumin pt s electrolytes were trended pt was significantly hypocalcemic but without symptoms the calcium was not repleted as it was felt that pt would soon become significantly hypercalcemic lysis of muscle cells ck and uric acid were also trended and they slowly trended down ivf were eventually discontinued secondary to pt s poor urine output and increasing volume overload hiv and hepatits serologies were negative upon transfer to the floor he continued improve with intermittent hd and fluid support his ck trended down and he did well acute renal failure initial differential consists of rhabdomyolysis dic ttp hus severe babesiosis given location renal was consulted and felt that this presentation was typical of atn rhabdomyolysis dic labs were negative as was parasite smear pt recieved aggressive fluid hydration as above pt s renal function did not improve over initial several days in micu pt was thus started on hemodialysis on hd he improved after rounds of hd and continued to mobilize fluids his creatinine plateaued in the mid s with good urine output he was able to void on his own without any issues acute hepatitis patient initially presented with transaminitis with initial differential including rhabdomyolosis alt and ast from muscle source rather than liver hepatitis b c given polysubstance abuse history severe babesiosis acetaminophen toxicity and alcoholic hepatitis unlikely as tox screen was negative hepatitis b and c serologies were consistent only with prior hepatitis b vaccination ruq u s was unremarkable for liver process and parasite smear was negative for babesiosis x osh and here as he improved his lft s returned to right upper extremity dvt pt found to have increased edema in right upper extremity and an ultrasound was done which did show dvt pt was started on heparin gtt lovenox not an option give repeat rue us prior to discharge showed no clot given resolved clot and low chance of clot in his baseline medical condition healthy yom prior to rhabdo and his new retroperitoneal bleed heparin gtt was stopped before discharge right flank pain rp hematoma patient had right flank pain that was persistent after arrived on the floor given his history of trauma and recent anticoagulation due to his ru dvt retroperitoneal bleed was considered ct of abdomen was done to eval for abnormalities and rp bleed was identified serial hct was stable vss and hd stable he was discharged with follow up instructions to his pcp polysubstance use pain patient admitted to actively using cocaine and alcohol sw consulted pt complained of severe diffuse muscle pain more than would be expected for rhabdomyolsis compartment syndrome was considered but pt s extremities remained warm and well perfused with good pulses also pt could not localize his pain to any one extremity pt was felt to likely be withdrawing from opioids pt does report occasional heroin use and other prescription medications pt was initially treated c fentanyl boluses and then transitioned to po morphine plus mscontin which were then slowly weaned pt treated with nephrocaps thiamine folate he was asymptomatic throughout his stay on the floor and remained so at discharge anemia hct on admit with mcv at osh hct dic hemolysis ttp were considered however other hemolysis and or dic labs were negative pt s hematocrits were trended and an active type and screen maintained he remained stable at discharge anion gap metabolic acidosis this was attributed to uremia in the setting of acute onset renal failure ethanol and asa screens were negative resolved on the floor hyponatremia given history of nausea and vomiting over days hyponatremia may be due to hypovolemia and gi losses serial na s were monitored and stable and ivf resuscitation was continued resolved on the floor prior to discharge thrombocytopenia differential diagnosis included liver disease splenic sequestration drug related alcohol use babesiosis and hiv hiv and hepatitis serologies were negative platelet counts were trended and stable hypoechogenic focus r kidney while findings could represent a prominent pyramid septated cyst is also a possibility recommend further evaluation with a renal protocol mri or ct on a non emergent basis medications on admission none discharge medications percocet mg tablet sig one tablet po every hours as needed for pain please note you should not operate vehicle or any machinary after taking this medication please read all instructions that comes with the medication before you take the medication disp tablet s refills amlodipine mg tablet sig one tablet po once a day disp tablet s refills pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po once a day disp tablet delayed release e c s refills folic acid b complex c no mg capsule sig one capsule po once a day disp capsule s refills discharge disposition home discharge diagnosis primary acute renal failure right upper extremity dvt rhabdomyolysis elevated liver enzymes secondary anemia respiratory depression anion gap metabolic acidosis hyponatremia thrombocytopenia renal cyst discharge condition stable ambulating afebrile alert and oriented discharge instructions you came to with acute renal failure secondary to a condition called rhabdomyolysis death of your muscle cells we given you iv hydration with temperary hemodialysis you kidney functions improved on an imaging test ct of your abdomen we found that you had a retroperitoneal bleed that was stable we followed you closely for the next couple of days and found that you did not have any active bleed additionally while you were in icu you had a deep vein clot in you right arm however after treatment and monitoring the clot resolved your kidney and liver functions are returning to normal at discharge we also found that you were hypertensive during your hospitalization you will need to take the antihypertensive medication amlodipine after discharge please follow up with you primary care physician for further management of all the above mentioned issues you are stable at time time of your discharge and able to ambulate with assistance please follow up with the doctors listed below we made the following changes to your medications percocet mg tablet sig one tablet by mouth every hours as needed for pain amlodipine mg tablet sig one tablet by mouth once a day pantoprazole mg tablet delayed release e c sig one tablet delayed release e c by mouth once a day folic acid b complex c no mg capsule sig one capsule by mouth once a day please go to the emergency room if you experience any chest pain shortness of breath changes in your urine color inability to urinate or any symptoms that is of concern to you followup instructions please follow up with your pcp at please call either family life or clinical center between brookwood ter or if you are going back to md medical services specialty internal medicine date and time walk in clinic location phone number special instructions if applicable first appointment is as a walk in and then can set up future appointments walk in hours are m f am until pm but must be signed in by pm for insurance purposes please notify mass health that dr is your pcp prior to going to first clinic appt please note that your kidney function is slowing returning to normal not completely recovered you need to follow up with your doctors your kidney is recovering please note that your creatinine at discharge is if this value does not improve at the time of your discharge you will need to follow up with a kidney doctor,"{
""Diagnoses"": [""Acute Renal Failure"", ""Acute Liver Failure"", ""Hemodialysis"", ""History of Present Illness"", ""HPI"", ""MR is a YO male"", ""Transferred from with new onset Acute Renal Failure"", ""CR/CK and elevated LFTs"", ""Bike accident with extensive bruising to legs and arms"", ""Involved in injecting cocaine""],
""Medications"": [""Fentanyl"", ""Zofran"", ""Morphine""]
}"
91333,admission date discharge date date of birth sex f service medicine allergies sulfa sulfonamides penicillins latex red dye darvon percodan aspirin aspartame fentanyl attending chief complaint blasts on routine differential major surgical or invasive procedure ommaya placement with intrathecal chemotherapy cycle of hypercvad right femeral a line right central line history of present illness year old woman with a history of all status post allogeneic transplant with subsequent disease recurrence status post dli with subsequent achievement of a complete remission p w several non spicific pain related complaints and dizziness and blasts on peripheral smear patient endorses dizziness generalized pain with sharp stabbing pain in her right mid back and neck also endorses shortness of breath she is unsure if it is exertional ros per hpi denies fever chills night sweats recent weight loss or gain denies headache sinus tenderness rhinorrhea or congestion denied cough 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 oncologic history the patient was diagnosed with acute lymphoblastic leukemia in after bone marrow biopsy was performed secondary to iron deficiency anemia workup she was treated with standard dose chemotherapy and had a good response she completed induction and consolidation chemotherapy and achieved a complete remission her course was complicated by severe bilateral avascular necroses of the hips due to steroid use she also had multiple dental issues requiring extractions remained in remission for several months but ultimately showed signs of disease recurrence in her marrow she underwent reinduction and achieved once again a complete remission she did well until the summer of when she developed evidence of relapse she received induction chemotherapy once again and achieved remission this course was complicated by neutropenic fever development of a coagulative negative staph bacteremia left upper extremity dvt aseptic necrosis of the bilateral hips and septic emboli of the liver then underwent a nonmyeloablative allogeneic stem cell transplant from matched unrelated donor with campath conditioning in she did well and subsequently achieved remission her posttransplant course was complicated by the development of a sore throat and question of low level ebv infection there was some concern at that time by involvement with a lymphoproliferative disease her ebv titer disappeared upon withdrawal of her cyclosporine she was followed by quantitative ebv levels which remained undetectable and she had fully recovered from this she had no definite evidence for gvhd she remained in remission until her relapse in since her relapse in received treatment with hyper cvad in and a donor lymphocyte infusion on she was again noted for relapse of her all in and was admitted to the hospital from to she had persistent pain in the perirectal area with incontinence and was found to have cns involvement of the cauda equina and received radiation therapy to her lower spine in she then received another cycle of hyper cvad in following the completion of her radiation therapy her day bone marrow showed no residual leukemia and she received another dli on she also received two doses of intrathecal methotrexate on and unfortunately by the end of she was noted for decreasing counts and was admitted with concern for relapsed disease which was confirmed on bone marrow aspirate and biopsy because of her debilitated state was not given any further treatment and she was sent home with increased support and to follow up with her local oncologist with a concern that her disease would relapse or progress further however since her discharge from the hospital in improved with normalization of her counts and no further evidence for disease recurrence she has required no further treatment but has had many chronic complications she developed increasing problems with with constipation and intermittent diarrhea as well as increasing pain in the rectal area as well as increasing pelvic and hip pain there have been no changes with mri of the lower spine the feeling was that she developed issues with anal stricture after her cauda equina syndrome and radiation therapy along with a neurogenic rectum that did not empty fully after approximately two years of significant stress with her bowel regimen and attempts at anal dilatation she underwent a diverting sigmoid colostomy in under the direction of dr at she also has had issues of chronic hip pain due to osteonecrosis of the hip and she is status post left hip replacement in was noted for increasing shortness of breath she underwent an echocardiogram which was noted for a drop in her ejection fraction to she has been started on captopril she underwent an adenosine stress test which did not show any evidence for coronary artery disease it was felt that this may have been related to a viral illness she did undergo a repeat echocardiogram on which showed improvement to about has been followed with continued normal counts until more recently when labs from an outside hospital have shown increased lymphocytes with atypical lymphocytes and decreasing neutrophils with anc of there were no immature cells noted and white count hematocrit and platelet count were normal she had been recovering from two upper respiratory infections given the persistent change in her counts was seen today for further evaluation and was noted for circulating blasts she underwent bone marrow aspirate and biopsy and is being admitted for further evaluation and probable treatment past medical history all juvenile rheumatoid arthritis h o paroxysmal supraventricular tachucardia and paroxysmal atrial tachycardia h o of laryngeal spasm irritable bowel syndrome w colostomy placed for chronic constipation avascular necrosis of the hips in the left shoulder and s p left hip replacement left upper extremity clot sjogren s shingles spring systolic chf ef in the s per patient social history mrs lives alone in her own home she has a personal home care assistant that helps with her cooking cleaning and personal hygiene she also is followed closely by the visiting nurses association and physical therapy she denies alcohol or tobacco use she reportedly has a remote history of marijuana use she has three children family history mother died of lung cancer with brain mets at y o also had gallstones and hypothyroidism the patient s father had prostate cancer hypertension and diabetes at least one of her paternal aunts had breast cancer and another had multiple myeloma one of the patient s paternal cousins has leukemia the patient s aunt has scleroderma physical exam vital signs t bp hr rr o sat ra weight lbs height in general alert oriented no acute distress chronically ill appearing heent sclera anicteric mmm oropharynx clear neck supple jvp not elevated cm nontender mobile l maxillary ln 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 ext warm well perfused pulses no clubbing cyanosis or edema neuro cn grossly intact unsteady gait pertinent results pm ret aut plt smr normal plt count pm hypochrom normal anisocyt poikilocy macrocyt microcyt normal polychrom normal how jol neuts bands lymphs monos eos basos atyps metas myelos other wbc rbc hgb hct mcv mch mchc rdw pm t tsh pm alt sgpt ast sgot ld ldh alk phos tot bili dir bili indir bil albumin calcium phosphate magnesium urea n creat sodium potassium chloride total co anion gap glucose pm bone marrow ipt d cd d cd d cd d cd d cd d cd d cd d cd d cd d cd d cd d hla dr a d kappa d cd d cd d cd d cd c d cd d cd d cd d cd d cd d lambda d cd d imaging and diagnostics bone marrow acute leukemia recurrent by immunostaining most immature blasts cells appear immunoreactive for cd and c kit a subset is in addition positive for nuclear tdt myeloperoxidase stains only approximately of the cells immunophenotypic findings consistent with relapsed acute leukemia karyotype xx xy interpretation a chimerism result was obtained from this unstimulated specimen three cells were xy and represent the male bone marrow donor the remaining cells were xx and represent the female patient nuc ish dxz x dxz dyz x fish was performed on interphase nuclei with probes molecular for dxz chromosome x alpha satellite dna at xp q and dyz chromosome y alpha satellite dna at yp q probes a chimeric xx xy hybridization pattern was observed in which cells were xx and cells were xy these xy cells represent that of the male donor and not the female recipient mr no masses edema or infarct nonspecific heterogeneous marrow which may represent hyperplasia or infiltration csf immunophenotypic findings consistent with involvement by acute leukemia csf there is a minor population of cd cells which in conjunction with the morphology on the cytospin are consistent with the patient s known leukemia csf atypical csf cell marker analysis was performed but was non diagnostic in this case due to insufficient numbers of cells insufficient amount of tissue for analysis and due to poor viability however morphologic assessment of the cytospin showed numerous blasts consistent with patient s known leukemia tte the left atrium is normal in size left ventricular wall thicknesses and cavity size are normal there is mild global left ventricular hypokinesis 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 number of aortic valve leaflets cannot be determined there is no aortic valve stenosis no aortic regurgitation is seen the mitral valve leaflets are structurally normal moderate mitral regurgitation is seen the pulmonary artery systolic pressure could not be determined there is a trivial physiologic pericardial effusion impression mild global left ventricular systolic dysfunction moderate mitral regurgitation compared with the report of the prior study images unavailable for review of left ventricular systolic function is probably similar mitral regurgitation may have slightly increased mr c t l spine diffuse leptomeningeal and cauda equina root enhancement in this setting strongly suspicious for leptomeningeal involvement by the patient s known all no discrete enhancing epidural or other paraspinal soft tissue mass diffusely abnormal bone marrow signal consistent with extensive replacement by known recurrent all no spinal canal stenosis micro cmv viral load final cmv dna not detected csf gram stain final no polymorphonuclear leukocytes seen no microorganisms seen fluid culture final specimen no growth on replant clostridium perfringens isolated from broth media only indicating very low numbers of organisms staphylococcus coagulase negative isolated from broth media only indicating very low numbers of organisms this was thought to be a contaminated specimen brief hospital course yo f with recurrent all status post non myeloablative allogeneic matched transplant from an unrelated donor in with relapse treated w chemo and dli in and all the patient was found to have recurrent bone marrow as well as cns disease after presenting with dizziness after c t l spine imaging the patient s csf was sampled and she was given it mtx through an ommaya biweekly for weeks after her csf cleared on the was then treated on a weekly basis starting on xxxx the patient was unable to tolerate arac due to severe nausea and vomiting after one treatment with ara c the patient instead recevied intra thecal methotrexate approximately twice per week her csf remained positive for blasts until tap on she also received a cycle of hypercvad she received part a as well as dexamethasone on d but vincristine was not given on d due to poor ostomy output and concern for further ileus peripheral blood smears showed resolution of peripheral blasts after days of systemic chemotherapy her course was complicated by mucositis poorly healing aphthous ulcers and poor po intake secondary to pain which complicated healing and cause electrolyte abnormalities requiring significant repletion she was changed from oral pain medication to a low dose morphine pca with good effect she was also started on tpn for nutrition and her electrolytes abnormalities resolved history of anthracycline induced cardiomyopathy repeat tte showed improvement in ef from in the past to on the patient became quite hypervolemic during hypercvad part a and required aggressive diuresis her home captopril was switched to lisinopril she was started on low dose maintenance lasix an attempt was made to start the patient on a low dose beta blocker as well but she developed an episode of fluid responsive hypotension most likely due to the addition of multiple anti hypertensive medications so beta blockade could not be initiated she was intermittently able to tolerate low dose lisinopril and lasix mg po with maintenance of euvolemia they were occasionally held in setting of low blood pressures she was intermittently hypotensive in the setting of poor po intake as above repeat echo on showed er essentially unchanged from prior hypothyroidism patient was maintained on home dose levothyroxine which she intermittently agreed to take tsh was elevated upon admission although free t was within normal limits the patient was encouraged to continue to take her medications in order to prevent symptomatic hypothyroidism micu course overnight ms became increasingly tachypneic and tachycardic and was transferred to the her omaya port was tapped and she was found to have infection in her csf which later speciated as vre her antibiotics were changed to linezolid and vancomycin for improved csf penetration code blue event on ms developed a supraventricular tachycardia at bpm with tenuous blood pressures ecg was performed and no obvious p waves were noted she was noted to have a history of svt atrial tachycardia in the past mg iv metoprolol were given without change in rate the metoprolol was repeated x again with no change in rate given her tenuous clinical status respiratory alkalosis and tachypnea mg diltiazem was given x with resulting improvement in her rate to the s her blood pressure at that time was in the s systolic and normal saline was hung wide open there was difficulty obtaining on the non invasive blood pressure phenylephrine was initiated to bring up the blood pressure given the difficulty in obtaining an accurate blood pressure several attempts were made to place a radial arterial line to obtain arterial blood pressure during these attempts her blood pressure ranged from systolic depending on the rate of phenylephrine infusion she continued to be tachypneic breathing at a rate of breaths per minute at her heart rate was noted to decline and asystole was subsequently noted a code was called within approximately seconds chest compressions were initiated mg atropine was given followed by mg epinephrine after one cycle of cpr she remained pulseless she was successfully intubated by anesthesia abg during code was cpr was continued she received another mg epinephrine followed by mg atropine she was subsequently given amp of cacl units of vasopressin and another amp of cacl with return of spontaneous circulation please see code sheet for further details the theory behind her cardiac arrest is calcium channel blocker poisoning from diltiazem given in the setting of hypocalcemia and alkalemia thus she regained her pulse after admininstering calcium chloride she was given amps of calcium chloride after return of circulation and grams of calcium gluconate she was given mg glucagon for possible beta blocker toxicity and to increase cyclic amp in the setting of calcium channel toxicity she had no further episodes of bradycardia several physicians attempted to place an arterial line after the code without success a repeat abg was on fio peep rate tv further micu course vre in cns blood cx negative since but now enterococcus in csf presumably the same bacteria omaya port which was seeded has now been removed daptomycin was switched to linezolid for better csf penetration although linezolid will cause bm suppression gentamicin for synergy initially later stopped tte was negative for vegetation but given new finding of likely vre in csf suspicion is high for endocarditis would need weeks of abx if vegetation present vs week if only cns infection s p source removal meropenem was discontinued given low suspicion for gram negative process tee would not affect immediate mgt and was thus not pursued in as she had just been extubated id consult is following hypotension patient had an episode of sbp s did not respond to cc bolus so far lactate also elevated likely secondary to poor perfusion differential includes sepsis and her new leukocytosis would go along with this although she is not neutropenic on very broad abx coverage and blood cx repeatedly negative also on the differential are cardiogenic shock ef recently in the post arrest period volume depletion adrenal insufficiency cns etiology pe but not hypoxic nor impressively more tachycardic she required levophed for day stim did not show evidence of adrenal insufficiency and infectious work up was negative bp improved altered mental status mental status changes likely multifactorial including recent sdh prolonged asystolic arrest cns infection possible recurrent cns lymphoma improved over days from not alert at all despite no sedation to alert and interactive she was extubated when neuro status had improved all neupogen was continued initially and thought o be responsible for her bump in wbc s p hyper cvad she is also s p intrathecal mtx and dli this admission per bmt will need further treatment for cns lymphoma in the future respiratory failure intubated in the setting of cardiac arrest with ongoing primary metabolic alkalosis cause is most likely intracranial process ongoing infection recent surgery pe was on the differential but lenis negative unable to do cta contrast allergy there is some concern for the risk of seizure with alkalemia but we are not able to give opiates to depress her respiratory drive because of hypotension respiratory alkalosis improved her neurologic status also improved such that she was extubated without difficulty days after the arrest event leukocytosis most likely secondary to counts recovering after chemo many immature forms however very sharp bump today is also concerning for an infectious etiology she has been afebrile since her evacuation procedure and is on very broad coverage as above will work up for infectious cause as above rash concerning for a drug allergy after discussion with id meropenem is a likely culprit although it has been on for a month it is possible to develop a new rash after this time would also be concerned that linezolid could be contributing since this was recently started although this drug is much less likely to cause rash rash improved after stopping meropenem elevated liver enzymes consistent with shock liver now downtrending inr climbing which may be secondary to synthetic dysfunction after hepatic injury s p asystolic arrest likely was secondary to ccb in the setting of a heart compromised by prior cardiotoxic chemotherapy recent echo showed significant interval worsening of ef over the past weeks without any focal wall motion abnormalities nodal agents were avoided and electrolytes repleted with particular attention to calcium she will need a repeat echo in weeks isolated elevation in ptt repeating this is likely a spurious value but if it remains high would pursue mixing studies to eval for acquired coagulopathy micu course respiratory distress unclear etiology flash pulmonary edema from cardiogenic shock given elevated troponins on her bmt intern found her to be in respiratory distress tachypneic and hypoxic she was able to maintain adequate o saturation on a non rebreather but was working hard and looked to likely be tiring she was transferred to the and intubated she required dobutamine and norepinephrine support for possible cardiogenic shock pt diuresed and eventually weaned off mechanical ventilation on transfer to the floor pt is comfortable at on l by nc speech and swallow evaluation recommended dysphagic diet observation hyponatremia until the patient had serum sodiums in the range of her sodium declined to until when it began to further deline now to a nadir of urine osms suggested siadh thought to be secondary to her recent known intracranial empyema vs pulmonary processes a medication effect from rarely micafungin or atovaquone is also possible she also likely has a component of heart failure and lasix associated exacerbation which are also contributing she received hypertonic saline w correction of na to on transfer to the floor pt is started on salt tabs vre infection w cns involvement s p omaya removal id continued to follow her linezolid was continued there were no further positive cultures micafungin stopped on transfer to floor per id anemia received prbcs w lasix in between to transfuse to hct transferred temporarily to micu on after episode of vtach likely in the setting of baseline heart disease and low k mg vtach resulted in decreased peripheral perfusion w elevated lactate and demand ischemia temporarily on amiodarone drip but became bradycardic so stopped treated temporarily w abx for possible septic infxn but discontinued as no evidence of active infection did continue linezolid for prior vre bacteremia pt improved to baseline by morning and transferred back to bmt floor since arriving back on the floor pt has required cc bolus of ivfs for hypotension and then this afternoon found to be more tachypneic initial abg and written for ativan prn for anxiety however upon reeval pt still tachypneic and appeared to be tiring respiratory code called pt intubated by anesthesia and transferred to pt transferred for acute respiratory failure s p intubation on thought to be shock cardiogenic vs septic vs combination cardiogenic shock acute on chronic chf from chemo repeat tte showed lvef sepsis prior vre infection l femoral tlc still in on transfer as pt has difficult access vs klebsiella pna based on sputum cx l femoral tlc d c d on new l femoral aline and r femoral venous tlc placed elevated lactate to on transfer hypoperfusion from shock though ddx included linezolid side effect vs nutritional thiamine deficiency so linezolid switched to daptomycin and thiamine administered continued broad antimicrobial coverage meropenem x days daptomycin x days ciprofloxacin days total atovaqone acyclovir monitored co ci and hemodynamics w vigileo system patient extubated on diuresed as tolerated by blood pressure with lasix mg iv x daily required one dose albumin for support blood urine and sputum culture negative she was transitioned to tube feeds video swallow study was deferred as patient was too weak and sleepy to cooperate transferred to floor on in am patient had been called out to the floor earlier in the am but respiratory status declined over a period of hours within arriving to the floor code blue was called for increased work of breathing patient intubated and immediately required initiation of pressors upon arrival to the sbps in s in spite of being maxed out on pressor and she was noted to be very cold in her extremities stat labs notable for worsening anion gap metabolic acidosis patient given stress dose steroids broad spectrum antibiotics started and quickly maxed out on pressors bedside tte revealed no significant pericardial effusion and pt given several amps of hco during this time the pt s pulse was maintained and chest compressions were not required stat aline was placed in sterile conditions in r femoral and abg obtained revealed with lactate given profound hypoxemia sbps in s in spite of being maxed out on pressors pt s son was called who agreed with withdrawing care pressors were turned off and pt s bps decreased to s however she did not expire until ett was removed several hours later son declined autopsy medications on admission ativan mg q po prn captopril po bid synthroid mcg daily oxycodone mg qid prn benadryl topical ointment for pruritis artificial tears discharge medications n a discharge disposition expired discharge diagnosis expired primary recurrent acute lymphoblastic leukemia with cns involvement cardiopulmonary arrest secondary acute on chronic systolic anthracycline induced congestive heart failure hypertension discharge condition expired discharge instructions n a followup instructions n a completed by,{}
21033,admission date discharge date date of birth sex m service history of present illness this year old gentleman a patient of dr with known prior coronary artery bypass grafting came in for outpatient cardiac catheterization due to a recent abnormal exercise tolerance test past medical history status post coronary artery bypass grafting x in vf arrest right kidney mass with possible right adrenal and liver invasion the patient is preoperative for partial nephrectomy hypertension hypercholesterolemia prior inferior myocardial infarction noninsulin dependent diabetes mellitus the patient was admitted through dr office in preparation for a cardiac catheterization on medications on admission hydrochlorothiazide mg p o q d atenolol mg p o q d verapamil mg p o q d glyburide mg p o q d diovan mg two tablets q a m allopurinol mg p o q d lipitor mg p o q d allergies dye gave him a rash laboratory data white count hematocrit platelet count inr sodium k chloride co bun creatinine and a blood sugar of the patient was given premedication for his dye allergy on when he was interviewed by telephone for admission on the morning of hospital course on the morning of the patient underwent cardiac catheterization was followed by dr and dr at approximately pm the patient complained of chest pain that had started approximately minutes prior to his admission to the floor he also had diaphoresis and pallor in the catheterization laboratory during the day he had stenting of the vein graft to the obtuse marginal and had received prehydration for his chronic renal insufficiency baseline creatinine of at in the evening when he started complaining of chest pain he had a lead ekg which showed elevations diffusely he was treated with o sublingual and intravenous nitroglycerin he was given a bolus of integrilin and started on integrilin drip he was also given morphine with no effect at the time his blood pressure was systolic this dropped to the range with nitroglycerin and morphine his heart rate was in the s sinus rhythm with st changes as described he was saturating his right femoral sheath was still in the interventional fellow from cardiology was called the patient was brought to the catheterization laboratory emergently at pm anesthesia was also called that evening to urgently intubate this gentleman with a question of a localized pericardial tamponade post catheterization his ph was with a pco of and po of on face mask he was intubated emergently by anesthesia at pm it was noted that he had a possible localized pericardial tamponade anesthesia was called to emergently consult on this gentleman in the catheterization laboratory attempts were made to reopen his vein graft to his obtuse marginal he did not have bleeding but was still hypotensive at the time transthoracic echocardiogram showed a small approximately cc loculated effusion the patient was intubated by anesthesia the loculated effusion was confirmed by transesophageal echocardiogram in the process of transferring him to the operating room when the patient had a ventricular fibrillation arrest with persistent hypotension a lateral thoracotomy was performed by dr of cardiothoracic surgery and a portion of his pericardial effusion was evacuated this was very difficult secondary to dense chest adhesions the transesophageal echocardiogram in the operating room showed persistent decreased heart function prolonged resuscitation over a minute period in the operating room took place but the patient could not sustain a blood pressure and was pronounced dead at pm by dr the patient expired in the operating room on final diagnoses status post coronary artery bypass grafting status post lateral thoracotomy with evacuation of pericardial effusion status post ventricular fibrillation arrest status post imi status post new renal mass noninsulin dependent diabetes mellitus hypertension prior inferior myocardial infarction it should be noted that the lateral thoracotomy was performed emergently as part of resuscitation and the patient did expire in the operating room at pm m d dictated by medquist d t job,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""m"", ""service history of present illness"", ""this year"", ""old gentleman"", ""a patient of dr"", ""with known prior coronary artery bypass grafting"", ""came in for outpatient cardiac catheterization"", ""due to a recent abnormal exercise tolerance test"", ""past medical history"", ""status post coronary artery bypass grafting"", ""x in vf arrest"", ""right kidney mass with possible right adrenal and liver invasion""],
""Medications"": [""hydrochlorothiazide"", ""atenolol"", ""verapamil"", ""glyburide"", ""diovan"", ""allopurinol"", ""lipitor""]
}"
60969,admission date discharge date date of birth sex f service cardiothoracic allergies no known allergies adverse drug reactions attending chief complaint chest pressure major surgical or invasive procedure coronary bypass grafting x with left internal mammary artery to the left anterior descending coronary artery reverse saphenous vein single graft from aorta to distal right coronary artery full left sided maze procedure with a combination of atricure bipolar system and the cryocath with resection of left atrial appendage history of present illness yo female with hx paf and chf who is status post previous electrical cardioversions presented to osh with chest presssure under bilateral breasts she had an echo performed which showed concentric lvh with ef cm ai tr last cardioversion was done she presented to osh on sun with chest pressure which developed at rest she had not taken lasix for days prior to presentation she was found to be in raf in the ed was started on diltiazem gtt and lasix iv bid she was cath d and found to be have vessel cad transferred to for cabg maze past medical history atrial fibrillation hypertension hyperlipidemia obesity history of cellulitis bilateral lower extremities last year social history race caucasian last dental exam years ago per patient she was told she needs tooth extracted from upper left lives with husband contact occupation retired lobbyist for the police association cigarettes smoked no yes x last cigarette years old other tobacco use etoh drink week drinks week x drinks week illicit drug use none family history no premature coronary artery disease father mi died in s mi mother died in s from rheumatic fever physical exam t pulse af resp o sat l b p right left height weight general aa x in nad skin dry intact chronic lower extremity changes bilaterally heent perrla x eomi x neck supple x full rom x chest lungs clear bilaterally x distant breath sounds heart rrr irregular x murmur ii vi sem distant heart sounds abdomen soft x non distended x non tender x bowel sounds x obese extremities warm x well perfused x edema trace le edema varicosities none x neuro grossly intact x pulses femoral right left dp right left pt left radial right left carotid bruit right none left none pertinent results vein mapping the right greater saphenous vein is patent throughout with the caliber of to in the thigh and to in the calf the left greater saphenous vein is also patent with a caliber ranging from to in the thigh and to in the calf carotid u s no significant carotid artery stenosis bilaterally mild atherosclerotic plaques in the carotid bulbs and internal carotid arteries bilaterally echo pre bypass moderate to severe spontaneous echo contrast is seen in the body of the left atrium moderate to severe spontaneous echo contrast is present in the left atrial appendage the left atrial appendage emptying velocity is depressed m s a left atrial appendage thrombus cannot be excluded no atrial septal defect is seen by d or color doppler left ventricular wall thicknesses are normal the left ventricular cavity is moderately dilated there is mild regional left ventricular systolic dysfunction with basal and mid inferoseptal and inferior wall hypokinesis overall left ventricular systolic function is moderately depressed lvef the remaining left ventricular segments contract normally right ventricular chamber size and free wall motion are normal the ascending aorta is mildly dilated there are simple atheroma in the ascending aorta there are simple atheroma in the aortic arch the descending thoracic aorta is mildly dilated there are simple atheroma in the descending thoracic aorta the aortic valve leaflets are moderately thickened there is mild aortic valve stenosis valve area cm mild aortic regurgitation is seen the mitral valve leaflets are moderately thickened trivial mitral regurgitation is seen there is a small pericardial effusion dr was notified in person of the results at time of surgery post bypass the patient is on an epinephrine infusion the patient is now a paced inferoseptal and inferior wall hypokinesis is still present though slightly improved from pre bypass exam estimated ef is right ventricular function is unchanged mild aortic regurgitation is seen mild aortic stenosis is unchanged trivial mitral regurgitation is seen the ascending aorta aortic arch and descending thoracic aorta are intact 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 pt inr pt am blood urean creat na k cl pm blood glucose urean creat na k cl hco angap am blood alt ast alkphos totbili brief hospital course mrs was transferred to for surgical evaluation upon admission she received medical management and underwent pre operative work up she was brought to the operating room on where she underwent a coronary artery bypass graft x with left internal mammary artery to the left anterior descending coronary artery reverse saphenous vein single graft from aorta to distal right coronary artery full left sided maze procedure with a combination of atricure bipolar system and the cryocath with resection of left atrial appendage cardiopulmonary bypass time minutes cross clamp time minutes please see operative report for further surgical details following surgery she was transferred to the cvicu for invasive monitoring in stable condition she arrived intubated on propofol levo epi and was a paced over sb s for optimal cardiac function sedation was weaned she was found to be neurologically intact and extubated without incident that postop night pressors were slow to wean off as she was acidotic requiring blood and epi was discontinued dobutamine was added for continued hemodynamic support betablocker was initially held due to hypotension and bradycardia once pressors and inotropy were weaned off by pod coreg and digoxin were started amiodarone was initiated for maze and post op rapid a fib mrs heart rate and hypotension improved an ace was added but she became hypotensive and was discontinued she continued to progress and on she transferred to the step down unit for further monitoring physical therapy was consulted for evaluation of strength and mobility anticoagulation was initiated for postoperative afib maze gynecology was consulted due to persistent vaginal discharge she had initially been consulted by gyn preop and a dose of diflucan was given however the micro resulted in nonfungal organisms she was placed on metronidazole po x days per gynecology the remainder of her hospital course was essentially uneventful she was cleared for discharge to in on pod all follow up appointments were advised medications on admission calcium mg po daily coumadin mg alternating with mg tues friday only lasix po daily skips occassionally lisinopril mg daily metoprolol mg zocor mg daily discharge medications potassium chloride meq extended release sig two extended release po bid times a day amiodarone mg sig one po tid times a day for days then decrease to mg x week then mg po daily until seen by cardiologist warfarin mg sig as directed po daily daily as needed for afib calcium carbonate mg calcium mg chewable sig one chewable po daily daily miconazole nitrate powder sig one appl topical tid times a day as needed for groin and skin folds senna mg sig one po bid times a day simvastatin mg sig two po daily daily docusate sodium mg capsule sig one capsule po bid times a day ranitidine hcl mg sig one po daily daily aspirin mg delayed release e c sig one delayed release e c po daily daily insulin regular human unit ml solution sig one injection asdir as directed per sliding scale digoxin mcg sig one po once a day carvedilol mg sig one po bid times a day metronidazole mg sig one po bid times a day for days furosemide mg sig one po bid times a day albuterol sulfate mg ml solution for nebulization sig one inhalation q h every hours as needed for wheezing ipratropium bromide solution sig one inhalation q h every hours albuterol sulfate mg ml solution for nebulization sig one inhalation q h every hours magnesium hydroxide mg ml suspension sig thirty ml po hs at bedtime as needed for constipation warfarin mg sig md once a day inr goal for af maze laa ligation discharge disposition extended care facility discharge diagnosis coronary artery disease s p coronary artery bypass graft x atrial fibrillation s p maze procedure past medical history hypertension hyperlipidemia obesity history of cellulitis bilateral lower extremities last year 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 bilaterally 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 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 office will call to arrange appointment 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 completed by,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""service cardiothoracic allergies"", ""no known allergies"", ""adverse drug reactions"", ""attending chief complaint"", ""chest pressure"", ""major surgical or invasive procedure"", ""coronary bypass grafting"", ""x with left internal mammary artery to the left anterior descending coronary artery"", ""reverse saphenous vein"", ""single graft from aorta to distal right coronary artery"", ""full left sided maze procedure with a combination of atricure bipolar system and the cryocath with resection of left atrial appendage""],
""Medications"": [""diltiazem"", ""lasix"", ""iv bid""]
}"
87008,admission date discharge date date of birth sex m service neurosurgery allergies amoxicillin attending chief complaint s p unrestrained driver in mva vs telephone pole major surgical or invasive procedure icp monitor placement tracheostomy and peg placement history of present illness this is a year old male who is status post motor vehicle accident and was found at the scene with a gcs he was brought to an outside hospital and intubated and transferred here for further care his parents arrive to the emergency department after the initial patient evaluation at the outside hospital the patient recieved dilantin gram rocuronium propofol past medical history none social history parents mom cell dad cell patient does not live at home with his parents family history unknown physical exam gen intubated gcs t heent right head laceration pupils l nr mm right sluggish reaction eoms no eye opening neck hard cervical collar extrem warm and well perfused neuro mental status intubated no eye opening non verbal orientation not oriented person place and date recall 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 v vii viii ix x xii unable to test motor strength withdraws x pronator drift unable to test toes downgoing bilaterally physical exam upon discharge movesd all extremities pupils mm mm eo to noxious follows simple commands pertinent results ct head w o contrast multiple punctate foci of hemorrhage while some of these may be in the subarachnoid space some appear at the white junction raising the question of right frontal subgaleal and subcutaneous hematoma with several foreign bodies no underlying fracture ct c spine w o contrast no acute fracture or malalignment ct head right frontal lobe bolt placement with small foci of hemorrhage along it multiple foci of punctate hemorrhages at the white matter junction consistent with diffuse axonal injury newly visualized subarachnoid hemorrhage in the interhemispheric fissure and in bilateral frontal lobes consistent with shifting of blood unchanged right frontal subgaleal hematoma ct head this study is significantly limited by motion however in the visualized portions the intraventricular hemorrhage appears unchanged fluid in the ethmoidal air cells and sphenoid sinuses which could be related to intubation cta chest bilateral upper lower and lingular consolidations have now progressed these likely represent areas of pneumonia ett is very high and should be advanced by cm mri head impression multiple foci of hemorrhagic diffuse axonal injury in the bifrontal and left posterior temporal subcortical white matter as well as abutting the temporal of the right lateral ventricle non hemorrhagic diffuse axonal injury in the posterior limb of the left internal capsule and in the splenium of the corpus callosum bilateral subarachnoid hemorrhage again noted along the convexities small amount of intraventricular hemorrhage also again noted mri c spine impression no findings suggestive of ligamentous injury or cord injury in the cervical spine mild cervical spondylosis as above mri a brain c spine impression no evidence of dissection in the vertebral or carotid artery diffuse axonal injury and small amount of blood in the occipital of the lateral ventricles better evaluated on dedicated mr head from mri shoulder impression limited exam due to suboptimal technique infraspinatus edema and probable bursal surface fraying of the infraspinatus tendon this is nonspecific and most likely represents posttraumatic musculotendinous tear lower in the differential diagnosis are etiologies such as early denervation and inflammatory etiologies possible small tear of the anteroinferior labrum lack of joint fluid limits evaluation of the labrum brief hospital course y o m s p mva vs telephone pole presents to with a gcs of ct head concerning for and punctate hemorrhages mannitol bolus was given in the ed and will continue at q h on examination patient is more brisk with his l side spontaneous and purposeful on the r he flexes and w d to noxious stimuli no eye opening or commands he was admitted to the icu and a bolt was placed with an icp of his icp was subsequently medically managed with hyperosmlar therapy repeat head ct was stable repeat ct head on remained stable and his icp remained stable on hyperosmolar therapy on he was started on vancomycin cefepime flagyl and cipro for significant hospital aquired pneumonia and respiratory failure he reamined intubated he had a cta chest that was negative for a pe on his icps remained and his exam remained stable his icp monitor was discontinued on an mri in the afternoon revealed multiple foci of hemorrhagic diffuse axonal injury in the bifrontal and left posterior temporal subcortical white matter his mannitol was weaned to mg qd and sqh was started that evening on his mannitol was discontinued due to persistent ventilation requirement a consult for a peg treach by general surgery was obtained and he went to the or on to have these placed pt s antibiotics changed to vancomycin only per id recommendation on pt was febrile on and blood cultures were obtained he was transferred to the sdu on on pt remained neurologically stable and afebrile infectious disease team recommended discontinuing antibiotics as the pt had completed sufficient course pt and ot were consulted for assistance with discharge planning and acute rehab was recommended on the patient was again stable and cleared for discharge to rehab facility pending bed availability he remained stable following this and on the morning of he was discharged to for rehab medications on admission none discharge medications famotidine mg tablet sig one tablet po bid times a day clonidine mg tablet sig one tablet po tid times a day white petrolatum mineral oil ointment sig one appl ophthalmic prn as needed as needed for dry eyes heparin porcine unit ml solution sig one ml injection tid times a day oxycodone mg ml solution sig ml po q h every hours as needed for pain quetiapine mg tablet sig one tablet po tid times a day as needed for anxiety senna mg tablet sig one tablet po bid times a day as needed for constipation docusate sodium mg ml liquid sig ten ml po bid times a day lorazepam mg ml syringe sig ml injection q h every hours as needed for agitation hydralazine mg ml solution sig ml injection q h every hours as needed for sbp greater than acetaminophen mg tablet sig tablets po q h every hours as needed for fever bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day ziprasidone hcl mg capsule sig one capsule po bid times a day lorazepam mg iv q h prn agitation agitation discharge disposition extended care facility discharge diagnosis punctate hemorrhages rivh discharge condition mental status confused always activity status bedbound level of consciousness lethargic but arousable discharge 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 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,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""neurosurgery"", ""allergies"", ""amoxicillin"", ""attending chief complaint"", ""s p unrestrained driver in mva vs telephone pole"", ""major surgical or invasive procedure"", ""icp monitor placement"", ""tracheostomy and peg placement"", ""history of present illness""],
""Medications"": [""dilantin"", ""rocuronium"", ""propofol""]
}"
393,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint tumor thrombus extending into right atrium major surgical or invasive procedure none history of present illness mr is a very pleasant yo man with a pmh of cirrhosis a combination of etoh and chronic hepatatis c who was transferred from an osh with extensive hcc and tumor thrombus extending up his ivc into his ra he was initially on the surgical service for possible thrombectomy but he is not currently a surgical candidate given the extent of the tumor thrombus he is being transferred to the medical service for palliative care the pt denies any pain or discomfort currently he denies chest pain shortness of breath or abdominal pain or discomfort he denies recent hematemesis melena or hematochezia although he did present to the osh with hematemesis requiring banding of a variceal bleed past medical history cirrhosis chronic hepatitis c and etoh social history smoker denies etoh for last years family history non contributory physical exam vitals t bp p r sao on l general awake drowsy nad pleasant cooperative heent eomi no scleral icterus mm dry neck no significant jvd pulmonary lungs with ronchi anteriorly cardiac rr soft s s no murmurs rubs or gallops appreciated abdomen nt moderately distended normoactive bowel sounds extremities trace edema bilaterally skin no rashes or lesions noted neurologic alert oriented x pertinent results abd pelvis ct findings consistent with multifocal hepatocellular carcinoma with large infiltrative lesion in right posterior lobe of the liver with associated extensive most likely bland thrombus expanding the entire right portal venous system and tumor thrombus infiltrating the middle hepatic and right hepatic vein tumor thrombus from the hepatic veins extends into the intrahepatic ivc and extends cranially approximately cm into the right atrium likely bland tumor thrombus extends approximately cm into the main portal vein the splenic vein left portal vein and smv all remain present moderately large amount of ascites surrounding the liver no definite peritoneal carcinomatosis brief hospital course yo m with cirrhosis presented from osh with diffuse hcc and tumor thrombus extending into the right atrium tumor thrombus no intervention possible given the prognosis palliative care was consulted and the patient was made cmo he should be given pain medicine hydromorphone po while still aware enough then subl ingual morphine concentrate without concern for respiratory status or somnolence he should be treated with lactulose for encephalopathy so that he may have as much time as possible with his family he should also be given lorazepam for agitation and livsin for secretions medications on admission vancomycin piperacillin tazobactam pantoprazole heparin sc tid discharge medications lactulose g ml syrup sig thirty ml po tid times a day hydromorphone mg tablet sig tablets po q h every hours as needed for pain dyspnea restlessness morphine concentrate mg ml solution sig mg po q hr as needed for pain restlessness dyspnea lorazepam intensol mg ml concentrate sig mg po q hr as needed for restlessness dyspnea levsin mg ml drops sig mg po q hr as needed for secretions acetaminophen mg suppository sig one suppository rectal every hours as needed for fever or pain discharge disposition extended care facility discharge diagnosis primary hepatocellular carcinoma tumor thrombus involving the inferior vena cava and right atrium cirrhosis chronic hepatitis c discharge condition comfortable discharge instructions please take all medications as prescribed please do not withhold pain medication for decreased respiratory rate or somnolence if the patient is in pain or agitated please treat followup instructions none md,"{
""Diagnoses"": [""tumor thrombus extending into right atrium"", ""cirrhosis"", ""chronic hepatitis C"", ""etoh""],
""Medications"": [""none""]
}"
23199,admission date discharge date date of birth sex m service neonatology history of the present illness baby boy is a gram former week male infant born to a year old g p now mother with serologies as follows a positive antibody negative rpr nonreactive rubella immune gbs unknown he was delivered via elective repeat cesarean section no maternal fever ruptured membranes at the time of delivery placenta accreta noted at delivery there was maternal blood loss transfusion per report the birth weight was grams lga apgar scores seven and eight the nicu team was called for persistent grunting post delivery physical examination on admission initial physical examination was remarkable for a male infant in room air pale pink and slightly mottled with grunting flaring and retracting he was admitted to the nicu for further evaluation and management of respiratory distress upon arrival in the nicu his initial d stick was he was pale pink active with slightly decreased but symmetrical tone the anterior fontanelle was open and flat no molding the lungs were well aerated bilaterally despite grunting the heart revealed a regular rate and rhythm without murmurs the abdomen was soft without hepatosplenomegaly male genitalia the hips were stable hospital course he was given cc per kilogram normal saline for poor perfusion and pallor respiratory the baby s initial chest x ray showed low volume and hazy lung fields consistent with surfactant deficiency he was intubated and given a total of three doses of surfactant with excellent response he was transitioned to cpap and subsequently to nasal cannula by day of life number four he subsequently weaned to room air on he has had no apnea and bradycardia cardiovascular after the initial normal saline had been hemodynamically stable he has no heart murmur on examination bp was fluids electrolytes and nutrition given his respiratory distress he was initially made n p o subsequently enteral feeds were started on day of life number four and since then he has been taking p o ad lib breast feeding with bottle supplements off iv fluids discharge weight is gm gi bilirubin level peaked on day of life number six at and no phototherapy was initiated infectious disease the baby s initial wbc was with polys and bands he was started on ampicillin and gentamicin for hours sepsis rule out blood cultures remained negative at this time hematology the baby s initial hematocrit was he was subsequently noted to be pale and mottled appearing a repeat hematocrit on day of life number one was he was transfused with cc per kilogram of packed red blood cells with a post transfusion crit on day of life number two of a repeat hematocrit on was genitourinary the baby was circumcised on sensory hearing screening was performed with automated auditory brainstem responses and passed in both ears condition on discharge the baby has been stable on room air for days he has been hemodynamically stable and he is doing well with ad lib breastfeeding discharge disposition the patient is to be discharged to home primary pediatrician dr telephone number fax number care and recommendations feeding at discharge p o ad lib breast feeding medications none at present if mother continues to exclusively breastfeed supplementation with vit d will be indicated with tri vi or polyfisol state newborn screen status sent immunizations received hepatitis b vaccine given follow up with pediatrician and vna set up in the next days discharge diagnosis respiratory distress syndrome status post surfactant therapy anemia from fetal maternal hemorrhage dr dictated by medquist d t job,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""neonatology"", ""history of the present illness"", ""baby boy is a gram former"", ""week"", ""male infant"", ""born to a year old"", ""g p now mother"", ""serologies"", ""positive"", ""antibody"", ""negative"", ""rpr"", ""nonreactive"", ""rubella"", ""immune"", ""gbs"", ""unknown""],
""Medications"": [""elective repeat cesarean section"", ""maternal fever"", ""ruptured membranes"", ""transfusion""]
}"
27696,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint chest pain major surgical or invasive procedure cardiac catheterization traumatic foley catheterization history of present illness mr is a year old gentleman with cad s p cabg in s p pci in chronic stable angina copd and gerd who experienced onset of severe substernal chest pain at am on the morning of pain radiated only to his left arm a call was placed to his cardiologist who instructed him to take aspirin ntg and cardiazem and referred him to the emergency department he said that this episode was more severe than any other episode of chest pain that he had before in the ed initial vs bp in triage then hr bp rr sats he was given ntg sl morphine mg x to control his pain ekg with no st changes set of enzymes was negative 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 absence of dyspnea on exertion paroxysmal nocturnal dyspnea orthopnea ankle edema palpitations syncope or presyncope past medical history coronary artery disease s p cabg in gastroesophageal reflux disease chronic obstructive pulmoary disease benign prostatic hyperplasia s p knee surgery s p trans urethral resection of prostate social history social history is significant for the absence of current tobacco use there is no history of alcohol abuse patient is a cardiothoracic surgeon family history there is no family history of premature coronary artery disease or sudden death physical exam vs t bp hr rr o on l gen wdwn elderly 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 with no jvd cv pmi located in th intercostal space midclavicular line distant heart sounds bradycardic rate normal s s no s no s sem chest well healed midline scar no other chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use bibasilar crackles abd obese soft ntnd no hsm or tenderness no abdominal bruits ext no c c e no femoral bruits skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid without bruit femoral sheath in place no femoral bruit dp left carotid without bruit femoral without bruit dp pertinent results admission labs cbc wbc rbc hgb hct mcv mch mchc rdw plt ct chem glucose urean creat na k cl hco angap calcium phos mg coags pt ptt inr pt ce s am blood ck cpk ck mb ctropnt am blood ck cpk ck mb ctropnt am blood ck cpk ck mb mb indx ctropnt pm blood ck cpk ck mb mb indx ctropnt am blood ck cpk ck mb ctropnt lipids triglyc hdl chol hd ldlcalc cardiac cath hemodynamics pressures right atrium a v m right ventricle s ed pulmonary artery s d m pulmonary wedge a v m left ventricle s ed aorta s d m heart rate beats min rhythm sinus o cons ind ml min m saturation data nl pa main ao final diagnosis branch vessel coronary artery disease patent lima to lad with excellent flow via a native lad patent svg to rca with an excellent competitive flow via a native rca ulcerated lesion in svg to om known occlusion of jump graft to d mildly elevated lv filling pressure two drug eluting stents placed to svg om graft echo overall left ventricular systolic function is normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets appear structurally normal with good leaflet excursion there is no aortic valve stenosis no aortic regurgitation is seen the mitral valve appears structurally normal with trivial mitral regurgitation there is an anterior space which most likely represents a fat pad brief hospital course y o m with cad s p cabg who presented with unstable angina and underwent pci with successful stenting of an occluded svg om graft procedure complicated by new t wave inversions on post cath ekg with persistent chest pain x several hours likely due to thromboembolic shower hospital course complicated by developmenyt of atrial flutter and foley catheter trauma with persistent hematuria cardiac a vessels patient was taken to cath lab with placement of cyper stent x in svg to om thromboembolic shower likely explains patient s post cath ekg changes and chest pain ekg changes resolved on serial ekgs and chest pain resolved on nitro gtt able to be weaned off on post cath day cardiac enzymes climbed post catheterization as expected iwth microemboli but peaked and then trended downwards he received integrillin gtt x hours he was then managed medically with aspirin a statin plavix isosorbide mononitrate and ranolzazine beta blocker was held given persistent bradycardia was borderline bradycardic at baseline prior to cath b rhythm a flutter patient with sinus bradycardia post cath patient reports baseline hr beta blockade ws held on post cath day patient developed atrial flutter with variable block he was entirely asymptomatic and hr was in the s he was placed on a heparin gtt while bridging to coumadin he underwent a tee which showed no and he was then cardioverted follow up ekg demonstrated nsr c pump lvef tte no chf issues hematuria patient failed initial vioding trial and so foley was replaced while in bed patient accidentally pulled on foley and had subsequent hematuria this persisted despite frequent ns foley flushes clots were removed during flushes urology was consulted who recommended against constant bladder irrigation recommending just prn flushes the hematuria was also felt to be exacerbated in part by his systemic anticiagulation with heparin while awaiting cardioversion he was scheduled for outpatient urologic followup with his primary urologist hypertension well controlled on medical therapy cri baseline cr remained at or better than baseline throughout stay with no evidence of post cath cin copd albuterol prn fen cardiac diet code status full code medications on admission ranolazine isosorbide mg daily protonix day aspirin day ntg prn flomax ventolyn another inhaler that does not remember the name discharge medications isosorbide mononitrate mg tablet sustained release hr sig one tablet sustained release hr po daily daily albuterol mcg actuation aerosol sig puffs inhalation q h every hours as needed aspirin 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 clopidogrel mg tablet sig one tablet po daily daily disp tablet s refills tamsulosin mg capsule sust release hr sig one capsule sust release hr po hs at bedtime warfarin mg tablet sig one tablet po qhs once a day at bedtime disp tablet s refills ranolazine mg tablet sustained release hr sig one tablet sustained release hr po bid times a day atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills outpatient lab work inr on pleaese fax result to dr discharge disposition home with service facility homecare discharge diagnosis primary unstable angina atrial flutter coronary artery disease hematuria discharge condition stable discharge instructions you were admitted with unstable angina you had a cardiac catheterization which showed an occlusion in one of your grafts you had two stents placed in this occlusion you had chest pain following this procedure which was secondary to microemboli from your catheterization during your hospital course you were also noted to have atrial flutter you were cardioverted and started on anticoagulation you will need to remain on coumadin for a minimum of weeks you had persistent hematuria from foley trauma you were evaluated by urology who recommend that you be discharged with the foley you should perform manual irrigation of the foley every hours you should follow up with your urologist next week you should take all of your medications as directed you should not discontinue taking plavix without the advice of your physician your atorvastatin was increased to mg because of you ldl not being at goal please follow up with your primary care doctor in that regards if you have any of the following symptoms please see your pcp or return to the ed chest pain difficulty breathing palpitations lower extremity swelling fever or any other serious concerns followup instructions you have an appointment with your urologist dr on at am please make an appt to see dr in the next weeks please get your inr checked on the result will be faxed to dr completed by,"{
""Diagnoses"": [""severe substernal chest pain"", ""chronic stable angina"", ""COPD"", ""GERD"", ""cardiac catheterization"", ""traumatic Foley catheterization""],
""Medications"": [""aspirin"", ""NTG"", ""cardiazem"", ""morphine""]
}"
18155,admission date discharge date date of birth sex f service cardiothoracic allergies tape attending chief complaint left shoulder and chest pain major surgical or invasive procedure cardiac catheterization history of present illness ms is a year old with a past medical history of hypertension and remote tobacco abuse who presents with substernal chest pain with the onset at rest at am while eating breakfast she called ems within hour of developing this pain and en route to hospital in aspirin and sublingual nitroglycerines were administered her pain then decreased to in the outside hospital emergency department she was found to have an inferior stemi with initial vital signs of and on l she was started on heparin integrellin and nitro drips and transferred directly to the cath lab there she was found to have vessel disease with a culprit rca lesion her rpl branch was stented on hemodyamic evaluation she was found to have tall v waves concering for mr however once her stent was placed the tall v waves resolved additionally to rule out shunt pathology as the etiology for the tall r waves her oxygen saturations were assessed she had no step up with pa sat and svc sat ct was consulted in the cath lab and they are working her up for possible cabg her cardiac output post cath was and her index was past medical history fibromyalgia glaucoma bilaterally right eye surgery right pupil does not respond to light social history children married and lives with son quit etoh years ago recovered alcoholic smoked ppd for years and quit years ago family history father with cad no dm physical exam afebrile bp hr on l gen loquacious nad heent maxillary and mandibular gums with blood oozing cor rrr no m r g pulm ctab no w r r anteriorly abd soft nt nd bs ext wwp dp bilaterally right groin with catheters in place dressings c d i no pedal edema pertinent results pm ck mb mb indx pm ck cpk am glucose urea n creat sodium potassium chloride total co anion gap am alt sgpt ast sgot ck cpk alk phos tot bili am albumin am wbc rbc hgb hct mcv mch mchc rdw am pt ptt inr pt echo the left ventricular cavity size is normal left ventricular systolic function appears grossly preserved but regional wall motion could not be fully assessed the inferior wall and apex were not well visualized right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened no aortic regurgitation is seen the mitral valve leaflets are mildly thickened moderate mitral regurgitation is seen there is no pericardial effusion brief hospital course ms is a year old woman who presented with an inferior stemi on she has vd with placement of a cypher stent in the rca rpl branch as culprit lesion she was started on plavix and aspirin she did appear to have ischemic mr since she had tall v waves which resolved after stent placement in the rpl which supplies the posterior leaflet of the mitral valve her repeat echo showed an ef of and mr cardiac surgery was consulted for operative revascularization she was taken to the operating room with dr on for cabgx lima lad svg om svg pda the mitral regurgitation was found to be mild in the operating room by tee and the mvr was not replaced she tollerated the procedure well and was transfered to the csru in stable condition upon arrival to the csru she was found to have st changes on her ekg a tee was performed which showed mild inferior hypokinesis which was not thought to be significant she was weaned and extubated from mechanical ventillation without difficulty and remained hemodynamically stable with a good cardiac index she developed atrial fibrillation on pod and was started on amiodarone she was transfered to the floor on pod where she began working with physical therapy she quickly progressed with physical therapy but repeatedly complained on feeling short of breath with ambulation her lasix was increased and a cxr did not show significant effusions or infiltrate on pod she was noted to have an elevated wbc medications on admission atenolol nifedipine aspirin evista elavil prn discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily clopidogrel bisulfate mg tablet sig one tablet po daily daily disp tablet s refills metoprolol tartrate mg tablet sig tablet po bid times a day disp tablet s refills clopidogrel bisulfate mg tablet sig one tablet po daily daily disp tablet s refills furosemide mg tablet sig one tablet po q h every hours for days disp tablet s refills potassium chloride meq capsule sustained release sig two capsule sustained release po q h every hours for days disp capsule sustained release 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 atorvastatin calcium mg tablet sig one tablet po daily daily disp tablet s refills amiodarone hcl mg tablet sig two tablet po once a day for months disp tablet s refills amitriptyline hcl mg tablet sig one tablet po hs at bedtime disp tablet s refills evista mg tablet sig one tablet po once a day discharge disposition home with service facility area vna discharge diagnosis s p st elevation myocardial infarction s p cabg hypertension glaucoma s p eye surgery anxiety discharge condition good discharge instructions you may take a shower and wash your incisions with mild soap and water do not swim or take a bath for month do not drive for month do not apply lotions creams ointments or powders to your incisions do not lift anything heavier than pounds for month followup instructions follow up with dr in weeks follow up with dr in weeks follow up with dr in weeks,"{
""Diagnoses"": [""Cardiothoracic"", ""Allergies"", ""Tape"", ""Chief Complaint"", ""Subernal Chest Pain"", ""Inferior ST Elevation Myocardial Infarction"", ""Vessel Disease"", ""Culprit RCA Lesion"", ""RPL Branch Stented""],
""Medications"": [""Aspirin"", ""Sublingual Nitroglycerin"", ""Heparin"", ""Nitro Drips""]
}"
1266,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint shortness of breath major surgical or invasive procedure none history of present illness yo male with cad diastolic chf severe pvd htn and dm admitted with rapid afib a flutter in setting of hypoxia hypotension and possible underlying copd he has had worsening sob over past two months initially started as doe he states that over the past few months he has been feeling increasingly short of breath he states he has to stop times when walking up one flight of stairts he denies any pnd orthopnea stable pillow orthopnea but he reports associated palpitations over the past few weeks he denies any chest pain jaw pain diaphoresis fever chills but does report intermittent nausea vomiting and diarrhea over the past few days he was started on combivent by pcp had inhalers in the past but was not using pt was recently hospitalized at nebh for left total hip arthroplasty right hip done in where he had a postop course complicated by delirium copd exacerbation aflutter with block hemodynamically unstable required neo electrically cardioverted pna ceftaz in ed hypoxic to tachycardic with afib flutter to s with hypotension he received cc bolusx combiventx and solumedrol on exam sitting upright with short shallow breaths poor air flow wheezes and rhonchi and trace edema past medical history pmhx cad lad stent cath lmca patent lad mild stenosis with d lcx mild distal to om rca mild irregularities with mid stenosis pvd r sfa stent htn hyperlipidemia cardiomyopathy depression osteoarthritis bilateral hip replacement social history pack year tobacco history quit yrs ago history of heavy alcohol use quit yrs ago lives with wife with assistance family history non contributory physical exam vs t hr bp rr o l gen elderly man sitting up speaking in full sentences shallow breathing on nc o nad heent perrl eomi bilaterally op clear mmm neck no jvd appreciated cv rrr very distant heart sounds nl s s no m r g appreciated lungs decreased bs throughout expiratory wheezes diffusely crackles at left base abd obese soft nt nd no hsm appreciated extr no c c pretibial pitting edema bilaterally very weak peripheral pulses bilaterally in le neuro grossly intact sensation and motor intact bilaterally pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood plt ct am blood pt ptt inr pt pm blood ptt am blood glucose urean creat na k cl hco angap am blood calcium phos mg am blood tsh ekg afib s s nl axis irregular cxr unremarkable cardiomegaly mild failure p mibi ef tte ef small pericardial effusion not hemodynamically significant mild dilation of left atrium cannot exclude wall motion abnormality due to poor study ekg sinus rhythm incomplete right bundle branch block lateral st elevation since previous tracing of no significant change chest portable ap am improving aeration at both lung bases residual minor atelectatic changes and small pleural effusions brief hospital course yo male with pmhx of cad pvd htn dm diastolic dysfunction cri atrial fibrillation admitted to the ccu in acute respiratory failure the setting of rapid afib in chf intubated extubated called out to the floor with persistent lower extremity edema refractory to multiple diuretic therapies respiratory failure pt was transfered to the ccu from the floor after an acute episode of respiratory distress and hypoxia in the setting of recurrent rapid afib sob did not resolve after attempted diuresis with iv lasix pt s respiratory failure was most likely secondary to acute chf secondary to volume overload resulting from acute renal failure in a pt with underlying copd pt initially was given bipap with progressive hypoxia pt was intubated and started on ac initially pt was difficult to ventilate pt started off with fio of and peep of on assist control over the next several days the ventilator settings were weaned down the patient was difficult to extubate and therefore remained intubated for the next weeks the pt was maintained on assist control for a while followed by multiple trials of pressure support and attempts at extubation since pt was significantly volume overloaded on admission aggressive diuresis is what helped in weaning the ventilator and moving towards extubation serial chest xrays were consistent with congestive heart failure without evidence of pneumonia initially pt was not aggressively diuresed since it was thought that he was septic after resolution of septic physiology pt was aggressively diuresed with prn lasix pt was able to tolerate ps for increasing periods of time eventually rsbi s decreased to s and pt was able to tolerate ps peep three attempts were made to extubate the patient during the first attempt pt had copious amounts of secretions but lacked a good cough reflex and was re intubated for inability to clear his secretions the second time the pt self extubated himself his appeared to be breathing decently but the pt subjectively experienced respiratory distress and wished to be intubated in addition he continued to have lots of secretions it was felt that tracheostomy was the most likely next step at this point the pulmonary service was consulted to help with extubation pulmonary suggested continued aggressive diuresis pt was started on lasix drip they also suggested checking for a cuff leak if cc consider short course of steroids for tracheal edema pt did not have signs of tracheal edema he was able to tolerate ps peep with low rsbi third attempt at extubation was made pt was able to stay extubated for days since at times pt appears to be working hard to breath but remained stable with rr o sats and decent abgs on pt was noted to be wheezy and strigorous re intubation was considered however both pulmonary and anesthesiology felt that pt did not need re intubation pt was started on standing solumedrol and racemic epinephrine with improvement in his wheezing and strigor pt became aggitated at times with increased in the work of breathing pt was given prn sublingual zyprexa mg with little improvement in aggitation and breathing haldol mg given with little improvement morphine mg given with some improvement on pt was give zyprexa mg prn with improvement in agitation eventually with aggressive diuresis the patient s respiratory status stabilized he went through a short period of time where he would become increasingly agitatd and desaturate during the evening and require sedation with cpap it was thought that the patient was sundowning and was sending himself into respiratory distress the patient was placed on a standing haldol dose in the evening and the prophylactically given cpap during the night the patient then no longer had desaturation episodes he was transferred to the floor and no longer required sedation or ventilatory assistance by discharge he required no oxygen supplementation his steroids were tapered to off hypotension pt was hypotensive on transfer to ccu and started on dopamine drip etiology of hypotension included new onset sepsis afib and chf swan numbers were more consistent with sepsis with a relatively low cvp high cardiac output index and low svr pt was continued on dopamine and levophed drips pt remained afebrile with an elevated wbc count pt was started on empiric antibiotics of vanco levo flagyl levofloxacin was switched to ceftazidime blood and urine cultures were collected and remained negative pt had positive urine culture on the floor week prior to transfer to ccu which grew out e coli extended spectrum beta lactamase esbl producer considered resistant to all penicillins cephalosporins and aztreonam given this information ceftazidime and flagyl were discontinued and switched to meropenum vanco was continued over the next several days pt s septic physiology resolved however pt still required small doses of levo and dopa pt was very slowly weaned off of both pressors over a period of weeks pt maintained an adequate bp for the majority of his stay on the floor the patient has two episodes of hypotension and bradycardia these episodes occurred in the setting of aggressive diuresis with dopamine and nesiritide and recent addition of patient s beta blocker to daily amiodarone he also felt nauseated and had emesis during these two events both times he was given atropine and had an appropriate response in bp and heart rate the thought was that he had a vagal response in the setting of diuresis beta blocker and amiodarone his beta blocker was held and nesiritide and dopamine stopped with no further episodes rhythm pt was in normal sinus rhythm on the floor cardioverted by amio before going to into rapid afib diltiazem which was previously used for rate control had been held in order to keep map elevated for renal perfusion and diuresis on pt went into recurrent rapid afib with hr in s with associated shortness of breath and hypoxia pt was given mg iv lopressor after pt was intubated in the ccu pt spontaneously converted back into sinus rhythm pt was continued on po amio to maintain sinus rhythm on pt went into rapid aflutter he was started on amio drip and was cardioverted into nsr pt was continued on iv amio later during hospitalization pt was noted to be in first degree av block which he continued to be in pt has had no more episodes of afib or aflutter since pt has received gm of amio this is an adequate loading dose starting on the patient was started on amiodarone mg po and had no major events on telemetry pump during pt s acute episode of afib pt developed associated sob and hypoxia a chest x ray showed that pt was in heart failure on the floor pt was given total of iv lasix and mg iv lopressor heart rate decreased to s and bp improved from to systolic but respiratory distress progressed despite attempted diuresis and rate control pt was transferred to ccu and intubated on admission to the ccu pt was had total body volume overload with signs of heart failure pt has preserved systolic function of but likely has diastolic dysfunction initially pt was not aggressively diuresed since it was thought that he was septic after resolution of septic physiology pt was aggressively diuresed with prn lasix which was later switched to a lasix drip pt lost kgs with a weight loss from to kg with increasing diuresis pt was able to be better ventilated the patient was extubated and evetually developed hypernatremia he was corrected by a light continuous infusion of d w because it was thought that he would not tolerate free water boluses in light of his diastolic dysfunction his lasix was also held eventually hypernatremia was corrected the patient had persistent lower extremity edema on the floor and multiple interventions were attempted the ultimate thinking was that his edema was from poor nutrition immobility and venous stasis disease he did not appear to be in cardiac failure as his lungs remained clear and he had no jvd he was given boost with meals to improve his nutritional status he was started on dopamine and nesritide drips but felt nauseated and had occasionally became hypotensive he was also tried on iv bumex and albumin he responded maximally to lasix drip with zaroxyln po qd prior to discharge he was switched to lasix mg po bid and zaroxylyn po bid which he showed strong reponse to he was also treated with diamox prior to discharge for diuretic associated alkalosis cad pt had no active issues on transfer to ccu cardiac enzymes were cycled and found to be negative pt was continued on asa and statin beta blocker and ace were held in the setting of hypotension and pressors renal failure pt presented with worsening acute on chronic renal failure creatinine on transfer was renal continued to follow the patient ultrafiltration was considered as a means for removing volume a dialysis line was place however ultrafiltration was not started because the pt began to diurese well on his own with a decrease in creatinine aggressive diuresis with lasix helped decrease creatinine to it did climb up to with standing iv lasix and the other aggressive diuretic regimens however when the intervention were stopped his creatinine always trended down towards his baseline id sepsis was considered as potential etiology of hypotension given swan numbers consistent with sepsis pt was pan cultured pt was started on vancomycin ceftazidime and flagyl for broad spectrum coverage pt had been on several antibiotics during this hospitalization including azithromycin ceftriaxone bactrim zosyn for treatment of pna and uti pt remained afebrile blood and urine cultures remained negative serial cxr had no evidence of pneumonia pt was evaluated by id on ccu day ceftazidime and flagyl were discontinued and a switch was made to meropenem since a urine culture from the floor grew out e coli resistant to ceftazidime vancomycin was continued renal ultrasound showed no perinephric abscess a hypoechoic contour defect adjacent to the upper pole cysts brought up the question of a solid renal lesion id requested mri of the abdomen to better evaluate this solid lesion since there was no definitive source of sepsis however mri was not performed while pt remained intubated and on pressors as he was not stable enough to go to radiology depite the fact that there was not definitive source of infection it is most likely that sepsis was the source of the pt s initial hypotension pt s overall clinical status significantly improved after starting on empiric antibiotics pt s hypotension improved and serial swan numbers no longer appeared septic most likely sources of infection include urosepsis from the pan resistant e coli and a question of lll pneumonia seen on a chest x ray pt completed a day course of vanco and meropenum on patient began to have a productive cough with persistent upper airway secretions he was pan cultured and started on levofloxacin and flagyl pt grew coag staph from blood cultures drawn from the picc line and wbc count became elevated to pt never mounted a fever and was also on his steroid taper on his wbc count rose to on vanco levo as a result he was started empirically on flagyl and his wbc began to trend down he was treated with a day course of vancomycin through his picc line and day course of flagyl surveillance blood cultures and urine cultures were all negative sputum gram stain showed gram cocci in pairs clusters but cultures were oropharyngeal flora after the full courses of abx therapy the patient wbc normalized gi on presentation pt had not had a bowel movement in around days a recent ct of the abdomen showed now signs of obstruction or perforation several kubs was performed which all showed distended stool filled loops of bowel without obstruction or free air noted pt has an ileus of multifactorial etiology pt was continued on an extensive bowel regimen of po and pr medications pt had difficulty absorbing the po meds which were given through the og tube pt put out greater than l of bilious fluid from his ogt daily it was noted that pt had no stool in the rectal vault disempaction was not an option a rectal tube was placed and found very little stool at the tip of the tube pt was started on around the clock enemas without success gi agreed that pt had an ileus and recommended holding off on po med and enemas and continuing supportive care pt had not had a bowel movement since as his clinical exam became more stable he was placed on an aggressive bowel regimen and he began having normal bowel movements dm blood sugars were initially managed on an insulin drip when tpn was started insulin was given in the tpn mixture pt was switched to insulin sliding scale when pt was started on solumedrol bs signficantly increased and pt was restarted on insulin drip upon transfer to the floor was reconsulted and pt resumed his humalog sliding scale w evening lantus he continued to remain in reasonable glycemic control for the rest of his stay ischemic foot as the patient began having persistent lower extremity edema that was refractory to diuresis his feet began to become erythematous he has known pvd w a sfa graft on the right he had skin breakdown with weeping on the dorsum of his left foot secondary to edema that required daily wound care on the patient complained of right foot pain had increased redness in his feet r l and had ischemic ulcers on his nd rd and th digits on the right lower extremity non invasivce studies were negative pt had lower extremity doppler studies that showed and abi of on the right and on the left consult was called to evaluate possible cellulitis pt had plain films of his right foot that felt did not represent osteomyelitis they felt his symptoms were from ischemia that were exacerabted by the patient s profound edema he was placed in unna boots b l per attg dr angiographic studies were held off because of possible damage patinet s kidneys could endure from dye load the decision was made to see how his feet would improve upon treatment of his lower extremity edema patient reported improved symptoms when his feet were elevated and as he was effectively diuresed he was given an appointment to follow up closely with both and dr upon d c anemia the patient had a persistently low hct in the s hemolysis labs and anemia work up were all negative it was deemed that his hct was likely low due to chronic phlebotomy medications on admission pletal asa lasix zestril lipitor wellbutrin flomax glipizide er lantus u qhs insulin sliding scale nkda discharge disposition extended care facility life care center at discharge diagnosis atrial fibrillation chf copd exacerbation pneumonia peripheral vascular disease discharge condition good discharge instructions please call dr if you experience chest pain shortness of breath greater than normal heart palpitations leg or foot pain or lack of feeling cough with thick colored sputum fever shaking chills blood in your stool please follow up your appointments with dr and after the new year regarding your leg swelling and poor blood flow to your feet if your condition acutely worsens you can come back to the followup instructions you will have your blood drawn at the rehabilitation facility on to monitor needed changes in your coumadin and lasix medication to rn at rehab facility please check chem and inr re dose coumadin and potassium supplementation accordingly provider clinic where cc unit phone date time provider unit phone date time pm completed by,"{
""Diagnoses"": [""Rapid Afib"", ""A Flutter"", ""Severe PVD"", ""Hypoxia"", ""Hypotension"", ""Possible Underlying COPD"", ""Major Surgical or Invasive Procedure""],
""Medications"": [""Combivent"", ""Inhalers"", ""NEBH"", ""Electrically Cardioverte""]
}"
97567,admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint respiratory distress major surgical or invasive procedure bronchoscopy history of present illness yof s p left cranioplasty and temporal lobectomy on for decompression after left mca dissection and infarct s p tracheostomy for subglottic tracheal stenosis followed by ip who initially presented to for pain at the tracheostomy site transferred for concern for dislodged tracheostomy being admitted to the micu for further evaluation and management past medical history significant for a left mca dissection and large left mca territory infarct with residual expressive aphasia and hemiplegia she underwent a bronchoscopy by ip at the time for residual dysphagia which showed subglottig stenosis above the stoma and a t tube was placed however the t tube was subsequently removed due to severe mucus plugging and a cuffed portex tracheostomy tube was placed she had been tolerating a passe muir valve but has been unable to tolerate capping for prolonged periods she is being evaluated for a possible button vs cannulation of the tracheostomy as an outpatient and is scheduled to see interventional pulmonology on for this evaluation per family she has not been using her passe muir valve at home very much and has been only requiring humidified oxygen at night to sleep currently per family report and ed report the patient has had increasing pain at the site of the tracheostomy tube since yesterday with mild erythema at the site of the tracheostomy but without swelling drainage or fevers per family she was short of breath since the onset of her pain but has not been wheezing and there was a question of whether the dyspnea was related to her anxiety about the tracheostomy she has a chronic cough which has increased in frequency but she has not had increased sputum and has not had yellow or green sputum the family was concerned as the tracheotomy tube appeared slightly displaced and the patient was having discomfort at the site and transported her to in the ed initla vs were on l trach mask the patient was not noted to be in respiratory distress at that time and was breathing comfortably she was given nebs and suctioned small amount of white sputum cxr at osh showed no displacement of the tracheotomy tube her family requested transfer to as she is followed by ip here and she was transferred to for further management in the ed initial vs ra for respiratory distress and wheezing the patient was given albuterol neb on arrival and morphine mg iv for pain at the tracheostomy site subsequently she had no respiratory symptoms and the trach was suctioned without difficulty the osh images were uploaded and ip was consulted who felt the tracheostomy tube was not displaced and recommended no further imaging studies and recommended discharge with outpatient f u on wednesday however the ed physicians recommended further monitoring in house and following rediscussion with interventional pulmonology empirical antimicrobials were initiated and patient admitted for monitoring of the pain at the trach site the patient was given keflex mg po and vancomycin gm iv and l ns she developed red man syndrome during vancomycin infusion no wheezing or airway involvement and was given benadryl mg iv she was admitted to micu for pulmonary toilet given her frequent suctioning requirement for regular non purulent mucus q hr per ed report on transfer vs were afebrile on humidified o l which was increased given the patient s significant anxiety on arrival to the micu the patient was comfortable and with adequate sao on high flow humidified air and denied shortness of breath on limited history while communicating with the use of hand signals she did acknowledge pain at the tracheostomy site but denied pain at any other site past medical history ich s p peg tracheostomy switched to t tube for tracheostenosis but subsequently reversed to tracheostomy on for respiratory distress s p right carpal tunnel release s p hysterectomy years ago htn seizures migraines gerd hap with gnr complicating icu course s p endometrial ablation under general anesthesia social history tobacco denies any history of tobacco use etoh denies illicit drugs denies expressive aphasia and hemplegic but able to communicate with yes and no signs and pictures currently resides at home with husband and children former special ed teacher family history sister also with stroke in s though etiology unknown sister also w dvt and headaches father with stroke in his s physical exam admission exam vs high flow trach mask gen pleasant alert interactive comfortable nad heent pupils equal and round eomi sclera anicteric mmm op without lesions tracheostomy in place with high flow mask cv rrr normal s and s no m r g resp cta b l with good air movement throughout no wheezes or rhonchi abd b s soft nt nd no masses or hepatosplenomegaly ext no c c e increased warmth and mild erythema and fullness of lle compared to rle dp pulses b l skin no rashes no jaundice no splinters neuro alert interactive uses yes and no hand signals and follows basic commands but comprehension difficult to assess given expressive aphasia moving all extremities 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 glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap brief hospital course yof s p left cranioplasty and temporal lobectomy on for decompression after left mca dissection and infarct s p tracheostomy for subglottic tracheal stenosis followed by ip who initially presented to for pain at the tracheostomy site transferred for concern for dislodged tracheostomy being admitted to the micu for management of acute tracheobronchitis or tracheal tube site infection and intermittent respiratory distress tracheostomy tube placement pt was transferred to with concern for malpositioning of her tracheotomy tube the patient s osh cxr was uploaded and reviewed by interventional pulmonology and the ed the patient s tracheostomy tube was able to be suctioned without difficulty and the placement was not felt to be dislodged based on imaging and clinical assessment pt was noted during her hospitalization to be very wheezy she was thus given albuterol nebulizers pulmonary toilet she was discharged with follow up with interventional pulmonary she was also recommended to use her albuterol inhaler more frequently pain at tracheostomy site she was also noted to have at the tracheostomy site which was likely due to mild irritation as a cellulitis process could not be ruled out she was discharged on a regimen of bactrim and keflex oxycodone was also prescribed prn for pain control h o ich recently evaluated by neurosurgery in with documented slow improvement of mental status speech and motor skills she was continued on her home regimen of levetiracetam htn she was continued on metoprolol hydralazine per home regimen dyslipidemia she was continued on simvastatin per home regimen depression continued citalopram per home regimen psych continued home methylphenidate and haldol medications on admission albuterol sulfate neb q h prn sob levetiracetam mg ml solution ml metoprolol tartrate mg tid hydralazine mg q h prn sbp methylphenidate mg haloperidol mg po bid citalopram mg daily omeprazole mg e c q h simvastatin mg daily acetaminophen mg tablet tablets q h prn pain oxycodone acetaminophen mg tablet tablets q h prn pain docusate sodium mg senna mg tablet daily bisacodyl mg e c two tablets daily simethicone mg q h sc heparin units tid discharge medications cephalexin mg capsule sig one capsule po q h every hours for days last dose disp capsule s refills sulfamethoxazole trimethoprim mg tablet sig one tablet po bid times a day for days disp tablet s refills metoprolol tartrate mg tablet sig one tablet po bid times a day simethicone mg tablet chewable sig one tablet chewable po qid times a day omeprazole mg capsule delayed release e c sig one capsule delayed release e c po bid times a day simvastatin mg tablet sig one tablet po daily daily levetiracetam mg ml solution sig seven y mg po bid times a day citalopram mg tablet sig tablet po daily daily methylphenidate mg tablet sig one tablet po bid times a day haloperidol mg tablet sig one tablet po twice a day albuterol sulfate mg ml solution for nebulization sig one inhalation every four hours as needed for dyspnea please take your nebs every hours for the first days then take your nebs as you usually do acetaminophen mg tablet sig tablets po q h every hours as needed for pain docusate sodium mg ml liquid sig one po bid times a day senna mg tablet sig one tablet po once a day as needed for constipation bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily hydralazine mg tablet sig one tablet po every six hours as needed for high blood pressure oxycodone mg capsule sig one capsule po every hours as needed for pain cause drowsiness disp capsule s refills discharge disposition home discharge diagnosis cellulitis around tracheostomy site discharge condition mental status clear and coherent but expressive aphasia level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions you presented to the hospital with pain at your tracheostomy site and concern for the placement of the tracheostomy tube you had a chest xray which did not show concerns for displacement of your tracheostomy tube and the interventional pulmonary specialist evaluated you and performed a bronchoscopy which did not show any concerning findings you were started on antibiotics for a possible skin infection around your tracheostomy tube you had shortness of breath initially on presentation to the emergency room but this improved with pain control and your oxygen saturations were excellent throughout your hospital stay just before leaving the hospital yesterday you had another episode of difficulty breathing we think this is from your wheezing and the pain at your trach site you were observed overnight and had no other issues the following changes were made to your home medications start keflex mg every hours for days to end start bactrim ds tablet twice daily to end metoprolol was decreased to twice daily for lower blood pressures you should increase your albuterol nebulizer treatments to every four hours for the next days after that you can take as much as you did before you can take oxycodone mg every hours as needed for your neck pain at the trach site if you do not have any pain you do not have to take this medication this medication causes sedation as we discussed it does not appear that you were taking the subcutaneous heparin injections to prevent blood clots that was on your medication list so this has been removed from you med list please follow up with your primary physician and neurologist neurosurgeon about your blood pressure medications followup instructions you will be contact to follow up at the interventional pulmonary clinic within the next days if you do not receive a phone call from them please call to schedule an appointment to be seen within the next days we have emailed the surgeon who placed your peg tube about removing it as it was unable to be done while inpatient they should be in contact with you about this but if you do not hear from them please call to follow up alternatively dr in interventional pulmonology may choose to do this at your next visit with him you have the following appointments scheduled department neurology when monday at pm with md building sc clinical ctr campus east best parking garage department west clinic when tuesday at am with md building de building complex campus west best parking garage md [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint dislodged tracheostomy major surgical or invasive procedure none history of present illness yof s p left cranioplasty and temporal lobectomy on for decompression after left mca dissection and infarct s p tracheostomy for subglottic tracheal stenosis followed by ip who initially presented to for dislodged tracheostomy tube transferred to for further evaluation the patient had a l mca dissection and large l mca territory infarct with residual expressive aphasia and hemiplegia she underwent a bronchoscopy by ip at the time for residual dysphagia which showed subglottig stenosis above the stoma and a t tube was placed however the t tube was subsequently removed due to severe mucus plugging and a cuffed portex tracheostomy tube was placed patient was recently admitted from to for bleeding around tracheostomy tube after discharge patient was doing well until today when she began coughing violently in shower during this coughing fit her tracheostomy tube became dislodged and fell out she was able to cough up a large amount of mucus after this episode she denied any cough shortness of breath or chest pain however patient still presented to osh ed for evaluation where they attempted to replace trach into track with no success patient was then transferred to for ip evaluation of note patient had planned evaluation in for downgrade of trade to montegomery tubing in ed patient was evaluated and appeared in no acute distress ip was consulted who recommended to leave tracheostomy tube out and to have patient admitted to icu for close monitoring in case of respiratory distress on arrival to micu patient was comfortable and had no complaints in fact patient appeared very happy to have tracheostomy tube out past medical history ich s p peg tracheostomy switched to t tube for tracheostenosis but subsequently reversed to tracheostomy on for respiratory distress s p right carpal tunnel release s p hysterectomy years ago htn seizures migraines gerd hap with gnr complicating icu course s p endometrial ablation under general anesthesia social history tobacco denies any history of tobacco use etoh denies illicit drugs denies expressive aphasia and hemplegic but able to communicate with yes and no signs and pictures currently resides at home with husband and children former special ed teacher family history sister also with stroke in s though etiology unknown sister also w dvt and headaches father with stroke in his s physical exam admission physical exam vs ra gen pleasant alert interactive comfortable nad heent pupils equal and round eomi sclera anicteric mmm op without lesions neck tracheostomy site intact no blood or pus mild erythema around trach site cv rrr normal s and s no m r g resp cta b l with good air movement throughout no wheezes or rhonchi no stridor abd b s soft nt nd no masses or hepatosplenomegaly ext no c c e increased warmth and mild erythema and fullness of lle compared to rle dp pulses b l skin no rashes no jaundice no splinters neuro alert interactive uses yes and no hand signals and follows basic commands but comprehension difficult to assess given expressive aphasia only able to move left side discharge afebrile hemodynamically stable satting well on room air no stidor good air movement b l pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt am blood plt ct am blood glucose urean creat na k cl hco angap am blood calcium phos mg ct neck airways vfindings the airway is grossly patent with an area of narrowing at the prior tracheostomy site at the level of c t there is no discrete mass or fluid collection or areas of abnormal enhancement around this area of stenosis there is the possibility of some granulation tissue but given the lack of enhancement this is difficult to assess there are slightly prominent lymph nodes bilaterally at the level a which do not demonstrate pathologic lymphadenopathy by imaging criteria the aortic arch is unremarkable and the neck vessels enhance bilaterally without significant stenosis the thyroid gland is normal the salivary glands are unremarkable in appearance the tonsillar pillars and piriform sinuses are unremarkable the visualized portion of the brain shows an area of encephalomalacia and post surgical changes previously noted on prior study in the left temporal region impression grossly patent airway with an area of narrowing at the prior tracheostomy site at the level of c t without discrete mass fluid collection or abnormal enhancement brief hospital course yof s p left cranioplasty and temporal lobectomy on for decompression after left mca dissection and infarct s p tracheostomy for subglottic tracheal stenosis admitted after dislodged tracheostomy tube dislodged tracheostomy tube osh ed was unable to replace tracheostomy tube back in track however patient was oxygenating well and without any evidence of upper respiratory compromise ip was consulted and evaluated patient ct of airways was obtained and showed grossly patent airways patient monitored in icu overnight and was subsequently discharged with close follow up with ip chronic issues no changes in medications or interventions necessary htn dyslipidemia depression h o cva medications on admission citalopram mg daily metoprolol mg keppra mg simvastatin mg daily asa mg daily discharge medications citalopram mg tablet sig one tablet po once a day keppra mg tablet sig one tablet po twice a day simvastatin mg tablet sig one tablet po daily daily aspirin mg tablet chewable sig one tablet chewable po daily daily metoprolol succinate mg tablet extended release hr sig one tablet extended release hr po once a day discharge disposition home with service facility discharge diagnosis primary endo tracheal tube removal secondary s p left cranioplasty and temporal lobectomy discharge condition mental status clear and coherent alert interactive uses eyes and no hand signals and follows commands pt has expressive aphasia level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear it was a pleasure taking care of you you came to the hospital after your endotracheal tube fell out you were breathing well with no difficult and your oxygen saturation has been very good you also had a cat scan of your airway which was reassuring and showed some narrowing of your airway but no obstruction you were evaluated by a interventional pulmonologist and we were in agreeement that it is safe for you to go home you will need to keep the tracheal area clean for next days and if there any concerns about your breathing you should call immediately you will need to follow up with interventional pulmonlogy within weeks as listed below we made no changes to your medication followup instructions you need to call interventional pulmonary clinic at on monday morning for an appointment with dr within weeks building complex department west clinic when tuesday at am with md building de building complex campus west best parking garage completed by [NEW_RECORD] admission date discharge date date of birth sex f service neurology allergies patient recorded as having no known allergies to drugs attending chief complaint right sided weakness and language disturbance major surgical or invasive procedure percutaneous tracheostomy with a bronchoscopy percutaneous endoscopic gastrostomy left sided craniotomy for decompression hemicraniectomy temporal lobectomy duraplasty history of present illness year old female with h o headaches and possible hypertension presents with right arm weakness and inability to communicate she was last seen normal yesterday at pm when she went to bed she usually wakes up at am in the morning to walk the dog she usually walks the dog in her pajamas her husband did not hear her get up this morning and is not sure whether she actually did walk the dog at she shook her husband to awaken him and could not say any words she was still in her pajamas at that time she was able to walk with his support then had a one minute episode of generalized shaking she was initially brought to where she received lorazepam mg phenytoin and solumedrol mg ct showed an asymmetrical dense left mca sign and the patient was transferred to for further management ros she started a new medication a few weeks ago for headaches she developed green discharge from the eyes when this medication was started this has now resolved x over the last month she has had a sensation that objects around her were moving x over the last month she has choked on her food at baseline she has decreased strength in her right hand from her carpal tunnel syndrome she has been limping for days she frequently moves around to prevent her headaches she occasionally has constipation for which she takes miralax she has not had any blood in her stool or urine denies recent problems with fever vision hearing cough vomiting weakness or paresthesias past medical history chronic headaches after being hit on the head by a child in a special education class she was teaching years ago s p right carpal tunnel release s p hysterectomy years ago question of hypertension family denies this and reports sometimes her blood pressure goes low but the patient is on cardizem and reports sometimes the doctors put on medications without a clearly known reason no prior seizures stroke intracranial hemorrhage or recent surgeries social history works as a special education teacher husband daughter and sister at bedside denies etoh smoking illicits family history sister had a stroke at age she does not know the cause of this sister has also had a dvt and headaches dad had a stroke at age physical exam initial t hr bp rr o sat l gen lying in bed nad heent normocephalic atraumatic mucous membranes moist neck supple back no point tenderness or erythema cv rrr nl s and s no murmurs gallops rubs lung clear to auscultation bilaterally abd bs soft nontender skin no rash ext no edema neurologic examination mental status general stuporous with sternal rub arouses for less than a minute then closes eyes again speech language moans with some unintelligible sounds that may be attempts at words does not follow simple commands cranial nerves ii pupils equally round and reactive to light to mm bilaterally ignores in right visual field iii iv vi near complete eye movement to the right but does not bury sclera extraocular movements otherwise intact without nystagmus v patient unable to state whether facial sensation is intact vii right lower facial droop with showing the teeth viii hearing grossly intact turns to voice ix x not tested not tested xii not tested motor normal bulk bilaterally tone normal no observed myoclonus or tremor able to bend right arm antigravity at elbow but cannot lift upper arm off bed when the arm is held up it falls back to the bed able to hold left arm right leg and left leg antigravity for seconds deep tendon reflexes biceps tric brachial patellar achilles toes right downgoing left downgoing positive crossed adductors sensation withdraws to noxious in all extremities coordination finger nose finger normal on the left gait not tested discharge exam t p bp r spo gen lying in bed alert but not verbal pertinent results ct perfusion thrombus within the distal left m segment with poor filling of left anterior temporal branches the focal moderate stenosis of the left internal carotid artery origin with no other evidence of vascular atherosclerosis may represent a dissection or intramural hematoma and may be a source of this thrombus ct perfusion reveals a very small region of relatively preserved cbv and cbf with in the most posterior superior region of the prolonged mtt which may represent a small area of ischemic penumbra however the vast majority of the prolonged mtt is matched cta thrombus within the distal left m segment with poor filling of left anterior temporal branches the focal moderate stenosis of the left internal carotid artery origin with no other evidence of vascular atherosclerosis may represent a dissection or intramural hematoma and may be a source of this thrombus ct perfusion reveals a very small region of relatively preserved cbv and cbf with in the most posterior superior region of the prolonged mtt which may represent a small area of ischemic penumbra however the vast majority of the prolonged mtt is matched mr interval expected evolution of the patient s large left mca territory infarct which spares the vast majority of the basal ganglia and thalamus the anterior and posterior portions of the infarct extend medially into the aca territories this could be secondary to interval emboli to these regions with without a component of watershed ischemia faint regions of susceptibility artifact within the infarct concerning for early petechial hemorrhage follow up with non contrast ct head tte impression mild pulmonary artery systolic hypertension normal biventricular cavity sizes with preserved global and regional biventricular systolic function no definite cardiac source of embolism identified if clinically indicated a tee would be better able to define a potential atrial septal defect patent foramen ovale cxr findings as compared to the previous radiograph the extent of air in the abdomen has minimally decreased also decreased is the pre existing relatively extensive right pleural effusion improved ventilation of the left lung base normal size of the cardiac silhouette no newly appeared focal parenchymal opacities post surgical ct findings the patient is status post left frontotemporal craniectomy there has been interval resolution of post operative pneumocephalus a large left parenchymal hypodensity in the middle and anterior cerebral artery distribution is unchanged compared to most recent studies foci of hyperdensity within this region likely representing foci of hemorrhagic conversion are also unchanged compared to prior there has been interval improvement in the rightward shift of normally midline structures with improvement in effacement of the left lateral ventricle and the basilar cisterns there is no evidence of new hemorrhage or infarct brief hospital course yr hispanic female right handed presents with sudden onset of global aphasia and right side weakness and possible seizure patient was intially treated at osh with ativan and solumedrol patient had ct of head that showed a hyperdense left mca concerning for an occlusion of the left mca there were no early signs of ischemia on that ct brain the patient was transferred to nihss at ed was initially and then decreased to cta brain showed a left mca distal m occlusion cta neck was concerning for a left proximal ica dissection ct perfusion showed a small area of mismatch in the superior division of the left mca neuro being out of the window for iv tpa patient was taken to angio suite and underwent a thrombectomy with the merci device after multiple passes with the merci clot retriever the left superior division of the mca was partially opened up vasospasm of the left superior division was noted which seemed to respond to nitroglycerin during the angio it was confirmed that patient had a left carotid dissection patient was admitted to the neuroicu w q hr neuro checks follow up head ct has demonstrated increased edema with mm of midline shift but no bleed since there was no intracranial hemorrhage on patient was restarted on aspirin however given her increased edema and potential increase in icp neurosurgery was consulted patient was placed on iv mannitol later on a central line was placed at pm on patient s pupils became dilated and fixed at mm with minimal gag minimal oculocephalic and minimal corneals patient was given hypertonic saline and hyperventilated ct demonstrated increase in shift to the right patient was given ml of ns extensive discussion was held with family including her husband and two daughters about goals of care and poor prognosis the family requested that left hemicraniectomy be performed to save her life they understood that left hemicraniectomy would not improve her function or reverse her deficits patient underwent left hemicraniectomy and partial left temporal lobectomy for the carotid dissection a follow up carotid u s was done which demonstrated l ica stenosis r ica stenosis stroke was thought to be secondary to thrombus that embolized from the dissection for secondary protection simvastatin mg was started for an ldl of a c was tsh was patient also had noted generalized shaking while at lgh she was loaded with phenytoin a routine eeg was performed which demonstrated encephalopathy no subsequent sz activity was noted during her hospitalization phenytoin levels remained stable patient was maintained on fosphenytoin mg iv q h for seizure prophylaxis and was kept on seizure fall and aspiration precautions cardiovascular patient initially kept at sbp goal must keep sbp dbp her bp goal was eventually lowered transthoracic echo demonstrated an lvef mild pulmonary artery systolic hypertension but no source of emboli pulmonary intubated prior to ir procedure gastrointestinal abdomen nutrition difficulty with ng tube placement resume feeds per post op care renal patient s i s and o s were monitored with foley endocrine patient was kept on an riss goal fs infectious disease patient has continued to trend upward on wbc count low grade fever at point of herniation going into or finished day course of zosyn afebrile hours no leukocytosis id fellow signed off prophylaxis dvt boots famotidine communication code status full medications on admission cardizem cd mg po daily amitriptyline mg po qhs gabapentin mg po bid ibuprofen mg po tid prn pain excedrin migraine mg q h prn headache miralax prn constipation discharge medications simvastatin mg tablet sig one tablet po daily daily senna mg tablet sig one tablet po bid times a day famotidine mg tablet sig one tablet 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 white petrolatum mineral oil ointment sig one appl ophthalmic prn as needed as needed for dry eyes polyvinyl alcohol drops sig drops ophthalmic prn as needed as needed for dry eyes lactulose gram ml syrup sig fifteen ml po q h every hours as needed for constipation aspirin mg tablet sig one tablet po daily daily magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed for constipation albuterol sulfate mg ml solution for nebulization sig one treatment inhalation q h every hours as needed for wheezing levetiracetam mg tablet sig three tablet po bid times a day metoprolol tartrate mg tablet sig one tablet po tid times a day discharge disposition extended care facility for the aged macu discharge diagnosis left sided mca stroke left ica dissection gram rods pneumonia discharge condition activity status bedbound alert but non verbal discharge instructions you were admitted to the neurology service at after you had onset of right sided weakness and difficulty speaking we attempted interventional thrombectomy and it was discovered there was an ica dissection after the procedure you developed swelling and required a temporal lobectomy and hemicraniotomy by neurosurgery you did not regain speech and were unable to follow commands on discharge you will be sent to rehab and will follow up with neurosurgery and neurology medications started aspirin mg daily simvistatin senna colace famotidine keppra mg bisacodyl lactulose metoprolol mg po tid followup instructions the patient will need to follow up with at in weeks a follow up appointment will be arranged the patient will need followup with neurosurgery in weeks an appointment will be arranged completed by [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint hypoxia major surgical or invasive procedure s p tracheostomy tube history of present illness ms is a year old female who sustained a large left sided mca stroke on thought secondary to a carotid dissection seizure disorder who was sent in from rehab due to hypoxia she was noted to be in respiratory distress in the morning and her sat was found to be her t tube was suctioned and washed out with normal saline with improvement of her o sats to ra she typically has her tube capped during the day and has humidified air overnight of note she was recently admitted for t tube placement on she tolerated the procedure well and was transferred to rehab in the ed initial vs were t p bp r o sat l on the floor she was seen by ip and her t tube was switched out for a tracheostomy tube she was noted to have another significant mucous plug which was suctioned out she was unable to verbalize how she was doing however she denied any pain or discomfort review of systems per hpi denies fever chills night sweats recent weight loss or gain denies headache sinus tenderness rhinorrhea or congestion denies cough shortness of breath or wheezing denies chest pain chest pressure palpitations or weakness denies nausea vomiting diarrhea constipation abdominal pain or changes in bowel habits denies dysuria frequency or urgency denies arthralgias or myalgias denies rashes or skin changes past medical history l mca cva ppresented with aphasia and r sided weakness thought to due to cva secondary to thrombosis and embolism from concurrent l carotid dissection thrombectomy attempted and partially successful but then developed edema and midline shift with progressive neurological deterioration in the face of hypertonic saline and mannitol therefore family elected to pursue l hemicraniotomy and partial l temporal lobectomy has persistent hemiplegia and aphasia but responds appropriately to questions possible hypertension possible seizure at the time of carotid dissction hap with gnr complicating icu course she completed a day course of zosyn chronic headaches after head injury hit in head by student in special ed class she was teaching s p right carpal tunnel release s p hysterectomy years ago social history currently resides rehab macu former special ed teacher two children no etoh smoking family history sister also with stroke in s though etiology unknown sister also w dvt and headaches father with stroke in his s physical exam vitals t bp p r o tracheostomy general alert answering yes or no questions actively coughing heent sclera anicteric mmm neck supple jvp not elevated no lad trach patent no erythema or swelling 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 has a peg in place gu no foley ext warm well perfused pulses no clubbing cyanosis or edema neuro no movement of right side strength on right side right facial droop left sided strength responding with appropriate left hand guestures to questions pertinent results chest x ray impression tracheostomy tube not visualized no acute cardiopulmonary abnormality chest x ray findings in comparison with the study of the tracheostomy tube is now in place low lung volumes may account for much of the apparent prominence of the transverse diameter of the heart no vascular congestion or acute focal pneumonia 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 lactate brief hospital course ms is a year old female who sustained a large left sided mca stroke on thought secondary to a carotid dissection seizure disorder who was sent in from rehab due to hypoxia most likley due to mucous plug hypoxia most likley due to mucous plug according to her husband her tube was not being capped during the day however according to nursing at rehab she was always capped during the day ip saw her when she arrived and switched her t tube to a tracheostomy which she tolerated well she was noted to have mucous occluding her t tube she should continue to have her trach suctioned and given humidified air overnight tachycardia appears to be sinus tachycardia on ekg underlying cause of tachycardia include respiratory distress vs albuterol use vs pain her tachycardia resolved the following day cva she has a baseline expressive aphasia dense hemiplegia on her right side and ability to communicate with yes or no guestures in an appropriate manner she was continued on aspirin mg and simvastatin seizure she is currenlty well controlled on her home regimen she was continued keppra hypertension currenlty well controlled on current regimen she was continued metoprolol mg agitiation she has a history of agitation which she responds well to haldol she was continued on haldol mg prn medications on admission aspirin mg tablet one tablet po once a day bisacodyl mg suppository one suppository rectal at bedtime as needed for constipation methylphenidate mg tablet chewable one tablet chewable po twice a day metoprolol tartrate mg tablet one tablet po twice a day omeprazole mg capsule delayed release e c one capsule delayed release e c po twice a day simethicone mg tablet chewable one tablet chewable po four times a day as needed for indigestion acetaminophen mg tablet tablets po four times a day as needed for pain morphine concentrate mg ml solution ml po q hrs prn as needed for pain lidocaine pf mg ml solution four ml injection q h every hour as needed for pain albuterol sulfate mg ml solution for nebulization puffs inhalation q h every hours as needed for dyspnea wheezing haloperidol mg tablet one tablet po bid times a day as needed for agitation lactulose gram ml syrup fifteen ml po qid times a day as needed for constipation levetiracetam mg ml solution seven y mg po bid times a day simvastatin mg tablet one tablet po daily daily docusate sodium mg ml liquid one hundred mg po bid times a day senna mg tablet tablets po bid times a day as needed for constipation milk of magnesia mg ml suspension thirty ml po once a day as needed for constipation t tube flushes keep open to humidified air flush with ml ns and suction back mucinex mg tab multiphasic release hr one tab multiphasic release hr po twice a day tab multiphasic release hr s omeprazole mg capsule delayed release e c two capsule delayed release e c po q h every hours as needed for gerd guaifenesin mg ml syrup fifteen ml po bid times a day discharge medications aspirin mg tablet chewable one tablet chewable po daily daily bisacodyl mg suppository one suppository rectal hs at bedtime as needed for constipation methylphenidate mg tablet tablet po bid times a day metoprolol tartrate mg tablet one tablet po bid times a day simethicone mg tablet chewable one tablet chewable po qid times a day as needed for indigestion acetaminophen mg tablet tablets po q h every hours as needed for pain haloperidol mg tablet two tablet po bid times a day as needed for agitation lactulose gram ml syrup fifteen ml po q h every hours as needed for constipation levetiracetam mg ml solution seven y mg po bid times a day simvastatin mg tablet one tablet po daily daily 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 magnesium hydroxide mg ml suspension thirty ml po q h every hours as needed for constipation guaifenesin mg ml syrup fifteen ml po bid times a day albuterol sulfate mg ml solution for nebulization one inhalation q h every hours as needed for sob wheezing lansoprazole mg tablet rapid dissolve dr one tablet rapid dissolve dr daily daily mucinex mg tablet er multiphase hr one tablet er multiphase hr po bid times a day discharge disposition extended care facility for the aged macu discharge diagnosis primary diagnosis hypoxia to mucous plug 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 dear ms you were admitted into the icu because you were noted to have low oxygen saturation this was most likley due to a blockage in your t tube you were seen by the interventional pulmonology who switched out your t tube for a tracheostomy tube you tolerated the procedure well and it was felt that you safe to return to rehab there were no changes to your medications it was a pleasure taking care of you we wish you a speedy recovery followup instructions please follow up with dr in weeks please call to make a follow up appointment md completed by,{}
24162,admission date discharge date date of birth sex m service nb history of present illness baby boy number one is a gram week twin male number one born to a year old g p to mother with serologies a negative antibody negative group b streptococcus unknown hepatitis b surface antigen negative rpr nonreactive varicella nonimmune mother antepartum was remarkable for clomid supported conception with resultant twinning mild gestational hypertension cholestasis of pregnancy treated with ursodiol and hypothyroidism treated with thyroid replacement hormones there is a normal fetal survey at weeks discordancy was noted at weeks and twin twin transfusion syndrome was diagnosed the mother was beta complete at weeks she received serial amnioreduction from to weeks with eventual stabilization of twin b s polyhydramnios she was admitted for induction the mother was taken for cesarean section secondary to fetal bradycardia the patient emerged with pallor but with a strong cry the patient was given blow by apgar scores were eight and nine physical examination notable for weight of grams below the mean length th percentile head circumference cm th percentile general this is an sga male whose size and pallor were likely related to twin to twin transfusion donor status his vital signs were stable his anterior fontanelle was soft he had normal facies with an intact palate his chest was symmetric without grunting flaring or retractions his breath sounds were clear his heart revealed a regular rate and rhythm without a murmur he had femoral pulses bilaterally his abdomen was flat soft nondistended no hepatosplenomegaly extremities intact phallus small chordae hips stable perfusion was fair his tone was appropriate his anus appeared patent his back was straight without hair or dimple he also had a three vessel cord hospital course respiratory the patient has been stable in room air since admission cardiovascular the patient was initially given two normal saline boluses secondary to perfusion his blood pressures have been stable since that time he has had no murmur and no need for cardiovascular support gastrointestinal fluids electrolytes and nutrition the patient was initially placed on cc per kilogram per day of d w and enteral feeds were initiated he has advanced himself nicely on entirely p o feedings and is currently taking between and cc each feeding which is approximately cc per kilogram per day his prefeed d stick this morning on day of life number three was at which time he was switched to q three hourly feeds he was also increased to breast milk enfamil kilocalories subsequent d sticks were and will continue to feed p o ad lib breast milk or e to maintain a minimum of mil per kilogram per day we also plan to start iron and tri vi prior to discharge gastrointestinal serial bilirubins were followed and phototherapy was initiated on day of life three for a bilirubin of he remains on phototherapy at this time and repeat bilirubin is hematology the initial hematocrit was he has required no blood transfusions infectious disease initial white blood cell count was with percent bands myelocyte metamyelocyte and segmented neutrophils blood culture was drawn and due to the left shift ampicillin and gentamicin were initiated blood culture was negative antibiotics were discontinued at hours he has shown no further signs of infection the patient is currently in an isolette set at degrees social the mother and father live in the pediatrician will be dr in brain tree they will consider transfer to if such time becomes appropriate diet on discharge breast milk and enfamil p o ad lib diagnosis prematurity at weeks twin to twin transfusion donor small for gestational age feeding immaturity hyperglycemia resolved hyperbilirubinemia sepsis evaluation negative dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service neonatology history of present illness baby is a gm twin male born to a year old gravida para now mother with serologies a negative antibody negative group b streptococcus unknown hepatitis b surface antigen negative rpr nonreactive and rubella non immune antepartum was remarkable for clomid and with resultant twinning moderate gestational hypertension cholestasis of pregnancy treated with ursodiol and hypothyroidism treated with thyroid replacement hormones there was a normal fetal survey at weeks discordance was noted at weeks and twin twin transfusion syndrome was diagnosed the mother was betamethasone complete at weeks she received serial amnio reductions from to weeks with eventual stabilization of twin b polyhydramnios she was admitted for induction mother was taken for cesarean section secondary to fetal bradycardia the patient emerged with pallor but with a strong cry the patient was given blow by oxygen his apgar scores were at one minute and at five minutes physical examination notable for weight of gm two and a half standard deviations below the means length cm th percentile head circumference cm th percentile general this is an small for gestational age male whose size and color were likely related to twin twin transfusion his vital signs were stable his anterior fontanelle was soft he had normal facies with an intact palate his chest was symmetric without grunting flaring or retractions his breath sounds were clear his heart revealed a regular rate and rhythm without a murmur he had femoral pulses bilaterally his abdomen was flat soft nondistended without hepatosplenomegaly extremities intact phallus small chordae hips stable transfusion was fair his tone was appropriate his anus was patent his back is straight without hair or dimples he has a three vessel cord hospital course respiratory the patient was stable in room air throughout his hospitalization he did not demonstrate any apnea of prematurity cardiovascular was initially given normal saline boluses secondary to poor perfusion his blood pressures since have been stable he has had no murmur and no need for further cardiovascular support gastrointestinal fluids electrolytes and nutrition was initially placed on maintenance iv fluids of d w and enteral feeds were initiated his advancement to full feeds was initially uncomplicated however he tired out on day of life and needed additional gavage feeds we were able to discontinue gavage feeds on he has since been taking all of his feeds well by mouth he is currently feeding neosure calories ounce neosure plus cal oz of mct will be sent home on iron and vitamin supplements heme the baby s initial hematocrit was he did not require any blood transfusions was followed with serial bilirubin measurements phototherapy was initiated on day of life for a bilirubin of he remained on phototherapy until subsequent bilirubin on was blood type is b positive antibody negative infectious disease initial white blood cell count is with percent bands myelocyte and metamyelocyte as well as segmented neutrophils blood culture was drawn but has remained negative secondary to the left shift on the complete blood count we elected to start treatment with ampicillin and gentamicin antibiotics were discontinued after blood cultures remained negative for hours he has shown no further signs of infection sensory passed his hearing screen on condition on discharge stable discharge disposition discharge to home primary pediatrician dr care recommendations feeds neosure calories neosure plus calories ounce of corn oil p o ad lib medications iron mg kg supplemental iron equals fer in cc q day tri vi cc p o q day carseat screening passed carseat test prior to newborn state screen has been sent the results are currently pending immunizations received received hepatitis b on discharge diagnosis prematurity at weeks twin twin transfusion syndrome small for gestational age feeding immaturity hyperbilirubinemia resolved sepsis evaluation negative dictated by medquist d t job,{}
5916,admission date discharge date date of birth sex m service nicu c date of transfer to the well baby nursery history of the present illness this is a twin male born to g po now mother at and ths weeks via cesarean section secondary to twin breech presentation pregnancy was complicated by cervical shortening at weeks with a cerclage placed that was removed five days prior to delivery at birth the birth weight was grams and between the th and th percentile head circumference was cm which is between the th and th percentile and the length was cm which is around the th percentile physical examination on physical examination the child was pink nondysmorphic the skin was notable for a mongolian spot on the left upper extremity as well as the sacrum head anterior fontanelle was open and flat the sutures were mobile the eyes had bilateral red reflex ent intact thorax symmetrical notable for grunting and retractions also nasal flaring there was limited aeration bilaterally in the lung fields heart revealed regular rate and rhythm s and s normal pulse abdomen no hepatosplenomegaly positive bowel sounds genitalia male with bilaterally descended testes anus was patent trunk and spine symmetrical no defects extremities were stable with negative ortolani and negative barlow reflexes were appropriate for gestational age hospital course respiratory initially the child presented with some mild grunting and increased work of breathing treated with nasal cannula at cc tolerated weaning within six hours and has been on room air ever since no surfactant was necessary no intubation no cpap no apneic episodes cardiovascular stable no murmurs fluids electrolytes and nutrition the patient was npo initially secondary to increased work of breathing and placed on iv fluids but subsequently took po on day of life feeding well at the time of transfer to the well baby nursery gi stable hematology stable the hematocrit was on day of life infectious disease blood cultures and cbc were drawn culture was negative to date no antibiotics were given initial blood cell count was with a normal differential of neutrophils no bands lymphocytes neurological neurologically the baby was stable sensory hearing not tested as yet but should be tested tomorrow on day of life in the well baby nursery ophthalmology not examined psychosocial seems to have very caring and loving interactive parents condition on transfer stable transfer to well baby nursery pediatrician dr telephone fax care recommendations the patient will be increasing feeding had a lactation consultation today no medications car seat should be placed in the back facing the back newborn state screening to be drawn tomorrow on day of life in the well baby nursery immunizations no immunizations received to date but hepatitis b should be given on day of life in the well baby nursery as well discharge diagnoses respiratory distress syndrome with lung immaturity m d dictated by medquist d t job,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""m service"", ""nicu c"", ""date of transfer to the well baby nursery"", ""history of the present illness""],
""Medications"": [""cerclage"", ""removed five days prior to delivery""]
}"
19786,admission date discharge date service allergies patient recorded as having no known allergies to drugs attending chief complaint wf with month history of shortness of breath major surgical or invasive procedure aortic valve replacement history of present illness this y o wf has had a history of a heart murmur since birth and developed shortness of breath past medical history h o chf h o aortic stenosis h o irritable bowel syndrome h o arthritis h o depression h o obesity s p bilateral tkr s p tah pertinent results hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct am basic coagulation pt ptt plt inr pt ptt plt ct inr pt am chemistry renal glucose glucose urean creat na k cl hco angap am radiology report chest pa lat study date of pm fa chest pa lat clip reason s p avr medical condition year old woman with reason for this examination s p avr preliminary report history aortic valve repair two views of the chest comparison is made with median sternotomy wires and aortic valve prosthesis are present the multiple tubes and lines have been removed there are small bilateral pleural effusions cardiomegaly and vascular congestion there are aortic calcifications no focal consolidations or pneumothorax impression mild chf brief hospital course the patient was admitted and underwent elective aortic valve replacement with a tissue valve on she tolerated the procedure well and was transferred to the csru on propofol cross clamp time was minutes and total bypass time was minutes she had a stable post op night and was extubated her chest tubes were d c d on pod and epicardial pacing wires were d c d on pod she did have wenkebach and mobitz heart block postop and had it preop as well she was stable with this rhythm and was evaluated by eps who felt she did not need to be anticoagulated or studied she was transferred to the floor on pod and did well despite some intermittent confusion she responded to low dose haldol and the delerium resolved she continued to progress and was discharged to rehab in stable condition on pod medications on admission celexa mg po qd lasix mg po qd immodium qd mvi po qd vitamin e iu po qd citrucel dextrol prn discharge medications potassium chloride meq tab sust rel particle crystal sig one tab sust rel particle crystal po once a day for days aspirin mg tablet delayed release e c sig one tablet delayed release e c po qd once a day acetaminophen mg tablet sig two tablet po q h every hours as needed furosemide mg tablet sig one tablet po bid times a day for days naproxen mg tablet sig two tablet po q h every hours as needed celexa mg tablet sig one tablet po once a day multivitamin capsule sig one capsule po once a day discharge disposition extended care facility of discharge diagnosis aortic stenosis type heart block chf discharge condition good discharge instructions follow medications on discharge instructions you may not drive for weeks you may not lift more than lbs for months you may shower let water flow over wounds pat dry with a towel followup instructions make an appointment with dr for weeks make an appointment with dr for weeks make an appointment with dr for weeks completed by,{}
6168,admission date discharge date date of birth sex m service medicine allergies heparin agents attending chief complaint hypoxia and seizure major surgical or invasive procedure thrombectomy ivc filter placement history of present illness i history of present illness i m dm dvt h o large l mca cva on returns from rehab following witnessed seizure and hypoxia br per ems records patient was found slumped on right side and unresponsive with foaming at mouth per report sats recorded at with labored breathing when ems arrived patient found alert with baseline aphasia vitals on field bp hr rr sat on unknown amount of o per rehab notes patient with low grade fever on pancultured cxr with bibasilar atelectasis br in ed patient noted to be hypotensive to s o sats in s improved w nrb ekg notable for sinus tach pt given broad spectrum abx vanco levo flagyl for concern of sepsis gram dilantin load l ns given concern for seizure as well as pe patient underwent head ct no contrast cta chest which revealed midline shift w mild uncal herniation and massive saddle pe br in discussion with neurology team it was felt that cerebral changes were expected finding from large mca stroke and that given length of time since stroke days patient could be safely anticoagulated given cardiogenic shock patient was started on levophed w good effect and taken to cath lab for emergent thrombectomy br in cath lab ci ra rv pa pcwp aorta past medical history s p left mca cva on with resultant right hemiparesis and global aphasia dm type hypertension history of dvt in past previously on coumadin unclear why off social history social history the patient lives with a roomate he is a nonsmoker he drinks beers week family history family history mother htn cad cva father htn cad mi physical exam vs p bp rr sao l general nad aphasia but responds with good yes good no heent perrl mm eomi no nystagmus anicteric neck central line placed r side supple no lad cardiovascular s s reg no murmurs lungs cta b l no w r r abdomen active bowel sounds nt nd extremities warm no edema neuro aaox asymetric smile r side droop unable to shrug shoulders toes down going l up going r motor right side left side pertinent results pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count pm calcium phosphate magnesium pm pt ptt inr pt pm ck mb pm ctropnt pm ck cpk pm glucose urea n creat sodium potassium chloride total co anion gap pm lactate pm urine rbc wbc bacteria few yeast none epi pm urine blood neg nitrite neg protein tr glucose ketone tr bilirubin neg urobilngn neg ph leuk neg cta impression saddle pulmonary embolus with extension into numerous segmental and subsegmental branches bilaterally enlarged right sided mediastinal and hilar lymphadenopathy ct head w o contrast impression further evolution with edema involving the large left sided middle cerebral artery distribution infarction there is mild mass effect with rightward subfalcine and uncal herniation no intracranial hemorrhage is identified b l le vein u s impression positive study with intraluminal thrombus demonstrated within the right upper superficial femoral vein extending into the right popliteal vein echo conclusions the left ventricle is not well seen lv systolic function appears depressed the right ventricular cavity is dilated right ventricular systolic function appears depressed the aortic valve leaflets appear structurally normal with good leaflet excursion tricuspid regurgitation is present but cannot be quantified there is no pericardial effusion compared with the findings of the prior report tape unavailable for review of the right ventricle now appears dilated and hypocontractile echo impression right ventricular cavity enlargement dilated ascending aorta normal estimated pulmonary artery systolic pressures compared with the prior study tape reviewed of the right ventricular cavity is slightly smaller brief hospital course massive pe mr was admitted initially to the micu and underwent a thrombectomy for a large saddle pulmonary embolus noted on ct imaging on follow up lower extremity ultrasound he was also noted to have positive an intraluminal thrombus demonstrated within the right upper superficial femoral vein extending into the right popliteal vein his previosu echocardiagram were also reviewed and showed no evidence of a pfo or asd he subsequently received an ivc filter having developed hit with a positive antibody he was anticoagulated with argatroban he platelets were monitored and when they surpassed coumadin therapy was initiated he was started on mg warfarin qd for days then subsequently increased to mg warfarin his inr became therapeutic after day of warfarin with an inr of his argatrabon was discontinued and his ptt was assessed three hours after discontinuation his inr became subtherapeutic and he was restarted on argatroban and was started on mg coumadin the desired inr range was between while on argatroban and his inr increased the day prior to discharge on the day of discharge his inr was the argatroban was discontinued and mg of vitamin k was administered an immediate inr taken had decreased to while off argatroban just prior to discharge a repeat inr indicated he was instructed to hold his coumadin mg for the evening and start taking his mg coumadin qhs with daily inr monitoring and adjustment per physician hit the patient had been receiving subcutaneous heparin at rehabilitation and arrived in a thrombotic state with decreasing platelets his antibodies hit ab ultimately were positive he was started on argatroban and all heparin products were discontinued his platelets were monitored for transfusion if below he did not require transfusions of platelets fever white count he was afebrile on admission he had previously had a low grade temperature while at was being treated with levaquin on admission he had an normal white count and was pan cultured no infectious source was found on blood urine cultures no pneumonia was seen on cta his low grade temperatures were likely secondary to his pulmonary embolism his central line was removed after stabilization of the patient and transfer to the medical floors and a peripheral line was placed the line tip was cultured with growth of staph coag negative likely contamination as the patient had no clinical signs of infection hypercoagulopathy the patient was hypercoagulable in setting of heparin with hit ab positive however he had a dvt on coumadin and has not had a full hypercoagulabe workup an ivc filter in place protein c was normal and protein s was slightly elevated at time of discharge a further hypercoaguable workup was deferred until outpatient as laboratory values not meaningful in acute period dm his sugars were controlled with a insulin sliding scale his sugars were consistently elevated to the s he was started on glipizide xl and his glargine was increased for stricter control his sugars were ultimately well controlled with u glargine and mg glipizide xl qd htn he remained normotensive during his hospital course and his antihypertensives were held seizures he was found unconsciousness hypoxic with a question of seizures secondary to the large mca territory infarct although it was unclear if patient actually had a seizure or not he was maintained on seizure precautions through his hospital course and was started on prophylactic doses of dilantin tid and levels were drawn he did not have any episodes of seizures during his hospital course and after discussion with neurology dilantin was discontinued l mca cva he was maintained on frequent neuro checks as there was concern for bleed in the setting of a large stroke and anti coagulation a ct of head was performed showing further evolution with edema involving the large left sided middle cerebral artery distribution infarction there is mild mass effect with rightward subfalcine and uncal herniation no intracranial hemorrhage is identified his aphasia and right sided weakness remained unchanged through his hospital course without development of new deficits he was aphasic but able to communicate through limited vocabulary fen a previous speech and swallow evaluation showed mild aspiration risk a repeat evaluation later showed him to tolerate thin liquids regular solids pills whole with water prophylaxis ppi argatroban access r scl placed in ed removed and a peripheral line placed dnr dni dispo rehabilitation medications on admission colace mg po tid asa mg po qd senna tabs po qd lisinopril mg po qd protonix mg po qd heparin units sq tid zocor mg po qd metformin mg po bid started on nph units qam units qpm discharge medications simvastatin mg tablet sig two tablet po daily daily disp tablet s refills protonix mg tablet delayed release e c sig one tablet delayed release e c po once a day disp tablet delayed release e c s refills glipizide mg tab sust release osmotic push sig one tab sust release osmotic push po daily daily disp tab sust release osmotic push s refills insulin lispro human unit ml solution sig one subcutaneous four times a day per sliding scale disp qs refills insulin needles disposable needle sig four miscell once a day disp qs refills insulin glargine unit ml solution sig one subcutaneous every morning u every morning disp qs refills acetaminophen mg tablet sig tablets po q h every to hours as needed disp tablet s refills aspirin mg tablet sig one tablet po daily daily disp tablet s refills warfarin mg tablet sig tablets po at bedtime please hold medication for evening of please start taking on adjust dose as required by inr disp tablet s refills discharge disposition extended care facility discharge diagnosis pulmonary embolism heparin induced thrombocytopenia cva insulin dependant diabetes discharge condition good stable afebrile discharge instructions you were admitted for a pulmonary embolism and for heparin induced thrombocytopenia low platelets you were anticoagulated with coumadin and need to continue with this therapy for six months you should have weekly monitoring levels of your on discharge and you need to hold your dose of coumadin mg for tonight and begin taking your medication tomorrow on per instructions you were noted to have enlarged right sided mediastinal and hilar lymphadenopathy in your lungs and should have a physician further investigate this once you finish your course of anticoagulation you should take your medications as instructed if you experience new motor sensory changes weakness chest pain shortness of breath fever chills you should contact your pcp or go to the emergency room followup instructions please take daily inr levels and adjust coumadin levels per physician recommendations to maintain inr between for proper anticoagulation for pe therapy until inr is stable for days then may monitor weekly,{}
11718,admission date discharge date date of birth sex f service hepatobiliary surgery service chief complaint ercp pancreatitis history of present illness the patient is a year old female who had presented to an outside hospital with symptoms consistent with upper respiratory infection the patient was started on amoxicillin when follow up labs indicated increased lfts further evaluation revealed thickened gallbladder wall mm with small x x mm shadow in the neck of the gallbladder with common bile duct approximately mm an ercp was performed which revealed common bile duct with definite impression of cut off in biliary system and underfilling of right branch a stent was therefore placed following this stent placement the patient developed increased nausea and abdominal discomfort localized in the epigastric region with subsequent development of mild jaundice past medical history none past surgical history none allergies no known drug allergies medications on admission vitamin b folic acid physical examination general the patient was a well developed well nourished female in no apparent distress heent at the time of discharge there was no evidence of scleral icterus moist mucous membranes no evidence of oral ulcers no evidence of cervical lymphadenopathy cranial nerves ii xii intact chest clear to auscultation bilaterally heart regular rate and rhythm no murmurs abdomen soft nontender nondistended extremities no evidence of edema or rash although there was flying resting tremor with mild cogwheel rigidity laboratory data on white blood cell was hematocrit platelet count sodium potassium chloride bicarb bun creatinine glucose alt ast amylase lactate total bilirubin albumin calcium phos magnesium hospital course the patient was a year old female with post ercp pancreatitis admitted to the surgical intensive care unit for close observation ct of the abdomen performed at the time of admission showed positive stranding around the pancreas with stent in place at the time of admission the patient was tachycardiac with pulse of with decreased urine output after placing a swan the patient was aggressively fluid resuscitated with repletion of electrolytes two units of packed red blood cells were administered and zosyn was empirically initiated with acute elevation of pancreatic enzymes resolving the patient was transferred to the floor on hospital day a repeat ct scan of the abdomen was performed which revealed worsening pancreatic inflammation at the neck of pancreas during this period the patient continued to spike fever and a protocol of panculturing was performed every hours with each fever spike cultures continued to be negative and picc line was inserted to provide nutritional support by the patient s clinical picture began to improve with minimal abdominal discomfort and decreasing pancreatic enzyme levels follow up ct scan was obtained which revealed decreased fat stranding inflammation and decreased mesenteric fluid with this improvement the patient was initiated on p o fluids neurology was consulted additionally to evaluate for persistent parkinsonism like tremor as a result metoprolol was initiated with mysoline the decision was made on to discharge the patient to home with resolution of pancreatitis at the time of discharge the patient was tolerating a regular diet without any abdominal discomfort and white blood cell count was normalized with amylase and lipase decreasing discharge status to home condition on discharge good discharge diagnosis status post ercp acute pancreatitis discharge medications protonix mg p o b i d haldol mg p o t i d lopressor mg p o b i d mysoline mg q days follow up the patient was instructed to follow up with dr in one week the patient was also instructed to follow up with the neurologist by calling the clinic at the m d ph d dictated by medquist d t job,"{
""Diagnoses"": [""Hepatobiliary surgery"", ""Pancreatitis""],
""Medications"": [""Amoxicillin"", ""Stent""]
}"
93581,admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint chest pain dyspnea major surgical or invasive procedure left heart cardiac catheterization with no intervention history of present illness this is a year old with no known past medical history who developed chest pressure and tightness with associated exertional dyspnea while on the elliptical machine on saturday days prior with pain that persisted through the evening the pain resolved the following day at first but then intermittently returned the morning of admission he awoke with persistent chest pressure resting dyspnea and diaphoresis his sister encouraged him to seek medical treatment he presented to ed with initial vs ra he was complaining of chest discomfort with some resting dyspnea an ekg showed nsr na ni st elevations in leads v and in leads ii iii avf inferolateral st changes cxr showed no acute intrapulmonary process laboratory studies showed a troponin i of ck creatinine wbc with hct inr patient was given nitro ointment inch aspirin mg po x plavix loaded with mg and atorvastatin mg po x he was heparin loaded with units and started on a continuous gtt metoprolol mg iv x doses was administered he was transferred to for further management the patient was urgently transferred to the cardiac cath lab given concern for an inferiorlateral stemi on cath he was noted to have an occluded large rpl branch and the vessel was unable to be opened successfully technically unsuccessful via rra access the patient transferred to the cardiology floor and upon transfer was found unresponsive with cold mottled extremities his bp was palp initially s systolic with a hr of s and stable o saturations l nc by the time the resident arrived he was alert awake and mentating the cardiology fellow evaluated him a recommended atropine mg iv x for presumed vasovagal episodes with hr increase to the low s he was given l ns iv x a bedside d echo showed evidence of a cm pericardial effusion with evidence of poor rv filling and possible tamponade physiology an abg showed with a lactate of he was transferred to cvicu patient is mentating well alert and interactive without lightheadedness or dizziness he denies chest pain trouble breathin no palpitations nausea or diaphoresis cardiac review of systems is notable for absence of chest pain dyspnea on exertion paroxysmal nocturnal dyspnea orthopnea ankle edema palpitations syncope or pre syncope currently ros the patient denies a history of prior stroke tia deep venous thrombosis or pulmonary embolus they deny bleeding at the time of prior procedures or surgeries denies headaches or vision changes no cough or upper respiratory symptoms denies chest pain dizziness or lightheadedness no palpitations denies shortness of breath no nausea or vomiting denies abdominal pain no dysuria or hematuria no change in bowel movements or bloody stools denies muscle weakness myalgias or neurologic complaints no exertional buttock or calf pain past medical history cardiac history none cabg none percutaneous coronary interventions none pacing icd none social history patient lives at home alone and works as a mechanic for gilette denies tobacco use prior smoker for years packs per week quit months ago social alcohol use denies recreational substance use family history denies family history of early mi arrhythmia cardiomyopathies father s sister died years old of sudden cardiac death physical exam admission exam weight kg general appears in no acute distress alert and interactive healthy appearing male heent normocephalic atraumatic eomi perrl nares clear mucous membranes moist no xanthalesma neck supple without lymphadenopathy jvd difficult to assess given neck habitus cvs pmi located in the th intercostal space mid clavicular line distant heart sounds regular rate and rhythm without murmurs rubs or gallops s and s normal no s or s resp respirations unlabored no accessory muscle use clear to auscultation bilaterally without adventitious sounds no wheezing rhonchi or crackles stable inspiratory effort abd soft non tender non distended with normoactive bowel sounds no palpable masses or peritoneal signs abdominal aorta not enlarged to palpation no bruit extr no cyanosis clubbing or edema peripheral pulses distal extremities appear cool derm no stasis dermatitis ulcers scars or xanthomas neuro cn ii xii intact throughout alert and oriented x strength bilaterally sensation grossly intact gait deferred pulse exam right carotid femoral popliteal dp pt left carotid femoral popliteal dp pt right radial access site with small stable hematoma without active bleeding pertinent results admission 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 ck cpk alkphos amylase totbili am blood calcium phos mg cholest pnd pm blood type art po pco ph caltco base xs pm blood lactate na k cl pm blood hgb calchct o sat pertinent labs and studies pm blood ck mb ctropnt am blood ck mb mb indx ctropnt pm blood ck cpk am blood alt ast ck cpk alkphos amylase totbili am blood ck cpk pm blood ck cpk pm blood ck mb ctropnt am blood ck mb mb indx ctropnt am blood ck mb mb indx ctropnt pm blood ck mb mb indx ctropnt am blood hba c eag am blood triglyc hdl chol hd ldlcalc am blood tsh echocardiogram focused study there is mild to moderate regional left ventricular systolic dysfunction with akinesis of the inferior wall and severe hypokinesis of the inferolateral wall basal to mid inferior septum and apex the remaining segments contract normally lvef the number of aortic valve leaflets cannot be determined no aortic regurgitation is seen no mitral regurgitation is seen there is a moderate sized pericardial effusion the effusion appears circumferential the effusion is echo dense consistent with blood inflammation or other cellular elements no right ventricular diastolic collapse is seen there is brief right atrial diastolic collapse there is significant accentuated respiratory variation in mitral tricuspid valve inflows consistent with impaired ventricular filling impression suboptimal image quality regional left ventricular systolic dysfunction c w multivessel cad moderate sized echodense pericardial effusion without echocardiographic evidence of frank tamponade physiology echocardiogram focused study to compare to earlier tte there is moderate regional left ventricular systolic dysfunction with focal severe hypokinesis to akinesis of the inferior wall inferolateral wall inferoseptum and apex the remaining segments contract well ef there are three aortic valve leaflets there is a moderate to large sized pericardial effusion which is circumferential cm and echodense no right ventricular diastolic collapse is seen compared with the prior study images reviewed of the pericardial effusion is slightly increased in size anterior to right ventricle in subcostal views catheterization preliminary selective coronary angiography of this right dominant system revealed two vessel disease the lmca had a ostial and long with distal stenosis the lad had focal calcification ostial mid bifurcation lesion involving large d timi flow consistent with microvascular dysfunction the lcx had retroflexed origin proximal before large branching om with slow flow consistent with microvascular dysfunction there were collaterals to rpl the rca had a crook configuration leading to proximal stenosis with diffuse plaquing the rpda had diffuse plaquing apical rpda runs laterally rpl proximal occlusion with faint filling of the very distal rpl via right to right collaterals timi slow flow into rpda no flow into rpl limited resting hemodynamics revealed elevated left sided filling pressures with lvedp mmhg there was normal systemic arterial pressure at the central aortic level mmhg there was no gradient across the aortic valve after careful pullback of the pigtail catheter left ventriculography was deferred final diagnosis two vessel coronary artery disease moderate left ventricular diastolic heart failure echo there is mild regional left ventricular systolic dysfunction with inferolateral akinesis the remaining segments contract normally lvef right ventricular chamber size and free wall motion are normal there is a very small pericardial effusion the effusion is echo dense consistent with blood inflammation or other cellular elements impression very small pericardial effusion mild regional left ventricular systolic dysfunction c w cad brief hospital course m with no significant past medical history who presented with days of chest pain and dyspnea found to have inferolateral st segment elevation myocardial infarction with occluded large rpl branch but unable to open vessel completely technically unsuccessful during cardiac catheterization with hospital course complicated by episode of unresponsiveness and hypotension with echocardiographic evidence of pericardial effusion and concern for tamponade physiology acute coronary syndrome st segment elevation myocardial infarction patient presented with acute coronary syndrome no prior history of chronic stable angina but he has some notable risk factors including family history prior smoking history no prior cardiac catheterizations or known coronary disease prior to admission ekg consistent with inferolateral st segment elevation myocardial infarction with occluded large rpl branch but unable to open vessel completely technically unsuccessful during cardiac catheterization cardiac cath demonstrated a right dominant system revealing vessel disease the lmca had a ostial and long with distal stenosis the lad had focal calcification ostial mid bifurcation lesion involving large d timi flow consistent with microvascular dysfunction the lcx had retroflexed origin proximal before large branching om with slow flow consistent with microvascular dysfunction there were collaterals to rpl the rca had a crook configuration leading to proximal stenosis with diffuse plaquing the rpda had diffuse plaquing apical rpda runs laterally rpl proximal occlusion with faint filling of the very distal rpl via right to right collaterals post procedure atorvastatin metoprolol were continued post procedure ekgs without persistent ischemic changes biomarkers peaked at troponin ck mb ck we held asa plavix coumadin for weeks total given hemorrhagic pericardial effusion this will be readdressed with his outpatient cardiologist pericardial effusion the patient transferred to the cardiology floor following post cath procedure and had an episode of unresponsiveness with hypotension to the palp range briefly with hr s received atropine mg iv x for presumed vasovagal component with rapid return to alert and interactive state with positioning and l ns x bp improved to s range and mentation was stable no oxygen desaturations were noted at that time bedside d echo demonstrated cm pericardial effusion with initial concern for tamponade physiology but this was later noted to be stable likely cause was iatrogenic due to manipulation during catheterization procedure specifically a coronary artery perforation pericardial effusion was seen to be very small on formal d echo performed on and the patient did not require pericardiocentesis or other drainage evidence of systolic dysfunction heart failure vs stunning the patient had no history of systolic dysfunction or valvular heart disease no prior d echo evaluations no overt signs of volume overload on clinical exam on admission d echo showed mild to moderate regional left ventricular systolic dysfunction with akinesis of the inferior wall and severe hypokinesis of the inferolateral wall basal to mid inferior septum and apex the remaining segments contracted normally lvef consistent with ischemic cardiomyopathy the patient was started on lisinopril mg daily metoprolol mg xl daily of note a repeat d echo on showed mild regional left ventricular systolic dysfunction with inferolateral akinesis the remaining segments contracted normally lvef there was a very small pericardial effusion the effusion was echo dense consistent with blood inflammation or other cellular elements the discrepancy between the two d echocardiograms and improvement in his lvef read in that short interval was attributed to his effusion resolution and likely reflects an average of the two reads lvef likely between on further review with dr in the echo lab transitions in care issues patient will hold aspirin plavix and coumadin for weeks given his hemorrhagic pericardial effusion issues this admission his outpatient cardiologist will address this in follow up no imaging studies microbiologic data or laboratory studies were pending at the time of discharge medications on admission nitric oxide gnc supplement powder prior to workouts protein powder following workouts discharge medications 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 extended release hr sig one tablet extended release hr po once a day disp tablet extended release hr s refills nitroglycerin mg tablet sublingual sig one tablet sublingual as directed as needed for chest pain take one tablet for chest pain can take second tab after minutes if needed disp tablets refills discharge disposition home discharge diagnosis primary diagnosis acute st elevation myocardial infarction iatrogenic pericardial effusion discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you were admitted to for chest pain and you were found to have a heart attack you underwent coronary angiography but did not receive intervention you subsequently were found to have fluid around your heart that was monitored closely and did not need to be drained we have made the following changes to your medicines start taking atorvastatin lipitor to decrease your cholesterol and help your heart recover from the heart attack start taking metoprolol to slow your hear rate and help your heart recover from the heart attack start taking lisinopril to lower your blood pressure and help with healing your heart because you had some bleeding around your heart you were not started on aspirin and plavix but will talk to dr about this when you see him in start taking nitroglycerin as needed for any further chest pain take one tablet under your tongue then wait mintues then you can take one more tablet if you still have chest pain call if you have chest pain after nitroglycerin tablets call dr or the heartline if you take any nitroglycerin at home please be sure to follow up with your physicians followup instructions primary care name location address ste phone appointment wednesday am the cardiology department will call you with an appt for an echocardiogram on around the time of your appt with dr department cardiac services when wednesday at am with md building campus east best parking garage your insurance records are incomplete please call our registration department at before your first appointment,"{
""Diagnoses"": [""Chest pressure and tightness"", ""Dyspnea""],
""Medications"": [""Nitro ointment"", ""Aspirin"", ""Plavix"", ""Heparin"", ""Atorvastatin""]
}"
84649,admission date discharge date date of birth sex m service cardiothoracic allergies percocet attending chief complaint irregular rhythm and occasional left arm pain with activity 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 om with y graft to om saphenous vein graft to posterior descending artery history of present illness briefly y o man with a history of crohn s diease colon cancer s p partial colectomy htn hyperlipidemia found to have skipped beats on recent examination at pcp s office and he arranged for stress echo he was referred to see dr the stress echo showed st depressions during peak exercise he presents today for cardiac cath which revealed significant cad past medical history crohns disease colon cancer s p partial colectomy c b wound infection hypertension hyperlipidemia arthritis in knees hernia gib secondary to chrons disease past surgical history s p partial colectomy c b wound infection in hospital for one month social history race caucasian last dental exam long time ago lives with wife contact his wife phone cell work occupation teacher and runs his own lock business cigarettes smoked no yes x last cigarette yrs ago hx etoh none illicit drug use none family history premature coronary artery disease all brothers have htn and hyperlipidemia older brother mi at younger brother had cabg in s father died of mi in s physical exam pulse resp o sat ra b p right left height ft weight lbs five meter walk test general skin dry x intact x heent perrla left pupil greater than right eomi x neck supple x full rom x chest lungs clear bilaterally x heart rrr x irregular murmur grade abdomen soft x non distended x non tender x bowel sounds extremities warm x well perfused x edema varicosities none neuro grossly intact pulses femoral right left dp right faint left faint pt faint left faint radial right cath site left carotid bruit right none left none pertinent results intra op tee conclusions prebypass no atrial septal defect is seen by d or color doppler left ventricular wall thicknesses are normal regional left ventricular wall motion is normal overall left ventricular systolic function is normal lvef right ventricular chamber size and free wall motion are normal there are simple atheroma in the descending thoracic aorta 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 trivial mitral regurgitation is seen there is no pericardial effusion dr was notified in person of the results on at am post bypass patient is av paced and receiving an infusion of phenylephrine biventricular systolic function is unchanged rest of examination is unchanged aorta is intact post decannulation 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 na k cl hco angap brief hospital course mr was a same day admit and on was brought directly to the operating room where he underwent a coronary artery bypass graft x left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal obtuse marginal obtuse marginal and posterior descending arteries please see operative note for surgical details cardiopulmonary bypass time minutes cross clamp time minutes following surgery he was transferred to the cvicu for invasive monitoring in stable condition within hours he was weaned from sedation awoke neurologically intact and extubated beta blocker was initiated and the patient was gently diuresed toward the preoperative weight the patient was transferred to the telemetry floor for further recovery chest tubes and pacing wires were discontinued without complication 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 home with vna services in good condition with appropriate follow up instructions medications on admission ergocalciferol vitamin d vitamin d prescribed by other provider dosage uncertain folic acid prescribed by other provider mg tablet one tablet s by mouth daily mesalamine asacol prescribed by other provider mg tablet delayed release e c two tablet s by mouth twice daily metoprolol succinate prescribed by other provider mg tablet extended release hr one tablet s by mouth daily medications otc aspirin prescribed by other provider mg tablet one tablet s by mouth daily coenzyme q prescribed by other provider dosage uncertain cyanocobalamin vitamin b vitamin b prescribed by other provider dosage uncertain magnesium prescribed by other provider mg tablet one tablet s by mouth daily multivitamin prescribed by other provider tablet one tablet s by mouth daily omega fatty acids vitamin e fish oil prescribed by other provider mg capsule one capsule s by mouth twice daily pyridoxine vitamin b prescribed by other provider dosage uncertain discharge medications potassium chloride meq packet sig one packet po once a day for days disp packet s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills ranitidine hcl mg tablet sig one tablet po bid times 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 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 mesalamine mg tablet delayed release e c sig two tablet delayed release e c po bid times a day disp tablet delayed release e c s refills folic acid mg tablet sig one tablet po daily daily disp tablet s refills lasix mg tablet sig one tablet po once a day for days disp tablet s refills metoprolol tartrate mg tablet sig tablets po tid times a day disp tablet s refills discharge disposition home with service facility discharge diagnosis coronary artery disease s p coronary artery bypass graft x past medical history crohns disease colon cancer s p partial colectomy c b wound infection hypertension hyperlipidemia arthritis in knees hernia gib secondary to chrons disease past surgical history s p partial colectomy c b wound infection in hospital for one month 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 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 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 wound check date time surgeon dr date time cardiologist dr date time 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 md completed by,"{
""Diagnoses"": [""cardiothoracic"", ""irregular rhythm"", ""left arm pain"", ""coronary artery bypass graft"", ""left internal mammary artery to left anterior descending saphenous vein graft to diagonal saphenous vein graft to om with y graft to om saphenous vein graft to posterior descending artery""],
""Medications"": [""Percocet"", ""Allergies"", ""Hypertension"", ""Hyperlipidemia"", ""Arthritis"", ""Hernia"", ""Gib secondary to Crohn's disease""]
}"
23876,admission date discharge date date of birth sex f service medicine allergies iodine containing agents classifier iron derivatives attending chief complaint transfer for nstemi major surgical or invasive procedure cardiac catheterization with balloon angioplasty to left main coronary artery and drug eluting stent placed to the right coronary artery history of present illness f with cad s p cabg and chf ef transferred from osh for nstemi and chf following a long hospital course she presented to osh on with cough and fever and was diagnosed with strep pneuo pna she also developed step pneumo bactermia and originally looked septic she was treated with vanc and ctx and seemed to have finished a course during this period she had an nstemi and cardiology consultation felt that this represents demand in the setting of infection her troponins peaked at during this hospital course she also developed other complications including arf with a creatinine that peaked at now recovered she also had chf with elevated bnp and was diuresed with consideration for arf there was also seen by vascular surgery for her severe pvd she also had diarrhea and was treated with flagyl although multiple cultures have been cdiff negative she was also anemic and was tranfused on review of systems denies hemoptysis black stools or red stools denies recent fevers chills or rigors 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 cad s p cabg s p ptca pci stenting of lad in vd patent svg diag svg pda mid lima lad occluded svg om lad mid total occlusion lcx mild diffuse rca prox vd cccluded svg d previously stented svg om was known occluded svg rca was patent filling an rca with severe lesions in the plb unchanged from prior studies lima lad was patent and supplied an lad with diffuse disease the subclavian artery had a origin lesion tia occluded l ica min plaque r ica dmi since age with triopathy gastroparesis htn hypercholesterolemia h o pneumonia iron deficiency anemia h o kidney stones h o dvt pvd s p l th toe amp s p sfa bypass graft and lfa a jump graft from femoral anterior tibial vein graft to dorsalis pedis artery with non reversed lesser saphenous vein and right fourth toe open amputation thrombectomy hx pericarditis i d lt buttocks abcess cardiac risk factors diabetes dyslipidemia hypertension cardiac history cabg lima to lad svg to om svg to diag svg to pda pacemaker icd none social history social history is significant for the presence of current tobacco use ppd there is no history of alcohol abuse drinks per week family history no cad mi dm mother and father healthy son age has high chol physical exam vitals lnc gen a ox nad heent perrl eomi op clear mmm neck no jvd cv rrr no m g r chest scattered crackles decreased breath sounds at left base no rhonchi or wheezes abd soft nt nd bs ext no peripheral edema pertinent results pm glucose creat sodium potassium chloride total co anion gap pm ck cpk pm ck mb notdone ctropnt pm calcium phosphate magnesium pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count ekg nsr at bpm na q in i almost lbbb st depressions laterally that are old j pt elevations in v and v d echocardiogram ef the left atrium is mildly dilated no atrial septal defect is seen by d or color doppler left ventricular wall thicknesses are normal the left ventricular cavity is mildly dilated overall left ventricular systolic function is moderately depressed with global hypokinesis basal to mid lateral wall moves best and distal lv apical akinesis there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve leaflets are mildly thickened moderate mitral regurgitation is seen the mitral regurgitation jet is eccentric the tricuspid valve leaflets are mildly thickened moderate tricuspid regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion compared with the prior study images reviewed of the overall lvef appears slightly lower cardiac cath selective coronary angiography revealed diffuse vessel disease the lmca had a lesion the lad was occluded proximally the lcx had diffuse disease with a proximal occlusion the rca was occluded proximally graft angiography revealed an occluded svg d previously stented the svg om was known occluded the svg rca was patent filling an rca with severe lesions in the plb unchanged from prior studies the lima lad was patent and supplied an lad with diffuse disease the subclavian artery had a origin lesion resting hemodynamics revealed an elevated lvedp of mmhg cardiac index was low normal at l min m successful stenting of the subclavian artery with a stent post dilated with a stent with no residual stenosis see pta comments final diagnosis three vessel coronary artery disease elevated filling pressures successful percutaneous intervention of the subclavian artery brief hospital course f with cad s p cabg and chf ef transferred from osh with nstemi and chf after a long hospital course cad the pt s cardiac biomarkers were followed and they trended down she underwent cardiac catheterization on the second hospital day with balloon angioplasty to a stenosis in the distal lad and placement of a des in the svg pda graft the patient required propofol sedation during the procedure and was monitored afterwards overnight in the ccu she was continued on her home asa plavix beta blocker pravastatin and acei the patient arrived from the osh on coreg this was continued instead of metoprolol pump the patient was previously known to have a depressed lvef repeat echo during this admission showed an ef of approximately she was felt to be mildly volume up and thus was gently diuresed she was continued on her home digoxin though this was decreased to every other day dosing beta blocker and acei she was started on spironolactone based on her ef assessment the patient is likely a candidate for icd implant in the future pvd the patient was continued asa and plavix she was seen by vascular surgery who recommended avoiding groin access during cath she will follow up in vascular clinic two weeks after discharge arf the patient s creatinine reportedly peaked at at the osh this renal failure appeared to have fully resolved by the time she was admitted to two days after cath she again developed arf that was felt to be contrast associated nephrotoxic medications were held and this slowly improved peak cr at was pna and bacteremia the patient completed courses of vanc and ceftriaxone at the osh repeat cultures at were negative and the patient did not have evidence of recurrent infection radiology advised a repeat cxr to evaluate for resolution of pna as an outpt sob the pt complained of shortness of breath throughout her hospital stay this was felt to be primarily due to volume overload and improved significantly with diuresis nevertheless the pt did have some wheezes on exam and it was thought that she might have some airway reactivity she noted good effect with fluticasone while in house and was continued on this medication at the time of discharge uti the patient had a positive ua at the time of admission but no urinary sxs her cultures growing only yeast she did report some itching and erythema in her groin folds bilaterally she was emperically treated with a three day course of cipro as well as topical clotrimazol to the groin diarrhea the patient was treated with flagyl at osh even though c diff studies were negative her c diff at the was again negative x and the patient did not complain of diarrhea anemia the patient was started on iron at the osh based on iron studies performed there she also receieved one unit prbcs at the osh iron supplementation was continued dm the patient was continued on lantus and a sliding scale an a c was checked and found to be elevated the service was consulted and assisted with her managment though no major changes were recommended for her regimen medications on admission lasix ambien nitropaste inch q h albuterol atrovent prn reglan tid oxycodone prn tylenol prn morphine prn coreg big ferrous gluconate omeprazole flovent digoxin nicotine patch flagyl tid heparin tid asa plavix neurontin tid pravachol lantus and apsart ss discharge medications fluticasone mcg actuation aerosol sig one puff inhalation times a day disp inhaler refills aspirin mg tablet sig one tablet po daily daily clopidogrel mg tablet sig one tablet po daily daily disp tablet s refills pravastatin mg tablet sig one tablet po at bedtime oxycodone mg tablet sig one tablet po q h every hours as needed for pain ferrous gluconate mg mg iron tablet sig one tablet po daily daily disp tablet s refills clotrimazole cream sig one tube topical times a day for days disp tube refills albuterol mcg actuation aerosol sig puffs inhalation every four hours as needed for shortness of breath or wheezing lisinopril mg tablet sig one tablet po once a day digoxin mcg tablet sig one tablet po every other day every other day furosemide mg tablet sig one tablet po bid times a day carvedilol mg tablet sig one tablet po bid times a day disp tablet s refills spironolactone mg tablet sig one tablet po daily daily disp tablet s refills tylenol codeine mg tablet oral gabapentin mg tablet sig one tablet po three times a day lantus unit ml solution sig eight units subcutaneous at bedtime humalog subcutaneous discharge disposition home with service facility all care vna of greater discharge diagnosis coronary artery disease congestive heart failure pneumonia peripheral vascular disease diabetes acute renal failure yeast infection of groins discharge condition good vitals stable chest pain free respirations improved ambulating well discharge instructions you were admitted with pneumonia and a small heart attack we have treated blockages in your heart coronary arteries with angioplasty and a stent your kidney function was impaired temporarily while you were here it has now improved we have removed excess fluid that accumulated in your lungs it is important that you continue to take your medications as directed we have made the following changes to your medication on this admission take your digoxin only every other day we have replaced your metopolol with a similar medication called carvedilol you were started on a new heart medication called spironolactone you iron levels were found to be low when you were first admitted we have started you on iron supplements we have started a medication called fluticasone to help with your breathing contact your doctor or come to the emergency room should your symptoms return also seek medical attention if you develop any new fever chills trouble breathing chest pain nausea vomiting or unusual stools followup instructions you are scheduled for a follow up appointment with dr nurse practitioner on at pm you have a follow up appointment in vascular clinic with dr on at pm you have a follow up appointment with dr on at pm your chest x ray showed a pneumonia during you admission it is recommended that you have a repeat x ray in six weeks to be certain the pneumonia has completely resolved [NEW_RECORD] admission date discharge date date of birth sex f service surgery allergies iodine containing agents classifier iron derivatives attending chief complaint gangrene of the right fourth toe major surgical or invasive procedure a jump graft from femoral anterior tibial vein graft to dorsalis pedis artery with non reversed lesser saphenous vein and right fourth toe open amputation history of present illness this year old lady with juvenile diabetes and long history of peripheral vascular disease has previously undergone a right femoral anterior tibial bypass to the proximal anterior tibial artery she subsequently developed episodes of recurrent ischemia in her right foot with a patent graft and was found to have disease in her anterior tibial artery to the vein graft but proximal to the dorsalis pedis artery this area has been angioplastied twice due to severe ischemia of her foot the second time we did it we decided to revise this with a bypass since the recurrence rate of stenosis between the episodes was quite short she has gangrene of her toe and requires toe amputation at the same time past medical history cad s p cabg s p ptca pci stenting of lad in tia occluded l ica min plaque r ica dmi since age with triopathy gastroparesis htn hypercholesterolemia h o pneumonia iron deficiency anemia h o kidney stones h o dvt pvd s p l th toe amp s p sfa bypass graft and lfa thrombectomy hx pericarditis i d lt buttocks abcess cath report unavailable cath vd patent svg diagonal patent svg pda patent lima lad occluded svg om comments lmca patent lad had a mid total occlusion lcx mild diffuse disease occluded om rca proximal stenosis svg pda mid stenosis lad beyond the touchdown patent w mild in stent restenosis echo not available pmibi ef apical akinesis mod min rev and apical perf defect social history lived with husband and two children worked as a nurse s aid for two women with ms p y drinks etoh week no drugs ivdu family history no cad mi dm mother and father healthy son age has high chol physical exam vital signs her blood pressure is pulse was and regular and her weight was stable at pounds skin without rash lesions or nodules she did have erythema of her right foot open wound on fore foot is c d i heent pupils are equal round and reactive conjunctivae nose and throat were clear hearing intact to finger rubbing neck without mass or thyromegaly without cervical or supraclavicular lymphadenopathy chest clear to percussion and auscultation heart showed normal pmi without s s or murmurs abdomen soft without masses tenderness or organomegaly she had tenderness in the right inguinal area there was tender lymphadenopathy extremities exam of the leg and foot was as above her ulcers appear dry and her skin is erythematous there is no edema pulses r dp pt dopp palp graft l dp pt dopp palp graft 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 pm urine color straw appear clear sp urine blood mod nitrite neg protein glucose neg ketone tr bilirub neg urobiln neg ph leuks neg urine rbc wbc bacteri few yeast none epi pm stool consistency loose source stool clostridium difficile toxin assay final feces negative for c difficile toxin by eia reference range negative pm swab site toe right th toe gram stain final no polymorphonuclear leukocytes seen no microorganisms seen wound culture final beta streptococcus not group a or b sparse growth anaerobic culture final no anaerobes isolated brief hospital course pt admitted on pre op d foot xrays show osteo of th digit ab started cx s taken underwent a a jump graft from femoral anterior tibial vein graft to dorsalis pedis artery with non reversed lesser saphenous vein and right fourth toe open amputation tolerated the procedure well no complications recovered in the pacu once recovered from the pacu sent to the vicu in stable condition bedrest hliv regualr diet low u o and decrease o sats responeded to lasix prbc given c o chest pressure diagnosis of chf and nstemi tx to ccu cardiology is consulted pt has been complaining of recurrent cp there was no ecg changes but cardiac enzymes returned positive tnt with cpk and cardiology was consulted on and pt was taken to cath lab for intervention cath showed diffuse severe disease of lmca lad lcx rca svg to rca was patent with rca which had lesions in the plb unchanged from previous angiography lima to lad was patent origin left subclavian had and left subclavian was stented with a genesis stent and the final residual was with normal flow lvedp was elevated at with pcw mean pt is getting admitted to ccu overnight for observation and diuresis transfer back to vicu pt undergoes a incision and debridement of r fourth toe amputation site under local wound watched with vac dressing changes ab tailored to treat strep b vac dc changed to wet to dry dressing changes pt case management pt stable for dc home on po ab creat stabalized from arf medications on admission plavix asa diltiazem isosorbide lisinopril toprol pravastatin percocet discharge medications nitroglycerin mg tablet sublingual sig one tablet sublingual sublingual prn as needed oxycodone acetaminophen mg tablet sig two tablet po q h every to hours as needed disp tablet s refills bisacodyl mg suppository sig one suppository rectal hs at bedtime as needed disp suppository s refills levofloxacin mg tablet sig one tablet po q h every hours disp tablet s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills aspirin mg tablet sig one tablet po daily daily tablet s pravastatin mg tablet sig two tablet po hs at bedtime disp tablet s refills clopidogrel mg tablet sig one tablet po daily daily disp tablet s refills isosorbide mononitrate mg tablet sustained release hr sig two tablet sustained release hr po daily daily disp tablet sustained release hr s refills pantoprazole 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 insulin insulin sc per insulin flowsheet sliding scale fixed dose bedtime glargine units insulin sc sliding scale breakfast lunch dinner bedtime humalog glucose insulin dose mg dl amp d mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units mg dl notify m d metoprolol tartrate mg tablet sig two tablet po tid times a day disp tablet s refills discharge disposition home with service facility all care vna of greater discharge diagnosis ischemic toe pad arf creat on admission on dc high discharge condition stable discharge instructions wound care please call us immediately for any of the following problems redness in or drainage from your wound s new pain numbness or discoloration of your lower or upper extremities notably on the side of the incision watch for signs and symptoms of infection these are a fever greater than degrees chills increased redness or pus draining from the incision site if you experience any of these or bleeding at the incision site call the doctor other information you may shower immediately upon coming home no bathing keep your open wound dry dressing changes twice a day avoid taking a tub bath swimming or soaking in a hot tub untill your wound is completely healed limit strenuous activity and or heavy lifting until the wound is well healed activity may prevent the wound from healing do not drive a car unless cleared by your surgeon try to keep your affected limb elevated when not in use this decreases swelling to the affected wound and helps in the healing process you may have an ace wrap around the affected limb with the wound this helps prevent swelling to the area you may take this off at night but when you are doing activity the ace wrap should be worn antibiotics you may have a prescription for antibiotics take as directed be sure you take the full course even if the wound looks well healed failure to do so may lead to infection followup instructions provider d phone date time provider m d date time call dr office and schedule am appointment for one week he can be reached at completed by,{}
31951,admission date discharge date date of birth sex m service ome history of present illness mr is a year old male with metastatic renal cell carcinoma admitted to begin cycle ii week two high dose il therapy his oncologic history began in when he developed bilateral pulmonary emboli with workup revealing right kidney mass and associated tumor thrombus into the ivc chest ct revealed multiple small pulmonary nodules he underwent right radical nephrectomy on with clear cell histology noted follow up cts revealed slow growth of lung nodules he began cycle week one high dose il therapy in receiving of doses week one and seven of doses week two complicated by shock and hypotension follow up cts revealed disease regression he began cycle ii week one high dose il on receiving of doses he has fully recovered from week one of therapy and now is ready to begin his next week of therapy past medical history hypertension hyperlipidemia depression anxiety history of pulmonary emboli history of migraine headaches history of eczema allergies codeine causes dizziness penicillin causes a rash medications paxil mg p o daily protonix mg p o daily relpax mg daily p r n migraine headache pravachol mg daily aspirin and coumadin currently on hold physical examination general well appearing male in no acute distress vital signs o sat on room air heent normocephalic atraumatic sclerae anicteric moist oral mucosa without lesions neck supple lymph nodes no cervical supraclavicular bilateral axillary or bilateral inguinal lymphadenopathy heart regular rate and rhythm s s chest clear to percussion and auscultation bilaterally abdomen rounded positive bowel sounds soft nontender no hsm or masses extremities no lower extremity edema skin dry desquamation neurologic alert oriented x speech clear and fluent laboratory data admission labs wbc hemoglobin hematocrit platelet count inr bun creatinine sodium potassium chloride co glucose alt ast ck alk phos total bili albumin calcium phosphorus magnesium hospital course mr was admitted and underwent central line placement to begin therapy his admission weight was kg and he received interleukin international units per kilogram equaling million units iv q h x potential doses during this week he received nine of doses with doses held related to shock requiring vasopressor blood pressure support and toxic encephalopathy on treatment day he developed hypotension unresponsive to fluid boluses and was placed on dopamine for blood pressure support he also developed severe arthralgias requiring intravenous morphine for pain control he had one episode of hypoxia on treatment day thought related to somnolence from narcotics he was placed on oxygen with o sats in the mid s on liters once weaned off dopamine on treatment day he did not require recurrent vasopressor blood pressure support he then developed evidence of toxic encephalopathy manifested by confusion and agitation treatment day into prompting il to be held his mental status improved and he was given one dose of il at o clock on treatment day mental status improved at the time of discharge other side effects during this week included nausea and vomiting improved with ativan diarrhea improved with lomotil and development of an erythematous skin rash during this week he developed acute renal failure with a peak creatinine of he was oliguric but not anuric during his stay he developed metabolic acidosis with a minimum bicarb of improved with bicarb repletion he was anemic without need for packed red blood cell transfusion he had no thrombocytopenia coagulopathy or myocarditis noted he developed hyperbilirubinemia with a peak bilirubin of improved to at the time of discharge he had no transaminitis noted he required intermittent electrolyte repletions by he had recovered from side effects to allow for discharge to home condition on discharge stable discharge status to home discharge diagnoses metastatic renal cell carcinoma status post cycle ii week two high dose il therapy complicated by shock acute renal failure and arthralgias discharge medications lasix mg p o daily x days or until you reach baseline weight protonix mg p o daily paxil mg p o daily relpax mg daily p r n migraine headache ativan mg q h p r n nausea vomiting benadryl mg q h p r n pruritus compazine mg q h p r n nausea vomiting ciprofloxacin mg p o q h x days lomotil tablets q i d p r n diarrhea coumadin mg p o daily with pcp to adjust coumadin dosing follow up plans mr will return to clinic in weeks after ct scans to assess disease response m d dictated by medquist d t job cc [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies penicillins codeine attending chief complaint pain major surgical or invasive procedure picc l ij tlc l shoulder arthrocentesis l shoulder washout r shoulder washout history of present illness mr is a year old male with a metastatic renal cell carcinoma who recently has had acute renal failure in the setting of il therapy he was readmitted today after discharge on the after he called his doctor s office complaining of neck and back pain in the context of a recent positive culture from a line tip for mrsa today he relates that his pain is all over in every joint and is especially bothersome when he moves he cites his right index finger and legs as the most painful currently he states that he has felt fatigued since his il treatment he denies any fever chills sweating diarrhea nausea vomiting dysuria frequency skin rashes chest pain abdominal pain past medical history as noted in prior notes reviewed in omr hypertension hyperlipidemia depression anxiety history of pulmonary embolus history of migraine headaches history of eczema oncologic history as previously noted confirmed in evaluation for sob cp revealed bilateral pe multiple lung nodules cm renal mass in r kidney revealed to be extending into r renal vein in hepatic portion of ivc bone scan showed osseous met to l th rib head ct negative for brain mets during this initial workup had r radical nephrectomy w tumor thrombus extraction at with pathology reportedly showing clear cell carcinoma ct scan no new evidence of recurrence metastasis high dose il for full week planned doses held in second week doses for hypotension also had a number of additional side effects including acute renal failure as well as hyperbilirubinemia n v d rash arthralgias fatigue restaging ct scan shows no evidence of disease progression recent hospital admission planned admit for il as above social history works as graphic designer no tobacco or ilicit drug use drinks glasses of wine with dinner family history remarkable for cad and dm physical exam vitals bp hr rr on l pain gen slightly pale fatigued appearing male sleepy but fully arousable pleasant heent neck nc at clear oropharynx slightly dry mm no scleral icterus or conjunctival pallor perrl emoi no cervical or throacic spine spinal tenderness or masses appreciated neck supple full rom cv tachycardic regular rhythm s s no m g r appreciated resp lungs ctab no w r r abd slightly distended nt bs no hsm appreciated no tymphany to percussion ext edema bilat warm well perfused dp bilaterally neuro tremor ue bilat a ox cns symmetric intact upper extremities grip left right pain remainder of upper extrs bilaterally lower limited by pain skin no rash dry flaking skin psych pleasant pertinent results complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct am am am am am am am renal glucose glucose urean creat na k cl hco am am am am am am mr thoracic cervical spine w o increased signal in the prevertebral soft tissues from c c on stir sequence which could represent edema inflammation or superimposition of adjacent tissues accurate assessment is limited due to lack of iv contrast to exclude abscess or active inflammation in this location no evidence of epidural abscess cord abnormality on the present study multilevel degenerative changes in the cervical spine with mild neural foraminal narrowing as described above cxr new bilateral left much greater than right and predominantly lower lobe interstitial and nodular opacity given history of elevated white blood cell count and immunosuppresion raises the concern for an opportunistic pneumonia the other consideration given cardiomegaly fissural fluid and right pleural effusion is asymmetric pulmonary edema ct chest multiple new lung consolidations and pulmonary nodules are more consistent with infection representing either disseminated pulmonary infection either pyogenic or fungal given the sudden appearance of the abnormality less than two weeks since metastasis is unlikely resolution of nodular opacities in left lower lobes since since some representing inspissated bronchi new small bilateral pleural effusion and pericardial effusion most likely reactive given the history of pulmonary embolism the subpleural areas of consolidation may represent pulmonary infarct reevaluation with contrast enhanced study might be warranted if clinically justified severe spleno megaly may be consistent with ongoing infectious process transthoracic echo the patient is tachycardic lvef moderate pulmonary artery systolic hypertension with right ventricular pressure overload small circumferential pericardial effusion without signs of tamponade the mitral and aortic valves are well seen with no significant regurgitation implying that endocarditis of these valves is unlikely mri l shoulder w o diffuse edema is present throughout the shoulder muscles with relative sparing of the subcutaneous soft tissues the finds represent a non specific myositis the differential diagnosis remains broad but would include infection moderate glenohumeral joint effusion nonspecific cm soft tissue mass superficial to the supraspinatus muscle it is unclear if this arrises from the acromioclavicular joint or represents a discrete soft tissue mass in this patient with a history of metastatic renal cell cancer right upper ext ultrasound limited study but no evidence of right upper extremity deep vein thrombosis liver ultrasound no focal or textural hepatic abnormality splenomegaly tiny gallbladder polyp transesophageal echo no echocardiographic evidence of endocarditis mri r shoulder w o large right shoulder joint effusion with extensive fluid collection to the deltoid muscle extending inferiorly anterior to the humerus and also superficial to the deltoid muscle given the history of systemic bacteremia the fluid may be of infective etiology although the appearance is nonspecific mrv chest w o limited evaluation of the central vessels without the administration of gadolinium due to the patient s low egfr non visualization of the right subclavian and right axillary veins suggesting possible occlusion recent ultrasound however demonstrates patency of the right axillary vein the right internal jugular right brachiocephalic and superior vena cava are otherwise widely patent without evidence of thrombus left upper lobe lung consolidation concerning for pneumonia small bilateral pleural effusions ct head w o no evidence of infarction or hemorrhage brief hospital course assessement plan yo m with metastatic rcc s p il therapy admitted with mrsa bacteremia cultured from catheter tip who presented with neck upper back pain and leukocytosis mrsa bacteremia cultured from catheter tip s p il therapy evidence on blood cultures from admission until no evidence of vegetation on tte or tee but bilateral septic shoulder joints s p arthroscopy with washout id consulted followed closely with recommendations on vancomycin start gentamycin for synergy levels were closely monitored given worsening lungs on imaging and sputum positive for mrsa linezolid was initated for a weeks duration pt to complete vancomycin regimen and follow up with id service pulm infiltrates ct chest concerning for septic emboli versus primary pulmonary infection pt without subjective shortness of breath or chest pain however o requirements during intubation for respiratory distress mental status changes in et tube with yellow sputum thus also new possibility of aspiration pneumonia pt was started on levofloxacin and metronidazole for total day course respiratory distress with acute mental status changes pt with respiratory alkalosis secondary to tachypnea pt was transferred to the micu and intubated head mri did not show any acute cns process leni s were negative and echo without evidence of rv strain making pe unlikely although with mrsa bacteremia undergoing treatment with antibiotics pt was not septic improved abg s and resolved tachypnea with resolution of mental status changes over the course of on return to the floor pt remained stable mental status changes s p general anesthesia for shoulder surgeries appeared to be possibly toxic in relation to anesthesia also in the setting of with mrsa bacteremia and iv hydromorphone for pain further acute worsening of mental status with delirium and hyperventilation required transfer to the concern for meningitis encephalitis or new brain lesions but ct head without evidence of lesion mental status improved without evidence of fever or leukocytosis was extubated and did not require lumbar puncture body joint pain initially admitted with neck upper back pain however without focal findings on neurologic examination or point tenderness over spine gradually developed generalized body joint pains l then r shoulder pain s e il therapy mri c t w o showed increased signal in the prevertebral soft tissues from c c on stir sequence which could represent possible edema inflammation or abscess but limited as no further imaging with constrast due to limited gfr imaging of bilateral joints revealed effusions arthrocentesis revealed infection thus pt underwent bilateral shoulder washout provided with iv dilaudid for pain control however pt with delirium continued on vicodin which controlled his pain acute renal failure poor gfr with cr on admission il capillary leak syndrome renal consulted and followed pt until resolved remained stable during the rest of hospital stay at anemia most likely r t anemia of chronic disease received blood transfusions during admission remained stable rcc s p il treatment no treatment during admission further therapies per dr dr elevated coagulation studies inr initially concerning for development of dic consumptive process however were relatively stable in the setting of longterm iv antibiotics some element of liver dysfunction recieved a dose of oral vit k remained stable during the rest of hospital stay elevated lfts liver ultrasound showed no focal abnormalities and resolved over time pt reached maximal hospital benefit and was discharged home with services and close followup medications on admission lasix mg p o till baseline weight protonix mg p o daily lorazepam mg q h p r n nausea vomiting benadryl mg to mg q h p r n pruritus compazine mg p o q h p r n nausea vomiting ciprofloxacin mg p o b i d for days lomotil tabs q i d p r n diarrhea paxil mg p o daily relpax mg p o daily p r n migraine headaches sarna lotion topically eucerin lotion topically pravastatin mg qday discharge medications outpatient lab work please draw cbc chem liver function tests and vancomycin trough level prior to dose of vancomycin every week until please fax results to attn dr office picc care please perform picc care per neht protocol paroxetine hcl mg tablet sig one tablet po daily daily disp tablet s refills metoprolol tartrate mg tablet sig three tablet po bid times a day disp tablet s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills lidocaine mg patch adhesive patch medicated sig two adhesive patch medicated topical daily daily as needed for pain apply to each shoulder keep on for hrs and off for hrs disp adhesive patch medicated s refills hydrocodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills lorazepam mg tablet sig one tablet po q h every hours as needed for anxiety disp tablet s refills vancomycin in dextrose gram ml piggyback sig one gram intravenous q h every hours for doses stop date of antibiotic iv disp gram refills protonix mg tablet delayed release e c sig one tablet delayed release e c po twice a day disp tablet delayed release e c s refills pravachol mg tablet sig one tablet po once a day discharge disposition home with service facility vna discharge diagnosis mrsa bacteremia bilateral septic shoulder joints metastatic renal cell ca discharge condition stable discharge instructions you were found to have bacteria in your blood which spread to both shoulder joints you underwent surgery to washout your shoulders and also received antibiotic therapy which you ll need to continue for a total of weeks we have made some changes to your home regimen we have increased your dose of metoprolol to mg please discuss these changes with your pcp you were noted to have some hearing difficulty which you report has been followed in the past by specialist we recommend that you have your hearing re evaluated please call your pcp or come to the emergency room if you develop chestpain fevers or any other worrisome signs followup instructions follow up with dr on at pm office pcp up with dr at pm provider scan phone date time provider md phone date time clinic at medical office bldg basement ma provider md phone date time,"{
""Diagnoses"": [""metastatic renal cell carcinoma"", ""bilateral pulmonary emboli"", ""right kidney mass"", ""tumor thrombus into the IVC"", ""lung nodules"", ""hypertension"", ""hyperlipidemia"", ""depression"", ""anxiety""],
""Medications"": [""il therapy"", ""paxil"", ""protonix"", ""relpax"", ""pravachol"", ""codeine"", ""penicillin""]
}"
15807,admission date discharge date date of birth sex f service cardiothoracic allergies codeine attending chief complaint chest pain major surgical or invasive procedure cardiac cath mitral valve replacement st mechanical maze rf ablation repair coronary sinus laa stapling history of present illness this is a year old woman with a history of rheumatic fever copd and gastric ulcer who presented to with chest pain the pain started at around pm while she was sitting at rest she first noticed bilaterally arm pain along with substernal chest pressure there was no associated sob n v or diaphoresis she has never had chest pain like this before she went to the ed at where she received sl ntg x which helped the pain somewhat but did not relieve it completely ekg at the osh showed aflutter with a rate in the s with mm st elevations in leads ii iii and avf at the osh she also received asa metoprolol mg iv x lipitor mg plavix mg and heparin and integrillin gtt were started she was then transferred to for cath in the cath lab here she was found to have a mid rca lesions as well as mr further intervention was done of note she had a recent admission to s hospital for sob and she was treated for a copd flare on that admission she was also told that she had a leaky valve currently she denies cp sob cough f c abd pain diarrhea she does complain of nausea past medical history asthma copd h o gastric ulcer h o rheumatic fever social history lives with her husband smoked ppd for years quit weeks ago occasional alcohol family history sister had several valve surgeries due to rheumatic fever no fh of cad physical exam vs t bp hr rr on l gen nad at rest lying flat in bed heent perrl eomi mmm op clear neck supple no jvd lungs ctab anteriorly heart regular ii vi soft systolic murmur at apex abd bs soft nt nd extrem no edema dp pulses pertinent results ekg osh aflutter rate s nl axis nl intervals mm st elevation in ii iii avf also possibly interpreted as buried flutter waves in those areas admit labs pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood neuts bands lymphs monos eos baso pm blood plt ct am blood pt ptt inr pt pm blood k am blood alt ast ld ldh alkphos amylase totbili am blood lipase pm blood mg am blood calcium phos mg cardiac enzymes osh labs pm tni pm blood ck mb mb indx ctropnt 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 pt ptt inr pt am blood pt ptt inr pt am blood pt ptt inr pt brief hospital course ms was taken to the operating room on where she underwent a mechanical mitral valve replacement a maze procedure a coronary sinus repair and stapling of she was transferred to the sicu in critical but stable condition on dobutamine and propofol drips she was extubated and weaned from her vasoactive drips the same day she received units prbcs for a hct of she was bolused with amiodarone and started on a amiodarone drip as well as coumadin for her atrial fibrillation she was transferred to the floor on pod she was started on heparin for her mechanical valve while her inr was subtherapeutic she received an additional unit of prbcs for an hct of with a repeat hct of she remained in the hospital while she was anticoagulated for an inr goal of she was discharged to home on pod she had continued problems with nausea as she did prior to surgery and was given compazine on discharge and asked to follow up with her pcp medications on admission lasix mg diltiazem cd mg albuterol prn spiriva advair prilosec discharge medications docusate sodium mg capsule sig one capsule po bid times a day disp capsule 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 pantoprazole 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 tiotropium bromide mcg capsule w inhalation device sig one cap inhalation daily daily disp cap s refills fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day disp disk with device s refills amiodarone mg tablet sig two tablet po once a day mg daily x week then mg daily ongoing disp tablet s refills warfarin mg tablet sig two tablet po daily daily for doses disp tablet s refills lasix mg tablet sig one tablet po once a day disp tablet s refills potassium chloride meq tab sust rel particle crystal sig one tab sust rel particle crystal po once a day disp tab sust rel particle crystal s refills metoprolol tartrate mg tablet sig tablet po bid times a day disp tablet s refills compazine mg tablet sig one tablet po q h prn as needed for nausea disp tablet s refills discharge disposition home with service facility discharge diagnosis mitral regurgitation aflutter asthma copd h o gastirc ulcer h o rheumatic fever nstemi osteoporosis c section abdominal surgery 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 no lifting more than pounds for ten weeks or driving until follow up with surgeon shower no baths no lotions creams or powders to incisions followup instructions dr weeks dr wednesday at pm for inr check and coumadin dosing completed by,"{
""Diagnoses"": [""cardiothoracic"", ""allergies"", ""codeine"", ""mechanical"", ""maze"", ""rf"", ""ablation"", ""repair"", ""coronary"", ""sinus"", ""stapling""],
""Medications"": [""asametoprolol"", ""lipitor"", ""plavix"", ""heparin"", ""integrillin""]
}"
31924,unit no admission date discharge date date of birth sex f service nb history of present illness this infant was admitted from the newborn nursery to the newborn intensive care unit for gross hematochezia she is gram product of a and weeks gestation born to a year old g p now mother by repeat cesarean section on prenatal labs blood type a positive antibody negative rpr nonreactive rubella immune hbsag negative and gbs negative this pregnancy was reportedly uncomplicated with benign fetal ultrasound there is a history of beta thalassemia trait in the mother delivery was uncomplicated with resuscitation only with drying and bulb suction apgars were and was admitted to the newborn nursery where she did well for the first days of life she had been breast feeding and well supplemented with enfamil formula her weight loss had been only of her birth weight and she had been stooling on the night of admission she was noted to have gross blood in her stool and otherwise appeared transitional in appearance but with streaks of bright red blood and parents claim she had been fussy all day she has been afebrile mother reports no bleeding from her nipples physical examination at discharge general active alert slightly jaundiced female in an open crib heent anterior fontanel soft and flat minimal molding no caput red reflex bilaterally patent nares mucous membranes moist palate intact neck no masses cardiovascular normal rate and rhythm no murmurs radial femoral pulses pulmonary clear bilaterally no respiratory distress abdomen soft nondistended no guarding no mass liver edge palpable cm below right costal margin spleen not palpable genitourinary normal female external genitalia no vaginal discharge patent anus no fissures back no cleft tuft or dimple extremities warm and well perfused skin mild jaundice otherwise clear neurologic alert moves all extremities well normal tone suck grasp and moro the infant s parameters at birth birth weight of grams which is th percentile length of cm which is th to th percentile head circumference of cm which is greater than th percentile summary of hospital course by systems respiratory the infant has remained stable on room air while in the newborn intensive care unit cardiovascular the infant has maintained cardiovascular stability while in the nicu with no murmurs normal heart rates and blood pressures fluids electrolytes and nutrition on admission to the newborn intensive care unit the infant was made npo and started on iv fluids due to the frank bloody stool found in the newborn nursery the infant continued to have frank blood streaked stool for few hours which over the next day transitioned to heme positive stool and then heme negative stool from that point forward with an occasional heme trace stool intermixed the infant had serial kubs done all of which just showed dilated bowel with no concerning area for necrotizing enterocolitis or no concerning area for malrotation or volvulus enteral feedings were restarted hours after the infant had been npo with neocate formula and the infant is presently ad lib p o feeding neocate and tolerating that well the most recent weight is grams and the infant is voiding and stooling and as above mentioned having only occasional heme trace positive stools electrolytes have been measured on this baby and they were within normal limits on and gastrointestinal peak bilirubin was on day of life the infant has required no phototherapy there is no history of milk protein or other food allergy or bowel problems in the family a year old brother is well and feeding normally on surgery was consulted due to the bloody stool and the surgeon who consulted was dr from no further surgical evaluations are needed hematology no blood typing has been done on this infant the patient s hematocrit on admission was with a platelet count of on the hematocrit was with a platelet count of the infant has required no blood product transfusions infectious disease cbc and blood culture were screened on admission to the nicu the infant was also started on ampicillin gentamycin and clindamycin as a rule out necrotizing enterocolitis precaution or gi infection cbc was benign with no left shift follow up cbc was done hours later and continue to be benign the antibiotics were discontinued after hours of negative blood culture and clinical status stabilizing there have been no further infectious disease issues neurology the infant has maintained a normal neurologic examination for a term infant sensory audiology hearing screen was performed with automated auditory brain stem responses and the infant passed psychosocial this is an intact couple with a year old son at home mother is chinese and speaks some english father is and speaks mandarin and also is able to translate as needed for the mother condition on discharge good discharge disposition home with the parents name of primary pediatrician dr from telephone no care recommendations ad lib p o feedings of neocate calorie per ounce medications none iron and vitamin d supplementation a iron supplementation is recommended for preterm and low birth weight infants until months corrected age b all infants fed predominantly breast milk should receive vitamin d supplementation at international units which may be provided as a multivitamin preparation daily until months corrected age state newborn screen was sent on and result is pending immunizations received the infant received the hepatitis b vaccine on immunizations recommended synagis rsv prophylaxis should be considered from through for infants who meet any of the following four criteria a born at less than weeks b born between and weeks with two of the following daycare during the rsv season a smoker in the household neuromuscular disease airway abnormalities or school age siblings with chronic lung disease hemodynamically significant congenital heart defect 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 patient 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 recommended with the pediatrician on at a m discharge diagnoses appropriate for age term infant sepsis ruled out bloody stools resolved with neocate formula likely milk protein allergy m d dictated by medquist d t job,"{
""Diagnoses"": [""Gross hematochezia""],
""Medications"": [""Enfamil formula""]
}"
83982,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint abdominal distention jaundice sbp major surgical or invasive procedure paracentesis paracentesis non tunneled hd line placement paracentesis paracentesis left picc placement paracentesis history of present illness this is a yo m with h o hepatitis c cirrhosis with known h o varices who presents with abdominal distention jaundice and found to have spontaneous bacterial peritonitis patient reports that days ago he noted yellowing of his skin lightening of his stool darkening of his urine and intermittent abdominal pain over the last days the patient noted chills had some nausea and poor po intake patient denies recent medication changes recent etoh or any confusion he was taking vicodin day for days for back pain and last took this days ago in the ed t bp hr rr o sat ra labs with wbc cr baseline ast alt tbili prior lactate paracentesis revealed wbc with pending differential rbc albumin he was given ceftriaxone gm iv x and admitted for further care past medical history hepatitis c cirrhosis contracted from blood transfusions after industrial accident and burns in not yet on transplant list due to obesity unable to complete course of ifn ribavirin leukopenia thrombocytopenia no h o hepatic encephalopathy sbp until now known grade i varices obesity h o le venous stasis ulcers ppd positive social history he stopped drinking alcohol in prior to that he would take drinks per day for approximately years he is disability previously worked as a title examiner not married and without children lives with his mother nonsmoker for approximately years no illicits ivda acquired hep c presumed from blood transfusions s p rd degree burns in an industrial accident in family history unknown physical exam 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 ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs ammonia lactate estgfr click for details alt ap tbili alb ast lip n l m e bas ascites protein glucose ldh albumin wbc rbc poly lymph mono agap ca mg p alt ap tbili alb ast ldh dbili tprot lip source line a line mcv wbc hgb plts hct pm blood culture source line a line blood culture routine preliminary yeast presumptively not c albicans definitive identification to follow am blood culture source line a line final report blood culture routine final enterococcus faecium final sensitivities high level gentamicin screen resistant to mcg ml of gentamicin screen predicts no synergy with penicillins or vancomycin consult id for treatment options high level streptomycin screen resistant to mcg ml of streptomycin screen predicts no synergy with penicillins or vancomycin consult id for treatment options daptomycin mcg ml sensitive sensitivities mic expressed in mcg ml enterococcus faecium ampicillin r linezolid s penicillin g r vancomycin r brief hospital course patient was admitted with acute decompensation of hep c cirrhosis while he was on the floor he was treated for sbp and r o for viscous perforation initial treatment was with ceftriaxone for days he received diagnosic taps which showed improvement of sbp he became sicker with increasing meld score and increased encehpalopathy causing vanc zosyn were substituted for ceftriaxone as he got sicker workup for liver transplant was initiated and transplant surgery was called in addition he developed arf likely hepatorenal syndrome renal was consulted and dialysis was initiated he was transferred to micu for further management of decompensated liver disease while awaiting liver transplant in the micu he had a doboff tube placed and tf started he developed leukocytosis and hypotension athough he remained afebrile and his mental status was unchanged he was started on neo and and a diagnostic paracentesis was negative for sbp with this in mind he was continued on vanc zosyn and completed a day course last dose subsequently his white count trended down and neo was able to be weaned down per recomendation by the transplant team he was started on albumin to help with his blood pressure he was also continued on hemodialysis for his hrs as he had been dialysed for more than ten days he was also listed for a renal transplant he was transferred to the floor however he continued to be intermittently hypotensive with hd and was transferred back to the micu for cvvh with the thinking that he would be more stable with continuous dialysis he then began spiking fevers again and vanc zosyn were restarted the family refused paracentesis initially and he was treated empirically for sbp with vanc zosyn cipro blood cultures then grew out yeast and gram positive cocci in pairs chains while on vancomycin and he was also started on micafungin and daptomycin he was maintained on levophed and vasopressin to keep maps and was continued on cvvh for arf hepato renal syndrome a family meeting was held and it was decided he would change goals of care to dnr dni the family wanted to wait for him to receive the last rites and then pressors were turned off and patient expired medications on admission lasix mg daily spironolactone mg daily nadolol mg daily discharge medications none discharge disposition expired discharge diagnosis primary decompensated hepatitis c liver cirrhosis spontaneous bacterial peritonitis hepatorenal syndrome secondary obesity h o le venous stasis ulcers ppd positive discharge condition deceased discharge instructions none followup instructions none,"{
""Diagnoses"": [""spontaneous bacterial peritonitis"", ""hepatitis C cirrhosis"", ""varices""],
""Medications"": [""ceftriaxone"", ""vicodin""]
}"
30107,admission date discharge date date of birth sex m service surgery allergies lorazepam attending chief complaint m w ulcerative colitis s p proctocolectomy and diverting ileostomy seven days prior to admission transferred from an osh with abd pain nausea emesis major surgical or invasive procedure percutaneous drain placement history of present illness following admission to an outside hospital he was extensively fluid resuscitated intubated due to respiratory distress required vasopressor support transfused units of rbc for a hct of started on tpn and started on iv antibiotics invanz and flagyl past medical history ulcerative colitis osteoporosis polyps depression social history non contributory family history non contributory physical exam on admission t hr bp rr on cmv x peep sats on vaso propofol gen intubated sedated ett ogt in place card rrr pulm coarse bilaterally abd soft mild distention hypoactive bowel sounds non tender abdominal wound healing clean base no surrounding erythema ileostomy with large amount of green stool guiaic negative pertinent results ct guided drainage outside ct of the abdomen and pelvis was not available at time of the procedure therefore a contrast enhanced ct of the abdomen and pelvis was obtained prior to the procedure with administration of cc of optiray ct demonstrates moderate amount of fluid in the abdomen and pelvis without definite loculated components or focal abscesses there is no evidence of bowel obstruction this patient is status post colectomy there is a right anterior abdominal wall ileostomy small amount of gas is present in the anterior abdominal wall compatible with recent postoperative state the liver is normal in size contour note is made of multiple hypoenhancing liver lesions some of which are compatible with simple cysts the rest are too small to be accurately characterized the gallbladder is mildly distended and contains hyperdense material likely reflecting vicarious excretion of contrast the spleen is enlarged and measures cm in ap dimension a cm splenule is seen medial to the splenic hilum the pancreas adrenals and kidneys are unremarkable the urinary bladder contains a foley catheter and is unremarkable the portal vein is patent using ct fluoroscopy for guidance an french catheter was placed into the pelvis into the largest fluid pocket utilizing seldinger technique via the left transabdominal approach after satisfactory position of the catheter was confirmed approximately cc of yellow minimally cloudy fluid was aspirated a sample was sent for culture and stain the catheter was secured to the skin by percutaneous catheter fasteners connected to a drainage bag and left to open drainage catheter care discussed with the surgical resident the patient tolerated the procedure well no immediate complications occurred radiology attending dr was present and supervised the entire procedure impression successful ct guided drainage catheter placement fluid sample sent for culture and stain ct fluoroscopy was used to guide insertion of a gauge guiding needle via the transabdominal approach however ct fluoroscopy images obtained during the procedure to confirm location of the guiding needle demonstrated significant rapid shift of fluid within the pelvis with only minimal amount of fluid remaining in the initially targeted left lower quadrant pocket following this the patient was repositioned twice to achieve better accumulation of fluid in the left lower quadrant however despite these attempts very minimal amount of fluid was seen most of which was interdigitating between bowel loops therefore percutaneous drainage of this free flowing fluid was deemed unsafe and therefore was not performed impression ct guided drainage was not performed as fluid demonstrated continuous shifting during the procedure which rendered percutaneous catheter placement unsafe at this time comparison ct of the abdomen and pelvis limited images through the lung bases demonstrate a moderate left pleural effusion and trace amount of right pleural fluid there is bibasilar subsegmental atelectasis the liver is normal in size and contour there is no intrahepatic or extrahepatic biliary dilatation multiple liver cysts are identified and additional smaller subcentimeter hepatic hypodensities that are too small to characterize the gallbladder is unremarkable the portal vein is patent the spleen is mildly enlarged and measures approximately cm in ap dimension the adrenal glands are within normal limits the kidneys enhance symmetrically there is no hydronephrosis the patient is status post total colectomy and ileal pouch to anal anastomosis there is a right anterior abdominal wall ileostomy as before note is made of a gap in the suture line of ileal pouch that measures approximately mm on axial images and cm on the coronal images series image this gap allows direct communication of the lumen of the ileal pouch with the pelvic fluid collection overall there has been no significant interval change in amount of intra abdominal fluid and peritoneal enhancement no definite focal loculated fluid collections are identified there is no evidence of gas within the intra abdominal fluid the small bowel is normal in caliber there is no evidence of bowel obstruction there is no evidence of bowel pneumatosis the urinary bladder is unremarkable there is a foley catheter in place bone windows no suspicious lytic or sclerotic lesions are identified there is a healing fracture of the posterior tenth rib impression no significant interval change in the amount of intraperitoneal fluid no definite loculated fluid collections are identified there is no evidence of gas within the intraperitoneal fluid gap within the right wall of the ileal pouch that directly communicates with the free pelvic fluid moderate left pleural effusion and tiny right pleural effusion pm fluid other site abdomen abdominal fluid final report gram stain final no polymorphonuclear leukocytes seen no microorganisms seen fluid culture final lactobacillus species sparse growth pm stool consistency not applicable source stool final report fecal culture final no enteric gram negative rods found no salmonella or shigella found campylobacter culture final no campylobacter found ova parasites final no ova and parasites seen clostridium difficile toxin assay final feces negative for c difficile toxin by eia brief hospital course the patient was admitted to the icu for continued close monitoring he remained intubated on pressor support continued tpn and broad spectrum antibiotics ampicillin ciprofloxacin flagyl pressors weaned off a ct abdomen was performed which demonstrated moderate amount of fluid in the abdomen and pelvis without definite loculated components or focal abscesses a catheter was placed and drained approximately cc of yellow minimally cloudy fluid ventilator settings weaned and patient extubated without difficulty diet advanced as tolerated from sips to clears to regular diet foley and central venous line discontinued transferred to the floor for continued monitoring cont to encourage diet ambulation po pain medication as needed ostomy wound care nurse of patient started replacing ostomy output with lr for high output antibiotics discontinued abdominal drain discontinued repeat ct scan abdomen demonstrating increase in the amount of intraperitoneal fluid and prominent peritoneal enhancement not not ammenable to drainage started on vanc zosyn ensure supplements added tid for nutrtional support repeat ct scan showing no significant interval change in the amount of intraperitoneal fluid no definite loculated fluid collections are identified there is no evidence of gas within the intraperitoneal fluid id was consulted they recommended adding caspofungin to the above regimen physical therapy began working with the patient to aid in ambulating and strength exercises picc line placed for iv antibiotic and tpn continued antibiotics encouraging po intake ostomy output replacement and tpn flomax started and foley catheter removed at midnight and the patient voided caspofungin discontinued started on fluconazole repeat ct scan demonstrating marked decrease in abdominal fluid collection the patient will be discharged home with vna set up for further home iv antibiotic treatment medications on admission prednisone qd protonix qd percocet prn fosamax zoloft qhs discharge medications fluconazole in saline iso osm mg ml piggyback sig one intravenous once a day for weeks disp refills ertapenem gram recon soln sig one intravenous once a day for weeks disp refills picc line care picc line care per neht protocol oxycodone mg tablet sig tablets po q hours as needed for pain disp tablet s refills tamsulosin mg capsule sust release hr sig one capsule sust release hr po hs at bedtime disp capsule sust release hr s refills prednisone mg tablet sig one tablet po daily daily disp tablet s refills sertraline mg tablet sig tablets po daily daily disp tablet s refills loperamide mg capsule sig one capsule po tid times a day disp capsule s refills discharge disposition home with service facility discharge diagnosis abdominal fluid collection discharge condition good discharge instructions please call your doctor or return to the er for any of the following you experience new chest pain pressure squeezing or tightness 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 see blood or dark black material when you vomit or have a bowel movement your skin or the whites of your eyes become yellow your pain is not improving within hours or becoming progressively worse or inadequately controlled with the prescribed pain medication 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 incision care you may shower pat incision dry avoid swimming and baths until further instruction at your followup appointment leave the steri strips on they will fall off on their own or be removed during your followup please call the doctor if you have increased pain swelling redness or drainage from the incision sites jp drain care please look at the site every day for signs of infection increased redness swelling tenderness odorous or purulent discharge maintain the bulb deflated to provide adequate suction note color consistency and amount of fluid in drain call doctor if amount increases significantly or changes in character be sure to empty the drain frequently and record the output maintain the site clean dry and intact keep drain attached safely to body to prevent pulling and possible dislodgement monitoring ostomy output prevention of dehydration keep well hydrated replace fluid loss from ostomy daily avoid only drinking plain water include gatorade and or other vitamin drinks to replace fluid try to maintain ostomy output between ml to ml per day if ostomy output exceeds liter take mg of imodium repeat mg with each episode of loose stool do not exceed mg in hours followup instructions please call the office of dr to make a follow up appointment in weeks at please call the office of dr to make a follow up appointment at you should have weekly cbc bun creatinine lfts performed and faxed to dr at,"{
""Diagnoses"": [""Ulcerative Colitis"", ""Proctocolectomy and Diverting Ileostomy""],
""Medications"": [""Lorazepam"", ""Invanz"", ""Flagyl""]
}"
86550,admission date discharge date date of birth sex f service obstetrics gynecology allergies sulfur elemental attending chief complaint lower extremity swelling weakness large pelvic mass likely advance endometrial cancer major surgical or invasive procedure exploratory laparotomy total abdominal hysterectomy bilateral salpingo oophorectomy lysis of adhesions radical resection of abdominal pelvic tumor cystoscopy ivf filter placement picc line placement history of present illness ms is a yo g p with a h o t dm and atrial fibrillation transferred from for further mgmt of a large pelvic mass likely advanced endometrial ca initially presented in with a month h o post menopausal bleeding at that time was found to be supra therapeutic on coumadin for her h o atrial fibrillation inr of and was also anemic the pelvic mass was discovered at that time she subsequently was discharged after adjustment of her anti coagulation and transfusion for anemia ct on showed a x x cm pelvic mass an endometrial cervical mass biopsy was performed during this initial hospitalization which was consistent with endometrioid adenocarcinoma ca was and cea was she was then seen after discharge by dr in consultation regarding this pelvic mass slides were reviewed at confirmed endometrial cancer she was re admitted to for weakness and bilateral le edema and was found to be hypotensive and with bilateral dvt as well as acute renal insufficiency v q scan was negative for pe in the intensive care unit she received vasopressin for blood pressure support as well as vancomycin zosyn and flagyl for presumed urosepsis due to her initial hypotension and a leukocytosis of with bands although u a showed only wbc her cr was from a baseline of on potassium was noted to be on admission urology was consulted for possible stent placement but opted to begin with hydration after which her renal function eventually improved her blood pressure also normalized and the vasopressin was discontinued hyperkalemia was treated with kayexelate after which she developed loose stools c diff was negative urine cx grew out yeast only and blood cx were negative so her antibiotics were stopped and fluconazole was initiated on the day of transfer she was also placed on a heparin drip for anti coagulation both for atrial fibrillation and her bilateral dvt rate control was achieved with metoprolol and digoxin she also received units prbc on she was deemed stable for transfer to for further evaluation and mgmt she currently reports some abdominal pain but otherwise has no complaints and is tolerating a regular diet she denies cp sob palpitations although she does endorse some mild dysuria per her report her vaginal bleeding is at baseline and her yeast infection groin area has improved past medical history obhx g p svd x gynhx benign per patient surghx ankle surgery medhx dm type atrial fibrillation anemia hyperlipidemia htn arthritis depression social history she is a nonsmoker she denies alcohol or drug use family history she reports an aunt had breast cancer at the age of physical exam vitals t po bp hr rr o sat on ac x fio peep gen appears older than listed age sedated intubated withdraws to painful stimuli will shake head no when asked if in pain attempts to squeeze hands b l when instructed obese anasarca heent eomi perrl sclera anicteric no nasal discharge ngt to wall suction with gastric contents mmm op clear neck no jvd carotid pulses brisk no bruits no cervical lymphadenopathy trachea midline cor tachycardic irreg irreg no m g r normal s s radial pulses pulm diffuse rhonchorous breath sounds b l but otherwise cta b l abd soft tender to palpation around large midline abdominal incision dressing c d i decreased bs throughout no hsm no palpable masses ext le edema no palpable cords le in waffle boots neuro intubated sedated to painful stimuli will shake head no when asked if in pain attempts to squeeze hands b l when instructed unable to perform complete neuro exam due to sedation skin no jaundice cyanosis or gross dermatitis no ecchymoses stage ii sacral decub ulcer with dressing c d i l scv dressing c d i without surrounding erythema l a line intact pertinent results imaging cxr there are no old films available for comparison the heart is mildly enlarged there is no focal infiltrate or effusion there is left subclavian line with tip in the svc there is no pneumothorax cxr et tube terminates with tip mm above the carina left side central line with tip terminating in the mid svc low lung volumes but no focal areas of consolidation or pulmonary edema no evidence of right sided pleural effusion left costophrenic angle was cut off from view cardiomediastinal silhouette is unremarkable cxr a single portable radiograph of the chest demonstrates similar cardiomediastinal contours to that seen on and support lines are in similar position to that seen on no consolidation is evident no effusion detected no pneumothorax trachea is midline support lines are in similar position the proximal side port of the nasogastric tube is at the level of the ge junction the nasogastric tube should be advanced cxr findings as compared to the previous examination the lung volumes have minimally decreased the left lung bases however is better ventilated than on the previous radiograph there is no focal parenchymal opacity suggestive of pneumonia no pleural effusion and no pneumothorax the size of the cardiac silhouette has minimally increased the monitoring and support devices are unchanged cxr a single portable radiograph of the chest demonstrates no change in the support lines when compared with heart and lungs appear similar no pneumothorax no effusion detected trachea is midline overall there is little interval change cxr a single portable radiograph of the chest demonstrates no change in the cardiomediastinal contours when compared with the nasogastric tube side port is at the level of the ge junction the nasogastric tube should be advanced the remaining support lines are unchanged appearance of the heart and lungs is unchanged cxr interval extubation with indwelling devices otherwise unchanged in position cardiac and mediastinal contours unchanged slight worsening of atelectasis at the left lung base but no substantial change in linear right perihilar atelectasis questionable small layering left pleural effusion versus technical artifact related to lack of centering of the patient labs labs on admission cbc wbc hgb hct plt neuts bands lymphs monos eos baso coags pt ptt inr chem na k cl hco bun cr glu ca phos mg labs on discharge cbc wbc hgb hct plts chem na k cl hco bun cr glu ca phos mag brief hospital course ms is a year old female with an extensive medical history including atrial fibrillation type ii diabetes and obestity who initially presented with a newly diagnosed pelvic mass bilateral hydronephrosis acute renal failure and bilateral dvts who is now s p exploratory laparotomy total abdominal hysterectomy bilateral salpingo oophorectomy lysis of adhesions radical resection of abdominal pelvic tumor and cystoscopy see operative note for details this patient was initially transferred to from at she was intubated in the icu for several days secondary to urosepsis she was transferred here for further management after she was stablized and extubated at on on hospital day she underwent surgery as above she went directly to the icu post operatively where she was managed until pod at which time she was transferred to the surgical floor her hospital course was complicated by the following issues cardiovascular post op hypotension in the immediate post operative period the patient s blood pressure was maintained on a levophed and phenylephrine drip in the icu her hypotension was likely secondary to large fluid shifts and hypovolemia however there was concern for cardiogenic shock on pod cardiac enxymes were cycled x and noted to be negative the patient s ekg was noted to be unchanged from her pre operative ekg her hypotension improved with aggressive fluid resuscitation and blood products her levophed drip was discontinued on pod and her phenylephrine drip was discontinued on pod she did not require pressors for the remainder of her hospitalization and was subsequently transferred out of the icu on pod atrial fibrillation the patient has a history of atrial fibrillation while in the icu she briefly required a esmolol drip for rate control while on pressors once transferred out of the icu the patient remained rate controlled on lopressor and digoxin she was monitored on telemetry throughout her hospitalization on pod the patient had a heart rate in the s however she remained asymptomatic it was noted that her lopressor dose had been held secondary to mildly low blood pressure the hold parameters on her lopressor were changed and the patient was given her usual dose of po lopressor with good rate control she remained adequately rate controlled for the remainder of her hospitalization history of hypertension her antihyperentive medications including lisinopril mg qdaily and hctz mg qdaily were held throughout her hospitalization however she did receive lopressor and digoxin her blood pressure remained within a normal range respiratory upon transfer to the patient was stable on room air post operatively she remained intubated in the icu secondary to massive fluid volume resusicitation and blood products she received iv lasix daily x days she was extubated on pod without difficulty she remained on oxygen via nasal cannula until pod she has remained stable on room air since that time heme on initial presentation to the patient was noted to have bilateral lower extermity swelling lower extremity dopplers revealed bilateral deep venous thrombosis v q scan at was negative for a pulmonary embolism the patient was placed on a heparin drip on the day prior to surgery that patient had an ivc filter placed without difficulty her heparin drip was restarted two hours after filter placement and then held hours prior to her scheduled surgery on her heparin drip was restarted pod with no evidence of bleeding she remained on heparin until pod at which time she was started on lovenox mg the patient received a total of units of prbcs over the course of her hospitalization she received units prbcs intra operatively unit prbcs on pod in the icu and unit prbcs on pod in the icu for blood loss anemia she never had any signs of dic and her platelet count remained stable on pod she received unit prbc to maintain a hemoglobin greater than the patient s hematocrit remained stable her hematocrit is on her day of discharge infectious disease prior to this hospital admission the patient was in the icu at with likely urosepsis at she was treated with vancomycin zosyn and flagyl her urine culture revealed yeast therefore iv fluconazole was added and she was treated for days on presentation to the patient was afebrile and her wbc count was her broad spectrum antibiotics were discontinued however her fluconazole was continued for days urine culture at revealed no growth post operatively the patient was noted to have a leukocytosis thought to be likely a stress response her wbc peaked at she was treated with broad spectrum antibiotics vancomycin kefzol and flagyl for hours post op she remained afebrile throughout her hospitalization and her leukocytosis normalized her blood culture revealed no growth renal upon presentation that patient was noted to be in acute renal failure with a creatinine of her ct scan revealed bilateral hydonephrosis secondary to tumor compression also likely the etiology of her renal failure post operatively her creatinine normalized and remained stable at on pod the patient s urine output dropped to cc per hour her creatinine and hematocrit were obtained and were noted to be stable she was bolused cc normal saline and her urine output responded appropriately her urine output remained adequate for the remainder of her hospitalization the patient s foley was left in place because she is not able to get out of bed unassisted and the wound care nurse felt that regular use of a bed pan may comprimise her sacral wound she was started on prophylactic macrobid mg qdaily on pod to be given as long as the patient s foley is in place gi the patient remained npo until pod when her ng tube was removed and her diet was advanced to clear liquids she was able to tolerate clears without difficulty and on pod she was advanced to a regular diet the patient was passing flatus and had multiple bowel movements prior to her discharge she was able to tolerate a regular diet on her day of discharge endocrine the patient is a type ii diabetic she remained on an insulin sliding scale until pod at which time her glimepiride mg was restarted per the patient she is also on a novolin sliding scale at home but she could not remember her usual regimen since pod we have maintained her blood sugars on glimepiride and a regular sliding scale of note the patient did receive stress dose steriods on pod gyn the patient complained of some vaginal itching on pod she was treated with po diflucan once wound care the patient is noted to have a stage ii sacral decubitus ulcer as well as bilateral ankle pressure ulcers the wound care nurse has been treating these wounds she has bilateral waffle boots in place the patient is also noted to have a small ulcer on her right lateral abdomen with some serous drainage this site opened spontaneously and has never appeared infected physical therapy the patient has been followed by physical therapy throughout her hospitalization access the patient initially had a left subclavian line which was removed on pod at which time a picc line was placed by interventational radiology her picc line was removed on her day of discharge code status the patient is full code this has been discussed with the family the patient was discharged to a rehabilitation facility on hospital day post operative day in stable condition she will follow up with dr in three weeks medications on admission home medications digoxin mg daily coumadin listed on ob gyn note but not listed on osh tranfer home med list lopressor mg amitriptyline mg qhs lovastatin mg daily lisinopril mg daily paxil mg daily hydrochlorothiazide mg daily glimepiride mg daily omeprazole mg daily vicodin prn nystatin powder prn lispro insulin sliding scale discharge medications amitriptyline mg tablet sig one tablet po hs at bedtime atorvastatin mg tablet sig one tablet po daily daily paroxetine hcl mg tablet sig one tablet po daily daily digoxin 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 one tablet po tid times a day please hold for blood pressure less than or hr less than tablet s oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills docusate sodium mg ml liquid sig one po bid times a day as needed for constipation disp refills miconazole nitrate powder sig one appl topical tid times a day as needed glimepiride mg tablet sig one tablet po qdaily tablet s enoxaparin mg ml syringe sig one subcutaneous q h every hours disp refills nitrofurantoin macrocryst mg capsule sig one capsule po qdaily capsule s insulin regular human unit ml solution sig one injection asdir as directed see insulin sliding scale provided discharge disposition extended care facility at silverlake in discharge diagnosis endometrial cancer ovarian cancer discharge condition stable discharge instructions please call your doctor or return to the hospital if you have increased pain redness or unusual discharge from your incision inability to eat or drink because of nausea and or vomiting fevers chills chest pain or shortness of breath any other questions or concerns other instructions you should not drive for weeks and while taking narcotic pain medications no intercourse tampons or douching for weeks no heavy lifting or vigorous activity for weeks you can shower and clean your wound but do not use perfumed soaps or lotions be sure to pat completely dry after washing you may resume your regular diet and home medications followup instructions provider md phone date time md,"{
""Diagnoses"": [""advanced endometrial cancer"", ""likely advanced endometrial cancer"", ""endometrial cervical mass"", ""endometrioid adenocarcinoma"", ""ca"", ""cea""],
""Medications"": [""coumadin"", ""anticoagulation"", ""transfusion"", ""anemia""]
}"
10401,admission date discharge date date of birth sex m service cardiac surgery chief complaint shortness of breath history of present illness the patient is a year old male with a history of insulin dependent diabetes who was admitted to outside hospital on following a cardiac catheterization showing a and three vessel coronary artery disease the patient has been hemodynamically stable and chest pain free since the catheterization chest x ray on admission showed a left lower lobe mass versus atelectasis ct scan on showed superficial opacity at the left lung base measuring cm at maximum diameter the patient was seen by pulmonary and infectious disease who felt that the patient s coronary artery disease should be addressed primarily and follow up ct scan in one month the patient is now transferred to for evaluation of coronary artery bypass graft past medical history noninsulin dependent diabetes mellitus status post colectomy for colon cancer in the year irritable bowel syndrome hiatal hernia status post right inguinal hernia repair status post right hydrocele removal social history lives with wife retired electrician the patient smokes one to two cigars per week for the past four or five years quit years ago the patient denies use of alcohol allergies no known drug allergies medications asacol mg po t i d lopressor mg po b i d enteric coated aspirin mg po q day glucotrol mg po q d regular insulin sliding scale metformin at home review of systems the patient denies chest pain fevers or chills nausea vomiting abdominal pain melena denies hematochezia denies dysuria physical examination temperature blood pressure heart rate respiratory rate satting on room air the patient is alert and oriented and in no acute distress extraocular movements intact pupils are equal round and reactive to light the patient had no lesions in the mouth the patient s head was normocephalic atraumatic examination of the neck revealed no lymphadenopathy no jvd no bruits chest was clear to auscultation bilaterally heart revealed a regular rate and rhythm without any murmurs rubs or gallops examination of the abdomen revealed soft nontender nondistended abdomen no hepatosplenomegaly no splenomegaly the patient had a surgical scar in the right lower quadrant the patient s extremities had no clubbing cyanosis or edema the patient had pulses bilaterally femoral popliteal dorsalis pedis and posterior tibial cranial nerves ii through were grossly intact extremities sensory and motor were intact laboratory white blood cell count on admission was hematocrit platelets inr sodium potassium chloride bicarb bun creatinine glucose hospital course the patient was admitted to the cardiac surgery service and underwent coronary artery bypass graft times three the patient had a left internal mammary coronary artery to the left anterior descending coronary artery saphenous vein graft to obtuse marginal saphenous vein graft to posterior descending coronary artery on postoperative day number one the patient was extubated and remained afebrile with stable vital signs on postoperative vancomycin and on insulin drip to control the glucose otherwise the patient was doing well on postoperative day number two the patient continued to do well the patient was completely weaned off all drips the patient was put back on home regimen for glucose control he remained afebrile with stable vital signs the patient continued to do well and was transferred to the floor overnight the patient had a bout of delirium the patient had a sitter and was put on low dose haldol on postoperative day number three the patient continued to do well the patient was on lopressor mg b i d and remained afebrile with stable vital signs the patient had good urine output the patient s wire was removed and the patient was continued with a sitter for confusion on postoperative day number four the patient continued to have bouts of confusion although improved urinalysis was negative the patient remained afebrile with stable vital signs physical therapy worked with the patient a standing dose of haldol was stopped and put on captopril and obtained a pa and lateral chest x ray which revealed small pleural effusion no pneumo on postoperative day number five the patient continued to do well the patient had eight beats of ventricular tachycardia overnight which was asymptomatic ep was consulted who recommended to replete the electrolytes and to do regular follow up with patient s cardiolgoist since the patient has no history of myocardial infarction or signs of ischemia on electrocardiogram the patient continued to do well on postoperative day number six the patient had no complaints remained afebrile with a blood pressure of and a pulse of the patient s metoprolol was increased to b i d the patient was taking good po and making good urine the patient was discharged to home condition on discharge good disposition discharged to home final diagnoses status post coronary artery bypass graft coronary artery disease status post colectomy for colon cancer in noninsulin dependent diabetes mellitus irritable bowel syndrome hiatal hernia status post right inguinal hernia repair status post right hydrocele removal lung nodule on x ray fop plans please follow up with dr in four weeks please follow up with primary care physician and dr in one to two weeks discharge medications aspirin mg po q d colace mg po b i d asacol mg po t i d glipizide mg po q day metformin mg po q a m mg po q p m captopril mg po t i d percocet one to two tabs po q to hours lopressor mg po b i d sliding scale insulin m d dictated by medquist d t job,"{
""Diagnoses"": [""cardiac surgery"", ""coronary artery disease"", ""insulin dependent diabetes"", ""noninsulin dependent diabetes mellitus"", ""colon cancer"", ""irritable bowel syndrome"", ""hiatal hernia"", ""right inguinal hernia"", ""right hydrocele""],
""Medications"": [""insulin"", ""metformin"", ""aspirin"", ""atenolol"", ""lasix"", ""prednisone"", ""ciprofloxacin""]
}"
12976,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint transfer from osh for liver and renal failure major surgical or invasive procedure liver biopsy dialysis catheter placement history of present illness this is a yo male with hiv diagnosed in but was only recently started on haart therapy about months ago in he also has hepc and disseminated mac with liver biopsy in demonstrating afb positive granulomas and was subsequently started on ethambutol azithro rifabutin he has had several recent admissions this past month at osh for pna neutropenia and left renal calculus with hematuria his current course started on when he presented to hospital with fever left flank pain and ruq pain the workup for his pain was difficult because he has chronic abdominal pain requiring narcotics workup includes multiple problems increased lfts pericholecystic fluid coagulopathy hyperkalemia and arf the differential for his liver failure at this time included hiv cholangiopathy vs drug induced hepatitis vs reactivation mac infection from starting haart therapy the differential for his renal failure included hiv nephropathy vs membranoproliferative glomerulonephritis hepc vs chronic renal calculi vs reconstition syndrom from haart therapy because of the concern for reconstitional syndrome his haart as well as mac therapy were stopped he was put on ceftriaxone for unclear reasons his potassium was as high as and there were reports of a pericardial rub he was urgently dialyzed on and with resolution of hyperkalemia given his liver failure renal failure and complex infectious history including hiv hepc and disseminated mac he was transferred to for tertiary care currently his chief complaint is left sided abdominal pain and ruq pain he denies fevers currently but reported having fevers at osh he denies chest pain or shortness of breath he has been passing gas and moving his bowels he is making urine and has no dysuria past medical history hiv aids diagnosed in off haart on religious grounds cd count and vl on hcv with cirrhosis genotype viral load million liver biopsy afb positive granulomas started on ethambutol azithro rifabutin for mac rifabutin later d c d for unclear reasons longstanding right sided abdominal pain of unclear etiology distended with pericholecystic fluid however hida normal surgeons do not feel this is cholecystitis prior ct demonstrating hypoechoic splenic lesions lymphoma vs infection admitted found to be in new renal failure secondary to glomerulonephritis hiv hcv associated at that time started on anti retrovirals kaletra and trizivir bilateral renal stones polysubstance abuse penile warts and perianal warts social history lives in home called new challenge home for rehab for polysubstance abusers with other residents he contracted hiv from a woman in moved from years ago but frequently returns for visits has extensive history of illicit drug use for years in the past that included cocaine heroine lsd marijuanna tobacco and alcohol he is married with children in family history father died of colon cancer mother died with diabetes and depression physical exam vitals ra gen a ox nad coughing no respiratory distress well nourished male heent perrl eomi sclera icteric mmm op clear neck no lad cv tachycardic regular pericardial rub heard best at lrsb no murmurs or gallops pmi at left nipple pulm scattered rhonchi with bilateral faint crackles no wheezes good air movement abd soft tender at epigatrum nondistended bs no costovertebral tenderness warts on penis ext pedal edema up to lower legs bilaterally neuro grossly nonfocal mobilizes all extremities pertinent results osh bun cr ast alt alk phos tb ua protein blood rbc per hpf osh bun cr tb db osh cr inr osh chem tprot alb cal tbili ap ast alt cbc mcv inr down from yesterday studies osh ct abd mm stone at ureterovesicular junction osh mri hepatosplenomegaly osh ct abd c contrast liver pancreas normal contours spleen slightly enlarged gallballder nl in diameter however an attenuated ring surrounds the gallbladder no intraluminal stones kidneys normal in size shape and positive no hydronephrosis no stones adrenal glands normal no retroperitoneal adenopathy no upper abd areas of ascites impression splenomegaly pericholecystic fluid suggestive of acalculus cholecystitis cxr no acute cardiopulmonary process ruq usn minimal gallbladder wall edema without significant distension or evidence of cholelithiasis acalculous cholecystitis cannot be excluded if there is concern for cholecystitis further evaluation with a hida scan could also be considered renal usn no hydronephrosis medical renal disease tte the left atrium is normal in size the estimated right atrial pressure is mmhg left ventricular wall thicknesses and cavity size are normal regional left ventricular wall motion is normal left ventricular systolic function is hyperdynamic ef transmitral and tissue doppler imaging suggests normal diastolic function and a normal left ventricular filling pressure pcwp mmhg right ventricular chamber size and free wall motion are normal the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve leaflets are structurally normal there is no mitral valve prolapse no mitral regurgitation is seen there is normal pulmonary artery systolic pressure there is no pericardial effusion impression no pericardial effusion preserved global and regional biventricular systolic function ct chest mild dependent peribronchial ground glass opacities are suggestive of aspiration either subclinical or due to early aspiration pneumonitis minimal right upper lobe bronchiolitis may be due to aspiration or focal small airways infection localized distribution is not typical of mac which is usually more diffuse follow up ct after treatment for bacterial infection may be considered if warranted clinically trace ascites probable splenomegaly and mm nonobstructing right renal stone ct sinus mild moderate degree of mucosal thickening is seen within the maxillary sinuses bilaterally sphenoid sinuses and ethmoid sinuses with aerosolized secretions in the left maxillary sinus minimal mucosal thickening noted within the frontal sinus right ostiomeatal complex appears patent left ostiomeatal complex is opacified by mucosal thickening nasal septum is midline right cribriform plate is approximately mm lower than the left no evidence of osseous destruction seen likely mm bone island is noted in the left orbital roof ct abd pelvis enlarged liver with perihepatic ascites nonspecific fat stranding along the anterior right retroperitoneum and right pericolic gutter extending about the cecum is nonspecific may be related to hepatic dysfunction distended gallbladder without disproportionate surrounding fat stranding if there is clinical concern for acute cholecystitis hepatobiliary nuclear medicine scan could be performed bilateral nonobstructing renal calculi appendix not definitely visualized fat stranding and fluid along the right pericolic gutter extends from the liver edge into the pelvis obscures its visualization if there is clinical concern for acute appendicitis mri could be performed in this patient who cannot have intravenous contrast splenomegaly no lymphadenopathy hida limited study no evidence of acute cholecystitis normal biliary to bowel transit time poor hepatic tracer uptake compatible with the stated history of mac hepatitis ercp four fluoroscopic spot images were obtained during ercp procedure by gastroenterologist without a radiologist present cholangiogram demonstrates opacification of a mildly dilated biliary tree a filling defect is seen within the distal cbd consistent with stone final image demonstrates placement of a biliary stent transjugular liver biopsy marked lobular regeneration with scattered apoptotic hepatocytes and moderate cholestasis localized areas of bile duct proliferation surrounded by fibrosis highly suggestive of cirrhosis trichrome stain shows prominent sinusoidal fibrosis see note no granulomas are seen no stainable iron seen bone marrow biopsy flow cytometry report flow cytometry immunophenotyping the following tests antibodies were performed hla dr fmc kappa lambda and cd antigens results three color gating is performed light scatter vs cd to optimize lymphocyte yield b cells are scant in number of lymphoid gated events and do not express aberrant antigens clonality could not be reliably assessed due to scant numbers and cytophilic staining t cells comprise of lymphoid gated events and express mature lineage antigens interpretation non specific lymphoid profile b cells are scant in number and clonality could not be reliably assessed t lymphocytes do not show any antigenic aberrancy correlation with clinical findings and morphology see separate report is recommended flow cytometry immunophenotyping may not detect all lymphomas due to topography sampling or artifacts of sample preparation usn guided paracentesis successful liter diagnostic paracentesis via the right lower quadrant under ultrasound guidance negative for sbp rus usn gallbladder wall thickening is secondary to contracted state and third spacing vein mapping upper extremities thrombophlebitis in right cephalic vein patent bilateral basilic with diameters as noted there is no left cephalic vein patent bilateral subclavian veins and brachial arteries ct abd pelvis small nonobstructing renal calculi bilaterally no dilated loops of small bowel seen evaluation of the colon is limited as it is not filled with oral contrast and surrounding pericolonic fat is obscured by ascites interval development of large amount of ascites hepatosplenomegaly unchanged brief hospital course comfort measures only this is a yo man with hiv aids and hep c cirrhosis not a candidate for interferon or haart with progressive liver and renal failure in accordance with the patient s and his family s wishes the patient is comfort care only below is a detailed history of his recent hospitalization id the patient has hep c and hiv not previously on medication until late per conversation with dr id at osh upon admission to osh he was noted to have cd vl undetectable cd vl in hep c viral load per osh records his haart was held upon admission to osh concern for reconstitution syndrome in addition to concern that haart regimen could be causing liver failure pt was briefly treated with solumedrol for reconstitution at osh but this was discontinued upon his admission his pcp prophylaxis and mac treatment were also held because of concern that these could be causing his elevated lfts upon presentation the patient was febrile daily with temps however serial blood urine sputum and stool cultures were generally unremarkable with the exception of sputum culture which showed gpc gpr however sample quality was poor and culture was negative the patient was ruled out for tb with sputum cx x pcp smears were negative cmv and ebv viral load were negative hepc viral load was million the patient was treated with a day course of zosyn upon presentation because of coarse breath sounds and fever however ct chest revealed only ground glass opacification at bases but no clear infiltrate id consult was obtained given his elevated bilirubin and alkaline phosphatase concern was for a biliary source of infection however ruq usn showed minimal gallbladder wall edema without significant distension or evidence of cholelithiasis the patient underwent hida which showed no evidence of acute cholecystitis given a high concern for biliary infection ruq pain fever elevated tbili the patient undwerwent ercp on at which time mildly dilated biliary tree was visualized with filling defect in distal cbd consistent with a stone thus stent was placed the patient s lfts continue to rise after stent placement and give his immunocomprimized state fungal etiologies were considered liver biopsy was performed on via transjugular approach koh prep revealed budding yeast and pathology specimens demonstrated yeast however culture data was unremarkable given elevated lfts and clinical suscpicion for fungal infection the patient was started on ambisome on bone marrow biopsy was obtained on which was unremarkable serum crypto urine histo and fungal blood cultures were negative galactomannan and beta glucan were negative lfts began improving on he was without elevated wbc throughout admission indeed was neutropenic as below he continued to have low grade temperatures until he was restarted on azithromycin for pcp prophylaxis on dosed qweekly however his tbili began rising again and this was discontinued on the patient was not felt to be a candidate for hep c treatment given his comborbidities on repeat hiv viral load was decision was made to continue to defer restarting haart while awaiting hiv genotype information pt s prior hiv regimen of trisovir kaletra was felt to be atypical in close consultation with the infectious disease team the patient was ultimately felt to not be a candidate for haart therapy out of concern for further liver toxicity and inability to tolerate the therapy after the patient s decision to be comfort only all antibiotics were discontinued gi liver the patient presented to an osh with fever and ruq pain the patient had known hepatitis c viral load on this admission was the patient had been started on mac treatment liver biopsy in which was afb positive on smear however no cultures had been sent mac treatment ethambutol rifabutin azithromycin were held upon admission at osh upon admission to osh pt had ast alt ap tb his lfts continued to rise and peaked after transfer to on alt ast but then trended down alt s ast s by tbil peaked on s p ercp with stent placement on upon presentation to his inr was presentation was primarily a cholestatic picture ruq usn hida scan and ercp were as above there was no evidence of hiv cholangiopathy hepatitis serologies were hepbsag hepbsab negative bepbcab positive anca negative weakly positive c c hepc viral load million hsv igg and igm positive given elevated lfts after ercp with stent placement pt underwent liver biopsy on which revealed fibrosing cholestatic hepatitis with cirrhosis lfts began trending down shortly after biopsy however thus pt s hepatic failure was felt more likely to be the result of medication most likely azithromycin or hiv medications superimposed upon hepatitis c infection and underlying fibrosing cholestatic hepatitis on pt s hct droped from requiring transferred to the icu renal the patient presented without a history of renal disease however creatinine upon presentation to osh up to upon transfer to his osh course was complicated by hyperkalemia for which he underwent hemodialysis on and upon presentation to pt was not felt to require urgent dialysis renal consult was obtained his temporary dialysis catheter was discontinued on the tip was sent for culture which was unremarkable the patient did apparently have complicated history of bilateral renal calculi and he was admitted at osh recently for renal calculi and hematuria abd ct at osh showed no hydronephrosis ua and ucx were unremarkable and ct abd pelvis this admission was negative for calculi or hydronephrosis the patient developed progressive renal failure etiology was ultimately felt most likely to be hepc induced mgpn biopsy was deferred as he was relatively high risk for the procedure and the relevance to management options in this patient as he was already known to not be a candidate for interferon therapy were limited the patient s renal failure continued to progress and in accordance with the patient s wishes he had a temporary dialysis catheter placed and cycles of hemodialysis in able to prolong his life to allow his family to see him after his family s arrival and in accordance with the patient s and his family s wishes his dialysis catheter was removed and the patient had no further dialysis heme onc the patient presented with anemia and thrombocyopenia the etiology was initially felt most likely hiv hepc renal disease bone marrow biopsy was performed which revealed hypercellular marrow with mild erythroid and megakaryocytic hyperplasia and left shifted myelopoiesis medications on admission medications at home mepron zithromax ethambutol diflucan kaletra triziver medication on transfer reglan prn flonase protonix zofran prn ambien prn ms mg oxycodone ir mg q prn morphine mg iv q h prn solumedrol mg iv bid tylenol prn procrit quweek starting ceftriaxone gram q last dose discharge medications acetaminophen mg tablet sig tablets po q h every to hours 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 po twice a day as needed for constipation simethicone mg tablet chewable sig one tablet chewable po qid times a day as needed for gas pain lorazepam mg tablet sig tablet po q h every to hours as needed for nausea or anxiety oxycodone mg tablet sustained release hr sig one tablet sustained release hr po q h every hours oxycodone mg tablet sig tablets po q h every to hours as needed for pain senna mg tablet sig one tablet po bid times a day as needed discharge disposition extended care facility radius discharge diagnosis primary aids hepatitis c disemminated mac acute renal failure acute liver failure secondary longstanding right sided abdominal pain of unclear etiology bilateral renal stones polysubstance abuse penile warts and perianal warts discharge condition hemodynamically stable afebrile discharge instructions you were admitted because of liver and kidney failure secondary to hiv hepatitis c and complications of these diseases the goals of care are your comfort you will be further cared for at a hospice facility in followup instructions a hospice nurse will be available to answer any questions for you and to obtain and provide medical care,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""m"", ""service"", ""medicine"", ""allergies"", ""patient recorded as having no known allergies to drugs"", ""attending chief complaint"", ""transfer from osh for liver and renal failure"", ""major surgical or invasive procedure"", ""liver biopsy"", ""dialysis catheter placement"", ""history of present illness""],
""Medications"": [""HAART therapy"", ""ethambutol"", ""azithro"", ""rifabutin""]
}"
31855,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint doe chest pain major surgical or invasive procedure s p avr mm porcine history of present illness this year old white male has a h o aortic stenosis and has been followed by serial echoes his most recent echo revealed severe as w cm he is now admitted for elective avr past medical history aortic stenosis chol diverticulosis benign colon polyps obesity social history pt lives alone in he is retired cigs none etoh none family history unremarkable physical exam gen wdwn in nad avss heent nc at perla eomi oropharnx benign neck supple from no lymphadenopathy or thyromegaly carotids bilat with radiating murmurs lungs clear to a p cv rrr without r g sem abd bs soft nontender without masses or hepatosplenomegaly ext without c c trace pedal edema bilat pulses bilat fem and radial dp and pt bilat neuro nonfocal 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 radiology preliminary report chest pa lat pm chest pa lat reason s p ct d c medical condition year old man with s p avr reason for this examination s p ct d c pa and lateral views of the chest three radiographs reason for exam s p avr post chest tube removal comparison is made with prior study performed a day earlier all the vascular lines and tubes have been removed patient is post median sternotomy and avr there are low lung volumes with left lower lobe atelectasis widened postoperative mediastinum is unchanged small bilateral pleural effusions are unchanged anterior pneumomediastinum is noted in the lateral view the left cardiac border is obscured by the pleural and lung abnormalities dr dr cardiology report echo study date of patient test information indication abnormal ecg aortic valve disease chest pain dizziness hypertension shortness of breath status inpatient date time at test tee complete doppler full doppler and color doppler contrast none tape number aw test location anesthesia west or cardiac technical quality adequate referring doctor dr measurements left ventricle septal wall thickness cm nl cm left ventricle inferolateral thickness cm nl cm left ventricle ejection fraction to nl aorta ascending cm nl cm aorta arch cm nl cm aortic valve peak velocity m sec nl m sec aortic valve peak gradient mm hg aortic valve valve area cm nl cm aortic valve pressure half time ms interpretation findings left atrium normal la size no mass thrombus in the laa good cm s laa ejection velocity right atrium interatrial septum normal ra size a catheter or pacing wire is seen in the ra and extending into the rv no asd by d or color doppler left ventricle mild symmetric lvh with normal cavity size mild symmetric lvh normal lv cavity size overall normal lvef transmitral doppler and tvi c w grade i mild lv diastolic dysfunction lv wall motion basal anterior normal mid anterior normal basal anteroseptal normal mid anteroseptal normal basal inferoseptal normal mid inferoseptal normal basal inferior normal mid inferior normal basal inferolateral normal mid inferolateral normal basal anterolateral normal mid anterolateral normal anterior apex normal septal apex normal inferior apex normal lateral apex normal apex normal right ventricle normal rv chamber size and free wall motion aorta normal aortic diameter at the sinus level mildly dilated ascending aorta mildly dilated aortic arch simple atheroma in aortic arch mildly dilated descending aorta simple atheroma in descending aorta aortic valve bicuspid aortic valve severely thickened deformed aortic valve leaflets no masses or vegetations on aortic valve moderate severe as area cm mild ar mitral valve mildly thickened mitral valve leaflets mild mitral annular calcification trivial mr tricuspid valve normal tricuspid valve leaflets with trivial tr physiologic tr pulmonic valve pulmonary artery normal pulmonic valve leaflets with physiologic pr pericardium no 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 conclusions pre cpb the left atrium is normal in size no mass thrombus is seen in 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 with normal cavity size there is mild symmetric left ventricular hypertrophy the left ventricular cavity size is normal overall left ventricular systolic function is normal lvef transmitral doppler and tissue velocity imaging are consistent with grade i mild lv diastolic dysfunction right ventricular chamber size and free wall motion are normal the ascending aorta is mildly dilated the aortic arch is mildly dilated there are simple atheroma in the aortic arch the descending thoracic aorta is mildly dilated there are simple atheroma in the descending thoracic aorta the aortic valve is bicuspid the aortic valve leaflets are severely thickened deformed no masses or vegetations are seen on the aortic valve there is moderate to severe aortic valve stenosis area cm mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened trivial mitral regurgitation is seen there is no pericardial effusion post cpb on infusion of phenylephrine well seated bioprosthetic valve in the aortic position no ai gradient of mmhg at cardiac output of l min mr is trace there is preserved lv systolic function the aortic contour is normal post decannulation electronically signed by md on brief hospital course the pt was admitted on and underwent avr mm mosaic porcine valve he tolerated the procedure well and had a cross clamp time of mins total bypass time of mins he was transferred to the csru in stable condition on propofol and neo he was extubated on the post op night and was transferred to the floor on pod and went into af that night he converted to sr on amiodorone and continued to progress his chest tubes were d c d on pod and his wires were d c d on pod he was discharged to rehab in stable comdition on pod medications on admission nifedipine xl lisinopril lipitor asa discharge medications potassium chloride meq capsule sustained release sig two capsule sustained release po q h every hours for days docusate sodium mg capsule sig one capsule po bid times 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 metoprolol tartrate mg tablet sig one tablet po tid times a day amiodarone mg tablet sig two tablet po bid times a day for days then decrease dose to mg po daily for days then decrease dose to mg po daily ibuprofen mg tablet sig one tablet po q h every hours as needed oxycodone acetaminophen mg tablet sig one tablet po every hours as needed lasix mg tablet sig one tablet po twice a day for days discharge disposition extended care facility of discharge diagnosis aortic stenosis chol htn diverticulosis colonic polyps discharge condition good discharge instructions follow medications on discharge instructions do not drive for weeks do not lift more than lbs for months shower daily let water flow over wounds pat dry with a towel do not use creams lotions or powders on wounds call our office for sternal drainage temp followup instructions make an appointment with dr for weeks make an appointment with dr for weeks make an appointment with dr for weeks completed by,{}
10519,admission date discharge date date of birth sex f service trauma s history of the present illness the patient is a year old female who is status post rollover motor vehicle accident in which she was an unrestrained passenger the patient had vascular compromise of the right upper extremity and positive loss of consciousness the patient was transferred to the from hospital in while at hospital the patient had a pulseless right arm which did have a dopplerable pulse while at hospital the patient had a head ct which was negative also the patient had no movement or feeling in her right arm the patient was transferred by helicopter to emergency room past medical history the patient has a past medical history for seizures the patient takes phenobarbital allergies the patient has no known drug allergies upon arrival at the emergency room the patient s temperature was blood pressure was heart rate respiratory rate she was on nonrebreather mask her pupils were equal round and reactive she had extraocular muscles intact she had a cm to cm laceration on the right side of her scalp she had no malocclusion of her teeth neck she was in a cervical spine collar chest chest was clear to auscultation bilaterally she had tenderness on her anterior chest and sternum she had no crepitus she had positive ecchymosis on the right scapula cardiac examination revealed regular rate and rhythm normal s and s abdomen soft nontender nondistended with positive bowel sounds back positive tenderness at t there were no stepoffs no deformity rectal on examination she had normal rectal tone guaiac negative extremities she had a positive dopplerable pulse on the right upper quadrant no sensation or movement in the right upper extremity neurological the coma scale was laboratory data on admission white count was hematocrit platelet count pt ptt inr blood gas and chem sodium potassium chloride bicarbonate bun creatinine the patient had an angiogram done which showed a right axillary artery disruption the patient was seen by the department of vascular surgery and taken to the operating room where she underwent a right axial brachial bypass with reverse greater saphenous vein there were no complications during surgery the patient recovered well in the pacu the patient was transferred to the surgical intensive care unit in stable condition the patient was transferred to the floor on hospital day the patient s chest x ray showed rib fractures on the right and a right scapular fracture with involvement of the intraarticular surface of the glenoid abdominal ct was negative and cervical spine ct was negative the scapular fracture was assessed by the department of orthopedic surgery it was determined that the comminuted scapular fracture could be repaired nonemergently and it was determined for that to be done two weeks after discharge from the hospital the patient was also assessed by the department of neurology it was suspected that she has a brachial plexus injury with possible nerve root tear or avulsion mri of the shoulder was attempted but the patient did not fit into the scanner it was determined that instead of mri the patient could wait two weeks and then receive electromyelogram to test nerve function of the brachial plexus on an outpatient basis the hospital course was marked by a decrease in her hematocrit during day to a low of the patient received two units of packed red blood cell transfusion with a resulting hematocrit of on discharge the hematocrit was during the hospital course the patient was also repleted with potassium magnesium and phosphorus the hospital recovery was otherwise uneventful she was evaluated by the departments of physical therapy and occupational therapy and given treatment and instructions on activities of daily living mobility and compensatory mechanisms with limited or no use of her right arm at this time during her hospital stay the physical examination of her right arm was not changed dramatically she appears to have some sensation to light touch of her right arm sensation and touch seems to localize to her epigastric area on the day of discharge the patient also reported some shooting pain into her right arm it is unclear if this was phantom pain or true pain transmitting from the limb the patient has continued to have no voluntary movement of her right arm the arm has continued to be warm with a strong radial pulse since the bypass graft the patient was cleared for discharge from pt and ot and prepared for discharge on hospital day because the patient has no insurance and case manager was unable to set up any home care for her plan has been developed for her to continue rehabilitation from home with the help of family members and followup with her primary care physician in on discharge the patient has been given instructions to followup in one week with dr department of orthopedics here at for repeat shoulder x rays and examination with the goal of surgical repair of the right scapula in approximately two weeks after discharge we are unable to arrange any followup with neurology it was determined with the patient that it would be better for her to followup with the neurologist in her home area with referral from her primary care physician neurologist that she sees in can assess her brachial plexus injury and determine what further diagnostic modalities may be needed although it should be noted that neurology here had recommended emg in two weeks the patient was discharged with instructions to use a sling and swathe of her right shoulder at all times she is instructed to use the exercises and skills as taught to her by pt and ot she was told to followup with her primary care physician early next week she was discharged with a prescription for percocet total count for pain and a prescription for phenobarbital total count because it was not clear if she would be going home or staying with relatives it is not clear if she has a supply of medication with her the patient s sutures and staples of her head laceration were removed on day of discharge the patient has staples at the site of the saphenous vein donor site which will need to be removed by her primary care physician in approximately two weeks post surgery which would be around on discharge the patient s diagnoses were the following discharge diagnoses right axillary artery injury repaired by saphenous vein bypass graft right scapular fracture right brachial plexus injury head laceration rib fractures closed head injury m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex f service trauma history of present illness the patient was a year old woman status post motor vehicle roll over patient was a restrained passenger the vehicle was going approximately miles per hour no air bag deployed patient had positive loss of consciousness and right shoulder pain and numbness in her hands the patient was taken to hospital in at hospital she had a head ct which was negative for acute change the patient had no palpable pulse in her right arm but she did have a doppler pulse on the right arm the patient was transferred by helicopter to on arrival at the emergency room the patient s temperature was blood pressure was pulse of respiratory rate and was on oxygen physical examination her pupils equal round and reactive to light were mm wide she had a right scalp laceration approximately cm extending anterior to posterior she was in a c spine collar her chest was clear to auscultation and it was equal bilaterally she had sternal tenderness her abdomen was soft and nontender she had normal rectal tone and negative guaiac she had no sensation or movement of her right upper extremity she did have dopplerable pulses of her right upper extremity she had coma score of she had no deformity of her back she had a hematoma around her right scapula heart auscultation showed normal s s chest x ray showed rib fractures on the right it showed a right scapular fracture with a question of apical capping and question of widened mediastinum c spine cat scan was negative from hospital right shoulder showed a intraarticular fracture through the glenoid of the right scapula the patient had angiography of the right upper extremity and aorta hospital course the patient was seen by vascular surgery and taken to the operating room for right axilla artery disruption she received a right axillary brachial bypass with greater saphenous vein there were no complications during surgery the patient recovered in the post anesthesia care unit and was admitted to the surgical intensive care unit the patient was transferred from the surgical intensive care unit to the floor on hospital day two her hospital course was marked by a decrease in her hematocrit to a low of on day three the patient received two units of packed red blood cells hematocrit increased to on discharge her hematocrit was during her hospital course the patient was also repleted multiple times with potassium magnesium and phosphorus throughout her hospital course the patient continued to have a warm right upper extremity with strong pulse minimal sensation of the right arm with some localization to the epigastric area with light touch to her right arm the patient was evaluated by the neurology team and was suspected to have a brachial plexus injury with possible severing or evulsion of nerve roots an mri was attempted per neurology requests but the patient was unable to fit into the mri scanner neurology recommended follow up in two weeks with an emg on day three of her hospital course the patient had a decreased hematocrit and received a transfusion of two units of packed red blood cells hematocrit reached a low of and was brought up to after transfusion on discharge her hematocrit was during her hospital course she was replenished several times for potassium phosphorus and magnesium the patient was transferred from the surgical intensive care unit to the floor on hospital day two the patient continued to recover well from her surgery and was evaluated by physical therapy and occupational therapy over a period of two to three days she had increased mobility and received therapy instruction on activities of daily living and mobility a plan was developed with the case manager and occupational therapy and physical therapy for home occupational therapy as well as continued therapy on part of the patient with help of family members m d dictated by medquist d t job,"{
""Diagnoses"": [""Rollover motor vehicle accident"", ""Vascular compromise of the right upper extremity"", ""Positive loss of consciousness"", ""Pulseless right arm""],
""Medications"": [""Phenobarbital""]
}"
62227,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint chief complaint r flank pain n v arf major surgical or invasive procedure central venous catheter right percutaneous nephrostomy tube placement right and left percutaneous nephrostomy tube replacement history of present illness mr is a y o m with hypertension prostate cancer s p xrt years ago s p l percutaneous nephrostomy for hydronephrosis secondary to retroperitoneal fibrosis who presents with r flank pain nausea vomiting and acute renal failure from the patient was admitted with hematuria on the medicine service he presented passing large clots of blood in his urine with intermittent hematuria since novemver hematuria was thought to be due to renal stones he developed worsening of his l flank pain and presented to the ed during hospitalization foley placed and cbi started ciprofloxacin was also started for positive ua cr was elevated to ct showed b l renal enlargement with perinephric stranding and hydronephrosis without obstructing stone cr trended downward after foley placed but then increased likely due to obstruction thus l percutaneous nephrostomy tube was placed on his hydronephrosis was thought to be obstructive in nature likely chronic due to rp fibrosis for his pyelonephritis he was treated with cipro for pan sensitive e coli x days discharged with urology f u for possible permanent indwelling nu tubes will be needed the patient presented on day of admission due to increasing r flank pain nausea vomiting and weakness his malaise and weakness started days ago he has been checking for fevers at home and his highest temperature was since yesterday overnightat pm he had chills nausea vomiting times with decreased po intake he noted that his l nephrostomy tube has had lower uop he also found it difficult to start his urine stream yesterday denies dysuria or hematuria his r sided flank pain is and sharp using a heating pad and taking a percocet helped with the pain somewhat his l sided flank pain is a but has been chronic for last months these symptoms are the same as his symptoms when he was previously hospitalized in the ed initial vs t hr bp rr o ra per and automatic cuffs did not correlate with manual bp rading and automatic cuff labs drawn and significant for leukocytosis with bands anemia of total bilirubin of hyperkalemia of bun cr and lactate foley placed ua via straight cath urine culture blood cultures sent ct abd pelvis performed with r sided hydronephrosis received l ns uop cc given morphine mg iv x zofran mg iv x albuterol neb x ciprofloxacin mg iv x acetaminophen gm x rij placed and confrimed with cxr also with g and g pivs cvp on transfer to micu past medical history hypertension prostate cancer hyperlipidemia non insulin dependent diabetes asthma chronic low back pain secondary to disc herniation left lung nodule on ct social history previous cocaine alcohol abuse no longer smokes uses alcohol or drugs family history non contributory physical exam micu admission vital signs t bp hr rr cvp gen pleasant jovial obese gentleman lying in bed shivering heent anicteric eomi perrl op no exudate no erythema mmm no cervical lad chest ctab no w r r cv tachy no m r g abd slightly distended soft decreased bs nt ext no c c e neuro a o x derm no rashes back mild l sided cva tenderness moderate r sided cva tenderness arrival to medical floor vital signs t bp hr rr o ra gen pleasant just showered sitting on edge of bed nad heent anicteric eomi perrl op no exudate no erythema mmm cv rrr no m r g chest ctab no w r r abd protuberant tympanic non tender hypoactive bowel ext no clubbing or cyanosis pitting edema to ankles bilaterally dpi neuro a o x derm no rashes back no cva tenderness dressings for nephrostomy tubes intact l and r r draining slightly pink but clear urine l draining clear yellow urine pertinent results b u labs b u b cbc b wbc hgb hct mcv plt ct n band l m e bas metas wbc hgb hct mcv plt ct fibrino ret aut ld ldh hapto wbc hgb hct mcv plt ct wbc hgb hct mcv plt ct wbc hgb hct mcv plt ct wbc hgb hct mcv plt ct b chemistry b glucose urean u creat u na k cl hco angap glucose urean u creat u na k cl hco angap glucose urean u creat u na k cl hco angap glucose urean u creat u na k cl hco angap glucose urean u creat u na k cl hco angap glucose urean u creat u na k cl hco angap glucose urean u creat u na k cl hco angap b urine b ua mod leuk lg blood nit positive ketone neg rbc wbc fewe bact epis b microbiology b urine e coli pan sensitive negative blood anaerobic with e coli pan sensitive negative to date aerobic with coagulase negative staph negative to date b u studies b u ct abd pelvis wo contrast impression increased perinephric and periureteral stranding on the right with mild hydronephrosis and hydroureter stranding likely due to progression of known retroperitoneal fibrosis but underlying infection cannot be excluded no renal or ureteral calculi identified status post nephrostomy on the left with decompression and no residual hydronephrosis hiatal hernia and esophageal wall thickening raises concern for esophagitis renal ultrasound no evidence of abscess brief hospital course hypotension sepsis due to e coli bacteremia patient had hypotension bandemia fever and urinalysis suggestive of urinary tract infection he was admitted to the micu and was given fluids but did not require pressors his blood and urine cultures grew pansensitive e coli he was treated with ciprofloxacin for a planned day course surveillance blood cultures remain ngtd except for one of two aerobic cultures from which grew coagulase negative staph which is felt to have been a contaminant as cultures from have been negative and only one of the set of cultures was positive he will be discharged with ciprofloxacin qday dosed for renal insufficiency to complete a day course hydronephrosis likely secondary to retroperitoneal fibrosis resulting from xrt for prostate cancer per urology instruction had right sided nephrostomy tube placed by ir with good result he had a foley which was removed on he reported seeing scant urine in his depends daily on the left nephrostomy tube was not producing output and was not able to be flushed by ir both the left and right tubes were replaced by ir on the right tube was functioning but was found to have an extra subcutaneous loop which may have been causing the patient discomfort on discharge both nephrostomies were draining well and the urine was not bloody acute renal failure secondary to upper gu obstruction now with bilateral percutaneous nephrostomies creatinine trended downward during hopital stay medications were renally dosed and nephrotoxins were avoided bph medications were continued hypertension antihypertensives were held for hypotension on the patient s blood pressure was s s and his amlodipine was restarted his benazepril was held until discharge anemia baseline hct is mid high s and he came in dehydrated on his hematocrit was and he was transfused unit of packed red blood cells he was also transfused on for graudally falling hematocrit on anemia was felt to be secondary to chronic kidney disease there was no evidence of acute bleeding iron studies from early were consistent with anemia of chronic disease non insulin dependent diabetes held oral hypoglycemics while in house and patient placed on insulin sliding scale will discharge on home medications hyperlipidemia statin continued asthma albuterol and ipratroprium continued chronic low back pain secondary to disc herniation percocet continued gerd secondary to hiatal hernia esophageal thickening on ct continued omeprazole lung nodules in left base stable on repeat ct medications on admission finasteride mg po daily amlodipine mg po daily oxycodone acetaminophen mg po q hours x days last day prilosec mg po bid simvastatin mg po daily tamsulosin sr mg po qhs glyburide mg po bid proair mcg puffs qid prn wheeze lotensin mg po daily discharge medications omeprazole mg capsule delayed release e c sig one capsule delayed release e c po bid times a day simvastatin mg tablet sig two tablet po daily daily finasteride mg tablet sig one tablet po daily daily tamsulosin mg capsule sust release hr sig one capsule sust release hr po hs at bedtime docusate sodium mg capsule sig one capsule po bid times a day oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain for days disp tablet s refills ciprofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills amlodipine mg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig two puff inhalation qid times a day albuterol sulfate mcg actuation hfa aerosol inhaler sig puffs inhalation q h every hours as needed for sob wheezing benazepril mg tablet sig one tablet po once a day glyburide mg tablet sig one tablet po twice a day discharge disposition home with service facility homecare discharge diagnosis primary sepsis secondary to urinary tract infection hydronephrosis acute renal failure secondary hypertension hyperlipidemia asthma gerd low back pain diabetes mellitis type discharge condition good discharge instructions you were admitted to the hospital because you had an infection in your kidney the infection had spread to your blood and that is why you spent several days in the intensive care unit you had a tube in your left kidney from your last hospitalization and one was placed into your right kidney during this hospitalization you need the tubes because the urine that is produced by your kidneys does not flow to your bladder easily this probably results from scar tissue from the radiation for your prostate cancer but the urology procedure on will investigate this further during your stay your left nephrostomy tube stopped draining both the left and the right tubes were replaced by the interventional radiologists you also received two blood transfusions the following changes were made to your medications start ciprofloxacin mg po daily please continue all other medications please be sure to complete your course of ciprofloxacin please keep your outpatient appointments please return to the hospital if you experience fevers chills uncontrolled pain dizziness or lightheadedness shortness of breath if you see blood draining from your nephrostomy tubes or for any other concern followup instructions you have a preop appointment on provider rm preadmission testing date time you have an appointment in nephrology kidney doctor on provider md phone date time please make sure that when you are here on you provide a urine sample so that the urology team will know that the antibiotics cleared the infection you can do this when you visit dr you have a procedure scheduled for you have an appointment with dr in provider md phone date time md dmd,{}
18323,admission date discharge date date of birth sex f service medicine allergies penicillins erythromycin base toradol compazine remicade attending chief complaint short of breath stridor major surgical or invasive procedure intubation history of present illness this is a year old female with history of asthma and crohn s intermittently on steroids who was admitted to the icu on with dyspnea stridor and wheezing requiring intubation past medical history asthma crohn s disease s p ileo cecal resection with ileo sigmoid anastomosis revision with ileostomy s p multiple sbos portacath social history disabled lives with partner non no etoh no ivdu or other drugs family history mother with colitis father died of lung and bone cancer physical exam vs temp pulse bp rr on nrb gen alert oriented cooperative female in obvious respiratory distress with wheezing audible from across the room heent mmm op clear no enlargement of tonsils or neck swelling perrl neck no lymphadenopathy or swelling stridor on exam lungs decreased breath sounds throughout stridor audible cv rrr nl s s no murmers abd soft non tender non distended positive bs ext no edema neuro alert and oriented x patient urgently intubated so remainder of exam deferred 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 esr am blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos amylase totbili am blood lipase pm blood ck mb am blood calcium phos mg am blood albumin calcium phos mg iron am blood caltibc vitb ferritn trf am blood crp am blood ethanol neg acetmnp neg pm blood type mix po pco ph caltco base xs intubat intubated pm blood type art po pco ph caltco base xs pm blood type art po pco ph caltco base xs intubat not intuba pm blood lactate pm blood lactate pm urine color straw appear clear sp pm urine blood sm nitrite neg protein neg glucose neg ketone tr bilirub neg urobiln neg ph leuks neg pm urine rbc wbc bacteri occ yeast none epi am urine hours random am urine bnzodzp pos barbitr neg opiates neg cocaine neg amphetm neg mthdone pos pm sputum source endotracheal gram stain final pmns and epithelial cells x field per x field gram positive cocci in pairs chains and clusters respiratory culture preliminary heavy growth oropharyngeal flora fungal culture preliminary no fungus isolated pm urine source catheter final report urine culture final no growth chest one view comparison with chest radiograph new small left pleural effusion and left lingular atelectasis right lung appears clear endotracheal tube nasogastric tube and left subclavian line are unchanged no pneumothorax osseous structures are unchanged impression new small left pleural effusion and left lingular atelectasis ct neck w contrast eg parotid reason evaluate for airway abnormalities causes of swelling in pa medical condition year old woman with history of asthma crohn s presenting with respiratory distress found to have severe stridor now s p intubation reason for this examination evaluate for airway abnormalities causes of swelling in patient with severe stridor contraindications for iv contrast none indication year old woman with a history of asthma and crohn s disease now with stridor and intubated comparison none technique contrast enhanced ct of the neck findings note is made of an endotracheal tube nasogastric tube and a left subclavian central venous catheter the soft tissues of the neck appear unremarkable there is no drainable fluid collection pathologically enlarged lymph nodes or other mass the airway demonstrates no significant narrowing although the study is limited by the presence of the endotracheal tube the vocal cords do not appear markedly swollen the lung apices demonstrate minimal scarring the paranasal sinuses demonstrate mucosal thickening in multiple ethmoid air cells as well as the right maxillary sinus likely related at least in part to the intubation impression no extrinsic mass or fluid collection in the neck portable ap chest radiograph was compared to obtained at p m the et tube tip terminates cm above the carina the left subclavian line tip terminates in mid svc the ng tube tip passes below the diaphragm most likely terminating into the stomach the heart size and mediastinal contours are unremarkable and the lungs are essentially clear with no sizeable pleural effusion identified portable upright chest p m indication respiratory distress evaluate for pneumonia findings no prior comparisons the heart is not enlarged no chf the left subclavian port a cath tip is at the level of the brachiocephalic svc confluence no definite pulmonary infiltrates or sizable effusions there is the suggestion of some prominence indistinctness of the markings at the right lung base medially which may just be due to overlying soft tissues but if there is a clinical suspicion of early pneumonia then followup pa and lateral views may be helpful to further evaluate this no other suspicious areas for pneumonia there is a tiny roughly mm nodule density projecting just lateral to the cardiac apex which is indeterminate for confluence of markings versus a small nodule granuloma or possibly a bone island attention to this on followup studies or comparison with prior old films or reports recommended brief hospital course acute respiratory failure intubation for airway protection etiology thought to be vocal cord dysfunction given that stridor stopped abruptly after intubation no wheezing aon exam and very low peak airway pressures were noted neck ct showed no pathology to account for stridor on discussion with the icu attending dr vocal cords were normal in apprearance she was treated with empiric coverage with levofloxacin for a day course last day prednisone taper nebs ppi was given in dosing given that gerd can worsen vocal cord dysfunction the patient will benefit from psychiatry follow up for anxiety and vocal cord dysfunction relaxation techniques she is also advised to discuss with pcp for an ent referral given above reasons this was unlikely to be an asthma exacerbation but given the severity of the situation she was treated with above a repeat chest xry is recommended to evaluate the findings above and also consider ct chest if the pleural effusion persists to follow up the nodule she should continue to follow up with her gi physicians at for management of crohns disease ativan was continued prn for anxiety methadone home dose was continued for chronic lbp ua revealed rbc she should get another ua with her pcp for follow up medications on admission albuterol advair diskus singulair mg daily lorazepam mg prn flexeril mg qd prn methadone mg qhs protonix mg daily discharge medications montelukast mg tablet sig one tablet po daily daily levofloxacin mg tablet sig three tablet po q h every hours for days disp tablet s refills pantoprazole 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 methadone mg tablet soluble sig one tablet soluble po daily daily advair diskus mcg dose disk with device sig one inhalation twice a day albuterol sulfate mg ml solution sig one inhalation q h every to hours as needed lorazepam mg tablet sig one tablet po twice a day as needed for anxiety prednisone prednisone mg po daily for days then decrease to mg po daily for days then decrease to mg po daily for days and then mg po daily for days and then stop no refills discharge disposition home discharge diagnosis acute respiratory failure likely due to vocal cord dysfunction asthma rbc in urine h o crohn s disease anxiety chronic low back pain discharge condition stable ambulating well o sats on room air discharge instructions return to the emergency room if you have worsening wheezing shortness of breath chest pain cough fever or any other symptoms you may have vocal cord dysfunction you are advised to follow up with your lung doctor hospital for a pulmonary function test also discuss with your doctor you to a ent specialist a psychiatrist for relaxation techniques you were started on a medicine called pantoprazole for acid reflux that may be causing the vocal cord dysfunction make a follow up appointment with your primary doctor dr as stated below in the next week take your medicine as prescribed talk to your doctor about a repeat chest xray in weeks followup instructions call dr l to a follow up appointment in the next week also call your pulmonary doctor an appointment in the next week,"{
""Diagnoses"": [""Dyspnea"", ""Stridor"", ""Wheezing"", ""Asthma"", ""Crohn's disease"", ""Pneumonia""],
""Medications"": [""Toradol"", ""Compazine"", ""Remicade"", ""Erythromycin"", ""Steroids""]
}"
51675,admission date discharge date date of birth sex f service surgery allergies no known allergies adverse drug reactions attending chief complaint pancreatic head mass major surgical or invasive procedure pylorus sparing pacreaticoduodenectomy whipple procedure history of present illness this is a year old female who presented initially with obstructive jaundice she underwent ercp at hospital on with sphincterotomy brushings and stent placement across a mid biliary duct stricture fine needle aspiration biopsy performed on revealed necrotic debris with remaining concerns for malignancy given the findings of a pancreatic head mass on endoscopic ultrasound she was admitted electively on following her pancreaticoduodenectomy whipple procedure past medical history pmh former smoker pack year obesity meniere disease psh tonsillectomy appendectomy social history attests to packs per day for years pack year rare alcohol use drinks year denies recreational substance use family history non contributory physical exam vitals afebrile vitals signs stable heent normocephalic atraumatic eomi perrl nares clear mucous membranes moist neck supple without lymphadenopathy cvs regular rate and rhythm without murmurs rubs or gallops s and s resp clear to auscultation bilaterally without adventitious sounds no wheezing rhonchi or crackles abd soft obese appearing appropriately tender non distended with normoactive bowel sounds no masses or peritoneal signs extr no cyanosis clubbing or edema peripheral pulses incision transverse incision is clean dry and intact without evidence of erythema or drainage minimal serosanguinous drainage noted staples open to air with steristrips between pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood creat na k cl am blood calcium phos mg am bile fluid should not be sent in swab transport media submit fluids in a capped syringe no needle red top tube or sterile cup gram stain final no polymorphonuclear leukocytes seen no microorganisms seen wound culture final a swab is not the optimal specimen collection to evaluate body fluids klebsiella oxytoca rare growth piperacillin tazobactam sensitivity testing available on request sensitivities mic expressed in mcg ml klebsiella oxytoca ampicillin sulbactam s cefazolin i cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s tobramycin s trimethoprim sulfa s anaerobic culture final no anaerobes isolated fungal culture preliminary no fungus isolated pathology examination name birthdate age sex pathology female report to dr gross description by dr dr dif specimen submitted gallbladder omentum whipple specimen procedure date tissue received report date diagnosed by dr vf diagnosis omentum a d unremarkable adipose tissue no malignancy identified gallbladder e i chronic cholecystitis and cholelithiasis one unremarkable lymph node no malignancy identified whipple specimen j ad pancreatic ductal adenocarcinoma arising in association with an intraductal pancreatic mucinous neoplasm see synoptic report pancreas exocrine resection synopsis staging according to american joint committee on cancer staging manual th edition macroscopicl specimen type pancreaticoduodenectomy partial pancreatectomy tumor site pancreatic head tumor size greatest dimension cm additional dimensions cm x cm other organs tissues received gallbladder omentum microscopic histologic type ductal adenocarcinoma histologic grade g well differentiated extent of invasion primary tumor pt tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery regional lymph nodes pn no regional lymph node metastasis lymph nodes number examined number involved distant metastasis pmx cannot be assessed margins margins uninvolved by invasive carcinoma distance from closest margin mm specified margin posterior margin black inked venous lymphatic vessel invasion absent perineural invasion absent additional pathologic findings chronic pancreatitis intraductal papillary mucinous tumor with high grade dysplasia involving main and side branch pancreatic ducts clinical pancreatic mass ap chest impression ap chest compared to and at a m small region of heterogeneous opacification at the right lung base has been present for several days whether this is pneumonia or atelectasis is indeterminate pulmonary vasculature is minimally engorged and there is no pulmonary edema pleural effusion if any is minimal cardiomediastinal silhouette is normal there is no obvious explanation for new hypoxia brief hospital course neuro pain the patient was maintained on iv pain medication in the immediate post operative period and had an epidural catheter in place in the immediate post op period and was transitioned to po narcotic medication with adequate pain control on pod the patient remained neurologically intact and without change from baseline during their stay the patient remained alert and oriented to person location and place cardiovascular the patient remained hemodynamically stable intra op and in the immediate post operative period she did require a minor amount of neosynephrine gtt iv intra operatively but this was weaned without post op requirement and she remained hemodynamically stable the patient was maintained on iv anti hypertensive medication in the immediate post op period with transition to their oral home anti hypertensives on pod their vitals signs were closely monitored the patient s home anti hypertensive medications were resumed on pod respiratory he patient was extubated in the immediate post op period successfully but given some hypercarbia and carbon dioxide retention attributed to underlying smoking history and likely a copd component the patient was on non rebreather in the pacu and required re intubation before transfer to the surgical icu for futher monitoring the patient was weaned to cpap and tolerated this well on pod with successful extubation on pod the patient denied cough or respiratory symptoms following this but continued to require supplemental oxygen pulse oximetry was monitored closely and the patient maintained adequate oxygenation on liters of nasal cannula supplementation requiring home oxygen on discharge to rehab intermittent lasix iv was given for diuresis gastrointestinal the patient was npo following their procedure and maintained on iv fluids for hydration while npo serial abdominal exams were performed and once flatus resumed the patient was transitioned to a clear liquid diet and their iv fluids were hep locked on pod the patient experienced no nausea or vomiting a nasogastric tube was maintained until the output was minimal and was removed on pod a regular diet was initiated on pod and the patient tolerated this well the patient was maintained on octreotide in the post op period as well which was discontinued on pod drain remained in place post operatively anf the output was greater than cc in a hour period thus she was discharged with the drain in place the drain had an amylase level of on pod after the patient tolerated full liquids and she was transitioned to diet without issue genitourinary the patient s urine output was closely monitored in the immediate post operative period a foley catheter was placed intra operatively and removed on pod at which time the patient was able to successfully void without issue the patient s intake and output was closely monitored for urine output ml per hour output the patient s creatinine was stable a mild transaminitis was noted following her procedure which was attributed to clamping of the bile duct during the procedure her lfts were trended and improved appropriately heme the patient s post op hematocrit was stable and trended closely the patient remained hemodynamically stable and did not require transfusion the patient s coagulation profile remained normal the patient had no evidence of bleeding from their incision id the patient showed no signs of infection and remained afebrile in the post op period their white count was stable post operatively and their incision was closely monitored for any evidence of infection or erythema the patient received only standard peri operative antibiotics and did not require further antibiotics post op endocrine the patient s blood glucose was closely monitored in the post op period with q hour glucose checks blood glucose levels greater than mg dl were addressed with an insulin sliding scale prophylaxis the patient was maintained on heparin units sq tid for dvt pe prophylaxis and encouraged to ambulate immediately post op once cleared by physical therapy the patient also had sequential compression boot devices in place during immobilization to promote circulation gi prophylaxis was sustained with protonix famotidine when necessary the patient was encouraged to utilize incentive spirometry ambulate early and was discharged in stable condition to a pulmonary rehabilitation facility medications on admission tylenol mg po bid calcium carbonate prn naprosyn prn discharge medications hydromorphone mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills metoprolol tartrate mg tablet sig one tablet po bid times a day ipratropium bromide solution sig one nebulizer inhalation q h every hours as needed for wheeze sob metoclopramide mg tablet sig one tablet po four times a day pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po once a day albuterol sulfate mcg actuation hfa aerosol inhaler sig puffs inhalation every six hours as needed for shortness of breath or wheezing colace mg capsule sig one capsule po twice a day discharge disposition extended care facility life care center of discharge diagnosis pancreatic head mass post op respiratory failure discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to dr surgical service for evaluation and management of your pancreatic head mass following your whipple procedure you are now being discharged in rehab please follow these instructions to aid in your recovery please call your doctor or go to the emergency department if you experience new chest pain pressure squeezing or tightness you develop new or worsening cough shortness of breath or wheezing you are vomiting and cannot keep down fluids or your medications if 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 see blood or dark black material when you vomit or have a bowel movement you experience burning when you urinate have blood in your urine or experience an unusual discharge your pain is not improving within hours or is not under control within hours your pain worsens or changes location you have shaking chills or fever greater than degrees fahrenheit or degrees celsius you develop any other concerning symptoms please resume all regular home medications unless specifically advised not to take a particular medication please take any new medications as prescribed please take the prescribed analgesic medications as needed you may not drive or operate heavy machinery while taking narcotic analgesic medications you may also take acetaminophen tylenol as directed but do not exceed mg in one day please get plenty of rest continue to walk several times per day and drink adequate amounts of fluids avoid strenuous physical activity and refrain from heavy lifting greater than lbs until you follow up with your surgeon who will instruct you further regarding activity restrictions please also follow up with your primary care physician incision care please call your surgeon or go to the emergency department if you have increased pain swelling redness or drainage from the incision site avoid swimming and baths until cleared by your surgeon you may shower and wash incisions with a mild soap and warm water gently pat the area dry if you have staples they will be removed at your follow up appointment if you have steri strips they will fall off on their own please remove any remaining strips days after surgery followup instructions provider md phone date time please follow up with your primary care physician weeks following discharge,"{
""Diagnoses"": [""obstructive jaundice"", ""pancreatic head mass"", ""malignancy""],
""Medications"": [""sphincterotomy"", ""stent placement"", ""fine needle aspiration biopsy"", ""Whipple procedure""]
}"
26913,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint asymptomatic ascending aortic aneurysm major surgical or invasive procedure redo sternotomy replacement of ascending aorta mm gelweave tube graft history of present illness mr is a year old male who in underwent an aortic valve replacement with a mechanical bjork shiley valve he has been followed for an enlarging ascending aorta and his most recent echo showed it to be now at cm he is now presenting for repair of the ascending aortic aneurysm past medical history s p avr bjork shiley s p icd mi at age cardiomyopathy chf aaa colorectal cancer uti colostomy hyperlipidemia htn social history retired lift truck operator pack year history of smoking he quit over years ago lives with his wife does not drink alcohol he is edentulous family history noncontributory physical exam gen nad neck supple from lungs clear heart rrr crisp valve click nl s s abd soft nt nd nabs ext warm well perfused edema neuro nonfocal no carotid bruits pertinent results echo pre cpb the left atrium is elongated no atrial septal defect is seen by d or color doppler left ventricular wall thicknesses are normal the left ventricular cavity size is normal due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded there is moderate to severe global left ventricular hypokinesis lvef there is moderate global right ventricular free wall hypokinesis the ascending aorta is markedly dilated this dilation appears to taper down near the arch but limited views prevent full assessment there are simple atheroma in the aortic arch there are focal calcifications in the aortic arch the descending thoracic aorta is mildly dilated there are complex mm atheroma in the descending thoracic aorta a single tilting disk type aortic valve prosthesis is present the aortic valve prosthesis appears to be well seated the disk is poorly seen but appears to be moving appropriately some fibrinous echodensities are seen on the lvot side of the valve and are likely evidence of some degeneration there is no aortic valve stenosis no aortic regurgitation is seen the mitral valve leaflets are moderately thickened mild mitral regurgitation is seen due to acoustic shadowing the severity of tricuspid regurgitation may be significantly underestimated there is a trivial physiologic pericardial effusion post cpb the patient is receiving epinephrine by infusion the left ventricle continues to display moderate to severe global dysfunction but now with slightly more hypokinesis of the inferior wall the ef is about the right ventricle displays somewhat improved function from pre bypass study now mildly globally hypokinetic the ascending aortic graft is only poorly seen the thoracic aorta appers intact distal to the graft mitral regurgitation is now trace no other changes from pre cpb study 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 pm blood alt ast ld ldh alkphos amylase totbili radiology final report chest pa lat pm chest pa lat reason evaluate for effusion medical condition year old man with s p asc aorta replac reason for this examination evaluate for effusion chest x ray history status post ascending aorta repair evaluate for effusion two views comparison with the patient is status post median sternotomy and mvr as before mediastinal structures are unchanged an icd remains in place a right internal jugular catheter has been withdrawn allowing for differences in technique there is no other significant change impression no significant interval change dr brief hospital course mr was admitted to the on for surgical management of his dilated ascending aorta heparin was started as he had been off his coumadin for days in aticipation of surgery on mr was taken to the operating room where he underwent a redo sternotomy with replacement of his ascending aorta an intraopertaive vascular surgery consult was obtained as it was decided to use his right axillary artery for arterial cannulation please see operative note for details postoperatively he was taken to the intensive care unit for monitoring by postoperative day one mr had awoke neurologically intact and was extubated aspirin beta blockade and a statin were resumed the electrophysiology service was consulted for interrogation of his pacemaker and it was reprogrammed to function appropriately haldol was used for some mild postoperative aggitation coumadin was resumed for his mechanical valve mr developed atrial fibrillation for which amiodarone was started mr remained in the intensive care unit for a few extra days due to agitation and confusion however this slowly cleared on postoperative day three he 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 his mental status cleared and on pod he was discharged to rehab in stable condition medications on admission aldactone mg qd captopril mg tid coreg mg coumadin lasix mg qd lovastatin mg qd multivitamin discharge medications furosemide mg tablet sig one tablet po q h every hours for days potassium chloride meq packet sig one packet po q h every hours for days docusate sodium mg capsule sig one capsule po bid times a day aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily ranitidine hcl mg tablet sig one tablet po bid times a day lovastatin mg tablet sig one tablet po once a day spironolactone mg tablet sig one tablet po daily daily warfarin mg tablet sig two tablet po once once dose for inr goal of trimethoprim sulfamethoxazole mg tablet sig one tablet po bid times a day as needed for uti for days metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po daily daily amiodarone mg tablet sig one tablet po daily daily albuterol sulfate mg ml solution sig one inhalation q h every hours as needed discharge disposition extended care facility health network discharge diagnosis mild ai dilated ascending aorta s p replacement s p avr s p icd s p colostomy af mi at age cardiomyopathy chf uti colorectal cancer aaa 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 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 follow up with dr in month follow up with cardiologist dr in weeks follow up with pcp in weeks call all providers for appointments completed by,"{
""Diagnoses"": [""asymptomatic ascending aortic aneurysm"", ""major surgical or invasive procedure (redo sternotomy replacement of ascending aorta)"", ""history of present illness (AAA)"", ""cardiomyopathy"", ""CHF"", ""colorectal cancer"", ""UTI"", ""hyperlipidemia"", ""HTN""],
""Medications"": [""BJork Shiley valve"", ""SP AVR BJork Shiley valve"", ""SP ICD"", ""MI at age"", ""colostomy"", ""hypertension medication"", ""lipid-lowering medication"", ""aspirin"", ""warfarin""]
}"
44799,admission date discharge date date of birth sex m service urology allergies no known allergies adverse drug reactions attending chief complaint m w bilateral renal masses major surgical or invasive procedure procedures left laparoscopic radical nephrectomy and left laparoscopic para aortic lymph node dissection procedure open splenectomy for splenic rupture history of present illness peripheral vascular disease cm right renal mass and solid left renal masses mri left kidney and solid lesion suspicious for papillary rcc right kidney cm solid lesion in the mid kidney suspicious for rcc mri significant increase in mass cm with perinephric nodules past medical history pmh htn bilateral renal masses hld psh splenectomy lap left radical nephrectomy r cea hernia repair x social history he is a senior project coordinator for the department of mental health specializes in networks he has a pack year smoking history continues to smoke one pack per day occasional alcohol no drug use he drinks rare alcohol he is retired but still works two days a week family history not available at time of dictation physical exam wdwn male nad avss interactive cooperative abdomen soft appropriately tender along incisions incisions c d i w out evidence hematoma infection foley catheter in place urine yellow clear jp to bulb in place extremities w out edema or pitting and no report of calf pain pertinent results pm stool consistency watery source stool final report clostridium difficile toxin a b test final feces negative for c difficile toxin a b by eia reference range negative am urine site clean catch clean catch final report urine culture final organisms ml 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 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 brief hospital course mr was admitted to urology after undergoing laparoscopic left nephrectomy there was splenic bleeding intra op with cc extravasation controlled with packing and dry at the end of the case post operatively mr had hypotension poor urine output and point drop in hct over hours so he was taken for emergent splenectomy total received u prbc and l crystalloid resuscitation excellent hemostasis at the end of splenectomy but had cc bloody jp output immediately post op remained asymptomatic and jp output slowed the patient received perioperative antibiotic prophylaxis the patient was transferred to the intensive care unit from pacu in stable condition on pod he was hydrated for urine output cc hour provided with pneumoboots and incentive spirometry for prophylaxis he was monitored with serial hematocrits he was eventually transferred from the icu to the general surgical floor where he made a gradual recovery and was advanced with diet basic metabolic panel and complete blood count were checked pain control was transitioned from pca to oral analgesics diet was advanced to a clears toast and crackers diet abdominal drain output was monitored and checked for creatinine and amylase and at discharge was left in place urethral foley was removed on day prior to discharge but he failed the voiding trial so it was replaced diet was slowly advanced but by discharge he was on a regular house diet the remainder of the hospital course was relatively unremarkable the patient was discharged in stable condition eating well ambulating independently and with pain control on oral analgesics on exam incision was clean dry and intact with no evidence of hematoma collection or infection the patient was given explicit instructions to follow up in clinic with dr for trial of void and staple removal and with dr for abdominal drain removal medications on admission metoprolol mg po bid simvastatin mg po qhs vitamin b mcg po daily asa mg po daily discharge medications docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills alum mag hydroxide simeth mg ml suspension sig mls po qid times a day as needed for heartburn acetaminophen mg tablet sig two tablet po q h every hours as needed for fever metoprolol tartrate mg tablet sig one tablet po bid times a day oxycodone mg tablet sig one tablet po q h every hours as needed for pain disp tablet s refills nicotine mg hr patch hr sig one patch hr transdermal daily daily do not smoke while concurrently wearing patch disp patch hr s refills tamsulosin mg capsule ext release hr sig one capsule ext release hr po hs at bedtime vitamin b mcg tablet sig one tablet po once a day simvastatin mg tablet sig one tablet po once a day aspirin mg tablet sig one tablet po once a day do not resume until cleared by dr or dr outpatient lab work please empty and measure and record the daily output of the drain and be prepared to share these findings with dr at your appointemnt discharge disposition home discharge diagnosis renal cell carcinoma splenic rupture discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions please also refer to the provided written instructions on post operative care instructions and expectations made available from dr s office the drain will remain in place until your follow up appointment with dr and the foley will be removed when you see dr later this week please empty and measure and record the daily output of the drain and be prepared to share these findings with dr at your appointemnt resume your pre admission home medications except as noted always call to inform review and discuss any medication changes and your post operative course with your primary care doctor do not resume your pre admission dose of aspirin mg po daily until explicitly cleared by dr or dr do not lift anything heavier than a phone book pounds or drive until you are seen by your urologist in follow up resume all of your pre admission home medications except as noted do not take aspirin or non steroidal anti inflammatories ibuprofen etc unless advised to do so call your urologist s office today to schedule confirm your follow up appointment in weeks and if you have any questions do not eat constipating foods for weeks drink plenty of fluids to keep hydrated no vigorous physical activity or sports for weeks or until otherwise advised tylenol should be your first line pain medication a narcotic pain medication has been prescribed for breakthrough pain replace tylenol with narcotic pain medication max daily tylenol acetaminophen dose is grams from all sources note that narcotic pain medication also contains tylenol if you have been prescribed ibuprofen the ingredient of advil motrin etc you may take this and tylenol together alternating for additional pain control please try tylenol first and take the narcotic pain medication as prescribed if additional pain relief is needed ibuprofen should always be taken with food please discontinue taking and notify your doctor should you develop blood in your stool dark tarry stools you may shower normally but do not immerse your incisions or bathe do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication discontinue if loose stool or diarrhea develops colace is a stool softener not a laxative if you have fevers f vomiting or increased redness swelling or discharge from your incision call your doctor or go to the nearest emergency room followup instructions please call dr office to arrange for trial of void and surgical skin clip removal for thursday this week the drain will remain in place until your follow up appointment with dr your appointment has been made for at am call dr office at for follow up and if you have any urological questions dr s nurse practitioner may be reached at the same number completed by [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint right leg weakness major surgical or invasive procedure operations fusion t t extra cavitary decompression t laminectomies t t instrumentation t cage placement at t autograft history of present illness this is a year old male with a history of metastatic renal cell carcinoma with metastasis to multiple ribs and lungs with associated pleural effusions s p genentech study drug who presents with right leg weakness urinary retention and constipation over the past several days ordinarily mr is able to ambulate with a walker without difficulty at home he prepares meals for himself at his home he shares with his wife over the past few days due to increasing weakness in his right leg he has had difficulty with walking he has also been constipated over this same time period his last bowel movement days ago his po intake has been diminished over the last several months although he takes considerable fluids he has also described urinary retention over the past three months otherwise he denies any other extremity weakness with no numbness or tingling back pain is minimal at rest although coughing does make it worse he recently had a pleurex catheter in place for pleural effusion during last admission an mri was performed on day of admission which reveals multiple spinal mets with significant collapse of the t vertebral body with epidural extension and marked canal narrowing with cord impingement at this level the other areas of metastases are not associated with cord compression for the mri the patient was intubated for claustrophobia and anxiety treatment he was immediately extubated thereafter without need for supplemental o neurosurgery saw the patient and plan on taking the patient to the or assuming that this plan is acceptable per the oncology team based on their overall treatment plan at time of transfer to floor the patient was comfortable with no pain but continued symptoms as described above past medical history past oncologic history on mri revealed a cm solid exophytic lesion arising from the lower pole of left kidney suspicious for clear cell renal cell carcinoma and a cm solid lesion in the anterior left pole of the left kidney and a cm lesion in the mid pole of the right kidney both of which concerning for tumor cell carcinoma papillary type he was referred to dr on given its small size he was recommended to have followup imaging mri at compared to ct without contrast from on he underwent repeat mri which showed no significant change and bilaterally no masses on he underwent repeat mri which revealed significant interval increase in the lower pole of the left kidney obstructing mass now measuring x cm from x cm and development of nodules in the perinephric fat consistent with extrarenal spread suspicious for clear cell renal cell carcinoma and there were also two other lesions that were minimally increased in size on he underwent laparoscopic left radical nephrectomy which revealed a cm clear cell carcinoma and a cm papillary renal cell carcinoma grade tumors with tumor extension into the perinephric tissue t a n of note the clear cell renal cell carcinoma shows no areas of signaling no definitive sarcomatoid differentiation renal cell carcinoma is diffusely positive ca negative for ck and patchy positivity for p s the papillary renal cell carcinoma is again diffusely positive for ck and p s and focally positive for ca packs two shows focal weak staining for both tumors with no after lymphovascular invasion as identified on ct staining on splenectomy showed vascular congestion with subcapsular hematoma on the lesion in the pole of the right kidney most consistent with papillary renal cell carcinoma is unchanged and fluid collection consistent with pseudocyst of one of the pancreas is noted on he underwent partial right nephrectomy of the cm papillary renal cell carcinoma grade t a nx with the size of the tumor measured as a solid part cm adjacent cyst continued minimal tumor specimen one in the belt of the cyst adjacent to the tumor right margin with papillary carcinoma cauterized on post nephrectomy period complicated by fever and treated for pneumonia he was noted to have a low o and underwent a chest x ray which noted a cm elliptical opacity in the left upper hemi collapse with apparent adjacent local destruction new since on ct abdomen and pelvis revealed a x soft tissue density lesion with destruction of the third posterior lateral rib fluid collection in the right partial nephrectomy bed with a seroma coronary and aortic valve calcifications enlarged pulmonary artery right lower lobe consolidation concerning for pneumonia a mm right lung nodule nonspecific left upper lobe ground glass opacity on admitted for pleural effusion which was tapped by ip interval need of supplemental o he was stopped on his experimental therapy past medical history pmh htn bilateral renal masses hld psh splenectomy lap left radical nephrectomy r cea hernia repair x social history he is a senior project coordinator for the department of mental health specializes in networks he has a pack year smoking history continues to smoke one pack per day occasional alcohol no drug use he drinks rare alcohol he is retired but still works two days a week family history non contributory physical exam physical exam on discharge vitals t bp hr rr sat l nc general nad tired appearing heent at nc eomi perrla anicteric sclera pink conjunctiva patent nares mmm nontender supple neck no lad no jvd cardiac rrr s s no murmers gallops or rubs lung ctab no wheezes rales rhonchi breathing comfortably without use of accessory muscles back dressing c d i with drain in place abdomen nondistended bs nontender in all quadrants no rebound guarding no hepatosplenomegaly extremities moving all extremities well no cyanosis clubbing or edema no obvious deformities pulses dp pulses bilaterally neuro cn ii xii intact strength biceps and triceps bilaterally left hip flexors plantar and dorsiflexion r dorsiflexion r hip flexors pertinent results mr there are multiple vertebral body metastases demonstrated these are identified at t t t t and sacrum the largest of these lesions is at t where there is collapse of the vertebral body to a considerably greater extent than present on the ct scan there is extensive soft tissue extending from the posterior vertebral body into the spinal canal producing severe spinal cord compression at t tumor extends into the canal from the t body and just touches the left anterior surface of the spinal cord tumor also extends into the canal from the t body again touching the anterior surface of the cord there is no evidence of cord or cauda equina compromise at the other metastatic levels at the level of most severe spinal compression there is hyperintensity in the spinal cord on the long tr images presumably edema related to severe compression the metastases enhance after contrast administration no intradural tumor is identified again noted are multiple other metastases in the chest wall incompletely evaluated on this examination also again seen are bilateral pleural effusions greater on the left than right conclusion multiple spinal vertebral metastases with collapse of the t vertebral body and a soft tissue extending into the canal at this level producing severe spinal cord compression soft tissue extends into the canal at t and t contacting the spinal cord but not producing cord compression brief hospital course mr is a m with metastatic renal cell carcinoma with known malignant right sided pleural effusion s p recent drainage who presented with several days of right sided leg weakness urinary retention for several weeks months and constipation with radiographic evidence of cord compression at the level of t as above cord compression upon admission mr clinical signs of cord compression including right leg paralysis and radiographic evidence of t cord invasion he underwent operative intervention on with decompression at the level of the t lesion fusion t t laminectomies at t and t instrumentation t cage placement at t and autografting please see the operative report for complete details following this procedure his strength improved he was placed on a post operative steroid taper starting at dexamethasone mg iv q hrs to be tapered down by mg q hrs every other day this regimen was converted to po on the day of discharge he was discharged taking mg po q hrs his next adjustment was to be a decrease to mg po q hrs to be initiated hours after discharge pleural effusion patient was recently discharged after drainage of a recurrent malignant right pleural effusion and placement of pleurx catheter admission cxr demonstrated a stable slightly decreased effusion he was saturating well on room air at time of discharge this collection was drained every other day per his regular scheduled hyponatremia stable sodium at upon admission previously attributed to siadh stable throughout this hospitalization sodium equal to on day of discharge hypercalcemia calcium at admission previous admissions with suspicion of etiology secondary to combination of bony metastases and paraneoplastic hypercalcemia though no definitive work up for pthrp performed managed well via intravenous fluids corrected calcium equal to on day of discharge leukocytosis patient with persistent leukocytosis of several years attributed on previous admissions to be secondary to his renal cell carcinoma relatively stable througout admission though did exhibit increase in wbc count status post initiation of dexamethasone therapy wbc count equal to on day of discharge comparable to previous values expected to trend downwards with tapering of steroids as above thrombocytosis patient s thrombocytosis attributed to previous splenectomy hyposplenism metastatic renal cell carcinoma had been receiving genetech study drug but discontinued on recent admission secondary to dyspnea and progressive disease mr is to follow up as an outpatient for re evaluation and initiation of chemotherapy chronic issues hyperlipidemia continued simvastatin hypertension continued metoprolol transitional issues mr remained full code throughout his hospitalization his hcp is girlfriend of many years cell phone he will require outpatient follow up with np after discharge he has an appointment with dr neurosurgery on tuesday at am medications on admission the preadmission medication list is accurate and complete acetaminophen mg po q h prn pain docusate sodium mg po bid metoprolol tartrate mg po bid senna tab po bid prn constipation simvastatin mg po daily tamsulosin mg po bid hydromorphone dilaudid mg po q h prn pain breakthrough pain hold for rr bisacodyl mg po daily morphine sr ms contin mg po q h polyethylene glycol g po daily prn constipation discharge medications acetaminophen mg po q h prn pain fever polyethylene glycol g po daily constipation tamsulosin mg po bid simvastatin mg po daily dexamethasone mg po q h duration hours ondansetron mg iv q h prn nausea pantoprazole mg po q h metoprolol tartrate mg po bid morphine sr ms contin mg po q h rx morphine mg tablet s by mouth q hrs disp tablet refills hydromorphone dilaudid mg po q h prn pain breakthrough pain hold for rr rx hydromorphone dilaudid mg tablet s by mouth q hrs disp tablet refills senna tab po bid prn constipation docusate sodium mg po bid discharge disposition extended care facility hospital discharge diagnosis primary metastatic renal cell carcinoma secondary t cord compression hypercalcemia 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 dear mr thank you for choosing for your medical care you were admitted to the hospital for compression of your spinal cord caused by a metastatic lesion from your renal cancer you underwent surgery to relieve this compression you did well upon discharge please keep all of your scheduled appointments with your doctors please take all medications as prescribed refrain from driving while taking pain medication please return to the hospital or call dr office at if you experience any of the following fever chills night sweats loss of conciousness chest pain trouble breathing opening of your incision foul smelling or pus like discharge from your wound worsening back pain increasing weakness or any other symptoms that concern you spine surgery recommendations per dr do not smoke keep your wound s clean and dry no tub baths or pool swimming for two weeks from your date of surgery dressing may be removed on day after surgery 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 do not take any medications such as aspirin unless directed by your doctor 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 you will have a follow up appointment in approximately weeks with dr and to discuss chemotherapy options they will call you with an appointment please call np if you have not heard from them within approximately one week neurosurgery follow up wound check w nurse date tuesday time am location t spine ct scan npo hrs prior to scan date tuesday time pm location clinical center m d phd date tuesday time pm location if you know that you will not be able to keep your appointment please give us a call and we will be happy to re schedule your appointment for you please call department neurology when monday at am with md building sc clinical ctr campus east best parking garage department neurosurgery when tuesday at am with np building lm bldg campus west best parking garage [NEW_RECORD] name unit no admission date discharge date date of birth sex m service urology allergies no known allergies adverse drug reactions attending addendum this addendum reflects notation of the vaccines provided prior to discharge the following three vacines were provided prior to discharge pneumococcal vac polyvalent ml im influenza virus vaccine ml im now x meningococcal conj vaccine menactra ml im once duration doses major surgical or invasive procedure procedures left laparoscopic radical nephrectomy and left laparoscopic para aortic lymph node dissection procedure open splenectomy for splenic rupture discharge disposition home discharge diagnosis renal cell carcinoma splenic rupture md completed by,"{
""Diagnoses"": [""bilateral renal masses"", ""solid left renal masses"", ""suspicious for papillary RCC right kidney"", ""solid lesion in the mid kidney suspicious for RCC"", ""significant increase in mass cm with perinephric nodules""],
""Medications"": [""none""]
}"
67397,admission date discharge date date of birth sex f service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint exertional dyspnea major surgical or invasive procedure aortic valve replacement pericardial coronary artery bypass graft svg rca history of present illness this year old woman recently was diagnosed with sigmoid colon adenocarcinoma she was found to have aortic stenosis during workup for cardiology clearance prior to treatment due to the severity of the valvular stenosis and the coronary disease she was referred for cardiac surgery prior to colon surgery past medical history sigmoid colon adenocarcinoma hypertension aortic stenosis coromary artery disease social history retired seamstress lives with brother tobacco or etoh use family history noncontributory physical exam admission vs t hr bp rr o sat ht wt k gen nad skin unremakable heent teeth in poor condition neck supple pulm cta bilat cv rrr sem with radiation to carotids abdm soft nt nd bs ext warm no edema neuro grossly intact discharge vs t hr bp rr o sat ra wt k gen nad neuro a ox non focal exam pulm cta bilat cv rrr no murmur sternum stable incision slightly erythematous at margins abdm soft nt bs ext warm pedal edema bilat wounds minimal erythema sternal wound no drainage stable tape burn in fold of neck pertinent results pm glucose na k pm urea n creat chloride total co pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm pt ptt inr pt am 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 echocardiography report portable tte complete done at pm final referring physician information c status inpatient dob age years f hgt in bp mm hg wgt lb hr bpm bsa m m indication h o cardiac surgery evaluate for pericardial effusion icd codes v test information date time at interpret md md test type portable tte complete son rdcs doppler full doppler and color doppler test location contrast none tech quality adequate tape w machine vivid i 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 systolic dimension cm left ventricle fractional shortening left ventricle ejection fraction left ventricle lateral peak e m s m s left ventricle ratio e e aorta sinus level cm cm aorta ascending cm cm aortic valve peak velocity m sec m sec aortic valve peak gradient mm hg mm hg aortic valve mean gradient mm hg mitral valve e wave m sec mitral valve a wave m sec mitral valve e a ratio mitral valve e wave deceleration time ms ms findings this study was compared to the prior study of left atrium elongated la right atrium interatrial septum mildly dilated ra a catheter or pacing wire is seen in the ra normal ivc diameter cm with decrease during respiration estimated ra pressure mmhg left ventricle mild symmetric lvh with normal cavity size and regional global systolic function lvef no resting lvot gradient no vsd right ventricle borderline normal rv systolic function paradoxic septal motion consistent with prior cardiac surgery aorta mildly dilated aortic sinus mildly dilated ascending aorta aortic valve bioprosthetic aortic valve prosthesis avr avr well seated normal leaflet disc motion and transvalvular gradients trace ar tricuspid valve mild tr indeterminate pa systolic pressure pericardium no pericardial effusion conclusions the left atrium is elongated 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 with borderline normal free wall function the aortic root is mildly dilated at the sinus level the ascending aorta is mildly dilated a bioprosthetic aortic valve prosthesis is present the aortic valve prosthesis appears well seated with normal leaflet disc motion and transvalvular gradients trace aortic regurgitation is seen the pulmonary artery systolic pressure could not be determined there is no pericardial effusion compared with the prior study images reviewed of a bioprosthetic avr is now present electronically signed by md interpreting physician f medical condition year old woman s p cabg and new tlc placement reason for this examination r o ptx assess line placement final report ap chest p m history status post cabg new line placement impression ap chest compared to new right jugular line ends low in the svc cardiomediastinal silhouette which widened appreciably between and is slightly wider today accompanied by mild pulmonary vascular engorgement and small bilateral pleural effusions which were not present on all findings could be due to cardiac decompensation alone but also raise possibility of hemodynamically significant pericardial effusion was paged no pneumothorax moderate left lower lobe atelectasis unchanged the study and the report were reviewed by the staff radiologist dr dr approved wed am brief hospital course ms was a same day admit to the operating room on at which time she had an aortic replacement and coronary artery bypass graft please see or report for details in summary she had an avr pericardial cabgx svg rca her bypass time was minutes with a crossclamp of minutes she tolerated the operation well and was transferred to the cardiac surgery icu in stable condition she remained hemodynamically stable in the immediate post op period was weaned from sedation and extubated on pod she was transferred to the stepdown floor for continued post op care once on the floor she had a largely uneventful post op course she did however have some intermittant atrial fibrillation which was treated with beta blockers and amiodarone following which she converted back to sr over the next several days her activity was advanced her medications were titrated as tolerated and all tubes lines and drains were removed on pod she was discharged home with visiting nurses there was minimal erythema of the sternotomy incision but no instability or drainage there was as well a tape burn in the skin fold on the right neck with some erythema oral cephalosporins were begun followup was in the wound clinic and with dr medications on admission lisinopril mg d 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 metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet s refills furosemide mg tablet sig one tablet po once a day for weeks disp tablet s refills lisinopril mg tablet sig one tablet po daily daily disp tablet s refills potassium chloride meq tablet sustained release sig two tablet sustained release po once a day for weeks disp tablet sustained release s refills acetaminophen mg tablet sig tablets po q h every hours as needed ranitidine hcl mg tablet sig one tablet po bid times a day for weeks disp tablet s refills influen tr split vac pf mcg ml syringe sig one ml intramuscular asdir as directed disp ml s refills amiodarone mg tablet sig as labeled tablet po twice a day tablet twice daily for days then one tablet twice daily disp tablet s refills simvastatin mg tablet sig one tablet po once a day disp tablet s refills keflex mg capsule sig one capsule po four times a day for days disp capsule s refills dilaudid mg tablet sig tablets po every four hours as needed for pain for weeks disp tablet s refills discharge disposition home with service facility vna discharge diagnosis s p aortic valve replacement pericardial coronart artery bypass graft svg rca hypertension adenocarcinoma of the sigmoid colon aortic stenosis coronary artery disease discharge condition good 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 or while taking narcotics for pain call with any questions or concerns followup instructions clinic in weeks dr in weeks dr in weeks please call for appointments completed by,{}
54241,admission date discharge date date of birth sex f service medicine allergies penicillins erythromycin base attending chief complaint post cardiac catheterization right femoral access site groin hematoma major surgical or invasive procedure cardiac catheterization history of present illness y o f with bicuspid aortic valve recent echo showed valve area who is undergoing workup for planned upcomming avr as well as aortic root replacement for cm aneurysm who presented to cath lab today for elective pre op cath cath revealed clean coronaries but post cath course complicated with right groin hematoma after pulling sheath as well as min vaso vagal episode requiring mg atropine and dopamine drip cath lab initialy tried radial approach and gave heparin unsuccessful so switched to right femoral cath revealed clean coronaries post cath sheath was pulled and hematoma developed in r groin pt also vaso vagaled post cath and bp s hr s given atropine mg x l ivf dopamine plan is to admit to ccu for monitoring overnight on arrival to the floor patient denied any active complaints she reports chronic mild chest pressure and shortness of breath with exertion no orthopnea or pnd no heart palpitations 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 she denies recent fevers chills or rigors 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 diet controlled dyslipidemia hypertension cardiac history cabg none percutaneous coronary interventions none pacing icd none other past medical history aortic stenosis rheumatic fever age scarlet fever age hypertension hypercholesterolemia hypothyroidism rt foot fracture s p orif s p appendectomy s p ovarian cyst removal osteoporosis arthritis rt hand social history she is a widow living alone looking for part time work she used to manage medical records for does not exercise she is a widow living alone sister lives nearby tobacco quit etoh wine wk family history both parents died early of alcohol abuse brother died of esophageal cancer she has two sisters living paternal uncle with sudden cardiac death in his s physical exam physical examination on admission vs t bp hr rr o sat lnc 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 no jvd noted cardiac harsh crescendo decrescendo systolic murmur heard throughout 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 femoral cath site intact with no evidence of active bleeding skin no stasis dermatitis ulcers scars or xanthomas pulses right dp left dp pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt pm 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 ret aut am blood glucose urean creat na k cl hco angap am blood alt ast alkphos amylase totbili pm blood cholest am blood hba c eag pm blood triglyc hdl chol hd ldlcalc microbiologic data urine culture negative staph aureus screening pending imaging studies cardiac cath selective coronary angiography of this right dominant system demonstrated no angiographically apparent flow limiting disease the lmca lad lcx and rca had no significant stenoses the rca had the catheter deeply engaged with pleating but no fixed stenoses it could not be selectively engaged without deep seating and damping limited resting hemodynamics revealed normal systemic arterial pressures ortography revealed a dilated thoracic aorta no angiographically apparent flow limiting coronary artery disease normal systemic arterial pressures dilated thoracic aorta vascular ultrasound of right groin color doppler and spectral analysis of the vasculature of the right groin was performed normal arterial and venous waveforms were seen in the cfa and cfv wihtout evidence of pseudoaneurysm the common femoral and greater saphenous veins were compressible and no filling defect was noted by grey scale imaging no focal fluid collection in the region of visible hematoma was observed cxr pa and lateral pending final read per radiology brief hospital course f with a pmh significant for acute rheumatic fever in childhood with known severe bicuspid aortic valve stenosis of cm and aortic root dilation now pre op for avr bental procedure on who came to today for an elective pre op left heart catheterization the procedure was attempted radially but was technically not possible so right femoral access was obtained the patient was heparinized during the case due to this initial radial attempt the femoral sheath was pulled and an appropriate act with good hemostasis was noted but then the patient felt a popping sensation and developed hypotension and a new groin hematoma she appeared to be having a vagal response and was given atropine and ivf with improvement she was started on dopamine gtt for hypotension but this could not be completely weaned off the patient was then transferred to the ccu for close monitoring hypotension patient likely developed a vasovagal episode in the settiong of groin hematoma and compression at the time of her cardiac catheterization procedure she received atropine and ivf resuscitation with some repsonse but then required initiation of dopamine gtt which was subsequently weaned the morning following her procedure her anti hypertensive medications were held in this setting her hematocrit was stable on serial evaluation range without evidence of further bleeding on exam we continued to monitor her hemodynamics serially and provided low dose fluid boluses as needed her blood pressure was still mildly low in the mmhg systolic range following dopamine discontinuation and we held her lisinopril and hctz at discharge bicuspid aortic valve aortic root dilatation aortic stenosis patient presents with valve area of cm she denies dyspnea syncope lightheadedness or pedal edema on this admission of note her aortic aneurysm was found to be cm she is scheduled for upcoming avr and aortic root replacement bentall procedure with cardiac surgery in she will continue her pre op surgical evaluation prior to her procedure with dr in groin hematoma in the cardiac catheterization lab patient was noted to develop right femoral access site groin hematoma following sheath pull with subsequent vagal episode her hematoma was clinically monitored and appeared stable overnight she had a stable hematocrit with no further evidence of bleeding we maintained an active type and screen with peripheral iv access at all times hypothyroidism we continued her home dosing of levothyroxine mcg po daily hyperlipidemia we continued her home dosing of ezetimibe mg po daily and simvastatin mg po daily transition of care issues stopped lisinopril and hctz at discharge because of low blood pressure she will check bp the day after discharge and call dr with the results scheduled follow up with dr her primary care physician after discharge at the time of discharge a chest x ray and staph aureus swab screening were pending medications on admission ezetimibe simvastatin vytorin mg mg tablet daily gentamicin cream apply twice daily hydrochlorothiazide mg daily ketoconazole cream apply to rash daily levothyroxine mcg daily lisinopril mg daily triamcinolone acetonide cream apply to ears and neck daily for to days tylenol extra strength mg calcium citrate vitamin d calcium citrate d dosage uncertain discharge medications vytorin mg tablet sig one tablet po once a day gentamicin cream sig one application topical twice a day ketoconazole cream sig one application topical once a day as needed for rash levothyroxine mcg tablet sig one tablet po daily daily tylenol extra strength mg tablet sig two tablet po twice a day as needed for pain calcium citrate vitamin d oral discharge disposition home discharge diagnosis primary diagnoses post cardiac catheterization right femoral access site groin hematoma secondary diagnoses hypertension hyperlipidemia diabetes mellitus type severe aortic stenosis bicuspid aortic valve history of acute rheumatic fever aortic root dilatation discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms it was a pleasure taking care of you during yuor admission you were admitted to the coronary care unit ccu at after you underwent elective cardiac catheterization prior to your planned valve surgery in of following the procedure you developed a small right groin hematoma evidence of bleeding and were closely monitored overnight in the ccu you briefly required iv medication to support your low blood pressure this medication was stopped and your blood pressure was stable but still slightly low your bleeding remained stable and your hematocrit blooc count was stable prior to discharge because your blood pressure was low we have stopped your home antihypertensives lisinopril and hydrochlorothiazide as was discussed prior to discharge please measure your blood pressure at any local pharmacy and call dr with the results please call your doctor or go to the emergency department if you experience new chest pain pressure squeezing or tightness you develop new or worsening cough shortness of breath or wheezing you are vomiting and cannot keep down fluids or your medications if 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 see blood or dark black material when you vomit or have a bowel movement you experience burning when you urinate have blood in your urine or experience an unusual discharge your pain is not improving within hours or is not under control within hours your pain worsens or changes location you have shaking chills or fever greater than degrees fahrenheit or degrees celsius you develop any other concerning symptoms changes in your medications upon admission we added none the following medications were discontinued on admission and you should not resume lisinopril mg daily hydrochlorothiazide hctz mg daily you should continue all of your other home medications as prescribed unless otherwise directed above followup instructions department medical group when thursday at am with dr building ma campus off campus best parking on street parking please call dr tomorrow with your blood pressure as he had discussed with you [NEW_RECORD] admission date discharge date date of birth sex f service cardiothoracic allergies penicillins erythromycin base nickel attending chief complaint aortic stenosis dilated ascending aorta major surgical or invasive procedure aortic valve replacement mm on x mechanical mm gelweave graft ascending aorta cor matrix pericardial closure history of present illness this year old white female has a known bicuspid aortic valve and a history of rheumatic fever serial echos have demonstrated progressive stenosis of the valve and now a dilated ascending aorta she has had peripheral edema and increasing dyspnea with exertion she was admitted now for operation having a catheterization in showing no coronary disease past medical history aortic stenosis h o rheumatic fever hypertension ypercholesterolemia hypothyroidism rt foot fracture s p orif s p appendectomy s p ovarian cyst removal osteoporosis social history she is a widow living alone looking for part time work she used to manage medical records for does not exercise she is a widow living alone sister lives nearby tobacco quit etoh wine wk family history both parents died early of alcohol abuse brother died of esophageal cancer she has two sisters living paternal uncle with sudden cardiac death in his s physical exam pulse b p right left resp o sat ra temp height weight general alert short statured female in nad skin color pink skin warm and dry rash right chest and neck belly button without erythema or drainage there is a small lesion with scab noted the skin is friable heent conjunctiva pink left eye lower lid droop left eye skin tag lower lid oropharynx moist dental bridge good dentition neck supple trachea midline chest clear heart rrr iii vi sem holosystolic nl s s no s or s abd soft nontender nondistended bowel sounds extremities no cce no varicosities neuro alert and oriented mildy anxious gait steady gross from pulses right left radial femoral pt dp carotids no bruits transmitted cardiac murmur 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 am blood pt ptt inr pt am blood pt ptt inr pt am blood pt ptt inr pt am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap pm blood urean creat na k cl hco angap echocardiography report portable tte complete done at am final referring physician information c status inpatient dob age years f hgt in bp mm hg wgt lb hr bpm bsa m m indication aortic valve disease h o cardiac surgery left ventricular function prosthetic valve function icd codes v test information date time at interpret md md test type portable tte complete son md doppler full doppler and color doppler test location anesthesia west sicu ctic vicu contrast none tech quality suboptimal tape aw machine vivid q echocardiographic measurements results measurements normal range 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 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 a wave m sec mitral valve e a ratio mitral valve e wave deceleration time ms ms tr gradient ra pasp mm hg mm hg findings this study was compared to the prior study of left ventricle mild symmetric lvh normal lv cavity size moderately depressed lvef right ventricle rv not well seen aortic valve mechanical aortic valve prosthesis avr avr well seated normal leaflet disc motion and transvalvular gradients no ar mitral valve mildly thickened mitral valve leaflets mild mitral annular calcification no mr tricuspid valve tricuspid valve not well visualized physiologic tr normal pa systolic pressure pericardium no pericardial effusion general comments suboptimal image quality poor echo windows the rhythm appears to be a v paced results were personally conclusions there is mild symmetric left ventricular hypertrophy the left ventricular cavity size is normal overall left ventricular systolic function is moderately depressed lvef a mechanical aortic valve prosthesis is present the aortic valve prosthesis appears well seated with normal leaflet disc motion and transvalvular gradients no aortic regurgitation is seen the mitral valve leaflets are mildly thickened no mitral regurgitation is seen the estimated pulmonary artery systolic pressure is normal the right ventricle is not well but its function is probably normal there is no pericardial effusion compared with the prior study images reviewed of there is now global left ventricular systolic dysfunction which is new electronically signed by md interpreting physician brief hospital course as a same day admit she went to the operating room where the aortic valve was replaced and the ascending aorta replaced using a mm on x valve and a mm gelweave graft the peicardium was closed with cor matrix as well she weaned from bypass on neo synephrine in stable condition she weaned from the ventilator and pressor support easily chest tubes and temporary pacing wires were removed per protocol coumadin was started for the mechanical valve and heparin on pod heaprain was stopped on pod when her inr was therapeutic at and was given mg of coumadin she developed a junctional rhythm in the s postoperatively and electrophysiology was consulted she converted to sinus rhythm subsequently she was aggresively diuresed towards her preoperative weight physical therapy worked with her for strength and mobility on pod she was cleared for discharge to in appropriate follow up instructions medications and appointments were given medications on admission ezetimibe simvastatin vytorin mg mg tablet daily gentamicin cream apply twice daily hydrochlorothiazide mg daily ketoconazole cream apply to rash daily levothyroxine mcg daily lisinopril mg daily triamcinolone acetonide cream apply to ears and neck daily for to days tylenol extra strength mg calcium citrate vitamin d calcium citrate d dosage uncertain discharge disposition extended care facility discharge diagnosis aortic stenosis bicuspid aortic vaslve dilated ascending aorta s p aortic valve replacement and ascending aortic replacement hypertension hypercholesterolemia s p appendectomy h o rheumatic fever osteoporosis s p hysterectomy s p ovarian cystectomy hypothyroidism s p open reduction and internal fixation of right foot fracture discharge condition alert and oriented x nonfocal ambulating with steady gait incisional pain managed with oral analgesics incisions sternal 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 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 labs pt inr for coumadin indication mech avr on x ascending aortic replacement gelweave goal inr first draw results to phone please arrange coumadin follow up on discharge from rehab followup instructions you are scheduled for the following appointments surgeon dr on at pm cardiologist dr on at oopm please call to schedule appointments with primary care dr in weeks labs pt inr for coumadin indication mech avr on x ascending aortic replacement gelweave goal inr first draw results to phone please arraneg coumadin follow up on discharge from rehab please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours completed by,"{
""Diagnoses"": [""admission for planned AVR and aortic root replacement"", ""complicated groin hematoma after catheterization"", ""history of present illness with bicuspid aortic valve""],
""Medications"": [""heparin"", ""atropine"", ""dopamine"", ""mg x l ivf""]
}"
74337,admission date discharge date service surgery allergies penicillins attending chief complaint free air on ct abdomen transfer from osh major surgical or invasive procedure diagnostic laparoscopy exploratory laparotomy sigmoid resection with an end left colostomy history of present illness m admitted to osh s p fall from chair incidentally found to have free air on imaging now transferred for further management the patient suffered a mechanical fall from his rocking chair and in the osh ed was found to have an elevated cpk and he was admitted for iv hydration the patient had a decreased o saturation and increased respiratory rate in the am and a ct chest was performed which incidentally revealed a large amount of intraabdominal air ct abd po iv contrast was then performed and demonstrated large free air with sigmoid perforation likely due to diverticulitis he has hemodynamically stable he did have a fever to f prior to being transferred to however before this he had been afebrile without chills nausea emesis he also denies any abnormality in the frequency consistency or color of his stools he was noted to have abdominal distention and he received levofloxacin and flagyl he was then transferred to past medical history dm elevated cholesterol bph copd a fib on coumadin arthritis nephrolithiasis social history etoh none tobacco remote devoted family family history unknown physical exam vs afvss gen nad aox cvs irregularly irregular pulm no respiratory distress abd soft but distended ttp llq without rebound or guarding tympanitic le no lle pertinent results am wbc rbc hgb hct mcv mch mchc rdw am plt count am pt ptt inr pt am glucose urea n creat sodium potassium chloride total co anion gap am glucose urea n creat sodium potassium chloride total co anion gap pm wbc rbc hgb hct mcv mch mchc rdw pm calcium phosphate magnesium cxr mild pulmonary edema with bilateral pleural effusions are similar to that seen one day prior the new major abnormality consists of left lower lobe collapse with leftward shift of the heart and mediastinal contents no pneumothorax is seen cxr the et tube tip is cm above the carina cardiomediastinal silhouette is unchanged compared to the prior study the ng tube passes below the diaphragm there is interval worsening of pulmonary edema and increase in bilateral pleural effusions as well as no change in the left retrocardiac opacity consistent with atelectasis respiratory culture final commensal respiratory flora absent staph aureus coag organisms ml oxacillin resistant staphylococci must be reported as also resistant to other penicillins cephalosporins carbacephems carbapenems and beta lactamase inhibitor combinations rifampin should not be used alone for therapy sensitivities mic expressed in mcg ml staph aureus coag clindamycin r erythromycin r gentamicin s levofloxacin r oxacillin r rifampin s tetracycline s trimethoprim sulfa s vancomycin s urine culture final staph aureus coag organisms ml oxacillin resistant staphylococci must be reported as also resistant to other penicillins cephalosporins carbacephems carbapenems and beta lactamase inhibitor combinations yeast organisms ml sensitivities mic expressed in mcg ml staph aureus coag gentamicin s levofloxacin r nitrofurantoin s oxacillin r tetracycline s trimethoprim sulfa s vancomycin s brief hospital course pt admitted to acs service on after extensive discussion with the patient and his four daughters decision was made to proceed to the operating room emergently for exploration while in the or the pt underwent a sigmoid resection with an end left colostomy he tolerated the surgery well and was brought to the pacu for recovery he maintained stable hemodynamics and had adequate pain control cvs pt with known history of a fib was persistently tachycardic to low s s while on the surgical unit his pre op lopressor was resumed and adjusted for rate control currentlt on mg of lopressor tid his heart rate is in the s his preop coumadin was restarted at mg daily on but his inr is only he will receive coumadin mg tonight and have his coumadin dosed daily based on his inr to achieve a goal between and pulm on pt triggered for decreased o saturation and increased o requirement sats dropped to low s on lnc while hr was in the s pt was placed on nrb mask and transferred to the icu for further management he underwent vigorous pulmonary toilet and nebulizer treatments but eventually required intubation he had copious secretions and underwent a bronchoscopy on multiple plugs were suctioned out and bal was positive for mrsa he was extubated on without difficulty currently he is on l oxygen with saturations in the range and is continuing with bronchodilator therapy as well as the incentive spirometer gi gu on pt noted to have grossly edematous penis and scrotum on pt only able to void x throughout the day bladder scanned for cc in the early afternoon urology consulted to place catheter due to difficult anatomy with significant swelling catheter placed successfully and he failed another voiding trial on his urine culture is also positive for mrsa he will follow up with the clinic for a voiding trial next week id vancomycin was started on for a week course thru for mrsa in areas his dose has been adjusted and his last trough was at currently he is on mg iv bid and his creatinine is a left basilic picc line was placed on for long term antibiotics mr did remarkably well after his transfer to the surgical floor his diet was gradually advanced to regular and his ostomy was active his blood sugars were in good control and he was on blood sugar checks qid he was seen by the ostomy nurse daily for ostomy care teaching and management and he was gradually learning as were his daughters his surgical incision was healing well and he was actively working with physical therapy to regain mobility and return home soon he was discharged to rehab on and will follow up in the clinic in weeks medications on admission actos glipizide er lopressor zetia zocor coumadin mvi meds on transfer advair puff duoneb nexium glipizide metoprolol actos spiriva zetia riss levo flagyl vit k mg sq discharge medications senna mg tablet sig one tablet po bid times a day as needed for constipation acetaminophen mg tablet sig tablets po q h every hours as needed for pain temp tramadol mg tablet sig tablet po q h every hours as needed for pain heparin porcine unit ml solution sig injection tid times a day pioglitazone mg tablet sig one tablet po daily daily glipizide mg tablet extended rel hr sig one tablet extended rel hr po daily daily pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day albuterol sulfate mcg actuation hfa aerosol inhaler sig one puff inhalation times a day ipratropium bromide mcg actuation hfa aerosol inhaler sig one puff inhalation times a day ezetimibe mg tablet sig one tablet po daily daily simvastatin mg tablet sig two tablet po daily daily warfarin mg tablet sig five tablet po once for adjust to keep inr metoprolol tartrate mg tablet sig one tablet po tid times a day vancomycin in d w gram ml piggyback sig mg intravenous q h every hours 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 discharge disposition extended care facility discharge diagnosis perforated sigmoid diverticulitis with feculent gross contamination mrsa pneumonia mrsa uti atrial fibrillation urinary retention 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 to the hospital with diverticulitis requiring surgery to remove part of your colon you have a colostomy now and will pass air and stool thru it over time you will learn how to manage the colostomy when you get home the vna will also help you you developed pneumonia after surgery and will need to continue antibiotics intravenously which will be given through your picc line you will also need to continue to cough deep breath and use your incentive spirometer to keep your lungs inflated you also have a urinary tract infection which will be taken care of with the antibiotic your catheter will probably be removed next week at the urology clinic your coumadin will be regulated at rehab followup instructions call the clinic at for a follow up appointment in weeks call the clinic at for a voiding trial next week md completed by,"{
""Diagnoses"": [""diverticulitis"", ""sigmoid perforation""],
""Medications"": [""levofloxacin"", ""flagyl""]
}"
12661,admission date discharge date date of birth sex f service intensive care unit history of present illness the patient is a year old female who was admitted to the intensive care unit after a klonopin overdose and was intubated for airway support she has a long history of bipolar disorder and was found slumped over in a car by report she was initially unresponsive and cyanotic with a respiratory rate of she was found by a family member who is an emergency medical technician she was given oxygen via nasal cannula and reportedly told the medical staff that she had taken klonopin and an empty klonopin bottle was found the patient s friend noted that other drugs were missing as well which included diabetic and hypertensive medications a suicide note was found as well and the patient was taken to the emergency department in the emergency department her temperature was degrees fahrenheit her blood pressure was and she was saturating on room air with a heart rate of on examination she appeared somnolent she received narcan times one in the emergency department without improvement there was consideration to give her flumazenil she was not given flumazenil for fear it would precipitate seizures with the chronic benzodiazepines use because of the need for nasogastric tube placement and activated charcoal she was nasally intubated for airway protection after she was intubated she was given ativan with an initial drop in her blood pressure into the s to s requiring minutes of levophed and intravenous fluid hydration with improvement she was subsequently taken off levophed her chest x ray showed no obvious pulmonary abnormalities she received a fast ultrasound in the emergency department which was unremarkable she was then admitted to the intensive care unit for further management past medical history bipolar disorder times eight years type diabetes mellitus osteoarthritis a questionable history of asthma gastroesophageal reflux disease history of gastric bypass surgery complicated by a ventral hernia and reversal of her bypass as well as abdominal wall abscesses and chronic abdominal pain status post cholecystectomy in history of iron deficiency anemia history of amenorrhea and possible polycystic ovary syndrome allergies unknown at the time of admission but was reported as no known drug allergies on previous medical records medications on admission by report her medications on admission included paxil mg by mouth once per day klonopin mg by mouth seroquel mg by mouth topamax trazodone ambien albuterol as needed by report medications the patient may have ingested which were prescribed to a friend of hers included glucophage glyburide lipitor wellbutrin and atenolol social history positive tobacco use no intravenous drug use by report the patient is homeless but has been living with friends she recently moved from physical examination on presentation vital signs on admission included a temperature of degrees fahrenheit her blood pressure was her heart rate was initially on assist control x with an fio of and a positive end expiratory pressure of with pips of and plateau pressures of on examination she was nasally intubated she was comfortable intubated and sedated head and neck examination revealed the sclerae were anicteric the mucosa were moist jugular venous distention was difficult to assess secondary to obesity the lungs were clear anteriorly and laterally cardiovascular examination revealed a regular rate and rhythm the abdomen was notable for positive bowel sounds there was a ventral hernia the abdomen was nondistended the extremities had trace edema bilaterally pertinent laboratory values on presentation initial laboratories were notable for a white blood cell count of her hematocrit was and her platelets were coagulations were normal initial chemistry revealed her sodium was potassium was chloride was bicarbonate was blood urea nitrogen was creatinine was and her blood glucose was her calcium magnesium and phosphate were within normal limits normal anion gap initial urinalysis with positive nitrites to white blood cells and many bacteria there were no epithelial cells her lithium level was initial urine toxicology screen was negative her liver function tests were within normal limits urine pregnancy test was negative pertinent radiology imaging initial head computed tomography revealed no intracranial hemorrhage no fractures suboccluded ethmoid sinuses likely secondary to nasogastric intubation an electrocardiogram with nonspecific st changes but no q t prolongation a chest x ray was without acute cardiopulmonary abnormalities brief summary of hospital course by issue system respiratory issues the patient was initially intubated for airway protection prior to nasogastric tube placement and activated charcoal for a likely overdose after the charcoal was given and the effects of the benzodiazepines had worn off she was slowly weaned off the ventilator and extubated on after her extubation she continued to have respiratory distress with an increased respiratory rate and increased a a gradient she continued to have respiratory distress with an increased respiratory rate and increased a a gradient on arterial blood gas because of this she was reintubated during her reintubation she had episodes of vomiting and was thought to have possible aspiration pneumonia a right internal jugular central line was placed and an arterial line was placed for close monitoring of her central venous pressure and blood pressure during her hospital course she had some difficulty weaning because of elevated transpleural pressures given her obesity her positive end expiratory pressures were increased accordingly because of these elevated transportal pressures a big boy bed was obtained which would allow the patient to sit more upright so she would have decreased pressure from the abdomen affecting her respiratory ability her sedation was weaned down and she had good respiratory rates and had done well on a breathing trial on she was extubated and slowly weaned off oxygen to nasal cannula it was felt that she likely had baseline oxygen saturations in the low s and was weaned down accordingly she was continued on nighttime level positive airway pressure as done previously infectious disease issues the patient likely had an aspiration pneumonia during her reintubation bronchial washings obtained were notable for methicillin resistant staphylococcus aureus and she was treated empirically for methicillin resistant staphylococcus aureus and or aspiration pneumonia with vancomycin and flagyl to complete a day course she had positive blood cultures which grew coagulase negative staphylococcus and were thought to likely be contaminant she had a transthoracic echocardiogram performed prior to the speciation of her blood cultures which was negative for vegetations and showed a normal ejection fraction subsequently her internal jugular line and arterial line were pulled she remained afebrile gastrointestinal issues the patient has a history of gastric bypass surgery with numerous complications including a ventral hernia and chronic abdominal pain records were obtained for where she had her previous surgeries on the day of her reintubation she was noted to have significantly increased abdominal distention and there was concern for a small bowel obstruction given her history of surgeries and likely adhesions the surgery service was consulted the orogastric tube was placed to suction and the patient had an abdominal computed tomography which was concerning for an ileus versus a small bowel obstruction she was kept on bowel rest and slowly had a decrease in her abdominal distention and had good bowel sounds after extubation her orogastric tube was pulled the patient was able to tolerate a by mouth diet with minimal abdominal pain she was felt to be at her baseline cardiovascular issues while intubated the patient required several intravenous fluid boluses to maintain appropriate central venous pressures and to maintain good urine output over her intensive care unit course she was over liters positive with no evidence of congestive heart failure or lower extremity edema after her extubation she auto diuresed a significant amount of fluid and was hemodynamically stable upon transfer psychiatric issues the patient was restarted on her outpatient medications once these records were obtained after she was extubated she was placed on a one to one sitter the psychiatry service was consulted their recommendations were to continue her on seroquel as well as klonopin and ativan as needed other medications would be added during subsequent psychiatric followup it was felt that she would likely need eventual transfer to an inpatient psychiatric facility after medically stabilized disposition issues the patient continued to do well after extubation and was felt to be stable from a respiratory standpoint her mental status was felt to be at baseline and she was tolerating by mouth without complaints she was then transferred to the medical team for further care with eventual transfer to an inpatient psychiatric facility given her history of bipolar disorder and recent suicide attempt note a follow up dictation will dictate the hospital course after dr dictated by medquist d t job [NEW_RECORD] name unit no admission date discharge date date of birth sex f service hospital course addendum since the previously dictated discharge summary the patient was called out from the intensive care unit to the regular medicine floor at the time of call out the patient was extubated and on five liters nasal cannula she was on day eight of antibiotics for treatment of aspiration pneumonia and she was constipated problem respiratory status within two days the patient s oxygen was weaned to room air and she was saturating percent in room air she was continued on metered dose inhalers atrovent and albuterol in addition the patient s family brought in her continuous positive airway pressure machine and she was started on continuous positive airway pressure at night she finished a ten day course of intravenous antibiotics metronidazole and vancomycin for treatment of aspiration pneumonia she was maintained on methicillin resistant staphylococcus aureus precautions as she had a positive sputum culture while she was in the intensive care unit the patient was ambulating well without dyspnea she had a chair bed to prevent hypoventilation during the night from lying flat problem constipation the patient had not had a bowel movement from the day of admission approximately ten days she was given an aggressive bowel regimen and had a large black bowel movement her hematocrit remained stable and her stool was not guaiac positive in addition the patient is on iron which is most likely the cause of the black coloration of her stool she continued to have stools daily prior to discharge problem diabetes glucose intolerance the patient has glucose intolerance at baseline she was placed on an insulin sliding scale however she did not require any insulin during her hospitalization this should be followed as an outpatient problem psychiatry the patient is status post a suicide attempt by overdose of klonopin the patient was maintained on seroquel klonopin and her paroxetine was increased from mg to mg prior to discharge the patient will be transferred to a psychiatric inpatient unit the patient is being discharged to care facility discharge condition ambulating oxygen saturation is approximately percent in room air using continuous positive airway pressure at night the patient is having bowel movements she is pleasant on a one to one sitter and off of antibiotics medical issues are resolved final diagnosis suicide attempt bipolar disorder klonopin overdose aspiration pneumonia with methicillin resistant staphylococcus aureus isolated from sputum hypotension anion gap metabolic acidosis partial small bowel obstruction hypoxia constipation urinary tract infection obesity sleep apnea on continuous positive airway pressure gastroesophageal reflux disease iron deficiency anemia glucose intolerance history of gastric bypass follow up she is to have recommended follow up with primary care physician as needed she is to follow up with a psychiatrist as directed discharge medications her discharge medications include ferrous sulfate mg p o b i d bisacodyl mg p o q day p r n constipation clonazepam mg p o t i d quatiapine mg p o b i d quatiapine mg p o q hours p r n lactulose cc q hours p r n constipation ipratropium metered dose inhaler two puffs q i d albuterol inhaler one to two puffs q hours p r n paroxetine mg p o q day colace mg p o b i d p r n constipation and senna mg p o b i d p r n constipation dr dictated by medquist d t job,"{
""Diagnoses"": [""Overdose"", ""Klonopin overdose""],
""Medications"": [""Narcan"", ""Flumazenil""]
}"
15085,admission date discharge date service ccu chief complaint transferred from an outside hospital for persistent left arm pain history of present illness an year old male with a history of coronary artery disease is status post myocardial infarction and percutaneous transluminal coronary angioplasty in at who presents with total body aching and malaise at outside hospital on he subsequently developed chest pain and left arm pain emts were called and gave the patient nitroglycerin the patient was started on nitroglycerin drip and became pain free however over the course of the next day he developed left arm pain and rest that was not relieved with nitroglycerin drip aspirin and lovenox he was then transferred to for emergent catheterization en route the patient was given integrilin drip as well as fentanyl mcg x with resolution of his pain past medical history transient ischemic attack coronary artery disease status post myocardial infarction with angioplasty in cm abdominal aortic aneurysm being followed by dr leg cramps outpatient medications atenolol echinacea multivitamin protonix pravachol doxazosin aspirin transfer medications nitroglycerin drip integrilin drip lovenox aspirin atenolol mg po q day fentanyl prn allergies no known drug allergies social history lives with his wife former and no alcohol use family history father with coronary artery disease at unspecified age physical exam on admission vital signs blood pressure heart rate o saturation on liters nasal cannula general elderly male lying flat in no acute distress head ears eyes nose and throat extraocular movements intact tongue midline no jugular venous distention cardiovascular normal s s regular rate and rhythm q systolic murmur at right upper sternal border lungs clear to auscultation bilaterally abdomen soft nontender obese normoactive bowel sounds extremities dp pulses bilaterally no groin bruits admission labs white blood count hematocrit platelets inr ptt sodium potassium chloride bicarbonate bun creatinine glucose ck with an mb of troponin of imaging electrocardiogram normal sinus rhythm at beats per minute q wave in and avf depression in v through v impression the patient is an year old male with non st elevation myocardial infarction with recurrent pain despite lovenox aspirin and nitroglycerin drip hospital course cardiovascular the patient was taken to cardiac catheterization on the morning of catheter was found to have a diffusely diseased and totally occluded right coronary artery with collateralization suggesting chronic occlusion there was a lad lesion and an om lesion which was stenosed the om lesion was felt to be the culprit given the electrocardiogram findings and this was percutaneous transluminal coronary angioplastied and stented with resulting stenosis and timi flow the patient was started on captopril which was gradually titrated up from mg to mg po tid and was then changed over to lisinopril mg po q day the atenolol was increased to mg po q day he was started on plavix mg and continued on the aspirin the patient was also started on lipitor mg po q day post catheter the patient continued to complain of bilateral shoulder pain and it was unclear if this was due to muscular and skeletal pain versus possibility of aortic dissection he underwent a ct angiogram on which showed the abdominal aortic aneurysm unchanged in size with no evidence of dissection there was also a small hematoma at the right groin site which was manually compressed and which stopped bleeding with stable hematocrit for two days with post catheter the patient s cks peaked at about and mb troponin peaked at and were trending down by the patient was seen by physical therapy who recommended cardiac rehabilitation and the patient is to follow up with his primary cardiologist at hospital within the next week discharge diagnoses acute myocardial infarction status post percutaneous transluminal coronary angioplasty and stent of om lesion abdominal aortic aneurysm leg cramps discharge condition good the patient is feeling well is ambulating without difficulty eating and drinking without any problems and is to be discharged home with plans for cardiac rehabilitation and cardiac follow up discharge medications lisinopril mg po q day atenolol mg po q day lipitor mg po q day aspirin mg po q day plavix mg po q day x year m d dictated by medquist d t job,{}
14785,admission date discharge date date of birth sex m service chief complaint shortness of breath history of present illness this is a year old male with a history of pe in obstructive sleep apnea and prostate cancer who presented with shortness of breath starting four days prior to admission but becoming acutely worse on the morning of admission the patient went to his primary care physician and was sent to the emergency department he had no chest pain no pleuritic chest pain no new lower extremity edema although the patient does have chronic stable lower extremity edema bilaterally the patient had recently flown to and returned five days ago no fevers or chills were noted no recent illnesses no melena no hematochezia past medical history pe in status post orthopedic surgery obstructive sleep apnea with cpap at mm of water hyperglycemia history without a diagnosis of diabetes mellitus last a c in obesity prostate cancer status post prostatectomy ankle fracture glaucoma hypertension diverticulosis chronic lower extremity edema allergies sulfa give the patient a rash medications aspirin multivitamin timolol hydrochlorothiazide started three days prior to admission social history the patient is the chief of anesthesiology at he does not smoke drinks occasional alcohol family history mother died of pe physical examination temperature was blood pressure pulse respirations saturating on five liters on room air general obese male mildly tachypneic with nasal cannula on alert and oriented x in no acute distress heent pupils were equal round and reactive to light and accommodation mucous membranes were moist extraocular movements intact anicteric sclerae benign oropharynx neck no lymphadenopathy no jugular venous distension appreciated chest clear to auscultation bilaterally cardiac regular rate and rhythm split s no rubs gallops or murmurs no heave abdomen obese nontender nondistended normal active bowel sounds no organomegaly extremities pitting edema bilaterally and equal neurologic no focal neurologic deficits the patient reports a rectal examination was done in the primary care physician s office and was negative laboratory data white blood cell count polys lymphocytes hematocrit platelet count mcv sodium potassium chloride bicarbonate bun creatinine glucose inr spiral cta showed large left main pulmonary artery embolus and large right pulmonary embolus slightly smaller than left both are in the main pulmonary arteries ekg normal sinus rhythm at question of right atrial abnormality otherwise normal axis no s q t no st changes no old ekg for comparison echocardiogram done in the emergency department showed an ejection fraction of greater than but increased pulmonary artery pressures mmhg he has a dilated right ventricle with decreased right ventricular function abnormal septal motion consistent with right ventricular volume overload and left apical sparing consistent with sign there was mild symmetric left ventricular hypertrophy hospital course this is a year old male with past pe presenting with massive bilateral pulmonary emboli and hemodynamically stable the echocardiogram does show signs of right ventricular strain pulmonary emboli massive bilateral pes with right ventricular strain but hemodynamic stability the patient was initially admitted to the intensive care unit after being started on heparin in the emergency department he was observed in the intensive care unit for two days without adverse events he was then called out to the floor and continued on his heparin gtt with coumadin dosing he was then switched from heparin to lovenox in anticipation for discharge he gradually was weaned from his nasal cannula and the patient was saturating on room air with ambulation upon discharge lower extremity duplex was performed to look for potential source of his pe this examination showed a nonobstructive left popliteal dvt because the patient was hemodynamically stable throughout his hospitalization and improving on anticoagulation he was not given thrombolysis treatment for his massive pe his anticoagulation will be managed by his primary care physician d diabetes mellitus the patient was hyperglycemic throughout his hospital admission his fasting blood sugars were repeatedly greater than and he was diagnosed with type diabetes mellitus he was started on glucophage mg p o q d a hemoglobin a c level was drawn which was consistent with his suspected diabetes mellitus gout the patient had a flare of gout in his left great toe podagra he was treated with indomethacin mg p o t i d with mild improvement upon discharge obstructive sleep apnea the patient was continued on his cpap of mm of water at night the patient was discharged home stable on room air with coumadin and lovenox bridging he will follow up at the office of dr on friday for an inr draw and follow up appointment discharge diagnoses massive pulmonary embolism diabetes mellitus gout obstructive sleep apnea discharge medications lovenox mg subcutaneous b i d until therapeutic inr as instructed by dr coumadin mg p o q d until appointment with dr and then doses according to her instructions timolol eyedrops b i d bilaterally latanoprost drops bilateral eyes q h s indomethacin mg p o t i d until gout relieved glucophage mg p o q d multivitamin one p o q d m d dictated by medquist d t job,"{
""Diagnoses"": [""Shortness of breath"", ""Obstructive sleep apnea"", ""Prostate cancer"", ""Hypertension"", ""Diverticulosis"", ""Chronic lower extremity edema""],
""Medications"": [""Aspirin"", ""Timolol"", ""Hydrochlorothiazide""]
}"
8992,admission date discharge date service ccu history of present illness the patient is an year old male with a history of atrial fibrillation chronic renal insufficiency status post abdominal aortic aneurysm repair in presenting with the acute onset of chest pain and presyncope on the morning of admission the patient was in his usual state of health until the morning of admission when he developed the acute onset of chest pressure and lightheadedness after awaking emergency medical service was called and the patient was noted to be bradycardic to a heart rate of to and hypotensive the patient was given atropine times two and started on a dopamine drip mental status was initially lethargic but then the patient was alert and oriented times three heart rate improved with atropine the patient was brought to the emergency department an electrocardiogram was obtained on arrival to the emergency department which showed evidence of inferior st elevations along with a slow atrial fibrillation with a regularized narrow complex escape rhythm he was administered atropine and dopamine the patient was taken emergently to the cardiac catheterization laboratory cardiac catheterization revealed a total occlusion of the posterior left ventricular and a right dominant circulation additionally diffuse disease of the left anterior descending artery up to proximally was identified hemodynamics revealed a cardiac index of with a pulmonary artery saturation of and a pulmonary capillary wedge pressure of the patient received a stent in his posterior left ventricular branch status post cardiac catheterization in recovery the patient received mg p o intravenous ativan for restlessness of the lower extremities soon after receiving ativan the patient became agitated with orientation decreased and slurred speech the symptoms did not improve with mg of flunisolide a ct scan of the had was done to rule out a head bleed the ct was negative for a bleed the patient was then transferred to the coronary care unit past medical history atrial fibrillation on coumadin chronic renal insufficiency status post left nephrectomy status post abdominal aortic aneurysm repair in hypertension echocardiogram done in revealed an ejection fraction of to medications on admission metoprolol mg p o b i d hydrochlorothiazide mg p o b i d zestril mg p o b i d synthroid mg p o q d coumadin mg p o q h s five days of the week along with mg p o q h s two days of the week xalatan eyedrops q p m cosopt eyedrops q a m and q p m alphagan eyedrops q a m and q p m allergies no known drug allergies social history the patient quit tobacco years ago family history the patient denies a family history of coronary artery disease physical examination on presentation physical examination on admission revealed a blood pressure of heart rate of respiratory rate of oxygen saturation of on liters nasal cannula in general the patient is an year old caucasian male appearing mildly agitated and restless alert and oriented only to person head and neck examination revealed pupils were equal round and reactive to light sclerae were anicteric the oropharynx was clear neck revealed jugular venous pressure was about cm there were no carotid bruits chest with mild bibasilar rales no wheezes or rhonchi good aeration throughout cardiovascular examination revealed a normal first heart sound and second heart sound rhythm was irregularly irregular there was a systolic ejection murmur at the left lower sternal border no rubs or gallops the abdomen was soft nontender and nondistended there were good bowel sounds in all four quadrants no masses extremities revealed no clubbing cyanosis or edema peripheral pulses were neurologic examination revealed the patient was alert and oriented times two to person and place the patient had difficulty speaking appeared confused was only able to follow some commands the patient was moving all four extremities pupils were equal round and reactive to light tongue was midline face was symmetric note the rest of this dictation will be continued at a later time m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service laboratory data on admission white blood cell count hematocrit platelet count pt inr ptt glucose bun creatinine sodium potassium chloride co calcium magnesium phosphorus ck troponin abg prior to cardiac catheterization as follows ph po pco abg after cardiac catheterization on liters nasal cannula as follows ph pco po cardiac index calculated at chest x ray on admission there is increased opacity along the upper right mediastinum unchanged from prior study and appears to be related to right apical scarring the opacities in the left retrocardiac region could represent atelectasis or an early infiltrate no evidence of pulmonary vascular congestion or pulmonary edema no pleural effusions ekg in the emergency room with chest pain on dopamine as follows atrial fibrillation with a heart rate of right bundle branch block v through v elevation with t wave inversions in lead and avf st depressions v and v of mm post cardiac catheterization ekg as follows decreased st elevations inferiorly and st depressions in precordial leads but persistent cardiac catheterization results as follows selective coronary angiography in this right dominant system revealed two vessel epicardial coronary artery disease the left main had a proximal stenosis the lad had severe proximal disease followed by a ulcerated mid portion the remainder of the vessel and the diagonal branches had mild luminal irregularities the circumflex artery had mild diffuse disease the dominant rca had mild luminal irregularities in the proximal and mid portion the plv had an abrupt cutoff with an acute appearance the pda was free of significant disease resting hemodynamic monitoring post angiography revealed elevated left heart filling pressures with a pulmonary capillary wedge pressure mean of mm v wave to mm were noted the calculated cardiac index by fick method was there was successful ptca and stent of the plv hospital course in summary mr is an year old male who is presenting with evidence of acute inferior st elevation mi cardiovascular a pump function the patient s cardiac index was recalculated and was noted to be given this low cardiac index it appeared reasonable to observe the patient in the intensive care unit setting overnight after cardiac catheterization and intervention it seemed surprising that the patient s cardiac index should be so low given an apparently adequate ejection fraction in the year the wave form given the low cardiac index and relatively low pulmonary capillary wedge pressure favored volume hydration to improve this initially the patient s urine output was used as a measure of end organ perfusion and was adequate an echocardiogram was repeated in order to re evaluate the ejection fraction which revealed an ejection fraction of mild left atrial dilation with severe hypokinesis of the inferoposterior wall which was new there was aortic regurgitation mitral regurgitation and tricuspid regurgitation the cardiac index that was measured post cardiac catheterization was surprisingly low and only slightly depressed ejection fraction on hospital day the patient was restarted on lopressor which was then discontinued as the patient had a bradycardic response to one dose of lopressor mg beta blocker was then added back on hospital day at lopressor mg which the patient tolerated well aside from asymptomatic two second pauses on telemetry monitoring the patient was also restarted on ace inhibitor mg po bid on hospital day and remained hemodynamically stable with stable and renal function after restarting the patient was continued on hydrochlorothiazide diuretic mg po bid to keep even to slightly negative fluid balance the patient s oxygen requirement diminished to room air by the time of discharge b ischemia patient was continued on integrilin for hours post cardiac catheterization the patient was also continued on aspirin and started on plavix mg po q d to continue a day course beta blocker was initially started and then stopped secondary to a bradycardic response beta blocker was eventually restarted and patient tolerated this well the patient was also started on ace inhibitor with no decline in renal function of concern was the lad lesion seen on cardiac catheterization which was not intervened on during this hospitalization it was decided to have the patient get an exercise thallium test as an outpatient to evaluate the lad territory for possible revascularization if this defect was reversible the patient did not have any further episodes of chest pain during hospital stay c rhythm the patient had a history of chronic atrial fibrillation beta blocker was initially held secondary to bradycardia and then was restarted with good effect as the patient had bleeding with foley insertion in the cath lab coumadin was initially held however coumadin was restarted on hospital day and inr was on the day of discharge renal the patient had a history of chronic renal insufficiency and was status post left nephrectomy the patient s renal function was watched closely especially after receiving a dye load from cardiac catheterization the patient had adequate urine output and stable renal function throughout hospital course even after restarting ace inhibitor hematology patient s coumadin was initially held on admission secondary to bleeding with trauma secondary to foley insertion however coumadin was later restarted with no evidence for bleeding with a therapeutic inr of by the time of discharge condition on discharge stable discharge status patient to be discharged home to follow up for an exercise thallium test as an outpatient in two weeks discharge medications hydrochlorothiazide mg po bid lopressor mg po bid coumadin mg po q d from saturday through wednesday and mg po q d on thursday and friday zestril mg po bid aspirin mg po q d plavix mg po q d to complete a day course lipitor mg po q d sublingual nitroglycerin prn flomax mg po q h s eyedrops as on admission synthroid mg po q d m d dictated by medquist d t job [NEW_RECORD] admission date discharge date service vascular surgery chief complaint infected ischemic left second toe history of present illness this is an year old nondiabetic white male with coronary artery disease status post myocardial infarction and ptca stent in atrial fibrillation hypertension hypothyroidism with history of renal cancer colon cancer and resection of abdominal aortic aneurysm he complained of recurrent left second toe infection the patient had been evaluated by dr in for an episode of left second toe infection and cellulitis the patient requested conservative treatment at that time rather than a work up for revascularization of his left leg because of his cardiac events in which were complicated by pneumonia as well the patient s left second toe became swollen discolored and tender approximately one week prior to admission past medical history coronary artery disease myocardial infarction ptca stent in atrial fibrillation anticoagulation with coumadin hypertension hypercholesterolemia hypothyroidism chronic renal insufficiency gout colon cancer renal cancer vertebral compression fractures glaucoma pneumonia in past surgical history abdominal aortic aneurysm repair with an aortobifemoral bypass graft in right nephrectomy in colon resection for cancer family history noncontributory social history the patient lives with his wife uses a cane to ambulate he quit smoking cigarettes years ago after two packs per day for approximately ten years he does not drink alcohol allergies the patient has no known drug allergies medications on admission coumadin mg p o q d metoprolol mg p o b i d lasix mg p o q hours synthroid mg p o q d lipitor mg p o q d allopurinol mg p o q d aspirin mg p o q d calcium supplement sublingual nitroglycerin p r n cosopt drop ou b i d alphagan drop ou b i d xalatan drop ou q h s physical examination vital signs were temperature pulse respiratory rate blood pressure o saturation equals on room air general alert cooperative white male in no acute distress heent pupils equal round and reactive to light extraocular movements intact neck range of motion within normal limits no lymphadenopathy or thyromegaly carotids palpable no bruits chest heart rate was irregularly irregular lungs clear bilaterally abdomen soft nontender extremities right lower extremity was warm without lesions the left second toe was swollen with surrounding erythema the toe itself was a bluish mottled color there was a superficial ulceration with dry eschar pedal pulses had doppler signals bilaterally neurological examination nonfocal laboratory data pt ptt inr sodium potassium chloride co bun urinalysis negative chest x ray showed no acute pulmonary disease ekg showed atrial fibrillation hospital course the patient was admitted to dr of podiatry cultures of the second toe were taken the patient was started on kefzol wound cultures grew sensitive staphylococcus aureus cardiology was consulted for preoperative clearance they felt that the patient was a high risk because of his known lad lesion from the cardiac catheterization done in they felt he was a poor candidate for any kind of cardiac intervention but recommended a pharmacological stress test and review of his previous cardiac catheterization the patient had a persantine thallium study on there was an inferior defect which was partially reversible there was no anterior wall defect which suggested that the lad stenosis was not hemodynamically significant therefore no other interventions were necessary and the patient was cleared for vascular surgery on the patient underwent an uneventful left femoral to below the knee popliteal bypass graft with nonreversed saphenous vein at the end of the surgery the patient had a warm left foot with dopplerable pedal pulses postoperatively the patient received two units of packed red blood cells the patient s anticoagulation with coumadin for his atrial fibrillation was restarted physical therapy evaluated the patient for full weight bearing ambulation the patient was doing very well at the time of discharge the patient s left leg incision was clean dry and intact his left second toe had improved considerably and would not require any intervention during this hospitalization his pedal pulses were dopplerable bilaterally the patient was instructed to follow up with dr in the office for staple removal in two weeks discharge medications coumadin mg p o q d lopressor mg p o b i d lasix mg p o q hours levothyroxine mcg p o q d allopurinol mg p o q d atorvastatin mg p o q d aspirin mg p o q d multivitamins p o q d colace mg p o b i d tylenol tablets p o q hours p r n tylenol tablets p o q hours p r n cosopt drop ou b i d alphagan drop ou b i d xalatan drop ou q h s condition on discharge satisfactory disposition discharged home with services discharge diagnoses ischemic infected left second toe left common femoral to below the knee popliteal nonreversed saphenous vein graft on secondary diagnoses blood loss anemia transfused atrial fibrillation requiring anticoagulation with coumadin coronary artery disease status post myocardial infarction and stent hypothyroidism renal cancer status post nephrectomy colon cancer status post colectomy abdominal aortic aneurysm repair gout m d dictated by medquist d t job [NEW_RECORD] admission date discharge date service vascular surgery history of present illness patient is an year old gentleman with an extensive history of coronary artery disease who is status post myocardial infarction with known peripheral vascular disease he is also status post left femoral to popliteal bypass graft in he originally presented to the emergency department with a history of increasing erythema and swelling of the left great toe and forefoot one month prior to this admission at that time he was admitted for one week and treated with iv antibiotics plan was to discharge him to home and readmit him at a later time for possible amputation on he returned with worsening symptoms on his left foot he denied any chest pain shortness of breath fever chills diarrhea or constipation he does have significant pain while ambulating there is known increased erythema around the left second toe amputation site going up to his mid calf prior medical history coronary artery disease status post ptca and stent in of afib rheumatic heart disease renal cell carcinoma status post nephrectomy on right side hypothyroid chronic renal insufficiency with creatinines ranging between and glaucoma status post colon cancer myelodysplastic disorder with decreased platelet count prior surgical history patient is status post left second toe amputation status post left fem bypass status post abdominal aortic aneurysm repair status post left lung lobectomy medications lopressor mg p o b i d levoxyl mcg p o q d allopurinol mg p o q d lasix mg p o q d lipitor mg p o q d aspirin mg p o q d alphagan q d effexor xr mg p o q d coumadin mg p o q d dorzolamide drops flagyl mg p o x a day levofloxacin mg p o q d physical examination on examination patient s in general is said to be well appearing pupils are equal round and reactive to light cranial nerves ii through xii are grossly intact extraocular eye motions intact lungs are clear to auscultation bilaterally cardiac is irregular without any murmurs rubs or gallops abdomen is soft nontender nondistended normal bowel sounds left leg is said to be erythematous swollen to the mid calf pulse examination shows radial pulses bilaterally carotid pulses no evidence of any bruits femoral pulses are palpable bilaterally dorsalis pedis is dopplerable pt is dopplerable and popliteal pulses are palpable brief clinical course on the patient was admitted to the vascular surgery service at that time his white blood cell count was hematocrit platelets were noted to be decreased at coagulation studies were pt of ptt of and inr of otherwise his laboratory results were unremarkable blood cultures and wound cultures were collected at that time and he was started on empiric therapy with vancomycin levofloxacin and flagyl by hospital day four the patient was continued on his triple antibiotic therapy cellulitis was said to be stable without any increase in inflammation throughout patient was afebrile and white count stayed within normal limits on hospital day five the patient was preoped for a left fem bypass graft the patient went smoothly on patient was extubated without any complications however was maintained in the pacu requiring neo synephrine and dobutamine drip requirement both intraoperative and postoperatively over the night of postoperative day the patient s drips were able to be weaned from the neo synephrine and dobutamine and patient was successfully switched to dopamine on the morning of postoperative day one the patient still requiring dopamine infusion for blood pressure support decision was made to transport him to the surgical intensive care unit in the intensive care unit patient was resumed on his levaquin and flagyl he did not require reintubation and did quite well until the night of postoperative day one when he started having episodes of acidosis initial blood gas showed a ph of pco of po gap at that time the decision was made to reintubate the patient this proceeded without complication and the decision was made to consult cardiology service for further guidance on maintaining blood pressure cardiology consult recommended switching from dopamine to levophed which was indeed done subsequent workup showed no evidence of ischemia decision was made to increase volume and once again attempt to wean inotropic agents on postoperative day three the patient was again doing well and decision was made to extubate he tolerated this well with a post extubation blood gas of and on liters mask over the next few days however patient s mental status continued to decline he became increasingly confused and blood gases showed increasing acidosis in consultation with the patient s daughter wife and brother it became clear that their wishes would be made dnr dni and he be made comfort measures only by the patient was showing increasing signs of cardiogenic shock per the family s wishes this was not treated by the late afternoon of the patient was having frequent episodes of brady systolic episodes and hypotensive episodes and on at ultimately was announced had a systolic episode and was pronounced dead dr was notified medical examiner was notified who declined examination m d dictated by medquist d t job,"{
""Diagnoses"": [""Atrial fibrillation"", ""Chronic renal insufficiency"", ""Abdominal aortic aneurysm repair"", ""Chest pain"", ""Presyncope""],
""Medications"": [""Atropine"", ""Dopamine""]
}"
16088,admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint transferred from osh w hypothermia transaminitis lactic acidosis bilateral pleural effusions major surgical or invasive procedure thoracentesis complicated by small left apical pneumothorax history of present illness f with htn severe as afib hypothyroidism right sided pleural effusion and bilateral adnexal cystic structures found on ct who is transfered back to the floor from micu after thoracentesis patient was initially transferred to for question of mesenteric ischemia she initially presented to on after sudden onset severe abdominal pain with loose yellowish stool that occured the night before presentation patient was in her usual state of health until about week prior to admission she developed a cough she was diagnosed with bronchitis and given a course of abx name shortly after starting to take the abx pt developed severe epigastric pain am unable to sleep then presented am of to hospital per report she also experience episodes of dizziness and at least episode of losing consciousness falling and hitting the back of her head in regards to her abdominal pain the patient stated that it was different from abdominal bloating in past she reported sense of burning along with two episodes of loose yellow stools preceding her admission along with dry heaves but no vomiting at hosp she was found to be hypothermic to core with waves on her ekg acidemic with ph of and a lactate exceeding measurable limit given her abd pain acidemia and lactic acidosis she was transferred to for possible mesenteric ischemia at ohs pt given l ivf moxifloxacillin flagyl vit k on presentation to pt slightly hypothermic rectal temp other vss labs notable for ph lactate wbc w n inr ptt alt ast ap na cr unknown baseline ce negative urine blood and stool for c diff were negative cxr demonstrated b l effusions bibasilar opacities ruq u s demonstrates cholelithiasis but no cholecystitis surgery saw pt in ed and but did not think she had mesenteric ischemia pt given vanc ampicillin flagyl units ffp in ed should be noted that pt requires reorientation to questions several times during interview pt notes abd bloating and abd tightness in band like pattern around waist x year episodes of stomach tenseness either all day vs hours never for minutes alone was told she has an ovarian cystic structure that is being followed fatigue is unchanged over the entire day not worse at the end of the day no outdoor exposures or cold exposure seen by gi last egd which showed only gastritis difficulty swallowing pills x years weight loss of lbs over months decreased appetite has globus sensation with solid foods notes constipation x year no cold intolerance but does have dry skin over last year hair unchanged no vision changes no muscle pains stable joint pains from oa no myxedema rashes notes micrographia over the last year past medical history afib severe aortic stenosis ao valve area htn gerd rising ca and persistent bilateral adnexal cystic structures seen by ob gyn recently ct of the abdomen and pelvis which was performed at on this revealed a new left sided pleural effusion which was described as moderate there was no abdominal mass or ascites per gyn note recommended further eval of r sided pleural effusion w thoracentesis per pt had fluid aspirated and was fine fallopian tube polyp thyroid nodules tonsillectomy d c cholesterol embolus to her eye peripheral neuropathy degenerative joint disease bilateral pleural effusions over the past months apparently s p thoracentesis at osh reportedly negative for malignancy social history the patient does not smoke or drink family history significant for cancer tissue of origin is unkown physical exam vs mn am after admission l i cc o uop cc past hrs general severely slow and lethargic heent unable to sustain upward gaze more than s perrl eomi ommm no erythema or exudates neck no thyroid nodules jvp cm no bruits supple cardiovascular s absent s iii vi systolic lsb some radiation to carotids lungs clear to auscultation abdomen hyperactive bowel sounds slightly obese neg sign no ttp no guarding no rebound extremities warm no cce neuro a ox cnii xii intact reflexes and normal relaxation strength and sensation grossly intact pertinent results pm freeca pm hgb calchct pm glucose lactate na k cl tco pm ph comments green top pm urine rbc wbc bacteria occ yeast none epi pm urine blood lg nitrite neg protein tr glucose ketone tr bilirubin neg urobilngn neg ph leuk neg pm urine color yellow appear clear sp pm pt ptt inr pt pm plt smr normal plt count pm hypochrom normal anisocyt normal poikilocy normal macrocyt normal microcyt normal polychrom normal pm neuts bands lymphs monos eos basos pm wbc rbc hgb hct mcv mch mchc rdw pm asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg pm crp pm cortisol pm tot prot albumin globulin calcium phosphate magnesium pm ck mb notdone pm ctropnt pm alt sgpt ast sgot ck cpk alk phos amylase tot bili pm glucose urea n creat sodium potassium chloride total co anion gap pm ck mb notdone pm ctropnt pm ck cpk pm pleural wbc rbc polys lymphs monos pm pleural totprot glucose creat ld ldh amylase albumin cytology of plereural fluid negative for malignant cells pelvis u s transvaginal pm impression cm complex cystic mass concerning for left ovarian neoplasm chest portable ap pm impression there are bilateral pleural effusions with associated adjacent bibasilar opacity while some of this may represent adjacent atelectasis the left retrocardiac opacity may represent atelectasis and or consolidation and clinical correlation is recommended chest portable ap pm 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 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 intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation the aortic valve leaflets are severely thickened deformed there is severe aortic valve stenosis moderate aortic regurgitation is seen the mitral valve leaflets are moderately thickened moderate mitral regurgitation is seen due to acoustic shadowing the severity of mitral regurgitation may be significantly underestimated moderate to severe tricuspid regurgitation is seen there is moderate pulmonary artery systolic hypertension there is no pericardial effusion brief hospital course f admitted with hypothermia resolving multisystem failure of unclear etiology in the setting of reported ovarian cyst severe abdominal pain and one year of slowing lethargy abdominal pain abd ct did not reveal any intraabdominal pathology other than pelvic mass pt with chronic bloating sensation and vague abd pain will add simethicone for the possibility of gas pains serial abd exams ovarian mass pt s history of lb weight loss over past months suspicious for cancer also elevated ca u ml normal range pelvic us shows complex mass concerning for ovarian neoplasm gyn onc following as mr echo shows as with valve area cm and mixed ar mr tr hyperdynamic lvef in setting of mr renal failure returned to hepatitis hep serologies negative lfts normalizing elevated ca has been evaluated by gyn as outpatient but no explanation of ca found as yet pleural effusions pt unable to tell us what the etiology of her effusion has been despite previous thoracentesis transudative tap in icu there was a question of meig s syndrome given pt also with elevated ca ovarian mass though this effusion is bilateral of note the thoracentesis fluid did not contain any malignant cells towards the end of her stay it was noted that the patient had a gait disturbance at first she simply refused to walk and then when she did try it was noted that she had an unstable slow and shuffling gait neurology was consulted they requested follow up after discharge and mri imaging of the neuroaxis ultimately the patient stablized without any specific interventions at this point the patient should have had a biopsy of the pelvic mass unfortunately the patient s cardiac condition severe aortic stenosis precluded this and the patient was only willing to deal with her cardiologist dr who was out of town until the furthermore the patient repeatedly and tearfully described her desire to leave the hospital and see her grandchild the patient was discharged with specific instructions to follow up with dr regarding her aortic stenosis and determining her fitness for a procedure to biopsy the mass in her pelvis medications on admission coumadin mg qhs toprol verapamil lasix levoxyl protonix discharge medications metoprolol tartrate mg tablet sig three tablet po bid times a day coumadin mg tablet sig one tablet po at bedtime verapamil mg cap hr sust release pellets sig one cap hr sust release pellets po at bedtime furosemide mg tablet sig one tablet po daily daily levothyroxine mcg tablet sig two tablet po daily daily pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours simethicone mg tablet chewable sig one tablet chewable po qid times a day as needed disp tablet chewable s refills captopril mg tablet sig two tablet po tid times a day disp tablet s refills discharge disposition home discharge diagnosis ovarian mass aortic stenosis aortic insufficiency mitral regurgitation coronary artery disease lactic acidosis acute liver failure resolved acute renal failure resolved pneumothorax hypothermia congestive heart failure bilateral transudative pleural effusion undiagnosed neurological deficits possible spinal stenosis possible peripheral neuropathy possible central nervous system process discharge condition the patient is able to ambulate toilet and tolerate a regular diet independently discharge instructions please return to the hospital if your abdominal pain worsens if your temperature drops or if you being feeling very weak and lethargic followup instructions please call dr on please follow inform your primary care doctor dr that you were evaluated by neurology while in the hospital and that they recommend a thoracic lumbar sacral mri please ask your primary care physician to schedule mri of the head to evaluate for old strokes once this is done please call the clinic at to follow up within one month of discharge please call the obstetrics and clinic at for follow up dr this should follow your visit with dr completed by [NEW_RECORD] admission date discharge date date of birth sex f service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint lightheadedness fatigue major surgical or invasive procedure avr mm on x mechanical valve history of present illness this is a year old female who had been followed for approximately one year for known aortic stenosis and recently had undergone increasing shortness of breath and exertional dyspnea recent echocardiogram showed and of as well as to mr and an ef of the patient has a history of atrial fibrillation and also had a previous recent ct of the chest which revealed calcifications throughout her ascending aorta based on all of these findings the patient was to undergo an aortic valve replacement as well as possibility of the ascending aorta replacement past medical history pmh severe aortic stenosis ao valve area afib htn gerd thyroid nodules cholesterol embolus to eye peripheral neuropathy degenerative joint disease chronic bilateral pleural effusions psh tonsillectomy d c nkda social history the patient does not smoke or drink currently she is retired she has a past packyear history of smoking family history significant for cancer tissue of origin is unkown physical exam general well developed well nourished and in no acute distress heent sclerae anicteric lymphatics lymph node survey was negative lungs clear to auscultation on right diminished bs on left base heart irregularly irregular with a harsh systolic ejection murmur there were no gallops abdomen soft and nondistended and without palpable masses there was no appreciable ascites extremities without edema nonpalpable dp pulse bilaterally neuro nonfocal pertinent results echo pre bypass there is severe symmetric left ventricular hypertrophy right ventricular chamber size and free wall motion are normal the ascending aorta is mildly dilated there are simple atheroma in the ascending aorta there are complex mm atheroma in the aortic arch and the descending thoracic aorta the aortic valve leaflets are severely thickened deformed there is severe aortic valve stenosis area cm trace aortic regurgitation is seen the mitral valve leaflets are moderately thickened mild mitral regurgitation is seen there is no pericardial effusion post bypass a prosthetic aortic valve is in place with no leak and no i trace mr systolic fxn aorta intact other parametes as pre bypass cxr worsened bilateral pleural effusions right greater than left no pneumothorax appreciated picc line placement uncomplicated ultrasound and fluoroscopically guided double lumen picc line placement via the right basilic venous approach final internal length is cm with the tip positioned in the distal svc the line is ready for use brief hospital course mrs was admitted to the on she was taken directly to the operating room where she underwent an aortic valve replacement with a mm on x valve please see operative note for details postoperatively she was taken to the intensive care unit for monitoring by postoperative day one she had awoke neurologically intact and was extubated aspirin and beta blockade were resumed she went back into atrial fibrillation and amiodarone was started coumadin was started for anticoagulation she was then transferred to the step down unit for further recovery she was gently diuresed towards her preoperative weight the physical therapy service was consulted for assistance with her postoperative strength and mobility heparin was started as a bridge to coumadin as her inr was subtherapeutic as she had difficult venous access a picc line was placed for blood draws mrs continued to make steady progress and was discharged home on dr will manage her coumadin dosing as an outpatient she will follow up with dr and her cardiologist as an outpatient medications on admission toprol a p coumadin lasix verapamil lisinopril protonix levoxyl discharge medications docusate sodium mg capsule sig one capsule po bid times a day for months disp capsule s refills pantoprazole 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 oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills levothyroxine mcg tablet sig one tablet po daily daily disp tablet s refills amiodarone mg tablet sig two tablet po once a day for take mg once daily until starting take mg daily until otherwise instructed months take mg once daily until starting take mg daily until otherwise instructed 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 toprol xl mg tablet sustained release hr sig one tablet sustained release hr po once a day disp tablet sustained release hr s refills toprol xl mg tablet sustained release hr sig one tablet sustained release hr po at bedtime disp tablet sustained release hr s refills furosemide mg tablet sig two tablet po bid times a day mg x days then mg daily disp tablet s refills potassium chloride meq capsule sustained release sig two capsule sustained release po bid times a day meq x days then meq daily disp capsule sustained release s refills coumadin mg tablet sig one tablet po once a day take as instructed by dr for a target inr of for atrial fibrillation and a mechanical aortic valve first blood draw disp tablet s refills discharge disposition home with service facility discharge diagnosis as htn gerd thyroid nodules cholesterol emboli to left eye neuropathy atrial fibrillation cad pvd djd 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 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 take coumadin as directed by dr goal inr please have blood checked at office lab on in the morning likely daily dose will be or mg daily take lasix mg once daily and potassium meq once daily for days then stop call with any questions or concerns followup instructions follow up with dr in month follow up with cardiologist dr in weeks please follow up with pcp for pt inr blood draw for coumadin dosing and in weeks for a routine postoperative appointment wound clinic in weeks please call all providers for appointments completed by [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies ciprofloxacin attending chief complaint referred for right renal artery stenting and coronary angiography major surgical or invasive procedure renal artery stenting cardiac catheterization with bms placed in lad two overlapping bms s placed in proximal lcx history of present illness ms is an year old woman with a history of aortic stenosis s p mechanical avr atrial fibrillation s p cardioversion htn gerd and pvd who presented for elective coronary and renal angiogram complicated by pna and and is transferred to the ccu s p cath for hemodynamic monitoring the patient was referred for renal angiogram after a recent hospitalization for claudication work up that revealed bilateral superior femoral artery disease and right renal artery stenosis she was referred for coronary angiogram after having an abnormal ekg at dr office of note she has been having episodes of chest burning for the last months described as heartburn that occurs primarily at rest and often when laying in bed after a late night snack this pain lasts min and is intermittently and inconsistently associated with bilateral arm and jaw pain and always self resolves without intervention the patient was admitted for pre cath hydration given her cr of she initially complained of epigastric tightness radiating to her chest and ekg showed no acute st changes past medical history aortic stenosis valve area in s p mechanical aortic valve replacement afib s p cardioversion htn gerd thyroid nodules thyroid goiter peripheral neuropathy degenerative joint disease sciatica chronic bilateral pleural effusions s p cholesterol emboli to left eye in per patient started on coumadin at that time s p tonsillectomy s p laparoscopic salpingo oophorectomy for benign ovarian mass s p cholecystectomy s p right hammer toe surgery social history tobacco denies currently year history of smoking cigarettes day etoh rare drugs denies married and lives at home with her husband retired functionally limited by pain from sciatica and djd but denies exertional chest pain or exertional dyspnea family history brother passed from sudden death age cause unknown mom with htn and possibly af physical exam on admission gen wdwn female in nad oriented x mood affect appropriate heent sclera anicteric eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthalesma neck supple with jvp difficult to assess prominent carotid pulse and ej but cm cv rr prominent s s giii holosystolic murmer at apex gii holosystolic murmer at lsb gii systolic murmer at rusb rv heave no s or s chest no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use rales at bases b l no wheezes or rhonchi abd soft ntnd no hsm or tenderness abd aorta not enlarged by palpation no abdominial bruits ext no c c pitting edema at ankles skin no stasis dermatitis ulcers scars or xanthomas bandaged left second toe pulses right carotid dp thready left carotid dp thready on discharge vs l gen pale elderly female in nad fatigued aaox mood affect appropriate heent perrla eomi slightly dry mmm neck supple jvp flat cv rr prominent s s giii holosystolic murmur at apex gii holosystolic murmer at lsb gii systolic murmer at rusb rv heave s no s chest no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use rales at bases b l and decreased breath sounds no wheezes or rhonchi abd soft nt nd bs no abdominal bruits no hsm ext no c c pitting edema to ankles b l skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid dp thready left carotid dp thready pertinent results reports echo cardiac cath coronary angiography in this right dominant system demonstrated two vessel cad the lmca was patent the lad had a proximal stenosis the lcx had a stenosis in the mid vessel the rca was known to be totally occluded and was not engaged limited resting hemodynamics revealed moderate systemic arterial systolic hypertension with an sbp of mmhg renal artery angiography demonstrated a recanalized total occlusion of the right renal artery successful revasculrrization of a chronically occluded recanalized right renal artery stented with a x mm genesis aviator stent with excellent result return for lcx intervention on thursday after hydration final diagnosis two vessel cad moderate systemic hypertension successful stenting of right renal artery with aviator stent return to cath lab for lcx intervention on thursday after hydration cxr ap impression new left mid lung opacity concerning for pneumonia right lower lobe atelectasis and bilateral effusions recommend followup radiograph in weeks following treatment to assess for resolution cardiac cath comments ptca and stenting of the proximal lcx with two overlapping x and x mm vision bmss with excellent results see ptca comments unsuccessful attempt to revascularize the om cto staged pci of the mid lad re attempt to open the om limited resting hemodynamic assessment showed mildly elevated systemic arterial hypertension mmhg final diagnosis three vessel coronary artery disease successful ptca and stenting of the proximal lcx with two overlapping vision bmss unsuccessful attempt to revascularize the om cto staged pci of mid lad monitor renal function continue with mucomyst and hydration add lasix to maintain urine output of cc hour continue medical therapy cardiac cath successful pci of the mid lad with a x mm bare metal stent unsuccessful attempt to open the occluded om branch final diagnosis three vessel coronary artery disease successful pci of the lad with bms unsuccessful pci of the occluded om branch renal artery u s normal sized kidneys with no evidence of hydronephrosis a likely dilated or calyceal diverticulum in the right kidney which contains milk of calcium patient was unable to breathhold due to dyspnea and therefore an accurate evaluation of the renal arteries could not be performed cxr findings new left picc terminates in the lower superior vena cava heart remains enlarged and there is bilateral asymmetrical perihilar alveolar pattern which has improved on the left but is newly developed on the right this is likely related to the patient s known multifocal pneumonia but coexisting edema is also possible moderate right pleural effusion with adjacent right retrocardiac opacity is not substantially changed moderate left pleural effusion has slightly changed in distribution but is probably similar in overall size brief hospital course f with htn mechanical avr a fib s p cardioversion pvd admitted for coronary and renal angiogram hospitalization complicated by nstemi acute renal failure pneumonia gi bleed and hyponatremia coronaries nstemi patient with non exertional epigastric tightness radiating to the chest found to have occluded left circ on cardiac angio on but was not intervened upon because of poor renal function patient had chest pain following renal stenting found to have new st depressions on ekg and rising cardiac enzymes consistent with nstemi pt needed cardiac cath but renal functions following renal artery stenting was elevated patient maintained on nitrodrip while renal functions improved patient was brought for cath on where she underwent a staged pci of the mid lad following which was directly transferred to ccu for closer monitoring overnight in the ccu the patient had more chest pain and concerning ekg changes which prompted a second cardiac catheterization on where she underwent a also placed in the lad she then remained on aspirin mg po daily after which was switched to mg po daily upon starting heparin and coumadin pt also on plavix the patient was also started on atorvastatin not due to arf the patient had no further episodes of chest pain anuric acute on chronic renal failure in the ccu the patient developed anuric arf after her rd catheterization on with a peak creatinine of the etiology was thought to be contrast induced atn as well as likely embolization from recent renal artery revascularization the patient developed anuria renal was consulted who recommended against hd instead they recommended lasix gtt which resulted in pt slowly starting to make urine unfortunately the patient developed hyponatremia thought to be secondary to diuresis from lasix and this was discontinued fortunately the pt made urine on her own electrolytes remained grossly normal except for hyperphos and hypermag which remained stable the patient s creatinine continued to improve on discharge her creatinine was patient will follow up with nephrology as an outpatient hyponatremia nadir down to thought to be secondary to free water excess in the setting of atn pt was aggressively fluid restricted down to l day and heparin drip d w solution was changed to ns and sodium improved on its own pt remained largely asymptomatic except for a headache and nausea which self resolved briskly on discharge her serum sodium was hypoxia thought to be secondary to multifocal pneumonia and moderate and loculated on side pleural effusions pulmonary edema was also thought to be a contributing factor pt remained hypoxic at a l o requirement throughout most of her ccu stay the effusions were thought to be most likely secondary to chf given the lack of fevers or white count even after antibiotics ip was consulted to tap the effusions to r o parapneumonic effusion however given the aspirin plavix heparin thought it would be too high risk and risk of parapneumonic effusion was low diuresis was also thought to wait given the patient s resolving arf the hypoxia remained stable saturating well on l and is expected to self resolve over time at rehab and beyond gi bleed on pt passed a small red clot of blood in stool pt without any history of gi bleed no endoscopy or colonoscopy in our system given the red blood seen this would suggest a lower gi source and given the lack of pain this would suggest diverticular disease bleeding is in the setting of being on a heparin drip patient was transfused units of prbcs over the course of this admission for a very slowly downtrending hematocrit she continued to have guiaic positive stool but no longer had any overt blood on discharge her hematocrit is a repeat hematocrit will be checked at rehab she would benefit from an outpatient colonoscopy patient will discuss this with her primary care physician history of as s p mechanical avr patient was maintained on heparin drip for most of her admission because warfarin was held for procedures she was restarted on warfarin goal inr of for the mechanical valve on discharge her inr was therpeutic at pump history of as s p mechanical avr in tte on this admission shows regional lv systolic dysfunction consistent with cad probable severe mitral regurgitation moderate to severe tricuspid regurgitation and pulmonary hypertension following chest pain patient found to have new s crackles on lung exam concerning for heart failure patient does not have baseline bnp for comparison patient was maintained on heparin drip for mechanical avr while warfarin was held because of need for procedures in the ccu the patient remained euvolemic to slightly hypervolemic no prolonged diuresis was attempted rhythm patient with h o afib s p cardioversion currently in nsr patient was continued on amiodarone pneumonia sepsis found to have left midlobe pneumonia had one episode of hypotension and was febrile for one night patient was treated with day course of vancomycin and cefepime with no further fevers confusion was confused delirious for a day likely due to morphine which was given for cp patient was kept off of sedating medications infectious workup was concerning for a pneumonia which was treated with iv antibiotics renal artery stenosis patient with severe r renal artery stenosis now s p stenting on creatinine worsened in setting of cardiac and renal angiogram may have been due to iv contrast embolized plaque from stenting newly started antibiotics hypoperfusion of kidneys from hypotension no eosinophils in urine less suggestive of cholesterol emboli to kidneys renal functions have been gradually improving on discharge her creatinine was trending down at she will follow up with nephrology as an outpatient hypertension patient was controlled on carvedilol gerd stable changed to ranitine given need for plavix thyroid nodules thyroid goiter continued on home levothyroxine peripheral neuropathy restless legs started on ropinirol urinary dysfunction continue home terazosin oxybutynin per home regimen degenerative joint disease pain control with tylenol as per home regimen s p cholesterol emboli to left eye continued on warfarin medications on admission aspirin mg tablet po daily amiodarone mg tablet po qod amlodipine norvasc mg po daily isosorbide mononitrate imdur sr mg po daily lisinopril mg tablet po daily metoprolol succinate sr mg po daily olmesartan hydrochlorothiazide mg mg tablet po daily warfarin coumadin mg tablet po daily last dose pre procedure ropinirole mg tablet po daily levothyroxine mcg tablet po daily oxybutynin chloride sr mg tab po daily terazosin mg capsule po daily alprazolam mg tablet po prn pantoprazole ec mg tablet po daily vitamin b complex ergocalciferol vitamin d tylenol prn duculax prn discharge medications amiodarone mg tablet sig one tablet po qod acetaminophen mg tablet sig tablets po q h every hours as needed for pain cholecalciferol vitamin d unit tablet sig one tablet po daily daily b complex vitamins capsule sig one cap po daily daily levothyroxine mcg tablet sig one tablet po daily daily clopidogrel mg tablet sig one tablet po daily daily atorvastatin 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 aspirin mg tablet chewable sig one tablet chewable po daily daily ipratropium bromide solution sig one nebulizer inhalation q h every hours as needed for shortness of breath or wheezing 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 seventeen grams po daily daily as needed for constipation calcium carbonate mg tablet chewable sig one tablet chewable po qid times a day as needed for gerd camphor menthol lotion sig one appl topical qid times a day as needed for itching ropinirole mg tablet sig one tablet po qpm once a day in the evening give hours before bedtime trazodone mg tablet sig tablet po hs at bedtime as needed for insomnia isosorbide mononitrate mg tablet sustained release hr sig one tablet sustained release hr po daily daily b complex vitamin c folic acid mg capsule sig one cap po daily daily metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po daily daily hydralazine mg tablet sig one tablet po bid times a day warfarin mg tablet sig one tablet po once a day discharge disposition extended care facility life care center of discharge diagnosis primary diagnosis acute renal failure nstemi hyponatremia pneumonia secondary diagnosis aortic stenosis valve area in s p mechanical aortic valve replacement afib s p cardioversion htn gerd thyroid nodules thyroid goiter peripheral neuropathy degenerative joint disease sciatica chronic bilateral pleural effusions s p cholesterol emboli to left eye in per patient started on coumadin at that time s p tonsillectomy s p laparoscopic salpingo oophorectomy for benign ovarian mass s p cholecystectomy s p right hammer toe surgery 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 to for renal artery stenting your hospital course was complicated with pneumonia acute renal failure and heartattack you were transferred to the cardiac icu where you were closely monitored and went for two cardiac catheterizations during which they placed bare metal stents to the arteries that feed your heart it will be important that you continue to take plavix every day for at least a year your kidney functions have been steadily improving you will need to follow up with a cardiologist and a nephrologist after discharge from the hospital you will need to follow up with your primary care physician after discharge from rehab you will need a colonoscopy please discuss this with your primary care physician your medications have changed please only take the medications as listed below amiodarone mg tablet sig one tablet po qod acetaminophen mg tablet sig tablets po q h every hours as needed for pain cholecalciferol vitamin d unit tablet sig one tablet po daily daily b complex vitamins capsule sig one cap po daily daily levothyroxine mcg tablet sig one tablet po daily daily clopidogrel mg tablet sig one tablet po daily daily atorvastatin 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 aspirin mg tablet chewable sig one tablet chewable po daily daily ipratropium bromide solution sig one nebulizer inhalation q h every hours as needed for shortness of breath or wheezing 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 seventeen grams po daily daily as needed for constipation calcium carbonate mg tablet chewable sig one tablet chewable po qid times a day as needed for gerd camphor menthol lotion sig one appl topical qid times a day as needed for itching ropinirole mg tablet sig one tablet po qpm once a day in the evening give hours before bedtime trazodone mg tablet sig tablet po hs at bedtime as needed for insomnia isosorbide mononitrate mg tablet sustained release hr sig one tablet sustained release hr po daily daily b complex vitamin c folic acid mg capsule sig one cap po daily daily metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po daily daily warfarin mg tablet sig one tablet po once daily at pm hydralazine mg sig one tablet po twice a day weigh yourself every morning md if weight goes up more than lbs followup instructions please follow up with your primary care doctor dr once you have been discharged from the rehabilitation facility her office number is please follow up with your cardiologist dr on at pm his office number is please follow up with dr neprhology on at pm the address is center the office number is,"{
""Diagnoses"": [""hypothermia"", ""transaminitis"", ""lactic acidosis"", ""bilateral pleural effusions"", ""major surgical or invasive procedure"", ""thoracentesis"", ""complicated by small left apical pneumothorax""],
""Medications"": [""name""]
}"
1528,admission date discharge date service acove history of present illness patient is an year old male nursing home resident with past medical history significant for dementia cva recurrent aspiration pneumonia who is admitted with lethargy and cough patient is a resident at home he was discharged there following a recent hospital admission from through where he was treated for an aspiration pneumonia with this admission his sputum cultures grew out mrsa and multiple gram negative rods and he was treated with vancomycin for seven days last dose on he also was treated for clostridium difficile colitis and was started on a day course of flagyl with last dose on patient was eating a diet of unpureed foods prior to admission and was noted to have moderate amount of difficulty with eating he was also noted to have increased lethargy decreased p o intake and a nonproductive cough for the day prior to admission upon arrival to the ed patient was nonverbal and did not respond to questioning past medical history dementia coronary artery disease status post cabg history of left parietal cva benign prostatic hypertrophy status post turp recurrent utis history of mrsa colonization avb history of aspiration pneumonia recent clostridium difficile colitis history of cerebellar pontine meningioma hypothyroidism atherosclerotic disease mild pulmonary hypertension cervical spondylitis medications at home levothyroxine q d metoprolol b i d atorvastatin q d lansoprazole q d colace b i d megestrol b i d latanoprost eyedrops allergies diamox hydrochlorothiazide physical examination on admission vital signs temperature pulse blood pressure respirations o saturation on liters of oxygen nasal cannula general elderly demented man lying in bed in no acute distress with contractures heent normocephalic atraumatic pupils left pupil fixed and dilated right pupil reactive oropharynx is dry with dentures and hardware in place neck no lad no jvd cardiovascular tachycardic regular rate systolic ejection murmur best heard at the axilla lungs rhonchi bilaterally anteriorly significant upper airway noise abdomen positive bowel sounds soft nontender nondistended extremities no edema dorsalis pedis pulses bilaterally right leg externally rotated neurologic nonresponsive does not follow commands or answer questions contractures particularly in the right upper extremity laboratories on admission white count hematocrit and platelets differential neutrophils bands sodium potassium chloride bicarb bun creatinine glucose anion gap urinalysis greater than white blood cells few bacteria moderate yeast lactate ekg sinus tachycardia with a rate of wandering baseline st depression in leads v and v mm chest x ray left lower lobe infiltrates hospital course sepsis patient admitted with fever tachycardia leukocytosis and lactic acidosis suggestive of sepsis given his laboratory and radiological findings he is thought to have a likely aspiration pneumonia and along with a concurrent uti patient was treated for sepsis per protocol he received multiple fluid boluses to keep his cvp greater than his blood pressure was maintained with fluid resuscitation he did not require any pressor support a co were monitored and patient was maintained on oxygen via nasal cannula he was started on iv antibiotics initially vancomycin ceftazidime and flagyl patient improved clinically on antibiotics the etiology of his sepsis was thought to be due to aspiration pneumonia with concurrent uti his stool also grew out clostridium difficile colitis which also contributed to his septic picture patient was transitioned over to p o antibiotics with plan to treat him with levaquin and flagyl for a total of days patient s sputum did not grow out a contributing organism he did have sparse mrsa in his sputum which was thought to be a contamination as patient is colonized with mrsa aspiration pneumonia patient with recurrent aspiration pneumonia patient has previous admissions for similar aspiration pneumoniae he had a failed swallowing study in the past however his family does not feel patient would want a peg tube feeding tube or other invasive measures they were cautioned that he is at risk for recurrent aspiration pneumoniae however they still declined any sort of invasive feeding measures patient was treated for aspiration pneumonia as per the above sepsis description patient was eventually weaned off oxygen and maintained excellent saturations on room air he did occasionally have mucus plugs with very brief desaturation down to approximately which cleared with coughing he will be continued on chest pt at the nursing home the nursing home will be instructed that should he desaturate this typically clears with coughing and this is not worrisome as long as his saturations normalize with a cough and clearing of the mucus clostridium difficile colitis patient s stool from grew out clostridium difficile he was recently on antibiotics which likely contributed to his infection he was started on p o flagyl with plans to treat for days his symptoms of diarrhea quickly resolved with treatment coronary artery disease patient with history of coronary artery disease status post cabg upon admission he was tachycardic with slight st depression in leads v and v this was thought to be a strain pattern due to his tachycardia and septic picture patient was also ruled out for a myocardial infarction his cardiac enzymes were negative and his ekg changes resolved with treatment of his other symptoms he was continued on aspirin and initially his statin and beta blocker were held in the setting of sepsis however these were restarted prior to discharge he also was started on low dose ace inhibitor afib patient with a history of afib a decision made to not anticoagulate given his high risk for falls patient went in and out of afib during the hospitalization he was restarted on metoprolol for rate control hypothyroidism patient continued on levoxyl per his home regimen fluids electrolytes and nutrition patient started back on puree foods which he tolerated well he was also placed on boost supplement drinks he was thought to be at risk of aspiration as per above however his family did not desire any invasive measures so p o was continued despite his risk for recurrent aspiration his electrolytes were followed throughout the hospitalization and were repleted as needed prophylaxis patient was placed on aspiration and fall precautions he was also on h blocker for gi prophylaxis subcutaneous heparin for dvt prophylaxis and a bowel regimen code status patient was initially full code on admission however later in the hospital course following an extensive discussion with the family his wife made the decision as his health care proxy to make the patient dnr dni patient was discharged with dnr dni status however they did wish him to be rehospitalized should he decompensate discharge condition stable discharge status home discharge diagnoses sepsis aspiration pneumonia clostridium difficile colitis urinary tract infection coronary artery disease rule out myocardial infarction hypothyroidism discharge medications aspiration mg q d megestrol mg tablet q i d levothyroxine mcg q d atorvastatin mg q d lansoprazole mg q d metoprolol mg b i d colace mg b i d senna two tablets b i d captopril t i d levofloxacin mg one tablet p o q h x days flagyl mg one tablet p o q h x days subq heparin b i d follow up plans follow up with pcp weeks m d dictated by medquist d t job [NEW_RECORD] admission date discharge date service medicine history of present illness the patient is an year old man who is a nursing home resident and has a past medical history significant for progressive neurologic decline over the last year who was transferred from the nursing home for feeding tube placement the patient had recently been discharged from after admission for aspiration pneumonia sepsis at that time the family was informed that the patient had failed swallowing evaluation and was at risk for recurrent aspiration if fed orally however the family refused feeding tube stating the patient would not want invasive measures nevertheless a couple of days prior to admission the patient began to develop increased cough during oral feeding and the family decided to accept invasive measures including feeding tube since the patient could not receive feeding via nasogastric tube at nursing home the patient was transferred to for nasogastric tube feeding and eventual percutaneous feeding tube placement at time of presentation the patient was nonverbal responsive only to painful stimuli as a result the patient could not provide additional history no other family members were present for further history of note the patient has a history of previous gastrostomy tube placement which was discontinued secondary to bleeding past medical history progressive neurological decline dementia history of left parietal cerebrovascular accident recurrent aspiration pneumonia mrsa colonization coronary artery disease status post coronary artery bypass graft cerebellar pontine meningioma benign prostatic hypertrophy status post transurethral resection of the prostate hypothyroidism recurrent urinary tract infection mild pulmonary hypertension av block cervical spondylitis family history noncontributory social history nursing home resident medications on admission aspirin megestrol mg po q i d levothyroxine micrograms q d atorvastatin mg q d lansoprazole mg q d metoprolol mg b i d colace senna two tablets b i d captopril mg t i d allergies diamox hydrochlorothiazide physical examination on presentation the patient was found to have vital signs as follows temperature heart rate blood pressure respiratory rate sat on room air the patient was nonverbal with minimal response to voice minimal response to touch and some response to painful stimuli the patient was markedly contracted heart sounds and lung sounds were difficult to appreciate laboratory studies hematocrit significant at sma unremarkable chest x ray some interval improvement in left basilar atelectasis pleural effusion hospital course fluid electrolytes and nutrition nutrition nasogastric tube was placed in the emergency department for tube feeding gastrointestinal was consulted and evaluated the patient on hospital day number three and recommended the patient be given percutaneous jejunostomy tube by interventional radiology to decrease the risk of aspiration interventional radiology attempted tube placement on hospital day number six but was unable to place tube secondary to anatomy as a result the patient was evaluated by general surgery on hospital day number seven and was taken to the operating room on hospital day number eight there was no intraoperative complications but immediate postoperative course was complicated by respiratory decompensation most likely secondary to an aspiration event the patient was admitted to the micu the patient was started on free water drip through the jejunostomy tube from discharge from the micu on hospital day nine these were temporarily held when the patient was briefly transferred back to the micu care secondary to likely mucous plug later that evening on hospital day number ten the patient was stable on the general wards and was started on tube feeds at half strength feeds were again held on hospital day for evaluation of abdominal tenderness and increased bilious nasogastric tube output tenderness was found to be secondary to hematoma around tube site with no evidence of ileus obstruction so feeds were restarted again at half strength on hospital day number surgery recommended the patient be advanced to and kept at strength feeds to decrease risk of bowel necrosis as a result the patient s goal rate was determined to be cc an hour at strength surgery also recommended cc free water boluses q hours this goal was reached on hospital day number an nasogastric tube was discontinued the patient continued to tolerate feeds well through the jejunostomy tube the patient was followed by nutrition service as well during admission at discharge the patient was on probalance feeds as recommended by the nutrition service electrolytes the patient received electrolytes replacement prn fluids the patient received fluid resuscitation prn respiratory the patient s respiratory status was stable until the patient experienced episode of desaturation about minutes after admission to the pacu following jejunostomy tube placement the patient was intubated and transferred to the micu event determined to be most likely secondary to aspiration the patient did well and was extubated on hospital day number nine the day following intubation and was discharged to the floor later that evening the patient desaturated again and was transferred back to micu care but secondary to bed shortage remained in the micu care but on the general the patient did well after nasal suctioning and was transferred back to care of the general medicine team on the morning of hospital day number during the remaining admission the patient received guaifenesin around the clock and q i d nasal suctioning to decrease risk of further desaturation from retained secretions the patient was also given a course of levofloxacin for likely aspiration pneumonia cardiovascular rhythm at admission the patient had a history of first degree av block the patient was also noted to have episodes of atrial fibrillation during this admission the patient was rate controlled with beta blocker and anticoagulated but was felt to be a poor candidate for further intervention pump the patient has a history of regurgitation and has had prophylaxis for dental procedures ischemia the patient has a history of coronary artery disease during this admission found to have electrocardiogram changes and elevated troponin in the setting of respiratory decompensation these normalized the patient was maintained on lovenox aspirin beta blocker ace inhibitor and statin the patient was felt to be a poor candidate for further interventions secondary to general medical condition neurology the patient has a history of rapid onset of neurologic decline that has led to abrupt decline over the last year to the point that the patient has become contracted bed bound and almost mute the patient had an mri during this admission which showed old left hemisphere infarct increased size of meningioma and atrophy parkinsonian syndrome was considered in the differential and neurology felt a trial of sinemet would be reasonable however they cautioned that the patient s history is not typical of classic parkinson s disease and that sinemet has much less benefit in other parkinsonian syndromes they recommended that if a trial of sinemet be pursued it should be delayed until after the immediate postoperative period this was not started during this admission of note over the course of the admission the patient had rare verbalization which was always logical there was also rare incidence in which the patient responded to commands i suspect that the patient may have significant comprehension but limited ability to verbalize as a result please keep this in mind when speaking in front of the patient hematology the patient required transfusion of units of packed red blood cells after hematoma development around the jejunostomy site hematocrit was stable following transfusion vascular deep venous thrombosis identified in the left brachial artery on hospital day number two the patient was initially maintained on lovenox in preoperative period this was switched to heparin in the postoperative period to decrease injections and improve patient comfort the patient was also started on coumadin at the time of discharge coumadin had been held for three previous nights secondary to supratherapeutic inr after discharge the patient should receive daily inrs and dosed with mg of coumadin q h s only when inr falls below endocrine the patient was maintained on synthroid for hypothyroidism during admission discharge medications as admission except levothyroxine increased from to mg q d coumadin for atrial fibrillation as well as deep venous thrombosis of note as stated above the patient became supratherapeutic on low doses of coumadin coumadin should be carefully dosed and inr should be followed closely tylenol and oxycodone for pain as the patient s rare verbalizations usually reflected expressions of pain guaifenesin to decrease retention of respiratory secretions albuterol and atrovent nebulizers the patient is to complete a ten day course of levofloxacin disposition to nursing facility discharge status bed bound significantly contracted in significant pain minimally verbal stable respiratory status on stable jejunostomy feedings discharge diagnoses failure to thrive dysphagia dementia history of stroke deep venous thrombosis aspiration pneumonia atrial fibrillation hypertension anemia secondary to blood loss hypothyroidism code status full discharge follow up none necessary m d dictated by medquist d t job,"{
""Diagnoses"": [""Lethargy"", ""Cough"", ""Aspiration pneumonia"", ""Methicillin-resistant Staphylococcus aureus (MRSA)"", ""Multiple gram-negative rods"", ""Clostridium difficile colitis"", ""Benign prostatic hypertrophy"", ""Recurrent urinary tract infections (UTIs)"", ""Methicillin-resistant Staphylococcus aureus (MRSA) colonization""],
""Medications"": [""Vancomycin"", ""Flagyl""]
}"
9868,admission date discharge date date of birth sex m service neonatology history of present illness baby boy is a weeks old infant delivered to a year old gravida para now mother prenatal screens showed blood type o positive antibody hepatitis b surface antigen negative group b strep unknown mom s history was significant for chronic hypertension for years and is on procardia and labetalol the pregnancy was uncomplicated mom was admitted on the morning of for monitoring of an elevated blood pressure membranes ruptured shortly after induction of labor on the evening of hours prior to delivery the baby was delivered vaginally at a m on apgar scores were at minute and at minutes the baby was transferred to the nursery at three hours of age he developed grunting and cyanosis he was then transferred to the neonatal intensive care unit for evaluation and observation physical examination on presentation vital signs revealed temperature was rectally heart rate was blood pressure was with a mean arterial pressure of respiratory rate was oxygen saturation was on room air and with blow by oxygen dipstick was his weight on admission was g length was cm and head circumference was cm he was a nondysmorphic male infant with moderate respiratory distress anterior fontanel was open and flat mild molding the skin was smooth and pink no rashes no birthmarks lips gums and palate were intact the chest was symmetrical moderate subcostal retractions nasal flaring and grunting breath sounds were slightly diminished to the bases he was pink and well perfused normal first heart sounds and second heart sounds no murmurs were auscultated pulses were in the upper and lower extremities the abdomen was soft with active bowel sounds no hepatosplenomegaly normal male genitalia with testes descended bilaterally a patent anus the spine was straight no hip clicks clavicles were intact tone was symmetrical he was moving all extremities hospital course by issue system respiratory issues moderate respiratory distress requiring administration of oxygen to maintain saturation at about initial chest x ray showed seventh to ninth rib expansion with diffuse streaky appearance consistent with retained fetal fluid he was able to tolerate a wean to room air briefly on day of life three however he had to go back on nasal cannula and since then been on nasal cannula with approximately cc of air flow on fio on two subsequent chest radiographs there was a right lower lobe opacification consistent with a right lower lobe pneumonia cardiovascular system the baby has been hemodynamically stable no murmurs fluids electrolytes nutrition issues baby boy has been taking breast milk and enfamil p o ad lib with improvement of his respiratory status and he has been tolerating that well taking approximately cc to cc every four hours his weight on the day of discharge was g gastrointestinal issues baby boy had mild jaundice with a bilirubin level of he was briefly started on single phototherapy with improvement of his jaundice his last bilirubin level on day of life five was approximately hours after phototherapy was discontinued hematologic issues baby boy initial hematocrit was he has not received any transfusions during his hospital course infectious disease issues given his chest x ray findings and clinical symptoms he was started on ampicillin and gentamicin for his right lower lobe pneumonia on day of life four on the day of discharge he had received three days of antibiotics out of a day course sensory issues baby boy passed his hearing examination bilaterally on condition at discharge baby boy has been stable on a minimal amount of oxygen via nasal cannula he has been tolerating his feeds well discharge disposition baby boy is to be discharged to hospital nursery for further administration of intravenous antibiotics and oxygen supplementation primary pediatrician primary pediatrician is dr telephone number care recommendations feeds at discharge breast milk enfamil p o ad lib medications on discharge ampicillin mg intravenously q h and gentamicin mg intravenously q d car seat test has been completed immunizations received hepatitis b 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 born between and weeks 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 a follow up appointment recommended upon discharge with primary pediatrician discharge diagnoses right lower lobe pneumonia reviewed by m d dictated by medquist d t rp job,"{
""Diagnoses"": [""History of Present Illness"", ""Neonatal Hypoxia"", ""Respiratory Distress Syndrome""],
""Medications"": [""Procardia"", ""Labetolol""]
}"
78195,admission date discharge date date of birth sex f service surgery allergies no known allergies adverse drug reactions attending chief complaint post rfa bleeding major surgical or invasive procedure ct guided rfa ablation of hepatic segment vii history of present illness f with metastatic invasive lobular carcinoma with recurrence of liver lesions despite prior resection presents s p rfa today of segment vii lesion the lesion was diagnosed in then not seen with ultrasound in however in she had a ct scan with a x cm lesion in vii with subsequent fna showing poorly differentiated adenocarcinoma she saw dr in clinic on where a resection was recommended patient elected for rfa ablation instead and underwent said procedure on past medical history pmh breast cancer invasive lobular dx er pr but her negative s p rx with zoladex tamoxifen letrozole liver mets hepatitis as a child nos psh partial mastectomy alnd partial liver resection lateral seg a child c sections x social history she is a stay at home mother of children ages and she is here in for their schooling and her husband works in she denies any tobacco use or alcohol abuse family history no family history of cancers both parents had htn and fatherdied from a stroke physical exam gen nad a ox cv rrr pulm ctab abd s nt nd wound dressed dressing c d i ext warm well perfused neuro grossly intact pertinent results pm hgb calchct o sat pm glucose lactate na k cl pm wbc rbc hgb hct mcv mch mchc rdw pm hgb calchct pm wbc rbc hgb hct mcv mch mchc rdw pm blood hct am blood hct ct guided rfa abdomen bilateral subsegmental atelectasis is seen the visualized portions of the heart are within normal limits the patient is status post resection of segment ii and iii reidentified is the hypoattenuating lesion in segment vii no other lesions are seen within the liver post procedurally small extravasation focus and subcapsular bleeding was identified as described small amount of perihepatic fluid is seen the gallbladder is within normal limits the spleen pancreas and both adrenals are within normal limits both kidneys enhance and excrete normally no concerning lymphadenopathy is seen within the abdomen no free fluid is identified within the abdomen the aorta and its branches are within normal limits the portal vein splenic vein and smv are of normal caliber and patent osseous structures no concerning lytic or osteoblastic lesions are seen limited examination of pelvis revealed small amount of pelvic fluid brief hospital course he patient was admitted to the general surgical service for serial hematocrit monitoring after rfa ablation of a liver lesion with subsequent subcapsular bleeding the reader is referred to the procedure note for details after a brief uneventful stay in the sicu with npo status and serial hematocrit checks the patient arrived on the floor on hd the patient was hemodynamically stable neuro the patient received iv dilaudid with good effect and adequate pain control when tolerating oral intake the patient was transitioned to oral pain medications cv the patient remained stable from a cardiovascular standpoint vital signs were routinely monitored her blood pressures remained stable and as stated her hematocrits were stable between and and was stable at upon discharge pulmonary the patient remained stable from a pulmonary standpoint vital signs were routinely monitored gi gu fen post procedure the patient was made npo with iv fluids diet was advanced as tolerated on hd which was well tolerated patient s intake and output were closely monitored and iv fluid was adjusted when necessary id the patient s white blood count and fever curves were closely watched for signs of infection of which there were none hematology the patient s hematocrit was serially monitored no transfusions were required prophylaxis the patient wore venodyne boots during her stay she was encouraged to get up and ambulate as early as possible at the time of discharge the patient was doing well afebrile with stable vital signs the patient was tolerating a regular diet ambulating voiding without assistance and pain was well controlled the patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan she will follow up with her pcp and oncologist medications on admission fosamax anastrozole vit d mvi discharge medications oxycodone mg tablet sig one tablet po every hours as needed for pain for weeks disp tablet s refills colace mg capsule sig one capsule po twice a day for weeks when taking narcotics to prevent constipation disp capsule s refills multivitamin tablet sig one tablet po once a day vitamin d oral anastrozole mg tablet oral fosamax oral discharge disposition home discharge diagnosis metastatic breast cancer with recurrence of liver lesions status post rfa ablation of liver lesions with post rfa bleeding discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions general discharge instructions please resume all regular home medications unless specifically advised not to take a particular medication you were prescribed oxycodone a pain medication and should take it as prescribed please get plenty of rest continue to ambulate several times per day and drink adequate amounts of fluids avoid lifting weights greater than lbs and strenuous activity for the next weeks avoid driving or operating heavy machinery while taking pain medications incision care please call your doctor or nurse practitioner if you have increased pain swelling redness or drainage from the incision site avoid swimming and baths until your follow up appointment you may shower and wash surgical incisions with a mild soap and warm water gently pat the area dry if you have steri strips they will fall off on their own please remove any remaining strips days after surgery followup instructions please follow up with your oncologist and pcp as they have directed you may call dr office at to discuss further follow up care regarding the lesion ablated on your liver and surgery additional procedures if indicated at that time completed by,"{
""Diagnoses"": [""metastatic invasive lobular carcinoma"", ""recurrence of liver lesions""],
""Medications"": [""zoladex"", ""tamoxifen"", ""letrozole"", ""liver mets""]
}"
58108,admission date discharge date date of birth sex m service medicine allergies ambien attending chief complaint shortness of breath major surgical or invasive procedure none history of present illness is a yo male with severe copd s p recent hospitalization for copd exacerbation and atypical pneumonia in cancer of the layrnx who presents with shortness of breath and productive cough the patient finished his prednisone taper approximately week ago his wife reports that his breathing worsened as the steroids were tapered but that it has been much worse since the steroids were off week ago when his breathing is at it s best he is able to do some household chores and walk across the room however for the past few days he has not been able to get out of his chair he has a chronic cough with white sputum at baseline but the sputum turned green approximately days ago he was started on azithromycin and levofloxacin approximately days ago without improvement in his symtoms he denies fevers and rigors but reports feeling chilled and sweaty he does not feel like he has a cold or flu he reports increased wheezing his wife reports poor po intake and increased confusion which is typical of his copd exacerbation patient s steroids were increased around and then quickly tapered of note pt takes bactrim for pjp ppx while on steroids in the ed initial vs were t hr bp rr o sat l he was tachypneic wheezy on exam and with poor airflow cxr was negative for infiltrates his ekg was unchanged he was hypoxic to on l so was placed on non invasive ventilation with improvemetn in o sats to patient was given ipratropium bromide albuterol nebs methylprednisolone sodium succ mg iv x and levofloxacin mg iv x vs prior to transfer were af cpap fio peep in the icu patient is no longer on non invasive ventillation past medical history copd on l home o followed by dr pt uses cpap at night and has done so for a long time possibly for osa vs night time ventilatory support for copd newly diagnosed t larynx cancer prostate adenocarcinoma depression h o pyloric stenosis memory loss no formal diagnosis of dementia social history patient lives with his wife grown children reports pack per day times years quit in served in history of exposure no current alcohol consumption denies any other illicit drug use family history brother died of emphysema also was a smoker physical exam general alert pursed lip breathing but not tachypneic heent ncat perrla eomi sclera anicteric dry mm oropharynx clear neck supple jvp cm no lad lungs poor airflow no wheezes rales rhonchi cv distant heart sounds regular rate and rhythm normal s s no murmurs rubs gallops abdomen epigastric scar soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly gu no foley rectal nl tone guiaic stool ext warm well perfused radial dp pt pulses no clubbing cyanosis or edema neuro a ox person place only strenght in ue le bilat sensation grossly intact pertinent results am wbc rbc hgb hct mcv mch mchc rdw am neuts lymphs monos eos basos am plt count am pt ptt inr pt am caltibc vit b folate ferritin trf am iron am glucose urea n creat sodium potassium chloride total co anion gap am lactate am type art po pco ph total co base xs comments green top pm lactate pm fibrinoge pm lactate pm type art po pco ph total co base xs pm lactate pm type art po pco ph total co base xs echo the left atrium is mildly dilated the right atrium is moderately dilated a right to left shunt across the interatrial septum is seen during valsalva maneuver release bubble study right ventricular chamber size and free wall motion are normal the aortic root is moderately 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 mildly thickened there is no mitral valve prolapse mild mitral regurgitation is seen the estimated pulmonary artery systolic pressure is normal there is no pericardial effusion impression right to left shunt at atrial level note that neither the size nor the predominant directionality nor the anatomic classification of the atrail shunt can be determined on thre basis of a positive bubble study however this most likely represents either a patent foramen ovale or a small secundum type atrial septal defect cxr impression no evidence of pneumonia ct chest impression resolution of left lower lobe pulmonary nodule consistent with infectious or inflammatory etiology new patchy consolidations involving the left upper lobe and lingula consistent with bronchopneumonia severe emphysema and diffuse bronchial wall thickening right renal cystic structure incompletely characterized if clinically warranted ultrasound on a non emergent basis could be considered brief hospital course y o male with a pmhx significant for severe copd on l of home oxygen who presented with worsening shortness of breath and productive cough dyspnea likely related to copd exacerbation he has gold stage iv copd there was a question of an underlying pneumonia based on ct findings however he was not noted to have fevers or a leukocytosis he was placed on bipap overnight and tolerated this well he was transitioned back to nc on th emorning following admission of note echo showed evidence of r to l shunt which could be contributing to hypoxemia he was placed on ipratropium and albuterol nevs his dose of advair was increased he was also started on prednisone given concern for possible infection cefepime was started he was also continued on his previously started day course of azithromycin he completed the day course of azithro and cefepime was discontinued on as there was low suspicion for infection pulmonary recommended the following consider switching to bipap qhs continue high dose advair on discharge slow prednisone taper on discharge with prompt outpatient pulmonary clinic follow up within month while still on taper outpatient sleep study as soon as possible following discharge follow up in sleep clinic following sleep study to titrate nippv settings the patient may benefit from bipap he will discuss with primary pulmonologist or at sleep clinic appointment to get bipap approved for home use it would be more for ventilatory failure rather than osa in the meantime he will continue with cpap hypernatremia on admission it was felt that this was hypovolemic hyponatremia in the setting of poor po intake given ivfs overnight and sodium was improved this morning anemia hematocrit noted to drift down during the first day of admission guiaic positive on exam fe studies c w borderline acd hematocrit was stable thrombocytopenia plt count trended down following admission and were also noted to be down from recent baseline thrombocytopenia could possibly be secondary to ppi coags wnl was placed on ranitidine thrombocytopenia improved in the end memory difficulties delirium the patient was a ox on admission the etiology is liekly multifactorial from a combination of hypoxemia hypercapnia hypernatremia and chronic dementia he was continued on aricept and an outpatient mri of his brain should be considered mental status improved on the morning following admission t larynx cancer patient is status post radiation therapy there was concern about possible metastatic disease on last chest ct repeat chest ct did not show evidence of metastatic disease prostate adenocarcinoma patient reports worsening urinary symptoms increased avodart as outpatient continue avodart at mg po daily depression continue prozac medications on admission fluticasone salmeterol mcg dose disk inhalation donepezil mg po am avodart mg po once a day with handihaler mcg capsule inhalation once a day fluoxetine mg capsule po daily ipratropium bromide inhalation q h albuterol sulfate mg ml neb q h prn omeprazole mg capsule tabs po daily albuterol sulfate mcg actuation hfa puffs qid prn wheezing levofloxacin mg po daily for past days azithromycin mg po x day now mg po daily discharge medications prednisone mg tablet sig taper po for weeks take mg daily for days then mg daily for days then mg daily for days then mg daily until otherwise advised by your pulmonologist disp tablet s refills avodart mg capsule sig two capsule po daily albuterol sulfate mg ml solution for nebulization sig one unit dose inhalation q h every hours albuterol sulfate mg ml solution for nebulization sig one unit dose inhalation q h every hours as needed for sob wheeze fluoxetine mg capsule sig two capsule po daily daily donepezil mg tablet sig two tablet po daily daily ipratropium bromide solution sig one unit dose inhalation q h every hours fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day disp disk with device s refills omeprazole mg capsule delayed release e c sig two capsule delayed release e c po once a day discharge disposition home with service facility discharge diagnosis primary diagnoses acute exacerbation of severe chronic obstructive pulmonary disease anemia hct stable guaiac positive stools thrombocytopenia resolved possibly ppi secondary diagnoses larynx cancer prostate adenocarcinoma depression history of pyloric stenosis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted for evaluation and management of an exacerbation of your copd your symptoms seemed to have flared after you finished your taper of steroids initially you had some episodes of confusion likely from your ventilatory status being so poor you were restarted again on prednisone and gradually improved over the last several days with regard to your mental status ambulatory status and breathing ability pulmonology consultation recommends a more formal assessment of your need for postitive pressure ventilation i e cpap or bipap a sleep clinic appointment has been arranged to assess these needs rehabilitation may be very helpful for your condition medication changes start prednisone taper mg daily for week then mg daily for week then mg daily for week then mg indefinitely until advised otherwise by your pulmonologist increase dose advair one inhalation twice daily previously twice daily stop levofloxacin and azithromycin if using ipratropium nebulizer treatments there is no need to use your inhaler named if using albuterol nebulizer treatments there is no need to use your inhaler for albuterol otherwise there were no other changes made to your medication regimen followup instructions department pulmonary function lab when wednesday at pm with pulmonary function lab building campus east best parking garage department pft when wednesday at pm department medical specialties when wednesday at pm with dr dr building sc clinical ctr campus east best parking garage department sleep when thursday at am with dr building sc clinical ctr campus east best parking garage [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies ambien attending chief complaint shortness of breath major surgical or invasive procedure none history of present illness is a yo male with severe copd s p recent hospitalization for copd exacerbation cancer of the layrnx and prostate status post xrt who is admitted with hypercarbic respiratory failure copd exacerbation he was in his usual state of health since his last admission and had been weaning his prednisone over weeks he was down from mg daily to with a plan to decrease to mg tomorrow however over the last week he became more dyspneic with exertion with increased sputum production he is normally sedentary but is able to bath himself without help though has dyspnea when this is completed and walk from his chair across the room over the last few days he was unable to talk in complete sentences and was more dyspneic with any movement he had an appointment with his outpatient pulmonologist today who sent him to the ed for evaluation he additionally reports several loose bowel movements a day for the last days associated wtih mild abdominal cramping this is not particularly bothersome and he does not have any abdominal cramping at time in the ed initial vs were t hr bp rr o sat l he was noted to be tachypneic and unable to speak in full sentences no abg was done he was placed on bipap and was noted to have improved symptoms cxr without new infiltrate given the chronicity ofhis symptoms over several days he was sent over to the icu on l nc he was given vancomycin zosyn solumedrol mg iv and combivent nebs x prior to transfer on the floor the patient is able to answer questions but begins to purse his lips and use accessory muscles to recover after speaking he denies any other symptoms on review of systems including chest pain headaches weakness abdominal pain diarrhea constipation dysuria he does endorse urinary hesitancy and frequency but this has been ongoing since his prostate cancer xrt past medical history copd on l home o followed by dr pt uses cpap at night and has done so for a long time possibly for osa vs night time ventilatory support for copd planning for bipap at night but has not yet arranged this t larynx cancer prostate adenocarcinoma depression h o pyloric stenosis memory loss no formal diagnosis of dementia social history patient lives with his wife grown children reports pack per day times years quit in served in history of exposure no current alcohol consumption denies any other illicit drug use family history brother died of emphysema also was a smoker physical exam general alert pursed lip breathing but not tachypneic heent ncat perrla eomi sclera anicteric dry mm oropharynx clear neck supple jvp cm no lad lungs poor airflow no wheezes rales rhonchi cv distant heart sounds regular rate and rhythm normal s s no murmurs rubs gallops abdomen epigastric scar soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly gu no foley ext warm well perfused radial dp pt pulses no clubbing cyanosis or edema neuro a ox person place only strength in ue le bilat sensation grossly intact pertinent results admission labs ph po pco 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 am blood ck cpk am blood ck mb ctropnt am blood calcium phos mg pm blood type art po pco ph caltco base xs am blood type art po pco ph caltco base xs pm blood type art po pco ph caltco base xs pm blood lactate pm blood lactate discharge labs imaging studies actual pred pred actual pred chg fvc fev mmf fev fvc cxray on pa and lateral views of the chest were obtained there is marked hyperexpansion of the lungs with upper lobe lucency and splaying of bronchovasculature which is compatible with known severe emphysema there is vague opacity in the left lower lung between the left eighth and ninth ribs posteriorly as well as at the left lung base which could represent small foci of scarring or residual of infection in this patient with recent pneumonia no pleural effusion or pneumothorax is seen cardiomediastinal silhouette is stable bony structures are intact impression severe emphysema residual infection versus scarring in the leftlower lung cxray portable on comparison is made with prior study performed a day earlier this examination is technically very limited only the upper portion of the thorax was included visualized portions of the lungs are clear the upper mediastinum is unchanged ekg on sinus rhythm with atrial premature beat consider left atrial abnormality although is non diagnostic otherwise tracing is within normal limits intervals axes rate pr qrs qt qtc p qrs t abdominal x ray single ap supine portable radiograph was submitted there is stool throughout the colon there is no evidence of bowel obstruction or pathologic calcifications in the abdomen degenerative changes are in the lumbar spine brief hospital course year old m with a pmh significant for severe copd on l home oxygen who presents with worsening shortness of breath and productive cough as well as diarrhea hypercarbic respiratory failure worsening of chronic co retention and respiratory acidosis in the setting of copd exacerbation requiring bipap there was no clear clear infiltrate on plain film the etiology was unclear though may have been in the setting of prednisone taper over the last week he was continued on bipap at night which he found helpful copd exacerbation patient s dyspnea is most likely related to copd exacerbation and possibly exacerbated by prednisone taper and changes in acid base status with diarrhea gold stage iv copd he was treated with standing nebs and a slow prednisone taper he will continue his nebs at home he was started on steroids and was discharged on mg prednisone he has pulmonary follow up on the day after admission and will taper the steroids according to his pulmonologists instructions he completed a day course of azithromycin advair was continued diarrhea c diff negative x resolved with conservative management unclear etiology anemia hct down from admission though now closer to baseline normocytic in nature iron studies b and folate wnl earlier this month he is having guaiac positive stools hct remained stable throughout admission will likely need inpatient or outpatient gi consultation memory difficulties continued donazepil t larynx cancer patient is status post radiation therapy no current treatment prostate adenocarcinoma patient reports worsening urinary symptoms increased avodart as outpatient depression continued prozac medications on admission fluticasone salmeterol mcg dose disk inhalation donepezil mg po am avodart mg po once a day fluoxetine mg capsule po daily ipratropium bromide q h albuterol sulfate q h prn omeprazole mg capsule tabs po daily discharge medications albuterol sulfate mg ml solution for nebulization sig one unit dose inhalation q h every hours albuterol sulfate mg ml solution for nebulization sig one unit dose inhalation q h every hours as needed for sob ipratropium bromide solution sig one unit dose inhalation q h every hours fluoxetine mg capsule sig one capsule po daily daily donepezil mg tablet sig two tablet po hs at bedtime fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day omeprazole mg capsule delayed release e c sig two capsule delayed release e c po daily daily avodart mg capsule sig two capsule po daily discharge disposition home with service facility vna discharge diagnosis primary diagnoses hypercarbic respiratory failure acute exacerbation of chronic obstructive pulmonary disease secondary diagnoses larynx cancer prostate adenocarcinoma depression anemia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to the for evaluation and management of worsening of your respiratory condition you were to have severe symptoms requiring initial management in the icu you improved significantly with treatment with bipap iv steroids antibiotics nebulizers and inhalers you were transferred to the floor in stable condition the pulmonary department arranged for you to have a bipap machine to use at home you will be going home on a slow steroid prednisone taper as well you should call the pulmonary clinic for follow up within the next weeks medication changes prednisone xxmg to decrease by mg each week until you are seen in pulmonary clinic followup instructions please make an appointment to be seen in pulmonary clinic within the next weeks department neurology sleep clinic when thursday at am with md building campus east best parking garage,"{
""Diagnoses"": [""severe copd"", ""atypical pneumonia"", ""cancer of the lungs""],
""Medications"": [""azithromycin"", ""levofloxacin""]
}"
94129,admission date discharge date date of birth sex f service medicine allergies vaccine toxoid preps combo classifier influenza virus vaccine attending chief complaint asthma exacerbation major surgical or invasive procedure none history of present illness ms is a year old female with history of asthma and copd requiring intubations and icu admissions in the past she reports feeling progressively short of breath for the past days with associated cough productive of clear phlegm runny nose sinus pressure no associated fevers no known sick contacts though she does live with her granddaughter she feels her breathing acutely decompensated yesterday after her daughter was using nail polish at home she is on singulair advair and albuterol prn at her baseline she uses the albuterol x week though she has used it increasingly over the past several days times this morning with no relief she was seen by pcp in with complaints of productive cough wheezing increasing dyspnea on exertion she was put on a prednisone taper and a course of azithromycin at that time in the ed inital vitals were on ra she was treated wtih multiple albuterol nebulizer treatments total ipratropium nebs total mg magnesium prednisone mg and mg solumedrol on exam patient was noted to have bilateral expiratory wheezes increased work of breathing inc e i ratio some accessory muscle use patient was noted to be getting tired and she was started on bipap in the ed prior to transfer vitals were bipap o peep pressure support she is followed by pulmonary here and was most recently seen by and dr in she had a ct scan for workup of a pulmonary lesion seen on prior cxray ct at that time revealed right basilar scarring with minimal post aspiration post infectious changes in the right lower lobe no evidence of pulmonary nodules she also had a sleep study performed with recommendations for cpap her most recent spirometry from revealed fev fvc she reports multiple exacerbations yearly most recently required hospitalization months ago she has been intubated times in the past years ago on the floor she reports continued feelings of tightness when breathing though improved significantly from admission she is tolerating bipap well and reports feeling comfortable past medical history obesity hepatitis c infection depression history of self injurious behavior and prior suicide attempts hypothyroidism status post rai tobacco use obstructive sleep apnea cpap with liters oxygen intermittent low oxygen saturation in the low to mid s steroid induced diabetes because of her intermittent requirement for oral prednisone social history she is still smoking she has history of drug abuse including marijuana cocaine iv heroin currently on methadone maintenance at mg per day family history no family history of asthma father and grandfather have diabetes physical exam admission exam vitals t bp p r o general alert oriented using accessory muscles to breath heent sclera anicteric mmm oropharynx clear left sided ptosis neck supple jvp not elevated lungs inspiratory and expiratory wheezing prolonged expiratory phase accessory muscle use with sternocleidomastoid muscle retractions cv regular rate and rhythm normal s s no murmurs rubs gallops abdomen soft non tender non distended hypoactive bowel sounds no rebound tenderness or guarding no organomegaly gu no foley ext warm well perfused pulses no clubbing cyanosis or edema skin multiple linear scars on forearms bilaterally and across abdomen from previous self injurious behavior diffuse areas of hypopigmentation involving face arms abdomen legs and feet 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 glucose urean creat na k cl hco angap portable upright ap view of the chest the cardiac mediastinal and hilar contours are normal the pulmonary vascularity is normal and the lungs are clear no pleural effusion or pneumothorax is visualized no acute osseous abnormality is visualized impression no acute cardiopulmonary process am rapid respiratory viral screen culture source nasopharyngeal swab final report respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at within week if additional testing is needed respiratory viral antigen screen final negative for respiratory viral antigen specimen screened for adeno parainfluenza influenza a b and rsv by immunofluorescence refer to respiratory viral culture for further information brief hospital course asthma exacerbation patient has long history of asthma and has required icu stays with intubation in the past because of her increased work of breathing and poor response to nebulizers magnesium and steroids she was initiated on bipap she required continuous nebulizers for several hours but was able to be weaned to nasal cannula suspect trigger may be viral as patient had prodromal illness for several days with acute trigger of environmental exposure to acetone odor from nail polish viral respiratory cultures negative at baseline patient s oxygen saturation appears to be she received days of iv steroids before being transitioned to po prednisone she will require slow day taper given severity of initial presentation she was also started on a day azithromycin course taper prednisone complete azithromycin course wrote for advair at patient s request as well as proair leukocytosis developed on hd likely secondary to steroids patient has no fever but will add diff and check ua to ensure no other infectious process normalizing by discharge hypothyroidism continued home synthroid mcg daily drug abuse continued home methadone mg daily and clonidine mg depression patient has been off prozac for several months now and feels that her mood is good will continue to monitor diabetes pt with history of steroid induced diabetes in the past will monitor sugars daily if elevated will start on ssi with fingersticks which were normal in house osa continued home cpap overnight medications on admission albuterol prn alendronate mg daily symbicort mg mcg actuation hfa aerosol inhaler puffs clonidine mg fluticasone mcg spray levothyroxine mcg daily methadone mg daily singulair mg daily omeprazole mg trazadone prn calcium carbonate vitamin d mg unit tablets daily discharge medications alendronate mg tablet sig two tablet po daily daily clonidine mg tablet sig one tablet po bid times a day levothyroxine mcg tablet sig one tablet po daily daily fluticasone mcg actuation spray suspension sig one spray nasal times a day methadone mg tablet sig six tablet po daily daily montelukast mg tablet sig one tablet po daily daily acetaminophen mg tablet sig tablets po q h every hours as needed for pain or fever omeprazole mg capsule delayed release e c sig one capsule delayed release e c po twice a day calcium d mg mg unit tablet sig three tablet po once a day albuterol sulfate mg ml solution for nebulization sig one nebulizer inhalation every six hours as needed for sob wheezing standing for the next week azithromycin mg tablet sig one tablet po once a day for days disp tablet s refills prednisone mg tablet sig tablets po qdaily as directed tabs mg daily through then tabs mg daily through then tab mg daily through then tab mg daily through then stop disp tablet s refills proair hfa mcg actuation hfa aerosol inhaler sig two puffs inhalation every hours as needed for shortness of breath or wheezing disp inhaler refills advair diskus mcg dose disk with device sig one puff inhalation twice a day disp disk refills discharge disposition home discharge diagnosis severe asthma exacerbation hypothyroidism hepatitic c discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted with a severe asthma exacerbation likely triggered by fumes from your nail polish with oxygen steroids antibiotics and nebulizers your symptoms improved it is very important that you take your medications as prescribed it is also very important that you schedule close follow up with your pcp and lung doctors we strongly advise against smoking during this time and avoidance of all environmental irritants medication changes prednisone taper as follows mg daily x days then mg daily x days then mg daily x days then mg daily x days then mg daily x days then stop please take your nebulizers and inhalers every hours for the next week please complete your azithromycin course followup instructions pcp w please call for week follow up appointment dr please follow up with your lung doctor in the next weeks,"{
""Diagnoses"": [""Asthma"", ""COPD""],
""Medications"": [""Singulair"", ""Advair"", ""Albuterol"", ""Prednisone"", ""Azithromycin""]
}"
50594,admission date discharge date date of birth sex m service medicine allergies sulfa sulfonamide antibiotics attending chief complaint sepsis from uti source major surgical or invasive procedure hematoma drain placement lithotrypsy history of present illness yo m with history of nephrolithiasis and retained left ureteral stent s p stent removal and left percutaneous nephrostomy tube placement month ago presents with fever chills left flank pain and altered mental status the patient was found lying on the floor by his partner the patient was noted to be sleepy not answering questions approriately the patient reports that he had nausea vomiting days pta and awoke with left flank pain on the morning of admission then became confused in the afternoon he reported that his nephrostomy tube which had given him frequent problems since it was placed was not functioning well draining blood puss in the ed the patient was initially drowsy and confused but his mental status gradually improved fluids he was given l ns vancomycin gm iv zosyn gm iv and tylenol gm po head ct and neck ct negative lactate was but rose to despite iv fluids vitals on transfer were t c hr rr sat l ros fever chills sweats no cp sob no cough nausea vomiting no diarrhea constipation no pain with urination or difficulty urinating left flank pain no weakness chronic extremity tingling numbness neuropathy past medical history nephrolithiasis neuropathy psoriatic arthritis anxiety depression gout seasonal allergies htn s p left nephrostomy tube h o retained left ureteral stent social history lives with partner works as psychiatrist tobacco none etoh none drugs none family history sister with nephrolithiasis physical exam vital signs t c hr bp sat ra gen diaphoretic having chills heent anicteric dry mucous membranes neck no jvd resp normal respiratory effort lungs ctab cv quiet heart sounds rrr no m g r abdomen bs soft nt nd no hsm gu left nephrostomy tube with serosanginous drainage around tube tube is not sutured in and moves in and out with respiration when drained tube puts out puss ext warm and well perfused dp and pt pulses neuro a ox cn ii xii intact strength throughout pertinent results ekg sinus tachycardia at bpm lad no st t wave changes no prior for comparison imaging ct abdomen pelvis with contrast x cm rim left subcapsular renal fluid collection which may represent a hematoma superinfection cannot be excluded left mm distal ureteral obstructing stone with severe hydro ureter and hydronephrosis despite a left nephrostomy tube in place hyperemic ureter consistent with ureteritis surrounding perinephric fat stranding ct head w o contrast no hemorrhage herniation hydrocephalus no ct evid for acute cortical stroke mucus retention cyst v polyp in l max antrum ct c spine without contrast no cervical spine fractures multi level degenerative disease cxr portable ap no definite acute pulmonary process renal us impression persistent lower pole left perinephric hematoma superinfection of the hematoma cannot be excluded by imaging appearance echo the left atrium is dilated the estimated right atrial pressure is mmhg 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 ascending aorta is mildly dilated the aortic arch is mildly dilated 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 there is no pericardial effusion no vegetation seen cannot definitively exclude renal us impression decrease in size of left perinephric hematoma bilateral non obstructing urinary calculi labs on admission 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 pt ptt inr pt pm blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap pm blood lactate am blood lactate am blood lactate micro data blood cultures positive for pan klebsiella sensitivities mic expressed in mcg ml klebsiella pneumoniae klebsiella pneumoniae ampicillin sulbactam s s cefazolin s s cefepime s s ceftazidime s s ceftriaxone s s ciprofloxacin s s gentamicin s s meropenem s s piperacillin tazo s s tobramycin s s trimethoprim sulfa s s urine positive subequent urine cultures all negative sensitivities mic expressed in mcg ml klebsiella pneumoniae enterococcus sp ampicillin s ampicillin sulbactam s cefazolin s cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s nitrofurantoin i s tetracycline s tobramycin s trimethoprim sulfa s vancomycin s brief hospital course yo m with complicated urologic history including nephrolithiasis longstanding left ureteral stent recently removed and recent percutaneous nephrostomy admitted to the micu with urosepsis ct abdomen pelvis showed left hydroureter distal obstructing stone and perinephric fluid collection c w infected hematoma improved but had continued fevers s p lithotrypsy in house with plans for outpatient nephrogram and possible nephrostomy tube removal and abx until hematoma evaluated urosepsis on admission the patient had tachycardia and elevated lactate ct showed left ureteral obstructing stone with severe hydroureter and hydronephrosis despite nephrostomy tube in place as well as a left x cm subcapsular fluid collection with superinfection unable to be ruled out the patient was started on vancomycin and zosyn and aggressively hydrated with normal saline tobramycin was later added he underwent drainage of the left subcapsular fluid collection but interventional radiology with drainge of bloody fluid that eventually grew pans klebsiella as anesthesia and interventional radiology were preparing for the procedure the patient became hypotensive and was started on phenylephrine after the procedure he was transferred back to the micu where multple attempts a central venous catheter placement were made including right internal jugular and left subclavian without success with further fluid resuscitation the patient was weaned off of phenylephrine he was given thiamine mg iv and his lactate trended down he was admitted to the floor where his fevers subsided but he continued to have positive blood cultures until with klebsiella of note his urine grew gpcs but was likely contaminant giving indwelling tube id was consulted and recommended iv ceftriaxone for the bacteremia after his blood cultures cleared then on he started having low grade fevers again it wsa thought to be due either to his infected impacted stone vs hematoma us of hematoma showed appropriate slow shrinking per ir it takes a long time to drain because hematomas slowly liquify and do not drain quickly despite these fevers all his cultures remained negative he was then taken by urology for lithotrypsy it went well and the stone was completely removed he was watched for two days after the procedure and continued to have low grade fevers these were likely due to his hematoma and he was discharged plan was for nephrogram the tues after discharge and possible removal of nephrostomy tube in ir also plan for repeat ct scan to evaluate hematoma with ir in a week and then f u with id prior to stopping iv abx he was discharged with a midline if he is doing well at id followup can likely transition to po cipro fevers as above were likely from infected hematoma urine blood and stool cultures were all negative anemia has known anemia hct initially dropped with iv resuccitation but then stabalized and trended upward throughout his hospitalization htn normotensive now with sbps s s we held his triamterene hctz given normal blood pressures and continued to hold it on discharge he states he has been slowly coming of his bp meds with weight loss so may not need this re initiated can follow up with pcp for further evaluation of bp anxiety depression stable appropriate mood here we continued zoloft nefazadone trazodone buspirone gout no active gout we continued allopurinol colchicine psoriatic arthritis on methadone for pain at home we continued his home dosing here at first and then per patient decreased it from qid to because he wasn t walking around much he did stop his naproxen while here to monitor for fever curve neuropathy secondary to chronic colchicine use per patient we continued neurontin at home doses hyperlipidemia continued gemfibrizol chronic bronchitis asymptomatic continued beclomethasone zyretc and fluticasone follow up outpatient nephrogram outpatient ct and hematoma eval in ir id follow up vna for midline care and abx medications on admission nefazodone mg tid patient says he takes mg qam and mg qpm zoloft mg daily buspirone mg tid trazodone mg qhs omeprazole mg hctz triamterene patient uncertain of dose allopurinol mg daily colchicine mg etodolac tablet methadone mg qid cetirizine daily flonase sprays twice daily detrol mg hour capsule once daily lopid gemfibrozil mg neurontin mg tid patient says he actually takes qam and qpm beclomethasone dipropionate mcg actuation aerosols once daily were confirmed with pharmacy discharge medications nefazodone mg tablet sig two tablet po tid times a day sertraline mg tablet sig one tablet po daily daily buspirone mg tablet sig two tablet po tid times a day omeprazole mg capsule delayed release e c sig two capsule delayed release e c po bid times a day allopurinol mg tablet sig one tablet po daily daily colchicine mg tablet sig one tablet po bid times a day fluticasone mcg actuation spray suspension sig two spray nasal times a day gemfibrozil mg tablet sig one tablet po bid times a day gabapentin mg capsule sig three capsule po tid times a day senna mg tablet sig six tablet po bid times a day docusate sodium mg capsule sig three capsule po bid times a day beclomethasone dipropionate mcg actuation aerosol sig one inhalation inhalation two puffs daily cetirizine mg tablet sig one tablet po daily trazodone mg tablet sig three tablet po hs at bedtime as needed for insomnia methadone mg tablet sig one tablet po four times a day acetaminophen mg tablet sig tablets po q h every hours as needed for pain fever tolterodine mg capsule ext release hr sig one capsule ext release hr po once a day ceftriaxone in dextrose iso os gram ml piggyback sig one piggyback solution intravenous once a day for days until may need to contniue but likely will switch to po this day disp solutions refills saline flush syringe sig one syringe injection once a day for days daily or as needed for flushing disp syringes refills dilaudid mg tablet sig one tablet po three times a day as needed for pain for days disp tablet s refills discharge disposition home with service facility infusion resource discharge diagnosis primary diagnosis urinary tract infection sepsis impacted kidney stone perinephric infected hematoma discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you came into the hospital with an infection in your urinary tract you had sepsis related to this infection and were in the icu the bacteria that grew was klebsiella which was sensitive to most antibiotics we were able to put you on ceftriaxone the infectious disease team was following along there were two possible places the infection was started first was an infected hematoma second was the stone we placed a drain in your infected hematoma and it started shrinking while you were here it takes a while for a hematoma to drain though the plan will be for a follow up ct scan with interventional radiology prior to seeing dr to monitor the hematoma s process while here the urologists did lithotrypsy to remove the stone they would like you to follow up with radiology for a nephrogram and for possible nephrostomy tube removal this upcoming tuesday for now the plan will be to go home on ceftriaxone until you see dr in the clinic at that time he can make a decision about how to proceed with treatment you should make sure to return to the hospital for high fevers chills pain or other concerns you still have an infection in you based on your low grade fevers so you are at risk of worsening although we don t expect it be aware of any changes you feel and make sure to report them the changes we made to your medications are start ceftriaxone gm q hrs stop your hctz triamterene your blood pressures have been normal while you were here and you might not need this anymore follow up with your vnas about your bp and pcp about whether or not to restart this in the future followup instructions appointment for nephrogram and nephrostomy tube removal department radiology care unit when tuesday at pm arrive hour early for procedure no food after midnight the day before may get sedation so need a ride home building de building complex campus west best parking garage department radiology will be here and is related to scheduling for the nephrogram touch base with front desk when checking in about being scheduled for two places likely will just be on of building for whole procedure when tuesday at pm with xsp west building cc clinical center campus west best parking garage appointment for pcp follow up department primary care name dr when wednesday at am call and change if working location address phone appointment for repeat ct scan and drain adjustment of hematoma department radiology care unit when tuesday at am building de building complex campus west best parking garage appointment department infectious disease when friday at am with md building lm campus west best parking garage appointment department infectious disease when monday at am with md building lm bldg campus west best parking garage please call above offices with any questions can always reach dr on with questions starting on monday please follow up with dr and call his clinic after nephrostomy tube removal completed by,"{
""Diagnoses"": [""Sepsis"", ""UTI"", ""Hematoma"", ""Drain Placement"", ""Lithotrypsy"", ""Nephrolithiasis"", ""Retained Left Ureteral Stent"", ""SP Stent Removal"", ""Left Percutaneous Nephrostomy Tube Placement""],
""Medications"": [""Vancomycin"", ""Zosyn"", ""Tylenol"", ""Lactate""]
}"
26929,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint fatigue major surgical or invasive procedure aortic valve replacement with a size mosaic tissue valve history of present illness this is a year male who presented complaining of dyspnea on exertion workup revealed that he had aortic insufficiency with a normal ejection fraction he underwent a catheterization that showed normal coronaries based on these findings the patient was recommended to undergo an aortic valve replacement past medical history af gi bleed elevated psa colonic polyps hoh social history retired salesman lives with wife denies ever using tobacco drinks drink per month family history noncontributory physical exam sr lbs gen wdwn elderly man in nad skin unremarkable heent eomi perrl injected os op benign neck supple from lungs cta heart rrr iii vi diastolic murmur abd benign ext warm well perfused no edema pulses no carotid bruits neuro grossly intact pertinent results echo pre bypass the left atrium is mildly dilated no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage no spontaneous echo contrast is seen in the body of the right atrium or right atrial appendage the left ventricular cavity is moderately dilated overall left ventricular systolic function is moderately depressed lvef right ventricular chamber size and free wall motion are normal the aortic root is mildly dilated at the sinus level there is a sinus of valsalva aneurysm the ascending aorta is mildly dilated 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 severe aortic regurgitation is seen the aortic regurgitation jet is eccentric the mitral valve leaflets are mildly thickened trivial mitral regurgitation is seen there is no pericardial effusion am blood wbc am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood plt ct am blood urean creat k am blood glucose urean creat na k cl hco angap brief hospital course mr was admitted to the on for surgical management of his aortic valve disease he was taken directly to the operating room where he underwent an aortic valve replacement using a mm mosaic porcine valve postoperatively he was taken to the cardiac surgical intensive care unit for monitoring he later awoke neuorlogically intact and was extubated aspirin and beta blockade were resumed on postoperative day one he was transferred to the step down unit for further recovery mr was gently diuresed towards his preoperative weight the physical therapy service was consulted for assistance with his postoperative strength and mobility he developed atrial fibrillation for which amiodarone was started he converted to normal sinus rhythm he had no complications postoperatively he was ready for discharge on pod medications on admission nifedipine mg qd multivitamin discharge medications docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills ranitidine hcl mg tablet sig one tablet po bid times a day disp tablet 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 metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po daily daily disp tablet sustained release hr s refills amiodarone mg tablet sig two tablet po bid times a day mg x days then mg daily x week then mg daily ongoing 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 q h every hours for days disp capsule sustained release s refills discharge disposition home with service facility hospice and vna discharge diagnosis as af gi bleed colon polyps s p bil tkr discharge condition good discharge instructions call with fevers redness or drainage from incisions 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 heavy lifting or driving until follow up with surgeon p instructions dr weeks dr weeks completed by,"{
""Diagnoses"": [""cardiothoracic"", ""aortic insufficiency"", ""aortic valve replacement"", ""aortic valve replacement with a size mosaic tissue valve""],
""Medications"": [""none""]
}"
93565,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint neck and pain major surgical or invasive procedure none history of present illness yo healthy gentleman who had a recent tooth infection that began week ago and s p urgent root canal days pta who presents with left sided neck and pain he reports that he developed painful swallowing and difficulty swallowing with dinner last night and that he felt that pills were stuck in his throat neck has worsened since root canal days ago he is unable to fully open his mouth he denies any difficulty breathing wheezing or handling his oral secretions he does report sweats but denies fevers or chills he was evaluated at which showed a neck ct with initial read concerning for airway impingement and abscess at osh ed he was given unasyn gm iv x morphine mg iv total and decadron mg iv at am and then transferred here in the ed initial vs were t hr bp rr o sat ra on exam patient l lower facial trismus but no distress labs notable for wbc ent was consulted and felt that his airway was stable but final recommendations are pending tentative plan is for decadron mg iv q hr maxillofacial surgery dr was also consulted and will plan to see the patient this afternoon he recommended keeping the patient npo patient was given unasyn and l ns in our ed icu admission requested for airwary monitoring his vs prior to transfer were ra in the icu the patient reports that his pain is much better currently past medical history tonsillectomy as child at age social history patient works as a building inspector and remodeler married with children he is a current smoker ppd for years he drinks to beers night but has not had any alcohol in past days no ivdu family history mother died of bone cancer at age physical exam general alert oriented no acute distress heent ncat perrla sclera anicteric neck supple jvp cm left submandibular tissue and pain but unable to identify a fluctuant focus only able to open mouth cm op with mm unable posterior op to evaluate for erythema lungs clear to auscultation bilaterally 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 ext warm well perfused radial dp pt pulses no clubbing cyanosis or edema neuro cn intact mae sensation grossly intact pertinent results am urine color straw appear clear sp am urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg am glucose urea n creat sodium potassium chloride total co anion gap am tsh am free t am wbc rbc hgb hct mcv mch mchc rdw am neuts lymphs monos eos basos am plt count panorex impression findings consistent with the given history of a recent tooth extraction presumably the right lower second molar history enlarged right lobe of thyroid seen on previous x ray findings the right lobe of the thyroid measures x x cm and contains a heterogeneous predominantly solid nodule at the mid to lower pole the nodule measures x x cm left lobe of the thyroid measures x x cm and contains two small benign appearing nodules cm in the upper pole and cm in the lower pole conclusion bilateral nodules the nodule in the mid to lower pole of the right lobe of the thyroid should be considered for fine needle aspiration brief hospital course this is a year old healthy male presenting with neck pain and trismus with evidence of tonsillar and peritonsilar cellulitis admitted to the icu due to concern for potential airway compromise he was seen by anesthesia and ent imaging was from was reviewed he was treated empirically with decadron and continued on his antibiotics he never developed airway compromise and was transferred to the medical floor and then home he was also noted to have multiple thyroid nodules for which outpatient follow up is recommended medications on admission percocet mg mg tab oral tablet s every hrs prn pain amoxicillin mg cap oral capsule s three times daily started days pta motrin mg po q hrs prn pain discharge medications amoxicillin pot clavulanate mg tablet sig one tablet po tid times a day continue until you see your dentist on disp tablet s refills discharge disposition home discharge diagnosis peritonsillar infection discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted for an infection from your recent dental surgery you were seen by ear nose and throat ent doctors who noted in your throat you were closely watched in the icu and treated with antibiotics and steriods over the course of hours this disappeared on reexamination by ent your steroids you were discovered to have a nodule in your thyroid that should be followed up with a biopsy followup instructions please call dr at to follow up regarding your recent hospitalization and re establish primary care please call dr for a follow up in weeks otolaryngology view map phone fax appointment for thyroid biopsy,{}
86421,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint shortness of breath major surgical or invasive procedure off pump coronary artery bypass graft x left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal obtuse marginal and right coronary arteries history of present illness mr is a year old man with a past medical history significant for hypertension hyperlipidemia and chronic obstructive pulmonry disease with exertional shortness of breath a single episode of exertional chest pain and an abnormal stress test referred for cardiac catheterization the patient was found to have lm and vd was referred for surgical revascularization past medical history hypertension hyperlipidemia chronic obstructive pulmonary disease gastro esophageal reflux disease stomach ulcer treated with surgical clipping and vagotomy anxiety depression arthritis anemia benign prostatic hypertrophy s p stomach ulcer clipping and vagotomy s p tonsillectomy s p hernia repair s p repair of dislocated shoulder social history mr quit smoking years ago and smoked pack per day for years he denies alcohol use mr lives with his wife family history non contributory physical exam pulse resp o sat ra b p right left height weight lbs general nad alert and cooperative skin dry x intact x heent perrla x eomi x neck supple x full rom x chest lungs clear bilaterally x heart rrr x irregular murmur abdomen soft non distended non tender bowel sounds well healed incision extremities warm x well perfused x edema varicosities none neuro grossly intact pulses femoral right left dp right left pt left radial right left carotid bruit right none left none pertinent results echocardiography report 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 coronary artery disease hypertension shortness of breath intraoperative tee 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 atrium four chamber length cm cm left ventricle ejection fraction aorta annulus cm cm aorta sinus level cm cm aorta sinotubular ridge cm cm aorta ascending cm cm aorta arch cm cm aorta descending thoracic cm cm aortic valve lvot diam cm aortic valve valve area cm cm mitral valve mean gradient mm hg findings left atrium dilated la no spontaneous echo contrast in the body of 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 lipomatous hypertrophy of the interatrial septum no asd by d or color doppler left ventricle overall normal lvef right ventricle normal rv systolic function aorta normal aortic diameter at the sinus level focal calcifications in aortic root normal ascending aorta diameter complex mm atheroma in the ascending aorta normal aortic arch diameter complex mm atheroma in the aortic arch mildly dilated descending aorta complex mm atheroma in the descending thoracic aorta aortic valve mildly thickened aortic valve leaflets no as no ar mitral valve mildly thickened mitral valve leaflets no ms mild mr tricuspid valve normal tricuspid valve leaflets with trivial tr pulmonic valve pulmonary artery pulmonic valve not well seen 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 the patient appears to be in sinus rhythm patient conclusions pre grafting the left atrium is mildly dilated 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 overall left ventricular systolic function is normal lvef the right ventricle displays normal free wall contractility on epiaortic scanning images not saved there are complex mm atheroma seen in the ascending aorta there are complex mm atheroma in the aortic arch the descending thoracic aorta is mildly dilated there are complex mm atheroma in the descending thoracic aorta 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 mild mitral regurgitation is seen dr was notified in person of the results in the operating room at the time of the study post grafting there is normal biventricular systolic function valvular function is unchanged the thoracic aorta remains intact 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 on mr a coronary artery bypass grafting times four left internal mammary to left anterior descending saphenous vein graft to diagonal saphenous vein graft to obtuse marginal saphenous vein graft to right coronary artery performed by dr he tolerated this procedure well and was transferred in critical but stable condition to the surgical intensive care unit he was weaned from pressors and extubated by the following day he was transferred to the step down floor his chest tubes were removed plavix was restarted he was seen in consultation by physical therapy and it was felt that he would benefit from rehab at the time of discharge he failed a voiding trial so his foley was replaced and his terazosin was restarted for known benign prostatic hypertrophy he had a short episode of confusion which resolved with sleep and the cessation of narcotics his epicardial wires were removed by post operative day four he was deemed ready for transfer to all follow up appointments were advised medications on admission amitriptyline mg po daily plavix mg po daily diltiazem hcl mg po daily cymbalta mg po daily nebivolol mg po daily simvastatin mg po daily terazosin mg po daily trazodone mg tablets tablets po qhs asa mg po daily ferrous sulfate mg po daily mvi i tab daily discharge medications metoprolol tartrate mg tablet sig one tablet po bid times a day simvastatin mg tablet sig one tablet po daily daily clopidogrel mg tablet sig one tablet po daily daily terazosin mg capsule sig two capsule po hs at bedtime trazodone mg tablet sig one tablet po hs at bedtime as needed for sleep amitriptyline mg tablet sig one tablet po daily daily tramadol mg tablet sig one tablet po q h every hours as needed for pain bisacodyl mg suppository sig one suppository rectal daily daily as needed for constipation aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily ranitidine hcl mg tablet sig one tablet po bid times a day 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 for pain fever duloxetine mg capsule delayed release e c sig one capsule delayed release e c po daily daily polyethylene glycol gram dose powder sig one po daily daily lasix mg tablet sig one tablet po twice a day for days ipratropium albuterol mcg actuation aerosol sig two puff inhalation q h every hours as needed for wheezing ferrous sulfate mg mg iron tablet sig one tablet po once a day m vit mg tablet sig one tablet po once a day discharge disposition extended care facility applevalley discharge diagnosis hypertension hyperlipidemia copd gerd h o stomach ulcer treated with clipping and vagotomy anxiety depression arthritis anemia bph 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 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 surgeon dr pm cardiologist dr on 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 md completed by,{}
32385,admission date date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint abdominal and back pain major surgical or invasive procedure scrotal debridment scrotal flap history of present illness yo male who initially presented to hospital with lower abdominal pain on but left hospital against medical advice then re presented again at the same hospital with similar symptoms including back pain fatigue acute renal failure and testicular swelling on he is s p operative scrotal debridement by urology he was transferred to for further management past medical history htn type ii dm family history noncontributory physical exam upon admission vitals t hr bp rr o sat l gen moderate distress alert head and neck at nc soft supple no masses heart rrr no murmurs lungs ctab no rhonchi no crackles abd soft nt nd decreased bs perineum extensive skin and subq tissue debridement of entire scrotum and perineal region left testicle pallorous no obviously necrotic tissue no emphysematous or erythema of surround skin exquisitely tender ext warm well perfused no edema 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 wbc rbc hgb hct mcv mch mchc rdw plt ct am stool consistency loose source stool final report clostridium difficile toxin assay final feces negative for c difficile toxin by eia reference range negative radiology report duplex dop abd pel limited study date of am scrotal ultrasound the right testicle measures x x cm the left testicle measures x x cm there is no subcutaneous gas within the tissues superior to the testicles bilaterally heterogeneously echogenic irregular soft tissue swelling is present this is distinct from the testicles the epididymis is unremarkable bilaterally color and doppler examination of the testicles reveal normal arterial and venous waveforms in the right testicle however the left testicle shows an overall relative decrease in blood flow and no arterial waveforms are identified venous flow is present impression no ischemic changes in the left testicle but no arterial flow is visualized though strangely venous flow is this raises concern for developing ischemia of the left testicle normal arterial and venous waveforms in the right testicle massive subcutaneous swelling superficial to the testes no subcutaneous air findings discussed with dr at a m radiology report scrotal u s study date of pm findings each testicle has been repositioned superiorly into the inguinal region of the ipsilateral side the right testicle measures x x cm the left measures x x cm the right testicle again shows normal color doppler flow as well as spectral arterial and venous waveforms compared to the right the left again shows less overall vascularity than the right on color doppler imaging doppler waveforms can be obtained in the left testicle which shows venous flow as well as greater pulsatile activity suggestive of low level arterial flow except for the appearance of greater pulsatility suggestive of arterial flow there has been no significant change impression similar appearance of reduced vascularity of the left testicle compared to the right although there is greater pulsatility in the doppler waveforms of the left testicle suggestive of low level arterial flow brief hospital course he was admitted to the surgical service under the care of dr he was initially taken to the surgical icu where he remained for several days infectious disease was consulted and his antibiotics were changed to vancomycin levofloxacin and flagyl he did have blood cultures drawn on and they were negative a stool for c diff was sent and was also negative twice daily dakin s dressing changes were continued urology was consulted and he underwent scrotal ultrasound to assess for residual infection and for flow he was transferred to the regular nursing unit he continued to have ongoing pain control issues requiring iv narcotics initially and this was changed to pca plastic surgery was then consulted for possible flap he was taken to the operating room on for open wound extensive debridement of skin subcutaneous tissue and bilateral local advancement flap elevation with baring of the scrotum in the abdominal and a suprapubic cavity his antibiotics levofloxacin and flagyl were continued and will need to continue for another week following the surgery his foley catheter was removed there was a fecal incontinence pouch system previously in place to keep open wound clean this was also removed his pain was much less postoperatively he no longer required iv narcotics and was changed to an oral pain regimen using long and short acting narcotics he was evaluated by physical therapy and they have recommended rehab after acute hospital stay medications on admission lisinopril metformin glyburide humulin insulin qhs diltiazem xr hctz atenolol medications heparin porcine unit ml solution sig one ml injection tid times a day diltiazem hcl mg capsule sustained release sig one capsule sustained release po daily daily famotidine mg tablet sig one tablet po bid times a day lisinopril mg tablet sig two tablet po daily daily hold for sbp levofloxacin mg tablet sig one tablet po q h every hours metoprolol tartrate mg tablet sig tablets po bid times a day hold for sbp hr morphine mg tablet sustained release sig one tablet sustained release po q h every hours oxycodone mg tablet sig tablets po q h every hours as needed for breakthrough pain metronidazole mg tablet sig one tablet po q h every hours magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed for constipation metformin mg tablet sig one tablet po bid times a day hydrochlorothiazide mg capsule sig one capsule po daily daily hold for sbp gabapentin mg capsule sig two capsule po bid times a day acetaminophen mg tablet sig two tablet po q h every hours insulin nph human recomb unit ml suspension sig forty units subcutaneous qam breakfast insulin nph human recomb unit ml suspension sig twenty units subcutaneous hs regular insulin sliding scale sig one dose subcutaneous four times a day as needed for per sliding scale see attached sliding scale disposition extended care facility rehabilitation and nursing center diagnosis fournier s gangrene condition hemodynamically stable tolerating an oral diet pain being adequately controlled instructions avoid any extremes of adduction abduction of hips in order to prevent placing pressure on the scrotum and operative site followup instructions follow up this friday at p m in plastic s clinic with dr location bldg surgical specialities call if the appointment needs to be changed follow up in clinic in weeks call for an appointment follow up with your primary care doctor from rehab completed by,"{
""Diagnoses"": [""admission date"", ""date of birth"", ""sex"", ""m"", ""service"", ""surgery"", ""allergies"", ""patient recorded as having no known allergies to drugs"", ""attending chief complaint"", ""abdominal and back pain"", ""major surgical or invasive procedure"", ""scrotal debridement"", ""history of present illness"", ""yo male who initially presented to hospital with lower abdominal pain on but left hospital against medical advice then re presented again at the same hospital with similar symptoms including back pain"", ""fatigue"", ""acute renal failure"", ""testicular swelling""],
""Medications"": [""s p operative scrotal debridement by urology""]
}"
74860,admission date discharge date date of birth sex f service cardiothoracic allergies mold dust mites attending chief complaint esophageal cancer major surgical or invasive procedure esophagectomy with intrathoracic esophagogastric anastomosis laparoscopic jejunostomy feeding tube wrapping of intrathoracic anastomosis with pericardial fat esophagogastroduodenoscopy laparoscopic reduction of hiatal hernia history of present illness mrs is a year old woman who has a t n esophageal cancer stage iib who is s p chemo radiation treatment she recently underwent pet scan which shows no evidence of distant uptake but does show two distinct areas of the esophagus with fdg avidity she presented for surgical resection of her esophageal cancer throughout she denies denies fevers chills nightsweats heartburn nausea vomiting abdominal pain odynophagia or dysphagia denies changes in weight she has a concurrent hiatial hernia past medical history diabetes mellitus type ii hypertension hyperlipidemia anemia large hiatel hernia asthma chronic sinus infections social history widowed with three supportive sons part time as a social worker with her own company never smoker etoh red wine x per week glasses each time denies illicit drug use no known exposures family history mother died of liver and colon cancer at age father died of liver colon and prostate cancer at age son with atrial fibrillation physical exam vs t hr s sr bp sats l wt kg general year old female sitting up in no apparent distress heent normocephalic mucus membranes moist neck supple no lymphadenopathy card rrr resp decreased breath sounds no crackles or wheezes gi abdomen soft non tender incision r chest incision clean dry intact neuro awake alert oriented 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 wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap bronchial washings final report gram stain final per x field polymorphonuclear leukocytes per x field gram positive cocci in pairs and clusters per x field budding yeast respiratory culture final ml commensal respiratory flora staph aureus coag organisms ml yeast organisms ml staph aureus coag clindamycin r erythromycin r gentamicin s levofloxacin s oxacillin s trimethoprim sulfa s cxr pulmonary edema has markedly improved left lower lobe opacity is unchanged likely atelectasis cardiomediastinal contours are unchanged right subclavian catheter remains in place with tip in the standard position multifocal right lung opacities are unchanged bilateral pleural effusions are small associated with adjacent atelectasis patient is status post esophagectomy esophagus single contrast upper gi series was performed barium passes freely into the esophagus and at the site of anastomosis there is no evidence of a leak at this site barium is pooled within the stomach after minutes a followup scout film and followup fluoroscopy image was taken which continued to show barium retained within the stomach with little passing to the small intenstine impression no evidence of anastomotic leak delayed gastric emptying mri spine impression no evidence of epidural abscess mild disc protrusion at t t level with anterior thecal sac indentation but no significant spinal canal narrowing or neural foraminal compromise seen chest pelvic ct impression improving pleural effusion pneumomediastinum and pneumothorax as compared to previous study no evidence of pneumonic process evidence of pneumonia no evidence of lymphadenopathy in the visualized areas all tubes and lines appear well placed no obvious foci of infection area of reduced perfusion in left lobe of liver may reflect sequelae from retraction brief hospital course mrs was admitted following esophagectomy with intrathoracic esophagogastric anastomosis laparoscopic jejunostomy feeding tube wrapping of intrathoracic anastomosis with pericardial fat esophagogastroduodenoscopy laparoscopic reduction of hiatal hernia she was transfer to the icu extubated with an ngt foley and epidural managed by the acute pain service while in the sicu she required multiple fluid challenges for hypotension once hemodynamically stable she transfer to the floor on events developed respiratory distress hypoxic requiring intubation and transfer to the icu bedside bronchoscopy was done with aspiration of sections and bile an ngt was placed temp vancomycin and zosyn started over the next few days here respiratory status improved she was successfully extubated her oxygen requirements improved with nebs incentive spirometer oxygen saturations of on l nc ct was done showed no anastomic leak id she was seen by infectious disease cultures grew mssa continue coverage for gnr anaerobes can switch vancomycin to ampicillin sulbactam gm iv q h x days starting from of note an mri of the spine was negative of epidural abscess following epidural removal cardiovascular immediately postop was sinus tachycardia iv lopressor was started she was hypotensive which responded to fluid bolus once taking po s her home dose diltiazem was restarted sinus rhythm s and blood pressure improved to s lisinopril was titrated as an outpatient gi ngt was removed pod requring placment on following aspiration event and removed ppi and bowel regime continued nutrition tube feeds replete full strength started pod increase to goal of ml hrs following esophagus study full liquid diet and will continue until seen by dr aspiration precautions at all times renal volume overload she was gently diuresed with iv lasix converted to po lasix until at preop weight of kg her renal function remain normal with good urine output her electrolytes were replete as needed endocrine maintained on insulin sliding scale to keep blood sugars she will restart her po diabetic medications upon discharge heme chronic anemia hct stable dispo followed by physical therapy she was discharged to in she will follow up with dr as an outpatient medications on admission citalopram mg daily diltiazem mg daily flovent glipizide mg daily lisinopril mg daily ativan as needed magic mouthwash metformin mg daily omeprazole mg daily zofran mg as needed for nausea roxicet ml every hours as needed for pain compazine mg every hours as needed for nausea simvastatin mg daily b vitamins vitamin d iron mvi fish oil discharge medications heparin porcine unit ml solution one injection tid times a day ipratropium bromide solution three ml inhalation q h every hours as needed for wheezing levalbuterol hcl mg ml solution for nebulization three ml inhalation q h every hours sodium chloride syringe three ml injection q h every hours as needed for line flush ampicillin sulbactam gram recon soln three recon soln injection q h every hours for days oxycodone acetaminophen mg ml solution mls po q h every hours as needed for pain simvastatin mg tablet two tablet po daily daily citalopram mg tablet one tablet po daily daily fluticasone mcg actuation aerosol four puff inhalation times a day lansoprazole mg tablet rapid dissolve dr one tablet rapid dissolve dr daily daily diltiazem hcl mg tablet one tablet po qid times a day ipratropium bromide mcg actuation hfa aerosol inhaler two puff inhalation q h every hours acetaminophen mg ml solution twenty ml po q h every hours as needed for fevers ha ondansetron hcl pf mg ml solution four mg injection q h every hours as needed for nausea lisinopril mg tablet one tablet po once a day home dose mg daily please increase as sbp tolerates metformin mg tablet one tablet po twice a day home dose mg increase as blood sugars tolerate lorazepam mg tablet one tablet po every twelve hours as needed for anxiety humalog insulin sliding scale mg dl units mg dl units mg dl units mg dl units mg dl units mg dl units furosemide mg tablet one tablet po once a day monitor daily weights and adjust as needed potassium chloride meq tablet er particles crystals one tablet er particles crystals po once a day give with lasix discharge disposition extended care facility discharge diagnosis esophageal cancer s p esophagectomy t diabetes mellitus hypertension hyperlipidemia large hiatal hernia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions call dr office if you experience fevers or chills increased shortness of breath cough or chest pain your incisions develop drainage difficult or painful swallowing nausea take anti nausea medication or vomiting increased abdominal pain pain acetaminophen mg every hours as needed for pain roxicet teaspoon every hours as needed for pain acitivity shower daily wash incision with mild soap water rinse pat dry no tub bathing swimming or hot tubs until incision healed do not apply lotions to incision sites no driving while taking narcotics take stool softner with narcotics followup instructions follow up with dr on the clinical center chest x ray radiology minutes before your appointment completed by,"{
""Diagnoses"": [""Esophageal cancer"", ""Major surgical or invasive procedure (esophagectomy with intrathoracic esophagogastric anastomosis)""],
""Medications"": [""Chemotherapy"", ""Radiation treatment""]
}"
1588,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint s p mvc traumatic arrest major surgical or invasive procedure cvl placement icp monitoring history of present illness m s p high speed mvc into another vehicle there was significant damage to vehicle and there were no brake marks on the road the patient had a gcs of was in cardiac arrest when police arrived and acls was instituted bringing a pulse back to the patient also report of prolonged extrication brought to osh transferred to after difficult intubation past medical history htn social history noncontributory family history noncontributory physical exam gcs t no collar perrla but no other neurol signs rrr cta b soft obese decreased rectal tone pertinent results ct head spine diffuse anoxic injury comminuted grade iii dens fracture c fracture transected high cervical spinal cord brief hospital course admitted to tsicu overnight icp monitor placed by neurosurgery initial icp mannitol given neo to maintain bp bradycardia reversed with isoproterenol rpt ct with no improvement patient began having myoclonic facial twitches seen by neuro med very poor prognosis lactate rising secondary to increased fuild avidity during family meeting on it was decided to make patient cmo he was discontinued from the ventilator expired soon thereafter his family was present his wife and the medical examiner both declined an autopsy medications on admission procardia xl toprol xl inspira kcl benacor lipitor folate urocrit vit b glucosamine beta carotene discharge medications n a discharge disposition expired discharge diagnosis traumatic brain injury anoxic brain injury comminuted c fracture spinal cord transection discharge condition deceased discharge instructions n a followup instructions n a md completed by,{}
25954,admission date discharge date date of birth sex f service medicine allergies percocet attending chief complaint abdominal pain major surgical or invasive procedure none history of present illness y o f s p total abdominal colectomy c diff toxic megacolon presents with abdominal pain right flank pain for days noted dark urine dysuria difficulty initiating urination she initially had pain at the site of her previous ostomy but it then radiated to her right flank she describes the pain as similar to her previous episode of pyelonephritis she also felt tired and occasionally dizzy denied fever chills diarrhea vomiting in the ed initial vital bp was hr t rr on ra she had blood and urine cultures received levofloxacin and flagy and l ns and bp remained at she was then started on a levophed gtt she remained afebrile had good urine output and her cvp was up to when she got to the icu her pressure was she was mentating well oriented x denied chest pain dizziness she continued to complain of ruq r flank pain but denied nausea vomiting she was weaned from levophed and given ml ns bolus and maintained sbp ros the patient denies any fevers chills weight change diarrhea constipation melena hematochezia chest pain shortness of breath orthopnea pnd lower extremity oedema cough lightheadedness gait unsteadiness focal weakness vision changes headache rash or skin changes past medical history hypertension hypercholesterolemia glucose intolerance last a c was ranging h o nephrolithiasis y ago during pregnancy h o pyelonephritis osteopenia severe osteoarthritic changes bilat hips l r to have left thr in fall of chronic lbp djd lower lumbar spine s p si steroid injection mri lumbar spine neg for compression h o c difficile toxic megacolon necessitating total abdominal colectomy s p ileostomy takedown with ileorectal anastamosis h o partial small bowel obstruction and ventral hernia gerd hiatal hernia s p lap nissen fundoplication gastritis stable pulmonary nodules mm mm bilateral likely granulomas tobacco pyhx quit yrs pta pshx s p ileostomy takedown with ileorectal anastamosis s p exploratory laparotomy splenic flexure take down total abdominal colectomy rectal hartmann s formation with end ileostomy feeding gastrojejunostomy and drain placement s p laparoscopic repair hiatal hernia nissen fundoplication s p cervical spine decompression s p appendectomy social history married lives with husband in has grown children daughters son one daughter is a cardiac nurse ppd smoker x years quit years ago glasses wine per week denies ivdu family history sister died at of mi brother with heart problems physical exam vs t hr bp o on l gen well appearing well nourished no acute distress heent eomi perrl sclera anicteric no epistaxis or rhinorrhea mmm op clear neck no jvd carotid pulses brisk no bruits no cervical lymphadenopathy trachea midline cor rrr no m g r normal s s radial pulses pulm lungs ctab no w r r abd multiple scars noted soft tender to palpation r upper and lower quadrants marked r cva tenderness guarding no rebound bs no hernia palpated ext no c c e no palpable cords neuro alert oriented to person place and time cn ii xii grossly intact moves all extremities strength in upper and lower extremities skin no jaundice cyanosis or gross dermatitis no ecchymoses pertinent results labs on admit am wbc rbc hgb hct mcv mch mchc rdw am asa neg ethanol neg acetmnphn bnzodzpn neg barbitrt neg tricyclic pos am calcium phosphate magnesium am alt sgpt ast sgot alk phos amylase tot bili am glucose urea n creat sodium potassium chloride total co anion gap am lactate br ct abdomen no acute pathology small bilateral pleural effusions minimal possible left hepatic biliary dilation eval limited due to lack of iv contrast perisplenic varices of unknown etiology br cxr evidence of mild volume overload taken after volume resuscitation br ruq us findings the liver is homogeneous in echotexture without evidence of focal lesion the gallbladder is mildly distended likely related to fasting stage there is no gallstone or gallbladder wall edema no intra or extra hepatic biliary ductal dilatation is seen the common duct measures mm the son sign is not present however it is difficult to assess since the patient received pain control medication small amount of perihepatic fluid the main portal vein is patent with antegrade flow impression no evidence of acute cholecystitis brief hospital course y o f s p total abdominal colectomy c diff toxic megacolon presents with abdominal pain with urosepsis presentation br sepsis patient met severe sepsis criteria with hypotension initially requiring levophed as pt initially admitted to icu acute renal failure and possible shock liver initially source appeared to be urosepsis pyelonephritis given day history of dysuria tea colored urine evolving right flank pain and positive ua however imaging unrevealing for radiological evidence of pyelo given extreme presentation plan is to treat for pyelonephritis for days with levofloxacin blood cx were negative throughout noted non pseudmonas organism growing out sensitive to quinolones of note vanc levo flagy were initially chosen in icu changed to vanc cipro flagyl to cover for urinary including enterococcus pathogens and later given her possible gi and uti sources single of zosyn was used once on floor abx was changed to po levofloxacin pt had good initial responce however with low grade temps even with iv zosyn ab w u as below for possible another occult source neg l sc subsequently d ced on temps improved following cath tip showed no sig growth and blood cx also without growth at time of d c pt was monitored to assure no gram infx pt again afebrile without leukocytosis at time of d c stable plan for to continue and complete day treatment for complicated uti pyelonephritis br abdominal pain resolved at time of d c but given r sided ab sx initial concern for choledocolithiasis along with complicating infectious process it was possible that she had a concominant biliary tract disease given ruq pain possible hepatobiliary dilatation on ct a p initially however she denied nausea vomiting ruq pain could be kidney inflammation surgery consulted in ed and followed patient initially no interventions indicated pt then with ruq us for further biliary evaluation results above neg study pt sx subsequently resolved at time lft s trended down with sepsis resolution as above br acute renal failure creatinine on admission down to at time of d c etiology to sepsis hypotension at baseline with stable lytes at time of d c br anemia hct down to from baseline of at at time of d c fe studies more consistant with anemia of chronic dz done in house stable at time of d c br hyponatremia hypovolemic hyponatremia patient reports trying to drink more to compensate for her low urine output this week so this is likely increased free water intake but overall lack of po intake on top of fever and then sepsis she does not take diuretics at home so this is an unlikely cause responded well to ns ivf hydration at at time of d c br resolved unstable angina pt with epigastric vs usa sx on ekg showed possible tw changes in v v pt monitored on tele with sets ce with pt s risk factors no further events and all ce were negative br depression continued amitryptaline br insomnia continued home temazepam br hyperlipidemia continued home statin br htn benign initially ace i held but once sepsis resolved bp increased restarted home dose of ace i and pt bp remained controlled br fen tolerating po well access left subclavian placed in ed ppx heparin subq pantoprazole riss bowel regimen code full confirmed with patient medications on admission alprazolam mg tablet tid prn amitriptyline mg tablet po qhs enalapril maleate mg daily simvastatin mg daily temazepam mg po qhs bisacodyl mg daily prn vicodin mg tablet po q hr prn discharge medications bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed temazepam mg capsule sig one capsule po hs at bedtime as needed for insomnia docusate sodium mg capsule sig one capsule po bid times a day simethicone mg tablet chewable sig one tablet chewable po qid times a day as needed senna mg tablet sig one tablet po bid times a day enalapril maleate mg tablet sig two tablet po daily daily oxycodone mg tablet sig one tablet po q h every hours as needed for pain levofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills amitriptyline mg tablet sig one tablet po once a day simvastatin mg tablet sig one tablet po at bedtime discharge disposition home discharge diagnosis primary diagnosis sepsis urinary tract infection pyelonephritis secondary acute renal failure hypertension hyperlipidemia anemia of chronic disease non cardiac angina discharge condition good discharge instructions you were admitted sepsis secondary to a severe urinary tract infection with likely pyelonephritis based your on your symptoms continue the antibiotic as prescribed if your symptoms return and get worse ab pain problems with urination or with new severe diarrhea along with fevers and chills call your pcp or return to emergency center follow up with your pcp as below appt made your pcp will be able to re assess you and decide the best course for your planned left hip surgery at that time followup instructions provider md phone date time provider rm preadmission testing date time provider phone date time md completed by [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint fevers low back pain dysuria major surgical or invasive procedure none history of present illness f h o htn chronic back pain nephrolithiasis y ago during pregnancy who presents after days of worsening lower back pain headache fever per pt and mental status change confusion pt states her symptoms began d pta with dysuria urgency and frequency she took otc analgesics with good releif however d pta pt noted gradual onset of frontal headache no visual changes n v numbness weakeness word finding difficulty not the worst headache of her life pt has h o a single migraine ha years ago and takes amitryptilline no neck stiffness photophobia pt seen by her pcp d pta and received cipro x doses for uti without improvement of note no ucx sent after developement of fever to per pt and mental status changes she presnted to ed upon presentation her vs tmax ra she was noted to have cva tenderness bilaterally she denies dysuria presently cxr was clear ua pt was started on ceftriaxone g x and tylenol sbps subsequently fell to with only modest improvement after l fluid bolus was given lactate was pt was transferred to icu for septic shock presumed uti pyelonephritis past medical history pmh hypertension nephrolithiasis chronic low back pain s p si steroid injection mri l spine negative for compression hypercholesterolemia gerd s p nissen fundoplication gastritis hiatal hernia stable pulmonary nodules mm mm bilateral likely granulomas social history social hx married lives with husband years x ppd tobbacco quit years ago glasses wine per week denies ivdu family history sister died at of mi brother with heart problems physical exam pe vs ra gen nad heent perrla eomi sclera anicteric op clear mm dry no lad no carotid bruits no jvd cv regular nl s s soft sem loudest at apex no r g pulm cta b no r r w abd soft nd bs no hsm tenderness to palpation suprapubic region cva tenderness bilaterally no tenderness to palpation over spine ext warm dp radial pulses bl neuro alert oriented x cn ii xii grossly intact strength symmetric triceps biceps delts hip flexion dorsoflexion plantarflexion sensation grossly intact hip extension on left chronic per pt sciatica hip extension on right pertinent results am blood caltibc ferritn trf am blood calcium phos mg iron 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 am urine blood sm nitrite pos protein tr glucose neg ketone bilirub neg urobiln neg ph leuks mod am urine rbc wbc bacteri few yeast none epi blood cx ngtd ucx on admission negative brief hospital course f with h o chronic back pain presenting with fevers dysuria cva tenderness and pyelonephritis on ct pelvis sepsis shock pyelonephritis ct abdomen consistent with left pyelonphritis treated initially with ctx but changed to ceftaz better urine pentration unfortunatley no urine cx was sent from the emergency department urine cx later on returned no growth because the patient was improving clinically on rd generation cephalosporins she was switched to cefpodoxime she will complete a total of days of po abx volume overload sbps responded well to l ivf bolus in the icu although she developed a slight increase in oxygen requirement and peripheral edema patient was called out to floor where she received mg iv lasix with excellent diuresis and normal sats anemia fe studies revealed mixed picture of anemia of chronic disease along with iron deficiency needs outpatient c scope htn bp agents intially held but patient will restart upon discharge medications on admission medications spironolactone hctz po daily enalapril maleate mg po daily fluvastatin mg po qd lescol alprazolam mg po tid prn tizanidine mg po tid prn back pain skeletal muscle relaxant tramadol mg po tid amitryptiline mg po qhs vit b mg qdaily ca mg po bid vit d iu po qdaily fish oil folc acid mg po bid discharge medications amitriptyline mg tablet sig one tablet po hs at bedtime disp tablet s refills alprazolam mg tablet sig one tablet po tid times a day as needed disp tablet s refills tizanidine mg tablet sig tablets po tid prn as needed for back pain disp tablet s refills pyridoxine mg tablet sig two tablet po daily daily disp tablet s refills cholecalciferol vitamin d unit tablet sig two tablet po daily daily disp tablet s refills tramadol mg tablet sig one tablet po tid times a day as needed disp tablet s refills ferrous sulfate 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 spironolacton hydrochlorothiaz mg tablet sig one tablet po once a day disp tablet s refills enalapril maleate mg tablet sig one tablet po once a day disp tablet s refills fluvastatin mg capsule sig one capsule po once a day disp capsule s refills cefpodoxime mg tablet sig one tablet po twice a day for days disp tablet s refills discharge disposition home discharge diagnosis primary diagnoses acute pyelonephritis organism not specified anemia secondary to iron deficiency chronic disease volume overload resolved herpes stomatitis secondary diagnoses hypertension h o nephrolithiasis chronic low back pain s p si steroid injection mri l spine negative for compression hypercholesterolemia gerd s p nissen fundoplication gastritis hiatal hernia stable pulmonary nodules mm mm bilateral likely granulomas discharge condition stable discharge instructions please make sure to take your temperature times a day if you have any fevers chills sweats worsening back pain nausea vomiting burning with urination or any other concerning symptoms please come back to the emergency room immediatley you may use over the counter treatments for your cold sores please call dr office on friday and leave a message with his staff informing them how you are doing in addition please speak to him about a colonoscopy as your are iron deficient followup instructions as above [NEW_RECORD] admission date discharge date date of birth sex f service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint right flank pain diarrhea major surgical or invasive procedure central venous line and arterial line placment exploratory laparotomy splenic flexure take down total abdominal colectomy rectal hartmann s formation with end ileostomy feeding gastrojejunostomy and drain placement history of present illness f recently hospitalized for pyelonephritis requiring icu admission and was discharged on cefpodoxime returns with right flank pain nausea and low grade fever past medical history pmh hypertension nephrolithiasis chronic low back pain s p si steroid injection mri l spine negative for compression hypercholesterolemia gerd s p lap nissen fundoplication gastritis hiatal hernia stable pulmonary nodules mm mm bilateral likely granulomas social history social hx married lives with husband in years x ppd tobbacco quit years ago glasses wine per week denies ivdu family history sister died at of mi brother with heart problems physical exam initial physical exam er nad dry mm op clear ctab rrr soft nd diffusely ttp cvat r l skin wwp pertinent results admission labs pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts bands lymphs monos eos baso pm blood hypochr anisocy poiklo occasional macrocy occasional microcy normal polychr normal ovalocy occasional schisto occasional pm blood plt ct pm blood glucose urean creat na k cl hco angap pm blood alt ast alkphos amylase totbili pm blood lipase am blood albumin calcium phos mg am blood cortsol am blood cortsol pm blood lactate discharge labs wbc hct ct scan ct of the abdomen and pelvis ct urogram indication for study urinary tract infection pyelonephritis failed antibiotic treatment evaluate for abscess comparison is made with recent ct scan from technique following a non contrast image acquisition the patient was administered cc optiray diffusely and helical scan obtained through the abdomen and pelvis during excretion of contrast findings abdomen with contrast again seen are small bilateral pleural effusions with bibasilar atelectasis not significantly changed from the prior study a small amount of ascitic fluid is newly noted adjacent to the liver and spleen the liver has an unremarkable appearance please note that portal venous flow cannot be evaluated on this study the spleen is not enlarged but again noted are multiple perisplenic variceal vessels which have been present in prior studies the precise etiology of these variceal vessels is uncertain head body and tail of the pancreas are unremarkable no intra or extrahepatic bile duct dilatation is present gallbladder is unremarkable a small amount of widely distributed ascitic fluid is noted in the upper abdomen again noted are features consistent with pyelonephritis in the left kidney with poor perfusion in multiple areas no focal abscess is identified within the left kidney the extent of perfusion anomalies in the left kidney is not appreciably changed contrast is being excreted into the left and right ureters pelvis with contrast ureters are well visualized down to insertion into the bladder ascitic fluid is again noted in the pelvis of uncertain etiology this is not appreciably changed in volume when compared with the prior study no adnexal masses or cystic lesions are identified bone windows multiple subchondral lucencies are present in the hip joint consistent with degenerative change no suspicious lytic or blastic lesions are identified elsewhere in the visualized skeleton impression thick and thin slab coronal and sagittal reformatted images again demonstrate the presence of severe pyelonephritis in the mid and lower poles of the left kidney with no evidence for abscess formation new small amount of ascitic fluid the etiology of this ascitic fluid which surrounds the upper spleen is uncertain again noted are extensive perisplenic variceal vessels brief hospital course was evaluated in the emergency department at on for right flank pain and low grade fevers she had recently been discharged from for uti pyelonephritis during her stay in the ed she became septic with low blood pressure and temperature spike at r her wbc count was and her urine showed moderate wbcs and bacteria a ct scan showed left pyelonephritis a right sc central line was placed for resuscitation she was admitted to the micu under the care of the medicine team and was placed on sepsis protocol levophed was administered to maintain adequate perfusion pressures a cortisol stem test was positive and steroids were provided vancomycin and ceftaz were started for empiric coverage pending cultures on hd her bp had stabilized she complained of worsening abdominal pain she was more distended and had diarrhea surgery was consulted an ngt was placed and she was made npo flagyl was started stool cultures were sent at hd her stool cultures were positive for c difficile tpn was started and she remained npo her wbc was elevated at at hd she was febrile tachycardic and in moderate distress with worsening abdominal exam fluid resuscitation was continued to maintain blood pressure and urine output she developed lactic acidosis she was taken to the operating room for an exploratory laparotomy splenic flexure take down total abdominal colectomy rectal hartmann s formation with end ileostomy feeding gastrojejunostomy and drain placement she tolerated the procedure and was taken to the icu intubated and sedated from this point her care was transferred to the surgery service at pod she remained intubated to allow for diuresis trophic tube feeds were started she was extubated later that day without complication her ceftaz was discontinued and she remained on the vancomycin flagyl her steroids were weaned at pod she was doing better she was afebrile and with adequate urine output she was transferred to the floor her drain was discontinued at pod her diet was advanced as tolerated and physical therapy was consulted for discharge planning the wound nurses were consulted to evaluate and teach ostomy care her rectal tube was removed at pod she was tolerating a regular diet her foley was removed but she had urinary retention and her catheter was replaced she remained with edema fluid and lasix was given for diuresis her central line was discontinued at pod her catheter was removed lasix was started daily for diuresis she was unable to void after removing the catheter and the foley was replaced a second time at pod she was discharged to home in good condition she went home with vna support for ostomy care and cycled tube feedings at night replete at ml hr home physical therapy was arranged the urinary catheter remained she was to continue her home medications and was sent on one week s worth of lasix mg and potassium her labs were to be checked every other day and faxed to dr office to monitor electrolytes she was to follow up with dr on medications on admission spironolactone hctz po daily enalapril maleate mg po daily fluvastatin mg po qd lescol alprazolam mg po tid prn tizanidine mg po tid prn back pain skeletal muscle relaxant tramadol mg po tid amitryptiline mg po qhs vit b mg qdaily ca mg po bid vit d iu po qdaily fish oil folic acid mg po bid discharge medications potassium chloride meq tab sust rel particle crystal sig two tab sust rel particle crystal po once a day for weeks disp tab sust rel particle crystal s refills temazepam mg capsule sig one capsule po once a day alprazolam mg tablet sig one tablet po three times a day as needed amitriptyline mg tablet sig one tablet po once a day enalapril maleate mg tablet sig one tablet po once a day spironolacton hydrochlorothiaz mg tablet sig one tablet po once a day folic acid mg tablet sig one tablet po daily daily lescol mg capsule sig one capsule po once a day tizanidine mg capsule sig one capsule po twice a day lasix mg tablet sig one tablet po once a day for weeks disp tablet s refills dilaudid mg tablet sig one tablet po every hours as needed for pain disp tablet s refills tylenol mg tablet sig two tablet po three times a day discharge disposition home with service facility homecare discharge diagnosis c diff toxic pseudomembraneous colitis with sepsis urinary retention requiring replacement of bladder catheter malnutrition hypertension discharge condition good discharge instructions please call or contact for fever f or chills abdominal pain decreased output from ostomy misplacement or pulling out of feeding tube or catheter redness or drainage from incision or feeding tube site dark cloudy or foul smelling urine any other concerns please continue your home medications we will be adding lasix and potassium to be taken until you see dr in clinic followup instructions please follow up with dr in clinic on the of the your appointment is at pm the office number is completed by,{}
66677,admission date discharge date service medicine allergies nsaids attending chief complaint chest pain shortness of breath major surgical or invasive procedure cardiac catheterization history of present illness yo f with sign pmh of htn dm and hyperlipidemia presented to hospital with epigastric pain increasing sob increasing le edema nausea and headaches she is having difficulty recalling the events of today so hpi is per her son she woke up this am and felt weaker than normal and was having epigastric pain and le edema she also is having sob while lying flat as well she was transferred to for questionable ecg changes but a negative troponin level she is on schedule for cardiac cath tomorrow for evaluation of coronary artery disease on arrival to the floor patient were t bp hr rr ra she was having difficulty answering my questions on exam and also was having difficulty describing the events that led to her coming to the hospital she was complaining of feeling weak and some epigastric pain ecg showed no ischemic changes labs at regional troponin i wbc hgb hct plt pt ptt inr on review of systems the pt was unable to answer my questions appropriately past medical history htn diabetes mellitus hyperlipidemia anxiety insomnia osteoarthritis s p b l knee replacements and hip replacement aortic stenosis social history tobacco history nonsmoker etoh denies illicit drugs denies family history mother died at with angina otherwise non contributory physical exam admission physical examination vs t bp hr rr ra general nad oriented to only person not place or time not able to say days of week backwards heent sclera anicteric perrl eomi conjunctiva were pink no cyanosis of the oral mucosa neck supple no jvp no cardiac rrr systolic ejection murmur present 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 abdominal bruits abdominal scar present extremities edema to distal calf skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid dp left carotid dp discharge physical examination pertinent results admission labs pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood glucose urean creat na k cl hco angap pm blood ck cpk pm blood ck mb ctropnt probnp pm blood calcium phos mg discharge labs colonoscopy report mild diverticulosis of the sigmoid colon dark blood was seen in the whole colon the cecum was partial obscured with dark blood and the ileocecal valve could not be entered the visualized colonic mucosa appears normal bleeding could be from a proximal colonic or small bowel source but it is impossible to tell definitively from this study we will discuss possibility of capsule endoscopy with primary team if rapid ongoing bleeding consider tagged rbc scan and angio egd report normal mucosa in the esophagus otherwise normal egd to third part of the duodenum cardiac echo the left atrium is elongated there is mild symmetric left ventricular hypertrophy with normal cavity size and regional global systolic function lvef tissue doppler imaging suggests an increased left ventricular filling pressure pcwp mmhg there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the aortic valve leaflets are severely thickened deformed there is severe aortic valve stenosis valve area cm mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild to moderate mitral regurgitation is seen there is moderate pulmonary artery systolic hypertension there is no pericardial effusion impression severe calcific aortic stenosis mild symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function mild aortic regurgitation mild to moderate mitral regurgitation moderate pulmonary hypertension cardiac cath selective coronary angiography of this right dominant system demonstrated multivessel coronary disease the lmca had a distal stenosis extending into the lad and lcx origin but fractional flow reserve this stenosis was suggesting that the degree of angiographic stenosis may be overestimating the potential to improve coronary flow in this region with pci the rca was totally occluded the patient and her family will consider whether to proceed with rca pci resting hemodynamics revealed mildly elevated right sided pressures and mild pulmonary hypertension the pcwp was moderately elevated at the cardiac index was preserved at l min m using an assumed oxygen consumption there was severe aortic stenosis with a mean gradient of mmhg and a calculated aortic valve area of cm left ventriculography was not performed as the aortic valve was calcified ct chest w o contrast lungs are clear aortic and coronary atherosclerotic calcifications aortic and dense mitral valvular calcification left lateral rib fx appear acute nodular liver with caudate hypertrophy suggests cirrhosis brief hospital course ms is a yo f who presented to hospital with chest pain increasing shortnes of breath head ache and lower extremity edema transferred to for ischemic ecg changes and a diagnostic theraputic cardiac cath following catheterization ms suffered a gi bleed for which an exhaustive search could find no source and which resolved spontaneously active problems chest pain on arrival to the floor the patient was not complaining of shortness of breath or chest pain ecg s on floor showed peaked t waves and approximately mm st elevations in v and a prolonged pr interval these changes were also present on a prior ecg from she had two negative troponins one at regional and another here she was euvolemic on exam so her home dose of lasix was held we continued her on aspirin mg amlodipine mg and lisinopril mg daily we started simvastating mg daily and metoprolol tartrate mg daily during this admission an echo cardiogram was performed which showed severe calcific aortic stenosis and mild symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function mild aortic regurgitation and mild to moderate mitral regurgitation was presnt as well as moderate pulmonary hypertension with an lvef these results were similar to a prior echo performed in a cardiac cath was performed during this admission which showed that the lmca had a distal stenosis extending into the lad and lcx origin but fractional flow reserve of this stenosis was the rca was totally occluded and resting hemodynamics revealed mildly elevated right sided pressures and mild pulmonary hypertension the pcwp was moderately elevated at the cardiac index was preserved at l min m using an assumed oxygen consumption there was severe aortic stenosis with a mean gradient of mmhg and a calculated aortic valve area of cm ct surgery was consulted who recommended core valve vs surgical valve replacement for her her family has decided to hold off on surgery for now they would like her to rest and regain her energy before they decide on surgery gi bleed she had one bm consisting of frank red blood with clots her vital signs remained stable and her hct dropped from to following the bleed the decision was made to hold off on transfusion for now a ppi drip was started on the floor and aspirin was changed from mg to mg daily digital rectal exam showed frank blood and also the presence of hemorrhoids a ct scan during this admission showed a new finding of a nodular liver with caudate hypertrophy suggestive of cirrhosis we felt this gi bleed was most likely a lower in origin but with this new finding of possible cirrhosis esophogeal varices could not be ruled out on the patient was on her commode when she had a large bloody bm and syncopized bp was initially in the s systolic she was transferred to the micu in the micu the patient received unit of prbcs and stayed hd stable still having bloody bms gi performed bedside colonoscopy and egd on egd was clean and just showed blood in the colon but no clear source on patient had a large bloodly bm she was transfused unit prbcs repeat hct tagged red cell scan did not show any active bleeding a capsule endoscopy revealed blood in the terminal ileum and continuous oozing although no clear source by ms had been without hematochezia x hours and hematocrits had been stable at for days she was deemed safe for transfer to a skilled nursing facility for further care urinary tract infection urinalysis on suggested that she had a urinary tract infection she was started on ceftriaxone for this and following sensitivities ciprofloxacin mg for a total course of days ceftriaxone plus cipro was started last day should be inactive problems htn she was hypertensive on admission with sbs in s she refused her medications at her center earlier on the day of admission we gave her home htn medications and her blood pressure responded appropriately we also started her on a beta blocker due to her coronary artery disease pancytopenia her hematocrit was low on admission at prior to bleeding baseline hematocrit per pcp and at osh prior to admission and prior to bleeding hct was the etiology of her anemia will need to be followed up as an outpatient it is possible that she is having an insidious bleed but in light of leukopenia wbc and thrombocytopenia s cannot rule out myelodysplastic syndrome dm she was started on a humalog sliding scale during this admission and restarted on her home oral hypoglycemics on discharge her glucose was well controlled during this admission with finger sticks ranging from gerd continued her home regimen of pantoprazole mg daily she was not complaining of symptoms of dyspepsia on transitional she has a follow up appointment scheduled with her primary care physician who also is her cardiologist dr md she and her family will need to ultimately decide whether they would like to follow through with aortic valve replacement she will need pulmonary function testing before the surgery if she decideds to follow through c made an appt for her w dr for for corvalve etc discussion medications on admission lotrel mg mg daily metformin hcl mg qhs protonix mg daily estrace mg daily lunesta mg qhs claritan mg daily vicodin mg qid glyburide mg furosemide mg daily discharge medications pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po every twelve hours for days disp tablet delayed release e c s refills metformin mg tablet sig two tablet po at bedtime lotrel mg capsule sig one capsule po once a day estrace mg tablet sig one tablet po once a day lunesta mg tablet sig one tablet po at bedtime claritin mg tablet sig one tablet po once a day vicodin mg tablet sig one tablet po four times a day glyburide mg tablet sig one tablet po twice a day furosemide mg tablet sig one tablet po once a day simvastatin mg tablet sig one tablet po once a day disp tablet s refills aspirin mg tablet chewable sig one tablet chewable po daily daily disp tablet chewable s refills ciprofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills metoprolol tartrate mg tablet sig tablet po bid times a day pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po once a day start once daily after days of twice daily pantoprazole is completed discharge disposition extended care facility center discharge diagnosis primary diagnosis coronary artery disease severe aortic stenosis gastrointestinal bleed secondary diagnosis diastolic congestive heart failure hypertension diabetes mellitus pancytopenia discharge condition mental status confused sometimes level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions ms it was a pleasure taking care of you at you were transfered to after having symtoms of chest pain shortness of breath and lower extremity swelling a cardiac catheterization was performed which showed diffuse disease of the arteries supplying the heart but not indication of a heart attack following this intervention however you began to have a severe bleed from your gastrointestinal tract we gave you blood and looked for the source of bleeding with a colonoscopy upper endoscopy capsule endoscopy and a tagged red blood cell scan but could not find a source after you had not bled for over hours we were confident sending you home changes to your medications started simvastatin mg daily metoprolol mg twice daily aspirin mg daily ciprofloxacin mg twice daily pantoprazole mg twice daily for days resume mg once daily after days please see below for your follow up appointments followup instructions please discuss with the staff at the facility a follow up appointment with your pcp when you are ready for discharge her phone number is other appointments department cardiac surgery when friday at pm with md building lm campus west best parking garage,"{
""Diagnoses"": [""admission"", ""discharge"", ""service"", ""medicine"", ""allergies"", ""nsaids"", ""attending"", ""chief complaint"", ""chest pain"", ""shortness of breath"", ""major surgical or invasive procedure"", ""cardiac catheterization"", ""history of present illness"", ""yo f with sign"", ""pmh of htn"", ""dm"", ""hyperlipidemia""],
""Medications"": [""none""]
}"
18814,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint luq pain major surgical or invasive procedure none history of present illness yo m with fatigue sore throat x days days before admission he developed luq abdominal pain which increased and began radiating to l shoulder pleuritic ct at osh revealed free fluid about spleen no f c n v anorexia no urinary sx past medical history none social history lives alone primary language english social etoh quit smoking occ marijuana use physical exam on discharge vitals afebrile wnl gen pleasant healthy appearing young man walking halls heent ncat pulm ctab cv rrr abd flat bs soft nt to palp but baseline pleuritic tenderness nd no masses or hsm appreciated ext no c c e pertinent results 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 hypochr normal anisocy poiklo normal macrocy normal microcy polychr normal am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos totbili am blood albumin calcium phos mg brief hospital course pt was transferred from osh to on for splenic rupture he was stable on admission management was conservative with admission to the icu for close monitoring strict bedrest x days serial hct s after days in the icu he was transferred to the floor and allowed activity as tolerated a thorough history did not reveal any inciting trauma an ebv test returned neg hem onc was consulted due to lack of known inciting event they recommended checking cmv ebv hiv vl and hiv antibody agree with monospot check haptoglobin reticulocyte count would also consider babesia in context of recent travel to obtain thin smears for parasites check hepatitis a b c blood cultures x repeat peripheral smear pending these tests will be drawn and follow up will be with dr at discharge he is stable ambulating and voiding on own tolerating a regular diet with no signs or symptoms of hemorrhage medications on admission none discharge medications oxycodone acetaminophen mg tablet sig one tablet po q h every to hours as needed for pain for weeks disp tablet s refills discharge disposition home discharge diagnosis mild splenomegaly and splenic laceration discharge condition good discharge instructions no contact sports for weeks please call your doctor or return to the ed for fevers chills lightheadedness fainting abdominal pain chest pain or shortness of breath followup instructions please call dr off for a follow up appointment in weeks phone completed by,"{
""Diagnoses"": [""Luq abdominal pain"", ""Pleuritic pain"", ""Anorexia"", ""Social history of marijuana use""],
""Medications"": [""None""]
}"
74591,admission date discharge date date of birth sex m service medicine allergies aspirin nsaids attending chief complaint nstemi major surgical or invasive procedure cardiac catherization inferior vena cava filter placement outside hospital aspirin densensitazation history of present illness mr is a year old male with cad s p ptca lcx hld aaa pe pad copd that was transferred to for c cath with complicated osh course consisting of anemia secondary to gib bilateral pe not on anticoagulation and nstemi with reduction of ef and acute systolic heart failure pt is transferred to the ccu prior to cardiac cath for asa desensitization protocol he was admitted on for sob at hospital contact number oximetry was in the low s at home responsive to home o via nc he endorses feeling cold type symptoms with coughing for quite a few weeks but became more dyspneic with increasing cough and clear sputum production chest ct showed new bilateral pulmonary emboli venous us was negative for dvt an ivf filter was placed on in setting of inability to anti coagulate with anemia admission labs were also notable for hgb hct of and guaiac positive stool he was treated for a presumed gib he was transfused units of prbc endoscopy performed on was unremarkable colonoscopy was attempted on but unable to be performed secondary to stool in bowel colonoscopy subsequently performed on showed diverticulosis and diminutive polyp x which showed fragments of adenoma labs were also significant for sets of elevated troponins and cpks echo on showed ef last ef on showed ef stress test showed large area of ischemia extending from the anterior wall and anterior apex of inferior wall there was evidence of prior small lateral wall infarction with significantly depressed lvef his latest cxr showed mild chf additional studies included abdominal us showing aaa that is stable compared to prior exam on hospital course also complicated by flash pulmonary edema on the patient was also treated for pneumonia although viral uri was favored with fever in setting of chronic prednisone therapy although no infiltrate noted he was treated with moxifloxacin mg po qd for a day course cxr did not suggest pneumonia pt describes an asa allergy consisting of redness on his face and rash diffusely many years ago on arrival to ccu he was afebrile with vs hr bp rr lnc repeated at pt denies chest pain chest pressure or sob he says that he has felt overall weak since he was admitted to the osh but that this has gotten better on review of systems he endorses overall weakness as above he says that he has had black stools for the past year but that the doctors t been able to figure out why he states that he went to the osh because he knew that his counts were low he denies fever or chills but continues mild cough with yellow sputum he also endorses previous leg cramping he denies any prior history of stroke bleeding at the time of surgery myalgias joint pains hemoptysis or red stools 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 he is able to walk blocks with having to stop times which is unchanged in the past year he performs all of his adl s and lives on his own past medical history cad s p mi in with ptca to of lcx bilateral pulmonary embolism s p ivc filter placement with prior history of pe year ago previously treated with coumadin hld pvd last abis in showing moderate right pvd temporal arteritis followed by dr of aaa cm on esophagitis longstanding anemia with recent transfusion dependent anemia secondary to gib osteopenia history of hemorrhoids history of prostate cancer s p turp in past history of gi bleeding gastric antrum depression right wrist fracture in past social history tobacco history he has smoked ppd for years etoh social drinking illicit drugs none patient had been widowed for a number of years the patient has an adoptive son who helps with his care he shops on his own and performs all of his own adl s family history his three brothers all had mi at various ages and no family history of dvt pe physical exam vs t bp hr rr o sats on l nc repeated at general pleasant elderly male sitting up in bed nad oriented x mood affect appropriate heent ncat sclera anicteric perrl eomi conjunctiva were pale no pallor or cyanosis of the oral mucosa no xanthalesma neck supple jvp not elevated cardiac distant heart sounds rrr s s not appreciated no m r g no thrills lifts no s or s lungs resp were unlabored no accessory muscle use poor air exchange throughout no wheezing noted or crackles abdomen bs soft ntnd no hsm or tenderness extremities warm dry no apparent mm wasting clubbing on hands and feet skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid pt unable to palpated dp left carotid pt unable to palpated dp pertinent results pm hba c eag 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 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 ekg s osh ekg dated at showing nsr vent rate bpm pr ms qrs ms qtc ms r axis q waves in iii avr avf v twi in i ii iii avf v v v flattening in v j point elevation in v and v vs sub mm st elevation sub mm st depression in v admission ekg similar to osh ekg with extensive st t changes left anterior hemiblock q waves are not present as documented above except in v v showing mm st depression d echocardiogram echo showing ef trace ai mild mr osh echo left ventricle hypokinesis of apical anterior apical inferior basal inferolateral and apical wall wall thickness mildly increased ef estimated mitral valve mild regurgitation tricuspid valve mild regurgitation aorta root exhibited mild dilatation abdominal us significant for infrarenal abdominal aortic aneurysm cm x cm similar us seen on prior on colonoscopy cm polyp ett stress myoview normal scans mild inferior base hypokinesis ef cardiac cath prior from not available prelim coronary angiography in this right dominant system demonstrated three vessel disease the lmca had a distal stenosis the lad had a mid stenosis and a stenosis of d the lcx had a mid stenosis the rca was occluded proximally and filled distally via left to right collaterals limited resting hemodynamics revealed normal systemic arterial pressures with sbp mmhg and dbp mmhg final diagnosis three vessel coronary artery disease and left main disease brief hospital course nstemi patient reported chest pain in setting of shortness of breath which appeared to be multifactorial denied any chest pain but does endorsed shortness of breath which improved complete cardiac biomarker set unavailable from outside records but appears had nstemi given biomarker elevation ekg changes and decreased ef resulting in acute heart failure s to s ef nuclera stress at osh showed large area of ischemia extending from anterior wall and anterior apex of inferior wall with evidence of prior small lateral wall infarction he was transferred to for consideration of cardiac catherization but first required aspirin desensitization as has documented aspirin allergy left cardiac icu after aspirin desensitization cardiac catherization confirmed triple vessel disease with rca occlusion and lad occlusion patient was informed of necessity of coronary artery bypass and declined surgical intervention multiple times based on patient wishes optimized medical management and defered surgical treatment medical management with atorvastatin mg qhs carvedilol mg po bid asa mg po qday captopril mg tid want to switch short acting captopril to longer acting lisinopril as an outpatient acute systolic heart failure last ef patient developed acute systolic heart failure given ef decline from to most likely from ischemic event as above his dry weight in unknown and he has experienced weight loss in the past months of about lbs at the osh had flash pulmonary edema and an oxygen requirement which resolved in house discharge weight steady at lbs and physical exam suggested euvolemia continued medical management with captopril mg po tid carvedilol mg po bid want to change short acting captopril to longer acting lisinopril as an outpatient deferred use of spironolactone as borderline hyperkalemia at bilateral pulmonary embolisms recurrent s filter placement he has had second episode of pulmonary embolism in past year uncertain as primary imaging report not available to classify as segmental subsegmental but overall did not appear to cause hemodynamic instability at presentation etiology unknown given advanced age lb weight loss and chronic tobacco abuse would suspect that neoplasm high on differential other etiologies like immobility or recent surgery not present to explain recurrence and no family history of thrombosis had heparin gtt in house discharged with days worth of enoxaparin injections with bridging therapy with coumadin to treat pe follow up cbc coag panel discuss with patient duration of anticoagulation life long confirm age appropriate cancer screening on outpatient basis per above consider thrombophilia work up as outpatient ivc filter in place microcytic anemia has a history of anemia at baseline admission to osh hct and post transfusion osh hct status post u prbc at hct stable in the low to mid s have had marrow suppresion in setting of viral illness as well as gi loss given history of adenomas hematology consult at osh impression was acd vs other process with consideration for bone marrow biopsy as outpatient for unclear reasons his epo level was elevated which could suggest chronic hypoxemia in setting of copd vs renal cell carcinoma vs appropriate response to anemia flow cytometry also not suggestive of abnormal myeloid maturation or an increased blast population or lymphoproliferative disorder spep performed but results were not available upon transfer no hypercalcemia or bony involvement to suggest mm he does have a history of prior gib in the stomach antrum osh colonoscopy and egd showed diverticuli and polyp consistent with adenoma but no active source of bleeding at patient excxlaimed he has had a lbs weight loss as well as night sweats a few times a week for the last month concern for malignancy but discussion with pcp is that he is aware of these symptoms and has performed age appropriate screening for this patient did have a history of prostate cancer but not complaints of bone pain at need to follow up final pathology of polyp from osh check cbc on follow up copd patient has long tobacco history and continues to smoke no evidence for active copd exacerbation cxr demonstrated diaphragmatic flattening consistent with copd discharged home on albuterol and tiotropium counseled on tobacco cessation but patient not interested in quitting additionally at osh was treated with a day course of avelox for low grade fever in setting of prednisone usage with no infiltrate on cxr or ct continued albuterol tiotropium at home f u with pft s prn abnormal alt incidentally patient s alt elevated to on with downtrend to on per osh report abdominal us showed no liver pathology alt on admission now trended to s prior to discharge follow up lft s as an outpateint chronic issues temporal arteritis no active issues continued prednisone mg daily weight loss broad differential for weight loss including depression given prior history poor access to food underlying chronic illness and possible occult neoplasm follow up per above defer to outpatient work up asymptomatic aaa aaa noted on osh us significant for infrarenal abdominal aortic aneurysm cm x cm stable from prior us dated defer to further outpatient management transitional issues code status in house changed to dnr dni confirmed with patient should reconfirm with patient as an outpatient and make sure power of attorney living will paper work is up to date patient counseled on necessity of continuing aspirin and that if he discontinues use for even one day may experience recurrence of allergic reaction given history of allergy patient understood necessity to take daily comm son pending labs osh colonoscopy pathology for adenoma hospital contact number medications on admission a home medications plavix mg po qd diltiazem mg po qd zetia mg po qd simvastatin mg po qd prednisone mg po qd iron supplement nitro sl prn b medications on transfer to plavix mg po daily zetia mg po daily simvastatin mg po daily captopril mg po tid carvedilol mg po bid nitroglycerin mg hr mg td qhs prednisone mg po qd allergies severe allergy to aspirin rash redness on face discharge medications acetaminophen mg tablet sig one tablet po q h every hours as needed for pain carvedilol mg tablet sig two tablet po bid times a day disp tablet s refills warfarin mg tablet sig three tablet po once daily at pm disp tablet s refills captopril mg tablet sig one tablet po three times a day disp tablet s refills atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills prednisone mg tablet sig two tablet po daily daily aspirin mg tablet sig one tablet po daily daily albuterol sulfate mcg actuation hfa aerosol inhaler sig one inhalation prn as needed for shortness of breath or wheezing disp inhaler refills tiotropium bromide mcg capsule w inhalation device sig one inhalation at bedtime disp inhaler refills omeprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily disp capsule delayed release e c s refills enoxaparin mg ml syringe sig one subcutaneous twice a day for days disp syringes refills nitroglycerin mg tablet sublingual sig one sublingual prn as needed for chest pain if chest pain not resolved after doses call your doctor report to the nearest ed or call disp tabs refills discharge disposition home with service facility greater vna discharge diagnosis primary pulmonary embolism coronary artery disease severe non st elevation myocardial infarction iron deficiency anemia secondary chronic obstructive pulmonary disease history of pe year ago hyperlipidemia peripheral vascular disease temporal arteritis abdominal aortic aneursym discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions mr you originally presented to another hospital because of shortness of breath there you were found to have multiple medical problems including clots in your lungs as well as evidence of a minor heart attack based on tests additionally you were found to have very low red cell count you were given bags of to replete your low counts and placed on thinners in an attempt to treat the clots in your lungs your small heart attack affected the way your heart could pump and as a result the doctors at your hospital suggested you come to for further evaluation at you had a procedure called a cardiac catherization this is a procedure where a catheter is inserted in the large vessel in your groin and wired to the heart dye was injected to analyze the vessels in your heart known as the coronary arteries there evidence of severe coronary artery disease which causes the vessels to become blocked off this finding was concering as it increases your risk of a severe heart attack your doctors informed of this finding and suggested you have surgery known as a triple bypass surgery to circumvent the blocks in your coronary arteries however after you were told about the risks and benefits of having the surgery you decided this is not a procedure you would want performed at this time because you declined to have the surgery we have attempted to medically optimize your medication regimen it is important to continue to take your medications as prescribed to help reduce your risk of having another larger heart attack in the future additionally you have been placed on medication to treat the clots in your lungs the first medication is called lovenox or enoxaparin it is injection you give yourself twice a day the second drug is called warfarin or coumadin it is a pill you will take to help keep your blodo thin as warfarin takes some time to work it is important you take enoxaparin in the interim to help keep your thin while warfarin starts to work in your body please use the enoxaparin injections for days or as arranged by your pcp is unclear why your red cell count was low when you came to the hospital it is importnat you follow up with your primary care doctor for further evaluation of this issue the following is your new list of medications please discontinue taking any medications that are not on this list and adhere to the medication dosing your were desensitzed to aspirin this means that if you continue to take it everyday you will not have an allergy to it however if you miss even a single dose please call your pcp to discuss whether or not he wants you to take the next dose before you take it acetaminophen mg tablet tablet by mouth every hours as needed for pain carvedilol mg tablet tablets by mouth times a day warfarin mg tablet tablets by mouth once daily at pm captopril mg tablet tablet by mouth three times a day atorvastatin mg tablet tablet by mouth at night prednisone mg tablet tablet by mouth daily aspirin mg tablet tablet by mouth daily omeprazole mg tablet tablet by mouth daily albuterol sulfate mcg actuation hfa aerosol inhaler inhalation as needed for shortness of breath or wheezing tiotropium bromide mcg capsule w inhalation device inhalation at bedtime enoxaparin mcg injection x a day for days nitroprusside sublingual as needed for chest pain it has been a pleasure taking care of you mr followup instructions it is very important that you see your pcp arrange for follow up within the week they can be reached at dr ko additionally it is importnat that you follow up with your cardiologist within the month for discussion of your cardiac issues please call your cardiologist and arrange for follow up md,"{
""Diagnoses"": [""NSTEMI"", ""Acute Systolic Heart Failure"", ""Gib"", ""Anemia"", ""Bilateral Pulmonary Emboli""],
""Medications"": [""ASA"", ""Densensitazation"", ""Copd"", ""Anticoagulation"", ""Nsaids"", ""Aspirin"", ""IVF Filter""]
}"
69172,admission date discharge date date of birth sex f service ome history of present illness ms ms is a year old female with metastatic renal cell carcinoma admitted today to begin cycle week high dose il therapy her oncologic history began in after she underwent an mri to evaluate back pain was incidentally found to have a left kidney mass she underwent left nephrectomy at that time a small liver lesion was noted during her yearly followup ct scans for which she underwent an ultrasound which did not reveal metastatic disease during an annual mammogram on she was discovered to have a new density in her right breast an ultrasound guided biopsy of this mass was performed on and pathology revealed the presence of an invasive carcinoma with clear cell features concerning for metastatic renal cell carcinoma pet ct performed on showed the presence of a lesion in the medial right hepatic lobe worrisome for a growing neoplasm an additional low attenuation lesion on the lateral right hepatic lobe was also seen no liver lesion was biopsied on with pathology consistent with renal cell carcinoma she was referred here to discuss treatment options she was planned for liver and breast resection on but her liver lesion was more extensive than thought prior to surgery and could not be resected she underwent right partial mastectomy with pathology from the breast and a repeat liver biopsy confirming metastatic kidney cancer systemic options were discussed and she wanted to consider high dose il therapy she passed eligibility testing and presents today to begin cycle week high dose il therapy past medical history thyroid cancer status post thyroidectomy and radioiodine treatment renal cell cancer as above status post tonsillectomy in bladder surgery in status post hysterectomy and bladder repair in cholecystectomy in multiple bladder repairs including a sling in and multiple rectocele repairs from arthroscopic left knee surgery in allergies levofloxacin morphine and tape medications evista mg p o daily effexor mg p o daily toprol xl mg daily on hold synthroid mcg daily with additional mcg on wednesdays temazepam mg p o at bedtime estrace cream every other day vitamin d units daily calcium mg p o b i d physical examination general well appearing female no acute distress performance status vital signs o sat on room air heent normocephalic atraumatic sclerae anicteric moist oral mucosa with areas of erythema on her bilateral lower mandible neck supple lymph nodes no cervical supraclavicular or bilateral axillary lymphadenopathy heart regular rate and rhythm s s chest clear bilaterally abdomen rounded soft nontender no hsm or masses extremities no edema neurologic exam nonfocal skin right upper quadrant right breast scars are well healed lab results white blood count hemoglobin hematocrit platelet count inr bun creatinine sodium potassium chloride co glucose alt ast ldh ck total bili albumin hospital course ms was admitted and underwent central line placement to begin therapy her admission weight was kg and she received interleukin units per kg based on adjusted ideal body weight equaling milliunits iv every hours x potential doses during this week she received of doses with doses held due to development of shock on day and doses held due to fatigue on days and side effects during this week included diarrhea improved with antiemetic therapy mild nausea improved with ativan an erythematous pruritic skin rash mucositis and fatigue on treatment day after her th dose of il she became hypotensive and was placed on dopamine to a max of mcg per kilogram per minute at that time her blood pressure was in the high s she was placed in trendelenburg with neo synephrine added and titrated up to mcg of neo with continued hypotension she was given a liter of normal saline she initially stabilized with blood pressure in the high to low s and then again developed hypotension to the range with additional iv fluids given she was hypoxic to the s requiring non rebreather and there was concern for pulmonary edema given recent il dosing capillary leak and fluid boluses she was also noted to be lethargic with difficulty staying awake decision was made to transfer her to the icu given maximum neo and dopamine dosing currently on the floor with associated hypoxia and lethargy concerning for co retention she was transferred to the unit where she improved from a mental status perspective she was slowly weaned off vasopressor therapy and was transferred out of the unit the following day doing well her hypoxia improved and she was treated with lasix on treatment day once her systolic blood pressure stabilized she had no further hypotension throughout her hospitalization during this week she developed acute renal failure with a peak creatinine of improved to at the time of discharge she had associated oliguria and metabolic acidosis with a minimum bicarb of improved with bicarbonate replacement intravenously electrolytes were monitored and repleted per protocol strict i s and o s serum chemistries were maintained intravenous fluids were initially continued at maintenance and increased when she developed hypotension during this week she developed transaminitis with a peak alt of and a peak ast of both improved at the time of discharge she developed hyperbilirubinemia with a peak bilirubin of improved to at the time of discharge she was anemic without need for packed red blood cell transfusion she developed thrombocytopenia with a platelet count low of without evidence of bleeding she had no coagulopathy or myocarditis noted by she had recovered from side effects to allow for discharge to home condition on discharge alert oriented and ambulatory discharge status to home with her husband discharge diagnosis metastatic renal cell carcinoma status post cycle week high dose il complicated by shock pulmonary edema and acute renal failure discharge medications lasix mg p o daily x days or until you reach pretreatment weight tylenol tablets q i d p r n fever or pain zantac mg p o b i d p r n indigestion lorazepam mg t i d p r n nausea vomiting benadryl mg q i d p r n pruritus compazine mg t i d p r n nausea vomiting keflex mg p o b i d x days lomotil tabs q i d p r n diarrhea eucerin cream topically sarna lotion topically levothyroxine mcg p o daily venlafaxine mg p o daily gelclair ml t i d p r n mucositis nystatin ml p o q i d p r n thrush percocet tablets t i d p r n pain followup plans ms will return in week for week number of therapy md dictated by medquist d t job,"{
""Diagnoses"": [""Metastatic renal cell carcinoma"", ""Invasive carcinoma with clear cell features"", ""Metastatic renal cell carcinoma""],
""Medications"": [""High dose il therapy""]
}"
56390,admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint pneumonia major surgical or invasive procedure intubation for mechanical ventilation history of present illness m with esophageal ca recent admission for ftt pneumonia the patient was sent from nursing home reportedly ill appearing we do not yet have any history from his facility i have left a message with the nurse on duty the patient s sister reports that he had been treated for pneumonia two weeks ago at our records suggest the patient was discharged on but not treated for pneumonia at that time the patient did have a prescription for levaquin in his records from so he probably was diagnosed with pneumonia recently his sister spoke to him the day before this hospitalization and says he sounded fine he was able to go to lunch and dinner that evening the patient s sister also reports that his usual nuring support could not reach him due to the inclement weather this week in the ed the patient was tachycardic hypoxic on ra on arrival he was brought in looking unwell hypoxic and with altered mental status in addition the patient was exteremly cachectic the patient s cxr showed pna and he received vancomycin levaquin zosyn recently admitted with pseudomonas the patient had terrible iv access and so was underresuscitated a right ij triple lumen was placed the patient was progressively tachypneic to low s and his lactate was after failureo f nrb the ed felt the need to intubate with sedation via fentanyl and versed though his sbp was before intubation afterward he had transient periods of sbp around phenylephrine was then started though altered pt wished to be full code his sister was unaware of her brother s exact wishes but felt he would probably want to be full code and would agree to all of the items on the icu consent form past medical history esoph ca s p esophagectomy with gastric pullup at years ago prostate ca nephrolithiasis social history immigrated from in worked for sears smoked until his esophagectomy years ago no recent etoh lives independently at takes his own medications sporadic nursing checks family history non contributory physical exam admission physical exam vs temp bp hr rr o sat gen intubated sedated cachectic heent perrl secretion in mouth oropharynx with some erythema likely secondary to intubation resp quiet breath sounds with wheeze cv s s no murmurs auscultated abd non distended quiet bowel sounds no guarding liver felt below costal margin ext clubbing of nails dusky fingernails with seconds capillary refill no edema skin many seborrheic keratoses neuro sedated small pupils but responsive to light biceps reflexes bilaterally patellar reflexes bilaterally babinski downgoing in left foot equivocal in right pertinent results admission labs pm wbc rbc hgb hct mcv mch mchc rdw pm neuts bands lymphs monos eos basos atyps metas myelos pm glucose urea n creat sodium potassium chloride total co anion gap pm calcium phosphate magnesium pm ctropnt pm lactate ct torso impression multifocal pneumonia and signs of atypical infection including tree in opacities which can be seen with endobronchial pna or tuberculosis as well as centrilobular ground glass nodules which can be seen with atypical pneumonia such as mycoplasma or viral pneumonia secretions within the right main stem bronchus and trachea are likely due to extensive infection as the patient is intubated and aspiration is less likely extremely limited evaluation of the abdomen however possible right hydronephrosis if clinically indicated a renal ultrasound could be performed for further evaluation small to moderate axial hiatal hernia 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 the aortic valve leaflets are mildly thickened but aortic stenosis is not present no masses or vegetations are seen on the aortic valve trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse no mass or vegetation is seen on the mitral valve there is moderate thickening of the mitral valve chordae no mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened moderate tricuspid regurgitation is seen there is moderate pulmonary artery systolic hypertension there is a very small pericardial effusion impression normal global and regional biventricular systolic function moderate pulmonary hypertension moderate tricuspid regurgitation very small pericardial effusion renal ultrasound impression echogenic kidneys compatible with medical renal disease although without atrophy indeed the parenchyma seems mildly swollen no evidence of hydronephrosis or abscess extensive ascites cxr findings as compared to the previous radiograph there is no relevant change minimally increase in opacities at the left lung base the other opacities in both the left and the right lung are constant unchanged high position of the endotracheal tube the tube could be advanced by to cm no newly appeared focal parenchymal opacities unchanged bilateral symmetrical apical thickening brief hospital course the patient had a complicated hospital course including a micu stay where he was on pressors for quite a while as well as refractory respiratory failure he was treated with multiple courses of antibiotics for hcap but failed to improve given his failure to improve and the severity of his illness a goals of care conversation was conducted by the micu team the patient s sister did not feel that pursuing a tracheostomy a peg tube and prolonged intubation were consistent with his wishes as such the patient was made dnr dni and was extubated on he actually did well initially as such a code conversation was had with the sister and he was made he was transferred out of the unit on he initially did well and was able to communicate with his sister and with myself however his respiratory status deteriorated he was given morphine for pain and for respiratory distress he ultimately passed away on at pm his family was at his bedside at the time of his death medications on admission nexium mg qd florinef mg qd zoloft mg qd bethanecol qd carafate g qid discharge disposition expired discharge diagnosis sepsis respiratory failure discharge condition deceased discharge instructions expired followup instructions expired,"{
""Diagnoses"": [""Pneumonia""],
""Medications"": [""Levaquin""]
}"
4359,admission date discharge date service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint shortness of breath major surgical or invasive procedure cardiac catheterization with ethanol septal ablation history of present illness year old male with hypertrophic cardiomyopathy mild aortic stenosis moderate mitral regurg htn hyperlipidemia and history of cad status post stents to proximal lad and proximal rca in the past who presented acutely to the lakes hospital after being found unresponsive at home by friends although scheduled for an elective ethanol septal ablation on friday the patient was acutely transferred to on for urgent septal ablation after he had been ruled out for mi head ct showed no hemorrhage however moderate cerebral atrophy and chronic microvascular infarcts were noted the patient had been falling a lot at home possibly undergoing syncopal episodes perhaps due to transient hypotension secondary to dynamic lv outflow obstruction falling was also exacerbated by alcoholism he rinks at least alcoholic beverages daily his serum alcohol level was at the osh due to the falls he had several pelvic bruises and ecchymotic swollen left elbow hematoma per report the left arm was without fracture on xray the patient reported feeling well before ablation he denied dizziness and presyncope no chest pain or shortness of breath telemetry displayed sinus rhythm with first degree heart block with a pr interval of he had bp afebrile o on ra cardiac catheterization performed revealed patent stents hocm and right dominant system past medical history hypertrophic obstructive cardiomyopathy cad s p stents to lad and rca in hypertension syncope ethanol abuse anemia peptic ulcer disease left rotator cuff repair social history lives at home with wife drinks a few drinks a day denies tobacco family history father died of mi in his s physical exam pe af vs hr rr sats ra gen pleasant elderly male appears younger than stated age no evidence of respiratory distress heent ncat perrl eomi no jvd op clear cvs rrr iii vi end systolic murmur loudest at rusb resp cta bilaterally no wheeze no crackles abd soft bs ntnd no masses ext no lower ext edema wwp dp pt pulses and symmetric lue cm hematoma over lateral aspect of elbow ecchymosis nontender normal rom x rays at osh reportedly neg per patient neuro cn ii xii intact no focal motor or sensory deficits pertinent results echo done significant hypertrophic cardiomyopathy with a resting gradient of mmhg and with valsalva a mmhg gradient severe mitral insufficiency mild to moderate ai ef aortic valve area labs at osh ruled out for an mi bun creat k na wbc hct plt inr not done will be done prior to transfer wt ekg sinus st degree av block borderline lvh no st tw changes no change from admission labs wbc rbc hgb hct mcv mch mchc rdw plt ct calcium phos mg glucose urean creat na k cl hco angap ck cpk ck mb mb indx ctropnt ck cpk ck mb mb indx ck cpk ck mb mb indx ctropnt discharge labs wbc rbc hgb hct mcv mch mchc rdw plt ct calcium phos mg glucose urean creat na k cl hco angap echo at mild symmetric lv hypertrophy with normal cavity size and systolic function lvef regional left ventricular wall motion is normal no left ventricular outflow obstruction at rest but a mild gradient peak mmhg was induced with valsalva rv chamber size and free wall motion are normal aortic root and ascending aorta are mildly dilated aortic valve leaflets are moderately thickened mild aortic stenosis with mild aortic regurgitation mitral valve leaflets are mildly thickened no systolic anterior motion of the mitral valve leaflets trivial mitral regurgitation estimated pulmonary artery systolic pressure is normal impression symmetric left ventricular hypertrophy with mild inducible valsalva lvot gradient mild aortic stenosis mild aortic regurgitation dilated ascending aorta cardiac cath no angiographically apparent flow limiting coronary artery disease moderate aortic stenosis severe left ventricular outflow tract gradient with the majority of the gradient related to hypertrophic obstructive cardiomyopathy successful ethanol ablation of the basal septum echo study date of there is mild symmetric left ventricular hypertrophy overall left ventricular systolic function is normal lvef there is no left ventricular outflow obstruction at rest or with valsalva the aortic valve leaflets are moderately thickened there is mild aortic valve stenosis mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen there is no pericardial effusion compared with the prior study tape reviewed of no significant lvot gradient was not inducible with valsalva ecg study date of am sinus rhythm with slowing of the rate compared to the previous tracing of right bundle branch block and left anterior fascicular block prior inferior wall myocardial infarction the st t wave abnormalities have improved the rate has slowed otherwise no diagnostic interim change brief hospital course year old man with hypertrophic obstructive cardiomyopathy treated with ethanol septal ablation cardiovascular a the patient has known cad with stents placed in to the proximal lad and rca in cardiac catheterizatin reveales patent stents and non flow limiting disease the patient was placed on an optimal medical regimen including metoprolol mg simvastatin mg qhs and asa mg b pump on catheterization severe left ventricular outflow tract gradient with the majority of the gradient related to hypertrophic obstructive cardiomyopathy the dynamic outflow tract gradient caused by hypertrophic obstructive cardiomyopathy was reduced after treatment with ethanol septal ablation therapy the gradient was not inducible with valsalva after the ablation c valves per echocardiogram the patient had mild as ar trivial mr and a normal tricuspid valve d rhythm normal sinus rhythm was observed on tele monitoring without sign of heart block post ablation he retained a temporary pacer wire with excellent threshold of who s firing was not required during the hospital visit the cardiac electrophysiology service was consulted for ecg showing new rbbb l axis deviation and known av prolongation no permanent pacer placement or further intervention was deemed necessary at this moment and he continued to perform well on subsequent monitoring follow up with outpatient cardiology was recommended for continued evaluation of his new rhythm and possible need for pacemaker placement renal the patient had mild chronic renal insufficiency with baseline creatinine of thus creatinine was followed alcohol abuse no medication was needed according to ciwa scale also he lacked signs of withdrawal outpotient counselling was recommended pulmonary the patient had moments of apnena on telemetry monitor and had sleep study in past however he does not use c pap at home due to discomfort we will have pt follow up with outpatient pcp sleep apnea medications on admission home metoprolol zocor prilosec folate norvasc transfer folate thiamin b b mvi fe lopressor bid prilosec zocor norvasc asa received pneumovax discharge medications simvastatin 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 metoprolol tartrate mg tablet sig two tablet po bid times a day disp tablet s refills multivitamin capsule sig one cap po daily daily disp cap 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 thiamine hcl mg tablet sig one tablet po daily daily disp tablet s refills folic acid mg tablet sig one tablet po once a day disp tablet s refills discharge disposition home discharge diagnosis primary hypertrophic obstructive cardiomyopathy secondary coronary artery disease hypertension syncope anemia pud discharge condition good discharge instructions please follow up with your doctors please take all of your medications as indicated the only medication change is a discontinuation of your norvasc your blood pressure and heart rate has been adequately controlled without the norvasc please consult your outpatient cardiologist regarding the changes in your medications followup instructions please follow up with your cardiologist within one week of discharge you can call to schedule an appointment at the time please have an ecg performed and your medication list reviewed,"{
""Diagnoses"": [""hypertrophic cardiomyopathy"", ""mild aortic stenosis"", ""moderate mitral regurgitation"", ""hypertension"", ""hyperlipidemia"", ""history of cad""],
""Medications"": [""ethanol"", ""septal ablation"", ""stents"", ""anti-hypertensive"", ""anti-coagulant""]
}"
16343,admission date discharge date service ccu history of present illness this is a year old female with past medical history including chronic obstructive pulmonary disease aortic insufficiency mitral stenosis and hypertension who presented from an outside hospital with pneumonia and congestive heart failure exacerbation in outside hospital notes notes record that the patient s daughter reports that the patient had some shortness of breath on the evening prior to admission it was worse on the morning of admission and so ems was called to transport the patient to the hospital on their arrival they found the patient to be severe respiratory distress with oxygen saturation of in room air and unable to speak the patient was given mg of lasix and easily intubated she was extubated in the emergency department at the outside hospital and initially did well on bipap however while on nonrebreather the patient s oxygen saturation decreased to and she was tachypneic at to arterial blood gases at that time revealed ph of pco of and po of the patient was intubated and transferred to the outside hospital coronary care unit in the coronary care unit at the outside hospital chest x ray was consistent with congestive heart failure with extensive infiltrate in the right lung white blood cell count was the patient was started on levofloxacin for presumed community acquired pneumonia during this time the patient was ruled out for a myocardial infarction with negative enzymes times three however her electrocardiogram showed symmetric deep t wave inversion when an attempt was made to wean the patient off the ventilator she developed rapid atrial fibrillation with a rate of she received diltiazem and lopressor with a decrease in her rate to the s she was subsequently started on heparin drip and cardioverted the patient was then transferred to for further care past medical history chronic obstructive pulmonary disease type diabetes mellitus aortic insufficiency aortic stenosis mitral stenosis history of rheumatic fever paroxysmal atrial fibrillation hypertension congestive heart failure coronary artery disease allergies sulfa medications on admission glucophage mg twice a day glyburide mg p o once daily prilosec mg p o once daily coumadin tiazac mg three times a day lasix mg p o once daily lanoxin mg p o once daily diovan mg p o once daily folic acid mg p o once daily evista mg p o once daily vitamin b mg p o once daily vitamin b mg p o once daily advair two puffs once daily rhinocort mg two puffs once daily physical examination on admission physical examination revealed a temperature of blood pressure heart rate the patient was intubated vent settings were assist control with a tidal volume respiratory rate peep and fio of in general the patient was sedated on ventilator nonresponsive cardiovascular regular rate and rhythm s and s iii vi systolic ejection murmur at the base no carotid bruits no appreciable jugular venous distention pulmonary coarse breath sounds bilaterally the abdomen is soft nontender nondistended positive bowel sounds no hepatosplenomegaly extremities revealed no cyanosis clubbing or edema dorsalis pedis pulses laboratory data sodium potassium chloride bicarbonate blood urea nitrogen creatinine glucose calcium magnesium phosphorus white blood cell count hematocrit platelet count prothrombin time partial thromboplastin time inr chest x ray on admission revealed a heart size the upper limits of normal upper zone redistribution with mild diffuse vascular blurry consistent with congestive heart failure probable right effusion increased retrocardiac density consistent with left lower lobe collapse and or consolidation minimal atelectasis at the right base hospital course cardiac coronaries the patient ruled out for myocardial infarction at outside hospital on admission electrocardiogram revealed sinus rhythm at beats per minute with deep t wave inversion throughout the precordium very well t waves were considered as possible explanation given the patient s negative cardiac enzymes a ct of the head was obtained on the evening of admission which was normal cardiac catheterization was subsequently performed on to evaluate the size of the patient s coronary arteries it revealed a right dominant system with mild single vessel disease the left main coronary artery had no angiographically appearing flow limiting stenosis the left anterior descending had no angiographically appearance of flow limiting stenosis the left circumflex had no angiographically flow limiting stenosis the right coronary artery had no significant disease and the posterior descending artery had a focal tubular lesion in the distal vessel resting hemodynamics revealed normal right sided filling pressures with a mean right atrial pressure of mmhg there were elevated left sided filling pressures with a left ventricular end diastolic pressure of the cardiac index was normal at three liters per minute per meter square there was moderate pulmonary hypertension with a pulmonary artery pressure of mmhg left ventriculography revealed mitral regurgitation no wall abnormalities and calculated ejection fraction of further evaluation of the aortic valve revealed a peak gradient across the aortic valve of and a mean gradient of calculated valve area was centimeter squared evaluation of the mitral valve revealed a mean gradient of although the patient had no critical coronary artery disease on cardiac catheterization given her history of diabetes mellitus she was started on a statin during the admission a lipid panel from revealed a triglyceride level of hdl of and ldl of rhythm the patient had a history of paroxysmal atrial fibrillation in the past and an episode of rapid atrial fibrillation during extubation attempt at the outside hospital she was electrically cardioverted at the outside hospital and arrived to on an amiodarone drip on her arrival the patient was in sinus rhythm she was continued on the amiodarone mg p o twice a day this dose was continued for one week at which time the patient s amiodarone dose was decreased to mg p o once daily for a total of one week at the end of this period the patient will be on a standing amiodarone dose of mg p o once daily in addition the patient was anticoagulated for her atrial fibrillation while in the hospital this was initially accomplished with a heparin drip as it was the plan for the patient to go for catheterization following catheterization the patient was restarted on coumadin with a heparin bridge until therapeutic the patient remained in sinus rhythm throughout the hospitalization pump the patient with a history of congestive heart failure on admission the patient did not appear volume overloaded an echocardiogram was obtained on to evaluate her pump status it revealed moderate dilation of the left and right atrium there was mild symmetric left ventricular hypertrophy with normal cavity size and systolic function with a left ventricular ejection fraction of greater than regional left ventricular wall motion was normal the aortic valve leaflets were moderately thickened with mild aortic regurgitation the mitral valve leaflets were moderately thickened they show characteristic rheumatic deformity with diffuse commissures and tethering of the leaflet motion there was mild mitral annular calcification there was moderate mitral stenosis mild to moderate to mitral regurgitation was also seen mild to moderate to tricuspid regurgitation was seen there was mild pulmonary artery systolic hypertension there was a small pericardial effusion with the information obtained from the echocardiogram and subsequent cardiac catheterization it was determined that the patient did not require immediate valve repair however this is the likely possibility in the future early during the admission the patient was gently diuresed for her congestive heart failure pulmonary the patient arrived from outside hospital with diagnosis of community acquired pneumonia however the infiltrate which had been visualized at the outside hospital was no longer present on chest x ray the morning following admission therefore it is most likely that the patient s acute respiratory decompensation and pulmonary symptoms were due to congestive heart failure exacerbation however a seven day course of azithromycin and ceftriaxone were completed for the presumed community acquired pneumonia the patient tolerated the ventilator well during the first few days of admission she was extubated on without events she continued to do well throughout the remainder of the admission with oxygen saturation in the high s in room air the patient s inhalers for chronic obstructive pulmonary disease were continued throughout the admission hypertension the patient s hypertensive medications were titrated up over the course of the admission her probable final doses on discharge will be metoprolol mg p o twice a day and lisinopril mg p o once daily hematology the patient anticoagulated for atrial fibrillation with heparin drip early in the admission in preparation for subsequent cardiac catheterization elevated inr was reversed with vitamin k times two doses following cardiac catheterization the patient was restarted on coumadin with a heparin bridge until she had a therapeutic inr the patient s hematocrit remained stable throughout the hospitalization she did not require any transfusion diabetes mellitus type the patient continued on sliding scale insulin and scheduled insulin throughout the admission american diabetic association diet prophylaxis the patient anticoagulated with heparin for her atrial fibrillation essentially covering her for deep vein thrombosis prophylaxis proton pump inhibitor for gastrointestinal rehabilitation the patient worked with physical therapy as an inpatient it was felt that she would benefit from a short stay in acute rehabilitation facility condition on discharge stable discharge status the patient will be discharged to acute rehabilitation facility for a short stay discharge diagnoses congestive heart failure mitral stenosis aortic valve insufficiency hypertension chronic obstructive pulmonary disease respiratory distress diabetes mellitus type paroxysmal atrial fibrillation history of rheumatic fever medications on discharge fluticasone mcg two puffs inhaled twice a day ipratropium mcg two puffs inhaled four times a day pantoprazole mg p o once daily aspirin mg p o once daily amiodarone mg p o once daily until and from that time on the patient will be taking mg p o once daily atorvastatin mg p o once daily eucerin cream topical four times a day p r n metoprolol mg p o once daily docusate sodium mg p o twice a day lisinopril mg p o once daily glucophage mg p o twice a day glyburide mg p o once daily folic acid mg p o once daily evista mg p o once daily follow up plans the patient will follow up with her cardiologist dr at the she will schedule this appointment to suit her convenience m d dictated by medquist d t job,"{
""Diagnoses"": [""pneumonia"", ""congestive heart failure exacerbation"", ""chronic obstructive pulmonary disease"", ""aortic insufficiency"", ""mitral stenosis"", ""hypertension""],
""Medications"": [""lasix"", ""bipap"", ""nonrebreather"", ""ariel""]
}"
79352,admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint fatigue major surgical or invasive procedure midline placement history of present illness mr is a very pleasant year old man with a pmh significant for dyslipidemia hypertension ckd copd afib bladder ca s po cystectomy prostectomy with urostomy parathyroid resection and lung nodule resection who presented to with a day s worth of weaknes there he was found to be hypotense to the s sytolic normally s at home on bp meds wbc a creatinine doubled to and a lactate of with an inr of he had a recent u a at a pcp s office a week ago which apparently showed a klebsiella uti for which he was treated with a week s worth of abx he is not sure which kind gave him levoquin and vancomyin he was also noted at to have a tropinin of in our ed he got a cvl for sbps int he s and got l ns he also recieved a dose of zosyn our ed labs were notable for wbc count of with a bandemia of and a hct of with plts of lactate in the ed was levophed was placed at bedside but not hung he says that his story started two mondays ago when he had some profuse vomiting leading to some back for which his pcp prescribed him oxycodone the next wed weeks ago he noticed some dark urine his pcp thus prescribed him an antibiotic to be taken for a week which he took diligently he a cxr showed a r ij in place but no overt pulmonary edema on arrival to the micu he was very pleasant aaox review of systems per hpi denies fever chills night sweats recent weight loss or gain denies headache sinus tenderness rhinorrhea or congestion denies cough shortness of breath or wheezing denies chest pain chest pressure palpitations or weakness denies nausea vomiting diarrhea constipation abdominal pain or changes in bowel habits denies dysuria frequency or urgency denies arthralgias or myalgias denies rashes or skin changes past medical history dyslipidemia hypertension ckd last cr on copd atrial fibrillation paroxysmal on coumadin bladder ca s p cystectomy prostatectomy hyperparathyroidism s p parathyroid resection lung nodule resection pcp s office has record of adenocarcinoma of the lung but no info on tx gout cad s p stent placement to lad and lcx social history patient lives with his wife a pk yr history but quit yrs ago has drinks week and denies drug use he is retired and used to work as at metal worker family history there is no family history of premature coronary artery disease or sudden death physical exam admission physical exam general alert oriented no acute distress heent dry neck supple jvp not elevated no lad cv afib lungs clear to auscultation bilaterally no wheezes rales ronchi abdomen soft non tender non distended bowel sounds present no organomegaly gu urostomy ext cool neuro cnii xii intact strength upper lower extremities grossly normal sensation reflexes bilaterally gait deferred finger to nose intact discharge physical exam vitals ra general alert oriented no acute distress very pleasant heent anicteric sclerae mmm oropharynx clear no jvd significant crusting and superficial ulceration of the upper and lower lips and perioral area cv irregularly irregular rhythm no m r g lungs minimal rales at bases bilaterally otherwise clear no wheezes abdomen soft non tender non distended bowel sounds present no organomegaly urostomy site clear without bloody output no cva tenderness ext no peripheral edema no calf tenderness 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 hypochr normal anisocy occasional poiklo occasional macrocy normal microcy normal polychr normal ovalocy occasional am blood pt ptt inr pt am blood fibrino pm blood fdp pm blood glucose urean creat na k cl hco angap am blood ck cpk am blood ck mb ctropnt am blood ck mb mb indx ctropnt pm blood ck mb mb indx ctropnt am blood calcium phos mg pm blood vanco am blood type art temp po pco ph caltco base xs intubat not intuba pm blood lactate am urine color yellow appear hazy sp am urine blood mod nitrite neg protein tr glucose neg ketone neg bilirub neg urobiln neg ph leuks lg am urine rbc wbc bacteri mod yeast none epi am urine mucous rare pertinent labs pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt am blood fibrino pm blood fdp pm blood glucose urean creat na k cl hco angap am blood alt ast alkphos totbili am blood ck mb ctropnt am blood ck mb mb indx ctropnt pm blood ck mb mb indx ctropnt pm blood lactate am urine color yellow appear hazy sp am urine blood mod nitrite neg protein tr glucose neg ketone neg bilirub neg urobiln neg ph leuks lg am urine rbc wbc bacteri mod yeast none epi discharge labs 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 am blood calcium phos mg micro path blood culture x no growth urine culture mixed bacterial flora colony types consistent with fecal contamination mrsa screen no mrsa imaging cxr findings there has been interval placement of a right sided internal jugular venous catheter the tip is slightly obscured by overlapping lead from pacemaker however appears to terminate in the low svc a single lead left sided pacemaker is unchanged within the lungs no focal opacity to suggest pneumonia is seen no pleural effusion pulmonary edema or pneumothorax is present there is mild vascular congestion the heart size is top normal unchanged chain suture is noted in the left hemithorax with volume loss suggestive of prior resection impression central catheter in standard position without pneumothorax abdominal u s impression small amount of gallbladder sludge no specific son sign to suggest acute cholecystitis top normal common bile duct diameter bilateral renal cysts and mild cortical thinning brief hospital course year old man with h o dyslipidemia hypertension ckd copd afib bladder ca s po cystectomy prostectomy with urostomy parathyroid resection and lung nodule resection who presented to osh with a one day of weakness transfered to for evaluation and treatment of sepsis from suspected urinary source active diagnoses sepsis from urinary source patient had a ua with wbcs and large bacteria in setting of unusual urologic anatomy with urostomy he was pan cultured and treated with vanc and zosyn initially empirically for urosepsis he was volume resuscitated with l in the ed with cvps at goal but continued to by hypotensive and was started on both levophed and vasopressin in the micu he was able to be weaned off these by the following day his antibiotics were changed to vanc cefepime flagyl after obtaining information from his pcp that he had recently been treated with doxycycline for a klebsiella uti resistant to ampicillin nitrofurantoin piperacillin sensitive to cephalsporins non esbl he was called out to the floor on for further management his antibiotics were narrowed to ceftriaxone his fevers leukocytosis k k lactatemia and other evidence of end organ ischemia resolved and he no longer required iv fluids to maintain his pressures all in house culture data was negative or c w contamination blood cultures were also negative no urine cultures there a midline was placed for him to finish his day total course of ceftriaxone last day acute renal failure on ckd concern for acute tubular necrosis resolved cr peaked in house to up from prior baseline of but trended back down to with pressors and fluids rec d in the unit and on the floor the likely cause for his arf was thought to be hypoperfusion secondary to distributive shock from sepsis causing atn cad troponin leak has known h o cad s p stenting to the lad and lcx in is not on anti platelet agents asa plavix given h o heavy bleeding was noted at to have a tropinin of and at was with normal mb index remaining stable on trend ekg was w o acute ischemic changes and pt was asymptomatic enzyme leak was attributed to demand in setting of shock as well as retention from arf atrial fibrillation patient presented in af but not in rvr with supratherapeutic inr likely in setting of recent antibiotics per his pcp coumadin dose had recently been changed from to mg in the setting of his elevated inrs his beta blocker and coumadin were held in the setting of his acute illness and elevated inr he received mg of vitamin k to help correct his inr of he was restarted on coumadin and his beta blocker on discharge thrombocytopenia in setting of elevated inr concern for dic fibrinogen and fdp were sent and negative low platelets were attributed to septis transaminitis likely from mild shock liver picture from hypoperfusion downtrending and almost wnl s at the time of discharge u s unremarkable for structural cause oral herpes simplex recurrence not causing many symptoms or pain started during his hospitalization likely related to the severe stress of medical illness he was started on a day course of renally dosed valacyclovir chronic diagnoses schf stable his home diuretic regimen was held during his acute illness but re started at the time of discharge copd stable he was continued on his home tioproprium transitional issues code status patient was full code during this admission antibiotics patient is receiving a day course of iv cephalosporins first cefepime now ceftriaxone to end urology follow up patient may benefit from urology follow up for strategies to avoid severe uti s in the past given his altered anatomy chf patient is not on an ace inhibitor which is indicated for his systolic chf transaminitis patient had mild transaminitis on discharge that was downtrending and almost within normal limits he had a relatively unremarkable u s we defer further evaluation of this issue to the outpatient setting inr this patient will need very tight monitoring of his inr given his fairly large swings even on low doses medications on admission coumadin mg daily changed to mg allopurinol mg po bid metoprolol succinate mg daily levoxyl mcg daily simvastatin mg daily isosorbide mononitrate mg daily furosemide mg daily sodium bicarb mg qid spectravite feosol mg daily stool softener coquenzyme q mg daily spiriva daily imdur daily discharge medications warfarin mg tablet sig one tablet po every other day disp tablet s refills allopurinol mg tablet sig one tablet po twice a day metoprolol succinate mg tablet extended release hr sig one tablet extended release hr po once a day levothyroxine mcg tablet sig one tablet po once a day simvastatin mg tablet sig one tablet po daily daily isosorbide mononitrate mg tablet extended release hr sig one tablet extended release hr po once a day furosemide mg tablet sig one tablet po once a day sodium bicarbonate mg tablet sig one tablet po four times a day spectravite tablet sig one tablet po once a day feosol mg mg iron tablet sig one tablet po once a day colace mg capsule sig one capsule po twice a day coenzyme q mg capsule sig one capsule po once a day spiriva with handihaler mcg capsule w inhalation device sig one inhalation once a day senna mg tablet sig one tablet po bid times a day as needed for constipation disp tablet s refills sodium chloride aerosol spray sig sprays nasal qid times a day as needed for dry nares disp bottle refills ipratropium albuterol mcg actuation aerosol sig puff inhalation four times a day as needed for shortness of breath or wheezing disp device refills ceftriaxone in dextrose iso os gram ml piggyback sig one intravenous q h every hours for days last dose disp doses refills valacyclovir g tablet sig one tablet po once a day for days disp tablet s refills ensure liquid sig one po three times a day disp cases refills heparin porcine pf unit ml syringe sig one ml intravenous prn as needed as needed for line flush disp syringes refills discharge disposition home with service facility discharge diagnosis primary sepsis from urinary source acute renal failure mild shock liver secondary schf ckd atrial fibrillation copd 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 you were transferred to for evaluation and treatment of sepsis from a urinary tract infection you were treated in the icu with fluids pressors and antibiotics and your condition improved dramatically you were further evaluated on the floor and you continued to improve with return of your kidney and liver function to your prior normal levels we placed a temporary line in you for further antibiotic administration to complete your course the following changes have been made to your medications start ceftriaxone gram iv once daily for more days last day start valtrex gram by mouth once daily for more day last day start ipratropium albuterol mdi inhalations four times a day as needed for shortness of breath wheezes start saline nasal spray as needed start senna tab by mouth twice daily as needed for constipation decrease coumadin warfarin to mg by mouth every other day start taking it continue taking your other home medications as directed please have your inr checked on friday weigh yourself every morning md if weight goes up more than lbs please follow up with the appointments listed below followup instructions name a primary care location medical associates address phone appt at am completed by,"{
""Diagnoses"": [""hypotension"", ""sepsis"", ""UTI"", ""hypertension"", ""dyslipidemia"", ""CKD"", ""COPD"", ""Afib"", ""bladder CA"", ""po cystectomy"", ""prostectomy with urostomy"", ""parathyroid resection"", ""lung nodule resection""],
""Medications"": [""Levoquin"", ""Vancomyin"", ""Zosyn"", ""Lepofed""]
}"
6107,admission date discharge date service medicine note the patient was admitted to the medicine service after being transferred from the micu for a detailed course of the patient s stay in the micu please refer to dictation summary from the micu history of present illness the patient is a year old male with a history of coronary artery disease congestive heart failure with an ejection fraction of hypertension atrial fibrillation depression and anxiety it should be noted that for atrial fibrillation the patient has not been on coumadin and there is a question of whether this is chronic versus paroxysmal the patient s ejection fraction is by echocardiogram done at last month the patient was admitted initially to the micu with respiratory distress and acute renal failure the patient was unable to answer questions so all history was obtained by the patient s primary care physician the patient lives is an assisted living facility he had mildly elevated creatinine to one week prior to admission this was felt to be secondary to lasix for congestive heart failure there is little history for past week but the patient saw his primary care physician on the day of admission and was tachypneic and sent to the emergency room for evaluation oxygen saturation could not be obtained but abg revealed a pao of on nonrebreather the patient was also hypotensive with an sbp in the s on presentation but blood pressure increased to on l normal saline bolus labs obtained that day found the patient to be hyperkalemic at creatinine was electrocardiogram revealed new st depressions and t wave inversions in v v the patient was given kayexalate and admitted to the micu for further care past medical history coronary artery disease details are unknown congestive heart failure with an ejection fraction of by echocardiogram done at last month hypertension atrial fibrillation not known whether chronic or paroxysmal the patient was not on coumadin the patient has a history of anxiety and depression medications on admission lisinopril mg p o q d lasix mg p o b i d zyprexa p o q d depakote dose unknown dexacen mg p o b i d colace mg p o b i d allergies no known drug allergies social history he lives in an assisted living facility per her primary care physician is severely deconditioned and debilitated but refuses other living arrangements daughter is active in his care physical examination vital signs on admission pulse was blood pressure after fluid oxygen saturation on nonrebreather respirations temperature general the patient was alert and in no acute distress heent within normal limits normocephalic atraumatic dry mucous membranes oropharynx clear neck supple no lymphadenopathy thyroid normal no jugular venous distention heart irregularly irregular no murmurs clicks or gallops lungs clear to auscultation bilaterally abdomen soft nontender nondistended no hepatosplenomegaly palpated extremities lower extremities with no clubbing cyanosis or edema skin without rashes neurological grossly normal laboratory data white count hematocrit platelet count inr sodium potassium chloride bicarb bun creatinine glucose depakote level abg ph ck mb troponin hospital course in the unit the patient was treated with vigorous intravenous fluids with improvement in renal failure and blood pressure his course was complicated by anemia which was felt to be secondary to dilutional acidosis which was and felt to be secondary to dilutional acidosis the patient had atrial fibrillation in the unit as well as persistent fever chest x ray revealed pneumonia felt to be secondary to aspiration pneumonia the patient was started on flagyl and levofloxacin the patient was then transferred to the floor pneumonia again this was felt to be secondary to aspiration pneumonia the patient s antibiotics were changed from levofloxacin and flagyl to levofloxacin and clindamycin to provide better coverage for gram positive aerobes on the floor the patient was initially stable on l oxygen he had vigorous chest physical therapy that was delivered to loosen up secretions and he became stable on room air with oxygen saturations on room air the patient s sputum culture was consistent with mixed oropharyngeal flora and no organism was isolated the patient was continued on clindamycin and levofloxacin and was discharged with these medications in regards to his hospitalization on the floor the patient remained stable in room air cardiovascular pump the patient was initially off afterload reducing agents such as ace inhibitor however lisinopril was added at mg p o q d once his creatinine stabilized to his baseline of around the patient tolerated this quite well rate control the patient was considered for beta blocker however he was very sensitive to low dose beta blockers with decrease in blood pressure and hence these were discontinued the patient throughout his hospitalization remained in atrial fibrillation which was mostly very well rate controlled in the s beta blockers and other nodal agents were not continued given that the patient is very sensitive and would have low blood pressures he otherwise maintained good blood pressure without problem ischemia there was no evidence of active ischemia the patient did have elevated ck ckmb and troponins however these were felt to be secondary to demand ischemia in the setting of renal insufficiency the patient did not actively complain of chest pain or have any other symptoms that would indicate active ischemia further management was deferred atrial fibrillation the patient has a history of atrial fibrillation this is unclear of whether this is chronic versus paroxysmal the patient was not on coumadin on admission and coumadin was not continued in house the patient was mostly very well rate controlled with rate in the s to s and had no evidence of acute embolic events throughout his hospitalization hypotension again this improved throughout his hospitalization the patient had no symptomatic hypotensive episodes his blood pressures were very well controlled on ace inhibitor at low dose acute renal failure by the time the patient was on the floor his renal failure had returned to baseline at approximately for his creatinine congestive heart failure the patient has a history of congestive heart failure his diuretics were stopped entirely throughout his hospitalization in fact the patient was aggressively fluid resuscitated on admission to the micu the patient was not maintained on diuretics at all and his only medications included lisinopril mg p o q d for afterload reduction the patient will not be discharged with a diuretic given that he is currently stable on room air and is not in decompensated heart failure has no evidence of lower extremity edema his lasix may need to be readded to his regimen as an outpatient once he is discharged from the hospital as his volume status changes his volume status should be followed quite aggressively and he should be maintained on a low sodium puree and thick liquid diet additionally his intake of fluids should not exceed cc per day the patient s urine output should also be followed fen again acidosis was non gap and felt to be secondary to expansion this resolved throughout his hospitalization the patient s hypernatremia again was felt secondary to fluid resuscitation and free water deficit he was repleted with d normal with resolution of his hypernatremia at discharge the patient s sodium of discharge was additionally hyperkalemia resolved with fluid resuscitation the patient had no electrocardiogram changes consistent with hyperkalemia the patient while in house had a video as well as bedside swallow study to evaluate his swallowing mechanism given that it was felt that his pneumonia was an aspiration event the patient passed his bedside swallow study however he also had a video swallow which he did not pass the overall recommendations from speech and swallow were that the patient should be maintained npo with consideration of peg tube for further tube feeding nutrition however the patient and his daughter refused tube feed as an option and did not want peg tube or ng tube placed it was explained to them that the patient could have further aspiration events if he continued on a p o diet however the daughter understood this as did the patient they were also explained that even with a peg tube aspiration events cannot prevented given that the patient can aspirate one s own secretions hence the daughter and patient both decided that the patient would continue on a puree and thick liquid diet and that all eating events would be monitored by staff the patient will be maintained on aspiration precautions and that the head of his bed should be elevated both daughter and the patient wanted to defer ng tube or peg tube at this time they wanted to continue the patient on p o diet as long as the patient could tolerate heme the patient throughout his hospitalization received u packed red blood cells again his drop in hematocrit was felt to be secondary to dilution after transfusion of his u packed red blood cells hematocrit remained stable between at discharge psychiatric the patient was continued on and valproic acid throughout his hospitalization with no acute events prophylaxis the patient was maintained on subcue heparin and h blocker disposition he will be discharged to a rehabilitation nursing home facility condition on discharge fair to stable he is stable on room air he is maintained on antibiotics he has been afebrile for greater than three days he has had no witnessed aspiration events mental status is at baseline discharge medications aspirin mg p o q d bacitracin zinc ointment to be applied q i d to the urethral meatus albuterol nebs q hours as needed ipratropium nebs q hours as needed olanzapine mg mg p o q d lisinopril mg mg tab p o q d clindamycin mg p o q hours for days levofloxacin mg p o q d for days valproic acid mg ml to be taken ml p o at bed time mg ml suspension to be taken at ml p o q d follow up the patient is to set up follow up with his primary care physician approximately one week after he is discharged from his extended rehabilitation facility discharge labs white count hematocrit platelet count sodium potassium chloride bicarb bun creatinine glucose calcium magnesium phos m d dictated by medquist d t job cc,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""service"", ""medicine"", ""note"", ""history of present illness"", ""coronary artery disease"", ""congestive heart failure"", ""hypertension"", ""atrial fibrillation"", ""depression"", ""anxiety""],
""Medications"": [""coumadin""]
}"
61636,admission date discharge date date of birth sex m service medicine allergies sulfa sulfonamides attending chief complaint chest pain dyspnea syncope major surgical or invasive procedure none history of present illness this is a year old male with past medical history notable for prostate cancer temporal arteritis hyperlipidemia and gout who presents today ont transfer with massive bilateral pe s per the patient he had been in his regular state of health until several weeks ago he developed a severe flare of his gout that he is finally getting over more recently approximately wks ago he developed intermittent chest pain that would occasionally radiate to his back or shoulder this was about a severity and each bout of pain would last perhaps a few minutes this pain was nonexertional in addition to this he developed some dyspnea on exertion which was not temporally associated with the chest pain this had perhaps been getting a bit worse with episodes most days over the past week this morning while getting his pills he passed out and awoke on the floor he denies any prodrome but after coming back to consciousness he felt sweaty and unwell he then was brought into the ed where he was diagnosed with massive bilateral pulmonary emboli he was started on heparin drip after bolus and transferred to in the ed initial vs were t p bp r o sat on l patient was admitted to the medical intensive care unit past medical history prostate ca s p external beam radiotherapy years ago temporal arteritis diagnosed gout first attack weeks ago hyperlipidemia hx umbilical hernia repair years ago hx appendectomy at age social history lives alone attorney never a regular smoker and no tobacco during past months approximately etoh beverage night no illicits family history dad w cva colon cancer and glaucoma on maternal side heart problems on father s side father with history of blood clots was on coumadin physical exam on transfer to medical floor vitals t bp p r o on l general alert oriented no acute distress heent sclera anicteric mmm oropharynx clear neck supple jvp cm 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 ext wwp bilateral ankle edema pertinent results laboratory pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts bands lymphs monos eos baso atyps metas myelos am blood pt ptt inr pt pm blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap am blood ck cpk ck mb notdone ctropnt pm blood ck cpk ck mb notdone ctropnt probnp am blood totprot am blood calcium phos mg am blood pep no specifi igg iga igm ife no monoclo microbiology mrsa screen positive ekg sinus arrhythmia right bundle branch block possible inferior myocardial infarction age indeterminate there is an s q t pattern possible pulmonary embolus non specific t wave changes no previous tracing available for comparison imaging thyroid ultrasound multinodular thyroid gland with small nodules which do not demonstrate any son worrisome features routine followup is recommended bilateral lower extremity ultrasound bilateral deep venous thrombus definitively involving but not completely occluding the right popliteal vein and also involving the left posterior tibial vein in the calf transthoracic echocardiogram the left atrium is normal in size the estimated right atrial pressure is mmhg left ventricular wall thickness cavity size and regional global systolic function are normal lvef there is no ventricular septal defect the right ventricular cavity is markedly dilated with depressed free wall contractility the aortic root is moderately dilated at the sinus level the aortic valve leaflets are mildly thickened but aortic stenosis is not present mild aortic regurgitation is seen the aortic regurgitation jet is eccentric directed toward the anterior mitral leaflet 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 cta there is extensive bilateral pulmonary embolism there is a saddle embolus involving the main and right and left pulmonary arteries with emboli extending into all lobar branches the right ventricle appears enlarged but the chronicity of this finding is unknown there is no pericardial or pleural effusion the aorta is tortuous scattered linear opacities in the dependent basal portions of the lower lobes are most consistent with atelectasis the tracheobronchial tree is patent to segmental levels there is no mediastinal hilar or axillary lymphadenopathy there is a cm solid appearing nodule with a coarse calcification arising exophytically from the posterior inferior aspect of the right thyroid lobe there is a cm cyst in the imaged portion of the right kidney and a cm cyst in the imaged portion of the left kidney other imaged other abdominal organs are grossly unremarkable in the early phase of contrast enhancement multilevel degenerative changes are present in the spine impression massive bilateral pulmonary embolism as described above right ventricular enlargement of unknown chronicity given the presence of massive pulmonary embolism this findings is concerning for acute right heart strain solid appearing cm right thyroid nodule further evaluation by ultrasound is recommended when the patient is stable if not performed previously brief hospital course pulmonary embolism deep venous thrombosis the patient was admitted to the medical intensive care unit with extensive pulmonary embolism and evidence of right heart strain he was later found to have bilateral deep venous thrombosis right greater than left anticoagulation was initiated with iv heparin the patient remained stable and was transferred to the medical floor on the medical floor warfarin was started and iv heparin was changed to lovenox the patient was taught how to self administer lovenox and how to manage his diet while on coumadin the patient will self administer lovenox until he has had a therapeutic inr for days the patient will follow up with his primary care physician for management of anticoagulation with the first two draws occurring on and the patient s inr was at the of discharge the patient was advised to stop his daily aspirin until his next appointment with his primary care physician and discuss resuming aspirin at that time the etiology of the patient s pe dvt was unclear there was no recent surgical history the patient has a family history of venous thrombosis father he has been less mobile than usual in the setting of gouty flair the patient has a possible inflammatory risk factor temporal arteritis he also has history of prostate cancer the patient is due for colonoscopy spep upep was ordered while the patient was in the hospital and the patient s primary care doctor should follow up on this the hypercoagulability work up will be completed in the outpatient setting thyroid nodule a thyroid nodule was identified incidentally on the patient s ct angiogram the patient underwent thyroid ultrasound which showed multiple nodules with no son suspicious features he should undergo further follow up for this as an outpatient hyperlipidemia continued home statin temporal arteritis continued home prednisone lower extremity edema the patient has been taking lasix for lower extremity edema the edema is likely related to his dvts the patient was instructed to stop taking lasix as this could cause a dangerous drop in his blood pressure in the setting of extensive pe glaucoma continue brimonidine timolol drops the patient will need to contact his ophthalmologist for a prescription refill gout the patient was without symptoms of gout and continued his home colchicine mrsa a routine mrsa swab in the medical intensive care unit was positive the patient was put on contact precautions medications on admission simvastatin mg po daily combigan drop each eye colchicine mg po daily prednisone mg po daily clonazepam mg po bid prn multivitamin tab po daily asa mg po daily caltrate d tab po tid lasix mg po daily discharge medications prednisone mg tablet sig one tablet po daily daily combigan drops sig one drop each eye ophthalmic twice a day colchicine mg tablet sig one tablet po daily daily simvastatin mg tablet sig one tablet po daily daily warfarin mg tablet sig one tablet po once daily at pm dose will need adjustment based on monitoring use as directed by your primary care doctor tablet s refills enoxaparin mg ml syringe sig one injection subcutaneous q h every hours for doses doses refills caltrate plus vitamin d mg unit tablet sig one tablet po three times a day outpatient work pt ptt inr check on and to be followed up on by patient s primary care physician fax number is discharge disposition home discharge diagnosis primary saddle pulmonary embolism secondary temporal arteritis hyperlipidemia glaucoma discharge condition hemodynamically stable maintains good oxygen saturation on room air tolerating oral diet alert and oriented discharge instructions you came to with symptoms of chest pain shortness of breath lightheadedness and an episode of passing out you were found to have a large blood clot in your lungs and you were transferred to for further treatment you were intially admitted to the medical intensive care unit but as your condition improved you were transferred to the medical floor you were treated with anti clotting medications you will go home on two anti clotting medications coumadin also called warfarin and lovenox also called enoxaparin coumadin is an oral medication that you will need to take at the same time every day coumadin requires frequent monitoring with blood tests in order to maintain the appropriate level of anticoagulation there are some foods that can alter the effects of coumadin and you met with a nutritionist to go over this many medications can alter the effects of coumadin so you will need more frequent monitoring whenever you start a new medication or change the dose of an old medication you will also need more frequent monitoring right now while you are first starting coumadin this week you will need to have a blood test called an inr checked on and in order to ensure an appropriate coumadin level it is very important that you follow up as advised because elevated levels of coumadin can put you at risk for serious bleeding and low levels of coumadin can put you at risk for further blood clots until your coumadin level is appropriate which will likely take about a week you will need to take a second anti clot medication called lovenox lovenox is a medicine that you will inject subcutaneously twice daily you have been taught how to use lovenox during your stay at the hospital we stopped your lasix you should not restart your lasix until instructed to do so as these could cause a dangerous drop in your blood pressure in the setting of the blot clots in your lungs you should stop your aspirin for now but you should discuss with you primary care physician whether this should be continued when you see him later this week you had ultrasounds of your legs which showed venous blood clots on both sides with more significant involvement on the right these blood clots are likely the source of the blood clots in your lungs your ct angiogram showed a thyroid nodule you had an ultrasound of your thyroid gland to follow up on this the ultrasound showed two benign appearing nodules you should follow up with your primary care physician for further evaluation of these nodules you should to the hospital if you develop lightheadedness chest pain difficulty breathing fever worsening cough or any other symptom that is concerning to you it is important for you to follow up closely with your physicians we have arranged a follow up appointment with your primary care physician for this thursday as explained below followup instructions you have an appointment to follow up with your primary care physician on thursday at p m you should talk to your primary care physician about colonoscopy you will need to have blood drawn on and to monitor your coumadin therapy md,"{
""Diagnoses"": [""Massive bilateral pleural effusion"", ""Gout"", ""Temporal arteritis"", ""Hyperlipidemia"", ""Gout flare"", ""Intermittent chest pain"", ""Dyspnea on exertion""],
""Medications"": [""None""]
}"
53466,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint s p fall major surgical or invasive procedure tracheostomy and peg placment history of present illness yo gentleman who fell down stairs sustaining multiple facial fractures he had multiple unseccessful attempts at intubation by emts in the field he was then transported to and was intubated past medical history bipolar depression htn bilateral inguinal hernias hiatal hernia social history married lives with wife family history noncontributory pertinent results pm glucose lactate na k cl tco pm urea n creat pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm pt ptt inr pt ct head w o contrast impression multiple facial fractures involving the left zygomaticomaxillary complex nasal bones and very likely the left orbital floor further evaluation with dedicated facial bone ct is recommended as discussed with dr and other members of the trauma surgery team moderate left proptosis marked left periorbital soft tissue swelling and subcutaneous emphysema air fluid levels in the paranasal sinuses consistent with hemorrhage no intracranial hemorrhage ct c spine w o contrast impression multilevel degenerative changes of the cervical spine no evidence of acute fracture ct chest w contrast pm ct chest w contrast ct abdomen w contrast impression large bilateral lower lobe consolidations likely representing a combination of aspiration and atelectasis aspirated material within the right and left mainstem bronchus ng tube terminates just below the ge junction with a distended stomach further advancement is recommended left adrenal lesions incompletely characterized on this single phase study with appearance suggestive of underlying hyperplasia this could be further evaluated with a dedicated ct or mri multiple hypoattenuating lesions within both kidneys too small to characterize cholelithiasis subcentimeter hypoattenuating focus within the right lobe of the liver too small to characterize large left inguinal hernia grade anterolisthesis of l over s with associated spondylolysis cardiology report ecg study date of pm baseline artifact regular wide complex rhythm intraventricular conduction delay right bundle branch block type inferior q waves consider prior inferior myocardial infarction this may be an idioventricular rhythm q t interval prolongation st t wave abnormalities since the previous tracing of the qrs complex has widened there are probable retrograde p waves in the st segment clinical correlation is suggested tracing intervals axes rate pr qrs qt qtc p qrs t brief hospital course he was admitted to the trauma service he was taken to the trauma icu where he was monitored closely plastic surgery was consulted given his facial fractures these injuries were nonoperative on the following day he underwent bronchoscopy and was found to have foreign body in his airway it appeared that it was fragments of his dentures these were removed without incident after several days in the icu his sedation was weaned and he was allowed to wake up with goal of extubation he was extubated and failed trials x and was re intubated after discussion with his family the decision was made to perform a tracheostomy he was taken to the operating room on for this as well as placement of a dobbhoff a speech and swallow evaluation was performed for passy muir he was able to tolerate and use of this was implemented into his plan of care he was started on a ground diet with thin liquids his diet consistency should be upgraded once re evaluation done at rehab his tracheostomy was removed at bedside on without incident and he has been maintaining adequate oxygen saturations on room air ent was also consulted given his repeated attempts pre hospital at intubation there was concern for damage to his epiglottis no acute issues were identified it is being recommended that he have an outpatient ent follow up either here at or through his primary care provider as an he was eventually transferred to the regular nursing unit and initially required a sitter as his mental status improved the sitter was discontinued there were no behavioral issues identified during his hospital stay he is alert and oriented and oriented x at times forgets where he is he is cooperative with his care he was evaluated by physical and occupational therapy and it has been recommended that he go to a rehab facility for a short time in order to improve his overall functional abilities medications on admission lithium sertraline trazadone qhs lisinopril discharge medications heparin porcine unit ml solution one ml injection tid times a day lithium carbonate mg capsule one capsule po tid times a day sertraline mg tablet two tablet po daily daily metoprolol tartrate mg tablet one tablet po tid times a day hold for hr sbp lisinopril mg tablet one tablet po daily daily hold fro sbp albuterol mcg actuation aerosol four puff inhalation q h every hours as needed for shortness of breath or wheezing ipratropium bromide mcg actuation aerosol four puff inhalation q h every hours as needed for shortness of breath or wheezing senna mg tablet one tablet po bid times a day hold for loose stools trazodone mg tablet tablet po hs at bedtime as needed for insomnia lansoprazole mg tablet rapid dissolve dr one tablet rapid dissolve dr daily daily acetaminophen mg tablet two tablet po q h every hours as needed discharge disposition extended care facility for the aged discharge diagnosis s p fall multiple facial fractures left zygomaticmaxillary nasal bone left orbital floor left medial ptyergoid plate respiratory failure discharge condition good followup instructions follow up with dr in weeks call for an appointment completed by [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies benzodiazepines attending chief complaint altered mental status and increased tremors major surgical or invasive procedure none history of present illness this is a yo m with h o bipolar depression s p traumatic brain injury s p mva and htn who presents with tremor and confusion he was recently hospitalized at from for altered mental status in the setting of a recent mva confusion thought to be multi factorial leg contusion with pain bipolar depression with questionable adherence to lithium worsening renal function and recent stressor of his wife passing away discharged home with hour care and vna since days prior he admission he has had worsening mental status and tremulous per his daughter he has had increasing falls and instability over the past few days as well today his daughter spoke to him on the phone and was concerned that he was non sensical his daughter is not aware of any recent fevers chills change in urine output in the ed labs significant for lithium cr baseline ua negative ekg nl seen by ed attg toxicologist who recommended ivfs given l ivfs and had foley placed he then became agitated and pulled out his foley resulting in siginificant bleeding ativan given for agitation with paradoxic effect of increased agitation nephrology called in the ed and will follow his vitals were afebrile hr ra past medical history bipolar depression htn bilateral inguinal hernias hiatal hernia s p trauma with multiple facial fractures s p fall down stairs in s p mva drove into something car rolled over his leg h o diabetes insipidus social history pt is a rabbi lives alone was primary caretaker of his wife until she was placed in a long term care facility wife passed away in after his most recent discharge he had hr care vna services at his house family has also hired a geriatric social worker to assist in his care family history noncontributory physical exam vs gen nad conversive and pleasant heent perrl pupils mm sclera anicteric conjunctivae clear op moist and without lesion neck supple no jvd cv reg rate normal s s no m r g chest ctab abd soft nt nd no hsm ext left leg slightly warmer than right leg but without swelling or erythema several healing scabs across the left knee chronic venous stasis changes edema b l hematoma on posterior left calf skin no rash neuro aaox moving all ext follows commands pertinent results pm blood glucose urean creat na k cl hco angap am blood lithium am lithium am plt count am neuts 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 urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg am urine osmolal am urine hours random urea n creat sodium final report study unilateral lower extremity venous ultrasound indication year old male presenting with increased left lower extremity edema assess for dvt comparisons ultrasound findings grayscale and doppler son of the left common femoral superficial femoral and popliteal veins are performed normal flow augmentation and compressibility is demonstrated flow is observed within the posterior tibial veins as well in the popliteal fossa there is a x x cm anechoic collection most likely representing cyst more inferiorly in the mid calf there is a heterogeneous collection measuring x x cm this area demonstrates no abnormal vascularity and is compatible son with a hematoma impression no deep vein thrombosis of the left lower extremity probable cyst mid calf collection most compatible son with an intramuscular hematoma clinical correlation recommended these findings were reviewed with dr on the morning of by dr over the telephone the study and the report were reviewed by the staff radiologist dr dr approved fri pm brief hospital course yo m with h o bipolar depression on lithium s p tbi and recent mva who presents with increasing confusion tremor and found to have elevated serium lithium level and arf presentation consistent with chronic lithium toxicity in the setting of worsening renal function lithium toxicity the patient presented with confusion tremor elevated serium lithium levels and arf recently had rpr tsh vit b that were wnl neuro exam without localizing lesions no recent h o head trauma does have some essential tremor at baseline by report toxicology and nephrology were consulted for recomendations re management of lithium toxicity he was admitted to the icu with aggressive ns hydration serial neurological exams and q h lithium levels other psychoactive serotonerigic medications trazodone sertraline gabapentin were held in the setting of his altered mental status he was called out to the floor on hospital day psychiatry was consulted given persistant agitation and he was given haldol for agitation with good effect the patient s delerium and confusion slowly improved and by the patient was essentially back to baseline his li level was at that time the plan will be as follows continue to hold all psychactive medications for at least another week prior to initiating any medications the patient was discharged to rehab and should follow up with psychiatry to decide which medications if any should be started this should be a discussion made with the patient family and his psychiatrist arf baseline cr on admission cr likely lithium toxicity but may also have additional prerenal component u a benign during his icu stay his lisinopril was held and he was continued on ns ivf at cc hr he maintained excellent urine output and his electrolytes were stable the patient s cr continued to improve with iv fluids and returned to his baseline of on bipolar depression held lithium trazodone gabapentin codeine and sertraline as above psychiatry consulted and plan as above urethral pain pt in his delerious state removed his foley causing trauma urology was consulted and replaced foley the patient continued to have pain during his admission and his foley was removed on s p mva with leg contusion ultrasound on revealed bakers cyst and lle intramuscular hematoma there is no evidence of dvt he was continued on tylenol for pain held codeine for now given confusion no signs of leg cellulitis on exam his leg will need to be monitored at rehab code full code confirmed with family son is his healthcare proxy medications on admission lansoprazole mg daily docusate sodium mg prn senna mg prn dulcolax mg daily prn gabapentin mg qhs sertraline mg daily lithium carbonate mg qhs metoprolol succinate mg daily trazodone mg qhs lisinopril mg daily acetaminophen mg q h prn codeine sulfate mg q h prn discharge medications lisinopril mg tablet one tablet po once a day metoprolol succinate mg tablet sustained release hr one tablet sustained release hr po daily daily senna mg tablet one tablet po bid times a day as needed for constipation ferrous sulfate mg mg iron tablet one tablet po daily daily lansoprazole mg capsule delayed release e c one capsule delayed release e c po once a day docusate sodium mg tablet one tablet po twice a day as needed for constipation dulcolax mg tablet delayed release e c two tablet delayed release e c po once a day as needed for constipation acetaminophen mg tablet two tablet po every eight hours discharge disposition extended care facility for the aged macu discharge diagnosis primary lithium toxicity bakers cyst secondary bipolar depression htn bilateral inguinal hernias hiatal hernia s p trauma with multiple facial fractures s p fall down stairs in s p mva drove into something car rolled over his leg h o diabetes insipidus discharge condition stable normotensive ambulating satting well on room air discharge instructions it was a pleasure taking care of you while you were in the hospital you were admitted to due to lithium toxicity you were very confused during your stay but slowly as your lithium level decreased your confusion began to clear as well additionally your renal function had also worsened when you were first admitted you were given iv fluids and your renal function improved back to your baseline we have stopped your psychiatric medications the psychiatrists at the rehab facility will work with your primary psychiatrist to determine what the safest and best regimen for you will be over the next few weeks you were also found to have a bakers cyst and a hematoma in your left leg the doctors at the rehab will follow this for you please follow the medications prescribed below please follow the appointments made below please call your pcp or go to the ed if you experience worsening confusion tremor delerium headache weakness pain blood in your urine shortness of breath chest pain or other concerning symptoms followup instructions provider md phone date time please follow up with your pcp follow up with nephrology dr or clinic completed by,{}
69088,admission date discharge date date of birth sex f service surgery allergies penicillins attending chief complaint abdominal pain small bowel obstruction major surgical or invasive procedure exploratory laparotomy with lysis of adhesions history of present illness f with abdominal pain and decreased po intake since pt was transferred here from osh after ngt decompression of one liter ct scan at osh showed small bowel obstruction pt s only surgery was an appendectomy at the age of no recent colonoscopy reported pt denies any nausea or vomitting pt s last bowel movement was reported to be pt denied fever chills chest pain sob constipation diarrhea or urinary symptoms patietn was transferred and upon receiveing patient it was decided that she would need an operation to relive the obstruction and was therefore booked for urgent laparotomy past medical history pmh afib htn niddm dementia hepatitis years ago psh appendectomy at age social history lives with husband none etoh occasional drugs none family history noncontributory physical exam physical exam on admission vs t p bp rr o sat ra gen wd wn in nad heent ncat eomi anicteric cv irregular rythym pulm cta b l w no w r r normal excursion no respiratory distress back no vertebral tenderness no cvat abd softly distended nt tympanitic no mass no hernia appreciated no hernia scar c w prior open appendectomy pelvis no femoral inguinal hernia ext wwp no cce no tenderness b l radial dp pt neuro a ox no focal neurologic deficits dementia derm rash over elbows psych normal mood affect 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 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 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 glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood alt ast alkphos amylase totbili am blood albumin calcium phos mg am blood calcium phos mg am blood lactate ct abdomen and pelvis findings concerning for midgut volvulus with ischemic segments of small bowel in the left abdomen the volvolus has led to complete small bowel obstruction with collapse of the colon differential diagnosis includes internal hernia although this is considered less likely brief hospital course the patient was taken to the or for exploratory laparotomy and lysis of adhesions on she tolerated the procedure well see operative note for details but in brief she had a band like adhesion causing obstruction and proximal to this she ahd a small bowel volvulus around the mesentery postoperatively in the pacu she had an episode of rapid atrial fibrillation and was given mg lopressor iv without effect and mg diltiazem iv with consequent improvement in heart rate ck mb cardiac markers were sent given potential st changes on ekg but these values were normal the patient was transferred from the pacu to the surgical intensive care unit for monitoring overnight she remained stable her pain was controlled with intravenous morphine on post op day two she was transferred to the surgical floor she was monitored with continuous telemetry she was given lopressor iv mg every four hours for rate control of her atrial fibrillation with rapid ventricular rate she had episodes of mild agitation and delirium with pulling at some of her intravenous and monitoring lines she was given haldol and risperdone by mouth for her agitation she had an episode of atrial fibrillation with rvr on the morning of post op day four that required metoprolol iv and subsequent hydralazine iv she was seen by our inpatient geriatrics team as her sleep wake cycle normalized she became lucid alert and oriented times three on post op day four she was advanced from sips to clears which she tolerated well she had a bowel movement ambulated and her foley was discontinued with subsequent incontinence baseline but no retention she was seen by our inpatient physical therapy team who recommended pt at home and hour supervision at home on post op day six she was restarted on her home regimen of coumadin and she received two mg doses before she left on she was felt to be medically stable enough for discharge to home with services she was ambulating with contact guarding she was pleasantly demented as was her baseline and she was cleared for home with supervision as attested to by her daughter medications on admission metformin metoprolol lasix diovan hctz coumadin alternates two days mg one day mg discharge medications metformin mg tablet sig one tablet po twice a day metoprolol tartrate mg tablet sig one tablet po twice a day lasix mg tablet sig one tablet po once a day diovan hct mg tablet sig one tablet po once a day coumadin mg tablet sig tablets po once a day alternates two pills for two days then pill for day and repeat discharge disposition home with service facility discharge diagnosis small bowel obstruction atrial fibrillation with rapid ventricular response hypertension diabetes mellitus dementia discharge condition mental status confused sometimes level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear ms you were admitted to the west surgery service at for a small bowel obstruction you had surgery for this issue and you improved nicely during your stay here please resume all regular home medications unless specifically advised not to take a particular medication please take any new medications as prescribed please take the prescribed analgesic medications as needed you may not drive or heavy machinery while taking narcotic analgesic medications you may also take acetaminophen tylenol as directed but do not exceed mg in one day please get plenty of rest continue to walk several times per day and drink adequate amounts of fluids avoid strenuous physical activity and refrain from heavy lifting greater than lbs until you follow up with your surgeon who will instruct you further regarding activity restrictions please also follow up with your primary care physician incision care please call your surgeon or go to the emergency department if you have increased pain swelling redness or drainage from the incision site avoid swimming and baths until cleared by your surgeon you may shower and wash incisions with a mild soap and warm water gently pat the area dry if you have staples they will be removed at your follow up appointment thank you for letting us participate in your care we wish you a speedy recovery followup instructions please call upon discharge to schedule an appointment in the office of dr in weeks or with any questions concerns clinic is located in the medical office building,"{
""Diagnoses"": [""small bowel obstruction"", ""adhesions"", ""abdominal pain""],
""Medications"": [""penicillins""]
}"
456,admission date discharge date date of birth sex m service ccu history of present illness the patient is a year old male without any significant cardiovascular history who while exercising this morning on the exercise bike at the gym slumped over and according to eyewitnesses was caught and lowered by his neighbor was given chest compression when found to be pulseless by a witness and was defibrillated times two by a portable defibrillator sensing probably ventricular fibrillation estimated time to defibrillation was five to minutes he was intubated and transported to center in the e d he was found to be agitated dyspneic and unresponsive to commands he was given lopressor and nitroglycerin his agitation and difficulty ventilating were improved with vecuronium and ativan he apparently had an exercise tolerance test earlier this year exercising to stage without any symptoms it was unclear at the time of admission why this test was obtained his cardiovascular risk factors included use of tobacco hypertension and hypercholesterolemia past medical history hypertension hypercholesterolemia outpatient medications buspar allergies unknown family history unknown physical examination on admission the patient was sedated and intubated vital signs were blood pressure of pulse afebrile o sat to on assist control ventilation with fio of laboratory data on admission sodium was potassium chloride bicarb bun creatinine glucose white blood cell count was hematocrit platelets hospital course the patient was emergently taken to the cath lab where coronary angiography was done which showed a right dominant system with two vessel coronary artery disease the left main coronary artery was angiographically normal the proximal lad had discrete stenosis with some haziness at the distal pole of the lesion suggesting thrombus the remainder of the lad had mild luminal irregularities as well as focal stenosis in the mid lad the first diagonal branch had proximal stenosis the left circumflex artery had mild luminal irregularities and produced a first obtuse marginal that was of moderate caliber and had proximal stenosis the rca had mild luminal irregularities and to mid rca stenosis the lad was stented without dissection and without residual stenosis and timi flow over the course of his stay in the hospital the patient remained hemodynamically stable and was successfully extubated he was continued on aspirin and plavix lopressor and captopril were added to his regimen as tolerated by his blood pressure repeat echocardiogram showed left ventricular cavity size to be normal overall left ventricular systolic function was mildly depressed with mild septal hypokinesis no lv thrombus was seen aortic valve leaflets were mildly thickened and mitral valve leaflets were also mildly thickened with mitral regurgitation in comparison with the previous study there was marked improvement in lv function in light of questionable thrombus on the first echocardiogram the patient was started on coumadin with cross coverage with heparin on day of discharge the patient s inr was therapeutic at and heparin was discontinued during the course of his stay the patient was also started on lipitor mg q day during his stay in the hospital the patient reported some short term memory loss and was scheduled to follow up with dr in behavioral neurology clinic the patient was discharged home with vna to help with medication education and monitoring of inr levels for anticoagulation discharge medications aspirin mg p o q day lopressor mg p o b i d buspar mg p o t i d lipitor mg p o q day benadryl mg p o q six hours p r n plavix mg p o q day for one month sublingual nitroglycerin mg p r n for chest pain zestril mg p o q day coumadin mg p o q h s discharge diagnosis acute mi with v fib arrest status post cath and stent to lad discharge status discharged home condition on discharge stable m d dictated by medquist d t job,"{
""Diagnoses"": [""Ventricular fibrillation"", ""Agitation"", ""Dyspnea"", ""Unresponsive to commands""],
""Medications"": [""Lopressor"", ""Nitroglycerin"", ""Vecuronium"", ""Ativan""]
}"
63741,admission date discharge date date of birth sex f service surgery allergies cephalosporins tetracycline penicillins acetaminophen hydrocodone attending chief complaint abdominal pain major surgical or invasive procedure endotracheal intubation attempted ercp attempted ir guided percutaneous biliary drainage history of present illness ms is a f from hospital pmh bilroth surgery h o recurrent pancreatitis presented to hospital with ruq pain and transaminitis reportedly concerning to the medicine team there for ascending cholangitis this prompted transfer to where unsuccessful attempts at ercp and ir guided percutaneous drainage of the biliary tract were performed in brief she initially presented tothe osh on with day history of acute onset epigastric abdominal pain without radiation nausea emesis or change in bowel habits an abdominal xray demonstrated stool and a chest xray was unremarkable labs were significant for a wbc hct alt ast tbili of lipase of and a lactate of o overnight her ast rose to and her alt rose to and total bili rose to she was frebrile to overnight concerned for ascending cholangitis the medicine team transferred her to for ercp as she appeared ill on arrival to a ct abdomen and pelvis was performed this suggested evidence of right sided abdominal stranding concerning for right sided colitis pneumobilia was also seen but considering the history of remote prior ercp sphincterotomy there was no clear biliary dilatation or obstruction ercp was attempted here and unsuccessful she subsequently went to ir where her left biliary system was dilated and full of air which is expected after ercp and the r side was patent without dilation her ir procedure was complicated to brief hypotension reponsive to neo and resolved with extubation on arrival to the icu initial vitals were and on l nc she was in significant abdominal pain moaning reponsive to simple commands review of systems unable to obtain past medical history s p gastrectomy with billroth ii reconstruction indication h o recurrent pancreatitis ercp cholecystectomy cad htn peptic ulcer disease left knee replacement anemia tah bso cva htn social history unable to obtain family history unable to obtain physical exam on admission vitals and on l nc general moaning responsive to simple commands writhing heent sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs tachypneic clear on anterior exam splinting cv difficult to discern exam given audible moaning however tachycardic without evidence of murmur abdomen tense but not rigid significant guarding with signficant pain to light and deep palpation in all quadrants no rebound tendernss positive bowel sounds gu foley ext warm and well perfused edema to shins pertinent results labs on admission pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood pt inr pt pm blood glucose urean creat na k cl hco angap pm blood alt ast alkphos amylase totbili pm blood ck mb pm blood calcium phos mg lactate levels pm blood lactate am blood lactate am blood lactate am blood lactate am blood lactate pm blood lactate pm blood lactate pm blood lactate brief hospital course ms is a f from hospital pmh bilroth surgery h o recurrent pancreatitis presented to hospital with ruq pain and transaminitis concerning for ascending cholangitis prompting transfer to for unsuccessful attempts at ercp and ir guided percutaneous drainage micu course was complicated by progressive septic shock with massive resusciatation leading to abdominal compartment syndrome for which she underwent exploratory laparotomy surgery consult noted that her transaminitis was greater than her obstructive chemistries and that there was increased urobilinogen in the urine suggesting the absence of biliary obstruction septic shock soon after arrival to the patient was noted to be tachypneic tachycardic and with rising lactic acidosis with evidence of acute oliguric renal failure likely sources include right sided colitis based upon evidence of colitits on ct versus ascending cholangitis much less likely the acute care surgery service was consulted for question of cholangitis and colitis vancomycin was added to existing cipro and flagyl to broaded coverage and early goal directed therapy was initiated with bolus iv fluids she was initially started on phenylephrine through piv which was changed to norepinephrine once central access was obtained renal service was consulted and she was treated with multiple rounds of sodium bicarbonate for severe lactic acidosis despite aggressive resuscitation the patient s lactic acid continued to rise cvvh was not initiated due to multiple failed attempts to obtain dialysis catheter placement at the bedside ir was consulted to assistance however before catheter could be placed repeat abdominal pressures obtained at the request of the acs service had elevated she was therefore transferred to the or for stat exploratory laparotomy for abdominal compartment syndrome she underwent decompressive laparotomy as well as right hemicolectomy for severe colitis her liver was unable to be completely visualized intra operatively but appeared very congested a true cut biopsy was performed she was brought to the ticu still intubated on multiple pressors despite aggressive resuscitation and management her septic shock continued to worsen requiring increasing pressor support with increasing lactate levels respiratory failure due to mixed acidosis the patient is probably hypercarbic at baseline which became problem with need for respiratory compensation in the setting of profound metabolic acidosis ultimately patient fatigued from rr in s and inadequate respiratory compensation and therefore was intubated she was kept intubated after her exploratory laparotomy and was unable to be extubated transaminitis patient underwent unsuccessful ercp and failed ptc by ir ct of her abdomen on admission showed evidence of r sided colitis there was pneumobilia but no clear biliary dilation or obstruction per ir her left biliary system is dilated and full of air which is expected after sphincterotomy but r side was patent without dilation elevation of transaminases to two nights ago at osh might be suggestive of shock liver or mof this improved with aggressive fluid rescussitation but then worsened again as shock worsened post operatively her liver failure continued to wrosen abdominal inflammation ddx concerning for right sided colitis no evidence of diverticulitis on ct scan or history of bowel changes including diarrhea or constipation preceding this hospital course per osh records on ct scan abdominal mesenteric vessels appear widely patent so unlikely ischemic bowel abdominal exam was significant for guarding and significant pain in all quadrants without rebound while in the micu the patient s bladder pressures steadily increased and therefore she was taken to the or for ex lap which showed ischemia and early necrosis of the right colon pud history of pud started on protonix at the osh mg iv htn managed on quinapril at home plan on holding in setting of peri operative hypotension and concern for sepsis after a family meeting on where we discussed her very poor prognosis and continued decline in spite of aggressive management the family decided to make her comfort measures only supportive care was withdrawn at on and she expired at medications on admission medications home accupril mg po daily oxycodone hydrocholoride tablets po q hrs prn as needed aspirin mg po daily triamterene oxycontin mg po as needed medications transfer ciprofloxacin mg iv q hrs metronidazole mg iv q hrs morphine q hrs pain prn zofran mg iv q hrs aspirin mg daily lovenox mg sc for dvt prontonix mg iv daily maalox ml daily prn dyspepsia discharge medications expired discharge disposition expired discharge diagnosis expired due to sepsis likely due to colitis superimposed on hepatic failure discharge condition expired discharge instructions expired followup instructions expired completed by,"{
""Diagnoses"": [""Ascending Cholangitis"", ""Recurrent Pancreatitis""],
""Medications"": [""cephalosporins"", ""tetracycline"", ""penicillins"", ""acetaminophen"", ""hydrocodone""]
}"
48958,admission date discharge date date of birth sex m service medicine allergies indomethacin attending chief complaint s p cardiac arrest major surgical or invasive procedure intubation pacer wire placement balloon pump placement history of present illness yo m with htn hld dm no known cad s p sfa stent for rle non healing ulcer who presented to caritas for resting ischemia with ulcer of the right foot with plans to undergo diagnostic angiography atherectomy angioplasty and possible stenting patient underwent angio for mapping that showed below the knee multiple vessel disease had a bump in creatinine going from and was held in house for observation the patient underwent an sfa stent on the right on in the am of he appeared well but around per the wife had been complaining of some chest pain the night before a rapid response team was called at and at code was intitated for an unclear prior rhythm there was a thought he might be in complete heart block with ventricular response in the s he received a shock of at for presumed vt strip not available and underwent epi x and atropine x and amps of calcium he was then transferred from the floor to the icu but int he icu coded again at and the code lasted until for at this time he received rounds of cpr and received amp of epi amp vasopressin amp atropine and amps of calcium g of magnesium and started a dopamine gtt also initated insulin and d during this code he was charted as having alternative and vt a temporary pacer was placed in the r subclavian bedside echo was performed and showed large wall motion abnormality trop i during the code was during the code given the finding of positive trop complete heart block with new lbbb morphology and large wall motion abnormalities he was taken to cath lab for presumed cad leisions while in cath lab he was had a intra arterial sbp of while on dopa iabp was placed his cath report showed vd but was noted to have noted to have timi flow the patient also had an external trancutaneous pace placed he was transferred to for a question of further management with potential bypass surgery transffered on heparin gtt dopamine gtt past medical history cardiac risk factors diabetes dyslipidemia hypertension cardiac history cabg none percutaneous coronary interventions none pacing icd currently transcutaneous as well as temporary right subclavian other past medical history htn dm hld depression diverticulitis ckd stage ii hx knee problems hx l in gout social history retired married tobacco history none etoh none illicit drugs unkown occupational exposure to asbestos family history dm and ckd runs in the family physical exam vitals t f bp hr rr gen not responsive to commands intubated and sedated myoclonic jerking at times heent no conjunctival pallor no icterus mmm op with ett and ogt r pupil mm l pupil mm no reaction to light neck supple no lad jvd cm normal carotid upstroke without bruits no thyromegaly cv pmi in th intercostal space mid clavicular line rrr normal s s iii vi holosystolic murmur at apex lungs coarse breath sounds with crackles anteriorly r l end expiratory wheezes noted abd nabs soft obese no hsm abdominal aorta was not enlarged by palpation no abdominal bruits ext feet cold legs cool no cce difficult to appreciate pedal pulpses bilaterally bilateral popliteal pulses intact skin mottled in the lower extremities neuro not responding to commands corneal reflexes and gag intact myoclonus noted in lower extremities pertinent results laboratory data cbc pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct coagulation pm blood pt ptt inr pt chemistry pm blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap lfts pm blood calcium phos mg pm blood calcium phos mg elementals pm blood calcium phos mg pm blood calcium phos mg blood gases pm blood type art po pco ph caltco base xs pm blood type art temp rates tidal v peep fio po pco ph caltco base xs aado req o intubat intubated vent controlled pm blood type art po pco ph caltco base xs lactate pm blood lactate pm blood lactate microbiology none imaging portable tte complete done at pm final echocardiographic measurements results measurements normal range left atrium long axis dimension cm cm left ventricle ejection fraction to aorta sinus level cm cm aortic valve peak velocity m sec m sec aortic valve peak gradient mm hg mm hg aortic valve mean gradient mm hg aortic valve lvot diam cm aortic valve valve area cm cm tr gradient ra pasp mm hg mm hg findings left atrium mild la enlargement right atrium interatrial septum a catheter or pacing wire is seen in the ra and extending into the rv left ventricle moderate regional lv systolic dysfunction no resting lvot gradient right ventricle rv not well seen aorta mildy dilated aortic root aortic valve moderately thickened aortic valve leaflets mild as area cm mild ar mitral valve mildly thickened mitral valve leaflets no mvp mild mitral annular calcification moderate mr tricuspid valve tricuspid valve not well visualized normal pa systolic pressure pulmonic valve pulmonary artery normal pulmonic valve leaflets pericardium no pericardial effusion general comments suboptimal image quality bandages defibrillator pads or electrodes suboptimal image quality body habitus regional left ventricular wall motion basal inferoseptalbasal anteroseptalbasal anterior basal inferiorbasal inferolateralbasal anterolateral mid inferoseptalmid anteroseptalmid anterior mid inferiormid inferolateralmid anterolateral septal apexanterior apex inferior apexlateral apex apex n normal h hypokinetic a akinetic d dyskinetic conclusions the left atrium is mildly dilated there is moderate regional left ventricular systolic dysfunction with focal hypokinesis of the mid to distal anterior wall anterior septum inferior wall and apex there is dyskinesis of the distal inferior wall the aortic root is mildly dilated at the sinus level the aortic valve leaflets are moderately thickened mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse moderate mitral regurgitation is seen the estimated pulmonary artery systolic pressure is normal there is no pericardial effusion impression suboptimal image quality focused views regional left ventricular dysfunction c w probable multivessel cad moderate mitral regurgitation at least mild aortic stenosis chest portable ap study date of pm impression the distal tip of the pacemaker device projected over the expected location of the mid right ventricle the nasogastric tube and intra aortic balloon pump are malpositioned as described above moderately severe acute pulmonary edema and probable bilateral moderately large pleural effusions chest portable ap study date of pm impression low position of intra aortic balloon pump proximal position of orogastric tube and change in positioning of transvenous pacing lead brief hospital course yo m with htn hld dm no known cad s p sfa stent for rle non healing ulcer who coded x at found to have diffuse vessels disease presenting to for further management with possible surgical intervention pump the patient was felt to be in cardiogenic shock on arrival initially on dopamine gtt ultimately uptitrated to pressors with dopamine levophed and vasopressin the patient s bedside echos both at osh as well as in house showed focal hypokinesis of the mid to distal anterior wall anterior septum inferior wall and apex as well as dyskinesis of the distal inferior wall cardiogenic shock as also presumed given the global hypoperfusion indicated by the patient s elevated lactate and anion gap acidosis the inciting factor for cardiogenic shock was not clear but the patient in the cath lab at osh was noted to have vd and there were comments in osh regarding arrhythmia which seems to be the two most likely factors to have instigated cardiogenic shock the patient was supported with pressors and balloon pump was continued at lactates were trended with bicarbonate provided to keep ph greater than in order to maintain effectiveness of pressors cad the patient has diffuse vd not amenable to stenting at osh it was not felt feasible or safe to perform stenting procedures the patient was evaluated by cardiac surgery but given the patient s very tenous status was not made a candidate for surgery patient was continued on heparin gtt asa atorvastatin and plavix for a presumed myocardial infarction the plan was for cardiac enzymes to be cycled rhythm the patient was noted by osh reports to have been in rd degree heart block and during his codes was noted to have a wide complex tachycardia with variations between the patient was paced intra venously but on arrival was having difficulty maintaing its position and having the heart capture said beats results in occasional need for transcutaneous pacing the ep fellow was able to guide the pacer wire under floroscopy the patient does not have any history of any underlying rhythm abnormalities but is is very possible that a rhythm distrubance precipitated hypoperfusion of the heart causing it to become ischemic causing poor ef causing global hypoperfusion the patient s rhtyhm was paced during his hospitalization neuroprotection s p arrest patient is not a candidate for artic sun cooling protocol given the amount of time since his event and start of cooling he was noted to have poor neurologic signs such as occasional lower limb jerking unresponsiveness and a lack of pupillary response to light he was sedated with fentanyl and midazolam and creatinine is up from a baseline of around per osh records likely secondary to poor renal perfusion secondary to cardiogenic shock transamitinits likely secondary to poor hepatic perfusions leukocytosis likely secondary to an inflammatory resposne secondary to patient s global hypoperfusion the patient is not currently febrile and cxr shows diffuse bilateral infilitrates not consistent with a pna goals of care the patient s prognosis was very poor on arrival given his his focal wall motion abnormalities his poor neurologic status his rise in creatinine and the rise in his lactate and rise in his lfts the family was gathered and hcp wife agreed to make the patient dnr subsequently during the night as the patient requiring continued pressor support the family was called to discuss the patient s clinical status and elected to withdraw care the patient passed away at pm on medications on admission venlafaxine allopurinol mg daily lovastatin mg daily gabapentin mg tid aspirin mg daily lantus u sq in am vicodin tablets po q h prn pain tylenol mg po prn pain stool softenser plavix mg po daily discharge medications expired discharge disposition expired discharge diagnosis expired discharge condition expired discharge instructions expired followup instructions expired md,{}
17722,admission date discharge date service chief complaint admitted for unresponsiveness history of present illness this is an year old gentleman with a past medical history significant for atrial fibrillation and hypertension who was found lying on the floor on the evening of admission by his son the patient lives in an facility and the family last spoke with him two days prior to admission on the day of admission the son tried to call the patient and when he got no answer on the second day in a row he went over to the appointment and found the patient lying on his side on the floor with his head against the wall he was believed to have been incontinent he was breathing heavily and not moving his left arm the patient s atrial fibrillation had been rate controlled in the past on diltiazem but the patient was determined not to be a candidate for anticoagulation due a history of poor medication compliance and a history of melena and hematemesis secondary to gastric polyps past medical history as above gastric polys status post polypectomy medications on admission multivitamin meclizine cordarone metoprolol procardia and accupril not entirely clear which medications the patient had been taking as an outpatient family history not available social history denies any tobacco use review of systems review of systems was unable to be obtained physical examination on examination heart rate blood pressure to to respiratory rate in general a large elderly man in mild distress heent revealed normocephalic and atraumatic mucosal membranes were dry oropharynx with thick mucous neck had no appreciable bruits cardiovascular examination was irregularly irregular tachycardic no appreciable murmur rubs or gallops lungs were clear to auscultation genitourinary was positive large amount of scrotal edema but no pedal edema on neurologic examination eyes were closed no response to nasal tickle or supraorbital pressure moved right hand and foot to command pupils were equal round and reactive to light there was a right gaze preference but with roving eye movements there was an absent corneal on the left no gag no obvious facial asymmetry but unable to induce a grimace on motor examination placid left upper extremity increased tone in the left lower extremity normal tone on the right spontaneously moved right upper extremity and lower extremity equally withdrew to noxious stimuli in lower extremity bilaterally reflexes were in the upper extremities patellars zero ankle jerks plantar responses were flexor on the right extensor on the left coordination was not assessed sensory revealed localizing in the lower extremity by withdrawing no grimace to nail bed pressure on the left laboratory on admission white blood cell count was hematocrit platelets were inr was an arterial blood gas was urinalysis showed a large amount of blood negative nitrites many bacteria a ct scan showed a large right hemispheric hypoattenuation involving the parietal and temporal lobes concerning for inferior division middle cerebral artery stroke there was a moderate amount of mass affect seen from this lesion as evidenced by some sulcus effacement and minimal subsultus herniation to the left the basilar were widely patent hospital course while in the emergency department the patient was showing increasing respiratory distress he was having atrial fibrillation with rapid ventricular response and did receive a small amount of diltiazem which slowed his heart rate however he continued to have respiratory distress with a decline in his oxygen saturation because of this a code status was held with the son who felt that everything should be done for his father thus he was intubated and admitted to the medical intensive care unit respiratory the patient s respiratory decline was felt to be secondary to an aspiration pneumonia and decline in mental status and mucus plugging he had thick yellow secretions suctioned once intubated and was started initially on augmentin and then was switched to levofloxacin and flagyl for the pneumonia and a urinary tract infection the patient remained intubated until at which time he was extubated he continued to maintain his oxygen saturation without difficulty though he was put on a shovel mask with moist mist cardiovascular from a cardiac standpoint the patient was given intravenous lopressor p r n for rapid heart rate he remained in atrial fibrillation throughout this his creatine kinases were cycled and were negative for the time being he was placed on intravenous labetalol for blood pressure control and once an nasogastric tube was placed he was then started on lopressor mg p o b i d his heart rate remained in the s to s for most of the time he did have an episode on the floor of a rapid heart rate which responded well to mg of intravenous lopressor and he continued to maintain a good blood pressure throughout the patient is not an anticoagulation candidate and was simply continued on an aspirin renal the patient was initially found to have rhabdomyolysis most likely having fallen and being down for a prolonged period however his kidney function remained stable with hydration neurology from a neurologic standpoint the patient remained quite lethargic he eventually opened his eyes briefly spontaneously however he was unable to follow commands he continued to have a right gaze preference and a neglect of his left side his left side remained extremely plegic and there were no distinct appreciable words noted his prognosis for a meaningful rehabilitation recovery remained quite poor fluids electrolytes nutrition a long discussion was held with the son who felt that his father would want to have his life prolonged for as long as possible no matter what therefore an ethics consultation was obtained and it was determined that indeed regardless of the quality of life the patient would want to continue to live initially the son was reticent to have percutaneous endoscopic gastrostomy tube placed but once he understood that this would be required in order to maintain his father and that an nasogastric tube could not be kept in for a prolonged period the patient underwent a percutaneous endoscopic gastrostomy tube placement on with tube feeds started discharge status at this time the patient s disposition was to be to a long term facility medications on discharge levaquin per g tube q d for a total of days flagyl mg p o g tube q h for a total of days aspirin mg per g tube q d lopressor mg per g tube b i d colace mg per g tube b i d zantac mg per g tube b i d ferrous sulfate mg per g tube t i d heparin units subcutaneous b i d replete with fiber to a goal of cc an hour discharge diagnoses large middle cerebral artery stroke likely embolic note an addendum to any changes will be made at discharge m d dictated by medquist d t job [NEW_RECORD] admission date discharge date service addendum hospital course the patient completed the antibiotic treatment for his aspiration pneumonia and for his atrial fibrillation his lopressor dose was increased to mg t i d for appropriate control clinically he improved a little bit in terms of alertness however his left hemiparesis did not improve a cardiology consult was obtained in regards to his atrial fibrillation and they strongly recommend anticoagulation with coumadin however at the present time his gastric polyps which have caused significant bleeding in the past prevent anticoagulation with coumadin if this issue resolves he can at that time be started on coumadin as there is no other contraindication otherwise he is prophylactically being treated with mg of aspirin during his remaining hospital days he remained afebrile for the most part and on occasion had a temperature of work up for infectious source including urinalysis chest x ray and blood cultures were negative he was however at one time dehydrated with a bun of but responded well to fluid correction his sutures around his peg site were removed the area was noted to be erythematous and initially was with a small exudate however this cleared well with the application of bacitracin scrotal ultrasound was performed for an enlarged scrotal mass his bilateral chronic hydroceles were confirmed urology was consulted who placed a foley due to the nature of his grossly enlarged scrotum a foley was placed their recommendations are that this be changed if there were any signs of infection and if the patient needs to return to the urology for proper placement this may be done at that time labs on revealed a white count of hemoglobin hematocrit mcv rdw platelet count urinalysis negative nitrite protein mg dl trace ketones rbc white blood cell count no bacteria no yeast no epithelial cells no growth sodium potassium chloride bicarb bun creatinine glucose alkaline phosphatase alt ast total bilirubin calcium phosphate magnesium tsh t t fecal smear showed no pmns c diff negative times three urine culture showed organisms of yeast ml chest x ray showed resolution of the right basilar atelectasis with persistent left hemidiaphragm atelectasis consolidation with no new lesions discharge medications lopressor mg q digoxin mg q d vitamin c mg q d heparin mg subcue b i d iron sulfate mg t i d zantac mg b i d aspirin mg q d tobrex t i d x more days diflucan mg p o q d x more days then to receive mg x dose discharge plan the patient was discharged to the for further care he is to follow up with his primary care physician within one month and with dr in the clinic within three months he is to follow up in the clinic only if necessary for a change in his foley catheter due to his gross hydrocele disposition stable discharge diagnosis right middle cerebral artery occlusion and stroke atrial fibrillation aspiration pneumonia urinary tract infection m d dictated by medquist d t job [NEW_RECORD] admission date discharge date service addendum mr on the night prior to discharge spiked a temperature to he was hemodynamic and respiratory signs were otherwise stable workup for the etiology of his fever revealed a urinary tract infection he was started on levaquin mg daily which he is to take for seven days blood and urine cultures are pending on discharge m d dictated by medquist d t job [NEW_RECORD] admission date discharge date service med blumga chief complaint acute renal failure history of present illness the patient is an year old male admitted from with complaints of loose bowel movements tea colored urine and increasing lethargy and dehydration on addition to the emergency the patient was lethargic with breathing dry mucous membranes bradycardic on admission with a heart rate of to potassium of the patient was treated with one amp of d units insulin one amp of calcium gluconate given lasix for congestive heart failure verified by chest x ray with poor response he was transferred to the cardiac care unit medical intensive care unit for closer observation past medical history atrial fibrillation treated with digoxin and on admission the level was gastric polyps history of gastrointestinal bleed methicillin resistant staphylococcus aureus in the urine anemia hypertension a massive left sided cerebrovascular accident on leaving the patient with left sided neglect and left hemiparesis physical examination on admission the patient s neurologic examination was significant for being able to open eyes spontaneously and reacting to painful stimuli he speaks only russian he moves his right side only soft restraints on right wrist to prevent the patient from pulling lines the respiratory examination showed coarse breath sounds with rales in both bases the patient also had occasional wheezes noted bilaterally he remains on room air and o saturation was he continues with frequent periods of apnea lasting to seconds breathing pattern and a question of a left lower lobe pneumonia on examination the heart rate was stable in the mid s occasional bradycardic episodes with rates down to the s occasional premature ventricular contractions rhythm consistent also with atrial fibrillation on genitourinary examination there is a foley draining cloudy amber urine in fair amounts the foley was leaking at the insertion site warm saline was added to the balloon with no effect gastrointestinal examination there was a g tube that was clamped and it was flushed well there was positive bowel sounds and he was passing small amounts of soft dark stool the skin integrity showed an ulceration on the left lateral malleolus the size of a nickel and with wet to dry dressings applied numerous small broken areas were noted on the coccyx and aloe vesta perineal cream was applied to that the patient was consistent repositioned on bed to prevent further breakdown the patient s vital signs on admission were a temperature of f a pulse of to respiratory rate oxygen saturation of on room air and a blood pressure of hospital course the patient remained in the medical intensive care unit for management of acute renal failure with creatinine going from to with minimal urine output it should also be noted that on physical examination the patient had bilateral hydroceles in the scrotum the patient was managed in the intensive care unit on admission with intravenous fluid hydration and ciprofloxacin treatment from through for a urinary tract infection he was transferred to the medical floor on his hospital course was significant for an increase in creatinine to a maximum of the differential diagnoses were thought to be acute tubular necrosis or acute interstitial nephritis possibly with minimal disease the patient had significant proteinuria of gm in hours the potassium managed initially well with kayexalate prednisone was begun at mg q day on to empirically treat possible acute interstitial nephritis the ciprofloxacin was discontinued secondary to the possible contribution of the acute interstitial nephritis the decision was made to initiate hemodialysis due to the worsening problems with the volume overload and electrolyte abnormalities in the patient on the patient underwent quinton catheter placement a right femoral was attempted without good flow a left femoral was successful and had catheter placement the patient underwent hemodialysis with a removal of kg on return to the medical floor the patient was noted to have a decrease of his systolic blood pressure to which improved with cc normal saline and gave a systolic blood pressure of later in the evening the patient had another episode of systolic blood pressure dropping below the hematocrit showed down from earlier in the day a ct scan of the abdomen obtained to assess for hematoma showed a right thigh hematoma apparently from the venous source there was no retroperitoneal bleed seen the patient was emergently transfused with one unit packed red blood cells and given additional cc of normal saline bolus there was a systolic blood pressure reaching the patient was still anuric oliguric arrangements were made for the transfer of the patient to the medical intensive care unit for closer monitoring of the bleed and respiratory status the patient s son was notified of plans for transfer full code was verified by the medical team after being transferred to the medical floor the patient remained stable except for a continued drop in hematocrit such that the patient received a total of six units of packed red blood cells over the course of through however over time the patient s hematocrit stabilized in addition the patient responded well to hemodialysis such that his mental status improved and a decrease in his global body edema was noted on physical examination the patient s condition continued to improve with hemodialysis as stated before and the ulcer noted on admission on the left lateral malleolus continued to heal with appropriate granulation and no other bed sores were noted on the patient thanks to appropriate nursing care the patient was also noted to have yeast in his urine on and on for which he was treated with diflucan and he had no other infections in summary of his diagnostic procedures done during the course of his hospital stay the patient s initial electrocardiogram showed atrial fibrillation with an average ventricular rate of since the previous tracing of the ventricular response rate has slowed slightly no other significant changes had occurred the intervals were normal he had a normal axis in addition the patient underwent several radiological examinations the significant one being the ct scan on which showed a large right groin hematoma tracking along the right medial muscle compartment to approximately the upper third of the femur there was no evidence of retroperitoneal hemorrhage second there were small bilateral pleural effusions the ultrasound of the patient s scrotum on showed bilateral hydroceles chest x ray done on showed right sided hemodialysis catheter tip in the distal svc as a quinton catheter was placed in the anterior thorax and there was no pneumothorax after the procedure there was also decreased pulmonary edema and congestive heart failure compared with the admission x ray and there was persistent left lower lobe collapse consolidation and there was an unchanged level of bilateral pleural effusions a doppler study of the right thigh to discover the extent of venous flow within the right leg although grossly limited study as described in its longer report there was no definite evidence of a deep vein thrombosis right common femoral artery superficial femoral popliteal veins were of a small caliber throughout which they have been related to venous compression from adjacent soft tissue swelling or the hypovolemic state the microbiological studies for the patient in summary the stool studies never showed any clostridium difficile and the urine culture was positive for yeast blood cultures have been consistently negative with the exception of a presumed contaminant of staphylococcus epidermitis the patient received overall six units of packed red blood cells during his stay in the hospital again the patient s mental status improved the bleeding was clinically determined to be over and the patient s volume and electrolyte status improved with hemodialysis to the point where he was ready for discharge discharge medications include albuterol atrovent nebulizer treatment enteric coated aspirin mg q day zantac mg q day diflucan mg q hours prilosec mg q day renagel mg q day niferex mg lopressor mg tylenol mg q four to six hours prn phoslo three tablets qid nystatin powder to the appropriate areas tube feeds are nepro and promod at cc hr for eighteen hours during the day code status full code allergies no known drug allergies discharge condition stable discharge status to a nursing facility discharge diagnosis acute renal failure underlying diagnoses hemiparesis from an middle cerebral artery stroke atrial fibrillation hypertension gastrointestinal bleeds urinary tract infections dementia m d dictated by medquist d t job [NEW_RECORD] admission date discharge date service addendum hospital course the patient s discharge is going to be the patient was kept longer because of difficulties related to placement in an appropriate facility and not because of a medical indication allergies no known drug allergies discharge medications the following modifications to the medicines are albuterol puffs q hours p r n tylenol mg q hours p r n prilosec mg pgt q d nepro plus promote tube feeds cc hr for hours during the day heparin u subcue b i d lopressor mg per g tube twice a day erythromycin ointment to the left and right eye b i d p r n nystatin powder to the perineal regions twice a day p r n enteric coated aspirin mg pgt q d calcium carbonate mg pgt times a day the patient is on scheduled hemodialysis three times a week on tuesday thursday and saturday m d dictated by medquist d t job [NEW_RECORD] admission date discharge date service medicine acove history of present illness mr is an year old male admitted from with complaints of loose bowel movements tea colored urine increasing lethargy and dehydration on presentation to the emergency room the patient was lethargic with breathing dry mucous membranes and a heart rate between and the patient was treated with one amp of d new units of insulin and one amp of calcium gluconate lasix was given for congestive heart failure and then he was transferred to the medical intensive care unit for closer observation past medical history the past medical history revealed atrial fibrillation treated with digoxin and on admission the level was history of gastrointestinal bleeding methicillin resistant staphylococcus aureus in the urine anemia hypertension status post large mca stroke on on the right leaving the patient with left sided neglect and left hemiparesis and gastric polyps admission physical examination vital signs revealed temperature degrees pulse respiratory rate oxygen saturation on room air blood pressure in general the patient was only able to speak russian he appeared to be moving his right side only and had soft restraints on the right wrist from pulling his lines heent examination revealed pupils equal round and reactive to light sclerae were anicteric the chest revealed coarse breath sounds transmitted diffusely with rales bibasilarly there were occasional wheezes noted over the right middle lobe region cardiovascular examination revealed normal s and s occasional premature beats and no murmurs rubs or gallops abdominal examination revealed t tube in place the site appeared clean dry and intact the abdomen was soft nontender and nondistended with normoactive bowel sounds genitourinary examination revealed foley catheter draining cloudy amber urine and leaking at the insertion site the patient was guaiac negative the extremities revealed no edema and no rash there was a small shallow ulcer roughly cm across over the left lateral malleolus hospital course the patient remained in the medical intensive care unit for management of acute renal failure with creatinine going from to with minimal urine output he was also begun on ciprofloxacin and treated from to for urinary tract infection he began receiving hemodialysis while in the unit for his acute renal failure and developed a right thigh hematoma from the catheter insertion site for which he received two units of blood transfusion and fluid resuscitation he was then transferred to the medical floor on his hospital course was significant for an increase in creatinine to a maximum of the differential diagnoses were thought to be acute tubular necrosis or acute interstitial nephritis possibly with minimal chain disease the patient had significant proteinuria of grams in hours potassium was initially managed well with kayexalate on admission it was and came down appropriately prednisone was begun at mg q d on to treat acute interstitial nephritis empirically no biopsy was obtained the decision was made to initiate hemodialysis due to worsening electrolyte abnormalities and volume overload on the patient underwent quinton catheter placement a right femoral was attempted without good flow a left femoral line was successfully placed the patient underwent hemodialysis with removal of kilograms later in the evening after hemodialysis the patient s systolic blood pressure dropped down below his hematocrit was down from earlier in the day a ct scan was obtained of the abdomen and lower extremities which showed a right hematoma no retroperitoneal bleed was noted the patient was emergently transfused and volume resuscitated after being transferred to the medical floor the patient remained stable except for a continued drop in his hematocrit such that he received a total of units of packed red blood cells over the course of to in addition to this the patient s volume status responded well to hemodialysis as a decrease was noted in his anasarca also the patient was noted to have yeast in his urine on and on for which he was begun on diflucan the patient had been instrumented since being at the rehabilitation facility in terms of the patient s atrial fibrillation he has been rate controlled successfully on lopressor however within the last week as he has undergone hemodialysis and has begun approaching his dry weight his blood pressure has begun to decline associated with the start of hemodialysis before volume was taken off his blood pressure was felt to be volume sensitive and we are in the processing of titrating his lopressor down from mg b i d which was initially used to control his atrial fibrillation to a dose that will be better tolerated by his blood pressure in addition to this it is recommended that at hemodialysis the temperature of the diasylate be decreased to prevent induction of hypotension the patient s blood pressure remained stable while he was on the floor in the range of with a pulse in the s his stay over the last two weeks of admission has been mostly uneventful except for an acute mental status change that appeared due to a urinary tract infection with subsequent urosepsis that was diagnosed on when the patient was noted to be producing turbid urine in his foley urinalysis sent off showed a high epithelial cell count and cultures of the foley specimen of urine grew out both yeast and staphylococcus aureus there was no evidence of an endovascular infection repeat urinalysis and urine culture grew out only yeast at colony forming units per milliliter and no staphylococcus aureus the patient was begun on ciprofloxacin and diflucan ciprofloxacin was given at mg p o q d to be dosed after hemodialysis on tuesdays thursdays and saturdays and the diflucan at mg p o q d both of these are anticipated to continue for a day course in him and they were started on during the course of his stay on the medical floor he has remained afebrile and other than the acute mental status change he has remained otherwise stable his baseline mental status appears to be conversant in russian with slurred speech that may be secondary to lack of dentures discharge medications prilosec mg per g tube q d aspirin mg per g tube q d nepro strength plus promod scoops cc per hour check residuals q i d and hold if greater than cc for hours calcium carbonate mg per g tube q hours lopressor mg per g tube b i d hold for systolic blood pressure less than or heart rate less than as well as hold a m dose on dialysis days tuesdays thursdays and saturdays heparin units subq b i d ciprofloxacin mg per g tube q d please give dose on tuesdays thursdays and saturdays after hemodialysis diflucan mg per g tube q d nystatin powder b i d p r n to perineum albuterol and atrovent nebulizers q hours p r n lopressor mg p o b i d condition on discharge the patient was discharged to a rehabilitation facility discharge status stable discharge diagnoses acute renal failure progressive to chronic renal failure urinary tract infection status post urosepsis atrial fibrillation cerebrovascular disease dementia discharge followup the patient should follow up with his primary care physician and should continue receiving hemodialysis tuesdays thursdays and saturdays with epogen dosing as per nephrology m d dictated by medquist d t job [NEW_RECORD] admission date discharge date service medicine history of present illness this is an year old male nursing home resident who has a complicated past medical history as listed he was in his usual state of health until when he was noted to have a temperature of axillary at hemodialysis during hemodialysis on he had blood cultures drawn and was given vancomycin and gentamicin and subsequently referred to the emergency department no further history is available due to the language barrier in the emergency department he was given lopressor for a heart rate in the s irregular subsequently his blood pressure dropped to palp so he was started on a dopamine drip this was later changed to a neo synephrine drip and the patient was transferred to the medical intensive care unit past medical history right middle cerebral artery stroke with a residual left hemiparesis and left neglect end stage renal disease secondary to nephrotic syndrome on hemodialysis since atrial fibrillation times nine years never anticoagulated hypertension dementia methicillin resistant staphylococcus aureus colonization question history of clostridium difficile g tube placed on history of hepatitis b history of aspiration pneumonia history of gastric polyps status post appendectomy status post hernia repair status post prostate surgery times two hydrocele times eight years medications on admission tube feeds nova source renal full strength cc per hour from p m to p m saliva substitute p o t i d ilotycin to both eyes q h s famotidine oral suspension cc q d dulcolax mg p r every three days folic acid mg p o q d aspirin mg p o q d heparin units subcutaneous b i d lopressor mg p o t i d imodium p r n medications on transfer lopressor mg p o b i d gentamicin mg after dialysis vancomycin g dosed by levels flagyl mg p o b i d prevacid suspension mg p o q d aspirin mg p o q d heparin units subcutaneous p o b i d ceftriaxone mg p o q d albuterol and atrovent nebulizers tube feeds social history the patient is a resident of nursing home since he is a widower his son makes health care decisions for him physical examination on presentation on transfer temperature was blood pressure pulse respiratory rate oxygen saturation on room air in general russian speaking groaning ill appearing head ears nose eyes and throat revealed pupils were equal round and sluggish bilaterally neck revealed left subclavian line in place hickman cardiovascular revealed irregularly irregular tachycardia no murmurs lungs revealed upper airway sounds bilaterally abdomen was soft nontender and nondistended positive bowel sounds g tube in place extremities revealed trace pitting edema bilaterally hospital course in the medical intensive care unit the right port a cath was removed due to purulent drainage being present initial antibiotic coverage included vancomycin for a possible line infection levofloxacin for the question of pneumonia flagyl for his history of clostridium difficile and gentamicin when the patient s urine cultures showed escherichia coli resistant to gentamicin and quinolones the levofloxacin and gentamicin was discontinued the patient was started on ceftriaxone on the patient s fevers defervesced and he was gradually weaned off pressors by the patient required a diltiazem drip for rate control until when he was transitioned to p o lopressor the patient had a temporary hemodialysis catheter in place after the old line was removed a hickman catheter was placed on and the patient underwent hemodialysis on and during the first day on the regular floor there was some difficulty in controlling the patient s rapid atrial fibrillation improved control was obtained with the addition of oral diltiazem in addition to his lopressor on flagyl was discontinued as there was no evidence that clostridium difficile was involved in his current infection at this time the plan is for ceftriaxone and vancomycin to be administered at hemodialysis for a total of two weeks of therapy at the time of this dictation all of the patient s blood cultures demonstrated no growth to date his line swab from showed mixed flora including methicillin resistant staphylococcus aureus his sputum culture from showed oropharyngeal flora his urine cultures from showed escherichia coli discharge diagnoses sepsis urinary tract infection versus line infection rapid atrial fibrillation medications on discharge aspirin mg per g tube q d heparin units subcutaneous b i d ceftriaxone at hemodialysis vancomycin at hemodialysis lopressor mg p o t i d diltiazem mg p o q i d ultracal with promod at cc per hour continuous condition at discharge medically stable for discharge to rehabilitation with continued antibiotic treatment at hemodialysis discharge status to rehabilitation m d dictated by medquist d t job [NEW_RECORD] admission date discharge date service medicine addendum this is a discharge summary addendum to the summary dictated on further hospital course gastrointestinal the patient had a large amount of bright red blood per rectum associated with large clots in the morning of the patient remained hemodynamically stable he was supported with transfusions as his bleeding appeared to be decreasing it was decided to treat this gastrointestinal bleed conservatively however on the night of the patient had significant more amount of bright red blood and clots therefore gastrointestinal was consulted and the patient underwent colonoscopy on findings at colonoscopy were many nonbleeding polyps the largest one approximately cm and sessile biopsy was taken of this polyp the results are pending at this time a few diverticula in the sigmoid and descending colon were also found the patient had no further evidence of bleeding after the colonoscopy and his hematocrit remained stable after multiple transfusions the patient s gj tube malfunctioned several times during this admission it eventually was not working at all and appeared to be broken interventional radiology will be replacing this tube prior to the patient s discharge cardiovascular the patient continued to have difficulty with rapid atrial fibrillation the patient s diltiazem was titrated up and reasonable rate control was obtained additional discharge diagnosis lower gastrointestinal bleed likely diverticular or from a bleeding polyp additional discharge medications diltiazem mg po q i d digoxin mg po q hours m d dictated by medquist d t job [NEW_RECORD] admission date discharge date service acove id this is an year old male with questionable pneumonia chronic pleural effusions and dehydration history of present illness the patient is an year old male russian noncommunicative with multiple medical problems who initially presented with vomiting and loose stools as well as dyspnea at his nursing home and was admitted to medical floor for presumed aspiration pneumonia while on the floor the patient became hypotensive and was then transferred to the on the patient s hypotension resolved after intravenous fluid resuscitation the patient on admission to the medical floor acove service was day of flagyl ceftriaxone and vancomycin for broad coverage for pneumonia antibiotics were discontinued given decreased white count no fever and no copious sputum production arguing against active pneumonia however flagyl was continued for possible clostridium difficile infection given that the patient was having continued loose foul smelling diarrhea the patient also has chronic pleural effusions with an increase in interval size a pleural tap was performed prior to transfer to the medical floor past medical history right middle cerebral artery cerebrovascular accident with residual deficits end stage renal disease secondary to nephrotic syndrome on hemodialysis started in atrial fibrillation times nine years hypertension dementia history of methicillin resistant staphylococcus aureus questionable history of clostridium difficile history of hepatitis b history of aspiration pneumonia gastric polyps status post epinephrine status post hernia status post prostate surgery times two bilateral hydroceles times eight years medications on transfer enteric coated acetaminophen folate multivitamin ilotycin ointment prevacid heparin subcutaneously tylenol lopressor diltiazem digoxin nepro tube feeds social history from nursing home since son is home work physical examination on admission vital signs revealed temperature pulse s and s irregular blood pressure of oxygen saturations on room air with respiration rate of to general appearance awake in no acute distress noncommunicative head eyes ears nose and throat slightly dry mucous membranes cardiovascular irregular rhythm and rate normal s and s no murmurs lungs decreased breathsounds at the bases with no rales or wheezing abdomen is soft nontender nondistended with normoactive bowel sounds extremities contracted lower extremities bilaterally with no edema and scrotal edema present chronic genitourinary foley catheter in place rectal tube in place guaiac positive laboratory data white blood count is hematocrit is platelets chem sodium potassium chloride bicarbonate bun creatinine and glucose calcium phosphate and magnesium repeat guaiac times three negative clostridium difficile negative times three fecal cultures negative blood cultures times four with no growth hospital course the patient is an year old male with a history of cerebrovascular accident atrial fibrillation hypertension and end stage renal disease on hemodialysis who was transferred to the medical floor in medically stable condition from the intensive care unit status post resolved hypotension with intravenous fluids questionable pneumonia treated with three days of vancomycin ceftriaxone and flagyl as well as a chronic left pleural effusion status post thoracentesis pulmonary questionable pneumonia was treated with three days of broad spectrum antibiotics initially a left lower lobe opacity versus atelectasis versus chronic effusion was visualized on chest x ray white blood cell count has decreased to normal the patient has been afebrile without sputum production therefore after three days of broad spectrum antibiotics all antibiotics were discontinued the initial insult causing the hypoxia that was noted in the nursing home may have been chemical pneumonitis from transient aspiration the patient did have a history of aspiration pneumonias during the rest of the hospital stay the patient remained afebrile with normal white count in addition the patient has had a history of chronic pleural effusions which had an increase in interval size since previous films it was therefore tapped while in the intensive care unit and pleural fluid studies were sent pleural fluid studies revealed no pmns no microorganisms and fluid cultures were negative for infection no further thoracentesis were recommended at this time cardiovascular the patient was initially found to be hypotensive on the medical floor at the other campus and was then transferred to the intensive care unit this is most likely secondary to volume depletion from loose stools and resolved upon resuscitation with intravenous fluids throughout the hospital stay the patient s blood pressure has remained stable no additional intravenous fluids were necessary in addition the patient has a history of atrial fibrillation with good rate control using diltiazem as well as lopressor and digoxin the patient remained hemodynamically stable throughout the hospital stay and was monitored on telemetry no significant events were found the patient has not been on anticoagulation due to the history of gastrointestinal bleeds renal the patient has a history of end stage renal disease on hemodialysis on monday wednesday and friday the patient received hemodialysis at during the hospital stay the patient received his scheduled dialysis initially there was some trouble with catheter access but the access issues will be dealt with as an outpatient gastrointestinal the patient has reportedly had a history of diarrhea for the past few months per nutritionist that has been following him all the cultures have been negative the patient has been guaiac negative times three as well as clostridium difficile negative times three the patient was continued on flagyl but was then discontinued in the past fiber has been added to tube feeds with good results and continued diarrhea nutrition has now recommended use of imodium will observe hematocrit has been somewhat stable during the hospital stay initial decrease in hematocrit was likely secondary to intravenous fluid resuscitation gastrojejunostomy tube became obstructed during hospital stay and was replaced with a larger tube french catheter by interventional radiology gastrojejunostomy tube now properly working will need b i d flushes to maintain patency disposition the patient is medically stable for return to nursing home the patient will return to for usual dialysis schedule discharge condition stable discharge status return to nursing home discharge diagnosis left pleural effusion status post thoracentesis atrial fibrillation end stage renal disease on hemodialysis cerebrovascular accident hypertension discharge medications diltiazem mg per gastrojejunostomy tube q i d digoxin mg per gastrojejunostomy tube q d lopressor mg per gastrojejunostomy tube t i d pepcid mg per gastrojejunostomy tube q d ilotycin both eyes q d folic acid mg q gastrojejunostomy tube q d prenatal vitamin one tablet q gastrojejunostomy tube q d imodium mg times one per gastrojejunostomy tube prn and then mg after each loose stool prn mg per day maximum acetaminophen mg per gastrojejunostomy tube q d nepro tube feeds cc per hour m d dictated by medquist d t job,"{
""Diagnoses"": [""unresponsiveness"", ""atrial fibrillation"", ""hypertension""],
""Medications"": [""diltiazem"", ""meclizine"", ""cordarone"", ""metoprolol"", ""procardia"", ""accupril""]
}"
1704,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint hypotension and altered ms major surgical or invasive procedure central line placement history of present illness y o male with end stage liver disease presented to osh from hospice with altered ms of breath with hemoptysis pt transfused units prbc at osh with hct up to transfered to after family reversed code status for further care in ed found to be hypotensive and tachypneic with hemoptysis pt intubated and ng lavage performed which was positive for coffee ground material cleared after cc guiac negative in ed per brother pt has been hospitalized numerous times since his diagnosis approx weeks ago and was treated at for upper gi bleed and had egd at that time unknown findings pt found to have elevated wbc to lactate wbc in urine received zosyn flagyl and vanco in the ed gi service consulted for gi bleed and pt started on sepsis protocol pt received liters ns in ed no blood products past medical history etoh abuse hep c social history pt was living with his brothers when he became increasingly ill and they were unable to care for him at home brothers told that there was a place that could take care of him were not informed that this place was hospice family history unable to obtain physical exam vs ax hr bp on levophed peep fio gen intubated and sedated jaudiced heent pupils at mm bilaterally and reactive no roving eye movements scleral icterus scleral edema cv tachy regular no murmur chest coarse bs throughout no wheeze appreciated abd mildly distented no fluid wave soft no masses appreciated difficult to palpate liver edge ext jaudiced warm to touch pulses pedal edema palmar erythema neuro sedated unresponsive pertinent results pm urine blood lg nitrite neg protein tr glucose neg ketone neg bilirubin sm urobilngn neg ph leuk mod pm urine rbc wbc bacteria many yeast few epi trans epi pm urine hyaline 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 albumin calcium phosphate magnesium pm neuts bands lymphs monos eos basos pm plt smr low plt count pm pt ptt inr pt head ct findings there is no evidence of acute intracranial hemorrhage mass effect shift of normally midline structures hydrocephalus or major vascular territorial infarcts the white matter differentiation is preserved the cisterns and sulci are maintained the visualized portions of the paranasal sinuses and mastoid air cells are normally aerated the patient is intubated impression no acute intracranial pathology including no evidence of acute intracranial hemorrhage cxr impression et tube in satisfactory position ng tube with its tip in the mid esophagus abnormal lung findings could be due to aspiration with partial atelectasis of the left lower lobe multifocal pneumonia or pulmonary edema brief hospital course y o male with end stage liver disease presents with gi bleed and sepsis sepsis pt started on sepsis protocol in ed for elevated wbc with no bandemia and respiratory compromise lactate possible sources include urosepsis given wbc in urine pna given resp failure vs abd source translocation from gi bleed stool became positive for c diff colitis and was started on broad spectrum abx in ed zosyn vanco and flagyl for coverage of gi flora and staph eventually change in goal to comfort only and so antibiotics were stopped resp failure likely secondary to sepsis and mental status changes cxr shows prominence of the pulmonary vasculature as well as patchy consolidation in the left lower lobe possible pna vs pulm edema given low albumin and fluid rescusitation hemoptysis likely secondary to upper gi bleed however cannot rule out lung process he was eventually extubated with change in goals of care to comfort gi bleed egd here with evidence of tear supported with blood products and coagulopathy reversed until change in goal of care liver failure pt has hx of etoh abuse and hep c cirrhosis pt was apparently diagnosed only months ago has received all of his care at not on transplant list that we can tell last etoh was months ago on diagnosis extent of disease is evident by inr and albumin was seen by liver team with elevated meld score and not a transplant candidate and again supportive measures only were taken renal failure likely secondary to hepatorenal syndrome low urine output throughout stay altered ms likely multifactorial end stage liver disease causing hepatic encephalopathy renal failure causing uremia and sepsis head ct negative for bleed however mental status only improved marginally to the point where he recognized family memebers but never back to baseline code famiy was not aware iniitially of patient s wishes for hospice and comfort care only once discussed with his physicians and his wishes made known they agreed in change of care to comfort care only and all medications and procedures were stopped except morphine drip and prn ativan and scopolamine patch he was then transitioned to equivalent dose of fentanyl patch and prn concentrated morphine solution for pain control medications on admission unknown discharge medications none discharge disposition extended care discharge diagnosis c diff sepsis tear resulting in gastrointestinal bleed hepatic failure from hepatitis c and alcoholic cirrhosis acute renal failure altered mental status discharge condition deceased discharge instructions followup instructions completed by,"{
""Diagnoses"": [""hypotension"", ""altered mental status"", ""hemoptysis"", ""end-stage liver disease"", ""upper gastrointestinal bleed"", ""elevated WBC to lactate"", ""sepsis""],
""Medications"": [""Zosyn"", ""Flagyl"", ""Vanco"", ""Liters of NS in ED"", ""Blood products""]
}"
59840,admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint overdose major surgical or invasive procedure none history of present illness y o f with history of depression ptsd and other psychiatric illness presented to ed on after taking asa at pm and tylenol at pm briefly patient with headache on took tylenol and aleve at therapeutic dosing reports that headache continued to be significant and then took the above meds on states this was not a suicidal gesture though endorsed being more depressed and thinking more about suicide lately this week she reports no big stressors although she did break up wth her boyfriend of years last week a friend convinced her to go to after the ingestion the asa were not enteric coated by her report c o shakiness and nausea in ed also c o tinnitus in the ed her t hr s and bp satting on ra her hr is recorded at but the ed reported tachypnea toxicology was consulted she was started on l of d with amps of bicarb and started on nac but it was discontinued she was given ativan mg iv x past medical history pud dxed on endoscopy last summer ptsd depression chronic suicidality h o cutting behavior history of eating disorder social history sophomore at bu studying medical engineering denies smoking denies drug use reports drinking drinks twice a week last etoh beverage was saturday she is from family history dad has hep c denies diabetes cancer htn or any other medical problems mom is alcoholic physical exam vitals p r ra general appears dysthymic nad heent nc at perrl eomi but blinking frequently mmm neck no adenopathy chest cta bilat heart rrr s s no murmur appreciated abdomen bs soft nd c o epigastric diffuse ttp extrem warm no edema neuro alert cn ii xii intact though some difficulty with eoms as above pertinent results pm asa pm urine color straw appear clear sp pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg pm urine hours random pm urine uhold hold pm urine color straw appear clear sp pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg pm type po pco ph total co base xs comments green top pm glucose urea n creat sodium potassium chloride total co anion gap pm estgfr using this pm alt sgpt ast sgot alk phos amylase tot bili pm albumin calcium phosphate magnesium pm asa ethanol neg acetmnphn bnzodzpn neg barbitrt neg tricyclic neg pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count pm pt ptt inr pt ct head no mass edema hemorrhage cxr no acute process brief hospital course assessment and plan f with psychiatric history who presents with asa and acetaminophen overdose acetaminophen overdose level at admission hours after ingestion per nomogram not toxic ingestion unless patient was off by hours in terms of ingestion time no lft abnormalities level on am toxicology followed and recommended holding further nac given low apap levels salicylate overdose patient with tachypnea agitation tinnitus at admission showing early signs of salicylate toxicity asa level on admission increased to and then decreased charcoal given per patient not enterically coated and would not anticipate levels to further rise classic metabolic acidosis resp alkalosis was seen on micu labs received bicarb fluids initially and then stopped per toxicology recs with improvement in levels tinnitus resolved by discharge question suicide attempt per patient was attempting to treat headache but seems very depressed and endoreses suicidality managing as if suicidal gesture psych followed and plan for inpatient psych disposition per psych team was kept on suicide precautions with sitter ssri not continued per psych recs was a relatively new med for her and of increased suicidality discharged to receive inpatient psych care at hypokalemia required multiple repletion doses in micu could be related to bicarb fluids now stopped vs diarrhea from ac sorbitol vs more chronic with history of eating disorders now stable x multiple checks headache ct negative in ed no fever or signs of infectious cause no known migraines though has had similar ha in the past differential includes migraine tension headache analgesia withdrawal somatization of psychiatric issues most likely oxycodone prn given she was also noted to have relatively decreased strength with more formal neurologic testing however this was also likely somatization as could be tricked into having normal exam pain and difficulty with l sided gaze but no complaints when she looked left in order to talk to someone standing on her left side plan to continue oxycodone if needed medications on admission nexium mg lexapro mg daily discharge medications oxycodone mg tablet sig one tablet po q h every hours as needed for headache lorazepam mg tablet sig tablets po q h every hours as needed for anxiety nexium mg capsule delayed release e c sig one capsule delayed release e c po twice a day discharge disposition extended care facility behavioral care discharge diagnosis acetaminophen intoxication aspirin intoxication major depression and suicidality headache nos discharge condition stable discharge instructions you were admitted after taking a large amount of aspirin and tylenol we treated your ingestions with medications and iv fluids and you have done well you will now be followed by the psychiatry team for further management of your depression please return to the hospital or call your doctor if you have worsening depression or thoughts of suicide or desire to hurt yourself shortness of breath weakness or numbness visual changes worsening of your headache or any new symptoms that you are concerned about further medication management and followup to be determined by your psychiatry team followup instructions followup to be determined by your psychiatry team,"{
""Diagnoses"": [""overdose"", ""major surgical or invasive procedure"", ""history of present illness"", ""depression"", ""psychiatric illness"", ""suicidal ideation""],
""Medications"": [""ASA"", ""Tylenol"", ""Aleve"", ""Lorazepam"", ""Bicarbonate"", ""NAC""]
}"
54764,admission date discharge date date of birth sex m service medicine allergies penicillins attending chief complaint elevated lfts major surgical or invasive procedure paracentesis liver biopsy colonoscopy with biopsy history of present illness m with t n papillary rcc s p l nephrectomy who recently started on pazopanib seen in clinic on day of admission and found to have elevated lfts father was doing well until roughly weeks prior to when he began to develop increased non bloody loose stool and mild increase in fatigue he did not start imodium and tried to increase his fluid intake he did well at home until yesterday when he developed llq discomfort spontaneous onset no fevers rare chills pain was localized and but persisted no n v no increased abdominal girth dark urine no melena baseline dark stools on iron he went to osh ed yesterday where cr hco hct wbc with polys but tbili alkphos alt ast ct done at osh but report not available he was told he had ascites and discharged with no speicific therapy today he notes that his abdominal discomfort has nearly resolved he continue to have loose stool up to times per day without blood he denies cough fevers no chest pain orthopnea or le edema no n v no ruq pain urine remains dark he denies rash vs in clinic bp heart rate weight height bmi temperature resp rate pain score o saturation past medical history past oncologic history developed hematuria and mild flank pain and was found to have a large lobulated cm mass in his left kidney consistent with renal cell carcinoma he underwent further preoperative evaluation and was found to have a cm lesion in the right kidney as well as a lesion in the l vertebrae which was positive by bone scan he underwent laparoscopic left nephrectomy at hospital by dr he was felt to be at high risk of recurrence particularly given the lesion in the right renal and l areas until present he has been managed conservatively with q month ct scans with most recent being in where all lesions were noted to be slightly increasing in size noted to have lb unintentional weight loss increased fatigue and worsening anemia with hct of transfused u prbc for worsening anemia ct torso for worsening fatigue disease progression with enlargment of known lesions and new ascites consented for ancillary trials df hcc and df hcc asl mri per df hcc done started on pazopanib mg po qd past medical history status post left shoulder surgery nephrolithiasis history of lumbar radiculopathy esophageal stricture status post dilatation macular degeneration hypertension hypercholesterolemia osteoarthritis status post epigastric hernia repair social history he continues to smoke cigarettes day and drinks beer week he is a retired priest and continues to work for the he does still perform occasional weddings family history no history of kidney cancer mother with breast cancer after no siblings physical exam on admission vs t bp hr rr o sat ra gen nad seated comfortably no jaundice heent pupils equal round and reactive extraocular movements intact oropharynx clear w o lesions or petechiae sclera anicteric neck supple cv nl s s regular rate and rhythm pulm clear to auscultation bilaterally w good air movement no crackles wheezes abd soft nd bs mild tenderness in llq ext warm well perfused no cyanosis clubbing edema no open lesions skin no rashes neuro aox cn grossly intact strength in all extremities grossly normal sensation gait steady discharge exam temp ra gen nad heent scleral and skin icterus mmm no jvd cv nl s s regular rate and rhythm no m r g pulm cta anteriorly abd ntnd bs ext pulses bil tibial edema trace skin icteric no rashes neuro grossly intact pertinent results am glucose urea n creat sodium potassium chloride total co anion gap am alt sgpt ast sgot ck cpk alk phos tot bili dir bili indir bil am tot prot albumin globulin calcium phosphate magnesium am tsh less than am asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg am wbc rbc hgb hct mcv mch mchc rdw am neuts lymphs monos eos basos am plt count am pt ptt inr pt 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 sm urobilngn neg ph leuk neg pm lactate pm urea n creat sodium potassium chloride total co anion gap pm estgfr using this pm lipase pm tot prot albumin globulin calcium phosphate magnesium pm acetmnphn neg pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm plt count pm gran ct am blood hbsag negative hbsab borderline igm hbc negative am blood hbsag negative hbsab negative hbcab negative hav ab negative igm hbc negative igm hav negative pm blood antitpo less than am blood ttg iga discharge labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt pm blood fibrino am blood glucose urean creat na k cl hco angap am blood alt ast alkphos totbili am blood calcium phos mg am blood caltibc vitb folate ferritn trf am blood t t calctbg tuptake t index free t brief hospital course this is a yo m with t n papillary rcc s p l nephrectomy who recently started on pazopanib who was originally admitted for elevated lfts thought to be pazopanib heptotoxicity c diff colitis and acute on chronic renal failure acute on chronic renal failure pt s p nephrectomy with baseline cr developed acute on chronic rf in the setting of sepsis which did not improve cr went up to tunnled dialysis line was placed and recieved dialysis treatments planned to start out patient weekly dialysis sessions on tuesday continues calcium carbonate mg tid for phos chelation nephrocaps cap qd low potasium diet infection initiatially treated for sepsis c dif with iv vanc flagyl po cipro vanco from now repeated stools for c dif neg otherwise bcx ucx negative was treated with total days of po vanco after disconinuing other systemic antibiotics diarrhea initially had c dif for which recieved treatment now repeated c dif assays negative yet diarrhea continues colonoscopy showed diffuse erythema friability exudates and ulceration likely pseudomembranes in the rectum and sigmoid but biopsies were normal continues to have diarrhea stool studies repeated and for c dif tox culture and ova parasites all negative celiac serology negative qualitative stool for fat is positive d d for continuing diarrhea malabsorption supported by positive fat possibly to his intra hepatic cholestasis drug side effect to abx infection less likely now with neg cultures and repeated ng c dif inflammatory unlikely in the setting of normal colonic biopsies diarrhea is now improved on loperamide continues loperamide mg tid consult with gi in the out patient seetting of no resolution a fib a number of afib flutter rvr episodes during this admission on rate control with metoprolol score per age htn but with liver failure increased inr anticoagulation differed d t bleeeding risk now well controlled with metoprolol po tid today aspirin mg daily is given for stroke prevention grave s disease newly diagnosed per elevated tfts ft tsh and positive tsi ab normal except for af episodes remains non thyrotoxic clinically started low dose methimazole mg q h will require repeated tft s in three weeks follow up with endocrinology has been arranged cholestatic liver injury and jaundice secondary to pazopanib heptotoxicity imaging w o structural abnormalities or ductal dilatation pt mentating well no asterixis continues cholestyramine and topical camphor menthol for pruritus will need continued follow up of his liver functions including inr and ptt follow up with liver service has also been arranged anemia normocytic high rdw no b folate iron deficiencies per labs but ferritin may be falsely elevated in the setting of his other conditions has possible malabsorption and a few guiac positive stools thus anemia is likely multifactorial and secondary to chronic illness crf possible malabsorption and occult gi bleeding epo was not started in the setting of malignancy cbc s should continue to be trended iron labs should be followed and repletion considered gi may be consulted for his intestinal issues renal cell carcinoma per patient s oncologist no further treatment is considered at this point due to patient s various other complicating medical issues htn was on several agents at home which were d c ed in the setting of sepsis and hypotension during his admission was well controlled on metoprolol alone tobacco abuse was on bupropion at which was held during this admission continued abstinence was advised pvd was on home cilostazol this was held during this admission goals of care and code status prognosis discussion goals of care and code status issues were broached and discussed during this admission at this point patient wishes to remain at full code continued discussion of the above is advised dvt ppx treated with sq heparin discharge planning screened and accepted to holy trinity nsg home in will continue dialysis with dialysis in as well medications on admission amlodipine mg tablet one tablet s by mouth daily bupropion hcl prescribed by other provider mg tablet sustained release tablet sustained release s by mouth daily calcitriol mcg capsule one capsule s by mouth every day cilostazol prescribed by other provider mg tablet tablet s by mouth twice a day hydrochlorothiazide prescribed by other provider mg tablet tablet s by mouth daily lisinopril prescribed by other provider mg tablet tablet s by mouth once a day lovastatin prescribed by other provider mg tablet tablet s by mouth daily metoprolol succinate mg tablet sustained release hr tablet s by mouth once a day omeprazole prescribed by other provider mg capsule delayed release e c capsule delayed release e c s by mouth daily pazopanib votrient mg tablet tablet s by mouth once a day medications otc cholecalciferol vitamin d unit capsule capsule s by mouth once a day ferrous sulfate mg mg iron tablet tablet s by mouth twice a day omega fatty acids fish oil otc dosage uncertain sodium bicarbonate antacid otc powder tsp twice a day vit c vit e copper znox lutein preservision prescribed by other provider dosage uncertain discharge medications omeprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily camphor menthol lotion sig one appl topical tid times a day as needed for itching cholestyramine sucrose gram packet sig one packet po bid times a day aspirin mg tablet chewable sig one tablet chewable po daily daily metoprolol tartrate mg tablet sig one tablet po q h every hours methimazole mg tablet sig one tablet po q h every hours calcium carbonate mg mg tablet chewable sig one tablet chewable po tid with meals loperamide mg capsule sig one capsule po tid times a day as needed for diarrhea b complex vitamin c folic acid mg capsule sig one cap po daily daily discharge disposition extended care facility holy trinity eastern orthodox nursing rehabilitation center discharge diagnosis elevated lfts secondary to pazopanib c difficile infection acute on chronic renal failure renal cell carcinoma grave s disease discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you were admitted to due to elevated liverfunction tests concerning for liver failure due to the chemotherapy pazopanib the hepatology team was consulted and agreed that the elevation in liver function tests was due to pazopanib you underwent a liver biopsy that was also consistent with drug induced liver injury you underwent a colonoscopy because of persistent diarrhea and biopsies were taken which were normal you were treated with antibiotics for clostridium difficile infection you were also noted to have an irregular heart rate we treated you with medications for this and it improved you also were noted to have worsening kidney function for which you were treated with dialysis at the time of discharge your renal functions seem to have stablized and the renal team s recommendation was that you continue dialysis treatments as an outpatient you were also noted to have an over active thyroid during admission you were started on medication for this please make the following changes to your medications the following medications were stopped amlodipin bupropion calcitriol cilostazol hydrochlorothiazide lisinopril lovastatin metoprolol succinate pazopanib cholecalciferol vitamin d ferrous sulfate omega fatty acids fish oil sodium bicarbonate antacid preservision this is now your full medication list omeprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily camphor menthol lotion sig one appl topical tid times a day as needed for itching cholestyramine sucrose gram packet sig one packet po bid times a day aspirin mg tablet chewable sig one tablet chewable po daily daily metoprolol tartrate mg tablet sig one tablet po q h every hours methimazole mg tablet sig one tablet po q h every hours calcium carbonate mg mg tablet chewable sig one tablet chewable po tid with meals loperamide mg capsule sig one capsule po tid times a day as needed for diarrhea b complex vitamin c folic acid nephrocaps mg capsule sig one cap po daily daily followup instructions please call your oncologist dr phone to arrange for further follow up please also keep the following appointments department div of gi and endocrine when tuesday at pm with md building ra complex campus east best parking main garage department liver center when monday at pm with md building lm bldg campus west best parking garage department west clinic when thursday at pm with m d building de building complex campus west best parking garage completed by,"{
""Diagnoses"": [""Ascites"", ""Elevated LFTs"", ""Major Surgical or Invasive Procedure"", ""Paracentesis"", ""Liver Biopsy"", ""Colonoscopy with Biopsy"", ""History of Present Illness"", ""Malignancy""],
""Medications"": [""Pazopanib""]
}"
14496,admission date discharge date date of birth sex f service cardiothoracic allergies morphine iodine containing agents classifier attending chief complaint f with doe and intermittent cp for days major surgical or invasive procedure cabgx svg lad diag om history of present illness f with a h o iddm htn chol chf who had progressive doe and intermittent cp for days she presented to and had q waves in v v and in v v with a ck of and an mb of troponin was and she was transferred to for further treatment past medical history iddm since age htn chol neuropathy retinopathy s p c section social history lives with husband and children works in childcare cigs minimal quit yrs ago etoh none family history dm physical exam gen wdwn wf in nad temp hr rr on liters nc bp heent nc at perrla eomi oropharynx benign neck supple from no lymphadenopathy or thyromegaly carotids bilat without bruits lungs bibasilar rales cv rrr without r g m nl s s abd bs soft nontender without masses or hepatosplenomegaly ext without c c e pulses bilat throughout neuro nonfocal 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 alt ast ld ldh pnd alkphos amylase totbili am blood lipase am blood ck mb mb indx ctropnt am blood albumin pm blood triglyc hdl chol hd ldlcalc am blood type art po pco ph calhco base xs am blood glucose lactate na k cl chest portable ap am chest portable ap reason please eval lungs patient s p emergent cabg pod previous medical condition year old woman s p emergency cabg x with iabp reason for this examination please eval lungs patient s p emergent cabg pod previously manifested ards pulmonary picture high pips and plateau pressure with pao fio ap chest compared to severe pulmonary edema has changed in distribution but not in severity right lung is now more consolidated than the left this raises the possibility of pulmonary hemorrhage or pneumonia but could be explained entirely by shift in edema heart is normal size and mediastinal vasculature is not particularly engorged tip of the intra aortic balloon pump is approximately a centimeter below the level of the left main bronchus approximately cm from the apex of the aortic knob small left pleural effusion is stable no right pleural effusion is demonstrated and there is no pneumothorax tip of the swan ganz catheter projects over the right pulmonary artery et tube is in standard placement midline and right pleural drains are in place nasogastric tube passes to the distal stomach mediastinum midline dr brief hospital course the patient was admitted and evaluated by cardiology and had cp with hypotension during the night of admission she underwent emergency cardiac catheterization which revealed lmca stenosis diffusely diseased tight ostial lad lesion ostial diffusely diseased diseased rca elevated filling pressures and ef an iapb was placed and she went for emergency cabgx svg lad diag om on she was transferred to the csru on levophed milrinone epi vasopressin insulin and propofol she had persistent hypotension and the propofol was d c d and she was placed on cisatricurium fentanyl and midaz she desaturated and required bronchoscopy and had copius mucous plugging she improved following this but had persistent tachycardia in the range and had a good cardiac output and urine output throughout dr at was consulted and she was transferred for the possibility of a heartmate insertion medications on admission humalog ss lantus u sc bid lisinopril mg po daily allergies mso discharge medications acetaminophen mg tablet sig two tablet po q h every hours as needed for temperature clopidogrel mg tablet sig one tablet po daily daily for months ranitidine hcl mg ml syrup sig one y mg po bid times a day epinephrine mg ml solution sig mg kg min injection infusion continuous infusion vasopressin unit ml solution sig mg kg min injection titrate to titrate to desired clinical effect please specify norepinephrine bitartrate mg ml solution sig mg kg min intravenous infusion continuous infusion fentanyl citrate pf mg ml solution sig one hundred fifty mg kg min injection infusion continuous infusion midazolam mg ml solution sig mg kg min injection infusion continuous infusion furosemide mg ml solution sig ten mg kg min injection infusion continuous infusion vancomycin in dextrose g ml piggyback sig one intravenous q h every hours for doses milrinone mg ml solution sig mcg kg min intravenous infusion cisatracurium mg ml solution sig mg kg min intravenous infusion continuous infusion discharge disposition extended care discharge diagnosis cad iddm htn mi chol chf neuropathy retinopathy discharge condition critical discharge instructions continue intensive care being transferred to followup instructions tx dr completed by,{}
16734,unit no admission date discharge date date of birth sex f service nb history baby girl was the gram product of a and week gestation born to a year old g p now mother prenatal screens o positive antibody negative rpr nonreactive rubella immune hepatitis surface antigen negative gbs unknown this pregnancy conceived by iui assistance complicated by iugr betamethasone complete planned cesarean section delivered early secondary to decelerations rupture of membranes at delivery nuchal cord x reduced apgars were and physical examination weight grams th percentile length cm th to th percentile head circumference cm th to th percentile anterior fontanel soft flat nondysmorphic intact palate with spontaneous effort he had adequate aeration and good breath sounds no murmurs normal pulses abdomen soft three vessel cord no hepatosplenomegaly normal female genitalia patent anus no hip click blind ending sacral dimple present with no evidence of hir tuft or lipoma active and moves all extremities normal tone summary of hospital course by systems respiratory was admitted to the newborn intensive care unit with transient respiratory distress and was placed on cpap for approximately hours transitioned quickly to room air and has been stable in room air since that time she has had documented episodes of apnea bradycardia during her hospital course the last of which was days prior to discharge cardiovascular she has been stable throughout her stay fluids electrolytes and nutrition birth weight was grams discharge weight is grams head circumference cm length cm the infant was initially started on cc per kg per day enteral feedings were started on day of life the infant has been ad lib po feeding throughout her hospital course taking in adequate amounts of breast milk calorie concentrate with similac powder would recommend to continue calorie for an extended length of time to help the infant regain weight have suggested bottle feedings day with enhanced calorie feedings weigth at the time of discharge is grams gastrointestinal peak bilirubin was on day of life of the infant was treated with phototherapy this issue has resolved hematology hematocrit on admission was she has not required any blood transfusions she is currently received ferrous sulfate supplementation of ml po once daily mg per ml infectious disease cbc and blood culture obtained on admission cbc was benign and blood cultures remained negative at hours antibiotics of ampicillin and gentamycin were discontinued at that time neurologic the infant has been appropriate for gestational age sensory hearing screen was performed automated auditory brain stem responses and the infant passed psychosocial the family has been involved and interested parents have experience had a previous and weeker years ago who is alive and well condition on discharge stable discharge disposition to home name of primary pediatrician dr telephone no care recommendations feedings continue ad lib feeding breast milk or similac calorie medications ferrous sulfate supplementation at ml po once daily mg per ml goldmine multivitamins ml po once daily car seat position screening was performed and the infant state newborn screens have been sent per protocol and have been within normal limits immunizations received hepatitis b vaccine on immunizations recommended 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 two of the following daycare during the rsv season a smoker in the household neuromuscular disease airway abnormalities or school age siblings with chronic lung 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 discharge diagnoses premature infant born at and weeks with mild respiratory distress syndrome rule out sepsis with antibiotics hyperbilirubinemia dictated by medquist d t job,{}
19995,admission date discharge date date of birth sex f service medicine patient is a year old female with a complex history significant for multiple sclerosis complicated by quadriplegia status post cholecystectomy status post hepaticojejunostomy status post ileal loop conduit and neo bladder formation multiple urinary tract infections multiple episodes of cholangitis and cholestasis she was in her usual state of health until two months ago when she suffered the sudden onset of a chronic abdominal pain and marked fever she was hospitalized at on for suspected ileus which was ultimately complicated by a pseudomonal bacteremia from the urine infection which was treated with ceftazidine although complicated by a c difficile colitis infection she had an endoscopic retrograde cholangiopancreatography performed on of this year which found evidence of a sharp cut off in the common bile duct and found evidence of a biliary stent which was removed although no dye was extravasated past the site of the cut off she was discharged home on flagyl and ceftazidine she was readmitted on at for a spiking temperature to degrees complaints of diffuse abdominal pain and protracted nausea and vomiting with evidence of nonbilious nonbloody vomitus her hospital course there was marked by elevation of her liver function tests above the baseline and although blood cultures found no evidence of bacteremia she was found to have a polymicrobial urinary tract infection providencia stuartii enterococcus and alpha hemolytic strep she was placed on zosyn and ampicillin to treat this and was referred to for evaluation of her chronically elevated liver function tests and recurrent episodes of cholangitis at she also received a hepatic biopsy which showed evidence of chronic bilious cholestasis with proliferation of bile ducts and fibrosis of hepatic tissue on transfer patient is without complaint of abdominal pain nausea vomiting shortness of breath or chest pain she does have a positive history of diarrhea within the last few days although recently she has been some chronic constipation as which is her baseline past medical history multiple sclerosis diagnosed years ago and followed by quadriplegia for the last five years cholecystectomy performed in at hospital complicated the contained leak of bile hepaticojejunostomy performed at hospital with roux en y jejunal limb attached to the site of biliary leak recurrent cholangitis greater than four episodes over the last year usually evaluated at chronic hepatitis work up has included negative viral serologies negative negative smooth muscle antibodies as well recent liver biopsy at as described ileal loop conduit urostomy with right ureteral stent for recurrent episodes of urosepsis peg placement c difficile colitis pseudomonas bacteremia recurrent urinary tract infection chronic anemia chronic back pain multiple decubitus ulcers requiring surgical repair depression medications on transfer subcutaneous heparin units b i d baclofen mg q i d prozac mg q d protonix mg q d reglan mg q i d levsin mg t i d duragesic patch mcg q hours last applied zosyn mg ampicillin mg intravenous q d milk of magnesia and dulcolax suppository p r n and osmolite tube feeding allergies none known social history lives at life care retired payroll administrator greater than pack year smoking history although quit ten years ago moderate alcohol intake but quit many years ago no history of intravenous drug use family history no history of gi disease in family one nephew with multiple sclerosis physical examination vitals on admission temperature degrees fahrenheit heart rate blood pressure respiratory rate o saturation percent on room air general she is a pleasant clearly debilitated woman in no acute distress jaundiced not moving extremities heent normocephalic atraumatic icteric sclerae pupils equal round reactive to light and accommodation extraocular movements intact thickened stiff neck pulmonary clear to auscultation bilaterally from anterior cardiac regular rate and rhythm normal s and s no murmurs rubs or gallops abdomen soft nondistended mild diffuse tenderness worse in right upper quadrant no rebound or guarding good bowel sounds peg in place urostomy in place well healed scar in right upper quadrant extremities dorsalis pedis and posterior tibial pulses bilaterally no clubbing or cyanosis pitting edema of the legs no decubitus ulcers on bedroll neurologic alert and oriented times three cranial nerves through intact not moving any extremities touch sensation intact on extremities relevant data chest x ray performed on hospital day one shows a left pleural effusion with atelectasis no evidence of consolidation admission laboratories include white count of hematocrit platelet count coags normal with inr of alt ast direct bilirubin total bilirubin alkaline phosphatase ggt sodium potassium chloride bicarb bun creatinine glucose calcium phosphate magnesium albumin urinalysis negative hepatitis serologies a b and c negative antimitochondrial antibody negative enka negative positive with titration of cea of and ca of hospital course infectious disease patient was admitted with a diagnosis of polymicrobial urinary tract infection with no evidence of septicemia with negative blood cultures at outside hospital infectious disease was consulted and recommended the discontinuation of ampicillin and continued zosyn with a day course ending and the adding on of flagyl for day course overlapping by five days past the end of the zosyn for fear of c difficile infection given past histories of c difficile colitis and flagyl end date is notably urine cultures showed no growth and blood cultures are negative thus far infectious disease consult considers likely source of recent fevers to be either biliary sepsis given recurrent episodes of cholangitis in the past or due to polymicrobial urinary tract infection of note infectious disease considers possibility that urinary tract infection may be fictitious given the possibility that the urine sample at the outside hospital may have been taken from her colonized urostomy bag rather than through direct catheterization of the urinary stoma given the lack of white cell counts in the outside hospital urinalysis is consistent with the possible diagnosis c difficile antigen test was obtained and came back negative ms remained afebrile throughout the duration of her hospital course with a mild low grade temperature of degrees recorded after ptc procedure was performed likely due to transient biliary bacteremia her white count decreased on intravenous zosyn and flagyl from admission of to on hospital day two trending up to a stable and then spiking to on hospital day six after performance of a percutaneous transhepatic cholangiography it is suspected this is due again to a transient biliary bacteremia and will likely resolve while covered by the intravenous zosyn and flagyl chronic biliary stasis the patient has had a diagnosis of chronically elevated liver function tests for several years and recurrent episodes of cholangitis a thorough work up of her chronic hepatitis was obtained at the outside hospital including negative viral serologies negative antimitochondrial antibody negative anti smooth muscle antibodies an endoscopic retrograde cholangiopancreatography was performed at the outside hospital and findings showed cut off at common bile duct upon comparison with earlier operative reports this seemed consistent with a surgical ligation of the common bile duct during performance of hepaticojejunostomy a liver biopsy was also obtained at the outside hospital showing evidence of chronic biliary stasis and biliary cirrhosis with proliferation of bile ducts and fibrosis of the biliary tree hepatology service was consulted and believes her overall picture was consistent with an obstructive cirrhosis with a predominantly direct hyperbilirubinemia suggestive of chronic cholestasis they suggested further evaluation by endoscopic retrograde cholangiopancreatography to evaluate for possible diagnosis and therapeutic intervention to correct a probable biliary stenosis an mrcp was obtained on hospital day one showing evidence of moderate intrahepatic biliary ductal dilatation and probable common hepatic duct stricture incidental findings of multiple cystic lesions in the pancreatic body and tail consistent with chronic pancreatitis or intraductal papillary mucinous tumor was also identified an endoscopic retrograde cholangiopancreatography consult was obtained and endoscopic retrograde cholangiopancreatography was performed on hospital day four finding evidence of previous sphincterotomy of the major papilla and surgical ligation of the common bile duct although the afferent limb of the roux en y hepaticojejunostomy was visualized it was not deemed safe to explore this further and the endoscopic retrograde cholangiopancreatography recommended further follow up with a percutaneous transhepatic cholangiography this ptc was performed on hospital day five showing a percent stricture of the anastomosis of the hepaticojejunostomy which was dilated and stented with placement of an external biliary drain per interventional radiology recommendations this external biliary drain was capped on hospital day six and it is recommended that it be kept in for four to six weeks to continue dilation and opening of the anastomosis it can be removed by follow up by interventional radiology cystic pancreatic lesions on hospital day one an mrcp was obtained which found an incidental finding of multiple cystic lesions in the pancreatic body and tail consistent with either chronic pancreatitis or intraductal papillary mucinous tumor this should be followed by the patient s primary care physician note cea tumor marker came normal at but a ca was highly elevated at the ca can be elevated by biliary stasis as well as cholangitis two conditions which the patient is known to have it is recommended that a repeat ca be obtained at the discretion of the primary care physician when these issues have further resolved possible work up by another endoscopic retrograde cholangiopancreatography with biopsy or mri may also be entertained multiple sclerosis the patient has maintained her baseline quadriplegia considering her high risk for deep venous thrombosis she was placed on pneumoboot and subcutaneous heparin prophylaxis she did not have any increasing oxygen demand suggestive of no pulmonary embolism access the patient was transferred from outside hospital with no peripheral intravenous access a femoral line was placed in her right groin without event on hospital day one and was removed on hospital day three when a picc line was placed by interventional radiology back pain the patient has chronic back pain which was treated successfully with baclofen and the institution of an air mattress she did not have any complaints of back pain throughout the duration of her hospitalization depression the patient has baseline depression responsive to prozac on which she maintained throughout the duration of her hospitalization disposition the patient is being evaluated for placement in a long term care facility further addendum will be dictated with any new discharge instructions m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex f service chief complaint respiratory distress transfer from floor transfer summary history of present illness the patient is a year old female with a history of advanced multiple sclerosis complicated by quadriplegia prior history of tracheostomy now dnr transferred from outside hospital on with evaluation for recurrent cholangitis in the setting of hepaticojejunostomy and cholecystectomy the patient is now postoperative day status post percutaneous transhepatic cholangiography and biliary drain placement on the evening of the patient had acute shortness of breath and hypoxia with desaturations to on liters improving to on nonrebreather despite atrovent nebulizations x lasix mg iv x and morphine mg iv x and deep suction with minimal secretions she had a chest x ray which was suggestive of a left lower lobe collapse the patient declined intubation and bronchoscopy and was transferred to the icu for mask ventilation and aggressive chest physical therapy with intent to re expand left lung at the time of initial icu eval the patient is in mild distress on mask ventilation she symptomatically feels less dyspnea denies chest pain fevers and chills past medical history as above longstanding advanced multiple sclerosis complicated by quadriplegia history of tracheostomy status post hepaticojejunostomy status post cholecystectomy history of liver biopsy in with a history of biliary cirrhosis status post ercp with common bile duct stent removal history of recurrent utis recent pseudomonas uti status post ileal conduit status post peg placement low back pain myodystrophy history of c diff in the past medications on transfer vancomycin gm flagyl mg day zosyn gm day colace senokot fentanyl patch mcg q h baclofen mg po tid l hyoscyamine mg tid reglan mg x per day lansoprazole mg qd prozac mg qd heparin subcutaneous milk of magnesia prn dulcolax prn benadryl prn compazine prn ambien social history she lives in a chronic care facility in a brother is involved in her care that number is allergies no known drug allergies initial evaluation the patient is afebrile at blood pressure pulse respiratory rate on room air her i s and o s are for hours her drain had drained cc over the last hours general she was responding appropriately to questions heent exam shows mild icteric sclerae cardiovascular significant for tachycardia regular lungs show scattered rhonchi and expiratory wheezing decreased breath sounds on the left side abdominal exam biliary drain present her peg shows mild erythema at site but no active exudate otherwise she had some mild right upper quadrant tenderness no rebounding extremities warm well perfused labs from am white cell count up from hematocrit platelets chemistries unremarkable her abg shows a gas of her lfts show an alt of ast alk phos up from total bili lactase she has blood cultures from and which are pending at time of transfer urine culture from the is also negative of note at the outside hospital from the patient had a urine culture with providencia stuartii enterococcus and in had a history of pseudomonas uti with c difficile infection she had an mr of the abdomen on showing status post cholecystectomy and choledochojejunostomy with moderate intrahepatic biliary dilation with question of a common bile duct stricture and multiple cystic lesions of the pancreatic body and tail consistent with a chronic pancreatis versus intraductal papillary mucinous tumor her chest x ray from time of transfer shows questionable consolidation in left lower lobe but no tracheal deviation and right side without focal consolidation hospital course by review of systems pulmonary the patient was transferred initially to icu for acute hypoxia and respiratory distress initial chest x ray suggestive of lobar collapse presumed secondary to mucous plugging she has a history of tracheostomy but at current point her code status is dnr dni she therefore was not a candidate for intubation one of the goals of transfer to icu was for more aggressive physical chest pt over the course of her icu stay the patient s respiratory status improved markedly zosyn and flagyl she had been on empirically for a history of utis the patient had vancomycin added for mrsa her sputum cultures were obtained but never did grow out positive organisms however clinically she did improve over her icu course and vancomycin was continued for a day course which will be completed on the there was also concern given patient s history that part of the respiratory demise may have been secondary to aspiration as such she underwent further adjustment of her peg tube to a j tube in an effort to minimize the risk of aspiration at the time of this dictation the patient is beginning to tolerate her tube feeds without difficulty in summary the patient will complete her vancomycin course for days she will still require aggressive chest physical therapy and mobilization she has been given inexsufflator to help mobilize secretions her o requirements have decreased dramatically at time of dictation she is satting into the mid s an fio of her chest x rays have shown remarkable improvement from her initial lobar collapse cardiovascular despite the patient s acute hypoxia the patient has remained hemodynamically stable during the entire icu course she was however found to be persistently tachycardic into the s and s ekgs and telemetry showed sinus rhythm the exact etiology of the sinus tachycardia is unclear she had several sets of negative cardiac enzymes a tsh was checked and was normal it was presumed that her volume status was optimized she also had an echocardiogram which essentially was unremarkable showing an ejection fraction of near without any structural abnormalities or definite pericardial effusions it is thought that some of the tachycardia may be secondary to autonomic dysfunction with her multiple sclerosis given the fact that she was also slightly hypertensive at times into the systolic s and s she was empirically treated with a beta blocker her heart rates have shown marked improvement she has come down into the s and s her pressures have shown improvement she will be discharged on atenolol gi the patient has a complicated biliary history having been status post hepaticojejunostomy and status post cholecystectomy with a history of recurrent cholangitis there was initially thoughts about biliary strictures she came to the icu postoperative day status post ptc she will be completing antibiotics ciprofloxacin and flagyl initially for urinary tract infections that also will cover any biliary source of infection during her icu course her lfts did show marked improvement her alk phos has been slightly elevated the patient is currently asymptomatic without any signs of fevers or white count and this will be followed quite closely also from a gi standpoint it was thought that aspiration may be a contributing factor to her respiratory demise she currently had a peg tube in place it was then decided that the patient may benefit from a j tube to prevent further risk of aspiration she underwent successful j tube placement on without complications at the time of discharge the patient is tolerating her tube feeds well she will likely need aggressive promotility agents including reglan and a possible return of her l hyoscyamine mg tid she also now has a double lumen picc in place also placed on in case she may require chronic tpn infectious disease the patient was initially transferred to the icu on both metronidazole and zosyn initially for treatment of urinary tract infections and also as coverage for biliary manipulation she will complete her course of flagyl on her zosyn was initially continued however she later developed a macular slightly raised rash on the lower extremities it was thought that this may have been secondary to a possible drug rash related to zosyn as such the patient was switched to ciprofloxacin on she will complete her course of cipro on meanwhile the patient was started on vancomycin on and was then transferred to the icu for thought of a possible infectious etiology of her respiratory compromise sputum cultures blood cultures and urine cultures from her icu stay have all been negative she has remained afebrile during her icu course and her white count has come down considerably although still mildly elevated hematology the patient s hematocrit and platelets have remained during the hospital course she as always will require constant continuous dvt prophylaxis also of note she had a double lumen picc placed in her left upper extremity on renal fen the patient s electrolytes remained stable during her hospital course she had good urine output she was felt to be relatively euvolemic at time of discharge she had her peg tube readjusted to a j tube and was restarted on tube feeding on the with promod with full fiber strength with goal tube feeding rate to be cc h it is important that she also receive promotility agents to prevent the risk of aspiration as mentioned above also she has a double lumen picc in the case that her new j tube does not reduce the risk of aspiration and the patient possibly may require tpn disposition the patient at this time is dnr dni she will be returning back to nursing home discharge diagnoses acute respiratory distress thought secondary to left lower lobe collapse secondary to mucous plugging questionable aspiration pneumonia now resolving history of recurrent cholangitis status post percutaneous transhepatic stable status post percutaneous endoscopic gastrostomy tube revision to jejunostomy tube mild hypertension and sinus tachycardia discharge condition fair discharge medications fentanyl patch mcg q h prozac mg qd reglan mg qid and at bedtime heparin u q dulcolax prn magnesium hydroxide prn senokot tabs colace compazine prn miconazole powder prn ambien prn baclofen mg tid protonix mg qd flagyl mg q until vancomycin gm q h until ciprofloxacin mg q until morphine iv prn please see addendum to discharge summary for further adjustments to medications prior to her discharge dr dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex f service acove this will be an addendum to the two previously dictated discharge summaries patient did well after transfer to the general medicine floor from the surgical intensive care unit issues are as below pulmonary patient s respiratory status continued to improve and by the time of discharge she had an oxygen saturation in the s on room air she will complete a day course of vancomycin for a question of mrsa pneumonia she did very well on the floor and no longer required use of the toughalator sputum and blood cultures have been negative gi patient has a long history of recurrent cholangitis as outlined above she is now status post ptc and will follow up with interventional radiology on for removal of her drain the tube is to remain capped until that time she has had no abdominal pains and her liver function tests have been stable with alkaline phosphatases trending downward she will complete a course of flagyl to end cardiac patient had issues with hypertension and sinus tachycardia while in the surgical intensive care unit both are much better controlled on atenolol continued to be monitored closely on the floor multiple sclerosis patient has severe multiple sclerosis complicated by quadriplegia she has continued on baclofen she is fentanyl patch and morphine p r n for pain condition on discharge stable discharge status patient will be discharged back to her long term care facility discharge diagnoses recurrent cholangitis status post ptc on polymicrobial urinary tract infection respiratory distress presumed secondary to mucous plugging aspiration and possible pneumonia status post conversion of peg tube to j tube multiple sclerosis status post cholecystectomy status post hepatocholojejunostomy status post ileal loop conduit urostomy status post peg tube placement history of c difficile colitis chronic low back pain chronic anemia depression fluoxetine mg p o q d medications on discharge lamiprazole mg p o q d fentanyl patch mcg transdermally q hours metoclopramide mg four times per day before meals and at bedtime subcutaneous heparin injection q hours fluoxetine mg p o q d bisacodyl mg p o q d p r n for constipation magnesium hydroxide ml p o q hours p r n for digestion senna tablet p o b i d docusate cc p o b i d trochlaperazine ml injection q hours as needed for nausea miconazole powder t i d p r n ambien mg p o q h s p r n baclofen mg p o q hours miconazole atenolol mg p o q d tylenol mg to tablets p o q to hours p r n morphine to mg intravenous q hours p r n metronidazole mg intravenously q hours vancomycin mg p o q d follow up plan patient will follow up with her primary care physician on thursday at o clock p m patient will follow up with interventional radiology on at o clock a m her tube feeds should be stopped at midnight on for this follow up appointment m d dictated by medquist d t job,"{
""Diagnoses"": [""Multiple sclerosis"", ""Quadriplegia"", ""Cholecystectomy"", ""Hepaticojejunostomy"", ""Ileal loop conduit"", ""Neo bladder formation"", ""Urinary tract infections"", ""Cholangitis"", ""Cholestasis""],
""Medications"": [""Ceftazidine"", ""Flagyl"", ""Cefazolin""]
}"
74984,admission date discharge date date of birth sex f service medicine allergies norvasc attending chief complaint shortness of breath major surgical or invasive procedure none history of present illness yo female w htn cri baseline p w sob for the past week she reports this began weeks ago and slowly worsened until this morning when she felt extraodinarily sob and couldn t breath she presented to where her bp she was given asa lopressor mg iv x lasix mg iv with liter uop she reported mild chest tightness ekg with evolving st changes ck trop she was given morphine heparin bolus gtt and nitro gtt and transferred to in ed she was noted to be severely hypertensive s t hr rr l exam with diffuse wet crackles edema cxr done no pulmonary edema or consolidation trop ck started on lasix gtt and bolus of mg heparin and nitro gtt continued in ed prior to arrival in ccu taken from admission note past medical history htn chronic renal sufficiency borderline personality glaucoma hyperlipidemia gout hyperparathyroidism social history lives in alone tobacco history smokes pack week etoh occasional drink wk illicit drugs denies family history pt does not know family history reports no family physical exam vs t bp hr rr o sat ra general middle aged aa female in nad oriented x odd affect heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa neck supple with jvp of cm cardiac pmi located in th intercostal space midclavicular line rr normal s s no m r g lungs resp were unlabored no accessory muscle use crackles at bases bilaterally abdomen soft ntnd no hsm or tenderness extremities edema at ankles warm and well perfused extremities skin no stasis dermatitis pulses right carotid dp pt left carotid dp pt neuro a o x cn grossly intact sensation intact throughout strength in ue le equally pertinent results am 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 glucose urean creat na k cl hco angap pm blood ck cpk am blood probnp pm blood ck mb ctropnt am blood mg pm blood triglyc hdl chol hd ldlcalc ldlmeas cxr no evidence of pneumonia or chf rounded opacities projecting over the right hilum may represent vascular structures or prominent lymph nodes lateral chest radiograph is recommended for further evaluation echo the left atrium is elongated left ventricular wall thicknesses and cavity size are normal there is mild regional left ventricular systolic dysfunction with inferior and inferolateral hypokinesis overall left ventricular systolic function is low normal lvef right ventricular chamber size and free wall motion are normal the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the mitral valve leaflets are structurally normal there is no mitral valve prolapse mild mitral regurgitation is seen the estimated pulmonary artery systolic pressure is normal there is no pericardial effusion impression mild regional left ventricular dysfunction brief hospital course yo female with history of htn hyperlipidemia and cri who presented with hypertensive emergency and pulmonary edema hypertension pt presented with severe htn dypsnea and elevated jvp neuro exam non focal she appeared to be in volume overload and was agressively diuresed with a lasix drip she was weaned off nitroglycerin gtt and her labetalol dose was increased these interventions brought her blood pressure under better control a repeat echo showed ef of and mild regional left ventricular dysfunction coronary artery pt was without symptoms of chest pain ekg initially concerning for st elevations t wave abnl in v v trop ck she was started on heparin which was then stopped in light of negative enzymes she was continued on asa a lipid panel was checked acute on chronic renal failure baseline appears to be and was elevated to on admission cr rose to on discharge cr elevation though to be related to poor forward flow gout held allopurinol given renal failure borderline personality continued haldol per home dose medications on admission allopurinol mg once daily lasix mg daily benztropine mg b i d haldol mg b i d labetalol mg b i d aspirin mg once daily discharge medications labetalol mg tablet sig two tablet po twice a day disp tablet s refills aspirin mg tablet sig one tablet po daily daily haloperidol mg tablet sig one tablet po bid times a day benztropine mg tablet sig one tablet po bid times a day furosemide mg tablet sig one tablet po bid times a day disp tablet s refills allopurinol mg tablet sig one tablet po once a day outpatient lab work please check bun creatinine k on and call results to dr phone and dr discharge disposition home with service facility vna discharge diagnosis hypertensive urgency pulmonary edema acute on chronic renal failure discharge instructions you had very high blood pressure and fluid in your lungs you received more labetolol to control your blood pressure your kidney function is worse it is important that you get an appt with dr to assess your laboratory test results new medicines we increased your furosemide to twice daily we increased your labetolol to mg twice daily please keep your follow up appt with dr dr and dr please stop smoking information regarding smoking cessation was given to you on admission this is the most important thing you can do for your health followup instructions primary care provider md phone date time at am cardiology provider phone date time at pm nephrology md phone please call your nephrologist to schedule an appointment in the next weeks completed by,"{
""Diagnoses"": [""Shortness of Breath"", ""Hypertension"", ""Chronic Renal Insufficiency"", ""Glaucoma"", ""Hyperlipidemia"", ""Gout"", ""Hyperparathyroidism""],
""Medications"": [""Norvasc"", ""Lopressor"", ""Heparin"", ""Nitro"", ""Morphine"", ""Epinephrine"", ""Lasix""]
}"
98094,admission date discharge date date of birth sex m service neurosurgery allergies penicillins attending chief complaint severe headache x wk major surgical or invasive procedure cerebral angiogram on with dr history of present illness yo male who reports a headache x week he reports hitting his head about weeks ago on a cabinet then had the flu with vomiting and diarrhea after vomiting he began to experience sharp headaches from the r occipital region to the right parietal area the headache would be severe with vomiting and coughing although he began to feel better the headache continued today his wife felt he was groggy and slightly more lethargic and called past medical history gastritis htn borderline high cholesterol rheumatic fever at yo tonsillectomy social history works for woodworkers as a sales person lives with wife no children reports alot of stress secondary to work and helping his father who is elderly denies tobacco etoh x wk denies recreational drug use family history father alive nph cardiac hx mother deceased ca siblings htn nph physical exam physical exam o t bp hr r o sats gen wd wn comfortable nad heent pupils to bilaterally eoms intact w o nystagmus extrem warm and well perfused neuro mental status awake and alert cooperative with exam normal affect orientation oriented to person said he was at and thought it was recall able to name current and past president able to recall events able to recall current events language speech fluent with good comprehension no dysarthria or paraphasic errors cranial nerves i not tested ii pupils equally round and reactive to light to mm bilaterally visual fields reveal left visual field cut 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 toes downgoing on left right does appear to have a left sided neglect could hear the person on his left but would not turn towards him or acknowledge upon discharge awake alert oriented x non focal exam distracted at times poor at identifying social skills pertinent results ct head impression large intraparenchymal hemorrhage within the right frontotemporal lobe with a small subdural component neighboring mass effect with up to a mm leftward shift of midline structures and trace intraventricular extension along the occipital of the right lateral ventricle these findings are relatively stable in comparison to the prior outside hospital study earlier this morning large frontal extra axial spaces likely secondary to chronic frontal lobe atrophy differential diagnosis remains broad however given particulars of appearance consideration can be given to frontotemporal dementia cta head and neck no vascular anomalies or aneurysms noted ct head impression essentially unchanged large intraparenchymal hemorrhage in the right frontotemporal lobe with a tiny subdural component unchanged mass effect as described no new foci of hemorrhage no evidence of developing hydrocephalus cerebral angiogram negative angiogram no vascular anomaly or aneurysm seen ct head impression stable parenchymal hemorrhage at the right frontotemporal lobe with very small subdural component likely representing slowly resolving hematoma with stable mass effect extensive region of perihemorrhagic vasogenic edema overall unchanged however the disproportionate edema particularly anterosuperiorly raises the possibility of an underlying lesion enhanced mri is recommended for better characterization as suggested previously no new focus of hemorrhage brief hospital course yo male admitted after c o a headache x week ct head revealed a right iph w effacement of the right lateral ventricle and small right sdh he was admitted to the icu for close monitoring a cta of the head and neck was done to r o any vascular anomalies because of his report that the headache began after vomitting his exam and head ct remained stable and on he was transferred from the icu to step down on a diagnostic cerebral angiogram was done and showed no indication of aneurysm or venous anomaly he was then transferred to the floor physical therapy and occupational therapy was consulted and cleared the patient for home but felt that he would need cognitive rehab medications on admission calcium w vit d atenolol hctz mvi discharge medications atenolol mg tablet sig one tablet po daily daily hydrochlorothiazide mg capsule sig capsules po daily daily acetaminophen mg tablet sig tablets po q h every hours as needed for pain docusate sodium mg capsule sig one capsule po bid times a day levetiracetam mg tablet sig two tablet po bid times a day disp tablet s refills pantoprazole 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 butalbital acetaminophen caff mg tablet sig one tablet po q h every hours as needed for headache disp tablet s refills discharge disposition home discharge diagnosis right intraparenchymal hemmorrhage right subdural hematoma discharge condition stable nonfocal exam but cognitive problems discharge instructions take your pain medicine as prescribed exercise should be limited to walking no lifting straining excessive bending increase your intake of fluids and fiber as pain medicine narcotics can cause constipation unless directed by your doctor do not take any anti inflammatory medicines such as motrin aspirin advil ibuprofen etc if you have been prescribed an anti seizure medicine take it as prescribed and follow up with laboratory blood drawing in days and fax results to 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 new onset of tremors or seizures any confusion 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 fever greater than or equal to f followup instructions you will need an mri mra which you can at please call dr office to set this up no driving until you are cleared to do so by your primary care physician please call your primary care physian to arrange for neuro psych testing please call to schedule an appointment with dr to be seen in weeks you will need a cat scan of the brain without contrast please call with any questions or concerns completed by,"{
""Diagnoses"": [""severe headache"", ""hit head on cabinet"", ""gastritis"", ""hypertension"", ""borderline high cholesterol"", ""rheumatic fever"", ""tonsillectomy""],
""Medications"": [""penicillins""]
}"
50772,admission date discharge date date of birth sex f service medicine allergies penicillins morphine attending chief complaint altered mental status major surgical or invasive procedure intubation history of present illness initial histpry and physical is as per icu resident dr yo w with pmh of cad cm copd dm afib s p pacemaker brought in by ambulance with ams since this am hx previous fall from wheelchair week ago without evaluation noted lethargy labored breathing fs was at nh pt given d on arrival vs t hr bp rr ra fs she received amps d with repeat fs despite correction of hypoglycemia she remained altered utox positive for opiates and she was given narcan with little response initially placed on bipap but then intubated for airway protection she was noted to have st depressions in leads v v cards felt this was not acs and ce s could be followed patient was transferred to the for further management past medical history cad s p cath on with non obstructive cad dm type copd afib on asa plavix s p pacemaker on osteoporosis chronic joint pain hyperlipidemia gerd anxiety social history nursing home resident family history nc physical exam initial exam in icu vs afebrile gen elderly woman sedated intubated minimally responsive to voice heent perrl og ett in place neck supple no jvd chest cta anteriorly no w r r cv irregular no m r g abd soft nt nd bs ext cool palpable pulses skin mottled blue toes no rashes neuro intubated sedated 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 sed rate pm ck cpk pm asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg pm glucose urea n creat sodium potassium chloride total co anion gap pm po pco ph total co base xs ekg atrial fibrillation with controlled ventricular response at bpm left ventricular hypertrophy with secondary st t wave abnormalities no change from previous cxr limited study with bibasilar atelectasis and vague right upper lung opacity cardiomegaly ct head no acute intracranial hemorrhage or infarction ct chest scattered ground glass and nodular opacities are worrisome for multifocal pneumonia cardiomegaly with bilateral small pleural effusions brief hospital course mrs is a year old female with a pmh significant for copd cad type dm afib s p pacer admitted with hypoglycemia and altered mental status likely secondary to aspiration pneumonia healthcare associated pneumonia this was the most likely cause of the patient s altered mental status and respiratory failure patient had a leukocytosis and cxr findings revealed a vague right upper lung opacity patient was intially intubated for respiratory failure and treated in the icu patient is s p bronchoscopy with bal and blood cultures ngtd sputum culture from with sparse coag neg staph patient is a nh resident and was treated empirically for healthcare associated pneumonia with vancomycin and ceftazidime her vanco trough was checked and was elevated to so vanco was held another vanco trough should be checked at the nh the morning of and vanco should be restarted at mg iv q h if trough is patient will need three more days of antibiotics to finish her course rue swelling patient developed rue swelling and discomfort a right upper extremity duplex was obtained and no dvt was found the swelling may have been due to trauma the swelling was subsiding at discharge the patient had some discomfort which was helped by tylenol which she was already on at her nursing home for chronic joint pain copd the patient was not felt to be having a copd exacerbation at admission she was continued on her home regimen of advair low dose prednisone diamox and albuterol atrovent prn atrial fibrillation patient was monitored on telemetry she became tachycardic to s during admission and her metoprolol was titrated upward for better rate control she will be discharged on lopressor mg po bid the patient was not anticoagulation at admission and this is reportedly due to fall risk cad at admission ecg showed st depression in ii iii avl v v cards was consulted and recommended following ce cardiac biomarkers x drawn with rise in troponin to with flat ck likely representing demand ischemia or lv strain the patient was continued on her home regimen of metoprolol asa plavix and lipitor type diabetes mellitus patient hypoglycemic on presentation on home basal nph which was initially held nph was reintroduced slowly and was titrated based on iss requirement during admission she will be discharge on nph units her admission regimen was u qam and u qpm this should continue to be adjusted as necessary at the nh the patient was also covered with a riss anxiety the patient was restarted on her home regimen of paxil adn prn klonopin prior to discharge chronic joint pain the patient complained of joint pain all over which was controlled once we restarted the tylenol which she was on at her nh it is unclear if she carries a diagnosis of osteoarthritis or not hypernatremia the patient had a serum na of at admission whioh was treated with free water and self correction with po intake her na should be monitored periodically at the nh constipation patient was continued on senns colace with prn miralax f e n the patient had a speecha dn swallow eval whcih revealed mild dysphagia her recommended diet is ground solids and thin liquids with pills whole with thin liquid she may need assistance with meals if her upper dentures are found and if they fit well when placed it would be safe to upgrade her diet to soft or regular consistency solids prophylaxis patient treated with heparin sq for dvt prophylaxis during admission code full dispo patient to be discharged back to the health care center in stable condition medications on admission paxil mg po daily lidoderm patch td q lasix mg po daily fosamax mg po q week diamox mg po daily senna tab po daily colace kcl sr mg po daily lipitor mg po daily lopressor mg po bid insulin nph u qam u qpm regular insulin sliding scale prednisone po bid klonopin mg po bid prn anxiety advair mcg dose disk puff inh tylenol tabs po q h prn pain fosamax mg po weekly plavix mg po daily albuterol nebs prn discharge medications senna mg tablet sig one tablet po bid times a day as needed aspirin mg tablet sig one tablet po daily daily clopidogrel mg tablet sig one tablet po daily daily paroxetine hcl mg tablet sig two tablet po daily daily atorvastatin mg tablet sig one tablet po daily daily furosemide mg tablet sig one tablet po daily daily acetaminophen codeine mg tablet sig tablets po q h every hours as needed for pain acetazolamide mg tablet sig one tablet po q h every hours alendronate mg tablet sig one tablet po qsat every saturday clonazepam mg tablet sig one tablet po bid times a day as needed for anxiety fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day prednisone mg tablet sig one tablet po bid times a day albuterol sulfate mg ml solution for nebulization sig puffs inhalation q h every hours as needed for shortness of breath or wheezing metoprolol tartrate mg tablet sig four tablet po bid times a day magnesium hydroxide mg ml suspension sig thirty ml po daily daily as needed for constipation docusate sodium mg capsule sig one capsule po bid times a day ipratropium bromide mcg actuation aerosol sig one neb inhalation q h prn as needed for shortness of breath or wheezing insulin nph human recomb unit ml suspension sig twenty five units subcutaneous twice a day ceftazidime gram recon soln sig one recon soln injection q h every hours insulin regular human unit ml solution sig one injection as directed for fsbs u fsbs u u u u u notify md discharge disposition extended care facility health care center discharge diagnosis altered mental status hospital acquired pneumonia discharge condition good discharge instructions continue all medications as prescribed follow up with physician at long term care facility continue antibiotics vancomycin ceftazadime for more days the patients vancomycin is being held for now your facility should check a vancomycin trough the morning of if the level is less than then her vancomycin should be restarted at mg iv bid encourage po free wated intake to prevent hypernatremia return to the ed if you have worsening shortness of breath chest pain palpitations or other worrisome signs symptoms followup instructions follow up with physician at long term care facility md completed by [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies penicillins morphine attending chief complaint shortness of breath major surgical or invasive procedure none history of present illness the pt is a y o f with a pmh of cad copd presenting with dyspnea the pt reported acute onset dyspnea starting the day of admission she denied cp she was found to be tachypnic and hypoxic with sats in low s on l nc she was placed on nrb with o sat increased to no n v pt was noted to be lethargic and confused pt recently hospitalized with acute cholangitis due to choledocolithiasis she underwent urgent ercp with stenting and was treated with cipro flagyl in the ed initial vs were t bp p r o sat nrb patient was given solu medrol mg iv x mg x ecg afib with rvr at bpm na lvh with recp st changes cxr demonstrated left basilar atelectasis and probable small left pleural effusion no overt chf cta chest showed pulmonary emboli involving the right main pulmonary artery right upper lobar segmental pulmonary artery and right middle lobe segmental pulmonary artery she was started on a heparin gtt on arrival to the icu the patient is resting comfortably on l nc denies cp states dyspnea is improving c o b l le pain at baseline uneventful micu course hd stable on coumadin echo w o rv strain should check w pcp prior to coumadin as this had not been started for afib le u s pending on transfer she states she feels hungry she does not know why she is in the hospital she denies cp sob she states she feels itchy unable to give further clarification of past medical history past medical history cad s p cath previously with reported non obstructive cad dm hyperlipidemia afib patient not anticoagulated copd fev unknown s p ppm osteoporosis chronic joint pain gerd anxiety gerd anxiety disorder nos dysphagia dementia depression hospital acquired pna with respiratory failure icu stay prior unknown abdominal surgery likely ventral incisional hernia repair with mesh social history the patient is currently a nursing home resident at health care center tobacco none etoh none illicits none family history non contributory physical exam on admission vitals t bp p r o on l nc general alert no acute distress oriented to person year but did not know place or current president heent sclera anicteric mmm oropharynx clear neck supple no lad lungs bibasilar crackles no wheezes rales ronchi cv irregular 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 pulses no clubbing cyanosis or edema calf tenderness r l pertinent results am glucose urea n creat sodium potassium chloride total co anion gap am ck cpk am ck mb notdone ctropnt am calcium phosphate magnesium am wbc rbc hgb hct mcv mch mchc rdw am neuts lymphs monos eos basos am plt count am pt ptt inr pt pm ptt ct chest performed on comparison is made with a prior chest ct scan from as well as a prior chest radiograph from clinical history year old woman with dyspnea evaluate for pe technique mdct was used to obtain contiguous axial images through the chest prior to and following the uneventful administration of cc optiray iv contrast multiplanar reformations were provided findings a pacer device is noted in the right chest wall with lead tips positioned in the right atrium and right ventricle non contrast imaging demonstrates coronary artery calcifications pneumobilia is noted in the upper abdomen there is an eccentric filling defect within the right main pulmonary artery best seen on series image which is compatible with a pulmonary embolism please note recanalized areas within this filling defect suggest that this is a chronic pulmonary embolism there is extension of this filling defect into the right upper lobar and anterior segmental pulmonary arterial branches recanalization through this region also suggests a non acute pulmonary embolism there is a filling defect also noted within the right middle lobe medial segmental branch of the right pulmonary artery this filling defect is occlusive and appears acute the remainder of the pulmonary arterial branches appear patent the aorta contains atherosclerotic calcification though is normal in caliber the heart is enlarged without pericardial effusion there is no lymphadenopathy the airway is centrally patent there is bronchial wall thickening especially in the right upper lobe which is unchanged from prior exam lung windows reveal confluent ground glass opacity in the lungs which is most apparent in the right upper lobe this finding is unchanged and is likely related to advanced rb ild desquamative interstitial pneumonia a nodule is again noted in the left lower lobe on series image which measures mm compressive atelectasis is noted at the lung bases bilaterally in the lingula left lower lobe and portions of the right lower lobe there is no pleural effusion in the visualized upper abdomen there is a small hiatal hernia and pneumobilia is identified within the liver pneumobilia is new from prior ct and clinical correlation is advised please note patient has prior ercp dated and findings are likely secondary to prior sphincterotomy bone windows no suspicious lytic or blastic osseous lesion is seen degenerative changes are noted in the thoracic spine impression pulmonary emboli involving the right main pulmonary artery right upper lobar segmental pulmonary artery and right middle lobe segmental pulmonary artery please note there are likely acute on chronic pulmonary emboli given the eccentric nature of the filling defects with evidence of recanalization through portions of the filling defects emphysema with parenchymal ground glass opacities most apparent in the right upper lobe suggestive of advanced respiratory bronchiolitis mm left lower lobe nodule for which followup in months is advised conclusions the left atrium is mildly dilated no atrial septal defect is seen by d or color doppler there is moderate symmetric left ventricular hypertrophy the left ventricular cavity is unusually small regional left ventricular wall motion is normal left ventricular systolic function is hyperdynamic ef there is no ventricular septal defect right ventricular chamber size is normal with borderline normal free wall function the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the tricuspid valve leaflets are mildly thickened the estimated pulmonary artery systolic pressure is normal there is no pericardial effusion impression no evidence of rv strain le u s prelim no dvt brief hospital course on initial presentation to the pts vitals were t bp p r o sat nrb patient was given solu medrol mg iv x mg x ecg afib with rvr at bpm na lvh with recp st changes cxr demonstrated left basilar atelectasis and probable small left pleural effusion no overt chf cta chest showed pulmonary emboli involving the right main pulmonary artery right upper lobar segmental pulmonary artery and right middle lobe segmental pulmonary artery she was started on a heparin gtt and admitted to the icu she was also found to have a urinary tract infection hospital course by problem embolism pt initially presented with dyspnea hd stable risk factors include immbolitiy and recent hospitalization she was started on a heparin gtt but was subsequently changed to lovenox because of poor iv access she remained on this and was not bridged with coumadin until her pcp dr was contact to discuss any contraindications to anticoagulation with coumadin he felt she did not have any known contraindications and would wish to start therapy and this could be discontinued in the future should she sustain a fall she had le ultrasound done for risk assessment which was negative she was discharged on lovenox mg sc bid with a bridge to coumadin she should remain on lovenox until her inr is at goal atrial fibrillation pt presenting with rvr in setting of hypoxia and pe her metopolol was titrated to mg with improved rate control hypernatremia na on presentation total body overloaded but likely intravascularly dry and was repleted with d w with improvement urinary tract pt was noted to have a uti growing mrsa and providencia stuartii she was initially treated with vancomycin and ceftriaxone but sensetivities returned which showed the mrsa sensetive to bactrim and providencia sensetive to ceftriaxone she will complete days of bactrim and cefpodoxime on discharge blood cultures showed no growth copd fev unknown no current evidence of exacerbation she was continued on outpatient regimen of prednisone mg fluticasone albuterol and atrovent cad chf pt was ruled out for an mi ekg w o ischemic changes she was continued on her beta blocker her aspirin and plavix were discontinued secondary to high bleeding risk with lovenox coumadin after discussion with her pcp her statin was continued lasix was continued per home dose dm pts glucose was elevated while in hospital she was started on nph u qam and u qpm she was given additional sliding scale insulin this should be further titrated as an outpatient hyperlipidemia continued home statin anxiety pt was continued on paxil and clonazepam prn dysphagia pt remained on soft dysphagia diet per home regimen nursing home pts ct showed incidental pulmonary nodule she will need a repeat ct scan in months medications on admission tylenol mg prn mg daily metoprolol mg atorvastatin mg qhs fluticason salmeterol mcg disk albuterol atrovent prednisone mg paroxetine mg qhs clonazepam mg prn alendronate mg q sun novolin ss plavix mg qhs dulcolax fleet enema colace furosemide mg tab daily discharge disposition extended care facility discharge diagnosis pulmonary embolism urinary tract infection discharge condition stable discharge instructions you were admitted to the hospital for some difficulty breathing you were found to have a clot in your lungs you were started on a medication to help break up the clot and keep your blood thin to resolve these clots you will continue to take coumadin for this medication and your blood will be drawn to check its level you were also found to have an urinary tract infection you were started on a medication called bactrim and cefpodoxime to treat this you will need to complete a day course your other medications were adjusted your plavix was stopped your aspirin was stopped your metoprolol was increased to mg twice daily if you have worsening shortness of breath chest discomfort fevers chills worsening abdominal pain or other symptoms please return to the er [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies penicillins morphine attending chief complaint shortness of breath major surgical or invasive procedure intubation extubation picc line history of present illness ms is a yo with history of dementia copd afib and recent pe dx on coumadin who was admitted from her nursing home on with several days of increasing dyspnea and hypoxia to on l nc per review of the nh records it appears she also had increased cough productive of brown sputum as well some fatigue in the ed she received solumedrol mg iv x although the team wanted to obtain a cta to evaluated for pe she became increasingly agitated after the dose of steroids and they were unable to obtain imaging despite trying mg of haldol moreover pe was felt to be low on the differential given that her inr was on presentation on the floor the team admitting her felt that she most likely had a copd exacerbation superimposed on some mild heart failure volume overload they were treating her with mg lasix daily increased from mg daily at nh and levofloxacin her home prednisone was continued at mg daily on the morning of transfer to the icu her oxygen saturation dropped from to on l she was noted to be in rapid atrial fibrillation with a rate of she had rales b l and elevated the team gave her an extra dose of lasix mg iv x her heart rate improved after metoprolol mg iv x but she remained hypoxic with oxygenation of on l face mask and was transferred to the unit for further care upon arrival to the icu the patient was refusing to converse with the doctors because she reported it worsened her shortness of breath she endorsed orthopnea as well past medical history cad per chart however had non obstructive cad on previous cath per report multiple bilateral pes dx dm dyslipidemia afib on coumadin copd per chart but no smoking history and no s p ppm unclear indication anemia with baseline hct osteoporosis chronic joint pain gerd anxiety depression dysphagia per records though not noted to be on special diet dementia prior unknown abdominal surgery likely ventral incisional hernia repair with mesh intubated in with mrsa pneumonia acute cholangitis in s p ercp with sphincterotomy social history the patient is currently a nursing home resident at health care center tobacco none etoh none illicits none family history non contributory physical exam upon arrival to icu on high flow mask with oxygen alert oriented to self and year but not place answering questions appropriately but often frustrated and swearing pupils equal eomi no scleral icterus face symmetric mucous membranes moist neck supple no thyroid enlargement somewhat elevated at cm s s irregularly irregular and somewhat distant heart sounds mild kyphosis tachypneic and speaking in short sentences using accessory muscles early coarse crackles way up on right and bronchial breath sounds in left lung fields abd soft and not tender not distended no hepatosplenomegaly speech intact strength in ue and le b l though patient is not particularly cooperative with exam pitting edema b l feet are warm and well perfused some clubbing of extremities dp palpable b l no rash or erythema on discharge similar exam with bp range systolic and hr range in s oxygen saturation is on ra whole body pitting edema heart with rrr and lungs with bibasilar crackles abdomen bs soft nt pertinent results admission urine color straw appear clear sp blood neg nitrite pos protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk sm wbc bacteria mod yeast none epi pt ptt inr pt lactate glucose urea n creat sodium potassium chloride total co anion gap ck cpk ctropnt wbc hct plt count ekg afib with normal axis and qtc of lvh with st depressions in i avl and v v isolated q wave in iii no change as compared to admission ekg or ekg from chest pa lat study date of pm impression findings are likely consistent with mild congestive heart failure with a persistent moderate left pleural effusion discharge wbc rbc hgb hct mcv mch mchc rdw plt ct was on abx and then stopped increased warfarin dose today to mg pt inr pt pt inr pt pt ptt inr pt pt ptt inr pt glucose urean creat na k cl hco angap alt ast alkphos amylase totbili calcium phos mg brief hospital course yo woman with h o afib and pe on coumadin admitted with hypoxia likely due to copd exacerbation she was subsequently transferred to the unit in the setting of worsening hypoxia and flash pulmonary edema due to a fib with rvr hypoxic respiratory failure ms was originally admitted for hypoxia that was attributed to copd exacerbation she was started on levofloxacin and steroids she was then noted to go into a fib with rvr on her second day of admission where she was noted to have flash pulmonary edema and was transferred to the icu in the icu she was noted to have a worsening left pleural effusion as well as a possible infiltrate she was noted to have ongoing respiratory distress on that attributed to a combination of the pleural effusion underlying parenchymal disease pulmonary edema as well as questional pna pt was intubated and started on hospital acquired pneumonia coverage of cefepime vancomycin and ciprofloxacin day although she did start levofloxacin on she has completed this course before discharge she was also given iv furosemide continued on her chronic prednisone of mg daily her home advair atrovent and albuterol was continued following improvement with oxygenation status she was extubated on and transferred to the floor on nasal canula l this was weaned over time back to room air with her oxygen saturation remaining she had been getting mg iv lasix daily she will be discharged on the equivalent lasix po mg daily please check chemistries on and again on to ensure increase in her creatinine afib with rapid rate stimulus for a fib with rvr likely hypoxia given her clinical status at that time she improved rapidly with metoprolol iv mg x doses in the icu her home metoprolol and diltiazem were continued and she had no further episodes of rvr note that during prior admissions she was not on coumadin because of fall risk this will need to be readdressed in future once she has completed coumadin course for her pe see below in addition her chads score is and she should be on coumadin for this st depressions elevated troponin lateral st depressions are not new and are likely related to her lvh she had a borderline elevated troponin which may have been demand related she denied chest pain her aspirin and metoprolol were continued likely uti treated to completion with cefepime for e coli uti diarrhea she had antibiotic associated diarrhea she was ruled out for c diff the diarrhea resolved days after the antibiotic course completed recent pe diagnosed coumadin dose was reduced while on antibiotics and she was subtherapeutic on day of discharge after the antibiotic course finished she is discharged on mg daily and should have coags checked on and then again on goal inr between hypernatremia likely from lack of access to free water improved with d iv fluids dyslipidemia continued statin dm adjusted nph insulin and adjusted sliding scale anemia baseline hct remained stable through admission osteoporosis carries this diagnosis per chart records however not on medications and is on chronic steroids should have outpatient eval chronic joint pain lidoderm patch for back continued anxiety and depression continued paxil her home clonazepam mg was changed to as needed dementia frequent reorientation gerd continued home ppi fen speech and swallow eval for possible dysphagia positive for dysphagia diabetic soft diet for now low sodium access picc line placed comm have been in contact with daughters who is her hcp other daughter is code full code confirmed with hcp medications on admission home medications per nh records prednisone mg daily metoprolol mg tid diltiazem mg daily lasix mg daily simvastatin mg hs paroxetine mg daily pantoprazole mg daily vicodin mg tablet q h prn pain tylenol mg mg q h prn pain senna tabs hs docusate mg milk of magnesia ml prn constipation fleet enema daily prn constipation bisacodyl mg prn constipation ocean spray intranasal tid prn atrovent neb q h prn advair guaifenesin cough syrup ml q h prn cough ambien mg qhs prn insomnia clonazepam mg lidoderm patch to upper back insulin novolin n units every morning and units at pm with a sliding scale of regular insulin discharge medications simvastatin mg tablet sig two tablet po daily daily lidocaine mg patch adhesive patch medicated sig one adhesive patch medicated topical daily daily guaifenesin mg ml syrup sig mls po q h every hours as needed for cough fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day paroxetine hcl mg tablet sig tablets po daily daily metoprolol tartrate mg tablet sig one tablet po tid times a day senna mg tablet sig one tablet po hs at bedtime as needed for constipation acetaminophen mg tablet sig tablets po q h every hours as needed for pain or fever insulin nph regular human unit ml suspension sig one subcutaneous twice a day prednisone mg tablet sig one tablet po daily daily warfarin mg tablet sig one tablet po once daily at pm zolpidem mg tablet sig one tablet po hs at bedtime as needed for insomnia insulin nph regular human unit ml suspension sig one subcutaneous twice a day pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po once a day vicodin mg tablet sig tablets po q h prn as needed for pain furosemide mg tablet sig one tablet po once a day diltiazem hcl mg capsule sust release hr sig one capsule sust release hr po once a day hold for sbp or hr less than milk of magnesia mg ml suspension sig one po once a day as needed for constipation ipratropium bromide solution sig one inhalation every six hours as needed for shortness of breath or wheezing clonazepam mg tablet sig one tablet po twice a day as needed for anxiety docusate sodium mg capsule sig one capsule po twice a day insulin lispro unit ml solution sig as directed subcutaneous as directed discharge disposition extended care facility healthcare discharge diagnosis primary copd exacerbation a fib with hospital required pneumonia diarrhea pulmonary edema secondary coronary disease h o bilateral pes diabetes mellitus ii dyslipidemia anemia osteoporosis discharge condition stable afebrile discharge instructions you were admitted to the hospital after experiencing difficulty breathing whilst in the hospital you were noted to go into an abnormal heart rhythm called atrial fibrillation with rapid rate and required care in the intensive care unit in the unit you had continued difficulty breathing and were intubated for days you were given a course of iv antibiotics as we think you also had pneumonia you were started on some new medications warfarin mg by mouth daily diltiazem mg by mouth four times a day you had some medication changes metoprolol increased from mg by mouth twice a day to mg by mouth three times a day insulin nph increased to units in the morning and units in the afternoon a new insulin sliding scale lasix increased from mg by mouth daily to mg by mouth daily for facility staff please check chem pt and inr checked on as well as if you experience any nausea fevers chills vomiting chest pain shortness of breath please return to the ed followup instructions provider scan phone date time dr your primary care physician will visit you at health care facility sometime over the next few days to monitor your progress md completed by [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies penicillins morphine attending chief complaint altered mental status major surgical or invasive procedure none history of present illness patient is a yof h o bilateral pe s af currently anticoagulated copd cad and dementia unclear baseline recently discharged to nursing home on to complete day course of cefepime and vancomycin for presumed hcap transferred from nursing home for concern of alt mental status with inc lethargy at baseline from prior dc summaries patient is awake confused oriented to name but answers commands per micu note initial ed vitals were unknown home much o underlying pna was thought to be etiology of ams and patient was continued on vanc cefepime abg showed pco of and patient was started on bipap note baseline co from prior abg s is from high s s patient was continued on antibiotics and completed her day course on during interview upon transfer patient reports she was brought to hospital because people felt she had another pna she reported cough but denied any fevers chills abdominal pain nausea or vomiting she did report some discomfort with urination but was unable to elaborate further or even if this was new or old she reports pain in her bilateral lower extremities a chronic issue severe arthritis and she reports being wheel chair bound at baseline she also endorsed a history of smoking and known dx of copd requiring o at baseline but was unable to elaborate further vital signs at transfer evaluation were irreg l patient was alert oriented to self only and able to answer some questions she had impaired attention but was able to follow most commands and participated in a brief neurological evaluation past medical history per omr cad multiple bilateral pe s tii dm dyslipidemia af on coumadin copd anemia with basline hct osteoporosis chronic joint pain gerd dementia anxiety depression dysphagia per records though not noted to be on special diet dementia mrsa pna req icu admission with ett earlier this year acute cholangitis social history resides at hcc reports h o smoking no etoh no drugs family history unknown physical exam vital signs t bp hr rr o on bipap physical exam general lethargic woman minimally responsive to voice and rub heent pupils equal round and reactive no jvd appreciated cardiac s s irregular no murmur appreciated lungs significant upper airway sounds difficult to appreciate breath sounds otherwise abdomen nontender or distended bs present soft extremities no edema or calf pain dorsalis pedis posterior tibial pulses neuro minimally responsive pupils as above cranial nerve exam otherwise deferred pertinent results pm urine color yellow appear clear sp blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg pm lactate pm glucose urea n creat sodium potassium chloride total co anion gap calcium phosphate magnesium pm wbc rbc hgb hct mcv mch mchc rdw neuts lymphs monos eos basos plt count imaging head ct chronic microvascular infarction no acute intracranial process no ich cxr recurrent left basal atelectasis and pleural effusion pneumonia cannot be excluded radiographically brief hospital course a p yof h o bilateral pe s af copd cad and dementia s p completion of day course for hcap with vancomycin and cefepime transferred from nursing home for concern of alt mental status with inc lethargy and found to be co retaining co retention endorses h o copd and smoking but unable to elaborate further s strongly suggestive of obstructive lung disease at baseline abg s reveal element of co retention with co s ranging from s unclear whether co retention was exacerbated by over resucitation with o or whether copd flare led to co retention and ams patient did not endorse sob fevers chills or additional infectious sx and patient is s p full day course of iv abx at admission patient was placed on bipap with rapid improvement of her abg and mental status patient was not noted to be fluid overloaded and likley picture represented copd exacerbation s p recent pna patient was maintained on prn nebs she did not experience any nocturnal desaturations and mental status remained at baseline throughout hospitalization pulmonology was consulted regarding potential evaluation for nocturnal bipap for copd treatment and arrangements were made at the time of discharge for pulmonology follow up for further evaluation and management altered mental status ams was attributed to co retention strengthened by rapid improvement with bipap neuro exam was non focal and imaging was not suggestive of any acute event at baseline patient is interactive able to answer questions and follow commands she is oriented only to self pneumonia initial cxr was a poor study with low lung volumes with possible continued retrocardiac infiltrate patient was afebrile with normal wbc count antibiotics were continued to complete day course from prior admission for hcap this was felt to likely represent treated pna with residual cxr changes further antibiotics were deferred dm ii patient was initially hypoglycemic at admission but easily correct with improvement mental status this episode may have contributed to overall clouded clinical picture patient was maintained on iss and her regular daily insulin regimine was continued at discharge af patient remained rate controlled throughout stay she was monitored on telemitry throughout her stay on the floor metoprolol diltiazem and coumadin were continued of note her coumadin was increased at discharge for a subtherapeutic inr code status presumed full confirmed at contacts daughter dispo patient was discharged to hcc with follow up appointments with pulmonology and for sleep study medications on admission per discharge fluticasone salmeterol mcg inh acetaminophen mg po q h prn pain pantoprazole mg po q ipratropium bromide inhalation q h albuterol sulfate mg ml neb q h prn dyspnea docusate sodium mg po bid paroxetine hcl mg po daily metoprolol tartrate mg po tid prednisone mg po bid simvastatin mg po daily dilt cd mg po daily senna mg po bid prn lidocaine mg patch tp daily clonazepam mg po bid ambien mg po qhs magnesium hydroxide prn guaifenesin mg ml syrup sig mls po q h prn hydrocodone acetaminophen mg q prn pain ferrous gluconate mg po daily lasix mg po daily warfarin mg po daily humulin units in am and units pm humalog sliding scale cefepime gram q until vancomycin g iv q until discharge medications acetaminophen mg tablet sig tablets po q h every hours as needed for pain ha 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 albuterol sulfate mg ml solution for nebulization sig one inhalation q h every hours as needed for wheezing dyspnea ipratropium bromide solution sig one inhalation q h every hours as needed for wheezing dyspnea paroxetine hcl mg tablet sig three tablet po daily daily pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours prednisone mg tablet sig one tablet po bid times a day simvastatin mg tablet sig one tablet po daily daily warfarin mg tablet sig one tablet po once a day diltiazem hcl mg tablet sig two tablet po qid times a day metoprolol tartrate mg tablet sig one tablet po tid times a day humulin unit ml suspension sig units subcutaneous q am units in am home dose humulin unit ml suspension sig units subcutaneous q pm units every pm home dose fluticasone salmeterol mcg dose disk with device sig one inhalation twice a day discharge disposition extended care facility healthcare discharge diagnosis co retention with narcosis secondary to copd exacerbation discharge condition good improved normal sats on l of oxygen patient in afib rate controlled discharge instructions ms you were admitted to the hospital out of concern that you had another infection in your lung testing showed that you were not breathing well we treated your breathing and completed the full course of antibiotics for your prior pneumonia you will benefit from seeing a lung doctor after you leave the hospital and we have arranged follow up you may also benefit from a device which can help you breath at night we are arranging an appointment for next week to be evaluated for this treatment please call your doctor or return to the emergency department for any of the following respiratory distress continued or worseninig chest pain new nausea with vomiting abdominal pain fevers chills passing out any other new or change in symptoms which concern you we made no changes in your medications please resume all of your home medications please note the following appointments we have arranged for you below lung doctors building on provider function lab phone date time provider interpret w lab no check in intepretation billing date time provider dr phone date time sleep study ma date time pm sleep study provider building date time am follow up followup instructions lung doctors building on provider function lab phone date time provider interpret w lab no check in intepretation billing date time provider dr phone date time sleep study ma date time pm sleep study provider building date time am follow up [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies penicillins morphine attending chief complaint hypoxia major surgical or invasive procedure none history of present illness f pt with a hx of copd spirometry with fvc fev ratio of predicted on l hx bilateral pe s af currently anticoagulated non obstructive cad ef to pacemaker and dementia baseline ao presented today from with hypoxia per records the pt was noted at pm to have the following vitalsl rr and on l baseline l usually in s the pt received albuterol nebs x pm and pm and was subsequently sent to the ed upon arrival to the ed pt reported to have crackles l r denied sob abg the pt was given neb solumedrol mg ivx ed was concerned for lul infiltrate and thus drew bcx and treated pt with vancomycin gm iv levofloxacin mg ivx vitals prior to transfer to the floor on l the patient unable to adeuately answer the following review of symptoms fever chills night sweats loss of appetite fatigue chest pain palpitations rhinorrhea nasal congestion hemoptysis dyspnea orthopnea paroxysmal nocturnal dyspnea nausea vomiting diarrhea constipation hematochezia melena dysuria urinary frequency urinary urgency focal numbness focal weakness myalgias arthralgias past medical history per omr af on coumadin cad per chart however had non obstructive cad on previous cath multiple bilateral pe s dmii dyslipidemia copd anemia with basline hct osteoporosis chronic joint pain gerd dementia anxiety depression dysphagia per records though not noted to be on special diet dementia mrsa pna req icu admission with ett acute cholangitis with acute cholangitis due to choledocolithiasis underwent urgent ercp with stenting pulmonary nodule noted on ct mm left lower lobe nodule social history reports h o smoking no etoh no drugs resides at hcc family history nc physical exam t bp hr rr o ra physical exam general pleasant chronically ill appearing appearing in nad oriented to self not location or date heent normocephalic atraumatic no conjunctival pallor no scleral icterus perrla eomi mmm op clear neck supple no lad no thyromegaly cardiac irregularly irregular s s no murmurs rubs or flat lungs dimished bs at right base left sided crackles poor airmovement no appreciable wheezes anteriorly or posteriorly abdomen nabs soft obese nt nd no hsm extremities trace bilateral pedal edema dorsalis pedis posterior tibial pulses skin no rashes lesions ecchymoses neuro a ox appropriate cn grossly intact strength in ues reflexes equal bl normal coordination gait assessment deferred psych calm pleasant pertinent results admission laboratory studies mcv neuts lymphs monos eos basos glucose urea n creat sodium potassium chloride total co lactate pt ptt inr pt abg o o flow po pco ph total co base xs aado req o comments nasal ua blood neg nitrite pos protein glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg rbc wbc bacteria many yeast none epi micro sputum gram stain gpc cx pending urine cx pending cxr evaluation is limited by the position of the head over the upper chest and low lung volumes again noted is increased opacification at the left lung base most likely atelectasis and increased pleural effusion although underlying infection is not excluded there is slight upper lobe redistribution particularly on the left with hilar fullness but there is no overt pulmonary edema the heart size is not significantly changed allowing for differences in technique two pacer leads follow a normal course from the right sided battery pack terminating in the expected position of the right atrium and ventricle degenerative change of the bilateral glenohumeral joints is noted with unchanged inferior displacement of the right shoulder impression slight interval increase in left pleural effusion and basilar atelectasis cardiomegaly and probable mild failure but no overt pulmonary edema micro urine cx gnr speciation pending sputm gram stain final pmns and epithelial cells x field per x field gram positive cocci in pairs chains and clusters 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 a p f pt with hx of bilateral pe s af copd non obstructive cad and dementia presenting with hypoxemia hypoxemia pt on baseline l at presented to the micu on l ed abg with p of pco of indicative of a a gradient no clear evidence of infiltrate on cxr although could not exclude retrocardiac opacity as source of infection pt now at baseline requirement unclear precipitating events for transient hypoxia copd excerbation resolving with steroids atelectasis fluid overload pe pt now at baseline without appreciable wheezes on exam no increase in sputum production from baseline no reported fevers of chills the patient was continued on l the pt was discharged with additional days of po cefpodoxime to treat presumed bronchitis hypercarbia pt with pfts suggestive of copd fvc fev ratio of predicted however pt with tachypnea wheezing increase in productive cough pt with hx of pco s currently breathing comfortably and mentating likely close to baseline hco of is at patients approximate baseline fluid status pt with initial hct of baseline approx in setting of increase bun and slightly increased pt that was suggestive of intravascularly depletion however her fluid status is difficult to assess given crackles on physical exam and suggestion of mild fluid overload on cxr the patient was felt to be close to euvolemia and thus was not diuresed during her hospital course uti pt positive urine cx k gnr per records the pt was part way through a course of po macrobid given the patients pulmonary symptoms the patient was started on po cefpodoxime to cover both urinary and pulmonary potential organisms mental status non focal neuro exam baseline reported to be aox patient currently calm unclear if patient altered from baseline the patients daughter was and per report her mental status exam was at baseline at the time of discharge dm ii iss while in house atrial fibrillation currently rate controlled on metoprolol and diltiazem inr was supratherapeutic without signs of bleeding the icu team anticipate jump in inr given pt received levaquin and thus the patients coumadin was held the patient was discharged on her home dosing of metoprolol and diltiazem the patients inr was on discharge given that she will remain on cefpodoxime for additional days the plan will be as following fri cefpodoxime no coumadin sat cefpodoxime no coumadin sun cefpodoxime mg coumadin mon cefpodoxime mg coumadin inr check tue cefpodoxime coumadin per inr medications on admission coumadin mg daily zocor mg po daily metoprolol mg po tid diltiazem mg po four times daily albuterol mg ml neb ipratroium advair mcg mcg humalog sq novolin clonazepam mg po bid paroxetine mg po daily zolpidem mg tab colace mg senna mg tabs po mom ferrous gluconate mg po daily pantoprazole mg daily vicodin mg guaifenesin mg ml lidocaine saline nasal spray discharge medications diltiazem hcl mg tablet sig one tablet po qid times a day albuterol sulfate mg ml solution for nebulization sig one neb inhalation every four hours as needed for wheeze guaifenesin mg ml syrup sig mls po q h every hours as needed for cough fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day metoprolol tartrate mg tablet sig one tablet po tid times a day lasix mg tablet sig one tablet po once a day vicodin mg tablet sig one tablet po twice a day pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours cefpodoxime mg tablet sig one tablet po q h every hours for days clonazepam mg tablet sig one tablet po bid times a day simvastatin mg tablet sig one tablet po daily daily ferrous gluconate mg mg iron tablet sig one tablet po daily daily bisacodyl mg suppository sig one suppository rectal hs at bedtime as needed for constipation senna mg tablet sig one tablet po daily daily paroxetine hcl mg tablet sig one tablet po daily daily docusate sodium mg capsule sig one capsule po bid times a day phenazopyridine mg tablet sig one tablet po tid times a day for days lidocaine mg patch adhesive patch medicated sig one adhesive patch medicated topical daily daily insulin nph regular human unit ml suspension sig units qam units qpm subcutaneous twice a day insulin lispro unit ml solution sig per sliding scale subcutaneous qachs zolpidem mg tablet sig one tablet po at bedtime as needed for insomnia prednisone mg tablet sig one tablet po twice a day discharge disposition extended care facility health care center discharge diagnosis primary diagnosis bronchitis secondary diagnosis copd discharge condition mental status confused sometimes level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions you were admited to the hospital with low oxygen levels which were not much diferent from your usual oxygen levels you had a chest x ray which did not show any pneumonia we think your symptoms may be from bronchitis you also had a urinary tract infection you were treated with days of cefpodoxime an antibiotic for both of these infections we made the following changes to your medications we added cefpodoxime for a urinary tract infection and bronchitis we added pyridium for urinary burning please keep all of your follow up apointments and take all of your medications as prescribed followup instructions please make an appointment to see your primary care doctor in the next weeks you should also follow up with your pulmonary doctor dr,{}
29392,admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint s p tracheostomy elective major surgical or invasive procedure awake tracheotomy direct laryngoscopy esophagoscopy biopsy of laryngeal mass laparoscopic gastrostomy tube insertion history of present illness year old woman who has had dyspnea dysphagia and hoarseness since these symptoms progressed and by late she was experiencing choking on with eating intermittent dysphagia with solids and shortness of breath that she attributed to increasing mucus production laryngoscopy in clinic showed a supraglottic mass a neck ct demonstrated a left sided supraglottic mass extending from the epiglottitis to the left vocal cord she was electively admitted for a planned tracheostomy and direct laryngoscopy for a recently discovered laryngeal mass at the time of admission she was eating without report of aspiration past medical history chronic obstructive pulmonary disease dyslipidemia hypertension social history she has a pack year smoking history but quit smoking seven years ago family history non contributory physical exam physical exam on admission vitals t hr bp r sat on shovel mask fio gen elderly woman laying in bed nad alert heent at nc anicteric eomi perrl op clear edentulous mmm neck jvp cm trach in place with some serosanguinous drainage on dressing chest rrr distant heart sounds no murmurs lungs cta apically laterally abd obese soft nd nt bs ext no e c c wwp with dp pulses neuro cn ii xii intact b l unable to assess to pain skin warm and dry pertinent results glucose urea n creat sodium potassium chloride total co anion gap calcium phosphate magnesium wbc rbc hgb hct mcv mch mchc rdw plt count tracheostomy tube is present with the tip at the thoracic inlet subcutaneous emphysema on both sides of the neck is present consistent with recent surgery no pneumothorax is seen atelectasis of the left base is present degree of failure is seen some densities are present in the left upper zone consistent with the pleural calcifications seen on the ct biopsy left larynx supraglottic mass biopsy poorly differentiated invasive squamous cell carcinoma brief hospital course year old woman with a laryngeal mass diagnosed with poorly differentiated laryngeal squamous cell carcinoma stable with tracheostomy and g tube placement carcinoma biopsy of the laryngeal mass done demonstrated poorly differentiated invasive squamous cell carcinoma intraop findings were notable for a bulky exophytic mass emanating from left aryepiglottic fold extending to medial wall of left piriform sinus and onto left true cord elective tracheostomy was also done on she tolerated the procedure well she required oxygen by trach mask she initially required quite a lot of suctioning but was later able to clear secretions mostly on her own patient underwent first session of planning by xrt on and should follow up with the rest of her session appointments on at she will also with dr for possible chemotherapy pneumonia there was concern that the patient may have had an aspiration event complicated by pneumonia following her tracheostomy procedure her wbc count rose to two days following the procedure although she never manifested a clear infiltrate on cxr and was not febrile sputum cultures were obtained but no pathogens were isolated she was initially treated with five days of levofloxacin this was broadened to pip tazo on when she developed increased secretions her secretions have since diminished she completed days of pip tazo for a total day course paroxysmal atrial fibrillation she had no prior hx of a fib before admission however while monitored in the icu she had at least three episodes of paroxysmal afib cardiac enzymes were negative she remained in sinus rhythm following this metoprolol was given at mg tid upon discharge it was changed to mg dysphagia she had difficulty with swallowing since prior to admission following her tracheostomy she had coughing after attempting po intake she had aspiration during her swallowing evalulation as laproscopic g tube placement was performed on she is tolerating tube feedings very well and remains npo free water flushes were increased to q hours due to hypernatremia pleural effusions these were relatively stable on cxr however given her effusions and peripheral edema we felt she warrented evaluation for chf echo showed normal ef mild atrial dilation moderate pa systolic hypertension she was oxygenating well and it was felt she did not need maintenance lasix hypertension her lisinopril was stopped in favor of rate control with metoprolol following episode of paroxysmal afib as bps have been normal to high her metoprolol may need to be titrated up her diuretics triamterene hctz were held given clinical stability and transient hypernatremia these can be restarted at rehab as needed for edema or pressure control copd albuterol and ipratropium neb treatments were given hyperlipidemia atorvastatin was continued full code medications on admission lipitor mg daily lisinopril triamterene hctz discharge medications albuterol mcg actuation aerosol puffs inhalation q h every hours as needed for wheeze ipratropium bromide mcg actuation aerosol two puff inhalation q h every hours lansoprazole mg tablet rapid dissolve dr one tablet rapid dissolve dr daily daily tablet rapid dissolve dr s miconazole nitrate powder one appl topical qid times a day as needed docusate sodium mg ml liquid ten ml po bid times a day atorvastatin mg tablet one tablet po daily daily acetaminophen mg ml solution ml po q h every hours as needed for pain metoprolol succinate mg tablet sustained release hr one tablet sustained release hr po twice a day hold for sbp hr discharge disposition extended care facility rehab center discharge diagnosis laryngeal cancer squamous cell carcinoma dysphagia paroxysmal atrial fibrillation copd discharge condition stable discharge instructions you were admitted for a planned tracheotomy and biopsy of the mass near your vocal cords the biopsy showed squamous cell carcinoma a type of cancer you met some oncology doctors and with them as an outpatient we also inserted a tube into your stomach for eating because you were having difficulty swallowing please take all of your medications as prescribed and keep all of your scheduled appointments please return to the hospital if you have difficulty breathing change in phlegm fever abdominal pain or any other new symptoms that you are concerned about we started the medications metoprolol and lansoprazole while you were here we have stopped your lisinopril and triamterene hctz for now but these may been added back by your doctors for pressure control instructions you have the following upcoming appointments wednesday pm for radiation therapy planning md phd oncology phone date time and md phone date time dr ear nose and throat tuesday at pm phone number is please have lab work including sodium check done on or about [NEW_RECORD] admission date discharge date date of birth sex f service emergency allergies patient recorded as having no known allergies to drugs attending chief complaint increased secretions major surgical or invasive procedure trach change history of present illness patient is a y o f with t n supraglottic scca currently undergoing chemo xrt and s p tracheotomy on who presents from w increased and thickened secretions with resultant difficulty breathing she notes progressive increased and thicker secretions over the past weeks worse yesterday and today she has difficulty breathing when the trach gets plugged with thick secretions and this is relieved w multiple suctioning passes she reports her last trach change was at approximately weeks ago she has been tolerating chemo xrt reasonably well and reports she has only remaining xrt sessions and remaining treatment of chemotherapy with reduced dose taxol and carboplatin she has had some reddness over the anterior neck x several weeks and throat pain since starting xrt denies fever chest pain n v abd pain she takes nothing by mouth and receives all nutrition per g tube at she had an episode of stridor and was given solumedrol mg x and albuterol atrovent nebs however she continued to have sob given concern for edema airway obstruction she was transferred to for evaluation in the ed vs were t hr bp rr l she was evaluated by ent in ed fiberoptic exam showed erythema but no airway edema ent recommended stopping passe muir valve humidified tc saline nebs qid tracheostomy tube change and speech and swallow evaluation currently the patient reports that she feels tired and is complaining of a sore throat she denies chest pain sob n v abdominal pain she reports that her secretions have improved past medical history laryngeal scca s p trach s p g tube currently undergoing chemo xrt afib w rvr h o aspiration pna htn copd dyslipidemia social history she has a pack year smoking history but quit smoking seven years ago currently living at rehab since her trach placement family history non contributory physical exam vs t bp hr rr tm general pleasant well appearing woman no acute distress heent mmm eomi perrl neck trach erythema surrounding trach site heart bradycardic regular no m r g lungs ctab abdomen soft nt nd bs no masses ext edema warm well perfused neuro aaox pertinent results chest pa and lateral a tracheostomy tube appears in appropriate position a rounded opacity at the left cardiophrenic angle which causes opacity posteriorly on the lateral film is consistent with fat herniating the diaphragm as seen on previous chest ct no focal pulmonary opacities to indicate pneumonia are seen there is flattening of the diaphragm and pruning of the pulmonary vasculature in the apices consistent with known emphysematous changes there is biapical scarring there is a convex right thoracolumbar scoliosis impression no acute cardiopulmonary disease ent fiberoptic exam via nose np no mass posterior pharyngeal wall no edema valleculae w some pooled secretions epiglottis slightly thickened c w xrt with diffuse erythema left tvf not mobile moderate thickened and erythematous mucosa over bil arytenoids pooled thick yellow secretions in post cricoid space and piriforms fiberoptic exam via trach trach in good position tracheal rings visible with normal mucosa ecg atrial fibrillation with rapid ventricular response left anterior fascicular block compared to the prior tracing of atrial fibrillation has appeared pm wbc rbc hgb hct mcv mch mchc rdw plt ct am wbc rbc hgb hct mcv mch mchc rdw plt ct am wbc rbc hgb hct mcv mch mchc rdw plt ct am wbc rbc hgb hct mcv mch mchc rdw plt ct pm neuts bands lymphs monos eos baso atyps metas myelos nrbc pm pt ptt inr pt am gran ct am gran ct pm glucose urean creat na k cl hco angap am glucose urean creat na k cl hco angap brief hospital course assessmen plan y o f with t n supraglottic scca currently undergoing chemo xrt and s p tracheotomy on who presents from w increased and thickened secretions with resultant difficulty breathing sob increased secretions airway evaluated by ent in ed and showed no evidence of edema increased secretions likely secondary to radiation induced scarring of upper airway and or use of passe muir valve and lack of humidified air through trach however we could not rule out infection as source of increased secretions levo flagyl started at switched to zosyn as well as improved trach care with humidified o q hr suctioning and trach change with inner cannula allowing frequent cleaning all these interventions led to significant improvement in respiratory status she should continue zosyn for additional days for a total day course she should continue trach care as above with constant humidified o frequent suctioning and cleaning of inner canula and spiriva nebulizers she should not use a passe muir valve as this inhibits clearing of secretions for the next days she should keep the trach cuff continously inflated after this time she may deflate it intermittently to speak she should then have speech and swallow evaluation for aspiration risk when previously seen by speech and swallow at at last admission she was deemed to be an aspiration risk but this may have improved after radiation and chemotherapy until that evaluation she should not take po food follow up with dr of ent has been arranged sputum gram stain showed gram positive rods cultures are still pending at this time the gram positive rods are not considered to be pathogenic at this time laryngeal ca patient is currently undergoing chemo xrt received doses of xrt while inpatient she should continue chemo and xrt as per her primary oncologist dr anemia stable low hematocrit no evidence of active bleeding neutropenia white count low on admission at with anc of this increased to on hd this made interpretation of white count difficult in determining presence of infection a fib admitted in nsr went into what was initially called atrial fibrillation during chest pt and converted to sinus spontaneously ekg done near that time showed p waves of several morphologies raising the possibility of mat although the patient was not tachycardic review of prior ecgs does not clearly show atrial fibrillation this diagnosis was made in during a prior icu stay and again reverted to sinus spontaneously she was rate controlled but not anti coagulated at that time she should see a cardiologist as an outpatient to consider holter monitor further diagnosis of atrial fibrillation vs mat as well as consider anticoagulation for paroxysmal afib hypertension bp well controlled with ace inhibitor and beta blocker hyperlipidemia continued statin copd no acute issues continued spiriva and albuterol code status full code patient reports that she does not what to be on life support however she currently is intubated via trach medications on admission tylenol tab q hrs lipitor mg qhs flagyl iv mg q hrs last at pm mvt miralax qam missed this am benadryl lidocaine maalox swish and spit fluconazole mg pgtube for two more days insulin ss not really needing nystatin swish and spit cc prevacid mg levaquin mg iv qhs until lisinopril mg daily lopressor mg tid spiriva daily discharge medications atorvastatin mg tablet one tablet po hs at bedtime hexavitamin tablet one cap po daily daily medication maalox diphenhydramine lidocaine ml po tid prn swish and spit nystatin unit ml suspension five ml po qid times a day as needed lansoprazole mg tablet rapid dissolve dr one tablet rapid dissolve dr daily daily lisinopril mg tablet one tablet po daily daily metoprolol tartrate mg tablet one tablet po tid times a day tiotropium bromide mcg capsule w inhalation device one cap inhalation daily daily heparin porcine unit ml solution units injection tid times a day albuterol sulfate mg ml solution one inh inhalation q h every hours as needed piperacillin tazobactam g recon soln one recon soln intravenous q h every hours day last day acetaminophen mg ml solution two vials po every hours as needed for pain please do not exceed grams of tylenol daily discharge disposition extended care facility rehab center discharge diagnosis primary respiratory distress tracheostomy laryngeal cancer atrial fibrillation discharge condition good no respiratory difficulty vital signs stable tolerating g tube feeding needs speech and swallow evaluation at discharge instructions you were admitted for increased secretions into your tracheostomy tube these may have been due to a combination of infection perhaps due to aspiration drying of secretions due to radiation therapy lack of humidified air through the trach and use of passe muir valve your tracheostomy was changed to one with an inner canula which will allow for more frequent cleaning you were seen by ent and speech and swallow services who recommended stopping the passe muir valve for at least the next days after which you can use it for short periods when you need to talk when not speaking you should keep the trach cuff inflated and have continuous humidified oxygen running through the tubing you should be evaluated by speech and swallow services at for aspiration risk when previously seen by speech and swallow at it was felt that you were aspirating secretions but that may have improved now with radiation and chemotherapy you had an episode of atrial fibrillation you should be evaluated by a cardiologist we have included information below for you to schedule an initial evaluation you were started on an iv antibiotic called zosyn which you should continue for more days this is to treat a possible infection causing increased secretions please return to the hospital if you experience worsening respiratory difficulties fevers chills or any other new or concerning symptoms instructions follow up with dr on thursday at am phone address please follow up with dr of cardiology to discuss management of possible atrial fibrillation phone date time location on of,"{
""Diagnoses"": [""Dyspnea"", ""Dysphagia"", ""Hoarseness"", ""Choking"", ""Intermittent dysphagia with solids"", ""Shortness of breath""],
""Medications"": [""Medicine"", ""Allergies""]
}"
77660,admission date discharge date date of birth sex m service cardiothoracic allergies proair hfa attending chief complaint aymptomatic aortic insufficency major surgical or invasive procedure resection of the ascending aortic aneurysm and aortic valve replacement with a bentall procedure with a medical mechanical valve conduit history of present illness m was treated for bronchitis in and found to have moderate to severe ai on echo as well as ascending aortic aneurysm of cm he is asymptomatic able to climb stairs and walk distances without difficulty cardiac cath revealed clean coronary arteries the patient presents today for pat he had dental extractions last week and will see his dentist in follow up for letter of clearance past medical history aortic insufficiency ascending aortic aneurysm history of hyponatremia hypertension high cholesterol cataract glaucoma depression anxiety tobacco use ppd x years vitamin d deficiency s p skin tag removal mild varicose veins s p left patellar fracture left foot crush injury past surgical history s p left knee surgery with titanium wires in place tonsillectomy social history lives with lives alone high stress due to laid off from job at in cargo cigarettes tob ppd x yrs quit etoh daily oz beers most days quit substance abuse past marijuana contact upon discharge brother in law family history premature coronary artery disease none physical exam pulse resp o sat ra b p right left height weight general aao x in nad skin dry x intact x left knee well healed scar heent perrla x eomi x several missing teeth with remaining teeth in poor repair neck supple x full rom x chest lungs clear bilaterally x heart rrr x irregular murmur x grade i vi abdomen soft x non distended x non tender x bowel sounds x extremities warm x well perfused x edema none varicosities right lower extremity neuro grossly intact x pulses femoral right left dp right left pt left radial right left carotid bruit right none left none pertinent results admission labs am hgb calchct am glucose lactate na k cl pm fibrinoge pm pt ptt inr pt pm plt count pm wbc rbc hgb hct mcv mch mchc rdw pm urea n creat sodium potassium chloride total co anion gap echo radiology report chest portable ap study date of am final report the patient is status post cardiac surgery sternal wires are intact the cardiomediastinal silhouette small left pleural effusion and minimal pneumopericardium are all stable there is no pneumothorax the right internal jugular line ends in the upper svc minimal left lung base atelectasis is unchanged there are no new lung opacities of concern am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood urean creat na k cl am blood pt inr pt brief hospital course mr was brought to the operating room on where the he underwent a bentall procedure with a mm mechanical valved conduit and ascending aorta hemiarch replacement with dr cardiopulmonary bypass time was minutes cross clamp time minutes and circulatory arrest minutes overall the patient tolerated the procedure well and post operatively was transferred to the cvicu in stable condition for recovery and invasive monitoring post operative day one 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 the patient was transferred to the telemetry floor for further recovery coumadin was initiated for the mechanical valve he did develop acute kidney injury with a rise in creatinine from to lasix and lisinopril were discontinued and urine output was monitored very closely by the end of his stay his renal function returned to baseline chest tubes and pacing wires were discontinued without complication the patient was evaluated by the physical therapy service for assistance with strength and mobility by the time of discharge on post operative day five the patient was ambulating freely the wound was healing and pain was controlled with oral analgesics the patient was discharged in good condition with appropriate follow up instructions medications on admission brinzolamide azopt prescribed by other provider drops suspension drop each eye two times daily latanoprost prescribed by other provider drops drop each eye at bedtime metoprolol succinate prescribed by other provider mg tablet extended release hr tablet s by mouth once a day medications otc aspirin prescribed by other provider mg tablet delayed release e c tablet s by mouth once a day multivitamin prescribed by other provider capsule capsule s by mouth once a day 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 brinzolamide drops suspension sig one ophthalmic latanoprost drops sig one drop ophthalmic hs at bedtime tamsulosin mg capsule ext release hr sig one capsule ext release hr po hs at bedtime disp capsule ext release hr s refills metoprolol tartrate mg tablet sig one tablet po tid times a day disp tablet s refills furosemide mg tablet sig one tablet po daily daily for days disp tablet s refills potassium chloride meq tablet er particles crystals sig one tablet er particles crystals po once a day for days disp tablet er particles crystals s refills oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills coumadin mg tablet sig two tablet po once a day take mg nightly or as directed by the office of dr disp tablet s refills outpatient lab work inr to be drawn on with results called to the office of dr inr goal for mechanical aortic valve is discharge disposition home with service facility homecare discharge diagnosis s p bental avr mm st mechanical valved conduit pmh aortic insufficiency ascending aortic aneurysm history of hyponatremia hypertension high cholesterol cataract glaucoma depression anxiety tobacco use ppd x years vitamin d deficiency s p skin tag removal mild varicose veins s p left patellar fracture left foot crush injury s p left knee surgery with titanium wires in place tonsillectomy discharge condition alert and oriented x nonfocal ambulating with steady gait incisional pain managed with percocet incisions sternal healing well no erythema or drainage 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 surgeon md p clinic a cardiologist md on at a 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 mechanical aortic valve goal inr first draw with results to the office of dr results to phone completed by [NEW_RECORD] admission date discharge date date of birth sex m service cardiothoracic allergies proair hfa attending chief complaint lethargy known pericardial effusion major surgical or invasive procedure left vats pleural effusion evac pericardial window procedure pericardiocentesis was performed via the left th intercostal space mid axillary line under direct ultrasound guidance using an micropuncture needle followed by placement of a f terumo sheath history of present illness yom s p resection of the ascending aortic aneurysm and aortic valve replacement with a bentall procedure with a medical mechanical valve conduit post op course c b acute renal injury with creatinine that returned to baseline prior to discharge discharged home on over past weeks has been noticing increasing dyspnea w exertion to the point that this weekend could not make it to the bathroom w o shortness of breath recovers w rest of note patient states his inr was subtherapeudic and he was put on lovenox weeks ago by pcp past medical history aortic insufficiency ascending aortic aneurysm history of hyponatremia hypertension high cholesterol cataract glaucoma depression anxiety tobacco use ppd x years vitamin d deficiency s p skin tag removal mild varicose veins s p left patellar fracture left foot crush injury past surgical history s p left knee surgery with titanium wires in place tonsillectomy social history lives with lives alone high stress due to laid off from job at in cargo cigarettes tob ppd x yrs quit etoh daily oz beers most days quit substance abuse past marijuana contact upon discharge brother in law family history premature coronary artery disease none physical exam pulse resp o sat ra b p right left height weight kg general nad skin dry x intact x heent perrla x eomi x neck supple x full rom x chest lungs clear bilaterally x heart rrr x irregular sharp click abdomen soft x non distended x non tender x bs 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 none left none pertinent results admission labs am pt ptt inr pt am plt count am wbc rbc hgb hct mcv mch mchc rdw am calcium phosphate magnesium am alt sgpt ast sgot alk phos tot bili am alt sgpt ast sgot alk phos tot bili am glucose urea n creat sodium potassium chloride total co anion gap discharge labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt pm blood pt ptt inr pt am blood glucose urean creat na k cl hco angap studies cxr left pleural effusion is small cardiomegaly is stable accentuated by projection there is minimal atelectasis in the left lower lobe there is no pneumothorax chest ct scan date x outside film impression large pericardial effusion measuring cm at apex fluid tracking about pericardium and up into anterior superior mediastinal space small left pleural effusion echocardiogram lvef there is a large pericardial effusion primarily anterior and apical in location the effusion appears loculated no signs of cardiac tamponade seen preserved contractile function and no septal or free wall rupture echocardiography report echocardiographic measurements results measurements normal range left ventricle ejection fraction tr gradient ra pasp mm hg mm hg findings this study was compared to the prior study of left ventricle overall normal lvef right ventricle normal rv chamber size and free wall motion abnormal septal motion position mitral valve mildly thickened mitral valve leaflets mild mr pericardium moderate pericardial effusion effusion echo dense c w blood inflammation or other cellular elements no echocardiographic signs of tamponade conclusions overall left ventricular systolic function is normal lvef right ventricular chamber size and free wall motion are normal there is abnormal septal motion position the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen there is a moderate sized pericardial effusion the effusion is echo dense consistent with blood inflammation or other cellular elements there are no echocardiographic signs of tamponade compared with the prior study images reviewed of the findings are similar there is a large echodense pericardial effusion over the anterior surface and near the apex of the heart the distal lateral wall and apex appear fixed in position likely due to pericardial adhesions there is a more prominent septal bounce raising concern for possible constriction however the wide qrs could also explain this septal bounce electronically signed by md interpreting physician radiology report chest pa lat study date of am comparison to at impression interval removal of the left chest tube no evidence of a pneumothorax residual subcutaneous emphysema is seen involving the lateral left soft tissues there is patchy opacity at the left base which likely reflects a combination of atelectasis and fluid in this patient status post median sternotomy with valvular replacement overall cardiac and mediastinal contours remain stable but enlarged in this postoperative patient right lung is grossly clear though there may be a trace pleural effusion as the costophrenic angle is slightly blunted no evidence of pulmonary edema brief hospital course the patient was admitted for evaluation of pericardial effusion after bentall avr he was referred for drainage of large pericardial effusion with tamponade physiology on echocardiogram after presenting with increasing dyspnea on exertion and exercise intolerance he initially had effusion drained in cardiac catheterization lab and was then brought to the operating room on for left video assisted thoracic surgery drainage of pleural effusion and exploration of pericardial space the patient tolerated the procedure well and post operatively was transferred to the cvicu in stable condition 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 was anticoagulated for previous mechanical valve with heparin and coumadin the patient was transferred to the telemetry floor for further recovery chest tubes were discontinued without complication per cardiac surgery protocol 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 the inr and coumadin dosing will be followed by dr w medications on admission azopt drop each eye latanoprost drop each eye hs toprol mg daily asa mg daily mvi daily coumadin discharge medications latanoprost drops sig one drop ophthalmic hs at bedtime 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 multivitamin tablet sig tablets po daily daily disp tablet s refills brinzolamide drops suspension sig one ophthalmic times a day tamsulosin mg capsule ext release hr sig one capsule ext release hr po hs at bedtime disp capsule ext release hr s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills metoprolol tartrate mg tablet sig two tablet po bid times a day disp tablet s refills tramadol mg tablet sig one tablet po q h every hours as needed for pain disp tablet s refills furosemide mg tablet sig one tablet po once a day for weeks disp tablet s refills warfarin mg tablet sig as directed tablet po once a day take mg on take mg on and then as directed by dr w disp tablet s refills discharge disposition home with service facility homecare discharge diagnosis pericardial effusion s p drainage pericardial window discharge condition alert and oriented x nonfocal ambulating gait steady sternal pain managed with tramadol left thoracotomy incision healing well no erythema or drainage edema to bilat 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 while taking narcotics drivng will be discussed at follow up appointment with surgeon 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 follow up with your cardiologist weeks tried to schedule appt office closed for holiday patient will need to call for follow up appt name md phone fax department thoracic surgery when tuesday at am with md campus east best parking garage please report minutes prior to your appointment to the radiology department in the clinical center for a chest xray department cardiac surgery when wednesday at pm with md campus west best parking garage labs pt inr for coumadin indication mechanical aortic valve goal inr first draw results to phone dr w completed by [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies proair hfa attending chief complaint shortness of breath possible syncopal event major surgical or invasive procedure none history of present illness y o male with htn hld ar and ascending aortic aneurysm s p resection and avr st on with course c with recent admission from for pericardial effusion with tamponade physiology s p pericardiocentesis followed by pericardial window believed to be post surgical also s p chest tube for pleural effusion who presented to today for inr check and developed shortness of breath with subsequent syncopal event he reports that he was walking into the ed and lost breath and was breathing heavy loc for seconds denies any urinary stool incontinence no shaking no tongue biting pt unsure if he felt flushed prior to the episode just remembers feeling very short of breath a tte was performed that by report revealed a medium sized effusion with rv collapse he was subsequently transferred to for further evaluation the patient states that he has had increasing doe over the last weeks to the point that he cannot walk to the bathroom without developing sob his sob does resolve with rest he was recently started on lovenox for a subtherapeutic inr since his surgery the patient reports having intermittent episodes of shortness of breath denies any associated chest pain palpitations chest tightness just reports some chest tightness pleuritic chest pain denies any pnd has not noticed any increasing le edema reports using two pillows to sleep at night but is able to lay flat without getting short of breath denies any headaches changes in vision no chest pain no palpitations no n v d reports constipation for three days abdominal pain which he attributes to lovenox injections no recent fevers chills on transfer to the ccu the patient reports feeling well chest pain free breathing comfortably on room air bedside echo showed small pericardial effusion without clear e o ra rv collapse though visualization of the ra and rv was difficult past medical history cardiac risk factors diabetes dyslipidemia hypertension cardiac history percutaneous coronary interventions see below pacing icd none aortic regurgitation s p avr ascending aortic aneurysm other past medical and surgical history h o hyponatremia cataract glaucoma depression anxiety vitamin d deficiency s p skin tag removal mild varicose veins left patellar fracture left foot crush injury s p left knee surgery with titanium wires in place tonsillectomy social history lives alone reports high stress after being laid off in from job at in cargo smoked ppd x years but quit former heavy drinker who drank oz beers on most days but stopped on used to smoke occasional marijuana family history premature coronary artery disease none reports cardiac issues in his family but unsure of what physical exam admission pe vs on l general nad oriented x pleasant elderly gentleman laying comfortably in bed heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthalesma neck supple jvp to earlobe chest well healed vertical scar extending from midsternum down to xiphoid three horizontal cm scars near xiphoid all well healed cardiac rr normal s s no m r g no thrills lifts no s or s mechanical valve click lungs clear to auscultation b l good air movement respirations unlabored no crackles wheezes rhonchi abdomen soft nontender nondistened bs extremities le edema warm well perfused skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid dp pt left carotid dp pt neuro strength and sensation normal throughout discharge pe tmax c f tcurrent c f hr bpm bp mmhg rr insp min spo heart rhythm sr sinus rhythm general nad oriented x pleasant elderly gentleman laying comfortably in bed heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthalesma neck supple jvp to earlobe chest well healed vertical scar extending from midsternum down to xiphoid three horizontal cm scars near xiphoid all well healed cardiac rr normal s s no m r g no thrills lifts no s or s mechanical valve click lungs clear to auscultation b l good air movement respirations unlabored no crackles wheezes rhonchi abdomen soft nontender nondistened bs extremities le edema warm well perfused skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid dp pt left carotid dp pt neuro strength and sensation normal throughout pertinent results admission labs 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 calcium phos mg pertinent labs am blood ck mb ctropnt pm blood alt ast alkphos totbili discharge labs 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 am blood ck cpk am blood ck mb ctropnt am blood mg micro path mrsa screen final no mrsa isolated imaging studies echo overall left ventricular systolic function is normal lvef right ventricular chamber size and free wall motion are normal a mechanical aortic valve prosthesis is present there is borderline pulmonary artery systolic hypertension there is a small to moderate sized pericardial effusion with preferential fluid deposition along the anterolateral aspect of the left ventricle measuring up to centimeters in greatest dimension the effusion is echo dense consistent with blood inflammation or other cellular elements there are no echocardiographic signs of tamponade no right atrial or right ventricular diastolic collapse is seen impression small to moderate sized echo dense pericardial effusion without echcardiographic evidence of pericardial tamponade borderline pulmonary artery systolic hypertension cxr pa lat findings as compared to the previous radiograph the retrocardiac lung areas are better ventilated the right lung also shows improved ventilation small bilateral pleural effusions persist mild areas of atelectasis at the left lung bases status post cabg the gas collection in the left lateral soft tissues has decreased in the interval tte overall left ventricular systolic function is normal lvef right ventricular chamber size and free wall motion are normal a mechanical aortic valve prosthesis is present there is borderline pulmonary artery systolic hypertension there is a small to moderate sized pericardial effusion with preferential fluid deposition along the anterolateral aspect of the left ventricle measuring up to centimeters in greatest dimension the effusion is echo dense consistent with blood inflammation or other cellular elements there are no echocardiographic signs of tamponade no right atrial or right ventricular diastolic collapse is seen impression small to moderate sized echo dense pericardial effusion without echcardiographic evidence of pericardial tamponade borderline pulmonary artery systolic hypertension brief hospital course y o male with htn hld h o ar and ascending aortic aneurysm s p avr c b pericardial effusion s p pericardiocentesis and pericardial window who presents with recurrent pericardial effusion without echocardiographic findings of tamponade physiology active diagnoses syncope recurrent pericardial effusion mr was transferred from osh for concern of pericardial tamponade after he experienced a syncopal event with an echo showing pericardial fluid he was found to be clinically stable on arrival without clinical evidence of tamponade he had an echo which demonstrated a significant amount of pericardial fluid but without echocardiographic evidence of tamponade he also did not have any arrythmias on telemetry but was found to have borderline blood pressures with mild orthostatic symptoms other labs and imaging were unrevealing for a cause of his syncopal event and repeat tte did not show significant interval progression of his effusion it was determined that his pericardial effusion was not the cause of his syncopal event or intermittent shortness of breath and no further management of this issue was undertaken at this time his home lasix was discontinued as it was beleived that he was likely hypovolemic and that his event may have been caused by orthostatic hypotension he was arranged with outpatient follow up chronic diagnoses asending aortic aneurysm and ar s p avr st his admission inr of goal of he was briefly taken off his coumadin and managed on heparin drip for his valve but his coumadin was resumed when it was determined he would not require a procedure hypertension he had somewhat borderline blood pressures during this admission but without tamponade he was continued on his home metoprolol but his home lasix was discontinued bph stable his tamsulosin was initially held for concern of tamponade but was later continued he was instructed to take this medication at night given our concern for possible orthostatic hypotension he stated his continued need for it in order for him to get a good night s sleep glaucoma stable he was continued on his home latanoprost and brinzolamide eye drops transitional issues he will need continued close outpatient monitoring of his symptoms as he may develop tamponade in the future if his pericardial window malfunctions should he continue to have pre syncopal or syncopal events he will need another syncopal workup medications on admission latanoprost drop ou qhs need to confirm if ou aspirin ec mg po daily multivitamin tablets po daily brinzolamide drop ou need to confirm if ou tamsulosin er mg po qhs docusate sodium mg po bid metoprolol tartrate mg po bid tramadol mg po q h prn pain usually only takes dose before bed furosemide mg po daily for weeks at d c so likely still on warfarin mg po daily discharge medications latanoprost drops sig one drop ophthalmic hs at bedtime brinzolamide drops suspension sig one ophthalmic aspirin mg tablet chewable sig one tablet chewable po daily daily warfarin mg tablet sig one tablet po once daily at pm multivitamin tablet sig one tablet po daily daily tamsulosin mg capsule ext release hr sig one capsule ext release hr po at bedtime docusate sodium mg capsule sig one capsule po bid times a day tramadol mg tablet sig one tablet po every four hours as needed for pain metoprolol succinate mg tablet extended release hr sig one tablet extended release hr po once a day disp tablet extended release hr s refills discharge disposition home discharge diagnosis primary diagnosis status post pericardial window for pericardial effusion aortic valve replacement 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 while you were hospitalized at you were admitted to the hospital because you had an episode of shortness of breath and then fell at an outside hospital while you were there they did an echocardiogram of your heart and thought that they saw fluid around your heart you were transferred to for further management when you got here we also did an echocardiogram and on our study we did not think that you had a significant amount of fluid around your heart that would account for your shortness of breath we did not think that any intervention was indicated at this time we do not think that you need to continue your water pill anymore the following changes were made to your medications stop lasix mg daily decrease metoprolol to mg daily please continue to take the rest of your medications as directed please call tomorrow to schedule an appointment with your pcp will also have to get your inr checked tomorrow and send the results to your pcp followup instructions name md location hospital department cardiology address phone appointment monday pm department hematology oncology when tuesday at am with md building sc clinical ctr campus east best parking garage department cardiac surgery when wednesday at pm with md building lm campus west best parking garage name w location health medical associates address phone appointment tuesday pm the office is going to call you at home with the next available cancellation appointment completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex m service cardiothoracic allergies proair hfa attending addendum revised med list 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 brinzolamide drops suspension sig one ophthalmic latanoprost drops sig one drop ophthalmic hs at bedtime tamsulosin mg capsule ext release hr sig one capsule ext release hr po hs at bedtime disp capsule ext release hr s refills metoprolol tartrate mg tablet sig one tablet po tid times a day disp tablet s refills furosemide mg tablet sig tablet po daily daily for days disp tablet s refills potassium chloride meq tablet er particles crystals sig one tablet er particles crystals po once a day for days disp tablet er particles crystals s refills oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills coumadin mg tablet sig two tablet po once a day take mg nightly or as directed by the office of dr disp tablet s refills outpatient lab work inr to be drawn on with results called to the office of dr inr goal for mechanical aortic valve is discharge disposition home with service facility homecare md completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex m service cardiothoracic allergies proair hfa attending addendum chief complaint shortness of breath lethargy history of present illness yom s p resection of the ascending aortic aneurysm and aortic valve replacement with a bentall procedure with a medical mechanical valve conduit post op course c b acute renal injury with creatinine that returned to baseline prior to discharge discharged home on over past weeks has been noticing increasing dyspnea w exertion to the point that this weekend could not make it to the bathroom w o shortness of breath recovers w rest of note patient states his inr was subtherapeudic and he was put on lovenox weeks ago by pcp impression yo man s p bental mech avr anticoagulated w coumadin and more recently lovenox now w large pericardial effusion and signs of tamponade by echo impression should reflect that the patient is admitted with large pericardial effusion after bental procedure which is likely a complication of the surgery associated with anticoagulation discharge disposition home with service facility homecare md completed by,"{
""Diagnoses"": [""cardiothoracic"", ""aortic insufficiency"", ""major surgical or invasive procedure"", ""resection of the ascending aortic aneurysm"", ""aortic valve replacement with a Bentall procedure with a medical mechanical valve conduit""],
""Medications"": [""ProAir HFA""]
}"
88626,admission date discharge date date of birth sex m service cardiothoracic allergies penicillins attending chief complaint chest pain major surgical or invasive procedure coronary artery bypass graaft surgery x with lima left anterior descending artery reverse spahenous vein graft obtuse marginal history of present illness year old male diagnosed with left main coronary artery disease in early at the same time he was diagnosed with lyme disease he underwent a full course of doxycycline per our id department dr and now returns for a heparin bridge and pat before his scheduled cabg on with dr mr has had no chest pain since past medical history clavicle and rib fx s p mvc coronary artery disease s p bare metal stent to lad diabetes mellitus type hypertension hyperlipidemia atrial flutter at new onset lyme disease social history occupation retired music director last dental exam fall lives with spouse and daughter race caucasian tobacco pack year history quit years ago etoh occassional a month at most family history non contributory physical exam admission pulse resp o sat ra b p height weight kg general nad skin dry x intact x rash with bulls eye all over majority on back he states it is improving 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 bilateral le neuro grossly intact a o x nonfocal pulses femoral right left dp right left pt left radial right left carotid bruit right no bruit left no bruit pertinent results pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg pm urine color yellow appear clear sp pm pt ptt inr pt pm plt count pm wbc rbc hgb hct mcv mch mchc rdw pm hba c pm albumin pm alt sgpt ast sgot ld ldh alk phos amylase tot bili pm glucose urea n creat sodium potassium chloride total co anion gap pm ptt pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood plt ct pm blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap complete done at pm final referring physician information r division of cardiothorac status inpatient dob age years m hgt in bp mm hg wgt lb hr bpm bsa m indication chest pain coronary artery disease left ventricular function preoperative assessment 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 aorta annulus cm cm aorta sinus level cm cm aorta sinotubular ridge cm cm aorta ascending cm cm findings right atrium interatrial septum no asd by d or color doppler left ventricle overall normal lvef lv wall motion regional left ventricular wall motion findings as shown below remaining lv segments contract normally right ventricle normal rv chamber size and free wall motion aorta normal descending aorta diameter simple atheroma in descending aorta aortic valve mildly thickened aortic valve leaflets no ar mitral valve mildly thickened mitral valve leaflets mild mr tricuspid valve normal tricuspid valve leaflets with trivial tr pulmonic valve pulmonary artery normal pulmonic valve leaflets 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 no tee related complications conclusions prebypass no atrial septal defect is seen by d or color doppler overall left ventricular systolic function is normal lvef the remaining left ventricular segments contract normally right ventricular chamber size and free wall motion are normal there are simple atheroma in the descending thoracic aorta the aortic valve leaflets are mildly thickened no aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen postbypass there is preserved biventricular systolic function the study is otherwise unchanged from prebypass m radiology report chest portable ap study date of am findings all of the monitoring and support devices have been removed specifically no evidence of pneumothorax in this patient with intact midline sternal sutures following cabg mild atelectatic changes persist at the left base dr brief hospital course mr was admitted preoperatively for heparin bridge while off his coumadin taken for atrial fibrillation he completed his preoperative workup and on was brought to the operating room for coronary artery bypass grafting please see or report for details in summary he had cabg x with left internal mamary artery to left anterior descending artery and reverse saphenous vein graft to obtuse marginal artery his bypass time was minutes with a crossclamp time of minutes he tolerated the operation well and was transferred from the operating to the cardiac surgery intensive care unit he did well in the immediate post operative period his he woke neurilogically intact was weaned fro the ventilator and extubated on pod he was ready for transfer to the stepdown floor he was begun on bblockers statin and diuretics and his activity level was gradually advanced all tubes lines and drains were removed according to cardiac surgery protocol on pod he was ready for discharge home with visiting nurses medications on admission lisinopril hctz daily ecaspirin daily metformin er mg daily tramadol mg daily vytorin mg daily atenolol mg daily naproxen mg twice a day loratadin mg nightly nasacort sprays each nostril daily coumadin mg daily allergies pcn hives 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 vytorin mg tablet sig one tablet po once a day metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet s refills potassium chloride meq tablet sustained release sig two tablet sustained release po once a day for weeks disp tablet sustained release s refills metformin mg tablet sig one tablet po once a day tramadol mg tablet sig one tablet po q h every hours as needed for pain disp tablet s refills loratadine mg tablet sig one tablet po q pm furosemide mg tablet sig one tablet po once a day for weeks disp tablet s refills naproxen mg tablet sig one tablet po twice a day lisinopril mg tablet sig one tablet po once a day disp tablet s refills nasacort aq mcg aerosol spray sig two sprays nasal once a day warfarin mg tablet sig one tablet po once a day take mg on thru then as directed by clinic disp tablet s refills discharge disposition home with service facility vna discharge diagnosis coronary artery bypass graaft surgery x with lima left anterior descending artery reverse spahenous vein graft obtuse marginal pmh clavicle and rib fx s p mvc coronary artery disease s p bare metal stent to left anterior descending artery diabetes mellitus type hypertension hyperlipidemia atrial flutter at new onset lyme disease right toe amputation d t osteomyelitis right knee replacement 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 please call with any questions or concerns followup instructions please call to schedule appointments dr in weeks at heart center dr in week dr in weeks pt inr for coumadin dosing indication atrial fibrillation goal inr first draw results to clinic heart center phone fax completed by,"{
""Diagnoses"": [""cardiothoracic"", ""allergies"", ""penicillins"", ""Lyme disease"", ""coronary artery disease"", ""diabetes mellitus"", ""hypertension"", ""hyperlipidemia"", ""atrial flutter""],
""Medications"": [""doxycycline"", ""heparin"", ""clavicle and rib fx"", ""SVT"", ""bare metal stent"", ""Lyme disease treatment"", ""ETOH"", ""occasional""]
}"
88790,admission date discharge date date of birth sex m service surgery allergies heparin agents attending chief complaint fever hypotension major surgical or invasive procedure left thoracentesis right hemicolectomy history of present illness this is a y o m with pmh of htn etoh cirrhosis no active etoh use hyperlipedemia and neuropathic right heel ulceration s p debridement and treatment with wound vac at rehab who was transferred from his rehabilitation facility to on with fevers hypotension and left shoulder pain at the osh initial vitals were remarkable for a bp of and hr subsequently developed atrial fibrillation with rvr received digoxin and beta blockade after which he converted to sinus rythm labs notable for a wbc of na cl hco cr bun ce x a renal us was unremarkable cxr with left infiltrate and ua with significant pyuria he had been recently started on augmentin mg for presumed uti he was treated with fluids and iv antibiotics vanc zosyn at for presumed sepsis as well as lovenox for pe vq scan was low probability for a pe and the lovenox was stopped a ct scan was done due to continued shoulder pain and sob which showed a mediastinal mass with extravasation of blood from the aortic arch the patient was transferred to on a labetolol drip for further evaluation by cardiothoracic surgery at the patient was found to be hd stable with hr in the s and sbp between o saturation of on l nc breathing breaths per minutes still reported left shoulder pain the pain has been present for days feels sharp wakes patient up from sleep occasionally he denies any chest pain or pressure past medical history alcoholic cirrhosis per reported history no drinks x yrs chronic neuropathic heel ulcer with hx of mrsa in the wound year ago s p debridement and treatment with wound vac at rehab htn depression chronic venous stasis social history homeless prior history of alcoholism but claims abstinence for years still smokes pack of cigarettes daily former nurse who worked at and who has not worked since family history cad father had vfib arrest per report parents may have also had hepatitis physical exam on admission vs ra general patient appears comfortable lying in bed more alert than prior lungs cta bilat no r rh wh good air movement resp unlabored no accessory muscle use heart rrr no mrg nl s s abdomen soft nt nd bsx extremities wwp no c c e peripheral pulses radials dps skin overlying right foot appears somewhat inflamed wrapped in bandage skin many healed scars on overabdomen ue and on legs lymph no cervical axillary or inguinal lad neuro awake alert and oriented moving all extremeties pertinent results laboratory 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 alkphos totbili pm blood calcium phos mg am blood caltibc vitb greater th folate hapto ferritn trf am blood hba c eag am blood tsh am blood hbsag negative hbsab negative igm hbc negative am blood ama negative smooth positive am blood anti tg less than thyrogl am blood hiv ab negative studies hospital microbiology ucx mssa u ml bcx mssa wound cx from foot ulcer abundant growth of pseudomonas insensitive to gent otherwise pan sensitive studies from tte without vegitations ct chest leaking ascending thoracic aortic aneurysm with hematoma within the superior mediastinum large left pleurall effusion splenic varices and splenomegaly renal us no hydronephrosis elongated son area in the upper pole of the left kidney which could represent and elongated cyst or dilated calix cxr three view impression mild hazy opacity in ll base could represent pna mild blunting of posterior costophrenic angles which could represent small effusions cxr portable impression new chf component of lll pna cannot be excluded vq scan impression low suspiscion lung scan for pulmonary embolic disease at imaging ct torso the patient is now intubated and there is focal parenchymal opacification distributed throughout the lungs bilaterally consistent with multifocal pneumonia bilateral pleural effusions left side stable appearance to a high density fluid collection in the anterior superior mediastinum when compared to prior imaging from cirrhotic liver with sequelae of portal hypertension including splenomegaly ascites and splenorenal varices no abdominal collection or abscess identified no evidence for anastomotic leak small seroma under the lower half of the laparotomy wound but there is no evidence for abdominal wall diastasis to suggest connection with the peritoneal cavity ascites tte suboptimal image quality as the patient was difficult to position normal biventricular cavity sizes with preserved global and regional biventricular systolic function cxr as compared to the previous radiograph there is no relevant change low lung volumes with multiple parenchymal bilateral opacities and bilateral pleural effusions unchanged coexistence of both fluid overload and multifocal infection no newly occurred focal parenchymal opacities no evidence of pneumothorax b l le u s no evidence of dvt renal u s very limited visualization of the kidneys due to the patient s body habitus no gross abnormality is identified arterial and venous flow is seen bilaterally within the kidneys large amount of ascites cxr as compared to the previous radiograph the patient position has completely unchanged on this basis the left hemithorax appears dense and the right hemithorax appears less dense than before overall however it is likely that the pre existing multifocal opacities have not substantially changed moderate cardiomegaly with retrocardiac atelectasis and moderate left pleural effusion no pneumothorax unchanged monitoring and support devices abdomen us mod ascites cxr cardiomegaly and widened mediastinum are unchanged right picc tip is in the lower svc et tube is in standard position ng tube tip is out of view below the diaphragm there is no evident pneumothorax widened mediastinum is stable large left pleural effusion is probably unchanged allowing the difference in positioning of the patient with adjacent atelectasis the right lung is grossly clear pulmonary edema has improved almost resolved cxr gradual mediastinal widening consider a follow up radiograph in supine positioning mediastinal contours demonstrate the lymphadenopathy and contained dissection pseudoaneurysm better seen on prior ct moderate left pleural effusion with underlying atelectasis and mild pulmonary edema underlying infection cannot be excluded cxr widened mediastinum is stable allowing the difference in positioning of the patient cardiomegaly is also unchanged right central catheter tip is in the lower svc et tube is seen in standard position ng tube tip is out of view below the diaphragm the stomach is very distended mild to moderate pulmonary edema is stable mild left pleural effusion is stable cxr in comparison with the study of there is little overall change renal u s no hydronephrosis mildly echogenic kidneys bilaterally consistent with chronic renal disease no evidence of renal artery stenosis mild ascites is noted cxr p tte circumferential pericardial effusion cxr impression endotracheal tube ends at the level of the clavicle approximately cm above carina consider advancing the endotracheal tube by approximately cm for appropriate seating right internal jugular line ends at upper mid svc and right picc line terminates at mid svc given the history of recent pericardial window for pericardial tamponade tip of a new line ending extending to the middle of cardiac silhouette may represent pericardial drain catheter bilateral moderate pleural effusions associated with lower lung atelectasis left side more than right and mild pulmonary edema is unchanged enlarged heart size and widened superior mediastinum is stable echo suboptimal image quality no pericardial effusion prominent left pleural effusion micro peritoneal fluid pmnc no organisms peritoneal fluid no pmnc no organisms cx enterococci sputum pmn no microorganisms mrsa screen no mrsa isolated bal gs pmn no org bact afb cx all ng afb cx p sputum culture negative viral screen insufficient sample for stain cx negative legionalla urine antigen negative peritoneal fluid gs pmn s no orgs cx negative catheter tip cx negative bal gs pmn s no orgs resp cx yeast resp cx inadequate specimen mrsa neg peritoneal fluid pmn s no orgs fluid cx ng anaer cx ng ucx yeast bcx p peritoneal gs pmns no orgs cx ng bcx p mrsa neg bcx p brief hospital course mr is a y o m with pmh of etoh cirrhosis and neuropathic right heel ulceration s p debridement who presented with mssa bacteremia mssa bacteremia the patient presented with hypotension and fever to hospital initial vitals remarkable for bp of and hr labs notable for a wbc of na cl hco cr bun ce x a renal us was unremarkable cxr with left infiltrate and ua with significant pyuria given ivf and started on vanc zosyn transferred to for possible bleeding aneurism as discussed below at blood cultures from grew mssa also with urine culture growing mssa now hd stable on cipro nafcillin urine cultures here with staph aureus and blood cx negative most likely site of entry is debrided heel wound with subsequent seeding of the renal parenchyma trend wbc fever curve f u bcx ucx id recs continue nafcillin cipro for mssa coverage tee aortic pseudoaneurysm per ct there is no urgent need for surgery on this patient s pseudoaneurysm there is some concern for infection in the area of the aneurism and surgery is deferring intervention will continue to follow on the floor cause of aneurysm is unclear likely atherosclerosis htn given smoking history although will also consider mycotic aneurism related to infection f u ct and vascular recs tagged wbc scan pending today continue to treat infection as above per ct will require repeat imaging once infection resolves pleural effusion underwent successful with l removed from pleural space yesterday appeared serous chemistries show an exudative effusion unknwon etiology at this time although large of wbc and low ph suspect infectious process continue to monitor for hypoxia f u bcx as above will obtain sputum cx if has good expectorations f u pleural fluid culture and cytology continue cefepime to cover for hcap also continue on vancomycin as above atrial fibrillation no known h o of afib although developed afib with rvr at the osh most likely due to infection sepsis vs new aoritic aneurism does not have a history of underlying heart disease and ce now back in sinus rhythtym chads score of so will not require ac continue bblocker for rate control monitor on tele consider cardioversion if reverts back to afib htn patient has a h o htn treated at home with bblocker only has had difficult to control htn in house which may explain developing aoritc aneurism bps have been well controlled over the past hours continue labetolol continue amlodipine target bp per ct hydralazine prn for bp new uptrending cr over the past days is concerning for worsening infection vs atn due to medications less likely pre renal given low bun cr ratio although will obtain urine lytes today trend cr treat bacteremia bacteuria f u urine lytes consider renal c s if cr does not stabilize cirrhosis the patient has a cirrhotic liver believed to be prior etoh abuse ct abdomen here shows cirrhosis albumin is low and inr elevated both of which are likely related to underlying liver disease bedside us yesterday surprisingly showed no ascites obtained records which were not particularly useful in determing progress to date of this patient s liver disease initiated work up here continue to monitor coags consider nadolol if concern for varices trnd lfts wnl here although this may be bland cirrhosis as seen in of cirrhotic patients cirrhosis w u pending including hcv hbcv anti mito anti sm alpha ceruloplasmis nutrition consult elevated lipase patient has an elevated lipase to unknown etiology patient does not appear to have an acute abdomen or other e o pancreatitis be related to prior hypotension which has now resolved repeat lipase is improved no need fo further monitoring anemia unknown baseline h h on admission here hgb was and has been stable no signs of active bleeding or hemolysis most likely related to myelosupression from udnerlying cirrhosis with possibly chronically depressed renal function decreased epo trend hct iron studies indicate some element of acd haptoglobin retic count unremarkable folate b wnl will transfuse for hct neuropathic joint unknown etiology of patient neuropathic heel which has led to ulceration and likely to present bacteremia hga c here is not c w dmii which would have been the most likely etiology be related to vascular disease although appears well vascularized and b deficiency from prior current etoh use also consider syphillis as above wound culture from osh growing gent resistant pseudomonas continue treatment of infectious processes as above wound care consult rpr neg podiatry recs feel wound is healing well continue wound vac txfer ed from floor for respiratory distress intubated upon arrival acidotic to ph o n started on bicarb ggt hypotensive briefly on neo gtt off neo gtt hct u cttorso po contrast iv contrast multifocal pna no anastomotic leak mini bal ordered consider formal bronch et suctioning af s sbp s lopressor x dilt x lasix decreasing pao inc peep to tv bladder pressure vanc held for trough nephrology following recommend lasix gtt or hd if persistently deranged electrolytes continued on lasix cc negative bronched with bal sent tte nl bivaentricular sizes lvef no wall motion abnl peritoneal fluid enterococci lasix held due to elev cr repeat urine lytes sent fena and feurea d c zosyn due to drug rash and start meropenem allow pt to autodiurese lasix held again auto diuressing growing vre from peritoneal cx started linezolid afib w hr s rate controlled w lopressor and dilt tf changed to nepro w goal attnd requested ir guided picc placement ir post pyloric dobhoff u s abd ascites tap and ip consult to tap left pleural effusion ip req repeat chest ct no bedside u s yet plan ir dobhoff picc bedside u s l paracentesis w p id to reconsult re abx regimen g alb ivlasix cc cvp lasix mg x given dopoff advanced and picc placed rate control held yesterday and then went into afib slightly more alert blood sputum suctioned from ett negative l lasix x per primary team bronchoscopy with blood secretions noted bal taken continued blood secretions no extubation per primary rad aline adjusted not successful afib occurred with physical therapy rate controlled dilt iv x r heel vac dsg by podiatry persistent midline ascitic drainage midline vac placed beneprotein dc d from nepro tf for elevated bun held all pain medications lopressor per primary team tolerating cpap kept intubated per primary team following commands intermittently u s guided paracentesis done at bedside l out given albumin x ns bolus of after tap for low uop converted into afib o n given dilt iv x in afib dilt mg x since dilt maxed at qid started metoprolol can uptitrate self extubated in am satting well on fm continues to be azotemic hrs started on octreotide midodrine albumin g standing x days hit panel sent hepatology renal consults placed may need cvvh in next day or so hit positive shq stopped awaiting heme recs on ie anticoagulation hd line placed cvvh started hypotensive to sbp s staretd on neo switched to vasopressin pt continues hypotensive maxed out on vaso started neo given u prbc will need bedside echo early this am bedside tte ccu resident c w circumferential pericardial effusion with early tamponade physiology hypotensive req vaso neo stable o n cardiac surgery consultation called discussion re decompressive pericardiocentesis v ex lap for hypotensive etiology cardiogenic v septic hepatobiliary team to or for ex lap pericardial window to bulb ex lap no leak no clear intraabdominal pathology cc pericardial fluid evacuated l ascites drained g albumin x post op oliguric post op rising lactate pulsesx bladder pressure transitioned from cpap to cmv continued dilt qid for rate control with metoprolol in pm dysynchronous from vent sedation increased lactate still rising with metabolic acidosis with improved sedation able to increase mv discussed with renal and diasylate changed to b also given amp bicarb x o n total gm ca repletion mg repletion abg slowly improved continued on cvvh cardioverted with j x for unstable vtach with pulses nsr with bp vasopressin started metoprolol d c dilt d c amio bolus and gtt on neo vasopressin even i o via cvvh cmo remains intubated on mivf map s o n no ectopy midaz fent no labs expired medications on admission metoprolol tartrate aldactone vit c prostat discharge disposition expired discharge diagnosis end stage liver disease s p right colectomy for perforation heart failure discharge condition expired md completed by,{}
1521,admission date discharge date date of birth sex f service history of present illness the patient is a year old female with a history of diabetes known gallstone disease transferred from an outside hospital for workup of presumed cholecystitis the patient had been feeling ill for two weeks prior to her admission to the outside hospital she was diagnosed with an upper respiratory infection by her primary care physician and given ciprofloxacin on the day of admission to the outside hospital she collapsed out of dizziness at the outside hospital she had a course significant for a pancreatitis with a lipase of a presumed cholecystitis with right upper quadrant ultrasound consistent with cholecystitis without biliary dilatation as well as a left upper lobe pneumonia she received cefuroxime for antibiotics and a ct scan which showed significant only for pancreatic atrophy she continued to have respiratory distress and gastrointestinal pain and was transferred to for further workup past medical history diabetes hypertension hospital course by system neurological patient with a normal mental status on her admission she was sedated for her intubation she was weaned periodically and her mental status was noted to be responsive cardiovascular ischemia patient with known coronary artery disease she was continued on her pr aspirin her beta blocker was held secondary to her hypotension pump the patient with a known low ejection fraction of anywhere from she was slightly volume overloaded on her admission and received dialysis as she was aneuric throughout her admission at afterload reduction was held since she was hypotensive rhythm patient with known v tach in the past and aicd placed in for v tach on the setting of a myocardial infarction she had multiple episodes of v tach while in house she was managed on lidocaine and amiodarone drips and was seen by ep service did receive multiple shocks throughout her admission hypotension patient was hypotensive likely secondary to sepsis from pneumonia was initially placed on phenylephrine to avoid beta action on the heart and which was eventually changed to norepinephrine pulmonary patient was admitted with a left upper lobe pneumonia thought to be community acquired she was continued on levofloxacin for her community acquired pneumonia she then developed bilateral infiltrates thought to be failure versus ards she was intubated on the third day of her admission for respiratory distress and hypoxia she did receive invasive pa catheter monitoring which is significant for a wedge of and after three days a swan was discontinued gastrointestinal patient with a transaminitis and pancreatitis by enzymes while she was here she received multiple right upper quadrant ultrasounds which was not significant for any cholecystitis but did have gallstones she received an ercp with sphincterotomy which revealed gallbladder sludge however her right upper quadrant enzymes never totally resolved and continued to have a pancreatitis however she is felt not to have an active cholecystitis throughout this admission heme the patient did have unit of blood transfusion while she was here but was guaiac negative had no clear bleeding source thrombocytopenia unclear origin she had a negative hit antibody endocrine patient on insulin drip while in house for her diabetes infectious disease the patient was maintained on vancomycin levo and flagyl throughout most of her admission to cover right upper quadrant bugs as well as her pneumonia she initially received two days of meropenem and this coverage was changed she was never febrile throughout this admission additional micu course the patient was considered septic throughout her time was continued on antibiotics and pressor support however her admission was complicated by multiple episodes of ventricular tachycardia she eventually had a sustained v tach which was pulseless the patient was coded unsuccessfully and received multiple shocks and we are unable to get a pulse back family was notified and no postmortem examination was requested m d dictated by medquist d t job,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""service history of present illness"", ""transferred from an outside hospital for workup of presumed cholecystitis"", ""upper respiratory infection"", ""pancreatitis"", ""cholecystitis"", ""left upper lobe pneumonia"", ""diabetes"", ""hypertension""],
""Medications"": [""ciprofloxacin"", ""cefuroxime""]
}"
22612,admission date discharge date date of birth sex f service medicine allergies demerol sulfa sulfonamides attending chief complaint hypotension ams major surgical or invasive procedure n a history of present illness yo woman with h o htn hypertrophic cmy lvef septal hk ppm for sss steroid dependent asthma adrenal insufficiency erosive esophagitis sliding hiatal hernia diverticulosis l sfv thrombus who was transferred from hospital for further management of sepsis and concern for perforated esophagus the patient was in her usoh until around when she presented to hospital with dyspnea of d progression she noted a lbs wt gain over this period she was found to have bnp worsened le edema was diagnosed with a chf exacerbation as well as a rll pna was diuresed and started on levaquin x d the patient was doing well but on the am of transfer was noted to have ams fever to f and hypotension she was started on zyvox linezolid and transferred to the icu at the osh there her sbp dropped to s she developed hypercarbic resp failure and she was intubated l fem line placed and pressors were started she underwent a ct of her neck chest abd pelvis which revealed a large rll infiltrate and a thickened gallbladder she was also noted to have small air in her biliary tree and portal vein of note the pt had been admitted in late with ugib requiring three units prbcs and with egd showing erosive esophagitis during her current admission the patient had an egd done which revealed severe esophagitis with biopsies showing granulomatous changes concern was raised that her esoph may have ruptured also of note patient was diagnosed with a dvt in her lle during her admit to the osh and had a ivc filter placed she was continued on stress dose steroids given her underlying adrenal insufficiency past medical history htn hypertrophic cmy lvef septal hk chronic le edema ppm for sss steroid dependent asthma adrenal insufficiency erosive esophagitis sliding hiatal hernia gerd diverticulosis l sfv thrombus s p ventral hernia repair at s p fall and humeral fx in in setting of nsvt social history lives on was recently in rehab facility no tobacco rare etoh family history n a physical exam vitals t hr av paced bp ac x fio peep gen intubated sedated caucasian woman with multiple areas of ecchymosis over chest upper extremtities neck heent pupils small but responsive to light no icterus ett in place dried blood in nares bilaterally and around ett neck swollen carotids bilaterally unable to assess jvp r cerv region with old needle puncture site no lad palpable cv distant hs unable to appreciate murmur no s lungs rales throughout l lung field exp wheeze throughout r lung field abd obese nondistended multiple well healed scars no ecchymosis ext pitting edema in b l le to mid thigh feet cool and dusky b l but with dp and pt pulses neuro sedated unarousable brief hospital course yo woman who was transferred from hospital for further management of septic shock with blood culture bottles with mrsa and mrsa in urine at osh patient was intubated and sedated requiring pressors at the time of transfer she continued to require pressors after hours and given her limited quality of life prior to this event her family made the decision to make her comfort measures only she was extubated and pressors were stopped she died on cardiology came to turn off her pacer family was present and declined autopsy attending was notified medications on admission ipitor mg qd carvedilol mg vasopressin units hr hydrocortisone mg q h prednisone mg qd imipenem with cilastin mg q h start linezolid mg q h start levophed mg kg min protonix mg iv q h paxil cr mg qd kcl meq po tid spironolactone mg qd sucralfate gm tid torsemide mg qd tylenol prn percocet prn ativan prn zofran prn discharge medications n a discharge disposition expired discharge diagnosis sepsis discharge condition deceased followup instructions n a completed by,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""service medicine"", ""allergies"", ""demerol"", ""sulfonamides"", ""ams"", ""hypotension"", ""ams major surgical or invasive procedure"", ""history of present illness"", ""yo woman with h o htn hypertrophic cmy lvef septal hk ppm for sss steroid dependent asthma"", ""erosive esophagitis"", ""sliding hiatal hernia"", ""diverticulosis"", ""l sfv thrombus""],
""Medications"": [""Levaquin"", ""Linezolid"", ""Zyvox""]
}"
91883,admission date discharge date service medicine allergies nitroglycerin transdermal norvasc attending chief complaint weakness shortness of breath major surgical or invasive procedure egd blood transfusions central line placement history of present illness yo m with a history of copd cad chf and remote history of duodenal ulcers presents with doe for several weeks and and worsening nonfocal weakness x days and his found to have guaiac positive stool and anemia at hospital today and is transferred to for further care patient reports days of weakness but denies other symptoms including nausea vomiting chest pain abdominal pain and loc he has been hospitalized twice this year for pneumonia and since that time has worse doe which has somewhat worsened over the last days he has been taking alleve tablets daily for arthritis x week and is also taking steroids for a recent copd exacerbation without any pud prophylaxis he denies melena or hematochezia but also reports he does not frequently look at his stool also of note patient has been recently started on antibiotics unsure what type for mrsa rle infection he has never had an upper endoscopy and had a normal colonoscopy years ago at osh patient was found to have brbpr and coffee grounds from ngt which cleared with lavage hct was found to be and there was an isolated bp of but was otherwise normotensive patient received u prbc mg of iv morphine and given one dose of protonix mg iv prior to transfer to at the ed repeat hct was found to be on exam rectal exam revealed melanotic stool without gross blood ngt output remains small amounts of coffee grounds patient was started on ppi drip and peripheral ivs were placed gi was consulted on transfer vs were l in the icu patient reports feeling overall about the same but htat dyspnea is slightly better he continues to deny abdominal pain chest pain nausea or vomiting he still feels weak nonfocally review of systems per hpi denies fever chills night sweats recent weight loss or gain denies headache sinus tenderness rhinorrhea or congestion denies cough or wheezing denies chest pain chest pressure palpitations or weakness denies nausea vomiting diarrhea constipation abdominal pain or changes in bowel habits denies dysuria frequency or urgency denies arthralgias or myalgias denies rashes or skin changes past medical history peptic ulcer per patient diagnosed years ago without endoscopy when he got a firefighting job with a tough boss but no ulcer problems since then unaware of h pylori evaluation hypertension emphysema copd not on home oxygen cardiomyopathy with ejection fraction of it was as low as when he presented with heart failure and had catheterization that showed only moderate right coronary lesion mitral regurgitation pulmonary hypertension prostate cancer s p brachytherapy urethral strictures s p dilation hyperlipidemia macular degeneration restless leg syndrome pulmonary htn osteoarthritis subdural hemorrhage after falling requiring craniectomy years ago pancreatitis x tuberculosis diagnosed as a child scar on lung past surgical history craniectomy craniotomy for subdural hematoma lt hip replacement cataract surgery bladder surgery with uretheral dilation social history denies current etoh use former etoh abuse former smoker yrs x ppd quit years ago widower x years children lives alone and does his own adls with daughter for help with shopping walks with cane retired former air force marine salesman firefighter and clock repairman traveled globaly in military family history father died at from renal failure mother died at from pulmonary embolism son had pud that resulted in significant gi bleeding requiring multiple transfusions physical exam examination at admission vitals t bp p r o l general alert oriented no acute distress heent sclera anicteric dry mm oropharynx clear neck supple jvp not elevated no lad lungs quiet bs crackles in the bases bilaterally moderate air movement 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 rle x ulcer expressing pus without exrythema chronic venous stasis changes mild pedal edema examination at discharge vs ra gen nad lying comfortably in bed heent palpable small mass in left lateral cervical area non tender no oropharyngeal lesions or erythema eomi no scleral icterus or conjunctival injection cv regular rate this am no m r g appreciated radial pulse pulm ctab poor air movement with kyphosis abd non tender bs soft without guarding ext upper extremity pitting edema persists right worse than left worst at elbows on right extends to the dorsum of the hand rle ulcers stable no signs of cellulitis skin erythematous area over lue forearm improved erythema with edema around elbows bilaterally neuro aox upper and lower extremity strength pertinent results cbc 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 hct 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 neuts lymphs monos eos baso coags pm blood pt ptt inr pt am blood pt ptt inr pt chemistry pm blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap am blood calcium phos mg misc pm blood ck mb ctropnt pm blood ck cpk am blood caltibc ferritn trf am blood tsh am blood cortsol pm blood type art po pco ph caltco base xs microbiology urine urine culture final negative foot culture wound culture final corynebacterium species diphtheroids stool clostridium difficile toxin a b test negative stool clostridium difficile toxin a b test negative serology blood helicobacter pylori antibody test negative imaging echo normal left ventricular cavity size with mild regional and mild global hypokinesis mild aortic regurgitation mild moderate mitral regurgitation mild pulmonary artery systolic hypertension compared with the report of the prior study images unavailable for review of the severity of aortic regurgitation has increased ct neck w contrast no evidence of neck masses or pathologic lymphadenopathy per discussion with the primary team palpable area of abnormality is consistent with a small lymph node severe atherosclerotic disease significant emphysema and calcified pleural plaques better evaluated on subsequent ct torso ct chest abd pelvis with co partially solid and calcified benign appearing dominant right lower lobe nodule this may represent a hamaratoma or sequela of prior tb in absence of prior exams confirming stability follow up chest ct in months recommended known emphysematous changes and dilatation of the main pulmonary artery is consistent with pulmonary hypertension mild dilatation of the ascending aorta up to cm in conjunction with atherosclerotic calcification involving the coronary arteries and aortic valve bilateral rib fractures as detailed above mild wall thickening and inflammation surrounding the esophagus which contains fluid this presumably relates to the known underlying esophageal dysmotility and esophagitis as seen on recent endoscopy bilat up ext veins us bilateral upper extremity dvt involving the right basilic and cephalic veins and one of two left brachial veins distally there is no extension into the axillary or subclavian systems chest portable ap moderately large left pleural effusion stable since possible left lower lobe atelectasis pneumonia stable since satisfactory position of medical devices egd mucous in the esophagus esophagus small non bleeding pre pyloric gastric ulcer small non bleeding stomach body ulcer distal lesser curvature small stomach body ulcer with stigmata of recent bleeding endoclip otherwise normal egd to third part of the duodenum egd coffee ground heme in the esophagus stomach and duodenum without active bleeding or source of bleeding diverticulum in the esophagus at cm from the incisors previously placed endoclip in good position without bleeding from underlying gastric body ulcer gastritis duodenitis otherwise normal egd to second part of the duodenum egd thick mucous in the esophagus esophagus non bleeding distal esophagitis non bleeding gastritis small non bleeding pre pyloric ulcer small previously clipped gastric body ulcer with endoclip in good position and no bleeding few small non bleeding angioectasias in the jejunum non bleeding duodenitis otherwise normal egd to mid jejunum brief hospital course brief hospital course year old male with a history of copd cad chf and remote history of pud presenting with ugi bleed hypotension and hct drop s p transfusion with units prbcs and found to hvae bilateral upper extremity venous thromboses active issues gi bleed patient transferred from outside hospital with melena the patient had multiple acute hct drops to low s and required prbc transfusion x at outside hospital at with stable hct since he had a total of egds and micu stays no active bleeding by egd with one ulcer with bleeding sequela endoclipped remote history of pud per pt recent use of nsaids and corticosteroids suggest upper gi ulcer as the source of bleeding h pylori evaluation was negative a more distal gi bleed beyond reach of egd is another possibility as the patient has evident angioectasias in the jejunum with no ulcers in the duodenum coagulation and platelet counts were consistently within normal limits since stool guaiac is expected to be positive for weeks given recent bleed he was maintained on pantoprazole mg and was advanced to a full diet without difficulty at time of discharge he was no longer having melena he should follow up with gi to have repeat egd to evaluate gastric ulcer and consider capsule endoscopy to further evaluate a small bowel source upper extremity dvt on his final transfer to the floor pt had bilateral pitting edema of upper extremities by u s pt found to have bilateral thromboses in upper extremity veins left side has dvt of brachial veins right side has superficial thromboses cephalic and basilic veins given bilaterality and largely unprovoked thormboses ij line with appropriate placement a hypercoagulable state is a possibility there is a positive family history of thrombosis as pt s mother died from pe a possible malignancy was also considered given the presence of a pleural effusion left cervial mass and nodule on cxr however a ct of the chest abdomen and pelvis found no evidence of overt malignancy as discussed above anticoagulation was held for concerning of life threatening gi bleed he was stated on aspirin mg daily for minimal anticoagulation paroxysmal atrial fibrillation no known history of a fib patient is unsure but pt developed a fib during this hospitalization with rapid ventricular response cause of new onset a fib is most likely from physical stress of recent bleeding events but alternatively may be from cardiac irritation due to thromboembolism or pneumonia alternatively worsening chf cad hyperthyroidism tsh wnl or hypertension pt currently normotensive on floor chads score is no documented history of cva tia or diabetes tte showed no intramural thrombosis he was given metoprolol for rate control mg and monitored by telemetry he will follow up with cardiology as an outpatient and consider initiating anticoagulation or possible cardioversion at that time leukocytosis patient had an elevated white count k with neutrophilia this admission which trended down over time and has been afebrile on the floor multiple etiologies of leukocytosis are potentially present pt presented on steroid taper for copd exacerbation which may be contributing to leukocytosis by promoting demargination bleeding itself can cause leukocytosis from a leukemoid recation rle ulcers over distal metatarsal and plantar aspect of the great toe may be site of infection soft tissue infection or osteomyelitis culture found diptheroids evaluated by podiatry however no erythema or purulence on le left upper extremity rash concerning for cellulitis though it is not spreading and not warmer than other skin concern for pna vs atelectasis in lll in most recent cxr and patient has a history of multipla pnas thrombosis causing upper extremity edema could also promote leukocytosis an underlying hematologic malignancy could explain leukocytosis but diff shows no atypicals urine culture was negative at admission and current antibiotics cover many uropathogens mrsa and on contact precautions the patient was given antibiotics per podiatry s recommendation and will complete a day course of augmentin no clinical evidence of cellulitis or foot ulcer infection at time of discharge white count normalized to right lower extremity ulcers afebrile and no evidence purulence or cellulitis leukocytosis may arise from occult rle infection though multiple alternative explainations exist wound culture grew corynebacterium which is a likely skin contaminant podiatry s evaluation is that the ulcer probes deep to bone without signs of infection they recommend disposition on po antibiotics weight bear on right heel with surgical shoe and that further surgical debridement planned as outpatient wound care recommended non weight bearing if patient cannot manage to only use heel he will be following with podiatry as outpatient for contact emphysema history of emphysema copd without home oxygen requirement at admission he was on a steroid taper for a recent copd flare the prednisone was tapered and stopped during the hospital admissionf for concern that it was contributing to gi losses he was continued on home medications for emphysema chf ef on tte from and found to be on his metoprolol and lasix was restarted before discharge with other antihypertensives being held there was no clear indication of chf exacerbation currently though persistent upper extremity edema is present likely due to upper extremity thromboses discharged on home lasix dose and increased metoprolol for increased rate control due to a fib as above restless leg syndrome the patient s symptoms were controlled by increasing his home ropinirole dose to mg at night transition of care upper gi bleeding patient admitted with severe gi bleeding requiring prbc transfusions he will need to be monitored for signs of gi bleeding including melena and bright red blood per rectum he will be following up as an outpatient with gi at the for repeat egd to evaluate gastric ulcers should have daily hct monitoring at rehab until stable upper extremity venous thrombosis bilateral venous thrombosis in upper extremities were found after the patient had persistent upper extremity edema superficial thrombi on right side deep thrombus on left side a discussion between his care teams the patient and the patient s family determined that anticoagulation will be held at this time to prevent life threatening gi bleeding re evaluation at a later date will determine the need for future anticoagulation he was started on asa mg daily atrial fibrillation the patient has no knowledge of prior atrial fibrillation but while in the hospital was noted to have episodes of fibrillation interspersed among periods of normal sinus rhythm with a chads score of coagulation could be recommended be given the recent gi bleed anticoagulation was held see above he will follow up with cardiology in weeks to re evaluate rhythm at that time if gi bleeding has been stable can reconsider anti coagulation or possible cardioversion if still in a fib foot care the patient will require follow up as an outpatient with podiatry for debridement and evaluation of his right foot ulcers for contact casting follows with dr and appt scheduled code status dnr dni medications on admission mvi kcl meq daily hydralazine mg po bid recently reduced from tid isosorbide mononitrate er mg daily metoprolol succinate er mg daily ropinirole mg qhs valsartan mg po daily fluticasone salmeterol mcg mcg dose daily furosemide mg daily unsure of dose prednisone taper per son taking mg today and wean to mg daily tomorrow fluticasone nasal spray antibiotic for rle cellulitis patient and son unsure of abx spiriva daily discharge medications albuterol sulfate mg ml solution for nebulization sig one inhalation q h every hours as needed for dyspnea acetaminophen mg tablet sig tablets po q h every hours as needed for pain fever fluticasone mcg actuation spray suspension sig one spray nasal times a day fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours amoxicillin pot clavulanate mg tablet sig one tablet po bid times a day for days last day furosemide mg tablet sig one tablet po daily daily ipratropium bromide solution sig one inhalation q h every hours as needed for sob metoprolol tartrate mg tablet sig one tablet po bid times a day calcium carbonate mg mg tablet chewable sig one tablet chewable po tid times a day ropinirole mg tablet sig tablets po qpm once a day in the evening miconazole nitrate powder sig one appl topical times a day as needed for groin rash aspirin mg tablet chewable sig one tablet chewable po daily daily discharge disposition extended care facility nursing rehabilitation center discharge diagnosis primary upper gi bleeding atrial fibrillation upper extremity dvt secondary restless leg syndrome hypertension 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 dear mr it was a pleasure taking care of you at you were admitted with blood in your stools which are likely coming from your small bowel you three endoscopies done to evaluate your esophagus stomach and part of your small intestine which did not show a lot of active bleeding but a metal clip was placed over an existing ulcer in your stomach your bleeding may also have been caused by nsaid use prior to admission you required blood transfusions and two icu stays for your bleeding to stabilize and at the time of discharge your blood counts were stable you will follow up with our gi doctors at the date time below to repeat an endoscopy and evaluate your stomach ulcers they may also consider to do further studies of your small bowel at that time during your hospitalization you were found to have atrial fibrillation which is an abnormal rhythm of your heart we did not see this documented previously in your records but it s possible that you have had this before without symptoms you likely developed it this time due to bleeding and stress you were also found to have a deep vein clot in one of your arms and a superficial vein clot in your other arm in people with these conditions we often start blood thinners but after several discussions with you and your family we decided the risk of re bleeding from your gi tract was too high we started you on a baby aspirin and you will follow up with cardiology in weeks to reassess your heart rhyhtm and discuss blood thinners at that time you will be going to a rehab facility to regain your strength we are attaching a list of the medications and changes we have made below please avoid significant amounts of alleve and try taking tylenol at home as this causes less bleeding we have made the following changes to your medications stop taking hydralazine imdur and valsartan for your blood pressure you can restart this week after your discharge or sooner if your pressure is running over start taking aspirin mg daily continue augment an antibiotic started in the hospital for your skin infection last day will be continue lasix mg daily increase metoprolol to mg twice a day increase ropinirole to mg at nighttime start pantoprazole mg twice daily completed by,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""service medicine"", ""allergies"", ""nitroglycerin"", ""transdermal"", ""norvasc"", ""attending chief complaint"", ""weakness"", ""shortness of breath"", ""major surgical or invasive procedure"", ""EGD"", ""blood transfusions"", ""central line placement"", ""history of present illness"", ""COPD"", ""CHF"", ""remote history of duodenal ulcers""],
""Medications"": [""Alleve"", ""steroids"", ""antibiotics""]
}"
68140,admission date discharge date date of birth sex m service medicine allergies penicillins bactrim attending chief complaint transfer from nh for hypotension and hypoxia major surgical or invasive procedure none history of present illness mr is an yom with dementia type diabetes mellitus bladder cancer s p resection and bcg treatment and recently discharged for uti who was at his nursing home yestderday when found to be having chills and lower extremity numbness his vitals were taken and was found to be afebrile hypotensive tachycardic and hypoxic o sat on ra his bilateral le were found to be cold and purple he was warmed up and put into bed and his bp stabilized in s he was placed on nonrebreather and his o sats came up only to per records he did not have any mental status changes of note osh records from mr previous d c summary in omr report he has had multiple recent utis over the past few months including multi drug resistent enterobacter on proteus on as well as klebsiella in mr was recently discharged from on for uti with pseudomonas resistent to cipro this admission was complicated by delirium and le dvt for which an ivc filter was placed due to concurrent hematuria he is not currently anticoagulated he was discharged on meropenem for days on the day prior to admission he presented to the ed b c of hematuria and passage of clots he was seen by urology and foley irrigation was performed and he was sent out on levofloxacin with plans to undergo cystoscopy with bladder biopsies and possible resection of turbt as an outpatient however the following day he had his hypotensive event described above and was sent to the ed in the ed his vitals were however his bp dropped to bp with sats in the s and a lactate of cxr showed no acute pulmonary process he was given vanc and meropenem and had an ij placed l fluid and foley showed gross hematuria he was transfered to the micu with concern for urosepsis where his pressure stabilized and he did not require pressors he was transfered to the medicine floor upon ariving to the floor vitals were on ra ros difficult to understand pt unsure if from dementia or adentulous pt alert but oriented only to self knew he was in but could not name hospital denied pain sob but stated he was cold and thirsty past medical history pulmonary embolism ivc filter not on anticoagulation pancreatitis dementia type diabetes mellitus hypertension but not on antihypertensives bph bladder cancer s p transurethral resection in completed bcg treatment missed treatment uti s p stab wounds h o rpr treated in s p penile implant osteoarthritis social history per previous records patient could not complete full history with me due to his delirium and dementia home lives in facility occupation retired long distance truck driver etoh remote history of social alcohol use denies etoh in years tobacco remote history of ppd smoking history could not tell me when he quit drugs denies family history could not complete due to patient s dementia physical exam vs ra general alert oriented to self only lying comfortably in bed heent dry mucous membranes edentulous pupils equal and reactive neck supple jvp not elevated no lad right ij in place appears clean and dry 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 ext pitting edema in left le and on right chronic venous stasis changes to skin of both les dps difficult to palpate but feet are warm neuro cn grossly intact uses both upper extremities purposefully foley with red urine in bag responded to questions but difficult to make out his answers mildly agitated not really holding coherent conversation pertinent results labs on 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 pm blood alt ast ld ldh alkphos totbili pm blood lipase pm blood ctropnt pm blood hgb calchct o sat pm blood glucose lactate pm blood lactate k labs on discharge 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 calcium phos mg 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 cxr findings lung volumes are markedly diminished with resultant bronchovascular reorientation at the lung bases no consolidation or edema is evident tortuosity of the thoracic aorta is slightly accentuated due to the low lung volumes similarly cardiac size is mildly accentuated but remains overall within normal limits no definite effusion or pneumothorax is seen extensive degenerative changes are again seen throughout the thoracic spine there are multiple bilateral rib deformities presumably due to remote trauma relatively stable when compared to the prior exam impression markedly low lung volumes with no acute pulmonary process identified renal u s findings the right kidney measures cm the left kidney measures cm no stones hydronephrosis or solid mass is identified within the lower pole of the right kidney is a cm simple appearing cyst there is also a cm simple appearing cyst within the upper pole of the left kidney no perinephric fluid collection is identified limited views of bladder reveal foley catheter with the bladder decompressed there is a heterogeneous cm mass in the bladder with vascular waveforms obtained compatible with the patient s known bladder mass impression no evidence of hydronephrosis no evidence of perinephric abscess or fluid cxr cardiomediastinal silhouette is stable right picc line tip is at the level of superior svc heart size is normal mediastinal contour is unremarkable there is questionable new small focal opacity at the mid portion of the left lung that might represent subpleural atelectasis nodule seen on the chest ct from with no new consolidations demonstrated the known pulmonary nodules are partially imaged on the current study due to the suboptimal sensitivity of this portable chest radiograph multiple rib fractures bilateral are unchanged since the prior study the ivc filter is in place ct chest without iv contrast there are numerous pulmonary nodules throughout all lobes of the lungs consistent with metastatic disease presumably from the patient s known bladder cancer unless there is an additional unknown primary neoplasm these are larger in the lung bases measuring up to mm bilaterally there is no significant pleural effusion there is bilateral mild subsegmental dependent atelectasis the trachea and bronchi are patent to the subsegmental levels there is no mediastinal lymphadenopathy note is made of multiple slightly prominent axillary lymph nodes which are not pathologically enlarged by size criteria there are numerous coronary artery calcifications as well as calcification of the aortic arch a right upper extremity picc terminates with the catheter tip in the lower svc limited axial imaging of the upper abdomen is fairly unremarkable although numerous renal hypodensities are again seen which are most consistent with cysts although better demonstrated on prior imaging studies the superior most aspect of an infrarenal ivc filter is seen small hiatal hernia is present osseous structures demonstrate numerous left sided chronic rib fractures at t as well as right sided rib fractures at t no suspicious lytic or sclerotic lesions are seen there is mild degenerative change of the thoracic spine impression innumerable bilateral pulmonary nodules consistent with metastatic disease no mediastinal lymphadenopathy chronic rib fractures bilaterally renal hypodensities most consistent with cysts better demonstrated on prior studies brief hospital course yo gentleman with h o bladder cancer recurrent utis and dementia called out from the micu for continuing treatment of urosepsis hospital course by problem as follows urosepsis patient received l ivf with improvement in blood pressure never needed vasopressor support he was started on meropenem given prior urine cx sensitivities he was transferred to the floor the following morning his renal function returned to baseline after volume repletion ucx pseudomonas k sensitive to cefepime ceftaz gent tobra recurrent utis across last several months with documented history of proteus enterobacter klebsiela and pseudomonas current urine cx showing pseudomonas no other clear source of infection as he did not have infiltrate on cxr no cough no abdominal pain bcx ngtd and no lines on admission picc line placed and he was treated for days with meropenem urology consulted recurrent uti s likely bladder cancer and urinary retention a foley catheter was placed at admission this was taken out overnight on he passed his trial of void with a cc residual volume he was noted to be incontinent of urine at baseline bladder cancer hematuria urology took for cystoscopy cm tumor unable to resect via scope ct to assess for invasion lymph node involvement no clear evid of invasion or ln involvement however mult lung nodules concerning for metastatic disease med onc consulted rec chest ct for accurate staging bx for tissue diagnosis and agreed to follow when outpatient given massive dvt and need for anticoagulation discussion had with family urology radiation oncology about possible palliative procedures to stop hematuria and allow for anticoagulation decision was made to proceed with palliative radiation tx as family wished to avoid any further invasive procedures palliative care also consulted patient underwent palliative radiation in attempt to control hematuria so that he could have anticoagulation given his large lower extremity dvt as below dvt h o pe dvt with ivc in place not anticoagulated due to history of hematuria patient noted to have swollen l leg leni dvt from l common fem to l popliteal ct scan done for staging as above showed dvt extended up to dvt filter anticoagulation attempted however was d c d as hematuria increased and patient dropped his hct palliative radiation therapy was given with the goal to control hematuria however the patient did continue to bleed with anticoagulation given that he bled enough to require multiple transfusions during this admission it was ultimately felt that anticoagulation should be held with the decision to re start deferred to the outpatient setting low grade fevers following treatment with meropenem for urosepsis as above patient developed recurrent low grade fevers no clear source ucx bcx and cxr negative for infection wbc stable in the end thought likely due to dvt by discharge still having once daily temperatures to f delirium continued on aricept ms waxed and waned however never returned to baseline he frequently became agitated pulling at his picc line and foley he frequently required soft restraints to prevent him from injuring himself and occasionally required haldol ecg checked and qtc wnl after his catheter was removed the restraints were removed and he was overall much more calm anemia baseline hct current hct likely hematuria iron studies were consistent with underlying anemia of chronic disease guiac was negative he was transfused a total of units of prbcs during this admission given blood loss from his friable bladder tumor his hct was stable around prior to discharge hypernatremia mild asymptomatic likely poor po water intake encouraged po intake of water and this resolved on its own type dm controlled with iss in house medications on admission imipenem mg im started for days ertapenem gm im qday x days started decubrite tab qday tylenol mg q h po prn lasix mg po qday levaquin mg po x days started donepezil mg hs gabapentin mg qday imdur mg qday famotidine mg po bid prn itch novalog ssi senna tabs prn vitamin d mg tabs qday colace mg citaloprom mg qday discharge medications famotidine mg tablet sig one tablet po every twelve hours disp tablet s refills cholecalciferol vitamin d unit tablet sig two tablet po daily daily tablet s citalopram mg tablet sig one tablet po daily daily donepezil mg tablet sig one tablet po hs at bedtime senna mg tablet sig one tablet po bid times a day docusate sodium mg capsule sig one capsule po bid times a day acetaminophen mg tablet sig tablets po q h every hours as needed for fever or pain polyvinyl alcohol drops sig drops ophthalmic prn as needed as needed for dryness disp bottle refills heparin porcine unit ml solution sig one injection tid times a day nystatin unit ml suspension sig five ml po qid times a day polyethylene glycol gram dose powder sig one packet po daily daily as needed for constipation cholecalciferol vitamin d unit tablet sig two tablet po daily daily insulin instructions please continue to take your humalog insulin sliding scale as taken during this admission a full sliding scale regimen is outlined below for the nurses to follow to be taken as needed at meal times and at bed time discharge disposition extended care facility discharge diagnosis primary urosepsis bladder cancer deep venous thrombosis secondary dementia deliriium type diabetes mellitus hypertension but not on antihypertensives discharge condition mental status confused always level of consciousness lethargic but arousable activity status bedbound discharge instructions it was a pleasure taking care of you during your admission at you were admitted for a urinary tract infection you were treated with antibiotics you had a catheter in your bladder for some time but we took this out and you were able to urinate on your own you received a course of radiation to help improve your bladder cancer symptoms you have a previous diagnosis of left lower leg blood clot we were unable to give you anticoagulant medications for this as you continued to have significant blood in your urine requiring blood transfusion after receiving these we have changed some of your medications during your admission please continue start or stop your medications as below continue citalopram mg daily continue donepezil mg daily continue famotidine mg twice daily continue polyethylene glycol for constipation as needed continue senna for constipation prevention continue vitamin d units daily stop fexofenadine continue colace mg twice daily continue tylenol as needed for pain fever as written continue using humalog insulin as needed with a sliding scale at meal times and bedtime as taken prior to this admission stop lasix discuss re starting this medication as an outpatient continue getting subcutaneous heparin three times daily while in followup instructions please follow up with dr and dr from urologic oncology on at pm dr office was called and notified that you will be going back to the upon return to the you will be seen by her nurse practitioner jiyan ms will help to coordinate your next visit with dr at your facility completed by [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies penicillins bactrim attending chief complaint hypoxia major surgical or invasive procedure none history of present illness yo male with recent complicated admission significant for bladder ca cm mass hematuria with innumberable pulmonary nodules likely metastases urosepsis ucx pseudomonas h o mutliple drug resistant utis treated with days of meropenem massive dvt with ivc filter not on anticoagulation hematuria during this admission palliative care was consulted and significant efforts were made to address goals of care given his poor prognosis he was made dnr dni he was discharged to a with the eventual goal of putting him under hospice care he was then found at his unresponsive his vs on arrival to the ed were t hr s bp spo on nrb with rhonchi on exam he received vancomycin g iv levofloxacin mg iv and flagyl mg iv on arrival to the floor patient was unresponsive was agonal breathing with an spo in the s on a fm with l nc past medical history pulmonary embolism ivc filter not on anticoagulation pancreatitis dementia type diabetes mellitus hypertension but not on antihypertensives bph bladder cancer s p transurethral resection in completed bcg treatment missed treatment uti s p stab wounds h o rpr treated in s p penile implant osteoarthritis social history per previous records patient could not complete full history with me due to his delirium and dementia home lives in facility occupation retired long distance truck driver etoh remote history of social alcohol use denies etoh in years tobacco remote history of ppd smoking history could not tell me when he quit drugs denies family history could not complete due to patient s dementia physical exam vitals bp p rr general agonal breathing unresponsive cv regular lungs coarse breath sounds bilaterally ext warm well perfused pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt am blood fibrino am blood urean creat am blood lipase am blood glucose lactate na k cl calhco brief hospital course year old man with a h o of metastatic bladder ca mutliple drug resistant utis massive dvt s p ivc filter who presented in respiratory failure likely pneumonia on admission the patient s hcp his wife expressed her desire to focus on his comfort he received supplemental oxygen antibiotics and was placed on a morphine gtt and he expired within hours of arriving in the icu medications on admission famotidine mg tablet sig one tablet po every twelve hours disp tablet s refills cholecalciferol vitamin d unit tablet sig two tablet po daily daily tablet s citalopram mg tablet sig one tablet po daily daily donepezil mg tablet sig one tablet po hs at bedtime senna mg tablet sig one tablet po bid times a day docusate sodium mg capsule sig one capsule po bid times a day acetaminophen mg tablet sig tablets po q h every hours as needed for fever or pain polyvinyl alcohol drops sig drops ophthalmic prn as needed as needed for dryness disp bottle refills heparin porcine unit ml solution sig one injection tid times a day nystatin unit ml suspension sig five ml po qid times a day polyethylene glycol gram dose powder sig one packet po daily daily as needed for constipation cholecalciferol vitamin d unit tablet sig two tablet po daily daily insulin sliding scale discharge medications expired discharge disposition expired discharge diagnosis respiratory failure discharge condition expired discharge instructions expired followup instructions expired md,"{
""Diagnoses"": [""hypotension"", ""hypoxia"", ""dementia"", ""type diabetes mellitus"", ""bladder cancer"", ""s p resection and bcg treatment"", ""uti""],
""Medications"": [""penicillins"", ""bactrim"", ""nonrebreather""]
}"
5952,admission date discharge date date of birth sex f service gyn allergies patient recorded as having no known allergies to drugs attending chief complaint vulvar infection major surgical or invasive procedure s p radical vulvectomy with groin lymph node dissection s p left groin debridements x history of present illness yo female who presented with a vulvar lesion on dr performed a biopsy which revealed high grade atypia most suggestive of squamous cell carcinoma she was admitted with a complaint of lower extremity erythema and swelling consistent with cellulitis past medical history had not been to the doctor for many years social history from was staying with her niece no t e d family history non contributory brief hospital course on the patient underwent a d c for postmenopausal bleeding this was following imaging studies including an mri on that revealed highly suspicious necrotic lymph nodes along bilateral pelvic nodal chain along with a two cm mass with papillary surface projecting into the bladder lumen from the right bladder wall highly suspicious for transitional cell carcinoma on dr performed cystoscopy and she was found to have a two cm superficial papillary bladder tumor lateral to the right ureteral orifice which was biopsied and consistent with papillary urothelial carcinoma low grade the endometrial curettage showed no evidence of malignancy a left vulvar biopsy however revealed invasive squamous cell carcinoma moderately differentiated on the patient underwent radical vulvectomy and bilateral groin lymphadenectomy with right groin nodes positive for metastatic carcinoma ans of lymph nodes in the left groin were positive for metastatic squamous cell carcinoma with extensive extracapsular extension and obliteration of nodal architecture on the patient with taken back to the or for a nonhealing left groin wound and underwent debridement and placement of a vacuum dressing the left groin excision revealed squamous cell carcinoma as well along with acute and chronic inflammation wound culture from that procedure revealed mixed bacterial types on she was taken to the or for further debridement with plastics surgery followed by a placement of vacuum dressing since the tissue felt to be too necrotic for a flap the dressing was removed on and the wound has been on wet to dry dressings since a large amount of lymph fluid drains from this with increased pitting edema in her left lower extremity greater than the right she is able to ambulate the rest of her incision remains clean dry and intact further issues vulvar carcinoma a cxr on showed some hilar fullness so a ct scan was done and showed pulmonary nodules c w metastatic disease a repeat ct on showed increased number and size of pulmonary nodules after discussion with the pt and her family it was decided not to pursue further treatment for this including further debridement or debulking or palliative chemotherapy id pt has persistent low grade fevers throughout her hospitalization all cultures blood urine deep tissue ppd and fungal myco have been negative it is not clear if this is merely tumor fever or if there is a superimposed infection despite different antibiotic regimens for more of her postoperative course including unasyn levofloxacin vancomycin and zosyn strongyloides histoplasmosis studies are still pending but very unlikely her wbc remains elevated had peaked at after her vac dressing was removed however pt remains asymptomatic her antibiotic regimen on discharge is augmentin flagyl and fluconazole po hypercalcemia the patient also developed hypercalcemia twice this admission on admission her calcium was but climbed to she received pamidronate with good response but then her calcium again began to rise until she received another dose of pamidronate on this is presumably caused by bony metastases it was felt that doing a bone scan however would not yield any information that would change her management pt will get electrolytes checked q week after d c and repleted prn heme anemia likely due to chronic infection she received a total of units of prbc with good effect thrombophlebitis of l superficial femoral vein noted on ct scan will continue heparin units sc tid pain control pt complained of increased pain toward the end of her hospitalization but adequate control was obtained with ms contin mg po q hrs with morphine ir mg po q hrs code after extensive discussion with the pt and family she is dni only she does request resuscitation discharge medications docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills heparin sodium porcine unit ml solution sig one units ml injection tid times a day disp units ml refills ferrous sulfate mg tablet sig one tablet po twice a day disp tablet s refills magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed for constipation disp ml s refills senna mg tablet sig one tablet po bid times a day as needed for constipation disp tablet s refills morphine sulfate mg tablet sig tablets po q h every to hours as needed for breakthrough pain disp tablet s refills ibuprofen mg tablet sig one tablet po q h every hours as needed disp tablet s refills metronidazole mg tablet sig one tablet po tid times a day disp tablet s refills fluconazole mg tablet sig one tablet po q h every hours disp tablet s refills morphine sulfate mg tablet sustained release sig one tablet sustained release po q h every hours disp tablet sustained release s refills amoxicillin pot clavulanate mg tablet sig one tablet po q h every hours disp tablet s refills compazine mg tablet sig tablets po every hours as needed for nausea disp tablet s refills heparin lock flush porcine unit ml syringe sig two ml intravenous qd once a day as needed disp ml s refills phenergan mg tablet sig tablets po every hours as needed for nausea disp tablet s refills reglan mg tablet sig one tablet po every hours as needed for nausea disp tablet s refills aquacel hydrofiber packing bandage sig two x inch bandages topical twice a day please place at base of wound disp boxes refills aquacel hydrofiber packing bandage sig two x inch topical twice a day please put at base of wound disp boxes refills msir mg ml solution sig mg po q hr prn as needed for pain for emergency kit disp cc refills gauze pad bandage sig five x in topical twice a day disp boxes refills super absorbant dressing sig five dressing twice a day disp boxes refills abd pads sig three pads twice a day disp boxes refills kerlix bandage sig four rolls topical twice a day disp boxes refills straps sig one pair once a week disp pairs refills levsin sl mg tablet sublingual sig tabs sublingual every hours as needed for increased upper airway secretions for emergency kit disp cc refills ativan mg tablet sig tablets po every hours as needed for emergency kit disp tablet s refills scopolamine base mg patch hr sig one patch transdermal q hrs as needed for nausea for emergency kit disp box refills zometa mg ml solution sig four mg intravenous once as needed for for calcium infuse over minutes disp bags refills outpatient lab work please check calcium level once a week if calcium please infuse zometa mg iv over minutes discharge disposition home with service facility discharge diagnosis vulvar carcinoma stage iv discharge condition stable discharge instructions please ambulate and use your incentive spirometer followup instructions provider b call to schedule appointment prn,"{
""Diagnoses"": [""vulvar infection"", ""major surgical or invasive procedure (SP radical vulvectomy with groin lymph node dissection)"", ""left groin debridements"", ""history of present illness (yo female who presented with a vulvar lesion)"", ""cellulitis"", ""postmenopausal bleeding"", ""necrotic lymph nodes (along bilateral pelvic nodal chain)"", ""transitional cell carcinoma (on dr performed cystoscopy and found a two cm superficial papillary bladder tumor)""],
""Medications"": []
}"
4648,admission date discharge date date of birth sex f service neonatal history this is a week infant girl admitted for issues of prematurity the infant was born to a year old gravida para mother with type o positive hepatitis b surface antigen negative rpr nonreactive antibody negative rubella immune gbs unknown estimated date of confinement was the prenatal course was significant for a cerclage preterm labor and admitted to at weeks gestation received betamethasone preterm labor resolved with magnesium sulfate insulin dependent gestational diabetes mellitus poorly controlled past obstetrical history notable for a week gestation born in at who was on the ventilator for two days and in the hospital for one and a half months full term infant in weeks in receiving oxygen only and a two week hospital stay present ob history mother transferred from on due to preterm labor unstable and due to vaginal hemorrhaging the infant was delivered by stat cesarean section under general anesthesia hemorrhage in retrospect probably due to cerclage removal no evidence of abruption apgars of at one minute and at five minutes at delivery the infant was noted to have a nuchal cord times one received positive pressure ventilation for seconds due to apnea slowly improved the infant was brought to neonatal intensive care unit receiving facial cpap gbs unknown no maternal fever rupture of membranes at delivery ampicillin given seven hours prior to delivery physical examination on admission birth weight grams greater than the th percentile head circumference cm which is the th to th percentile length cm which is to th percentile active anterior fontanel open and flat normal s s no murmur breath sounds coarse intercostal and subcostal retractions noted the infant is on cpap in room air abdomen soft nontender nondistended extremities were warm and well perfused tone appropriate for gestational age summary of hospital course by systems the infant was initially placed on continuous positive airway pressure of cm of water receiving and infant was noted to be tachypneic initially gas on admission showed a ph of co of the infant was transitioned to room air by day of life one the infant is currently in room air with respiratory rate of s to s saturating to the infant has had approximately three to five apnea and bradycardia spells per day over the last two days the last apnea and bradycardia was on the infant is not being treated with methylxanthine therapy at this time cardiovascular the infant has remained cardiovascularly stable this hospitalization with heart rates in the s to s no murmur mean pressure to fluids electrolytes and nutrition the infant was initially nothing by mouth receiving cc per kilogram per day of d w infant started enteral feedings on day of life two and has advanced to full volume feedings as of at cc per kilogram per day of premature enfamil calories per ounce the infant has tolerated feeding advancement without difficulty glucoses have been stable and have been to the most recent electrolytes on day of life three showed a sodium of chloride potasium pco of at that time fluids were advanced from cc per kilo per day to cc per kilogram per day urine output has been cc per kilogram per hour the most recent weight is up grams from yesterday gastrointestinal the infant is currently under single phototherapy and was started on phototherapy on day of life three for a bilirubin level of and a direct of repeat bilirubin level on is hematology the infant has not received any transfusions this hospitalization hematocrit on day of admission was repeat cbc was sent on day of life one which showed a hematocrit of the most recent hematocrit level on day of life two showed a hematocrit of with a reticulocyte count of infectious disease the infant was noted to have a left shift on the initial cbc white cell count hematocrit platelets neutrophils bands enucleated red cells the infant was started on ampicillin and gentamicin and remains on ampicillin and gentamicin currently day six of a seven day course a lumbar puncture revealing clear spinal fluid on day of life one showed a white cell count of red cells polys lymphocytes monocytes protein level glucose the gentamicin level was drawn on day of life two which showed a gentamicin trough of and a gentamicin peak of neurology a head ultrasound on day of life two was within normal limits no intraventricular hemorrhage normal neurological examination sensory hearing screening is recommended prior to discharge home ophthalmology the infant is to receive first examination at three weeks of age psychosocial social work was involved with family the contact social worker can be reached at the parents involved condition at discharge week gestation female now day of life five but stable in room air discharge status to level ii nursery at primary pediatrician dr phone number care recommendations feedings at discharge premature enfamil calories per ounce currently at cc per kilogram per day medications ampicillin mg per kilogram per day gentamicin mg per kilogram per day currently day six of a seven day course car seat position screening recommended prior to discharge state newborn screen was sent on day of life three results are pending hepatitis b vaccine is recommended prior to discharge 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 day care 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 at weeks gestation female status post respiratory distress presumed sepsis indirect hyperbilirubinemia apnea of prematurity m d dictated by medquist d t job,"{
""Diagnoses"": [""Prematurity"", ""Neonatal history"", "" Gestational diabetes mellitus"", ""Poorly controlled"", ""Obstetrical history""],
""Medications"": [""Betamethasone"", ""Magnesium sulfate"", ""Insulin"", ""Oxygen""]
}"
90451,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 language changes major surgical or invasive procedure intubation history of present illness yo rh man with diet controlled dm high cholesterol memory loss who presents with not feeling well x days his daughter spoke with him this am and he stated he didn t feel well daughter noted trouble articulating words brought him to dr office for an appt thought he was doing reasonably well reassured patient and sent him home brother in law was not convinced of his wellness because he seemed to have things to say but unable to say them thus brought him to the ed patient walked into the ed around am bp head ct revealed ich left temporal lobe during his ed stay he became more confused less fluent more slurred after dilantin infusion bp at this time repeat head ct essentially shows no change to my eye x cm bleed left temporal lobe x slices after head ct bp was s and he improved a bit in that he became more fluent nonsensical words but fluent at least in ed got dilantin g iv and dex mg iv x neurosurg consulted and rec d the above plus mri neuro c s considering taking him to the or also per son in law he was was not able to carry a conversation hrs ago on a walk outside time of onset of symptoms is not clear at minimum was hrs ago possibly more like days patient lives alone past medical history left corneal transplant on eye drops no other medical problems per daughters but per pcp diet controlled dm pmr high cholesterol memory loss anemia lbp chronic dizziness orthostatic hypotension no h o stroke cancers social history lives alone with daughter on widowed daughters smoker ppd x many years no etoh drugs former worker for inspector family history no h o stroke or ich physical exam pe vitals ra gen elderly man picking at sheets and lines talking nonsensically about to climb out of bed quite strong heent nc at anicteric sclera mmm neck supple no carotid bruits chest cta bilat cv rrr without mur abd soft nt nd bs extrem no edema wwp neuro mental status initially awake not answering any questions including orientation questions or following simple commands babbling nonsensical words one or two at a time nonfluent globally aphasic unable to name neologisms grabbing at lines etc later after bp was a little higher was fluent albeit still talking nonsensically would mimic commands but not follow any simple commands does not appear to neglect either side as he orients to each side spontaneously cranial nerves pupil exam left pupil is surgical right is mm and min reactive ptosis on the left eom exam intact to all movements facial symmetry mild right lower face weakness gag reflex present tongue appears midline when he mimics me motor slightly increased tone throughout moving all extremities vigorously holds arms up x sec holds legs up x sec no asymmetry no drift sensory withdrawls and winces x he even wags his finger at me as if to say don t do that reflexes ue le upgoing toe right downgoing on the left pertinent results pm type art temp rates tidal vol peep o po pco ph total co base xs intubated intubated vent controlled pm lactate pm freeca pm urine color yellow appear clear sp pm urine blood neg nitrite neg protein neg glucose neg ketone bilirubin neg urobilngn neg ph leuk neg am glucose urea n creat sodium potassium chloride total co anion gap am alt sgpt ast sgot alk phos amylase tot bili am lipase am albumin calcium phosphate magnesium am wbc rbc hgb hct mcv mch mchc rdw am neuts lymphs monos eos basos am plt count am pt ptt inr pt ekg sinus rhythm and occasional ventricular ectopy compared to the previous tracing of the rate has increased there is occasional ventricular ectopy otherwise no diagnostic interim change cxr ap upright chest the tip of an endotracheal tube terminates in a standard position cm above the level of the carina the tip of a nasogastric tube terminates in the proximal stomach with its side port located at the gastroesophageal junction lung volumes are low the heart size is normal the aorta is slightly tortuous without focal dilatation alveolar airspace opacities are identified in the bilateral infrahilar region are concerning for aspiration developing infiltrate the pulmonary vasculature is prominent with upper zone redistribution reflecting likely mild interstitial edema no pneumothorax is identified the visualized soft tissue and osseous structures are unremarkable impression endotracheal tube in a standard position no pneumothorax patchy infrahilar opacities concerning for aspiration developing infiltrate mild pulmonary edema ct brain initial non contrast head ct findings there is an approximately x cm intraparenchymal area of high density within the left temporal lobe surrounding hypodensity is consistent with edema there are small amounts of mass effect exerted upon the frontal of the left lateral ventricle as well as focal effacement in the left temporal lobe there is no shift of the normally midline structures there is slight prominence of the contralateral ventricle without frank hydrocephalus the basal cisterns are well visualized an approximately cm area of hypodensity involving the cortex of the left frontal lobe is best seen on series image additionally multiple hypodensities are seen within the periventricular white matter as well as within the left basal ganglia consistent with chronic small vessel infarction the visualized paranasal sinuses and mastoid air cells are pneumatized and well aerated atherosclerotic calcifications are noted within the distal vertebral arteries as well as within the intracranial and internal carotid arteries the surrounding soft tissue structures including the orbits appear unremarkable impression acute lobar hemorrhage in the left temporal lobe with surrounding edema in elderly person this constellation of findings raises the possibility of amyloid angiopathy wedge shaped hypodensity in the left frontal lobe suggests a subacute or chronic infarction in this region extensive periventricular white matter chronic small vessel infarction as well as findings consistent with a lacunar infarction in the left basal ganglia findings were relayed to the emergency department dashboard at p m on ct brain repeat non contrast head ct scan comparison at a m findings again seen is a x cm intraparenchymal area of high density within the left temporal lobe with a considerable amount of surrounding edema this has not significantly changed compared to the prior examination there is a small degree of mass effect exerted on the frontal of the left lateral ventricle as well as focal effacement of the left temporal lobe there is slight trapping of the right lateral ventricle again seen are multiple subcortical periventricular and left basal ganglia hypodensities consistent with chronic small vessel infarction the osseous structures are unremarkable the visualized paranasal sinuses and mastoid air cells are well aerated atherosclerotic calcifications are noted within the distal vertebral arteries as well as the intracranial and internal carotid arteries impression acute lobar hemorrhage in the left temporal lobe with surrounding edema the differential diagnosis includes hemorrhagic contusion and amyloid angiopathy underlying neoplasm or avm cannot be excluded correlation of the onset of the patient s symptoms to the initial head ct scan may help narrow the differential diagnosis mri with contrast would better evaluate for neoplasm if this is of clinical concern mr head w w o contrast mra brain w o contrast reason evaluate head bleed with and without contrast please pos contrast magnevist medical condition year old man with confusion ich on ct reason for this examination evaluate head bleed with and without contrast please possible mass clinical history confusion hematoma on ct technique multiplanar pre and postcontrast t weighted images axial t weighted susceptibility flair and diffusion weighted images were obtained comparison is made to a ct examination performed at p m on the same day findings there is a superficial hematoma in the anterolateral left temporal lobe not significantly changed in size compared to the ct it measures approximately cm in greatest dimension on the sagittal t weighted images unchanged allowing for the differences in technique it consists largely of deoxyhemoglobin there are few small areas of t hyperintense methemoglobin within it there is surrounding flair hyperintensity there is effacement of the left cerebral sulci and some flattening of the left lateral ventricle with minimal if any shift of the septum pellucidum there is extensive flair hyperintensity in the deep cerebral white matter corresponding to low attenuation seen on the ct from a m the apparent small infarct in the left frontal lobe seen on that ct is not identified perhaps the cavity of a chronic infarct has been compressed by the left sided mass effect there is no evidence of a recent infarct on the diffusion weighted images the brainstem and cerebellum are intact no enhancing lesions are seen there is susceptibility effect associated with the hematoma as well as in the basal ganglia which is normal in this aged patient there may be minimal gyriform susceptibility effect in the right temporoparietal region the ambient cisterns are roughly symmetric and no mass effect on the brainstem is seen impression there is a cm left temporal hematoma unchanged in size compared to studies dating back to a m on the same day no enhancing lesions are seen elsewhere to suggest hemorrhagic metastatic disease there may be minimal susceptibility effect superficially in the right temporoparietal region but no diffuse abnormalities are seen to strongly suggest amyloid angiopathy although obviously that diagnosis remains possible the degree of mass effect is unchanged there are extensive microvascular changes in the cerebral white matter mra of the head technique a d time of flight study was derived from overlapping axial slabs through the inferior cranium findings there is symmetric decreased signal intensity in the siphons likely artifactual the distal left vertebral artery is poorly seen where it curves inferiorly at the c level the basilar artery is widely patent the major branches of the cerebral arteries are normal no abnormal vessels are seen in the region of the left temporal hematoma impression allowing for slight artifact normal mra of the skull base circle of levels an atretic right a segment is noted ct head routine non contrast head ct comparison findings again seen is intra parenchymal hemorrhage within the left temporal lobe with slight interval increase in the surrounding hypodensity consistent with edema there has been no change in the degree of mild mass effect on the lateral ventricle again there is no shift of midline structures no new foci of hemorrhage are identified the surrounding osseous and soft tissue structures are unremarkable the visualized paranasal sinuses show fluid within sphenoid sinus and mild maxillary sinus mucosal thickening impression left temporal intra parenchymal hemorrhage unchanged with mild increase in surrounding hypodensity consistent with edema no change in the degree of mild mass effect without midline shift brief hospital course yo man on asa who presents with days of feeling unwell with headaches found to have a left temporal lobe intracranial hemorrhage on head ct in the ed on exam he initially had a wernickes type aphasia fluent nonsensical words neologisms cannot repeat or name and right lower facial weakness he was intubated and admitted to the neurosurgical service icu because of the proximity of the bleed to the cerebral peduncle the differential diagnosis of which was thought to include amyloid angiopathy hemorrhagic conversion of a stroke mass tumor avm aneurysm less likely htn has no h o htn less likely trauma no history of this but patient lives alone toxins aspirin use sinus thrombosis less likely as only has one bleed not multifocal he was loaded with dilantin and placed on maintenance dose at mg x d mri a was performed which showed no obvious underlying lesion ie vascular or neoplastic lesion head ct was repeated and was unchanged antiplatelets and anticoagulation was avoided bp was kept between and systolic his family declined surgical interventions he was extubated on and transferred to the neurology service floor for further workup of the cerebral hemorrhage imaging was suggestive of amyloid angiopathy because of the lobar cortical location of the bleed although no microbleeds were present however on further history he recalled bumping his head on a car door two weeks before admission and thus traumatic hemorrhage could not be ruled out exam improved and he made less paraphasic errors with improved comprehension strength and fluency were normal on the day of discharge he felt well was walking around his room and had at least comprehension with some anomia and occasional paraphasic errors when asked to name but otherwise normal pt recommended home pt and he was discharged in stable condition medications on admission none except asa and eye drops for cornea transplant occ sleeping pill discharge medications acetaminophen mg tablet sig tablets po q h every to hours as needed for pain fever senna mg tablet sig one tablet po daily daily disp tablet s refills cholecalciferol vitamin d unit tablet sig one tablet po daily daily disp tablet s refills calcium carbonate mg tablet chewable sig one tablet chewable po tid times a day disp tablet chewable s refills phenytoin sodium extended mg capsule sig one capsule po three times a day take extra mg with night time dose see other prescription disp capsule s refills phenytoin sodium extended mg capsule sig two capsule po at bedtime take with night time dose to total mg at night disp capsule s refills outpatient physical therapy diagnosis intracerebral hemorrhage discharge disposition home with service facility greater vna discharge diagnosis intraparenchymal hemorrhage left temporal lobe discharge condition good language comprehension to at least baseline discharge instructions please md or return to ed if you experience new symptoms of speech or language problems new weakness numbness visual or hearing changes problems walking severe headache or vertigo followup instructions please call dr office for neurology appointment in weeks office is located on provider apg sb date time md completed by [NEW_RECORD] admission date discharge date date of birth sex m service neurology allergies phenytoin attending chief complaint evalaute for large iph major surgical or invasive procedure none history of present illness yo man with pmh significant for l temporal hemorrhage followed by dr in neurology was transfered from osh for evaluation of large iph he was last seen in his usal state of health at pm he did not respond to phone calls from his friend who called his daughter she called he was found unconscious and unresponsive was intubated taken to osh where ct scan showed large iph in r frontal lobe he was transfered to for further care past medical history left temporal hemorrhage thought to be due to amyloid angiopathy possibly left corneal transplant pmr diabetes hyperlipidemia anemia memory loss low back pain chronic left head pain as above social history lives alone independent in adls family history no h o stroke or ich physical exam pe vs t hr bp intubated gen intubated on ventilator cv rrr nl s s no m r g chest cta bilaterally abdomen soft ntnd bs ext warm perfused no c c e neurologic examination unsconsciuos unrepsonsive intubated not on sedatives pupils bl has corneal opacity on left side pupils fixed and non reactive no corneal reflex no dolls eye movement mild gag motor withdraws to painful stimuli in all limbs no spontaneus movements reflexes and symmetric throughout bl plantars upgoing pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood plt ct am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap ct head non contrast head ct there is a large right frontal intraparenchymal hemorrhage which allowing for differences in technique is not definitely larger compared to the outside hospital study performed three hours prior this large focus measures x cm there is diffuse cerebral edema which is worst in the right frontal lobe with associated large amount of mass effect including effacement of the right lateral ventricle cm leftward shift of normally midline structures leftward subfalcine herniation of the right frontal lobe and downward transtentorial herniation there is dilatation of the posterior of the left lateral ventricle which is filled with blood otherwise the frontal of the left lateral ventricle third ventricle and fourth ventricle are effaced there are other foci of intraparenchymal hemorrhage such as in the right occipital lobe as well as diffuse foci of subarachnoid hemorrhage particularly along the right cerebral hemisphere blood is also seen in what appears to be the third ventricle the soft tissues appear grossly unremarkable the patient has had prior left lens replacement secretions are noted layering posteriorly within the nasopharynx no skull fracture is demonstrated there is mucosal thickening noted within the anterior ethmoid air cells bilaterally as well as mildly within the left maxillary sinus the mastoid air cells are aerated vascular calcifications are noted along the cavernous carotid arteries as well as the right vertebral artery impressions large right frontal intraparenchymal hemorrhage diffuse cerebral edema with particular hypodensity in the right frontal lobe probably related to the hemorrhage but also could be due to right frontal infarction due to right frontal subfalcine herniation towards the left diffuse effacement of the ventricular system except for slightly dilated posterior of the left ventricle other smaller foci of intraparenchymal hemorrhage as well as diffuse subarachnoid hemorrhage downward transtentorial herniation brief hospital course mr was admitted to neuro icu for management of iph he was transfered from osh for evaluation of large right frontal bleed he was intubated when he arrived in ed and his exam showed dilated fixed pupils no corneals no dolls eyes very mild absent gag with gcs of and bl upgoing toes he was seen by neurosurgery who felt intervention was not beneficial given huge bleed and signs of brainstem death with herniation the prognosis was discussed in detail with family including hcp prognosis was poor due to large bleed and unfavourable neuro exam he was made comfort measures and extubated in icu he was given morphine and ativan for comfort measures he expired on at am medical examiner was called as death occured in less than hrs after arrival who waived the case medications on admission gabapentin citalopram discharge medications none discharge disposition expired discharge diagnosis right frontal bleed discharge condition dead discharge instructions none followup instructions none md,"{
""Diagnoses"": [""headache"", ""language changes"", ""memory loss"", ""high cholesterol"", ""diet controlled diabetes mellitus"", ""intubation history""],
""Medications"": [""dilantin"", ""dexamethasone"", ""iv""]
}"
9734,admission date discharge date date of birth sex m service tsurg allergies patient recorded as having no known allergies to drugs attending chief complaint difficulty breathing major surgical or invasive procedure tracheal reconstruction history of present illness mr has a history of legionaire s disease with respiratory failure that required intubation in he had a tracheostomy for two months and suffered stridor and complained of dyspnea on exertion since decanulation in past medical history legionelle pneumophilia infection social history packs for years smoker quit in lives with wife and has children denies drugs and etoh family history non contributory physical exam t hr bp oxygen on ra general nad heent perrla eomi trachea midline no jvd well healed tracheostomy scar present just below the sternal notch about a centimeter and a half below the cricoid no adenopathy and no masses pulmonary thorax is symmetrical without lesions lungs are cta b l cardiac rrr with a soft murmur abdominal well healed gastrostomy site non tender non distended extremeties no clubbing or edema neuro grossly non focal with appropriate mental status 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 k pm blood pt ptt inr pt brief hospital course mr was taken to the or on and underwent tracheal reconstruction the surgery went well with minimal blood loss a was placed to prevent extension of the trachea the procedure revealed moderate secretions mostly in the upper trachea and larynx and he was placed on cefazolin and flagyl he also started erythromycin eye drops for an apparent left eye infection the patient received chest pt up until with good results he was able to void and move his bowels normally he was able to tolerate a normal diet his was removed and he was discharged on off antibiotics with instructions to follow up with dr and dr in weeks medications on admission none discharge medications tylenol mg tablet sig one tablet po every hours as needed for pain discharge disposition home discharge diagnosis status post tracheal reconstruction legionaire s disease discharge condition good discharge instructions go to an emergency room if you experience new and continuing nausea vomiting fevers chills or shortness of breath also go to the er if your wound becomes red swollen warm or produces pus leave the steri strips on until they begin to peel then you may remove them if you experience clear drainage from wounds cover with a clean dressing and stop showering until drainage subsides for at least days no heavy lifting or exertion for at least weeks take your complete course of antibiotics you may resume your regular diet as tolerated no baths showers only followup instructions call and schedule a follow up appointment in weeks with dr,"{
""Diagnoses"": [""Difficulty breathing"", ""Major surgical or invasive procedure"", ""Tracheal reconstruction"", ""Legionnaire's disease"", ""Respiratory failure"", ""Stridor""],
""Medications"": [""Oxygen"", ""Intubation"", ""Tracheostomy"", ""Pulmonary therapy"", ""Cardiac therapy"", ""Gastrostomy""]
}"
82048,admission date discharge date date of birth sex f service surgery allergies penicillins attending chief complaint abdominal pain major surgical or invasive procedure laparscopic converted to open cholecystectomy with adhesion lysis exploratory laparotomy a line placement ij line placement ercp with stent placment history of present illness ms is a yo woman with h o chronic cholecystitis who initially presented for day surgery for a laparoscopic cholecystectomy on her procedure was converted to an open cholecystectomy because of difficulty with adhesions there was some minor bleeding in the hepatic fossa per the op note ebl was cc she was extubated without difficulty after the operation and she was admitted to the surgical floor post op for monitoring overnight she had problems with persistent abdominal pain for which she received iv morphine dilaudid and was put on a pca pump she had nausea and dry heaving but no frank emesis although there was some concern from the team that she may have aspirated her urine output fell off and she complained of dizziness with standing she was receiving standard post op fluids at cc hr overnight at am on the morning of transfer she triggered for marked nursing concern in the setting of increasing oxygen requirement dropped from to on l and poor urine output a bladder scan showed cc of urine and a foley was placed she was noted to have crackles and be wheezing she was started on antibiotics with flagyl levo for possible pneumonia in the setting of her worsening clinical status she was transferred to the medical icu for further care upon arrival to the icu she was sleepy but answering questions appropriately she had pain with deep inspiration or movement of note ms reports having a slight non productive cough prior to her surgery otherwise had been feeling well no fatigue fevers or chills past medical history hypertension lichen sclerosis hypothyroidism osa on cpap attention deficit disorder s p tah for uterine abscess per prior notes s p appendectomy social history works as a school teacher lives alone has three children who live nearby smoked in the past but quit around age has one glass of wine per week no drugs per family family history dm asthma and htn in brother physical exam on face mask sleepy but rousable with some effort oriented to family place and year face symmetric pupils equal but small b l no scleral icterus op clear mmm neck supple no thyroid enlargement or adenopathy s s regular tachycardia systolic murmur at apex no rub decreased breath sounds at bases with bronchial breath sounds at right base expiratory wheeze tender throughout her abdomen especially at ruq peritoneal signs with rebound and guarding present bowel sounds are present able to move all her extremities with significant urging no tremor finger grip intact b l no le edema b l dp b l no rash pertinent results 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 alkphos totbili pm blood lipase am blood lipase pm blood alt ast alkphos amylase totbili dirbili indbili am blood alt ast ld ldh alkphos amylase totbili am blood calcium phos mg pm urine osmolal pm urine hours random urean na uric ac pm urine casthy pm urine rbc wbc bacteri none yeast none epi pm urine blood neg nitrite neg protein tr glucose neg ketone neg bilirub neg urobiln neg ph leuks neg pm urine color yellow appear clear sp bal am bronchoalveolar lavage gram stain final per x field polymorphonuclear leukocytes no microorganisms seen pm sputum source expectorated gram stain final pmns and epithelial cells x field per x field gram negative rod s per x field gram positive cocci in pairs respiratory culture preliminary sparse growth oropharyngeal flora influenza dfa negative brief hospital course yo woman admitted after open cholecystectomy and transferred to the icu in the setting of persistent post op pain hypoxia and decreased urine output leukocytosis and fever unclear cause however on investivgation her cxr was suggestive of infection given history of recent emesis may have been from aspiration on transfer to she was very tachypnic and later the day of transfer she required intubation due to increased work of breathing she also had a line and central line placed also we were concerned about other posible abdominal sources of infection given persistent severe post op pain surgery closely followed the pt while in and due to her presistant pain increased abomnial distension and fevers they were concerned about abdominal process on she had a repeat ercp without albnormality they she was taken back to or for exploratory lap without casue of fevers and pain found back in the she had a brochoscopy with bal and the showed increased thick secretions in rml concerning for aspiration pna she was continued on tx with vanc levo flagyl her wbc started to trend down and she was transferd to the sicu for closer post operative monitoring she had a negative flu test sputum cultuers showed acute renal failure was thought to be prerenal cr up to on day of admission given aggressive ivf and it improved to medications were renally dosed altered mental status this as likely from narcotic pain medications but also partially likely from hypercarbic respiratory failure alternatively altered mental status may have been a sign of developing sepsis at transfer pt was sedated and intuabted respiratory acidosis be due to underlying osa chronic hypoventilation vs decreased respiratory drive while on narcotics she had an a line placed on day of admission she will need cpap again once extubated pain control was very difficult to control changed from demerol to fentynl after ercp and ex lap pain was thought to be mainly from regular post op recovery pancreatits lipase became elevated as abd enlarged and was more tender i o monitored to keep pt hydrated but not compromise resp funciton anemia baseline hct at admission was hct hct was serially monitored active type and screen negative hemolysis labs htn home meds were held dut to concern for hypotension due to shock hypothyroidism continued on levothyroxine add held home adderall comm with surgery and family daughter is hcp was transfered from to sicu on for closer post operative care by surgery patient continued to recover on the floor currently she is up ambulating independently on regular diet and tolerating well abdominal incision is oozing small amounts of fluid dressing changes done daily she is still having problems with urinary incontinence urine culture and analysis negative with no urinary retention will have her follow up with dr she will also follow up with dr medications on admission home meds confirmed with family ibuprofen mg daily lisinopril hctz mg daily synthroid mcg daily adderall mg daily prn project study needs mvi daily discharge medications hydrocodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills levothyroxine mcg tablet sig two tablet po daily daily lisinopril mg tablet sig one tablet po daily daily lisinopril mg tablet sig one tablet po daily daily hydrochlorothiazide mg capsule sig two capsule po daily daily levofloxacin mg tablet sig one tablet po q h every hours disp tablet s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills bed semi electric bed for home dx asp pneumonia abd incision discharge disposition home with service facility vna discharge diagnosis primary diagnosis cholecystitis discharge condition stable discharge instructions you are being discharged on medications to treat the pain from your operation these medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely you must refrain from such activities while taking these medications please call your doctor or return to the emergency room if you have 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 see blood or dark black material when you vomit or have a bowel movement 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 and take any new meds as ordered activity no heavy lifting of items pounds for weeks you may resume moderate exercise at your discretion no abdominal exercises wound care you may shower no tub baths or swimming if there is clear drainage from your incisions cover with clean dry gauze your steri strips will fall off on their own please remove any remaining strips days after surgery please call the doctor if you have increased pain swelling redness or drainage from the incision sites followup instructions provider md phone date time please follow up with your primary care provider weeks to obtain chext x ray to ensure pneumonia has resolved provider urologist monday at building completed by,"{
""Diagnoses"": [""Cholecystitis"", ""Adhesions"", ""Laparoscopic conversion to open cholecystectomy"", ""Laparotomy"", ""IJ line placement"", ""ERCP with stent placement""],
""Medications"": [""Morphine"", ""Dilaudid"", ""PCA pump"", ""IV fluids"", ""Post-op fluids""]
}"
87470,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint mr is a year old gentleman with advanced rectal cancer preoperative neoadjuvant chemoradiation was given here at which somewhat shrunk the tumor mass at the mucosal level major surgical or invasive procedure abdominal perineal resection history of present illness mr is a year old gentleman who has advanced rectal cancer preoperative neoadjuvant chemoradiation has been given here at which has somewhat shrunk the tumor mass at the mucosal level on underwent ap resection with flexible cystoscopy with bilateral ureteral stent placement rigid sigmoidoscopy and colostomy past medical history rectal carcinoma s p chemo and xrt social history year old cantonese male who has no significant past medical history he is married with one son does understand some english speaks little english lives with his wife and son family history not available physical exam vitals afebrile bp hr rr sat on ra gen thin asian gentlemen accompanied by wife and son mm bil eomi neck free range of motion lung clear to auscultation cor rrr no murmurs abdomial soft flat lower abdominal tenderness no masses rectal deferred ext bilateral pedal edema dp s bilaterally neuro via interpreter alert and orientated x speech clear no tremors pertinent results hematocrit wbc electrolytes within normal limits urinalysis negative urine creatinine chest x ray for post op hypotension fever cardiac size is top normal aside from linear left lower lobe retrocardiac opacity and faint opacity in the right mid lung the lungs are clear there are no pneumothorax or large pleural effusions brief hospital course the patient underwent an abdominal perineal resection of his rectal mass with flexible cystoscopy with bilateral ureteral stent placement rigid sigmoidoscopy and colostomy see operative report for full details post op fever the patient continued to spike intermittent fevers for a few days post operatively with normal white blood count negative chest x ray and urinalysis and blood cultures from with no growth to date the fevers were most likely attributable to post operative atelectasis pain the acute pain service managed the patient s pain via a continuous epidural infusion through post operative day on day he was transitioned to a dilaudid pca and on day to oral percocet with good pain control wound care the patient had dry dressings to the abdominal wound and miconazole powder with dry dressings to the perineal wound they remained clean and dry with staples in the abdominal wound drains the ureteral drains were removed on post operative day one drain was removed and the patient returned home with the second vna will come to the patient s home for drain teaching ostomy the patient s ostomy remained healthy looking functional and he received teaching from the ostomy nurse via an interpreter as did his family on how to care for it he demonstrated his ability to do so before discharge the patient will have vna come to his home for ostomy teaching pathology pending on discharge the patient had stable vital signs was afebrile was ambulating and voiding he will follow up with dr and vna will come to his home for ostomy and drain care medications on admission morphine mg po bid oxycodone apap discharge medications oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for breakthrough pain disp tablet s refills morphine mg tablet sustained release sig one tablet sustained release po q h every hours as needed for pain pantoprazole 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 docusate sodium mg capsule sig one capsule po bid times a day discharge disposition home with service facility homecare discharge diagnosis rectal carcinoma with resection discharge condition stable discharge instructions please call your doctor for severe pain fever nausea vomiting inability to eat drink or urinate bleeding or drainage of foul smelling discharge from your incisions problems with your ostomy or any other questions or concerns do not drive while taking percocet no heavy lifting over pounds for weeks you may shower do not swim or take tub baths for weeks followup instructions provider md phone date time please call dr for a follow up appointment in weeks at md [NEW_RECORD] admission date discharge date date of birth sex m service neurosurgery allergies alcohol attending chief complaint headache dizziness major surgical or invasive procedure right posterior fossa craniotomy for mass resection history of present illness m w pmh of rectal ca lung mets undergoing chemotherapy c o month h o of worsening h a and dizziness denies nausea other than after chemo and going away with meds denies any vomitting denies any fall denies fevers or any other symptom past medical history rectal carcinoma status post chemotherapy and radiation initial reseciton in lung mets seen in social history year old cantonese male who has no significant past medical history he is married with one son does understand some english speaks little english lives with his wife and son family history non contributory physical exam on mse per translator family intact oreinted x no dysarthria no naming errors cn ii xii intact no abnormalities motor full strength in upper and lower extremities sensory intact to light touch pinprick temperature b l reflex and symmetric at bicep tricep patellar ankle jerks coordination no dymetria on either side noted gait narrow based stable on discharge xxxxxxxxxxx pertinent results labs on admission am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood neuts lymphs monos eos baso pm blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap am blood calcium phos mg labs on discharge xxxxxxxxxxx imaging head ct non contrast there is a peripherally enhancing lesion in the right cerebellar hemisphere measuring x x cm with moderate vasogenic edema extending to the left side of midline with deformity of the fourth ventricle and mass effect on the fourth ventricle and the right side of the midbrain and pons resulting in mild obstructive hydrocephalus with dilated temporal horns and mild dilatation of the lateral ventricles the posterior aspect of the lesion has enhancing nodular component bilateral basal ganglial calcifications are noted no suspicious lytic or sclerotic lesions are noted there is mild mucosal thickening of the ethmoid air cells on both sides the soft tissues of the scalp are unremarkable impression x x cm peripherally enhancing lesion enhancing nodular component posteriorly with moderate vasogenic edema mass effect on the fourth ventricle and mild obstructive hydrocephalus likely represents a metastatic lesion less likely possibility of a neoplasm mri head without and with iv contrast per tumor protocol is necessary for better assessment of the lesion and to exclude any associated lesions mri head findings there is a heterogeneously enhancing lesion with central nonenhancing necrotic areas and peripheral nodular enhancement in the right cerebellar hemisphere adjacent to the tentorium measuring x x cm in the ap transverse and the cc dimensions there is moderate vasogenic edema and mass effect on the fourth ventricle right side of the pons and inferior midbrain along with downward displacement of the cerebellar tonsils on the right side the edema is seen to extend to the left side of the midline onto the left cerebellar hemisphere as well no other lesions are noted there is mild to moderate obstructive hydrocephalus with dilatation of the temporal horns and the lateral ventricles the extent of dilatation of the ventricles has mildly increased compared to the most recent ct study the major intracranial arterial flow voids are noted there is mild mucosal thickening in the ethmoid air cells on both sides impression x x cm heterogeneously enhancing lesion in the right cerebellar hemisphere with moderate to marked vasogenic edema mass effect on the fourth ventricle right side of the pons and the inferior mid brain along with extension of the edema to the left side of the midline into the left cerebellar hemisphere and downward displacement of the right cerebellar tonsils mild to moderate obstructive hydrocephalus mildly increased compared to the recent ct study this likely represents metastatic lesion given the history of rectal cancer less likely a primary neoplasm neurosurgical consult and when appropriate stereotactic guided biopsy can be considered based on the neurosurgical consult no other lesions noted brief hospital course patient was admitted with complaints of ha and dizziness for month imaging of his head showed a t rt cerebellar mass he was taken to the or for resection on there was a good resection of the tumor with a good follow up mri showing removal of the tumor post op the patient did well and has an intact neurologic exam he was kept on a decadron taper he will follow up with for f u radiation treatment medications on admission fluorouracil zofran proclorperazine lorazepam tylenol fluorouracil gram ml solution mg via continous infusion over hours beginning days and of a day cycle lorazepam mg tablet one two tablet s by mouth every hours as needed for nausea ondansetron hcl mg tablet one tablet s by mouth three times per day as needed for nausea oxycodone acetaminophen mg mg tablet one two tablet s by mouth every hours as needed for pain do not exceed tablets per day prochlorperazine maleate mg tablet one tablet s by mouth three times per day as needed for nausea discharge disposition home discharge diagnosis rt cerebellar mass resection final pathology pending discharge condition neurologically stable discharge instructions 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 and or staples 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 unless directed by your doctor do not take any anti inflammatory medicines such as motrin aspirin advil and ibuprofen etc clearance to drive and return to work will be addressed at your post operative office visit make sure to continue to use your incentive spirometer while at home unless you have been instructed not to call your surgeon immediately if you experience any of the following new onset of tremors or seizures any confusion 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 any signs of infection at the wound site redness swelling tenderness or drainage fever greater than or equal to f followup instructions follow up appointment instructions please return to the office in days from your date of surgery for removal of your staples sutures and or a wound check this appointment can be made with the nurse practitioner please make this appointment by calling if you live quite a distance from our office please make arrangements for the same with your pcp please call to schedule an appointment with dr to be seen in weeks you will need a ct scan of the brain without contrast you will be called by dr for a radiation oncology appointment [NEW_RECORD] admission date discharge date date of birth sex m service neurology allergies alcohol attending chief complaint referred to ed for dvt admitted for fever major surgical or invasive procedure intubation extubation lumbar puncure history of present illness year old male with metastatic rectal cancer with ongoing chemo c d of folfox on s p brain radiation s p resection in presented with an alleged thrombus in right common iliac vein seen on routine staging ct he was referred to the ed by his outpatient oncologist patient reports no symptoms at home no respiratory difficulty no leg swelling or warmth or swelling besides his mild fatigue that has been going on for months a few days ago he had a fever that then spontaneously resolved no coughs no dysuria no sick contact chills headache visual changes chest pain shortness of breath abdominal pain diarrhea constipation weakness numbness tingling in the ed initial vitals were t hr bp rr ra exam was unremarkable lenis were negative he was about to be discharged when he spiked a fever to f wbc was with bands patient received neulasta on and had bands last week cxr urinalysis was unremarkable received vanco and cefepime in the ed admitted for further management past medical history rectal adenocarcinoma diagnosed in neoadjuvant capacitabine and radiation from mid to by m d followed by surgical resection and a colostomy completed cycles of adjuvant capacitabine on chest ct on showed pulmonary metastases and a right lung biopsy showed adenocarcinoma treated with bevacizumab and folfox since headache in summer head ct and mri on disclosed a cm mass in the right cerebellum resected by on followed by cyberknife radiosurgery to the resection cavity on social history cantonese speaking he is married lives with wife and son in he does understand some english speaks little english family history non contributory physical exam gen middle aged chinese man in no acute distress heent eomi perrl sclerae anicteric op moist without lesion neck supple no lad lungs ctab cv normal rate regular rhythm normal s s no m r g abd soft nontender nondistended bs present ext no swelling no warmth no tenderness bilateral pedal pulses neurological exam on first evaluation by neurology team neurologic mental status alert oriented x able to relate history without difficulty via interpreter on telephone language is fluent with intact repetition and comprehension normal prosody able to follow both midline and appendicular commands there was no evidence of apraxia or neglect cranial nerves i olfaction not tested ii perrl to mm and brisk vff to confrontation 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 no pronator drift bilaterally no adventitious movements such as tremor noted no asterixis noted full strength of neck flexors and extensors delt bic tri wre ffl fe io ip quad ham ta edb l r sensory decreased proprioception at toes bilaterally and decreased vibration seconds patient reported pinprick intact throughout dtrs at biceps triceps brachioradialis at patellars and achilles bilaterally however patient was unable to relax legs appropriately for testing despite repeated attempts plantar response was flexor bilaterally coordination no intention tremor no dysdiadochokinesia noted no dysmetria on fnf or hks bilaterally no truncal ataxia gait good intiation wide based unsteady short stride falls in all directions romberg positive neurological exam awake alert appears ill his rr is and his sao is speech is fluent perrl mm bilaterally eomi bilaterally without nystagmus bifacial weakness palate elevates symmetrically tongue midline movements intact he reports feeling diffusely weak with some giveway weakness and other real weakness he can keep his bilateral arms lifted above gravity but both drift down to the bed no myoclonus or tremor decreased pinprick sensation in his bilateral legs to way up the lower leg normal in the bilateral hands trace reflexes in the bilateral brachioradialis otherwise and symmetric in the biceps triceps knees and ankles tri we fe ip h q df r l neurological exam at time of discharge cognitively intact no limitations mild bifacial weakness l r otherwise cranial nerves normal reflexes diffusely absent strength at least in all muscle groups deltoids biceps triceps gastrocs are to some effort dependence pertinent results pm wbc rbc hgb hct mcv mch mchc rdw pm neuts bands lymphs monos eos basos atyps metas myelos promyelo pm plt smr low plt count pm pt ptt inr pt pm glucose urea n creat sodium potassium chloride total co anion gap imaging studies lenis no dvt head ct there has been previous right occipital craniectomy with slight interval increase in hypodensity within the cerebellar resection bed there is no hemorrhage mass effect shift of midline structures or evidence of major vascular territorial infarction unchanged bilateral basal ganglia calcifications there is mild right maxillary sinus mucosal thickening impression no hemorrhage or mass effect apparent increase in hypodensity at right occipital craniectomy site mri w gadolinium recommended to evaluate for tumor recurrence cxr prelim no acute cardiopulmonary process mri spine evaluation of the cervical spine demonstrates no evidence for osseous metastatic disease multilevel spondylosis is seen including a disc osteophyte complex at c c and c c there is also a left paracentral disc protrusion which is broad based at c c extending into the foramen there is moderate stenosis at these two levels there is a small nonspecific lesion in the right thyroid lobe measuring approximately mm there is no epidural disease seen evaluation of the thoracic and lumbar spine demonstrates mild marrow hypointensity there is high signal within the sacrum which may be related to prior radiation to the rectum no convincing evidence for epidural or intradural metastatic disease is seen there is a central to left paracentral disc protrusion at l l causing left lateral recess narrowing and then abutting the left l nerve root there is heterogeneous appearance to the iliac wings bilaterally which again may be related to prior radiation the pre and para vertebral soft tissues are unremarkable impression no evidence for metastatic disease degenerative changes in the cervical and lumbar spine as detailed probable post radiation sequela in the sacrum emg clinical interpretation abnormal study the electrophysiologic abnormalities are most consistent with a moderate generalized neuropathy with demyelinating and axonal features the sural nerve is spared given the time course of progression the findings are consistent with an acquired neuropathy such as syndrome the low amplitude motor responses may or may not be due to axonal involvement a follow up study would clarify the extent of axonal involvement if indicated prior studies torso ct new dvt in the r common iliac v appears to emanating from the r internal iliac v the thrombosis extends to near the confluence of the common iliac recommend urgent dvt ultrasound in the lower extremities interval decrease of lung disease burden decrease of mediastinal and hilar lad post radiation changes in the perirectal region no bowel obstruction brief hospital course m with rectal carcinoma s p resection chemoradiation who was referred to ed for r common iliac dvt and was found to be febrile he was treated with lovenox empiric antibiotics however developed progressive weakness initially concerning for spinal cord compression mri pan spine showed no cord compression while mri of head showed a stable cerebellar herniation through craniotomy site without evidence of infection his exam progressed to bilateral leg weakness worsened bilateral hand and lower leg numbness tongue numbness and dysphagia to liquids and solids and patient developed progressive loss of reflexes he underwent lp and was diagnosed with gbs he was transferred from medicine service to neurology service on gbs patient with ascending weakness loss of reflexes and csf with albuninocytologic dissociation his nif and vital capacity apparently declined while in medical icu and he was intubated on based on above and in setting of tachypnea completed days of ivig on his strength slowly improved however there remained mild assymetry of l r weakness including face as well as more proximal vs distal weakness he has made steady improvement throughout his recovery phase and is at least antigravity strength in all muscle groups at the time of discharge weakness and parathesias overnight patient developed neurologic sxs concerning for cord compression of the low cervical or high thoracic vertabrae however normal spinal mri without compression also be complicated by cerebellar mets and chemo induced neuropathy neurology and neurosurgery followed the patient and he was maintained on standing dexamethasone which was subsequently discontinued given negative imaging he failed a speech and swallow and was determined to be likely aspirating on so was changed to levo flagyll he subsequently proved to have steadily improving oropharyngeal control and was taking all calories po at the time of discharge of note at admission the patient did have diarrhea though he was camplobacter negative also on the patient developed dyspnea with a rr to the low s and maintance of oxygen saturation in the s on ra he developed urinary retention bladder scan with cc though also may have been holding in his urine due to physical difficulty using urinal he developed difficulty managing his secretions with nifs to and was then transferred to the icu a bedside lp was attempted on and was unsuccessful on the patient had an ir guided lp revealing elevated protein with wbcs a diagnosis of gbs was made based on progressive weakness and loss of reflexes see above for gbs management dvt r common iliac thrombus seen on outpatient ct lenis showed no lower clot enoxaprin was initially started and then held starting for an lp he was switched to heparin sc tid during that interval and changed back to lovenox on he continues on treatment doses of lovenox fever given recent chemotherapy was initially concerning for infection however patient was not neutropenic bandemia reflects recent neulasta administration no evidence of sepsis cxr u a ucx were unremarkable fever might also be related to dvt or chemo itself at admission patient was maintained on cefepime vanc after switch to levofloxacin he spiked and was thus changed back to cefepime vanc before being changed to levo flagyll as above with plan to continue for days following completion of this course he remained fever free all of infectious evaluations proved to be unrevealing including bcx ucx stool cx c diff assay legionella antigen sputum and bal washings antibiotics were thus discontinued on he continued to have intermittent low grade fevers f which were attributed to dvt rectal cancer no intervention done this admission patient should follow up with dr office one month following discharge from the hospital this appointment has already been made elevated blood glucose hemoglobin a c of suggests glucose intolerance he was maintained on an insulin sliding scale it is suggested that metformin be started discharge full code confirmed with interpreter at admission and confirmed with dr outpatient oncologist medications on admission ranitidine mg discharge medications enoxaparin mg ml syringe ml subcutaneous q h every hours sodium chloride aerosol spray sprays nasal qid times a day as needed for dry nose senna mg tablet tablets po bid times a day as needed for constipation bisacodyl mg tablet delayed release e c two tablet delayed release e c po daily daily as needed for constipation acetaminophen mg tablet one tablet po every four hours as needed for fever or pain metoprolol tartrate mg tablet one tablet po bid times a day 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 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 lansoprazole mg tablet rapid dissolve dr one tablet rapid dissolve dr daily daily discharge disposition extended care facility discharge diagnosis primary syndome secondary pelvic dvt additional rectal adenocarcinoma metastases to the cerebellum s p resection discharge condition mental status intact strength diffusely weak distal proximal at least in all muscle groups with scattered s in bilateral tri gastrocs near daily improvement in exam throughout his recovery period reflexes diffusely absent sensory intact to fine touch position temperature discharge instructions you were admitted to with a clot in your left leg and fevers you were evaluated for multiple causes of the fever but they were negative you were temporarily treated with antibiotics but in the end were treated for the blood clot with a blood thinner you also developed progressive weakness in your arms and legs and difficulty swallowing and were diagnosed with syndrome also known by the acronym aidp for this you were treated with ivig immunoglobulin and required temporary intubation breathing tube to make sure you do not suffocate your weakness improved somewhat but will likely require several weeks perhaps as long as weeks to return to normal in addition while at the hospital you were found to have signficantly elevated blood sugars this may be related to stress or an underlying early diabetes you should follow up with your primary care doctor regarding this please follow up with all of your appointments should you develop any symptoms concerning to you or some of the listed below please call your doctor or go to the emergency room followup instructions neurology dr at pm building call with any questions oncology dr and dr on pm call with any questions pcp your pcp within week of discharge from rehab to review the many changes to your medical care over the last few weeks completed by,"{
""Diagnoses"": [""advanced rectal cancer""],
""Medications"": [""neoadjuvant chemoradiation"", ""ap resection"", ""flexible cystoscopy"", ""bilateral ureteral stent placement"", ""rigid sigmoidoscopy"", ""colostomy""]
}"
17460,admission date discharge date date of birth sex f service medicine allergies penicillins iodine iodine containing attending chief complaint sob major surgical or invasive procedure implantation of l sided pleural bases pigtail catheter history of present illness yo female with metastatic melanoma dx in found to have mets to the lung by cxr in ct confirmed a right lower lobe and left lower lobe nodules she underwent bilateral vats resection with pathology consistent with melanoma in follow up ct revealed a right pleural abnormality and she underwent a repeat bronc and right vats with talc poudrage on biopsy confirmed recurrent melanoma pt presented to ed today with increasing dyspnea for the past days and new cough productive of white sputum pt did note blood in sputum on one occasion over the weekend denies fevers or chills chest pain has had poor appetite and decreased po intake no black or bloody stools reported further ros negative in the pt was found to have b l multi loculated pleural effusions with l r ip was consulted and pt underwent thoracentesis with placement of pigtail catheter under ct guidance patient was admitted to micu for further observation given episodes of tachycardia transient hypotension tachypnea past medical history metastatic melanoma s p flex bronch vats talc pleurex cath pmh psh hchol migraines metastatic melanoma s p l vats c pleural bx and bilateral lower lobe nodule wedges s p l heel excision c stsg s p r vats w pleural biopsies and talc pleurodesis social history lives in w sons separated from husband has sons pt lives in former smoker quit glass of wine x week family history nc physical exam pe vitals hr bp rr oxygen sat gen thin pale anxious female heent atraumatic anicteric eomi mmm perrla op clear neck no jvd cv tachy no murmurs no rubs lungs decreased bs at bases conversational dyspnea wheeze abd soft nt hypoactive bs non distended ext warm dry no proximal muscle strength and intact b l in both ue and le dp pulses palpable b l neuro a o x cn ii xii grossly intact no focal deficits pertinent results 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 ck cpk am blood ck mb notdone ctropnt am blood calcium phos mg pm urine blood lg nitrite neg protein tr glucose neg ketone bilirub neg urobiln ph leuks neg brief hospital course the patient with past medical history as detailed above with initially admitted to the icu for shortness of breath she had a placement of a l pleural based pigtail catheter for palliative purposes she was transferred to omed and while on the floor it was decided that the patient was to receive comfort measures while being made comfortable the patient passed on family was present at the bedside medications on admission discharge disposition home with service facility vistacare discharge diagnosis primary diagnosis metastatic melanoma discharge condition expired completed by,"{
""Diagnoses"": [""metastatic melanoma"", ""recurrent melanoma""],
""Medications"": [""penicillins"", ""iodine"", ""talc poudrage""]
}"
7143,admission date date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint s p fall with sternal fx left rib fx pneumothorax major surgical or invasive procedure tracheostomy peg tube placement history of present illness yo male fell off a bridge whlle intoxicated etoh swam to shore after the fall fall from feet questionable loc head lac and chest pain pt reportedly dove into water b c he thought he saw a baby in the river reportedly drank beers pint of vodka past medical history none social history etoh has been to rehab drinks qod family history nc physical exam p gen nad resp cta b cv rrr s s abd nt nd ext bilateral knee abrasions rectal good tone guiac left shoulder abrasion c spine tenderness pertinent results pm glucose lactate na k cl tco pm urea n creat pm ck cpk amylase pm ck mb mb indx ctropnt pm wbc rbc hgb hct mcv mch mchc rdw pm pt ptt inr pt pm urine bnzodzpn neg barbitrt neg opiates neg cocaine pos amphetmn neg mthdone neg brief hospital course pt was originally admitted to floor bed but developed a tension ptx on the floor mediatinal shift pt was intubated chest tube was placed and he was transferred to tsicu on hd remained in the icu intubated for days pt received tracheostomy on hd he progressively regained neurological function on hd it was determined that ptx was resolved and his chest tube was removed without difficulty pt received peg tube placement on hd and tolerated tf well throughout hospital course at d c patient was to goal at cc hr pt received multiple courses of abx during his hospitalization for presumed pneumonia abx included day course of levofloxacin vancomycin and a short course of zosyn on pt was afebrile without increased wbc for days pt cervical spine remained immobilized until he was conscious enough for clinical clearance on hd pt received flex ex c spine x rays which were wnl and with clinical c spine clearance c collar was d c pt c o sternal chest pain throughout his floor stay multiple cxr were wnl and cardiac enzymes were wnl with no ekg changes the pain is attributed to his sternal fracture and has been controlled on his pain medication upon patient was highly functional walking grooming dressing on his own medications on admission none medications senna mg tablet sig one tablet po bid times a day as needed disp tablet s refills bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed disp tablet delayed release e c s refills ferrous sulfate mg ml liquid sig three y five mg po daily daily disp qs one month refills quetiapine mg tablet sig one tablet po bid times a day disp tablet s refills metoprolol tartrate mg tablet sig two tablet po tid times a day disp tablet s refills lansoprazole mg susp delayed release for recon sig thirty mg po daily daily disp qs one month refills ipratropium bromide solution sig one nebulizer inhalation q h every hours disp nebulizer refills oxycodone acetaminophen mg ml solution sig mls po q h every hours as needed for pain ng disp ml s refills nicotine mg hr patch hr sig one patch hr transdermal daily daily disp patch hr s refills albuterol sulfate solution sig one neb inhalation q h every hours as needed for sob disp neb refills disposition extended care facility diagnosis left rib fracture sternal fracture resolved left hemopneumothorax condition good instructions return to emergency room for fever difficulty breathing severe chest pain dizziness loss of consciousness followup instructions folow up in trauma clinic in weeks please call to schedule an appointment follow up with your primary care doctor completed by,{}
67620,admission date discharge date date of birth sex m service orthopaedics allergies no known allergies adverse drug reactions attending chief complaint guillain major surgical or invasive procedure bronchoscopy and bronchial lavage total laminectomy of c and fusion c to autograft and allograft history of present illness y o male with pmhx breast ca s p mastectomy in c b right frozen shoulder squamous cell ca of the penis s p resection glaucoma who is being transferred for concern of guillain syndrome per the pt s niece he was in his usual state of health until when he fell while unloading a piece of furniture from his car per osh notes he did not lose conciousness nor complain of any cardiac prodrome he felt this was a mechanical fall he was too weak to get up on his own and was on the ground for hours prior to being found by his neighbor was taken to and admitted to a telemetry unit he was noted to have elevated ck which peaked at then trended down with ivf cardiology was consulted but felt this was a mechanical fall and had planned to obtain an echocardiogram on the patient was noted to have increased weakness and progressed to a feeling of an inability to move his extremities on shortly after this he became bradycardic and hypotensive and went into respiratory failure he was intubated had cpr performed then was transferred to the ccu he was intermittently on pressors and was felt to have developed an aspiration pneumonia he was initially on clindamycin then broadened to vancomycin and cefepime his o requirement improved and there were plans to extubate him on however a nif was noted to be and the patient was noted to have complete paralysis of bilateral extremities ct was negative neuro consulted and felt he may have an ascending paralysis such as gbs and recommended transfer to a tertiary care facility in the icu the patient is intubated he is able to shake his head yes and no to questions past medical history breast ca s p mastectomy penile squamous cell ca s p resection glaucoma social history tobacco none alcohol none illicits none family history unknown physical exam vitals t bp p rr spo general intubated heent sclera anicteric mmm oropharynx clear lungs decreased breath sounds on the left coarse breath sounds on right cv rrr normal s s tachycardic abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly gu foley in place ext warm well perfused pulses no clubbing cyanosis or edema neuro able to shake head yes and no to simple questions pupils track across midline right hand with minimal movement when asked to squeeze no movement in rest of extremities sensation unable to be assessed no reflexes noted on exam rectal exam deferred until collar able to be placed pertinent results admission labs pm wbc rbc hgb hct mcv mch mchc rdw pm neuts bands lymphs monos eos basos atyps metas myelos pm hypochrom normal anisocyt normal poikilocy normal macrocyt normal microcyt normal polychrom normal pm pt ptt inr pt 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 ctropnt pm albumin calcium phosphate magnesium pm type art temp rates tidal vol peep o po pco ph total co base xs aado req o intubated intubated microbiology bronchial lavage pm other body fluid polys lymphs monos imaging cxr mr findings there is exaggerated lordosis of the cervical spine there is minimal retrolisthesis of c over c vertebra by mm the vertebral bodies are normal in height and marrow signal intensity there is no evidence of acute fracture prevertebral soft tissue is noted from c to c level hyperintensity is noted in posterior paraspinal muscles and soft tissues from c to c levels a small hypointense area is noted in right paraspinal muscles at the c t level measuring x x cm in craniocaudad ap and transverse dimensions this likely represents calcification there is multilevel disc degenerative disease there is desiccation of all cervical intervertebral discs at c c level there is no significant spinal canal or neural foraminal narrowing at c c level there is a broad based posterior disc protrusion causing indentation and compression of spinal cord there is severe spinal canal stenosis the disc with uncovertebral and facet osteophytes causes moderate bilateral foraminal stenosis at c c there is posterior disc protrusion causing indentation and compression of the spinal cord and severe spinal canal narrowing the disc with uncovertebral and facet osteophytes causes moderate right and mild left foraminal narrowing at c c there is diffuse posterior disc bulge causing indentation of the anterior subarachnoid space there is no evidence of significant spinal canal or neural foraminal narrowing at c c level there is diffuse posterior disc bulge without significant spinal canal or neural foraminal narrowing hyperintense signal is noted in cervical spinal cord from c to c level this likely represents combination of compressive edema and contusion secondary to fall brief hospital course y o male with pmhx breast ca s p mastectomy in c b right frozen shoulder squamous cell ca of the penis s p resection glaucoma with neurologic signs concerning for cervical spine injury vs gbs vs myositis weakness paralysis concerning for cervical spine injury may have occurred during intubation vs ascending paralysis such as gbs vs myositis myopathy given elevated ck on admission patient has no clear history of prodromal illness for gbs but this is not necessary for the diagnosis ck trending down without any intervention for myositis making it less likely mr performed early showed chronic djd of c spine with significant narrowing of spinal canal compression of spinal cord and associated edema from c t spine surgery was consulted and felt that the paralaysis is secondary to spinal cord compression with poor prognosis if patient taken to the or and very low probability of recovery of any function spine surgery had a discussion with family who chose to pursue surgical repair hypoxemic respiratory failure diaphragmatic weakness and pneumonia mucus plugging cxr on presentation showed complete whiteout of left lung bronchoscopy the evening of showed copious amounts of mucus plugging that was suctioned out post bronch has been able to be weaned to fio a repeat cxr on showed substantial improvement with possible consolidation in the lll due to neuromuscular dysfunction he was continued on ventilation hcap signs of lll pna seen on bronchoscopy with edematous red airways was thought to have aspirated at osh and covered with vanco cefepime has been in hospital hours so needs to be covered for hcap plan to continue coverage and request sputum culture results from osh thrombocytopenia platelets of on down from on admission to osh no signs of spontaneous bleeding at this time differential includes med effect vs decreased production anemia mild normocytic anemia on admission hgb was be dilution vs decreased production vs bleed although no evidence plan to follow cbc elevated ast alt mildly elevated other lfts are normal including bili be related to periods of hypotension plan to trend lfts bradycardia bradycardic at osh has been stable here be secondary to or other neuro problem affecting autonomic nervous system presumably was ruled out for mi after this happened but unknown if this did happen ekg shows no evidence of infarct echo planned for may be deferred given emergent surgical intervention elevated ck likely secondary to rhabdo from fall ck s have been trending down without acute intervention and renal function is stable fen ivf as needed replete electrolytes npo for now prophylaxis pneumoboots and subq heparin access peripherals communication patient disposition patient was transferred to trauma icu for possible surgical intervention per spine surgery in the evening of after discussion with patient and family members the patient s code status was changed to comfort measures only his pain was controlled with iv morphine at pm the patient was noted to have no respiratory drive no pulse and no heart lung sounds the on call resident was called to evaluate the patient and the patient was pronounced dead at pm on medications on admission home medications xalatan combivent mvi advil discharge disposition expired discharge diagnosis cervical stenosis spondylosis quadraplegia pneumonia discharge condition expired completed by,{}
5990,admission date discharge date date of birth sex m service surgery allergies penicillins attending chief complaint s p assault major surgical or invasive procedure orif facial fractures tracheostomy and peg history of present illness yo male s p assault with brass knuckles found down etoh broken teeth intubated because of facial swelling past medical history none family history noncontributory physical exam vs upon admissio nto the trauma bay t hr bp o sat gen vented paralyzed sedayted heent pupils mm not reactive oral bleeding facial laceration and swelling neck collared chest equal bs cor regular abd soft rectum guaiac negative extr warm well perfused pertinent results pm type art temp po pco ph total co base xs intubated intubated pm glucose k pm hgb calchct pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm lactate am plt count am pt ptt inr pt mr cervical spine pm mr cervical spine reason assess for soft tissue swelling in c spine medical condition year old man with assualt reason for this examination assess for soft tissue swelling in c spine exam mri cervical spine clinical information patient is status post assault for further evaluation technique t t and inversion recovery sagittal and t and gradient echo axial images of the cervical spine were acquired correlation was made with the ct of findings from skull base to t level there is no evidence of abnormal bony signal seen to indicate marrow edema or fracture no evidence of vertebral malalignment seen no evidence of abnormal signal is seen within the ligamentous structures no evidence of disruption of the ligaments seen soft tissue changes are seen in the nasopharynx and oropharynx secondary to retained secretions the spinal cord shows normal signal intensities without extrinsic compression impression no mri evidence of bony or ligamentous injury to the cervical spine no evidence of extrinsic spinal cord compression or intrinsic spinal cord signal abnormalities ct sinus mandible maxillofacial w o contrast am ct sinus mandible maxillofacia reason suspected mandib fx medical condition year old man with facial trauma reason for this examination suspected mandib fx contraindications for iv contrast none indication year old male with facial trauma sinus and facial ct without contrast multiplanar reformation images are reconstructed findings note is made of multiple comminuted and displaced fracture of the mandibular symphasis as well as comminuted and displaced fracture of the bilateral mandibular rami involving tmj joints with bone fragments there is mm indentation of right inferior orbital wall with air fluid level in the right maxillary sinus representing orbital floor fracture note is made of marked deviation of the nasal septum to the left note is made of small amount of fluid in bilateral ethmoid sinuses nasopharynx is opacified with fluid and air the patient is status post intubation note is made of soft tissue swelling in the subcutaneous tissue anteriorly impression multiple communicated and displaced fractures of the mandible involving symphasis as well as bilateral rami at the tmj joints with bone fragment deviation of the nasal septum to the left seven millimeter indentation of the right orbital wall containing fat associated with air fluid level in the right maxillary sinus representing orbital wall fracture on the right the information was discussed with the trauma team in person approximately at a m on brief hospital course patient admitted to the trauma service plastics and omfs were immediately consulted because of his multiple facial fractures he was taken to the operating room for orif of his facial fractures on his jaws are wired shut he was trached and peg was placed early on during his hospital course speech and swallow evaluation was done to determine if patient could tolerate oral fluids he did pass the swallowing test and is taking liquids and boost supplements nutrition was consulted he will need to continue with bolus feedings through his g tube as well to maintain his nutritional requirements social work and the center for violence prevention and recovery have closely followed patient during his hospital stay he has been given information on victim s compensation as well physical therapy has worked with patient and has determined that he is independent and safe for discharge home from a functional perspective nursing has worked with patient and family regarding care of his tracheostomy g tube and bolus feedings medications on admission none discharge medications chlorhexidine gluconate mouthwash sig one ml mucous membrane times a day oxycodone acetaminophen mg ml solution sig mls po q h every to hours as needed for pain disp ml s refills docusate sodium mg ml liquid sig one po bid times a day senna mg ml syrup sig mls po daily daily as needed disp ml s refills simethicone mg tablet chewable sig one tablet chewable po qid times a day as needed disp tablet chewable s refills phenol phenolate sodium mouthwash sig one spray mucous membrane q h every hours as needed for throat pain ciprofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills discharge disposition home with service facility discharge diagnosis s p assault mandible fracture right orbital floor fracture discharge condition stable discharge instructions you will need to follow up with oral maxillo facial surgery after discharge from hospital once your wires are removed you should start with soft solids ans slowly advance your diet as tolerated follow up in trauma clinic in clinic once your jaw wires are removed sothat we can make plans to remove your tracheostomy and feeding tube you will need to continue to administer nutrition via your feeding tube until the jaw aires can be removed you may continue to drink liquids by mouth followup instructions call the oral maxillofacial surgeons at for a follow up appointment in weeks the clinic is held on friday s from pm please inform the clinic that you will need to have your jaw wires removed call for an appointment in the trauma clinic after your jaw wires are removed completed by,"{
""Diagnoses"": [""assault"", ""soft tissue swelling in c spine""],
""Medications"": [""penicillins"", ""sedatives"", ""paralytics"", ""pain management medications""]
}"
9641,admission date discharge date date of birth sex m service nb history of present illness the patient is a gm product of a week twin gestation born to a year old gravida para woman whose pregnancy was complicated by maternal chronic hypertension marked oligohydramnios she recently became aware that she was pregnant several weeks ago mother treated with hct up until a few weeks ago for hypertension this drug is relatively contraindicated in pregnancy she changed to metoprolol when the pregnancy was diagnosed when seen for prenatal visit on the day of delivery marked oligohydramnios and nonreassuring fetal heart tracing was seen this lead to a transfer from bronkton and the decision was made to perform a cesarean section no prenatal betamethasone was given prenatal screens revealed positive antibody negative hepatitis b surface antigen negative rpr nonreactive rubella immune group b streptococcus unknown the infant emerged with decreased heart rate and tone no respiratory effort given bag mask ventilation with rapid response in heart rate apgars were two at one minute and six at five minutes the infant was intubated in the delivery room and then transferred to the neonatal intensive care unit after visiting with parents physical examination birth weight gm length cm head circumference cm on examination pink pale infant with decreased activity and tone skin with bruising throughout trunk extremities and face physical examination consistent with to weeks gestation head eyes ears nose and throat notable for markedly enlarged posterior fontanelle and occipital suture question of softened cranial bones lungs coarse bilaterally normal s and s without murmurs abdomen benign genitalia normal premature male both testes undescended hips normal extremities notable for flat feet left hand with only two diagonally oriented creases limbs mobile with full range of motion neurologic decreased tone and activity throughout spine intact anus patent hospital course the infant required peak inspiratory pressure as high as below s to move chest in the neonatal intensive care unit the infant was placed on high frequency oscillating ventilator given normal saline boluses times two for perfusion and blood pressure this is a to week infant with respiratory failure requiring high frequency oscillating ventilator the most likely cause is hyaline membrane disease with a possible component of pulmonary hyperplasia dysmorphism may be due to deformation but the possibility of chromosomal abnormalities exist respiratory the infant required the high frequency oscillating ventilatory immediately on admission the infant received two doses of surfactant maximum ventilatory settings of a mean airway pressure of and a delta p of requiring percent fio on those ventilatory settings of the blood gases showed ph in the range of to cardiovascular infant required a dopamine infusion as high as mcg kg minutes and received multiple normal saline boluses fluids electrolytes and nutrition the infant was receiving nothing by mouth receiving cc kg day of d w via a umbilical venous catheter glucoses ranged from to hematology hematocrit on admission was the infant received cc kg of packed prbc transfusions this hospitalization infectious disease the infant was started on ampicillin and cefotaxime the infant continued in a state of critical condition during the afternoon of he had refractory hypoxia and metabolic acidosis he continued on high frequency ventilation with a mean artery pressure of and amplitude of and percent fio he was profoundly hypotensive despite dopamine support at to mcg kg minute several normal saline boluses and a transfusion of packed red blood cells he was also given bicarbonate to improve his acid based balance he was given morphine for pain and discomfort during his life he was anuric and generally edematous which was worrisome due to the lack of renal function his chest x ray showed poor expansion of the chest consistent with pulmonary hypoplasia the family was kept informed of the several times during the afternoon of the infant s progress including a discussion of the grim prognosis given his unresponsiveness to medical intervention the family and all members of the care team agree that redirection of care to comfort measures were in his best interests he was extubated at on and was held by his mother and other members of his family the infant expired at on md dictated by medquist d t job,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""m"", ""service"", ""nb"", ""history of present illness""],
""Medications"": [""hct"", ""metoprolol""]
}"
2625,admission date discharge date date of birth sex f service cardiothoracic allergies amiodarone quinidine attending chief complaint icd firing on the day of admission unable to tolerate quinidine diarrhea nausea decreased pos major surgical or invasive procedure cardiac cath mitral valve repair with mm ce annuloplasty ring placement of lv lead history of present illness yo f w multiple medical problems she has a h o mi at age with an ef of cath at that time was normal she had an icd placed in for nsvt she has had recent admissions for inappropriate icd firing due to paf she was changed from amiodarone to quinidine d t increase in nsvt but has had gi upset with poor po intake had an echo on which revealed an decrease in here ef to and mr she came to the ed today d t icd firing and reaction to quinidine past medical history congestive heart failure ef h o myocardial infarction age hyperlipidemia hypertension diabetes mellitus paroxysmal atrial fibrillation nonsustained ventricular tachycardia w icd placement s p spleenectomy d t itp s p hysterectomy s p tosillectomy chronic renal insufficiency social history she is single and lives alone she works as office manager for construction company doesn not smoke social drinker family history father died of mi in his s and mother died of cri in her s there is no family history of premature coronary artery disease or sudden death physical exam vs on ra gen well appearing lying in bed eating dinner in nad heent perrl eomi pink conjunctiva oral mucosa moist and clear neck supple no jvd carotid bruits auscultated no thyromegaly chest ctab well healed icd pocket in left pectoral region cvs nl s s sem llsb abd bs soft nt nd ext warm without edema pulses b l neuro ao appropriate answering questions appropriate following commands sensation to light touch intact strength grossly symmetric pulses right carotid femoral popliteal dp pt left carotid femoral popliteal dp pt pertinent results cardiac cath selective coronary angiography in this right dominant system demonstrated no angiographically apparent cad the lmca lad lcx and rca were normal left ventriculography was deferred resting hemodynamics demonstrated elevated right and left sided filling pressures rvedp was mmhg and pulmonary capillary wedge pressure was mmhg there was severe pulmonary arterial hypertension with a pa pressure of mmhg central aortic pressure was low normal at mmhg cardiac index was low at l min m le u s no evidence of right lower extremity dvt echo the left ventricular cavity is severely dilated due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded overall left ventricular systolic function is normal lvef although intrinsic function is more depressed given severity of mitral regurgitation tissue doppler imaging suggests an increased left ventricular filling pressure pcwp mmhg overall left ventricular systolic function is normal lvef tissue synchronization maging demonstrates no significant left ventricular dyssynchrony however cannot exclude since images were technically suboptimal right ventricular chamber size and free wall motion are normal the mitral valve leaflets are mildly thickened moderate to severe mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened there is moderate pulmonary artery systolic hypertension significant pulmonic regurgitation is seen there is no pericardial effusion echo the left atrium is moderately dilated left ventricular wall thicknesses are normal the left ventricular cavity is severely dilated there is severe global left ventricular hypokinesis no masses or thrombi are seen in the left ventricle right ventricular chamber size is normal with mild global free wall hypokinesis there is abnormal septal motion position 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 a mitral valve annuloplasty ring is present there is no mitral stenosis mild mitral regurgitation is seen moderate tricuspid regurgitation is seen there is moderate pulmonary artery systolic hypertension the end diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension there is no pericardial effusion compared with the prior study images reviewed of a mitral valve ring is now identified with marked decrease in the severity of mitral regurgitation the left atrial and left ventricular cavity sizes are now smaller the severity of pulmonary artery systolic hypertension is also reduced global left ventricular systolic function is now depressed brief hospital course ms was admitted under medicine cardiology service for evaluation of her icd she underwent a cardiac cath on which revealed clean coronaries with severe pulmonary hypertension an lv gram was deferred d t her increased creatinine she was started on heparin for anticoagulation for her atrial fibrillation coumadin was stopped she was seen be ep service for icd management as was well as cardiac surgery for mitral valve repair she was medically managed over the next several days and her creatine trended down during this time she underwent another echocardiogram which revealed a normal ef with mr on she was taken to the operating room and underwent a mitral valve repair with lv lead placement for biventricular pacing please see operative report for surgical details following surgery he was transferred to the csru for invasive monitoring in stable condition later on op day she was weaned from sedation awoke neurologically intact and extubated she initially required some inotropes which were slowly weaned off ep service continued to follow patient and interrogate her icd post operatively she was in atrial fibrillation chest tubes were removed on post op day two beta blockers and diuretics were started per protocol she was gently diuresed towards her pre op weight and lopressor was titrated for maximal hemodynamics on post op day four chest tubes were removed and coumadin was started already started on heparin an ace inhibitor was added and she was transferred to the telemetry floor on post op day seven she continued to work with the physical therapy service daily she was gently diuresed towards her preoperative weight ms continued to make steady progress and was discharged home on she will follow up with the electrophysiology service dr her cardiologist and her primary care physician as an outpatient medications on admission furosemide mg po tid aspirin mg po daily famotidine mg po daily spironolactone mg po daily omega fatty acids mg capsule one capsule po qid pravastatin mg po daily calcium carbonate mg tablet po bid docusate sodium mg po bid warfarin mg po qtuthsasu warfarin mg po qmowefr metoprolol succinate mg po qam and mg po qpm quinidine gluconate mg po q h started lorazepam mg po q h prn digoxin mg day 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 pravastatin mg tablet sig one tablet po daily daily disp tablet s refills oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills calcium carbonate mg tablet chewable sig one tablet chewable po qid times a day as needed disp tablet chewable s refills captopril mg tablet sig tablet po bid times a day disp tablet s refills metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet s refills lasix mg tablet sig one tablet po twice a day disp tablet s refills coumadin mg tablet sig one tablet po see directions below take mg ttss and mg mwf disp tablet s refills outpatient work pt inr on saturday please call results to dr discharge disposition home with service facility vna discharge diagnosis mitral regurgitation s p mitral valve repair congestive heart failure ef pmh h o myocardial infarction age hyperlipidemia hypertension diabetes mellitus paroxysmal atrial fibrillation nonsustained ventricular tachycardia w icd placement s p spleenectomy d t itp s p hysterectomy s p tosillectomy chronic renal insufficiency 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 heavy lifting or driving until follow up with surgeon followup instructions please see dr in weeks please see dr in weeks please see dr in weeks please see dr in weeks please ask your pcp to check white blood cell count about weeks after discharge given its elevation during your admission if it continues to be elevated a hematology work up is recommended please take a pt inr on saturday with results to dr completed by [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies amiodarone quinidine attending chief complaint palpitations major surgical or invasive procedure none history of present illness y o with hx mi age ef icd paf vt s p trials of amiodorone dofetilide quinidine recently admitted for mvr d t mr presents with palpitations found to be in afib with hr in the s and sbp s s when discharged yesterday was in nsr admitted to the ccu for further management past medical history mitral valvuloplasty for mr physio ring mi vs viral myocarditis at age ef less than s icd spleenectomy d t itp paroxysmal atrial fibrillation intolerant of amiodarone dofetilide and quinine therapy hypertension hyperlipidemia noninsulin dependent dm chronic kidney disease social history she is single and lives alone she works as office manager for construction company does not smoke social drinker family history father died of mi in his s and mother died of cri in her s there is no family history of premature coronary artery disease or sudden death physical exam blood pressure was mm hg while supine pulse was beats min and irregular respiratory rate was breaths min generally the patient was well developed well nourished and well groomed the patient was oriented to person place and time the patient s mood and affect were not inappropriate there was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa the neck was supple with jvp of cm the carotid waveform was normal there was no thyromegaly the were no chest wall deformities scoliosis or kyphosis the respirations were not labored and there were no use of accessory muscles the lungs were clear to ascultation bilaterally with normal breath sounds and no adventitial sounds or rubs palpation of the heart revealed the pmi to be located in the th intercostal space mid clavicular line there were no thrills lifts or palpable s or s the heart sounds revealed a normal s and the s was normal there were no rubs murmurs clicks or gallops the abdominal aorta was not enlarged by palpation there was no hepatosplenomegaly or tenderness the abdomen was soft nontender and nondistended the extremities had no pallor cyanosis clubbing or edema there were no abdominal femoral or carotid bruits inspection and or palpation of skin and subcutaneous tissue showed no stasis dermatitis ulcers scars or xanthomas pulses right carotid femoral popliteal dp pt left carotid femoral popliteal dp pt pertinent results am pt ptt inr pt am plt count am wbc rbc hgb hct mcv mch mchc rdw am glucose urea n creat sodium potassium chloride total co anion gap pm pt ptt inr pt pm plt count pm ctropnt pm ck mb notdone probnp imaging brief hospital course ms was admitted to the on for further management of her atrial fibrillation esmolol was used with good rate control and eventual conversion back into normal sinus rhythm amiodarone was also started to maintain her in a normal sinus rhythm coumadin was continued for anticoagulation the electrophysiology service followed ms given her pacemaker in situ and new atrial fibrillation she remained in normal sinus rhythm and was discharged home on she will follow up with dr of the electrophysiology service dr her cardiologist and her primary care physician as an outpatient medications on admission asa pravastatin percocet prn calcium carbonate qid captopril metoprolol tartrate lasix warfarin mg ttss mg mwf discharge medications amiodarone mg tablet sig one tablet po bid times a day disp tablet s refills aspirin mg tablet chewable sig one tablet chewable po daily daily calcium carbonate mg tablet chewable sig one tablet chewable po qid times a day as needed for osteoporosis furosemide mg tablet sig one tablet po bid times a day insulin please resume your pre hospitalization insulin regimen metoprolol tartrate mg tablet sig one tablet po bid times a day pravastatin mg tablet sig one tablet po daily daily warfarin mg tablet sig one tablet po mwf monday wednesday friday warfarin mg tablet sig one tablet po x week tu th sa outpatient work pt ptt inr on wednesday and friday please fax results to dr office fax discharge disposition home with service facility vna discharge diagnosis primary atrial fibrillation with rapid ventricular response s p mv annuloplasty secondary mitral valvuloplasty for mr physio ring mi vs viral myocarditis at age ef less than s icd spleenectomy d t itp occasional palpitations with documented non sustained vt hypertension hyperlipidemia noninsulin dependent dm chronic kidney disease discharge condition stable afebrile tolerating po ambulates without assistance discharge instructions you were admitted to the hospital for atrial fibrillation with a rapid heart rate you should return to the er or call your doctor if you experience any of the following symptoms fever palpitations chest pain shortness of breath weakness dizziness nausea vomiting or any other concerning symptoms please take all medications as prescribed please follow up with all appointments as scheduled vna will be visiting your home on wednesday and friday to check your blood work your coumadin dosing should be adjusted accordingly by dr followup instructions pt ptt inr check on wednesday and friday will be done by vna services results to be sent to dr phone an appointment has been made for you with dr phone on thursday at p return to on tuesday for your post op check and staple removal with cardiothoracic surgery please follow up with your pcp weeks you have the following appointments scheduled provider m d phone date time completed by,{}
3099,admission date discharge date service micu chief complaint fever and mental status changes history of present illness this is an year old male with a history of progressive body dementia and a seizure disorder who was a resident of with a recent general functional decline since two months that has manifested as a decrease interactiveness recent anorexia refused orals and decrease functional ability activities of daily living he was noted by his neurologist to be likely progressing with his dementia as recently as he was started on sinemet at that time hospital course he presented to with fevers of degrees fahrenheit a heart rate of and a blood pressure that was palp and a respiratory rate of and saturating on liters with decreased urine output he was also noted to be unresponsive on admission a chest x ray was consistent with a right middle lobe infiltrate he was given levofloxacin and vancomycin as well as flagyl for presumed pneumonia versus urinary tract sepsis he was hypotensive with a poor response to fluid boluses he was given a total of liters in the emergency department he was started on a dopamine drip with no response he was switched to neo synephrine with an increased blood pressure and arousability he was transferred to the medical intensive care unit where his hypotension worsened requiring a second pressor vasopressin plus fluid boluses he became increasingly acidotic with lactate initially at that increased to during the evening of he also had worsening bicarbonate levels from initially decreasing to he was intubated with a pre intubation arterial blood gas that was post intubation his arterial blood gas was on oxygen he was given sodium bicarbonate followed by a sodium bicarbonate drip his antibiotics were continued and he was given stress dose steroids for presumptive adrenal insufficiency in the setting of sepsis levophed was added on as another pressor for hypotension blood cultures from earlier that day in the emergency department grew gram negative rods and the patient was started on ceftazidime he was also noted to have severe coagulopathy and was treated aggressively with fresh frozen plasma and vitamin k he was also transfused several units of packed red blood cells for a rapidly decreasing hematocrit in the setting of fluid restriction despite all of these aggressive interventions including triple pressors the patient s mean arterial pressure remained in the s and his heart rate started to drop at p m on he became asystolic on the monitor his pupils became fixed and dilated and he expired his sister was present and refused the autopsy at that time the attending as well as the were notified of his death m d dictated by medquist d t job,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""service"", ""MICU"", ""chief complaint"", ""fever"", ""mental status changes"", ""history of present illness"", ""progressive body dementia"", ""seizure disorder"", ""resident of"", ""general functional decline"", ""anorexia"", ""decrease interactiveness"", ""decrease functional ability activities of daily living"", ""neurologist"", ""pneumonia"", ""urinary tract sepsis"", ""hypotensive"", ""poor response to fluid boluses"", ""dopamine drip"", ""neo synephrine""],
""Medications"": [""Levofloxacin"", ""Vancomycin"", ""Flagyl""]
}"
26812,admission date discharge date date of birth sex m service neurosurgery history of present illness this year old high school teacher had a major seizure in he had fifteen to twenty second spells and was not feeling quite normal all over his body dating back to high school and recurring once or twice per month but this had not been he was placed on trileptal and even the minor spells seemed to have stopped his mr scan with gadolinium showed a by cm left medial temporal lobe cystic lobulated lesion with enhancing solid components the mass was situated in the amygdala region his eeg confirmed the onset of epileptic activity from the region of the cystic enhancing lesion the decision was made to remove the decorticography and cortical brain mapping past medical history he does not use tobacco or alcohol he had right knee arthroscopy in he had anterior cruciate ligament reconstruction of the right knee in allergies he had rashes from aspirin and motrin he had anaphylaxis and rash with penicillin medications he is taking of trileptal twice a day physical examination his vital signs show a blood pressure of pulse height weight pounds his head eyes ears nose and throat were normal his neck was supple with no adenopathy no thyromegaly trachea to midline chest clear to auscultation and percussion his cardiac examination showed a regular rate and rhythm normal s and s no murmurs his abdominal examination showed no organomegaly no masses or tenderness normal bowel sounds to be present his neurological examination showed a slight left facial asymmetry remaining cranial nerves were normal and his motor examination was normal for strength tone and fine movement his sensory examination was normal his deep tendon reflexes were out of and symmetric in the upper and lower extremities single leg stance and tandem walking were normal laboratory data his admission cbc was normal his postop cbc showed an elevated white count which came down over the period of three days his hematocrit was in the upper s postoperatively hospital course following admission the patient was taken to the operating room where a left anterior temporal lobectomy was carried out immediately postoperatively he had normal neurological examination including speech function his blood pressure tended to run in the to range systolically and in the to range diastolically he was kept on fluid restriction and had mg of decadron given every six hours he was continued on the preoperative trileptal dose of mg twice a day after initially treating him overnight with intravenous dilantin he had increasing naming difficulties over the second and then third postoperative day and had marked expressive aphasia by the afternoon on the third postop day however he seemed to be improving by the fourth postoperative day but then was having very intermittent periods of almost normal speech and severe speech deficits particularly with naming and having problems with orientation he was tending to perseverate a ct scan showed no evidence of mass effect from swelling or hemorrhage and an excellent result of removal of all of the area of tumor the eeg showed some slowing but showed no evidence of seizure activity however it was thought that he probably was having intermittent seizure activity in the area of the removal and posterior to the removal and so his trileptal was increased to mg twice a day following that he had no further problems with increased speech deficit during that time he was also placed back on intravenous decadron until the day of his discharge when he was again placed on oral decadron his incision was free of drainage his temperatures were ranging in the to range he was started on decadron taper only after his discharge discharge diagnoses ganglioglioma epilepsy secondary to diagnosis one discharge status approved discharge disposition discharged to home with follow up appointments to be arranged m d dictated by medquist d t job,"{
""Diagnoses"": [""neurosurgery"", ""epilepsy"", ""cystic lesion in amygdala region""],
""Medications"": [""trileptal""]
}"
21674,admission date discharge date date of birth sex m service nb history baby is the gram product of a week twin gestation born to a year old g p now mother prenatal screens a positive antibody negative hepatitis surface antigen negative rubella immune rpr nonreactive gbs unknown mother presented with rupture of membranes in preterm labor infants were delivered by cesarean section for twin gestation and repeat c section twin a emerged vigorous with good cry apgars were and at and minutes respectively physical exam on admission weight kg length cm head circumference cm anterior fontanel open and flat palate and clavicles intact clear breath sounds with fair aeration regular rate and rhythm no murmur good femoral pulses abdomen soft nondistended no masses normal male patent anus moves all extremities pink and well perfused history of hospital course by systems respiratory has been stable in room air throughout hospital course with no episodes of apnea or bradycardia cardiovascular no issues fluid and electrolyte birthweight was kg discharge weight is grams infant has been in excess of per kg over the last hours of breast milk or enfamil calorie gi peak bilirubin was on day of life of he has not required any intervention hematology hematocrit on admission was has not required any blood transfusions infectious disease cbc and blood culture obtained on admission cbc was benign and blood cultures remain negative at hours neuro infant has been appropriate for gestational age sensory hearing screen was performed with automated auditory brain stem responses and the infant passed condition on discharge stable discharge disposition to home name of primary pediatrician care recommendations feeding continue ad lib feeding breast milk or enfamil calorie medications nonapplicable car seat position screening has been performed and infant passed the minute screening immunizations received infant received hepatitis b vaccine on discharge diagnoses premature twin rule out sepsis mild hyperbilirubinemia dictated by medquist d t job,"{
""Diagnoses"": [""rupture of membranes"", ""preterm labor"", ""twin gestation"", ""cesarean section"", ""repeated c section"", ""twin emergence""],
""Medications"": [""breast milk"", ""enfamil"", ""bilirubin""]
}"
26123,admission date discharge date date of birth sex m service trauma history of present illness mr is a year old man who fell approximately feet from a ladder there is a question if there was an electrocution injury secondary to contact with a wire the patient loss consciousness at the scene and was found to be opening his eyes spontaneously but confused and combative he was intubated at the scene and sedated with versed he was boarded and collared and arrived at the hemodynamically stable with a gcs of t past medical and surgical histories at the time of admission past medical past surgical histories were unknown medication lipitor allergies none known exam general the patient was intubated and sedated vital signs heart rate pulse palp on being bagged head ears eyes nose and throat his pupils were equal his tympanic membrane on the right was bloody he had a right raccoon eye back cervical spine no step off chest clear to auscultation heart regular abdomen soft nontender nontender the pelvis was stable extremities there were no obvious deformities of the extremities small superficial laceration on the left elbow and left fifth finger rectal heme negative with decreased tone laboratory studies white count hematocrit normal chemistries inr of arterial blood gases and ck of trauma work up head ct revealed a right cerebellar and left temporal intraparenchymal hemorrhage with right posterior fossa and subarachnoid blood there is no herniation but effacement of the cisterns there are multiple bilateral temporal fractures right occipital fracture right orbital fracture and right subdural hematoma abdominal ct showed no evidence of injury small anterior right pneumothorax right th and th rib fractures and right st or th lumbar transverse process fractures ct of the chest showed no aortic injury question of t t compression deformity and right st th th and th rib fractures hand elbow films showed no fracture or dislocation neurosurgical and oral maxillofacial consultations were obtained in the trauma bay neurosurgery placed a vault that showed an icp of greater than a post procedure head ct showed increased cerebellar hemorrhage and the patient was taken emergently to the operating room for evacuation the patient underwent a suboccipital craniectomy with resection of right subdural bleeding and dural expansion he was taken intubated and sedated to the trauma intensive care unit where the rest of his course will be summarized by system hospital course neurologic the patient had undergone injuries as described above and went to the operating room for evacuation of the hematoma a ventricular ostomy drain was placed in the operating room and it was continued until approximately the patient slowly regained motor function of initially of his left upper and lower extremities followed by his right upper and lower extremities follow up head ct did not show any extension of bleeding of note the patient remained sedated for an extended period of time given his multiple injuries as the sedation was weaned he initially had difficulty with agitation and difficulty weaning the propofol however this eventually resolved and at the time of dictation the patient requires no sedation the cervical spine was cleared with an mri his thoracic and lumbar spines were cleared with ct scans ct did reveal an l vertebral body corner fracture and l through right transverse process fractures which are not treated operatively cardiovascular the patient never had hemodynamic instability throughout his course and required no pressors or drips for blood pressure control respiratory the patient was intubated on arrival at the he remained on vent support during the course of his stay due to his sedation his clinical course improved he was weaned to extubation on however he quickly developed upper airway stridor and respiratory distress and was reintubated a percutaneous tracheostomy was placed at the bedside on after this point the patient continued on vent support while he was sedated once sedation was weaned he was weaned to trach mask at the time of dictation he has been on trach mask for approximately days his respiratory course is complicated by right middle lobe and right lower lobe pneumonia culture data showed this to be enterobacter which was resistant to multiple antibiotic agents and he eventually was started on a day course of imipenem which started approximately cultures also grew methicillin sensitive staphylococcus aureus from his sputum no acute distress he received an approximately day course of gram positive coverage consisting of vancomycin and oxacillin the patient was weaning well from the vent however on he was noted to have an acute desaturation chest x ray was unremarkable and ct angiogram of the chest was performed that showed bilateral pulmonary emboli on an ivc filter was placed however it was noted that the patient had anomalous venous architecture and on the second ivc filter was placed in the lower ivc a repeat ct angiogram at this time also revealed no further extension of the clot given his slight respiratory compromise from the clot anticoagulation was readdressed to the neurosurgery team and after a follow up negative head ct the patient was started on heparin drip and subsequently is being coumadinized gastrointestinal the patient was initially kept npo without tube feeds post pyloric feeding tube was placed under fluoroscopic guidance in the intensive care unit he received regular tube feedings through this without difficulty the day prior to peg placement the tube feed was inadvertently moved on transfer the patient s peg was placed on and the patient tolerated feedings through that well thereafter of note the patient had a point hematocrit drop on esophagogastroduodenoscopy revealed a mm prepyloric ulcer that was cauterized he had been maintained on appropriate antacid prophylaxis however after this event he was changed to protonix and then prevacid at the time of dictation the patient is tolerating two k per cc tube feeds this will be changed today to k per cc as the patient is no longer requiring fluid restriction genitourinary foley was placed in the initial trauma work up and has remained in place since the patient has never had issues of inadequate urine output or electrolyte abnormalities he is currently hep locked heme the patient s hematocrit drifted down throughout his stay and had the acute drop related to his upper gastrointestinal bleed he required several units of transfusion at that time but since his hematocrit has been stable to slowly increasing anticoagulation for his pulmonary embolus initially consisted of heparin drip with a goal ptt of to followed by commencement of coumadinization at this point the patient s inr is only so he is being discharged on a heparin drip until his inr is between and please see the nursing notes as to the doses the patient has received of coumadin to this point infectious disease as noted above the patient s main infectious complication has been pneumonia he has had right middle lobe and right lower lobe infiltrates cultures have shown enterobacter and methicillin sensitive staphylococcus aureus and he is receiving a day course of imipenem which should complete around to he also has been treated for methicillin sensitive staphylococcus aureus pneumonia and has completed his course of vancomycin and oxacillin of note the only positive blood cultures were coagulase negative staphylococcus aureus from an a line which had been removed and the patient was not considered to have had a blood stream infection endocrine the patient has been maintained on a sliding scale insulin regimen and has not had issues of hyper or hypoglycemia during his stay prophylaxis the patient remains on prevacid down his tube he is getting tube feeds at goal he is on a heparin drip and being coumadinized again goal ptt of to and goal inr of to the heparin may be stopped once the patient is therapeutic on coumadin of note the patient also has two ivc filters he also has venodyne boots tubes lines and drains the patient has a tracheostomy and percutaneous endoscopic gastrostomy tube which were placed on he also has a picc line which was placed on the tipped confirmed to be at the right atrium he has a foley catheter and that is all disposition the patient has been screened and accepted to a rehabilitation facility anticipated discharge day is discharge medications heparin drip titrate for ptt to until the inr is between and coumadin adjust dose daily for inr of to promod with fiber cc per hour via the peg tube colace mg per peg tube prevacid mg per peg tube reglan mg per peg q h imipenem gm intravenous q h through nystatin swish and spit ml po tid tears drops both eyes qid sliding scale regular insulin as outlined on page follow up trauma clinic in two weeks time please call for an appointment the patient should also follow up with neurosurgery dr phone number in approximately two weeks time please see the physical therapy and occupational therapy recommendations page and reports md dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service trauma history of present illness mr is a year old man who fell approximately feet from a ladder there is a question if there was an electrocution injury secondary to contact with a wire the patient loss consciousness at the scene and was found to be opening his eyes spontaneously but confused and combative he was intubated at the scene and sedated with versed he was boarded and collared and arrived at the hemodynamically stable with a gcs of t past medical and surgical histories at the time of admission past medical past surgical histories were unknown medication lipitor allergies none known exam general the patient was intubated and sedated vital signs heart rate pulse palp on being bagged head ears eyes nose and throat his pupils were equal his tympanic membrane on the right was bloody he had a right raccoon eye back cervical spine no step off chest clear to auscultation heart regular abdomen soft nontender nontender the pelvis was stable extremities there were no obvious deformities of the extremities small superficial laceration on the left elbow and left fifth finger rectal heme negative with decreased tone laboratory studies white count hematocrit normal chemistries inr of arterial blood gases and ck of trauma work up head ct revealed a right cerebellar and left temporal intraparenchymal hemorrhage with right posterior fossa and subarachnoid blood there is no herniation but effacement of the cisterns there are multiple bilateral temporal fractures right occipital fracture right orbital fracture and right subdural hematoma abdominal ct showed no evidence of injury small anterior right pneumothorax right th and th rib fractures and right st or th lumbar transverse process fractures ct of the chest showed no aortic injury question of t t compression deformity and right st th th and th rib fractures hand elbow films showed no fracture or dislocation neurosurgical and oral maxillofacial consultations were obtained in the trauma bay neurosurgery placed a vault that showed an icp of greater than a post procedure head ct showed increased cerebellar hemorrhage and the patient was taken emergently to the operating room for evacuation the patient underwent a suboccipital craniectomy with resection of right subdural bleeding and dural expansion he was taken intubated and sedated to the trauma intensive care unit where the rest of his course will be summarized by system hospital course neurologic the patient had undergone injuries as described above and went to the operating room for evacuation of the hematoma a ventricular ostomy drain was placed in the operating room and it was continued until approximately the patient slowly regained motor function of initially of his left upper and lower extremities followed by his right upper and lower extremities follow up head ct did not show any extension of bleeding of note the patient remained sedated for an extended period of time given his multiple injuries as the sedation was weaned he initially had difficulty with agitation and difficulty weaning the propofol however this eventually resolved and at the time of dictation the patient requires no sedation the cervical spine was cleared with an mri his thoracic and lumbar spines were cleared with ct scans ct did reveal an l vertebral body corner fracture and l through right transverse process fractures which are not treated operatively cardiovascular the patient never had hemodynamic instability throughout his course and required no pressors or drips for blood pressure control respiratory the patient was intubated on arrival at the he remained on vent support during the course of his stay due to his sedation his clinical course improved he was weaned to extubation on however he quickly developed upper airway stridor and respiratory distress and was reintubated a percutaneous tracheostomy was placed at the bedside on after this point the patient continued on vent support while he was sedated once sedation was weaned he was weaned to trach mask at the time of dictation he has been on trach mask for approximately days his respiratory course is complicated by right middle lobe and right lower lobe pneumonia culture data showed this to be enterobacter which was resistant to multiple antibiotic agents and he eventually was started on a day course of imipenem which started approximately cultures also grew methicillin sensitive staphylococcus aureus from his sputum no acute distress he received an approximately day course of gram positive coverage consisting of vancomycin and oxacillin the patient was weaning well from the vent however on he was noted to have an acute desaturation chest x ray was unremarkable and ct angiogram of the chest was performed that showed bilateral pulmonary emboli on an ivc filter was placed however it was noted that the patient had anomalous venous architecture and on the second ivc filter was placed in the lower ivc a repeat ct angiogram at this time also revealed no further extension of the clot given his slight respiratory compromise from the clot anticoagulation was readdressed to the neurosurgery team and after a follow up negative head ct the patient was started on heparin drip and subsequently is being coumadinized gastrointestinal the patient was initially kept npo without tube feeds post pyloric feeding tube was placed under fluoroscopic guidance in the intensive care unit he received regular tube feedings through this without difficulty the day prior to peg placement the tube feed was inadvertently moved on transfer the patient s peg was placed on and the patient tolerated feedings through that well thereafter of note the patient had a point hematocrit drop on esophagogastroduodenoscopy revealed a mm prepyloric ulcer that was cauterized he had been maintained on appropriate antacid prophylaxis however after this event he was changed to protonix and then prevacid at the time of dictation the patient is tolerating two k per cc tube feeds this will be changed today to k per cc as the patient is no longer requiring fluid restriction genitourinary foley was placed in the initial trauma work up and has remained in place since the patient has never had issues of inadequate urine output or electrolyte abnormalities he is currently hep locked heme the patient s hematocrit drifted down throughout his stay and had the acute drop related to his upper gastrointestinal bleed he required several units of transfusion at that time but since his hematocrit has been stable to slowly increasing anticoagulation for his pulmonary embolus initially consisted of heparin drip with a goal ptt of to followed by commencement of coumadinization at this point the patient s inr is only so he is being discharged on a heparin drip until his inr is between and please see the nursing notes as to the doses the patient has received of coumadin to this point infectious disease as noted above the patient s main infectious complication has been pneumonia he has had right middle lobe and right lower lobe infiltrates cultures have shown enterobacter and methicillin sensitive staphylococcus aureus and he is receiving a day course of imipenem which should complete around to he also has been treated for methicillin sensitive staphylococcus aureus pneumonia and has completed his course of vancomycin and oxacillin of note the only positive blood cultures were coagulase negative staphylococcus aureus from an a line which had been removed and the patient was not considered to have had a blood stream infection endocrine the patient has been maintained on a sliding scale insulin regimen and has not had issues of hyper or hypoglycemia during his stay prophylaxis the patient remains on prevacid down his tube he is getting tube feeds at goal he is on a heparin drip and being coumadinized again goal ptt of to and goal inr of to the heparin may be stopped once the patient is therapeutic on coumadin of note the patient also has two ivc filters he also has venodyne boots tubes lines and drains the patient has a tracheostomy and percutaneous endoscopic gastrostomy tube which were placed on he also has a picc line which was placed on the tipped confirmed to be at the right atrium he has a foley catheter and that is all disposition the patient has been screened and accepted to a rehabilitation facility anticipated discharge day is discharge medications heparin drip titrate for ptt to until the inr is between and coumadin adjust dose daily for inr of to promod with fiber cc per hour via the peg tube colace mg per peg tube prevacid mg per peg tube reglan mg per peg q h imipenem gm intravenous q h through nystatin swish and spit ml po tid tears drops both eyes qid sliding scale regular insulin as outlined on page follow up trauma clinic in two weeks time please call for an appointment the patient should also follow up with neurosurgery dr phone number in approximately two weeks time please see the physical therapy and occupational therapy recommendations page and reports md dictated by medquist d t rp ce job,"{
""Diagnoses"": [""Trauma"", ""Electrocution injury""],
""Medications"": [""Versed"", ""Lipitor""]
}"
8432,admission date discharge date date of birth sex f service cardiothoracic history of present illness ms is a year old woman with a history of rheumatic fever and mitral regurgitation who had two valvuloplasties in the past in and referred from dr to for a potential mitral valve replacement she had undergone a cardiac catheterization in that revealed normal coronaries moderate mistral stenosis and mild mitral regurgitation as well as mild diastolic ventricular dysfunction with moderate pulmonary hypertension she is being admitted to at this time for anticoagulation with heparin so that she can come off of her coumadin in preparation for a mitral valve replacement by dr past medical history rheumatic fever atrial fibrillation status post permanent pacemaker hypercholesterolemia diabetes mellitus past surgical history appendectomy pacemaker mitral valve replacement allergies she has no known drug allergies medications on admission digoxin once per day coumadin mg once per day she stopped on neurontin mg twice per day potassium meq twice per day lipitor mg once per day aldactone mg once per day glucophage mg three times per day glyburide mg twice per day lasix mg once per day ferrous sulfate mg once per day z pack which she finished on the day of admission social history the patient is married with three children she lives with her husband she denies tobacco use occasional ethanol use physical examination on presentation in general in no acute distress head eyes ears nose and throat examination revealed pupils were equally round and reactive to light anicteric the neck was supple with no lymphadenopathy cardiovascular examination revealed an irregular rate and rhythm a holosystolic murmur the lungs were clear to auscultation bilaterally the abdomen was soft nontender and nondistended with positive bowel sounds extremities were warm and well perfused with edema neurologic examination was grossly intact pertinent laboratory values on presentation brief summary of hospital course the patient was admitted to cardiothoracic surgery service and started on heparin infusion and was scheduled for redo mitral valve replacement on the patient had an uneventful preoperative course on she was brought to the operating room where she underwent redo mitral valve replacement please see the operative note for full details in summary she had a redo mitral valve replacement with a mm st mechanical valve her bypass time was minutes with a cross clamp time of minutes she tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit at the time of transfer the patient had a mean arterial pressure of with a central venous pressure of she had a propofol infusion as well as a nitroglycerin infusion the patient did well in the immediate postoperative period her anesthesia was reversed she was weaned from the ventilator and successfully extubated she remained hemodynamically stable throughout the night of her surgery requiring only a nitroglycerin infusion to adequately control her blood pressure the patient remained hemodynamically stable on postoperative day one her nitroglycerin infusion was weaned to off she was started on oral medications her chest tubes were removed on postoperative day two the patient continued to be hemodynamically stable her central lines were removed as were her temporary pacemaker wires and she was transferred to the floor for continued postoperative care and cardiac rehabilitation once of the floor the patient had an uneventful hospital course with the assistance of the nursing staff and the physical therapy staff her activity level was gradually increased she was again begun on her coumadin as well as a heparin infusion while awaiting an adequate increase in her inr by postoperative day six it was decided that the patient was stable and ready to be discharged to home at the time of discharge the patient s physical examination was as follows vital signs revealed a temperature of heart rate was ventricularly paced blood pressure was respiratory rate was and oxygen saturation was on room air the patient s laboratory data on the day of discharge revealed a white blood cell count of hematocrit was and platelets were sodium was potassium was chloride was bicarbonate was blood urea nitrogen was creatinine was and blood glucose was inr was medications on discharge colace mg by mouth twice per day percocet one to two tablets q h as needed lipitor mg once per day glucophage mg three times per day glyburide mg twice per day lasix mg twice per day coumadin mg once per day discharge instructions followup the patient had an appointment with dr in one week an appointment with dr in one to two weeks and an appointment with dr in four weeks her inr is to be followed by the clinic here at with a goal inr of to condition at discharge her condition at the time of discharge was good discharge status the patient was to be discharged to home with services discharge diagnoses status post redo mitral valve replacement with a mm st mechanical valve hypercholesterolemia diabetes mellitus atrial fibrillation status post permanent pacemaker status post appendectomy m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint epigastric pain major surgical or invasive procedure egd colonoscopy barium swallow with small bowel follow through history of present illness year old femalw with a past medical history significant for dm type rheumatic valve disease s p mvr with st judes valve in on coumadin therapy s p ppm for symptomatic bradycardia as well as a history of chf who presents with a day history of epigatric abdominal pain with radiation to the back r l she also describes associated n v x no hematemesis no change in bowel habits she denies recent c p or sob in the ed initial vitals were she was found to have an elevated inr at not reversed r o mi was also initiated by the ed team she was observed overnight and in am was found to have an inr of and hct drop from with a history of blood tinged stools in the ed however she refused iv placement blood draws t s and admission her pcp spoke to her who felt that she had si psych was called but the patient changed her mind and agreed to be admitted psych consult deferred past medical history rheumatic mitral valve disease s p valvuloplasty in s p st judes mvr in s p multiple cardiac catheterizations with clean coronaries atrial fibrillation s p vvi placement for symptomatic bradycardia in dm type history of chf hypercholesterolemia history of hepatic congestion of unclear etiology as well as history of hemangiomas improved after mvr depression breast mass with negative work up vitamin b deficiency anemia social history she is married with children lives with her husband history of etoh or alcohol consumption family history non contributory physical exam physical exam on admission vitals t hr bp rr sat on room air gen agitated in nad heent ncat eomi no scleral icterus clear op neck jvp flat resp cta bilaterally cvs rrr gi bs normoactive abdomen soft mild tenderness to palpation ofver epigastrium no rebound or guarding trace guaiac postivie stools ext no pedal edema neuro cn ii xii intact strenght throughout pertinent results releavant laboratory data on admission cbc brief hospital course gi bleed pt had gi bleed of unclear source before admission likely supratherapeutic inr in setting of coumadin therapy for mvr she was initially admitted to the micu markedly decreased hct on anticoagulation however she was hemodynamically stable during her entire hospital course coumadin was d c on admission and the pt was placed on heparin gtt for anticoagulation in prep for workup for source of bleed egd showed gastric erosion w no evidence of active bleeding colonoscopy was normal sbft was performed and demonstrated no clear source of bleeding coumadin was restarted when no source of bleeding was identified and heparin was continued until inr reached goal of after which the heparin was d c at d c there is no evidence of active bleeding and hct is stable it is likely that her initial bleed was gastric bleeding in setting of inr of she will require f u after d c for coumadin monitoring mvr the pt was initially supratherapeutic on coumadin w inr coumadin was d c until inr was normal meanwhile the pt was anticoagulated w heparin gtt as above when inr normalized coumadin was restarted for goal inr of and heparin was continued until inr reached goal as above the pt will need to continue coumadin after d c afib rate controlled during this admission pt w vvi pacer chf no evidence of decompensated heart failure during this admission treatment was continued w her outpt dose of lasix w good effect dm pt s oral meds were held on admission in case of need for iv contrast bg was controlled w riss during that time at d c the pt will resume her usual outpt regimen code status was full code during this admission medications on admission digoxin mcg tablet sig one tablet po daily daily gabapentin mg capsule sig one capsule po daily daily furosemide mg tablet sig three tablet po daily daily pantoprazole sodium mg tablet delayed release e c sig one tablet delayed release e c po once a day disp tablet delayed release e c s refills atorvastatin calcium mg tablet sig one tablet po once a day glyburide mg tablet sig one tablet po twice a day metformin hcl mg tablet sig one tablet po twice a day calcium carbonate mg tablet chewable sig one tablet chewable po bid times a day warfarin sodium mg tablet sig one tablet po once a day ranitidine hcl mg tablet sig one tablet po twice a day spironolactone mg tablet sig one tablet po twice a day niferex mg capsule sig one capsule po once a day disp capsule s refills senna mg tablet sig one tablet po bid times a day as needed docusate sodium mg capsule sig one capsule po bid times a day coumadin mg tablet sig one tablet po days per week monday thursday disp tablet s refills discharge medications digoxin mcg tablet sig one tablet po daily daily gabapentin mg capsule sig one capsule po daily daily furosemide mg tablet sig three tablet po daily daily pantoprazole sodium mg tablet delayed release e c sig one tablet delayed release e c po once a day disp tablet delayed release e c s refills atorvastatin calcium mg tablet sig one tablet po once a day glyburide mg tablet sig one tablet po twice a day metformin hcl mg tablet sig one tablet po twice a day calcium carbonate mg tablet chewable sig one tablet chewable po bid times a day warfarin sodium mg tablet sig one tablet po once a day ranitidine hcl mg tablet sig one tablet po twice a day spironolactone mg tablet sig one tablet po twice a day niferex mg capsule sig one capsule po once a day disp capsule s refills senna mg tablet sig one tablet po bid times a day as needed docusate sodium mg capsule sig one capsule po bid times a day coumadin mg tablet sig one tablet po days per week monday thursday disp tablet s refills discharge disposition home discharge diagnosis primary gi bleed in setting of supertherapeutic inr secondary rhreumatic mv s p valvuloplasty and mvr in afib on coumadin s p vvi pacer for symptomatic bradycardia chf with normal ef dm with neuropathy colonic polyps b deficiency discharge condition good with no gi bleeding stable hct she has persistent anemia that will need to be followed as an outpt discharge instructions weigh yourself every morning md if weight lbs adhere to gm sodium diet please call your pcp or return to the ed for blood in your stool or black tarry stool dizziness fainting shortness of breath chest pain fevers chills or other concerning symptoms take medications as prescribed follow up as below followup instructions please see your pcp in one week call to make an appointment ask him if you need to change your dose of digoxin and if you might benefit from starting an ace inhibitor medication present to coumadin clinic on friday for evaluation and leb testing provider m d where cardiac services phone date time provider where phone date time [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies lisinopril adhesive tape vancomycin attending chief complaint coffee ground emesis major surgical or invasive procedure upper endoscopy history of present illness yo f with h o gi avms but none on scope year ago on warfarin for mechanical mitral valve showed up at clinic and had an episode of coffee ground emesis there denies fever chills chest pain in the ed initial vs were patient reported as having pallor and appearing fatigued at presentation ng lavage initially with scant coffee grounds and cleared on second ml lavage hct at in ed down from on patient was crossmatched for six units no vitamin k or ffp given in the ed receiving first unit of prbc at time of signout to floor vitals at time of signout to icu were t afebrile hr bp rr o sat ra gi reportedly aware of patient and planning to scope in am unless becomes unstable upon arrival patient appears fatigued pale her husband describes that she was recently admitted for acute decompensated right sided heart failure and was aggressively diuresed she was discharged to home and about hours later began to have worsening nausea and began to vomit she vomited for several days without evidence of coffee grounds or hematemesis and reduced po intake she eventually came in to for further evaluation where she vomited and was found to have coffee grounds in her emesis and was sent to the ed the only recent medication changes were that her spironolactone was increased from mg to mg and that she was told to stop taking her diovan she has had no sick contacts or travel she admits to chills but no fevers no diarrhea or abdominal pain no dysuria or shortness of breath review of systems per hpi denies fever night sweats recent weight loss or gain denies headache sinus tenderness rhinorrhea or congestion denies cough shortness of breath or wheezing denies chest pain chest pressure palpitations or weakness denies nausea vomiting diarrhea constipation abdominal pain or changes in bowel habits denies dysuria frequency or urgency denies arthralgias or myalgias denies rashes or skin changes past medical history rheumatic mitral valve disease s p valvuloplasty in s p st judes mvr in s p multiple cardiac catheterizations with clean coronaries h o lgib thought to be secondary to avm s atrial fibrillation s p vvi placement for symptomatic bradycardia in now s p two replacements with last replacement in dm type history of chf hypercholesterolemia history of hepatic congestion of unclear etiology with multiple abdominal ultrasounds over last few years as well as history of hemangiomas improved after mvr depression breast mass with negative work up vitamin b deficiency anemia social history tobacco none alcohol none illicits none she is married with children lives with her husband in no history of etoh or tobacco use originally from worked running a pizza shop on mass ave but now not able to work due to chf family history mother with diabetes lived to physical exam vitals t bp p r o l general fatigued somewhat somnolent but arousable heent sclera anicteric mm dry oropharynx clear neck supple jvp not elevated no lad lungs bibasilar crackles cv regular rate and rhythm iii vi holosystolic murmur heard best at llsb with mechanical s abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding significant hepatomegaly with liver edge palpated to finger breadths below the costal margin ext warm well perfused pulses no clubbing cyanosis or edema pertinent results cardiology report ecg study date of pm ventricular paced rhythm compared to the previous tracing of there is no change intervals axes rate pr qrs qt qtc p qrs t radiology report chest pre op ap only port study date of am single portable ap semi upright chest radiograph severe multichamber cardiomegaly pulmonary vascular engorgement and right basal septal thickening persist the patient is status post mitral valve replacement there are multiple median sternotomy wires in unchanged position the left chest wall pacemaker is in unchanged position there is no large pleural effusion consolidation or pneumothorax impression persistent severe cardiomegaly probably no acute decompensation liver or gallbladder us single organ study date of pm findings the hepatic veins and their confluence are markedly distended consistent with provided history of heart failure the hepatic echotexture is normal without evidence of a focal lesion the main portal vein is patent with hepatopetal flow with pulsatility again reflective of right heart failure small gallstones are present within the gallbladder without secondary findings for cholecystitis there is no intra or extra hepatic biliary ductal dilatation with the cbd measuring mm the spleen is normal in size measuring cm no ascites is evident the pancreas is normal in echotexture without evidence for peripancreatic or fluid collection no pancreatic ductal dilatation or calcifications are evident impression no peripancreatic fluid identified markedly distended hepatic veins and pulsatility of the portal vein compatible with provided history of tricuspid regurgitation cholelithiasis ct abd w w o c study date of am findings in the liver segment iv hypodense lesion measuring less than cm is again identified too small to characterize but unchanged from prior study impression no ct evidence of acute pancreatitis or complications thereof including no peripancreatic stranding peripancreatic fluid collections vascular compromise or evidence of pancreatic necrosis findings reflecting known congestive failure including marked dilation of the ivc and hepatic veins contrast reflux into the venous system on arterial phase imaging heterogeneous hepatic parenchymal perfusion and periportal edema gallbladder wall edema secondary to third spacing multiple bilateral low attenuation renal lesions previously characterized as cysts by ultrasound 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 neuts lymphs monos eos baso pm blood pt ptt inr pt pm blood pt inr pt am blood pt ptt inr pt am blood pt inr pt pm blood glucose urean creat na k cl hco angap am blood 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 alt ast ck cpk alkphos totbili am blood alt ast ld ldh ck cpk alkphos totbili am blood alt ast alkphos pm blood lipase am blood lipase pm blood ctropnt am blood ck mb ctropnt am blood calcium phos mg am blood caltibc vitb ferritn trf am blood triglyc am blood digoxin brief hospital course yo f with history of right sided chf admitted with ugib found to have acute renal failure in the setting of aggressive diuresis presenting with gi bleed upper gi bleed the patient was admitted to the micu after having coffee ground emesis at she was placed on a protonix drip and received units of prbcs and units of ffp while in the ed prior to admission to the micu due to her mechanical valve her supratherapeutic inr was not reversed with vitamin k she underwent an egd on micu day which showed evidence of erosive gastritis she had no further bleeding after the egd and was called out to the floor with her diet being advanced to clears she has a known history of avms in her small bowel and colon which could have contributed to gi bleed but bleeding was felt to be secondary to gastritis patient s hct trended downwards slowly on floor and she was transfused u prbcs after which her hct was stable for several days aspirin was held and may be restarted by primary care physician in the future if felt to be safe anticoagulation s p mechanical mitral valve and paroxysmal afib upon discharge inr was subtherapeutic for mechanical mitral valve felt to be secondary to poor absorption of warfarin when taken with sucralfate which was discontinued upon discharge she was initially on enoxaparin bridge until noted to have slow hct drop on floor enoxaparin bridge was stopped because of gi bleed risk risk for stroke in a few days felt to be less than risk of gi bleed inr should be rechecked on monday at followup appointment acute renal failure her creatinine was rising upon discharge from her last admission after aggressive diuresis and symptoms of nausea and vomiting very likely related to marked uremia with bun of on admission bun creatinine ratio and urine electrolytes were in keeping with a pre renal cause patient was noted to be auto diuresing in micu which may have been post atn diuresis patient did take low dose valsartan for days post discharge when creatinine was elevated after aggressive diuresis this may have exacerbated an atn patient has also had poor po intake for several days likely worsening prerenal state at home prior to presentation worsening uremia on the floor kidney function was stable at baseline and patient was re started on po diuretic regimen right sided heart failure managed by dr at s with recent admission for decompensation she was intravascularly volume deplete from aggressive diuresis and ugib diuresis was held during her icu stay and she was given gentle iv fluids upon transfer to floor a po diuretic regimen was started after a few of days of monitoring gi bleed and question pancreatitis she was discharged on spironolactone mg and furosemide mg daily she was restarted on low dose valsartan which she was on previous to the last hospitalization for cardioprotection pancreatitis patient was noted to have epigastric pain radiating to the back with eating initially attributed to her gastritis though she likely had some component of pancreatitis her lipase was elevated to s and she complained of pain and nausea she tolerated a diet of clears for a few days and diuresis was held initially abdominal ultrasound and pancreatic protocol ct did not show any signs of gallstone pancreatitis peripancreatic fluid or pseudocyst cholelithiasis patient was noted to have gallstones on abdominal ultrasound she intermittently complained of right sided scapular pain which may be secondary to her cholelithiasis she did complain of some right side abdominal discomfort radiating to the back with eating fatty foods ultrasound showed no evidence of cholecystitis patient may benefit from general surgery evaluation as an outpatient iron deficiency anemia patient has chronic iron deficiency anemia for which she takes iron supplements she does have known avms and newly discovered erosive gastritis with no signs of ulcers on egd b and folate are not low medications on admission aspirin mg tablet sig one tablet po once a day atorvastatin mg tablet sig one tablet po daily calcium carbonate ferrous sulfate mg metformin mg tablet sig one tablet po twice a day glyburide mg tablet sig one tablet po once a day gabapentin mg capsule sig one capsule po q h omeprazole mg capsule daily warfarin mg tablet digoxin mcg tablet sig one tablet po daily daily spironolactone mg tablet daily furosemide mg discharge medications pantoprazole 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 ferrous sulfate mg mg iron tablet sig one tablet po bid times a day metformin mg tablet sig one tablet po twice a day glyburide mg tablet sig one tablet po once a day gabapentin mg capsule sig one capsule po q h every hours atorvastatin mg tablet sig one tablet po daily daily digoxin mcg tablet sig one tablet po daily daily valsartan mg tablet sig one tablet po once a day disp tablet s refills warfarin mg tablet sig one tablet po once daily at pm furosemide mg tablet sig tablets po daily daily disp tablet s refills spironolactone mg tablet sig one tablet po daily daily disp tablet s refills calcium carbonate vitamin d mg mg unit tablet chewable sig one tablet chewable po twice a day disp tablet chewable s refills docusate sodium mg capsule sig one capsule po bid prn disp capsule s refills acetaminophen mg tablet sig one tablet po every six hours as needed for pain discharge disposition home with service facility all care vna of greater discharge diagnosis primary diagnosis upper gi bleed secondary diagnoses iron deficiency anemia chronic diastolic heart failure discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mrs you were admitted to the hospital because you had vomited up some dark blood which was concerning your blood counts dropped so you were given blood transfusions you had an upper endoscopy while in the icu with the small camera they were able to look inside your stomach and the beginning part of your small intestine and saw that you have bad gastritis which means that your stomach lining is very inflamed they did not see any ulcers while you were here you kidney function appeared to become normal you have a little bit of extra fluid but it is stable please weigh yourself every morning call your doctor if weight goes up more than lbs please remember to avoid as much sodium salt in your food and drink as possible while you were in the hospital we also found that your pancreas was a little inflamed for a little while but it improved your gall bladder has some stones but it is not clear whether this is causing your right sided back pain or not when you see dr in you may discuss this issue with him and whether or not you should go to general surgery clinic to be evaluated or not the following changes have been made to your medications please increase your furosemide back to your old dose of mg daily please decrease your spironolactone dose back to your old dose of mg daily please restart your valsartan diovan mg daily please start pantoprazole mg twice daily to reduce your stomach acid please stop your aspirin mg for now because it can irritate your stomach further please start calcium carbonate with vitamin d twice daily you may take tylenol extra strength mg for pain at home please do not take more than of these pills per day grams total you may take docusate colace stool softeners twice daily to help soften your stool and make it easier for you to pass bowel movements your visiting nurse should check your blood pressure when she visits your home to make sure it is not too low and to make sure you are not having symptoms of lightheadedness or dizziness you will also need to have your inr coumadin level checked on monday at your primary care appointment at please also remember to check your blood sugars every morning and two hours after finishing lunch please do not drink juice as this will raise your blood sugar followup instructions please be sure to keep all of your followup appointments as listed below department when monday at am with post clinic building sc clinical ctr campus east best parking garage at this first visit please have your inr coumadin level checked department gastroenterology when monday at am with md building lm campus west best parking garage department div of gastroenterology when wednesday at pm with md building ra complex campus east best parking main garage department when tuesday at pm with m d building sc clinical ctr campus east best parking garage department cardiac services when tuesday at pm with device clinic building sc clinical ctr campus east best parking garage md,{}
16276,admission date discharge date date of birth sex m service nb history of present illness was born at weeks gestation by spontaneous vaginal delivery to a year old gravida para now woman the mother s prenatal screens blood type a antibody negative rubella immune rpr nonreactive hepatitis b surface antigen negative and group b strep positive woman this mother s prenatal history was remarkable for a previous loss at weeks with dandy walker syndrome this pregnancy was complicated by a large stomach bubble seen at prenatal ultrasound and polyhydramnios and an amniotic fluid index of the mother also had a group b strep urinary tract infection and completed treatment for that on the day prior to delivery this infant emerged with spontaneous respirations he was intubated in the delivery room his apgars were at minute and at minutes admission history of present illness vigorous extremely preterm infant anterior fontanel soft and flat eyes eyelids open palate intact breath sounds mild subcostal retractions good air entry heart regular rate and rhythm no murmur femoral pulses present abdomen soft nondistended no hepatosplenomegaly three vessel umbilical cord patent anus no sacral anomalies appropriate tone for gestational age an abdominal x ray did confirm a double bubble consistent with duodenal atresia neonatal intensive care unit course by systems respiratory status he was intubated at delivery he received dose of surfactant he weaned to continuous positive airway pressure on day of life he was briefly intubated on day of life during a sepsis course he extubated the cpap on day of life transitioned to nasal canal oxygen on day of life of and then to room air on day of life where he remains he has been treated with caffeine citrate since day of life for apnea of prematurity he continues on that at time of transfer he has episode of apnea bradycardia he remained on nc o os ml min physical examination he has mild subcostal retractions with good air entry lungs are clear and equal cardiovascular he required dopamine for blood pressure support from shortly after admission until day of life he has remained normotensive since that time on the murmur prompted a cardiac echo which showed a small to moderate sized patent ductus arteriosus and a patent foramen ovale and an otherwise structurally normal heart he was treated with dose of indocin on day of life and a follow up echo on revealed no patent ductus he has an intermittent very soft systolic ejection murmur at the left sternal border and is pink and well perfused fluids electrolytes nutrition at the time of transfer his weight was g he remained npo since the time of admission on parental nutrition and intralipids of dextrose and g kg per day of protein and g kg per day of intralipids and meq of sodium chloride per ml and meq of potassium acetate ml fluid he is also being given ranitidine mg per kg per day in his parenteral nutrition in addition carnitine mg per kg in his parenteral nutrition his last electrolytes on were sodium potassium chloride bicarbonate triglycerides he remains euglycemic with blood dextrose to on his calcium was and phosphorus gastrointestinal status he continues to have to low continuous suction draining ml daily on days of life and he passed a small amount of meconium stool he was treated with phototherapy for hyperbilirubinemia of prematurity from day of life to day of life his peak bilirubin on day of life was total of and direct he has had an increasing direct bilirubin the last on of total direct indirect that was unchanged from his liver function tests on were alt ast of his last alkaline phosphatase test on was hematology he has blood type b dat negative has received transfusions of packed red blood cells during his nicu stay the last on his last hematocrit was on prior to a blood transfusion infectious disease status he was started on ampicillin and gentamicin at the time of admission for sepsis risk factors he completed a day course for presumed sepsis his blood culture did remain negative he remained off antibiotics until day of life he had clinical presentation of sepsis and cellulitis over his nasal bridge he was then started on vancomycin and gentamicin his blood cultures from that time were positive for staphylococcus coagulase negative he completed a day course of antibiotics his follow up blood culture and his cerebrospinal culture his cerebrospinal fluid had a white blood cell count of genetics he did have chromosomes sent after admission they were normal xy neurology his st head ultrasound on was remarkable for a grade intraventricular hemorrhage on the left and a grade with a question of blood in the th ventricle a follow up head ultrasound on showed a grade intraventricular hemorrhage on the right and a grade on the left with moderate ventriculomegaly that ultrasound was reviewed subsequently days later and was read as a grade intraventricular hemorrhage on the right only additionally a follow up head ultrasound on showed a grade on the right and the left side within normal limits on the head ultrasound showed a resolving right germinal matrix hemorrhage and the left normal ophthalmologic his eyes were most recently examined on and found to have immature retinal vessels but no retinopathy of prematurity a follow up exam is intended for weeks from that date psychosocial parents have been very involved in the infant care throughout his nicu stay mom is an oncology social worker discharge condition good disposition he is transferred to newborn intensive care unit for continuing care a primary pediatric care provider has not yet been identified care and recommendations parenteral nutrition and intralipids with its composition as described above until the time that enteral feeds can be initiated medications caffeine citrate mg iv q h mg kg per day ranitidine in his parenteral nutrition of mg kg carnitine mg kg in his parenteral nutrition he has not yet had a car seat screening test his state newborn screen sent on was within normal limits a routine followup was sent on he received his st hepatitis b vaccine on recommended immunizations 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 or school age siblings or with chronic lung disease influenza immunization is recommended annually in the fall for all infants once they reach months of age before this age and for the st months of the child s life immunization against influenza is recommended for household contacts and out of home caregivers discharge diagnoses prematurity at weeks gestation status post respiratory distress syndrome status post presumed sepsis status post hyperbilirubinemia of prematurity duodenal atresia status post patent ductus arteriosis status post staphylococcus epi bacteremia anemia of prematurity right germinal matrix hemorrhage immature retinal vessels direct hyperbilirubinemia dictated by medquist d t job,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""m"", ""service"", ""nb"", ""history of present illness""],
""Medications"": [""rubella immune"", ""hepatitis B surface antigen negative"", ""group B strep positive""]
}"
73594,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint s p mva intubated major surgical or invasive procedure none history of present illness mr was an unrestrained driver in a rollover accident in pepperall his gcs was initially then he decompensated at the scene requiring intubation he was initially sent to st hospital in n h then transferred to for further evaluation and management he has a c fracture multiple facial fractures and lacerations past medical history hepatitis c polysubstance abuse social history single unemployed tobacco recent heroine use etoh family history non contributory physical exam temp hr bp intubated with spontaneous respirations heent face ecchymosis and edema around left eye cm lac on left upper eyelid swelling on left side of face full thickness laceration through left lateral commisure of mouth eyes hyphema on left pupil dilated minimally reactive on right pupil pinpoint and reactive negative swinging light test no pupil per ophthalmology exam no gross nerve entrapment globe intact no afferent defect eye pressure of and hyphema noted neck cervicle collar in place chest clear with equal breath sounds no deformities no crepitus cor rrr abd soft not distended nl rectal tone no blood ext warm hematoma left ankle track marks right arm pertinent results pm pt ptt inr pt pm plt count pm wbc rbc hgb hct mcv mch mchc rdw pm urine bnzodzpn pos barbitrt neg opiates pos cocaine pos amphetmn neg mthdone neg pm asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg pm lipase pm urea n creat pm glucose lactate na k cl tco c spine type dens fracture without significant displacement right c transverse process fracture involving the neural foramen cta was recommended by radiology to exclude vertebral artery injury but was thought unlikely to lead to any therapeutic options acutely by the trauma team left c transverse process fracture head ct no acute intracranial hemorrhage extensive left facial bone fractures which are detailed on the ct facial bones performed subsequently ct sinus and mandibles multiple left sided facial bone fractures as detailed above crush injury to the left maxillary sinus involves every wall with involvement of the left nasal bone and nasal septum ct torso tree in nodularity in the superior segment of the right lower lobe with pooling of secretions in the lower trachea concerning for aspiration would recommend ng tube to prevent further aspiration no acute sequelae of trauma left ankle no fracture brief hospital course mr was admitted to the trauma icu intubated lightly sedated and his neck was stabilized with a j collar his superficial facial lacerations were sutured with absorbable material his sedation was gradually weaned off and he was able to move all extremities and follow commands he was easily extubated hours after admission he was seen by the opthomology service on multiple occasions his orbit was intact and there was no entrapment but his intraocular pressure was elevated and he was placed on multiple eye drops following transfer to the trauma floor he was up and ambulating without difficulty his pain was controlled with dilaudid and a clonidine patch and he was able to tolerate a regular diet his j collar was in place at all times mr fractures are non operative and he will require every other week xrays and physical exams in the clinic the plastic surgery service will repair his orbital fracture next week as as his c spine is stable he will continue his eye drops and will follow up in week with the opthomologist he was discharged on with multiple instructions for follow up and he seemed to understand the necessity of keeping up with his eye drops immobilzing his neck and following up with his appointments medications on admission none prescribed discharge medications prednisolone acetate drops suspension sig one drop ophthalmic q h every hours disp bottle refills atropine drops sig one drop ophthalmic once a day disp bottle refills clonidine mg hr patch weekly sig one patch weekly transdermal qmon every monday disp patch weekly s refills brimonidine drops sig one drop ophthalmic q h every hours disp bottle refills dorzolamide timolol drops sig one drop ophthalmic q h every hours disp bottle refills hydromorphone mg tablet sig one tablet po q h every hours as needed for pain disp tablet s refills discharge disposition home discharge diagnosis s p mva with type dens fracture right c transverse foramen fracture left c transverse foramen fracture left orbital wall fracture left maxillary sinus fracture nasal bone nasal septum fracture hepatitis c discharge condition stable discharge instructions wear hard cervicle collar for weeks continue eye drops 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 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 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 call the opthomology department at for an appointment call plastic surgery clinic on tuesday at for a follow up appointment to determine when your surgery will be call dr for a follow up appointment in weeks at call ortho spine at for a follow up appointment in weeks with ct of c spine completed by,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""m"", ""service"", ""surgery"", ""allergies"", ""patient recorded as having no known allergies to drugs"", ""attending chief complaint"", ""s"", ""mva"", ""intubated"", ""major surgical or invasive procedure"", ""history of present illness"", ""mr was an unrestrained driver in a rollover accident in pepperall"", ""his gcs was initially"", ""then he decompensated at the scene requiring intubation""],
""Medications"": [""none""]
}"
10103,admission date discharge date date of birth sex f service cardiothoracic allergies penicillins codeine vicodin attending chief complaint relapsing polychondritis w trach here for decannulation major surgical or invasive procedure decannulation recannulation after respiratory arrest history of present illness yr old female w relapsing polychondritis requiring trach since presents to from for decannulation past medical history relapsing polychondritis psh chole tonsilectomy trach social history married lives w husband in has very supportive daughter family history non contributory physical exam vs ra general well appearing trach d female sitting in w c in nad heent unremarkable w the exception of recent decannulation of metal trach stoma site covered w dsd resp lungs cta bilat no wheezes no rhonchi heart rrr s s abd soft nt nd bs extrem no c c e brief hospital course pt was decannulated on w o complication until am on when pt developed severe resp distress requiring emergent re intubation unable to orally intubate d t edema after multiple attempts pt s stoma was enlarged at the bedside and a shiley trach was ultimately successfully replaced bag mask ventilation was maintained until secure tracheal airway was established pt was in sinus tacycardia w adeq profusion during event post event pt was awake alert an approp she was monitored in an icu bed overnoc then observed on the floor w stable o sats on room air she was able to cough clear and expectorate secretions she is very knowledgeable re care of her long standing trach and her family is very supportive there are no future plans for decannulation medications on admission pred mtx q tues nexium actonel dyazide zyrtec singular folic acid effexor skelaxin prn duoneb calciumd ambien xanax protonix discharge medications ibuprofen mg tablet sig one tablet po q h every hours as needed alprazolam mg tablet sig one tablet po qhs once a day at bedtime zolpidem tartrate mg tablet sig two tablet po hs at bedtime risedronate sodium mg tablet sig one tablet po q sunday methotrexate mg tablet sig six tablet po x week tu triamterene hydrochlorothiazid mg capsule sig one cap po daily daily montelukast sodium mg tablet sig one tablet po daily daily folic acid mg tablet sig one tablet po daily daily venlafaxine mg capsule sust release hr sig one capsule sust release hr po daily albuterol sulfate solution sig one inhalation q h every hours as needed metaxalone mg tablet sig one tablet po tid esomeprazole magnesium mg capsule delayed release e c sig two capsule delayed release e c po bid times a day prednisone mg tablet sig one tablet po daily daily muco fen dm mg tablet sustained release hr sig one tablet sustained release hr po bid times a day acetylcysteine mg ml solution sig one ml miscell q h every to hours as needed ipratropium bromide solution sig one inhalation q h every to hours as needed pantoprazole sodium mg tablet delayed release e c sig one tablet delayed release e c po bid gentamicin cream sig one topical qd as needed for tracheostomy site disp refills discharge disposition home discharge diagnosis relapsing polychondritis resp arrest due to mucous plugging discharge condition good discharge instructions call dr office if you have any questions call your pulmonologist if you develop chest pain shortness of breath increased congestion followup instructions call your pulmonologist for follow up completed by,"{
""Diagnoses"": [""relapsing polychondritis"", ""tracheostomy""],
""Medications"": [""penicillins"", ""codeine"", ""vicodin""]
}"
14456,admission date discharge date date of birth sex f service medicine allergies penicillins vicodin relafen diclofenac bactrim keflex voltaren attending chief complaint chest pain and sob major surgical or invasive procedure cardiac cath history of present illness yo female with pmhx of cad s p mi year ago diastolic dysfuction with ef of iddm hyperlipidemia hypothroirid copd on l home o presented to hospital with complaints of sob and chest pain for days and was noted to be pale and diaporhetic and bradycardic at the osh wirh hr in the s and bp in s he was started on nitro gtt heparin gtt and atropine was given she was persistantly bradycardic and then required dopamine she had elevated ck and troponins and was transferred here for further evalution she states that over the past few dys she has had increased episodes of jaw pain her anginal equlivant with increased doe and orthopnea she was told to double her lasix doses on friday by pcp and was prescribed an antiobiotic tht she does not know the name of ros jaw pain doe with a few feet increased orthopnea with pillows no edema or palpitations no syncope past medical history vertigo endocarditis years ago ra gastritis hypothyroidism depression carpal tunnel syndrome hypertension hyperlipidimia heart failure social history does not smoke of drink family history nc physical exam vitals t hr bp rr sao on face mask general appears uncomfortable in distress heent normocephalic and atraumatic head no nuchal rigidity anicteric sclera moist mucous membranes neck no thyromegaly no lymphadenopathy no carotid bruits obese neck jvp difficult to assess chest her chest rose and fell with equal size shape and symmetry her lungs had coarse breath sounds bilaterally cv pmi appreciated in the fifth ics in the midclavicular line without heaves or thrills rrr normal s and s no murmurs rubs or gallops abd normoactive bs nt and nd no masses or organomegaly back no spinal or cva tenderness ext no cyanosis no clubbing trace edema with dorsalis pedis pulses bilaterally pertinent results ekg av block st depression in i avl v increased pr interval cxr bilateral pleural effusion and in creased pulm vasculature cath selective coronary angiography demonstrated one vessel coronary artery disease in a left dominant system the lmca and lad had no angiographically apparent cad the rca was a small non dominant vessel that filled only acute marginal branches the lcx had a proximal stenosis the om came off the circumfle distally and was completely occluded the om came off at the same level as the om and had a proximal stenosis the distal circumflex was totally occluded limited hemodynamics revealed normal left heart filling pressures and a preserved cardiac output left ventriculography was not performed due to concerns about excess dye load successful placement of x mm cypher drug eluting stent in the proximal lcx final angiography demonstrated no residual stenosis in the proximal vessel no angiographically apparent dissection and normal flow see ptca comments unsuccessful attempt to treat om branch with balloon angioplasty or stenting due to inability to cross chronically occluded lesion with wire final angiography demonstrated no change in the total occlusion and no angiographically apparent dissection see ptca comments successful balloon angioplasty of the om branch with a maximal mm balloon final angiography demonstrated a residual stenosis no angiographically apparent dissection and normal flow see ptca comments successful placement of three overlapping cypher drug eluting stents in the distal lcx proximal x mm mid x mm and distal x all post dilated with a x mm quantum maverick balloon final angiography demonstrated no residual stenosis no angiographically apparent dissection and normal flow see ptca comments final diagnosis one vessel coronary artery disease normal left heart filling pressures successful placement of drug eluting stent in proximal lcx unsuccessful attempt to cross totally occluded om branch successful balloon angioplasty of om branch successful placement of three overlapping drug eluting stents in distal lcx echo ef mr tr brief hospital course rhythm the patient was in new heart block with bradycardia to the s and low systolic bp no urine output and decreased mental status when admitted pacer pads were placed and an emergent cordis was inserted into her right ij for pacer wires the patient was paced breifly at a rate of and regained a faster native heart rate by the evening she began to make urine and her mental status improved with this intervention as her blood pressure began to increase her dopamine was weaned off pt only required temp pacer for the first few days and remained in normal rate tachycardia pt developed frequent pvc s and bigeminy s when she was hypertensive tachycardic and po metoprolol was added for rate control and bp control pt has remained in normal sinus rhythm with occasional pvc s for rest of the hospital course cad most likely coronary disease in the setting of new ekg changes and block she was ruled in by enzymes with peak troponin of she was started on asa statin beta blocker was initially held given bradycardia and heart block but later re started acei was also held for arf prior to cath she has had recurrent cp which responded to nitro and morphine pt was on heparin gtt and nitro gtt when she came in heparin gtt was continued nitro gtt was initially weaned but re started for bp control cath was postponed due to acute renal failure initially and also later for respiratory distress from penumonia febrile chf later pt underwent cath once creatinine normalized to her baseline and her respiratory status improved after antibiotics and diuresis cath showed the lmca and lad had no angiographically apparent cad the rca was a small non dominant vessel that filled only acute marginal branches the lcx had a proximal stenosis the om came off the circumflex distally and was completely occluded the om came off at the same level as the om and had a proximal stenosis the distal circumflex was totally occluded successful drug eluting stents placement in proximal lcx x stent over lapping stents in distal lcx balloon angioplasty of om pump diastolic chf with ef cxr and clinical history are c w chf excerbation pt has a hx of endocarditis tte showed mr but no obvious vegetations pt went into flash pulm edema requiring iv lasix for diuresis swan was placed since pt remained on nrb bipap for several days despite diuresis pcwp was in the s so pt was aggressively diuresed further with iv lasix until pcwp was her dry weight when pcwp was kg pt was discharged with standing po lasix mg qd homeo dose potassium supplement pt was instructed to weigh herself daily to keep her wt at or below kg respiratoy failure pt has been using home o for unclear reason pt has no hx of copd and no hx of smoking she was recently diagnosed with a pneumonia by her pcp and was started on levofloxacin prior to admission when admitted she was very difficult to oxygenate despite nrb she was started on levofloxacin but remained febrile so vancomycin and flagyl were added with improvement in symptoms and wbc pt was diuresed neg l daily without improvement in her respiratory symptoms swan ganz catheter was placed which showed pcwp of s pt was then aggressively diuresed with iv lasix until pcwp of she was eventually weaned off to nc l however pt still desaturate to mid s on l nc with ambulation and also at night while she is asleep pft s were done which showed restrictive pattern most likely from obesity fvc fev fev fvc erv also pt most likely has sleep apnea component as well and should get an outpatient sleep study pt was discharged with home o since she destaturated to mid s with physical therapy activity dka the paitent missed a dose of insulin the morning of admittance he had an elevated blood glucose and an anion gap of she was started on an insulin drip requiring up to units per hour her gap then normalized and she was started on a sliding scale pt resumed her home regimen of nph and humalog and was stable acute renal failure cr on admission baseline per pcp most likely secondary to decreased c o in a setting of nstemi and bradycardia pt initially had low uop but improved after temp pacer was placed to treat bradycardia creatinine came down to as low as however after aggressively diuresing her for chf her cr came up to at the time of discharge anemia hct of on admission but drifted down to pt got units of prbc but with inappropriate response guiac was negative iron studies were consistent with anemia of chronic disease most likely from her renal disease pt needs an outpatient follow up of her anemia since she may benefit from epogen pt would should have her pcp refer her to a nephorologist if her hct continues to trend down id pt was diagnosed with pneumonia prior to admission and received levofloxacin by her pcp was continued on levofloxacin but continued to have fever and leukocytosis with cxr with no improvement vancomycin and flagyl were added with improvement in symptoms levo and flagyl were eventually discontinued although none of her cultures grew anything she was treated with presumed mrsa pneumonia since she responded to vanc and not levo she will complete a day course of iv vancomycin medications on admission asa avapro cardizem cyclobenzaoime fosamax lasix isosorbide tid levoxyl lipitor nadolol zoloft insulin nph ans humalog qam insulin nph and humalog qpm discharge medications aspirin mg tablet sig one tablet po daily daily disp tablet s refills levothyroxine sodium mcg tablet sig one tablet po daily daily disp tablet s refills atorvastatin calcium mg tablet sig two tablet po daily daily disp tablet 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 clopidogrel bisulfate mg tablet sig one tablet po daily daily disp tablet s refills toprol xl mg tablet sustained release hr sig one tablet sustained release hr po once a day disp tablet sustained release hr s refills lisinopril mg tablet sig one tablet po daily daily disp tablet s refills potassium chloride meq packet sig one po daily daily disp refills vancomycin hcl mg recon soln sig one intravenous once a day for days disp mg refills insulin nph human recomb unit ml cartridge sig as directed subcutaneous once a day units nph in am units nph in pm humalog unit ml solution sig as directed subcutaneous twice a day units in am and units in pm zoloft mg tablet sig one tablet po once a day lasix mg tablet sig one tablet po once a day disp tablet s refills fosamax mg tablet sig one tablet po once a day avapro mg tablet sig one tablet po once a day disp tablet s refills discharge disposition home with service facility vna discharge diagnosis chf pneumonia cad s p cath cri anemia discharge condition hemodynamically stable breathing comfortably on l nc discharge instructions patient was instructed to take all of the medications as indicated patient needs to seek medical attention if she develops shortness of breath chest pain fatigue dizziness increased weight decrease in urine output patient needs to weigh herself daily and seek medical attention pcp if she has more than kg weight gain she had a low sodium cardiac and diabetic diet instruction and should continue that at home followup instructions follow up with pcp weeks follow up with her cardiologist dr in weeks provider breathing tests where pulmonary function lab phone date time provider exam room is no charge where is no charge date time provider dr where medical specialties phone date time completed by,"{
""Diagnoses"": [""chest pain"", ""sobrenal"", ""bradycardia"", ""hypertension"", ""diastolic dysfunction"", ""hyperlipidemia"", ""hypothyroidism"", ""vertigo"", ""endocarditis"", ""gastritis""],
""Medications"": [""nitro"", ""heparin"", ""atropine"", ""dopamine"", ""lasix"", ""ros"", ""antibiotic""],
}"
32522,admission date discharge date date of birth sex f service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint aaa major surgical or invasive procedure open aaa repair attempted ercp right ij tunneled cath l subclavian cvl placement history of present illness y o female with known asymptomatic aaa x six years now increasing in size to cm she now presents to for repair of her aaa past medical history aaa history of aortic valve disease stenosis history of pulmonary hypertension with diastolic lvf dysfunction ef history of hypertension history of dyslipidemia history of former tobacco use x pk yrs quit history of arthritis history of carotid plaques bilaterally without stenosis by u s history of gastritis gastric ulcer s p subtotal gastrectomy history of nephrolithiasis and renal cyst by ct scan postoperative ischemic colitis s p colonoscopy postoperative acute renal failure started on hemodialysis postoperative thrombocytopenia hit negative postoperative cholecystitis with pancreatitis resolving s p attempetd ercp postoperative blood loss anemia transfused postoperative volume overload secondary to renal failure postoperative failure to thrive s p tpn social history former smoker denies etoh use family history unknown physical exam hr bp rr on l nc gen nad heent soft bilateral carotid bruits l r lungs clear to auscultation heart rrr harsh ejection mumur at base transmitted to carotid and apex abd soft nontender nondistended well healed midline abdominal incision pv palpable femoral pulses bilaterally pedal pulses dopperable bilaterally neuro nonfocal 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 alt ast alkphos amylase totbili am blood lipase am blood ck mb ctropnt am blood calcium phos mg pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood plt ct am blood glucose urean creat na k cl hco angap am blood amylase am blood lipase am blood calcium phos mg am blood triglyc pm blood lactate pm blood freeca sigmoidoscopy report erythema ulceration and friability in the distal sigmoid colon extending through out the proximal descending colon compatible with ischemic colitis the rectal mucosa was normal there was no evidence of ulcerations or bleeding renal u s port am markedly abnormal blood flow to the right kidney this raises concern for renal artery thrombosis normal flow to the left kidney ct abdomen w o contrast pm interval development of mild to moderate pleural effusions and small ascites the free fluid within the pelvis is slightly dense which may represent a component of blood likely related to recent procedure cannot rule out acute extravasation due to lack of iv contrast bilateral tiny nonobstructive renal stones dilated cbd with a mm hyperdense focus within the lumen that could represent a stone ultrasound is recommended for further characterization ct abdomen w o contrast am exam is still limited by small amount of oral contrast and lack of progression distally there is still suggestion of wall edema involving the sigmoid colon with remaining intrapelvic bowel appearing unremarkable no evidence of free air or pneumatosis unchanged choledocholithiasis better appreciated on recent ultrasound unchanged renal calculi stable bilateral simple pleural effusions and adjacent compression atelectasis unchanged mild to moderate amount of slightly hyperdense free fluid within the abdominal and pelvic cavity no evidence of retroperitoneal hemorrhage unchanged caliber of sub cm abdominal aortic aneurysm status post repair us abd limit single organ am choledocholithiasis with probable cholelithiasis and findings suggestive of acute vs chronic cholecystitis please note in retrospect cbd stone dilatation appears to have been present on ct ercp evidence of a previous gastrojujenostomy was seen the scope was passed through both anastomotic limbs but could not reach the papilla due to either long limb b ii or roux en y anatomy brief hospital course aaa resection transfered to pacu intubated and sedated pod remained sedated and intubated episode of hypotension requiring fluid resustation and dobutamine hct episode of bright red rectal bleeding followed by acute pain service for epidural patient oliguric and acidotic gi consulted for bloody stools sigmoidoscopy performed ischemic colitis of sigmid colon extending to proximal descending colon general surgery consulted and recommended conserative managment and serial exams pod oligutia continued with climbing creatinine renal consulted for cvvh thrombocytopenia hit sent negative pod remained intubated continued iv zosyn continued epidural new radial line placed lasix began cvl changed pod minimal response to lasix cvvh and tpn started epidural cath discontinued pod remained in icu care pod status slowly improved now on pressure support pod continued cvvh swan catheter converted to cvl zosyn discontinued pod insulin gtt for hyperglycemia cvvh discontinued hemodialysis instituted pod hemodialyis short run secondary to hypotension transfuse for hct of post transfusion hct cvvh restarted pod extubated transfused for hct hemodialyis trial pod zosyn restartred for persistant elevated wbc and ct findings of fluid in the pelvis pod a line discontinued tpn continued clear sips started for ercp pod transfered to vicu u s performed that demonstrated ruq common bile duct diltation pod attempted ercp unable to reach ampulla due to previous subtotal gastrectomy pod tunneled right ij line placed by transplant for hd tpn d c d diet advanced lft s improving pod hd performed pod abdominal incision staples d c ed pod pt s creatinine plateau ed pt again dialyzed per nephrology it appears that the patient will not need hemodialysis for an extended period of time zosyn d c ed left triple lumen catheter d c ed pt d c ed from to rehab medications on admission zestril hctz simvastatin asa discharge medications erythromycin mg g ointment sig inch ou ophthalmic qid times a day aspirin mg tablet sig one tablet po daily daily atorvastatin mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig one tablet po tid times a day amlodipine mg tablet sig one tablet po daily daily acetaminophen mg tablet sig tablets po q h every hours as needed ursodiol mg capsule sig one capsule po bid times a day albuterol mcg actuation aerosol sig puffs inhalation q h every hours as needed ipratropium bromide mcg actuation aerosol sig two puff inhalation qid times a day nitroglycerin mg tablet sublingual sig one sublingual x times sarna anti itch lotion sig one appl topical daily daily as needed furosemide mg tablet sig one tablet po bid times a day metoclopramide mg tablet sig one tablet po q h every hours pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours discharge disposition extended care facility rehab hospital discharge diagnosis aaa history of aortic valve disease stenosis history of pulmonary hypertension with diastolic lvf dysfunction ef history of hypertension history of dyslipidemia history of former tobacco use x pk yrs quit history of arthritis history of carotid plaques bilaterally without stenosis by u s history of gastritis gastric ulcer s p subtotal gastrectomy history of nephrolithiasis and renal cyst by ct scan postoperative ischemic colitis s p colonoscopy postoperative acute renal failure started on hemodialysis postoperative thrombocytopenia hit negative postoperative cholecystitis with pancreatitis resolving s p attempetd ercp postoperative blood loss anemia transfused postoperative volume overload secondary to renal failure postoperative failure to thrive s p tpn discharge condition stable discharge instructions what to expect when you go home it is normal to feel weak and tired this will last for weeks you should get up out of bed every day and gradually increase your activity each day you may walk and you may go up and down stairs increase your activities as you can tolerate do not do too much right away it is normal to have incisional and leg swelling wear loose fitting pants clothing this will be less irritating to incision elevate your legs above the level of your heart use pillows or a recliner every hours throughout the day and at night avoid prolonged periods of standing or sitting without your legs elevated it is normal to have a decreased appetite your appetite will return with time you will probably lose your taste for food and lose some weight eat small frequent meals it is important to eat nutritious food options high fiber lean meats vegetables fruits low fat low cholesterol to maintain your strength and assist in wound healing to avoid constipation eat a high fiber diet and use stool softener while taking pain medication what activities you can and cannot do no driving until post op visit and you are no longer taking pain medications you should get up every day get dressed and walk gradually increasing your activity you may up and down stairs go outside and or ride in a car increase your activities as you can tolerate do not do too much right away no heavy lifting pushing or pulling greater than pounds until your post op visit you may shower let the soapy water run over incision rinse and pat dry your incision may be left uncovered unless you have small amounts of drainage from the wound then place a dry dressing over the area that is draining as needed take all the medications you were taking before surgery unless otherwise directed take one full strength mg enteric coated aspirin daily unless otherwise directed what to report to office redness that extends away from your incision a sudden increase in pain that is not controlled with pain medication a sudden change in the ability to move or use your leg or the ability to feel your leg temperature greater than f for hours bleeding from incision new or increased drainage from incision or white yellow or green drainage from incisions followup instructions follow up in weeks with dr please call for an appointment follow up weeks after discharge from rehab with nephrologist dr please call for an appointment [NEW_RECORD] name unit no admission date discharge date date of birth sex f service surgery allergies patient recorded as having no known allergies to drugs attending addendum the patient was discharged to rehab on oxygen by nasal cannula instructions were given to titrate the oxygen to maintain spo greater than discharge disposition extended care facility rehab hospital md completed by,"{
""Diagnoses"": [""AAA"", ""asymptomatic AAA"", ""aortic valve disease"", ""pulmonary hypertension"", ""diastolic LV dysfunction"", ""hypertension"", ""dyslipidemia"", ""former tobacco use"", ""arthritis"", ""carotid plaques"", ""gastritis"", ""gastric ulcer"", ""subtotal gastrectomy"", ""nephrolithiasis"", ""renal cyst""],
""Medications"": [""ERCP"", ""CVC placement"", ""L subclavian"", ""CVL placement"", ""hemodialysis"", ""platelets"", ""blood"", ""transfused""]
}"
7744,admission date discharge date date of birth sex m service history of present illness mr is a year old gentleman with a history of hepatic cirrhosis secondary to alcohol status post a variceal bleed in and type diabetes on insulin who presented with as a transfer from an outside hospital after suffering a variceal bleed he had been in his usual state of health until the afternoon prior to admission when he ate at mcdonald s and began to feel nauseous he returned home and vomited bright red blood and called emergency medical service at the outside hospital his vital signs were initially stable but he continued to hematemesis and dropped his blood pressure to and then responded to fluids an emergent esophagogastroduodenoscopy at the outside hospital revealed bleeding esophageal varices which were successfully banded he was started on an octreotide drip his hematocrit remained stable at and he was transferred directly to medical intensive care unit for additional care past medical history type diabetes times years on insulin cirrhosis secondary to alcohol awaiting transplant history of variceal bleed hepatitis b and hepatitis c negative allergies no known drug allergies medications on admission nadolol isosorbide mononitrate glucotrol insulin units subcutaneously twice per day effexor methylphenidate ambien prilosec physical examination on presentation vital signs revealed his temperature was his heart rate was his blood pressure was his respiratory rate was and his oxygen saturation was in general in no acute distress his heart rate and rhythm were regular normal first heart sounds and second heart sounds no murmurs his oropharynx was clear with no blood his extraocular muscles were intact cranial nerves ii through xii were intact his lungs were clear to auscultation bilaterally his abdomen was soft nontender and nondistended there was no fluid wave no caput medusae no spider angiomata his extremities were warm and dry with trace edema pertinent laboratory values on presentation his white blood cell count was his hematocrit was and his platelets were his sodium was potassium was chloride was bicarbonate was blood urea nitrogen was creatinine was and blood glucose was calcium was magnesium was and phosphorous was inr was and partial thromboplastin time was total bilirubin was pertinent radiology imaging a chest x ray was within normal limits electrocardiogram revealed a normal sinus rhythm at normal axis and normal intervals q wave in iii poor r wave progression no st changes or t wave changes no change compared to a prior brief summary of hospital course after transfer mr was managed conservatively two large bore intravenous lines were placed he was typed and crossed for units of packed red blood cells which he never required he was kept nothing by mouth and he was started on protonix intravenously the octreotide drip was continued for hours while in house given his initial hypotension his nadolol and isosorbide were held and then restarted the next morning he was fluid resuscitated with normal saline a gastrointestinal consultation was called to evaluate his bleeding the decision was made to hold off on a repeat endoscopy for re look instead the decision was made given his stability and lack of active bleeding at this point to wait until his regularly scheduled esophagogastroduodenoscopy in two weeks following his discharge throughout his stay of three days until discharge on the he remained stable he had no repeat episodes of hematemesis his hematocrit remained stable after being checked every day he was restarted on his insulin and his antihypertensives including nadolol condition at discharge condition on discharge was stable discharge disposition discharge disposition was to home discharge diagnoses variceal bleed alcoholic cirrhosis type diabetes mellitus medications on discharge nadolol isosorbide mononitrate glucotrol insulin units subcutaneously twice per day effexor methylphenidate ambien prilosec discharge instructions followup the patient was to follow up with his primary care physician and gastroenterologist physician for a repeat endoscopy in to days m d dictated by medquist d t job,"{
""Diagnoses"": [""Hepatic cirrhosis"", ""Variceal bleed"", ""Type diabetes"", ""Hematemesis""],
""Medications"": [""Octreotide"", ""Insulin""]
}"
18075,admission date discharge date date of birth sex m service neonatology history of present illness the patient was born at weeks gestation to a year old g p mother with the following prenatal labs o negative status post rhogam at weeks hepatitis b surface antigen negative rpr nonreactive rubella immune gc and chlamydia negative sickle negative gbs unknown this infant had prenatal concerns for cerebral ventriculomegaly for which he was admitted to the neonatal intensive care unit original ultrasound had been obtained at weeks this demonstrated bilateral ventriculomegaly this finding was followed with most recent ultrasound on showing only mild right sided ventriculomegaly dr from neurology has been involved on this issue with prenatal consultation this infant was delivered by cesarean section for placenta previa he emerged vigorous with need for only blow by o apgar s were nine and nine physical examination on admission well appearing infant in no acute distress weight kg heent anterior fontanel open and soft non dysmorphic palate intact no nasal flaring normocephalic atraumatic red reflexes present bilaterally chest clear to auscultation no retractions good breath sounds bilaterally cardiovascular regular rate and rhythm normal s and s systolic ejection murmur at upper left sternal border without radiation warm and well perfused abdomen nontender nondistended soft no organomegaly no masses bowel sounds active anus patent normal umbilical cord genitourinary normal male genitalia with testes descended bilaterally central nervous system active and alert responsive to examination axial and appendicular tone normal and symmetrical reflexes intact and symmetrical musculoskeletal normal spine limbs hips and clavicles hospital course respiratory the patient has been stable from a respiratory standpoint without any concerns cardiovascular the infant was noted to have a soft murmur on admission this resolved on follow up exams fluids electrolytes and nutrition the patient has been feeding ad lib without any difficulty glucose has been within normal limits d stick neurological the infant was admitted to the neonatal intensive care unit overnight he was evaluated by neurological service with recommendation for a postnatal head ultrasound this study was obtained on and revealed mild right sided unilateral ventriculomegaly with a resolving grade i hemorrhage on the right this is consistent with prenatal studies neurology intends to follow up on ultrasound results and may recommend additional studies their note in the chart discussed the possibility of magnetic resonance imaging these findings and additional workup have been discussed with the mother disposition the patient was transferred to the newborn nursery on for the duration of the mother s hospitalization discharge weight gm lbs oz primary pediatrician dr pha follow up appointment dr neonatal neurology program reviewed by m d dictated by medquist d t job,"{
""Diagnoses"": [""neonatology"", ""cerebral ventriculomegaly"", ""placenta previa""],
""Medications"": [""Rhogam"", ""Hepatitis B Surface Antigen"", ""RPR Nonreactive"", ""Rubella Immune Gc"", ""Chlamydia Negative"", ""Sickle Negative"", ""GBS Unknown""]
}"
23444,admission date discharge date date of birth sex f service neonatology history of present illness this is the kg product of a week gestation born to a year old g p mother the pregnancy was uncomplicated prenatal screens were completely unremarkable the patient was delivered by spontaneous vaginal delivery and did well with apgars of after seen in the delivery room in the newborn nursery the patient was noted to have several maroon colored stools there did not appear to be a lot of swallowed maternal blood at delivery but she did have blood tinged amniotic fluid at time of ruptured membranes she was admitted to the nicu for further management hospital course by system she was made npo and given iv fluid several kubs were obtained which showed an initial distention which resolved over time a complete blood count and blood culture were obtained which were within normal limits no antibiotics were started the followup abdominal films were within normal limits feeds were initiated given the probable diagnosis of swallowed maternal blood the patient tolerated these feeds normally without any incident the child passed normal stools and never had any other symptoms at the time of discharge the patient was tolerating full feeds adlib without any problems from a cardiovascular and respiratory point of view the patient was always stable without requiring any intervention the child was discharged home with instructions to followup with the pediatrician condition on discharge good discharge disposition home discharge instructions the patient was discharged home with instructions to followup with the pediatrician and to monitor for signs of abdominal distress discharge diagnoses ingestion of maternal blood normal healthy infant m d dictated by medquist d t job,"{
""Diagnoses"": [""Swallowed maternal blood""],
""Medications"": []
}"
45536,admission date discharge date date of birth sex f service neurosurgery allergies pollen extracts attending chief complaint cerebellar brain mass vertigo major surgical or invasive procedure suboccipital craniotomy for mass resection history of present illness year old female who was recently seen in outpatient clinic having been referred for a newly diagnosed intracranial lesion the patient was worked up at an outside facility and presented with films indicating an approximately x cm contrast enhancing lesion most consistent with a tentorial notch meningioma since the patient is significantly symptomatic from this lesion the patient is also in need of a histopathological diagnosis to further decide on treatment and management past medical history s p hysterectomy cerebal palsy social history married resides at home with husband in no history of tobacco or illicit substances family history non contributory physical exam on admission patient is alert oriented to person place date mildly depressed affect but pleasant full motor strength throughout upper and lower extremities on discharge afebrile alert and oriented x following all commands perrla mm to mm speech is clear cn ii xii intact eom s full with conjugate gaze no diplopia or nystagmus no pronator drift surgical suture line is clean dry and intact there is no edema erythema or eccymosis there is no drainage present the patient has been out of bed and ambulating she has been cleared by pt for d c to home 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 calcium phos mg imaging mri head w contrast findings patient is status post left suboccipital craniotomy with expected post operative changes there are a few approximately mm sized punctate foci of t hyperintensity in the surgical resection bed which have corresponding susceptibility artifact on gradient recalled echo sequence and likely represent small residual foci of post operative hemorrhage on t w post gadolinium sequences there is more planar or sheet like enhancement along the aspect of the tentorium which likely relates to operative manipulation on t w mp rage and se post gadolinium sequences there are several small enhancing vessels seen along the posterior aspect of the surgical resection bed seen on the pre operative study which likely represent normal vessels at the margin of the surgical resection bed allowing for the above no definitive evidence for residual tumor is seen the ventricles and sulci are normal in size and in contour there is no shift of normally midline structures no new enhancing mass is identified no foci concerning for infarction seen on diffusion weighted imaging am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood plt ct am blood plt ct brief hospital course patient was electively admitted on for suboccipital craniotomy for cerebellar mass resection intraoperatively she diureised nearly seven liters of urine which was treated with albumin and crystalloid iv fluids due to the excessive urine output and elecated lactate in this setting she was kept intubated overnight in the icu for concerns of potential airway compromise on pod dvt prophylaxsis was started and mri of the head was performed to evaluate for residual tumor burden post operative mr imaging was obtained routinely she has been followed by neuro oncology social service pt and ot while inpt she has progressed as expected in the immediate post op course with no perioperative complications she is tolerating all p o food and fluid well she will follow up as outlined in the neurosurgery and brain tumor clinics medications on admission antivert discharge medications acetaminophen mg tablet sig tablets po q h every hours as needed for bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for docusate sodium mg capsule sig one capsule po bid times a day methocarbamol mg tablet sig one tablet po tid times a day disp tablet s refills metoprolol tartrate mg tablet sig one tablet po bid times a day as needed for htn disp tablet s refills dexamethasone mg tablet sig one tablet po tid times a day x days then taper to mg for three days disp tablet s refills senna mg tablet sig one tablet po bid times a day pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours discharge disposition home discharge diagnosis cerebellar mass discharge condition neurologically stable discharge instructions general instructions information 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 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 unless directed by your doctor do not take any anti inflammatory medicines such as motrin aspirin advil and ibuprofen etc you are being sent home on steroid medication make sure you are taking a medication to protect your stomach prilosec protonix or pepcid as these medications can cause stomach irritation make sure to take your steroid medication with meals or a glass of milk clearance to drive and return to work will be addressed at your post operative office visit make sure to continue to use your incentive spirometer while at home call your surgeon immediately if you experience any of the following new onset of tremors or seizures any confusion 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 any signs of infection at the wound site increasing redness increased swelling increased tenderness or drainage fever greater than or equal to f followup instructions follow up appointment instructions please return to the office in days from your date of surgery for removal of your sutures and a wound check this appointment can be made with the nurse practitioner please make this appointment by calling if you live quite a distance from our office please make arrangements for the same with your pcp you have an appointment in the brain clinic on pm with dr the brain clinic is located on the of in the building their phone number is please call if you need to change your appointment or require additional directions you will not need an mri of the brain as this was completed during you acute hospitalization completed by,"{
""Diagnoses"": [""tentorial notch meningioma""],
""Medications"": [""none""]
}"
88269,admission date discharge date date of birth sex f service neurology allergies no known allergies adverse drug reactions attending chief complaint garbled speech and left hemiplegia major surgical or invasive procedure peg tube placement history of present illness the pt is a year old woman with htn hl previous embolic strokes atrial fibrillation on asa and clopidogrel recent pacemaker followed by mi with resultant chf who presents as a transfer from osh for acute onset of garbled speech and left hemiplegia the patient had been admitted for constipation issues at this morning the patient was seen well at the patient was found with garbled speech and left hemiplegia a nchct was done that reportedly did not show any specific findings the patient was transferred to the osh icu and then transferred here for evaluation for possible neuro interventional procedure past medical history hl htn previous strokes late embolic with hemorrhagic conversion dx with a fib at this time and started on pradaxa stemi bms placed in lad subsequent tte ef was with akinesis of anterior septum wall apex and a paf sick sinus syndrome prolonged qt pacemaker placed pradaxa stopped prior to pm placement chronic dependent edema hx of bleeding stomach ulcer osteoporosis recurrent utis hx diverticulosis ibs social history patient had been living with her daughter up until mi in since which she was in rehab prior to this stroke she was able to ambulate with a cane walker her two daughters are her hcp widowed family history non contributory physical exam physical exam on admission vitals t p r bp sao on l nc general eyes closed in bed heent nc at no scleral icterus mmm neck supple no carotid bruits no nuchal rigidity pulmonary decreased breath sounds at bases bilaterally cardiac irreg irreg nl s s systolic murmur abdomen soft nt nd normoactive bowel sounds no masses or organomegaly noted extremities bilateral pitting edema 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 limited history speaking in word phrases inattentive requiring repeated stimulation during interview intact comprehension speech was not dysarthric able to follow both midline and appendicular commands denies l hand as own l neglect r gaze preference cranial nerves i olfaction not tested ii perrl to mm and brisk no blink to threat on left iii iv vi l gaze palsy can overcome with ocrs limited down vertical gaze v decreased facial sensation along left hemiface vii left facial droop viii hearing intact to finger rub bilaterally ix x palate unable to be visualized strength in trapezii and scm bilaterally xii tongue protrudes in midline motor full strength in right side left side is flaccid and plegic sensory decreased sensation on left hemibody intact on right dtrs tri pat ach l r plantar response flexor on right and extensor on left coordination no dysmetria in rue gait deferred neurologic exam on discharge mental status lethargic arouses to voice mostly nods in response to questions but can occasionally provide word responses inattentive requires repeated stimulation comprehension intact follows some simple commands l neglect but identifies left hand as her own cranial nerves i olfaction not tested ii perrl to mm and brisk iii iv vi r gaze preference but able to cross midline to the left v decreased facial sensation along left hemiface vii left lower facial droop viii hearing intact to voice bilaterally ix x palate unable to be visualized strength in trapezii and scm bilaterally xii tongue protrudes in midline motor full strength in right side left hemiplegia with no spontaneous movement observed increased tone throughout l arm and leg sensory decreased sensation on left hemibody intact on right dtrs tri pat ach l r plantar response flexor on right and extensor on left coordination no dysmetria in rue gait deferred pertinent results pm ck cpk pm ck mb pm urine color yellow appear clear sp pm urine blood sm nitrite neg protein glucose neg ketone neg bilirubin neg urobilngn neg ph leuk sm pm urine rbc wbc bacteria none yeast none epi pm urine wbcclump mod am glucose urea n creat sodium potassium chloride total co anion gap am estgfr using this am alt sgpt ast sgot ld ldh ck cpk alk phos tot bili am ck mb ctropnt am albumin calcium phosphate magnesium cholest am hba c eag am triglycer hdl chol chol hdl ldl calc am tsh am wbc rbc hgb hct mcv mch mchc rdw am plt count am pt ptt inr pt ct cta ctp head neck impression occlusion of the right ica at its bifurcation with no evidence of intracranial flow lack of right internal carotid atheromatous disease or dissection suggests a proximal embolic source elevated mtt low cbv and low cbf in the entire right mca territory suggesting completed acute infarction in this region large hypodensities of right parietotemporal and left occipital region regions compatible with late subacute right mca and left pca infarction atheromatous plaque of left common carotid bifurcation without significant luminal stenosis large bilateral dependent pleural effusions with associated adjacent compressive atelectasis ct head impression progressive cytotoxic edema in the right cerebral hemisphere compatible with evolving right mca infarction no evidence of hemorrhagic transformation at this time established left occipital and einferior right frontal infarctions with encephalomalacia cxr findings in comparison with the study of there is a slight decrease in the diffuse bilateral pulmonary opacifications most likely reflecting some decrease in pulmonary edema despite lower lung volumes the possibility of supervening pneumonia would have to be considered in the appropriate clinical setting cxr impression signficantly improved bilateral diffuse pulmonary opacities stable moderate left sided pleural effusion and resolved right sided pleural effusion video swallow study findings video swallow examination was performed in conjunction with the speech and swallow division multiple consistencies of barium were administered there was moderate silent aspiration of the nectar and honey thick barium with significantly delayed cough and swallowing reflexes there was no aspiration or penetration with pudding however there was significant oral residue but no evidence of pharyngeal residue ct abdomen without contrast impression large hiatal hernia equivocal perfusion defects in the kidneys which are of uncertain significance but the possibility of infection cannot be entirely excluded by this study correlation with clinical factors is recommended the most distinct abnormality involves the mid to lower pole where there is suspected volume loss which may suggest longer chronicity and according the lesion may be due to more chronic scarring brief hospital course ms was transferred from an outside hospital to our neuro icu on upon arrival to our nicu approximately h after the onset of her symptoms she was awake and answered questions her eyes were deviated to the right and she had a dense left hemiplegia along with left sided neglect her examination was consistent with a large right hemispheric mca parietal syndrome stat ct ctp and cta showed bilateral old infarcts in various arterial territories left occipital right frontal and a less defined hypodensity in right parietal region extending into the deep basal ganglia cta showed occlusive lesion and decreased flow signal in the left right ica mca these findings were consistent with new acute subacute right mca infarct likely cardioembolic due to af untreated with oac recent mi and low ef she was not a candidate for endovascular intervention ia t established infarction on ct we discussed her condition with her daughters and confirmed her code status as full we placed a dobhoff tube for feeding and provided supportive post stroke care she was monitored in the icu overnight and as she remained stable was transferred to the floor stroke service on neuro her examination has remained largely stable since being transferred to the floor on she is appearing somewhat more awake nodding shaking head to questions occasionally verbalizing a few words and following commands she continues to have a significant left hemiplegia left sided neglect is improving she was initially continued on aspirin and plavix for secondary stroke prevention as well as cardioprotection given her recent stent per discussion with her outpatient cardiologist dr plavix was stopped on approx month after bare metal stent placement and she was transitioned to coumadin and aspirin mg daily lipid panel revealed tg hdl ldl and hba c was she was continued on her home rosuvastatin blood pressure was initially allowed to autoregulate and she was slowly started back on her home antihypertensives and diuretics pt ot and speech therapy were consulted she continued to have persistent dysphagia and remained npo despite multiple repeat swallow evaluations a dobhoff tube was placed for feeding but came out on and was unable to be replaced peg tube was subsequently placed on she has been tolerating tube feeds well but remains npo cv she was maintained on telemetry monitoring during her admission she was continued on aspirin and plavix as well as amiodarone digoxin and carvedilol lasix was initially held but was then restarted at her home dose of mg daily due to concerns for volume overload with pulmonary edema her respiratory status improved with diuresis spironolactone was also restarted on a tte performed at the outside hospital prior to her transfer revealed ef of and no evidence of a cardioembolic source although could not fully assess for thrombus on she was noted to be tachycardic to s her pacemaker was interrogated and revealed abnormal sensing a cxr confirmed rv lead migration pacemaker settings were adjusted our cardiology team spoke with the patient s daughters about potentially removing the rv lead but it was decided to hold off as her tachycardia resolved with adjustment of the pacemaker settings her tachycardia improved once peg was placed and she was started back on her home medications per discussion with her outpatient cardiologist dr plavix was stopped on approximately month after bare metal stent placement and she was transitioned to coumadin mg daily and aspirin mg daily id she had one episode of fever to overnight on cxr was concerning for pulmonary edema as well as potential aspiration pneumonia ua and cultures were negative and blood cultures were negative as well she was started on vanc zosyn and completed an day course she remained afebrile throughout the rest of her admission on she was noted to have some vaginal discharge and was started on miconazole cream for presumed candidiasis pulm she was restarted on lasix mg daily due to concerns for pulmonary edema on a cxr her respiratory status improved and repeat cxr showed signficantly improved bilateral diffuse pulmonary opacities she was continued on lasix and her respiratory status remained stable spironolactone was also restarted on endo she was maintained on finger sticks qid and insulin sliding scale with a goal of normoglycemia hgba c was gi nutrition she continued to have significant dysphagia and remained npo despite multiple repeat swallow evaluations a dobhoff was placed and tube feeds were initiated the dobhoff was lost on and unable to be replaced per discussion with ms and her family the decision was made to place a peg tube surgery was consulted and recommended a ct of her abdomen which showed a large hiatal hernia initially it was thought that this may preclude the option of a peg and the possibility of an open j tube placement was discussed with the pt and her family ultimately it was determined that peg placement would be the preferred option if possible she was taken to the or on and underwent successful placement of a peg tube she was started on tube feeds on which she has been tolerating well prophylaxis she was maintained on subq heparin for dvt prophylaxis she was maintained on a bowel regimen and a ppi for gi prophylaxis fall and aspiration precautions were maintained code status her daughters and health care proxies confirmed her code status as full during this admission dispo she was discharged to rehab in good condition on transitional care issues she was started on coumadin mg daily on this was decreased to mg daily on due to rapidly increasing inr inr was upon discharge coumadin should be held and inr should be rechecked on inr should be closely monitored until stable at goal she will also need to remain on aspirin mg daily she will need intensive pt and ot as well as speech therapy nutrition should also be involved for adjustment of her tube feeds she has a follow up appointment scheduled with dr in neurology clinic on at pm medications on admission amiodarone mg po daily ampicillin mg cap to be completed for uti aspirin mg po daily coreg mg po bid vitamin b mcg digoxin mg tab docusate famotidine ferrous sulfate po daily folic acid mg po daily furosemide mg po daily lactulose daily lisinopril mg po daily proctofoam hc rectal foam crestor mg po daily spironolactone mg po daily acetaminophen mg po q hr milk of magnesia ml daily prn discharge medications docusate sodium mg ml liquid sig one po bid times a day hold for loose stools bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for constipation cyanocobalamin vitamin b mcg tablet sig two tablet po daily daily folic acid mg tablet sig one tablet po daily daily amiodarone mg tablet sig one tablet po daily daily acetaminophen mg ml solution sig six y mg po q h every hours as needed for pain carvedilol mg tablet sig one tablet po bid times a day insulin regular human unit ml solution sig one unit injection asdir as directed as per insulin sliding scale rosuvastatin mg tablet sig two tablet po daily daily senna mg ml syrup sig one tablet po bid times a day hold for loose stools ferrous sulfate mg mg iron ml liquid sig five ml po daily daily miconazole nitrate cream sig one appl vaginal hs at bedtime for days through digoxin mcg tablet sig one tablet po daily daily famotidine mg tablet sig one tablet po bid times a day spironolactone mg tablet sig tablet po daily daily modafinil mg tablet sig tablet po qam once a day in the morning warfarin mg tablet sig three tablet po once daily at pm hold recheck inr aspirin mg tablet chewable sig one tablet chewable po once a day citalopram mg tablet sig one tablet po daily daily nystatin unit ml suspension sig five ml po qid times a day as needed for thrush discharge disposition extended care facility discharge diagnosis right mca middle cerebral artery stroke pneumonia dysphagia discharge condition mental status confused sometimes level of consciousness lethargic but arousable activity status out of bed with assistance to chair or wheelchair neurologic pupils equal and reactive r gaze preference but able to cross midline toward left left neglect but recognizes hand as her own left lower facial droop left hemiplegia with increased tone in upper and lower extremity no spontaneous movement moves right side spontaneously anti gravity with full strength left toe upgoing discharge instructions dear ms you were admitted to on for left sided weakness you were found to have a stroke in the right side of your brain your stroke is likely related to your atrial fibrillation in the context of your recent heart attack and pacemaker placement per discussion with your cardiologist your plavix was stopped and you were changed to aspirin and coumadin to help reduce your future risk of stroke you were also treated for pneumonia with iv antibiotics you were found to have difficulty swallowing due to your stroke a nasogastric tube was placed initially to provide you with nutrition and medications as you continued to have difficulty swallowing a peg percutaneous endoscopic gastrostomy tube was placed you will need intensive pt ot and speech therapy after your discharge to regain your strength and hopefully your ability to swallow as well we made the following changes to your medications started coumadin mg daily should be held inr should be rechecked started modafinil mg daily to help increase your alertness and energey level started celexa mg daily to help with depression you should continue to take the rest of your medications as prescribed 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 you have the following appointment scheduled with dr in our stroke clinic provider md phone date time sc clinical ctr neurology unit cc sb,{}
81938,admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint acute pancreatitis major surgical or invasive procedure none history of present illness mr is a m with h o etoh abuse alcoholic pancreatitis cad who presented to hospital with on day of n v abd pain and found to have acute pancreatitis and etoh withdrawal on at the time of presentation his lipase was and ct abd pelvis showed mild peripancreatic edema and fluid infiltration in retroperitoneum the patient was intially treated on the medicine service with ivf analgesia and kept npo however his course was complicated by delirium tremens for which he was transferred to the critical care unit on he was treated with dexmedetomide and iv lorazepam with improvement at this time the patient is days out from his last drink and maintained on iv lorazepam the patient began to complain of increasing abdominal pain with note of increased abdominal girth and tenderness on exam repeat ct showed enlargement of the pancreas with circumferential peripancreatic fluid collection and enlarging collection in lesser sac and splenic hilium as well as retroperitoneal fluid and findings suggestive of pancreatic necrosis in addition the patient has been persistently febrile over the past few days with maximum temp of with persistant leukocytosis wbc k with bands his cultures prior to transfer were negative to date other than cdiff he was found to have postive cdiff pcr and was started on iv flagyl planned to start po vancomycin but not administered prior to transfer he has remained hd stable throughout his course with bp s hr in s o stas on l nc dropping to on ra foley in place draining cc hr on d ns kcl at cc hr he has been kept npo and was on ppn prior to transfer he apparently failed speech and swallow evaluation on the day of discharge he was transferred to for further management of his pancreatitis with consideration of needle aspiration of pancreatic bed to exclude superinfection on the day of discharge labs were significant for lipase albumin normal lfts glucose prealb wbc hct past medical history etoh abuse alcoholic pancreatitis previous sepsis pe ivc filter cardiomyopathy w vfib arrest s p placement of cardioverter defibrillator hypertension hyperlipidemia coronary artery disease gerd splenic infarct social history per records ambulates with cane at baseline employed as a sheet metal worker he has never smoked tobacco occasional marijuana and cocaine use drinks beers approximately days per week he is married with children family history per records no significant cardiac history physical exam vitals t on l nc general alert oriented to self intermittently to place and date heent sclera anicteric dry mmm white plaque on tongue perrl neck supple jvp not elevated cv regular tachycardic normal s s no murmurs rubs gallops lungs clear anteriorly but difficult to assess due to poor patient cooperation abdomen distended bowel sounds present soft tender to palpation largely in epigastrium gu foley with clear yellow urine skin erythematous rash in groin ext warm well perfused pulses no edema neuro altered intermittently able to respond to questions appropriately moves all exremities discharge labs vs ra bg i o bm gen generally well appearing but does appear uncomfortable heent eomi sclera anicteric op clear neck no lad cv rrr no m r g nl s s lungs ctab no wheezing no crackles abd no epigastric tenderness normal bowel sounds non distended ext no edema radial dp pt pulses bilaterally erythematous and slightly tender r great toe no abnormalities appreciated on left foot neuro cn ii xii intact moving all four extremities spontaneously gait normal appropriate alert pertinent results osh ct abd pelvis small right mod left pleural effusion heart enlarged no pericardial effusion no biliary dilation but high density material in gallbladder progressive severe pancreatitis wit pancreatic enlargement and new findings of pancreatic necrosis peri pancreatic lesser sac retroperitoneal mesenteric fluid collections new thickened transverse colon pancreatic severity index admission 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 albumin calcium phos mg pertinent am blood pt ptt inr pt am blood alt ast ld ldh alkphos totbili am blood lipase am blood triglyc am blood lactate am blood freeca am urine color yellow appear clear sp am urine blood mod nitrite neg protein glucose neg ketone neg bilirub neg urobiln neg ph leuks neg am urine rbc wbc bacteri few yeast none epi pm urine source cvs final report urine culture final no growth pm blood culture source venipuncture final report blood culture routine final no growth pm blood culture source venipuncture final report blood culture routine final no growth pm urine source catheter final report urine culture final no growth am blood culture source venipuncture final report blood culture routine final no growth am blood culture source venipuncture final report blood culture routine final no growth pm urine source catheter final report urine culture final no growth pm blood culture source venipuncture final report blood culture routine final no growth am blood culture source venipuncture final report blood culture routine final no growth am blood culture source venipuncture final report blood culture routine final no growth am mrsa screen source nasal swab final report mrsa screen final no mrsa isolated studies cxr feeding tube tip is in the distal stomach there is obscuration of the left hemidiaphragm in the retrocardiac region consistent with volume loss infiltrate the remainder of the lungs are clear single dual lead cardiac pacemaker is again visualized 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 mr is a m with h o etoh abuse pancreatitis cad who presented to hospital with acute pancreatitis on c b etoh withdrawal with transferred to the micu for further management of pancreatitis and delirium who has been managed conservatively acute care acute pancreatitis patient with h o pancreatitis likely secondary to etoh abuse tg there was concern for pancreatic necrosis at osh however review of imaging here showed acute pancreatitis but no etiology of necrosis upon transfer from osh he was initially febrile with a mild leukocytosis and this was attributed to possible cytokine release from pancreatitis he was managed at osh and at with ivf npo and pain control received tube feeds this was subsequently stopped and dobhoff was discontinued he was then trialed on clear diet but had recurrence of pain he was again npo with iv dilaudid pain medications and then diet was advanced and he was transitioned to po dilaudid without any worsening of pain he was discharged on brat diet with very cautious advancement cdiff colitis tested positive at osh and given iv flagyl but was started on po vanc on for day course at time of discharge he was having formed stools etoh abuse delirium tremens last drink over weeks ago patient s course complicated by delirium tremens he was started on precedex and lorazepam gtt at the osh this was tapered off and discontinued with radical improvement in mental status which could indicated that benzo intoxication was a large contributor to his delirium no signs of alcohol withdrawal he was started on thiamine mvi folic acid social work was consulted and he was felt to be pre contemplative regarding cessation of alcohol gout r podogra possibly some left foot metatarsal pain improved with treatment with indomethacin mg tid for now and also omeprazole to decrease risk of gib not preventative at time of discharge he had mild pain at r podogra but no pain on left foot anemia likely secondary to etoh abuse mildly elevated ldh but haptoglobin is elevated making hemolysis unlikely osh labs showed low iron high ferritin consistent with anemia of chronic disease no evidence of bleeding transaminitis resolved but initially was mild and consistent with alcohol related liver disease fungal infections the patient endorsed crural candial infection and was treated with miconazole powder he also had oral candidiasis and was treated with nystatin s s transitions of care communication wife hcp cell home code full confirmed with wife in micu issues to discuss at follow up consider asa outpatient egd recommended pending studies at time of discharge none medications on admission home medications omeprazole dialy percocet tabs q six hours prn flexeril mg po dilay tramadol mg po q six hours prn citalopram mg po daily indomethacin mg po q hrs prn tricor mg po daily medications on transfer acetaminophen heparin u sq q hours hydromorphone mg iv q hours prn ativan mg iv q hours prn lorazepam mg iv q hrs metoprolol mg iv q hrs ondansetron mg iv discharge medications senna mg tablet sig one tablet po bid times a day as needed for constipation disp tablet s refills omeprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily citalopram mg tablet sig one tablet po daily daily tricor mg tablet sig one tablet po once a day vancomycin mg capsule sig one capsule po q h every hours for days disp capsule s refills docusate sodium mg capsule sig one capsule po once a day as needed for constipation disp capsule s refills thiamine hcl mg tablet sig one tablet po daily daily disp tablet s refills multivitamin 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 quetiapine mg tablet sig tablets po twice a day one pill in the morning and pills in the evening disp tablet s refills indomethacin mg capsule sig two capsule po tid times a day as needed for gout disp capsule s refills miconazole nitrate powder sig one appl topical qid times a day as needed for itch in groin disp container refills hydromorphone mg tablet sig tablets po every hours as needed for pain do not drive or drink alcohol while taking this medication do not exceed the recommended dose disp tablet s refills discharge disposition home discharge diagnosis primary diagnosis alcoholic pancreatitis alcohol withdrawal gout clostridium difficile colitis secondary diagnosis hypertension hyperlipidemia coronary artery disease discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you were admitted for pancreatitis which was likely due to alcohol your hospital course was complicated by withdrawal from alcohol and gout both of which have improved you should eat a very conservative diet and avoid alcohol above all else we recommend for you to eat a brat diet which stands for banana rice applesauce and toast you must quit drinking alcohol you have expressed your desire to engage with aa and we highly recommend that you follow through with your intention to do this please note the following changes to your medications stop percocet stop flexeril stop tramadol start dilaudid for pain discuss decreasing the dose with your pcp start senna and colace as a bowel regimen while you are taking dilaudid start folic acid start thiamine start multivitamin start vancomycin for more days start miconazole powder for the itch in your groin as needed start indomethacin for gout stop when no longer needed do not exceed mg three times per day start seroquel one dose in the am and two doses in the pm please be sure to follow up with your primary care physician recommend that you get an outpatient egd please discuss this recommendation with your pcp followup instructions name md specialty primary care address steet phone when at pm department cardiac services when wednesday at pm with device clinic building sc clinical ctr campus east best parking garage department cardiac services when wednesday at pm with m d building sc clinical ctr campus east best parking garage,"{
""Diagnoses"": [""acute pancreatitis"", ""etoh withdrawal"", ""delirium tremens""],
""Medications"": [""ivf analgesia"", ""iv lorazepam"", ""dexmedetomide""]
}"
96645,admission date discharge date date of birth sex f service medicine allergies aspirin attending chief complaint hemetemesis major surgical or invasive procedure upper endoscopy egd history of present illness yo f pmhx hcv cirrhosis c b ascites encephalopathy and hcc s p multiple tace recent hospitalization for and ams who presents after episodes of coffee ground emesis per hcp report she was in her normal state of health normally aox mildly lethargic secondary to chronic when she had two witnessed episodes of hematemesis one at home and one here while waiting for previously scheduled head mri she reports no fevers chills abdominal pain she had a routine mri of abdomen performed yesterday to evaluate for progression of liver disease which showed a cirrhotic heterogeneous liver with multiple hypoenhancing nodules similar in appearance to past scans she had been admitted earlier this month for work up of lethargy fatigue elevated lactate down to and arf thought to be due to acute toxic metabolic encephalopathy in the setting of hypovolemia from decreased po intake and recent addition of diuretics to her medication regimen renal functions improved with fluids and holding of her diuretics on that admission received unit of prbc for hct of in the ed initial vs were ra exam was notable for aox lethargic nontender abdomen labs notable for lactate of had been at last discharge hematocrit of had been at last discharge creatinine of baseline and k of previously normal ekg was unchanged from prior patient was bolused with iv fluids and tranfused units of prbcs ng lavage attempted but unsuccessful per hepatology service iv pantoprazole and octreotide drips were initiated gram of ctx was given empirically at time of transfer she had received l ns had gauge peripheral ivs vitals were hr ra on arrival to the micu vital signs were ra patient was mildly lethargic sleeping but arouseable reporting no pain or discomfort past medical history hepatitis c status post failed treatments with interferon and ribavarin hypothyroidism hypertension depression status post cholecystectomy hepatocellular carcinoma status post tace to the right liver on left liver on right liver and most recently a superselective right liver segment v viii tace on she underwent an mri after that on that showed good response to treatment of three lesions in segment ii vii and viii and no enhancement seen in those lesions there are no new arterially enhancing lesions and the spleen was enlarged pancreas and adrenals are unremarkable social history tobacco history denies history or current etoh denies history yrs ago illicit drugs none home lives with her son and daughter in law she has seven children five of whom live in the area she is originally from the republic and has lived in united states for years work does not work family history per brother and sister are both status post liver transplant it is unclear whether they had hcc or cirrhosis father mi at age brother mi with cabg at age mother htn physical exam admission exam vitals ra general mildly lethargic comfortable heent icterus mmm oropharynx clear perrl neck supple no jvd no lad cv tachycardic no murmurs lungs clear to auscultation bilaterally abdomen distended non tender dull to percussion no rebound guarding or cva tenderness gu foley ext warm well perfused dp pt no cyanosis edema neuro aox name hospital moving all extremities asterixis on discharge vitals were t bp hr rr o sat ra she was aaox with mild asterixis felt to be her baseline mental status pertinent results admission labs pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts lymphs monos eos baso am blood pt ptt inr pt pm blood urean creat na k cl hco angap pm blood alt ast alkphos totbili am blood albumin pm blood totprot calcium phos mg am blood lactate k 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 ascitic fluid pm ascites wbc rbc polys lymphs monos mesothe macroph pm ascites totpro glucose albumin less than imaging mri of abdomen limited evaluation of the hepatic parenchyma secondary to non breathhold technique used because patient was having difficultly following inststructions treated lesions in segment ii segment vii the junction of segments v and viii again demonstrate no enhancement and are grossly unchanged there are no new arterially enhancing lesions identified cirrhotic heterogeneous liver with multiple hypoenhancing nodules similar in appearance to top normal spleen small moderate ascites and edematous bowel wall all attest to the presence of portal hypertension ct head no acute intracranial process area of white matter hypodensity on the left frontal subcortical region likely represents sequelae of small vessel ischemic disease correlation with mri is advised if clinically warranted cxr et tube in satisfactory position approximately cm above the carina apparent new patchy opacity in the left infrahilar region an ng tube is present the tip lies approximately cm above the carina an ng tube is present tip extending beneath diaphragm off film there is rotated positioning with low inspiratory volumes this likely contributes to accentuation of the cardiomediastinal silhouette and pulmonary vasculature compared with at p m the patchy opacity at the left base is slightly more pronounced there is minimal blunting of the right costophrenic angle and new atelectasis at the right base patchy opacity left greater than right bases atelectasis versus pneumonic infiltrate overall appearances are similar to at p m ruq ultrasound patent main portal vein and hepatic veins cirrhotic liver and multiple liver lesions better assessed in the prior mri study of brief hospital course yof with h o hcv c b esld and hcc s p multiple tace admitted for hematemesis ugib active issues hematemesis acute anemia patient admitted to for coffee ground emesis concerning for variceal bleed in a cirrhotic patient patient was started on pantopraole and octreotide gtt for likely variceal bleed and started on prophylatic ceftriaxone for sbp in setting of gi bleed patient underwent intubation and egd per hepatology where bleeding varices were found and banded her initial hct was and it came up to after units of rbcs so pt received additional rbcs she received units of rbcs in total her hct then stabilized and she was transferred to the floor without recurrence of bleeding she completed days of iv ceftriaxone for sbp prophylaxis she was discharged home on nadolol and pantoprazole carafate cirrhosis c b ascites encephalopathy hcc patient was restarted on lactulose after she was extubated she had no e o acute liver decompensation during admission her aldactone and lasix were initially held in the icu in setting of acute gi bleed and then restarted on discharge elevate lactate pt had elevated lactate on admission likely representing poor perfusion of tissues in setting of poor clearance by liver in addition to hypovolemia gib pt was resuscitated with prbcs and her lactate trended down and was wnl on discharge arf creatinine on admission up from baseline likely pre renal hypovolemia in setting of gib as above creatinine normalized after volume resuscitation with rbcs hyperkalemia pt with k of in ed no ekg changes likely as well as k sparing diuretic resolved with kayexalate potassium remained stable for remainder of hospitalization chronic issues altered mental status at baseline patient is lethargic has had extensive outpatient workup for her mental status per her hcp her mental status was at her baseline she will follow up with her pcp for ongoing evaluation htn pt s home metoprolol was discontinued due to starting nadolol for variceal bleed she was continued on amlodipine depression continued fluoxetine hypothyroidism continued levothyroxine transitional issues medication changes start nadolol mg daily start pantoprazole mg daily take for days start carafate g four times daily take for weeks stop metoprolol succinate please follow up with your primary care physician about whether to restart this medication in the future stop omeprazole while taking pantoprazole you can resume your home omeprazole after you finish your course of pantoprazole follow up she is scheduled to follow up with dr in clinic and for repeat liver mri on the day after discharge she is scheduled to f u with her pcp days after discharge code status full medications on admission fluoxetine mg daily levothyroxine mcg daily omeprazole mg daily risperidone mg qhs prn insomnia lorazepam mg qhs prn insomnia metoprolol succinate mg daily amlodipine mg daily lactulose ml qid multivitamin tablet daily aldactone mg daily lasix mg daily ensure can tid with meals discharge medications fluoxetine mg capsule sig one capsule po daily daily sucralfate gram tablet sig one tablet po qid times a day for weeks disp tablet s refills pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po once a day for months disp tablet delayed release e c s refills nadolol mg tablet sig one tablet po daily daily disp tablet s refills furosemide mg tablet sig one tablet po daily daily amlodipine mg tablet sig one tablet po once a day lactulose gram ml syrup sig thirty ml po tid times a day for bowel movements daily levoxyl mcg tablet sig one tablet po once a day spironolactone mg tablet sig one tablet po once a day risperidone mg tablet sig one tablet po at bedtime as needed for insomnia lorazepam mg tablet sig tablet po at bedtime as needed for insomnia discharge disposition home discharge diagnosis acute blood loss due to upper gi bleed esophageal varices hepatocellular carcinoma hepatitis c cirrhosis 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 because you were vomiting blood you had a procedure called an endoscopy which showed that the blood was coming from bleeding vessels in your esophagus we banded these vessels to stop the bleeding and started you on new medications to prevent the bleeding from happening in the future please note the following changes to your medications start nadolol mg daily start pantoprazole mg daily take for days start carafate g four times daily take for weeks stop metoprolol succinate please follow up with your primary care physician about whether to restart this medication in the future stop omeprazole while taking pantoprazole you can resume your home omeprazole after you finish your course of pantoprazole we made no other changes to your medications while you were in the hospital please continue taking the rest of your medications as prescribed by your outpatient providers you are scheduled to follow up with dr in clinic and have a repeat mri of your liver tomorrow please see below for your appointment times it has been a pleasure taking care of you at and we wish you a speedy recovery followup instructions department liver center when thursday at am with md building lm campus west best parking garage department radiology when thursday at pm with radiology mri building campus east best parking garage department hmfp when friday at am with md building ra complex campus east best parking main garage department when friday at am with c m d building sc clinical ctr campus east best parking garage md,"{
""Diagnoses"": [""Hepatitis C"", ""Cirrhosis"", ""Ascites"", ""Encephalopathy"", ""HCC""],
""Medications"": [""Aspirin"", ""Diuretics""]
}"
10883,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint exertional chest discomfort major surgical or invasive procedure cabg x lima lad svg diag om om pda on history of present illness yo m with exertional symptoms ett referred for cardiac cath which showed vd then referred for surgiocal evaluation past medical history arthritis htn spondylosis hoh anemia l tkr appy bilat cataract surgery cranial surgery post mva as a child social history retired office worker quit cigar smoking years ago scotch day family history nc physical exam nad hr rr bp nad lungs ctab rrr no m r g abd benign well healed appy scar r groin s p cath c d i no carotid bruits pertinent results am 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 am blood glucose urean creat na k cl hco angap brief hospital course he was taken to the operating room on where he underwent a cabg x he was transferred to the sicu in critical but stable condition he was extubated and weaned from his vasoactive drips later that day he was transferred to the floor on pod he did well postoperatively he had no problems with arrhythmias and he was easily diuresed he was discharged home on pod medications on admission motrin carisprodol lisinopril atenolol apap lipitor mvi isosorbide mononitrate discharge medications metoprolol tartrate mg tablet sig one tablet po bid 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 capsule sustained release sig two capsule sustained release po q h every hours for days disp capsule sustained release s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills ranitidine hcl mg tablet sig one tablet po bid times 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 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 as needed for pain disp tablet s refills atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills soma mg tablet sig one tablet po once a day disp tablet s refills discharge disposition home with service facility vna discharge diagnosis cad htn chronic low back pain discharge condition good discharge instructions may shower no bathing or swimming for month no lifting for weeks no creams lotions or powders to any incisions followup instructions with dr in weeks with dr in weeks with dr in weeks completed by,{}
72197,admission date discharge date date of birth sex f service medicine allergies penicillins atenolol attending chief complaint stemi major surgical or invasive procedure cardiac catheterization with bare metal stent to proximal and distal rigth coronary artery history of present illness the patient is a y o f with a pmh of cad s p nstemi l subclavian steal hypertension admitted with inferior stemi the patient presented to the ed with complaints of diarrhea of sudden onset x hours denied chest pain she denies nausea vomiting no fever chills or shortness of breath in the ed initial vitals were t hr bp rr o labs demonstrated a ck of mb and trop abg she was given atropine mg dopamine gtt and levophed gtts were started asa mg was given ecg demonstrated inferolateral st elevations right sided leads showed elevations in v r she was taken emergently to the cardiac cath lab on arrival to cath lab the patient s respiratory status worsened and she required emergent intbuation in the cath lab r and l femoral access was obtained for possible iabp placement cardiac cath demonstrated a proximal rca occlusion she had bms stents placed to proximal and mid distal rca with good subsequent flow she received l ivf during cath and was weaned off of pressors hr stable and no temp wire was required on arrival to the ccu the patient remains intubated and sedated review of systems unable to be obtained past medical history nstemi medically managed left subclavian steal therefore has discrepancy in bp in r versus l arm bp should be measured in r arm hypertension tobacco habit half pack per day times years hyperlipidemia primarily ldl elevation right carotid bruit peripheral vascular disease status post stenting to right iliac artery thyroid cancer papillary carcinoma removed with total thyroidectomy in of note had two hyperfunctioning nodules and one cold nodule on synthroid left rotator cuff tendonitis status post left hand crush injury in distant past social history tobacco history currently smokes ppd for years etoh none illicit drugs none patient lives alone in functional with adls and iadls drives no help needed for ambulation family history cva in brother at years of age chf in mother at years of age physical exam vs t hr bp ac x peep fio general intubated and sedated heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthalesma 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 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 r groin site with oozing and hematoma skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid femoral dp dopplerable pt dopplerable left carotid femoral dp dopplerable pt not dopplerable pertinent results am wbc rbc hgb hct mcv mch mchc rdw am neuts lymphs monos eos basos am glucose urea n creat sodium potassium chloride total co anion gap am calcium phosphate magnesium am ck mb mb indx am ctropnt am ck cpk am lactate comments coronary angiography in this right dominant system demonstrated single vessel disease the lmca had mild luminal irregularities the lad had a proximal lesion with otherwise mild luminal irregularities the lcx had minimal luminal irregularities the rca was occluded proximally with faint left to right collaterals resting hemodynamics limited to central aortic pressure revealed cardiogenic shock with sbp s and hr s at the beginning of the case which markedly improved following rca reperfusion with sbp s and hr s at the end of the case successful primary pci of the proximally occluded rca in setting of cardiogenic shock and maximal pressor support following intubation mechanical ventilation performed in cath lab sucecssful stenting of the proximal rca with two overlapping minivision bms x mm distally and x mm proximally covering the ostium with excellent results see ptca comments successful stenting of the distal rca subtotal occlusion with a x mm minivision bms with excellent result see ptca comments successful poba of the distal rca just adjacent to the edges of the mm stent with a mm balloon with excellent results see ptca comments deployment of an entrapped x mm minivision stent inside the proximal rca stents at high pressure followed by postdilatation with a balloon to atm final angiography showed excellent results significantly improved hemodynamics following rca reperfusion as evidenced by the weaning off of vasopressors final diagnosis single vessel coronary artery disease cardiogenic shock secondary to inferoposterior and rv acute mi requiring maximal pharmacologic hemodynamic support severe acidosis and hypercapnia requiring emergent endotracheal intubation and mechanical ventilation successful ptca and stenting of the proximal rca with two overlapping x and x mm bms all postdilated to successful stenting of the distal rca with x mm minivision bms successful poba of the distal rca with mm balloon deployment of an entraped x mm minivision bms inside the stented proximal rca postdilated to at atm successful closure of the lcfa with perclose device unsuccessful closure of the rcfa with perclose device requiring application of manual pressure with successul hemostasis asa mg daily for a month then mg daily thereafter plavix once ng tube placed in ccu mg load then mg daily for at least year continue integrillin unless bleeding develops brief hospital course ms is a y o f with cad s p nstemi left subclavian steal hypertension who was admitted with inferior stemi inferior stemi patient was admitted with inferior stemi with bradycardia and hypotension in the ed initially requiring norepinephrine and dopamine ecg showed st elevations in leads iii ii and v r suggesting rv involvement initial ck was with trop o she was not given any nitrates in setting of inferior mi hypotension and bradycardia were consistent with acute mi with rv involvement she was sent for cardiac catheterization where bms was placed in proximal and distal rca she improved hemodynamically following pci without evidence of continued bradycardia pressors were also weaned off quickly after pci she was started on integrilin initially she was continued on home dose aspirin mg and started on clopidogrel mg for days then mg daily ck peaked at and trop peaked at she was given atorvastatin mg daily during hospitalization then switched back to home simvastatin mg upon discharge home pindolol was held initially in the setting of bradycardia but was restarted the day after admission when bradycardia resolved she was also restarted on her home dose of lisinopril for cardioprotection and hypertension tte showed moderate pulmonary artery systolic hypertension symmetric left ventricular hypertrophy and mild dilation of right ventricular cavity with focal basal free wall hypokinesis hypertension patient was hypotensive on presentation in setting of inferior stemi but hypotension quickly resolved post pci she was hypertensive for the rest of hospitalization so her home blood pressure medications were restarted slowly and titrated upwards she was discharged on her home medications of hydralazine lisinopril and pindolol with the pindolol dose increased to mg tid mechanical ventilation patient was intubated given hemodynamic instability on presentation and need for catheterization after pci she was hemodynamically stable and pressors were weaned off patient was extubated without complications she was somewhat agitated for several hours after extubation diarrhea patient reported diarrhea at home prior to hospitalization though she did not have any diarrhea during hospitalization diarrhea was of unclear etiology possibly viral gastroenteritis stools were guaiac negative hyperlipidemia patient was treated with atorvastatin mg during hospitalization but switched back to home simvastatin mg daily on discharge lipids were checked and calculated ldl was mildly elevated at medications on admission aspirin mg tablet daily hydralazine mg tablet po tid levothyroxine mcg daily lisinopril mg tablet daily pindolol mg tablet simvastatin mg tablet daily discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily clopidogrel mg tablet sig two tablet po bid times a day for days disp tablet s refills clopidogrel mg tablet sig one tablet po once a day disp tablet s refills simvastatin mg tablet sig one tablet po once a day disp tablet s refills levothyroxine mcg tablet sig one tablet po once a day pindolol mg tablet sig one tablet po twice a day disp tablet s refills lisinopril mg tablet sig one tablet po daily daily disp tablet s refills hydralazine mg tablet sig two tablet po tid times a day fluticasone mcg actuation spray suspension sig one spray nasal times a day disp bottle refills pilocarpine hcl mg tablet sig one tablet po three times a day discharge disposition home with service facility home health discharge diagnosis inferior st elevation myocardial infarction hypertention tobacco abuse paroxysmal atrial fibrillation phlebitis right wrist s p intravenous line 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 needed to have a breathing tube to help you through the acute event you needed bare metal stents to be placed in your right coronary artery your right and left groin have bruises after this procedure but there is no evidence of new bleeding or infection if you notice increasing and painful lumps in your right or left groin please call dr it is very important that you take all of your medicines every day it is epsicially important that you take your plavix and aspirin every day and don t miss otherwise the stents could clot off and you could have another heart attack medication changes take plavix mg twice daily for days followed by plavix mg daily to prevent the stents from clotting off take aspirin every day to prevent the stents from clotting off increase the pindolol to mg twice daily stop taking capropril decrease lisinopril mg to once daily please keep your right arm elevated with warm packs every hour the phlebitis is improving today but please call dr if you notice increasing redness pain or swelling followup instructions primary care and cardiology p phone date time friday at am [NEW_RECORD] admission date discharge date date of birth sex f service surgery allergies penicillins atenolol attending chief complaint chest pressure with cm descending thoracic aortic aneurysm major surgical or invasive procedure emergent stent graft repair of descending thoracic aortic aneurysm with tag endoprostheses the endoprostheses are the following a catalog batch code b reference batch code c reference lot d catalog batch code left common iliac artery stenting with two cm x mm viabahn stents repair of left common femoral artery iatrogenic injury with a mm dacron tube graft with patch angioplasty of the superficial femoral artery thoracic and abdominal aortography peg placement history of present illness mrs is a year old female recently admitted with chest pressure and hypertensive urgency found to have cm taaa has been present since at least but now larger who presents with the same symptoms she had a cta done on showing an aortic aneurysm all the way from the aortic arch to the iliac bifurcation her chest pressure started this morning when she bent forward and has continued unabated for hours she describes the location as substernal with radiation to her back and intense in nature the pressure is worse than on last admission and the back radiation is new she has no abdominal pain nausea vomiting diarrhea or shortness of breath her sbp is in the right arm as on initial examination of the patient she was also hypertensive when picked up by ems in the interim her pressure has intermittently dropped after nitroglycerin administration she has known left subclavian stenosis and sbp in the left arm is typically around consequently she has a pmh of stemi s p stenting of rca in during the last admission cardiac enzymes were cycled and were normal throughout past medical history nstemi medically managed left subclavian steal therefore has discrepancy in bp in r versus l arm bp should be measured in r arm hypertension tobacco habit half pack per day times years hyperlipidemia primarily ldl elevation right carotid bruit peripheral disease status post stenting to right iliac artery thyroid cancer papillary carcinoma removed with total thyroidectomy in of note had two hyperfunctioning nodules and one cold nodule on synthroid left rotator cuff tendonitis status post left hand crush injury in distant past social history tobacco history currently smokes ppd for years alcohol none illicit drugs none patient lives alone in functional with adls and iadls drives with no help needed for ambulation family history cva in brother at years of age chf in mother at years of age no history of collagen fibrillin disorders no history of aneurysms physical exam on presentation vs temp hr bp ra cv regular rate rhythm no appreciable murmurs rubs or gallops pulm clear to auscultation bilaterally abd soft bs nondistended nontender extrem no lower extremity edema bilaterally moves all extremities purposefully pulses fem pt dp r p p p p l p p p p upon discharge vs tcurrent hr bp rr o sat l nc cv regular rate rhythm no murmurs rubs gallops pulm clear to auscultation bilaterally abd soft bs non distended nontender extrem left groin mildly indurated stable no fluctuance no erythema no drainage palpable femoral pulses dopplerable popliteal pulses palpable dorsalis pedis pulses dopplerable pt pulses bilaterally paraplegic from t unable to move lower extremities mute plantar reflexes full rom strength of left upper extremity passive rom of right upper extremity please refer to neurologic exam in discharge summary for further details neuro alert oriented to person place approximate sense of time appropriate responses less withdrawn more interactive cn ii xii grossly intact pertinent results cxr no acute intrathoracic process with unchanged cm thoracic aortic aneurysm subsequent cta demonstrates intramural aortic hematoma which is not visible by plain radiography ct chest abd pelvis with without contrast type b intramural hematoma of the thoracic aorta extending from the aorta just distal to the left subclavian origin to the mid descending thoracic aorta no significant interval change in the size of the fusiform descending thoracic aortic aneurysm maximally measuring cm with internal intramural thrombus within the aneurysm stable appearance of the fusiform infrarenal abdominal aortic aneurysm maximally measuring cm stable chronic occlusion of the left subclavian artery origin with distal reconstitution mr lumbar spine woc elevated signal linear in pattern within the mid thoracic spinal cord at approximately the t level cord is not swollen however recent aortic surgery raises the suspicion for developing infarction there does not appear to be any spinal cord compression within the lumbar region there is generalized moderate desiccation of the discs with mild bulging disc noted at l moderate left and milder right foraminal stenosis lower extremity non inasive studies no dvt bilaterally ct head woc im no evidence for acute intracranial hemorrhage large mass mass effect edema or hydrocephalus prominent extra axial csf spaces sulci and ventricles suggest age related involutional changes white matter hypodensities are likely secondary to small vessel ischemic disease mra head neck with without contrast limited by motion diminished flow signal in the left ica is seen in the cavernous region and in the petrous region but the flow signal in the mca is poorly visualized due to motion flow signal is seen in the sylvian branches of both middle cerebral arteries the right cca visualized right subclavian artery and the right ica demonstrate no evidence of high grade stenosis or occlusion right vertebral artery is tortuous but demonstrates normal flow without stenosis cta head neck head ct shows no hemorrhage ct angiography of the neck demonstrates slight narrowing of the origin of the left cca but no evidence of diminished flow seen distal to the origin approximately stenosis in the left internal carotid bifurcation region is identified with calcification the left subclavian artery is occluded near the origin and is reconstituted through collateral flow from the left vertebral artery ct chest abdomen pelvis with contrast satisfactory appearance of the thoracic aortic stent graft small left pleural effusion noted with compressive atelectasis in the left lower lobe post surgical changes seen in the left inguinal region with a seroma overlying the right common femoral artery access point bilateral lower extremity non invasives no evidence of deep venous thrombosis in either extremity peg tube study appropriate positioning of peg with placement confirmed by contrast no evidence of contrast extravasation ct torso with contrast stable appearance of thoracic aortic stent graft small pleural effusions left greater than right stable cardiomegaly with pericardial effusion status post gastrostomy placement with expected trace free air severe atherosclerotic disease with multivessel narrowing at the origin and high grade stenosis of the left renal artery origin enlarged left inguinal fluid collection with no rim enhancing lesion ecg sinus rhythm bpm left ventricular hypertrophy with secondary repolarization abnormalities compared to the previous tracing findings are similar brief hospital course the patient was admitted to the surgery service on for urgent repair of a descending thoracic aortic aneurysm with intramural thrombus and pending rupture associated with chest pressure and hypertensive urgency she was properly consented for and was informed of the risks and benefits of the procedure including death stroke paralysis and significant bleeding from iliac injury she subsequently underwent an endovascular thoracic aortic repair with stent placements in her left common iliac artery and left external iliac artery and repair of a left common femoral artery iatrogenic injury with a mm dacron tube graft with patch angioplasty of the superficial femoral artery the reader is referred to the operative notes in omr for further details of the procedure by system neurologic a lumbar drain was placed pre operatively due to the large portion of aorta that needed to be covered as well as for protective measure for paralysis prevention at the immediate time the patient s pt inr had not returned at the time but after discussion with the cardiothoracic surgery and anesthesia teams the small risk of epidural hematoma was less than the risk of not having a lumbar drain it was decided at the time to proceed with lumbar drain in the immediate post operative period the patient received iv fentanyl and propofol for sedation and relief of pain while in the cardiovascular icu she was weaned from cpap within the next hours with appropriate concomitant weaning of propofol and fentanyl it was at this point on pod around am on when the patient was found to have a change in her motor function with inability to move her lower extremities with preserved passive motion the patient was noted to have volitional movements of all four extremities until pm the prior evening with no nursing neurologic assessments documented until am when the team was notified of the change in status the initial impression at the time was that she had paralysis at the thoracic level secondary to spinal cord ischemia the neurology service was consulted immediately and an mri of the spine was performed which showed mid thoracic spinal cord ischemia at the t t level initial neurology recommendations were implemented namely to achieve map maintain the lumbar drain at mmhg without the need for steroid therapy prior to this change in neurologic exam her csf pressures had been low with minimal non bloody drainage with her initial map goal for her csf pressures and output remained unremarkable until the lumbar drain was removed on pod her cks were trended which initially were but peaked to the s on pod which were thought to be related to low perfusion during her prolonged operative time her creatinine at the time was within normal limits at and there was no evidence of acidosis at that time her neurologic exam as detailed by the neurology service confirmed absent active movement and sensation of the lower extremities with absent quadriceps patellar and achilles tendon reflexes bilaterally her pulse exam was noted for preserved dopplerable pt signals and palpable femoral and dp pulses bilaterally during the remainder of her stay in the cvicu through or pod the patient was alert and oriented to person place and time was able to follow simple commands and responded appropriately to verbal tactile and noxious stimuli she was able to move both her upper extremities but not her lower extremities on pod while in the cvicu she was persistently hypertensive despite her current regimen of oral anti hypertensives including clonidine hydralazine metoprolol and lisinopril she remained consistently in the s s and was kept in the cvicu for blood pressure control nicardipine drip was started at this time which was weaned off soon thereafter when stable the patient was transferred to the vicu and overnight on pod was noted to have right upper extremity weakness an mra of the head and neck and cta head were performed which demonstrated a likely embolic stroke in the left frontal lobe as well as in the subcortical region around the periatrial area there was also note of a stenosis in the left internal carotid bifurcation region identified with calcification given her presentation and radiologic findings the source was concluded to be likely of embolic source and heparin drip was immediately started and blood pressure managed with both iv and oral anti hypertensives she remained in sinus rhythm with no sustained arrythmias she was unable to squeeze her right hand and actively move her right arm after this event on pod with no deterioration in her status for the next several days she remained on heparin drip with therapeutic goal acheived which was discontinued on pod and received a plavix load for long term anti coagulation in this interval the patient was intermittently cooperative with inconsistent ability to obey commands although it was difficult to ascertain whether this was secondary to depression and apathy or from a change in neurologic status a repeat ct of the head on pod demonstrated a likely evolving cva in the previously left frontal area the patient was continued on anti coagulation aspirin and plavix for at least months as recommended by the neurology service with no aggressive changes at that time psychiatry was also consulted at this time please refer to separate section below her neurologic status otherwise between pod and that prior to discharge improved slightly with the ability to obey commands respond to both verbal tactile and painful stimuli her attention improved although she remained largely withdrawn likely secondary to depression she remained unable to move her lower extremities as before with noted preservation of her left upper extremity movements and strength of note when agitated or angry she would actively flex her arm with concern for spasms jerky movements neurology was re consulted on pod with little suspicion for encephalitis or seizure activity it was thought that the patient would become agitated secondary to frustration and would flex her arm accordingly this remained her baseline the few days prior to discharge with no changes in her neurologic status she remained on frequent neurologic status checks and assessment of pain level her pain in the initial post operative period while in the icu was transitioned to morphine iv and acetaminophen iv with appropriate addition of oral pain medications after passing a speech and swallow evaluation this regimen included tramadol and lidocaine patch with good effect and adequate pain control the chronic pain service was consulted in the early post operative period with recommendations to add gabapentin for neuropathic pain which was added to her regimen with good effect she noted mostly back pain and abdominal pain consistent with her spinal cord infarct the chronic pain service was re consulted for this reason and it was concluded that she may have been experiencing neuropathic pain secondary to her cord infarct prior to discharge her pain which was mainly in her back was well controlled with oral pain medications including oxycodone gabapentin and tylenol as well as lidocaine patch on discharge the patient grimaced to pain in both upper extremities but not in the lower extremities bilaterally tone her right upper extremity and bilateral lower extremities remained flaccid strength in the left upper extremity was at least reflexes in the right upper extremity were and in the left upper extremities reflexes were absent in the quadriceps achilles bilaterally plantar response was mute bilaterally cardiovascular upon presentation in the ed the patient was noted to be hypertensive in the s which was moderately controlled with oral and iv anti hypertensives intra operatively the patient was noted to have sbp with t wave inversions ck and troponins were cycled with troponins or and ck mb peaking at on pod then returning to baseline her aspirin and beta blocker were continued for cardioprotection as well given her history of cad and rv stemi she was monitored continuously on telemetry and remained within sinus rhythm with good rate control largely in the s in the cvicu with no further evidence of myocardial ischemia as noted earlier the patient was found to be hypertensive post operatively wth systolic blood pressures ranging between map goals were kept at mmhg with a regimen of nicardipine drip hydralazine and metoprolol in the immediate post operative period her blood pressures were placed under strict parameters with sbp to remain while in the cvicu her pressures were managed with both iv metoprolol hydralazine and nicardipine drip the latter of which was titrated appropriately and weaned off by the end of pod after transfer to the floor her blood pressure was initially managed with metoprolol xl daily among prn of hydralazine however she was noted to be borderline bradycardic in the s with beta blockade changed to mg po tid her blood pressures were maintained with clonidine patch hydralazine po and iv prn lisinopril and hctz she was monitored on telemetry and remained in sinus rhythm with rate consistently in the s blood pressure was stable in the range systolic on the stated regimen prior to discharge her blood pressure goal remained within and she did not require much of her hydralazine iv prn prior to discharge as she remained within this range for specific discharge medication please refer to medication section of the discharge summary pulmonary the patient underwent her procedure on the evening of and was extubated after being transitioned to cpap on pod which she tolerated well she achieved excellent o sats on face mask the day of extubation prior to this a cxr for drop in hematocrit had been performed on which showed a small left pleural effusion and atelectasis which remained largely unchanged in subsequent cxrs on pod in the context of placing a dobhoff tube for nutritional supplementation the patient expectorated green yellow sputum which was found to grow klebsiella pneumoniae a cxr demonstrated a possible lll consolidation or effusion the patient was then started on a two week course of iv vancomycin and cefipime with no leukocytosis on daily cbc or spike in temperature until with a temperature spike to f cxr was performed which was unremarkable for and blood cultures sputum sample and u a were sent her antibiotic coverage was broadened to vancomycin ciprofloxacin metronidazole this was discontinued after a few days secondary to fever spike to f with subsequent negative blood and urine cultures and unchanged ct findings id was consulted at this time with the suspicion that his fevers with their cyclical nature were likely drug fever related please see the id section for further details gi after successful extubation on pod the patient underwent a speech and swallow evaluation with advancement of diet to nectar thick liquids and pureed solids her intake was initially limited by pain but improved somewhat over the course of her stay in the cvicu after transfer to the floor the patient continued to be intermittently despondent and withdrawn out of concern for her nutritional status calorie counts were started on pod and a tube feed was placed on pod with feeds started and nutrition recommendations in place her tube feeds were set for a goal cc hr daily with kcal grams of protein which would provide of the patient s estimated needs this was in conjunction with the patient s estimated oral intake which ranged from calories per day the patient was encouraged to take her supplemental shakes with every meal however the dobhoff soon became clogged despite multiple attempts after much discussion with the patient family and interventional radiology peg placement was attempted on pod by ir without success as the patient refused consent at the time for any form of gastric placement in the interim a picc line was placed on pod for tpn supplementation which was coordinated by nutrition with appropriate supplements and calories tailored for the patient s needs the tpn was kept continuously during the next few days until after repeated discussions about the declining nutritional status of the patient the clear decline in skin integrity of the patient s pressure ulcers it was then decided by the family and patient and team to proceed with a peg tube placement on pod by the thoracic surgery service the placement was successfully performed under general anesthesia with no issues the peg tube was kept to gravity overnight then was used for medications the next day which the patient tolerated tube feeds were started on pod which again the patient tolerated with no complaints of nausea emesis or reflux the patient was kept on a bowel regimen consisting of miralax senna colace and milk of magnesia which was titrated appropriately for regular bowel movements prior to discharge the patient s tube feeds were at cc hr with a goal of cc hr tpn had been discontinued and the patient was encouraged to take in oral intake calorie counts were continued as well which upon discharge averaged about calories per day nutrition followed closely with appropriate changes to her tube feeds given her caloric intake genitourinary given the level of the patient s spinal cord infarct long term foley management was discussed with regular changing of the foley catheter her renal function remained robust with creatinine largely below peaking only twice at upon discharge her creatinine was between perioperatively the patient received adequate fluid resuscitation with good blood pressures and brisk urine output she continued to have good urine output throughout her admission and prior to discharge she also underwent routine u a checks for uti the most recent on which was negative she will require long term foley management with routine replacement every weeks and routine u a checks heme the patient initially presented with a hematocrit of in the emergency department received adequate resuscitation with lr intra operatively and received no blood products intra operatively her post operative hematocrit in the cvicu was frequent hematocrit checks were employed which were changed to hematocrit checks her hematocrit did drift to on pod but remained stable at this point her hematocrit remained within the high s to mid s during her admission with no requirement for blood transfusion her platelets were originally at found to be on pod a hit panel was sent around this time which was ultimately negative subcutaneous heparin was intially held until the assay returned negative and was continued throughout her stay for dvt prophylaxis for her post operative embolic stroke and per neurology recommendations the patient was continued on plavix and aspirin for at least a month course id the patient was given standard iv vancomycin and cefazolin peri operatively with no initial signs of infection she remained largely afebrile with no overt leukocytosis on daily labwork as mentioned earlier in the pulmonary section on pod the patient produced green yellow sputum which grew klebsiella that was sensitive to cefipime the culture also grew gram positive rods gram positive cocci which did not speciate but was covered with a day course of iv vancomycin and cefipime she tolerated this well with no signs of infection and her course was completed prior to discharge as noted cxr demonstrated a lll consolidation pleural effusion with later on ct chest abd pelvis was likely to be post surgical changes which was stable and not consistent with abscess or infection but more likely blood or serous fluid as noted earlier the patient spiked a fever to f on with subsequent urine and blood cultures her iv antibiotics were subsequently discontinued and bactrim was started for a possible bacterial uti on repeat u a she remained on a three day course of bactrim with no fever spikes her tmax reaching and upon discharge was afebrile at f her foley was changed weekly while on the floor the patient maintained excellent o sats on room air with no additional oxygen requirement endo the patient underwent routine fingersticks while on tpn and tube feeds and placed on riss for goal her fingersticks were generally within normal range throughout her admission with very little requirement for insulin s her fsbg values were within the s prior to discharge psych a psychiatry consult was placed on in light of the patient s intermittent cooperation with exam and poor oral intake at this time pharmacologic therapy was deferred until the patient was able to engage in discussion conclusions and recommendations included that the patient was likely experiencing an adjustment disorder with disturbance of emotion with the decreased capacity at the time to refuse medically necessary treatment psychiatry was again re consulted later during her admission as her oral intake plateaued despite encouragement from family and staff with the recommendations at the time to use haldol prn for any agitation and to add remeron which would help both her appetite and sleep the patient appeared less active while on this regimen thus her remeron was changed to celexa within the next few days ritalin was suggested as an appetite stimulant which was also added soon thereafter with some improvement in both mood and appetite nutrition the patient was kept npo status until a speech and swallow evaluation on pod which she passed recommendations were implemented for nectar thick liquids pureed solids which the patient tolerated this was under supervision while sitting upright to avoid aspiration as described in the gi section the patient was later fed by tube feeds for a few days before placement of a picc for tpn while the family and team discussed peg placement which she received the week of discharge she was fed via tube feeds which were eventually cycled at night and encouraged to eat with appropriate supplemental shakes she tolerated both well prior to discharge skin care the patient was noted to have a sacral wound within the first few post operative days a formal wound consult was obtained on pod which noted a cm x cm area on the left sacrum with recommendations for wound care and frequent repositioning as well as supportive nutrition and hydration these were implemented aggressively with frequent wound checks when transferred to the floor the patient was again evaluated by wound care with noted increase over the next few weeks of her sacral decubitus pressure ulcer which according to wound care was unstageable in that the wound could not be staged since the depth could not be appreciated covered by eschar it was thought that the progression of her ulcer was mainly from poor nutritional status which had been addressed several times via several interventions first by oral intake then dobhoff feeds tpn via picc then ultimately a peg placement which was agreed on by all parties her nutritional labs demonstrated a poor state with albumin of although her iron studies were within relative normal range wound care recommendations included off loading pressure of the sacrum with special pillows roho cushion for hour twice daily and avoiding direct pressure on the area frequent repositioning q h was also implemented as well as mattress change to a air step bed her wound was dressed and cleansed daily and upon discharge was noted to be cm x cm with open area measuring cm x cm the base has mixed tissue black eschar red yellow tissue primarily on the right side on the right superior edge there was some serous drainage from the wound and it did not appear infected prophylaxis the patient was started on protonix for gi ulcer prophylaxis she also received subcutaneous heparin throughout her stay for dvt prophylaxis medications on admission lisinopril mg qd pindolol mg simvastatin mg mg qd levothyroxine mcg qd hydralazine mg tid 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 heparin porcine unit ml solution sig one ml injection tid times a day lisinopril mg tablet sig two tablet po daily daily hydralazine mg tablet sig two tablet po q h every hours hydralazine mg iv q h prn sbp pantoprazole mg iv q h senna mg tablet sig one tablet po hs at bedtime simvastatin mg tablet sig one tablet po daily daily levothyroxine mcg tablet sig two tablet po daily daily clonidine mg tablet sig one tablet po tid times a day bisacodyl mg suppository sig one suppository rectal daily daily lidocaine mg patch adhesive patch medicated sig one adhesive patch medicated topical daily daily hydrochlorothiazide mg capsule sig one capsule po daily daily docusate sodium mg ml liquid sig one po bid times a day gabapentin mg ml solution sig one po tid times a day citalopram mg tablet sig tablet po daily daily methylphenidate mg tablet sig one tablet po bid times a day metoprolol tartrate mg tablet sig one tablet po tid times a day acetaminophen mg tablet sig one tablet po every hours as needed for fever pain therapeutic multivitamin liquid sig five ml po daily daily miconazole nitrate powder sig one appl topical prn as needed as needed for yeast oxycodone mg ml solution sig one po q h every hours as needed for pain disp refills insulin regular human unit ml solution sig one injection asdir as directed aspirin mg tablet chewable sig one tablet chewable po daily daily glucagon human recombinant mg recon soln sig recon solns injection q min as needed for hypoglycemia protocol ipratropium albuterol mcg actuation aerosol sig puffs inhalation q h every hours as needed for dyspnea acetaminophen mg ml solution sig one po q h every hours as needed for pain simvastatin mg tablet sig one tablet po daily daily dextrose in water d w syringe sig one intravenous prn as needed as needed for hypoglycemia protocol sodium chloride flush ml iv q h prn line flush peripheral line flush with ml normal saline every hours and prn 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 loperamide mg ml liquid sig one po bid times a day discontinue if pt has constipation insulin sliding scale insulin sc per insulin flowsheet sliding scale fingerstick qachs insulin sc sliding scale breakfast lunch dinner bedtime regular regular regular regular glucose insulin dose insulin dose insulin dose insulin dose mg dl proceed with hypoglycemia protocol mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units instructons for npo patients evening prior to surgery procedure if on glargine or detemir give of usual dose if on nph give usual dose morning of surgery procedure if on glargine or detemir give of usual dose if on nph give of usual dose if on premix insulin e g take total number of am units ordered divide by and give that many units as nph if on sliding scale of short acting insulin administer according to hs schedule hold all oral antidiabetic medications and consider sliding scale coverage if appropriate give ivf with dextrose to prevent hypoglycemia discharge disposition extended care facility hospital for continuing medical care discharge diagnosis hypertensive urgency with cm thoracic aortic aneurysm with pending rupture hypertensive urgency with cm thoracic aortic aneurysm with pending rupture discharge condition mental status alert awake oriented to person place appropriate responses but withdrawn ambulatory status paraplegic t able to actively move upper extremity wheelchair bound discharge instructions you were admitted to the hospital with chest pressure and known thoracic aortic aneurysm which on imaging was found to be close to rupturing your blood pressure was found to be very high and was controlled with medications both oral and through iv a scan of your chest and abdomen showed a pending rupture of your aneurysm thus you were consented for and explained the risks and benefits of a thoracic endovascular aneurysm repair unfortunately your course was complicated by a spinal cord infarct at the thoracic level which although small is a known complication of the procedure additional imaging and consult from the neurology service confirmed this with recommendations to keep you on aspirin and plavix for at least three months you also developed a left sided stroke with resulting right upper extremity paralysis again confirmed with imaging and review by the neurology service it was concluded this was likely a plaque that had embolized from your arteries your left arm has preserved function and strength and you have been taught to use this arm to reposition yourself while in bed and to stabilize yourself you will continue your aspirin and plavix for the next months for stroke prevention and you should remain on heparin shots for the prevention of deep vein clots you worked with physical therapy regularly to get out of bed to chair at least twice a day during your initial weeks out of the intensive care unit when your sacral decubitus ulcer or pressure ulcer along your tailbone which was noted peri operatively was found to get increase in size despite wound care dressing changes and cushions you worked with pt regularly to sit up in bed for minutes and avoid prolonged pressure on your sacrum this was in accordance with wound care recommendations which were implemented aggressively with wound cleansing protective barriers and cushions as well as a more pressure sensitive mattress bed despite these efforts however your pressure ulcer continued to increase in size largely due to your nutritional status which was addressed on the second day after your surgery regarding nutrition specifically you maintained very poor intake on thin liquids and ground solid foods because of this a feeding tube was placed which was a temporary measure for tube feeds this was replaced by nutrition by iv or tpn total parenteral nutrition during the last week of your hospitalization then to a peg g or gastric tube by your consent and your family s consent you are currently receiving at least adequate nutrition for your body s needs but there is much more progress to be made for your nutritional health as it relates to your overall well being as well as energy and skin integrity your tube feeds will continue at your rehabilitation facility and specific instructions on timing and rate of feeds will be provided to your team regarding your subsequent stroke you should stay on your aspirin and plavix daily you should continue doing exercises with your right arm on a daily basis bladder function you will require a permanent foley to collect your urine from your bladder this should be changed every weeks in a sterile manner you should follow up with dr a urologist at regarding management of your foley please refer to the follow up section for details bowel function you had regular bowel movements upon discharge you should continue taking your laxative and stool softener unless you have loose bowel movements or diarrhea as mentioned earlier your tube feeds should continue and be cycled at night you are encouraged to eat soft solids and can drink thin liquids physical activity you should continue using your left arm to position yourself in bed and to reach for items you should sit up at the edge of bed with supervision for about minutes a day on a soft cushion you should be getting out of bed to chair once a day followup instructions please follow up with dr your foley placement on at pm you may call his office at provider lab phone date time provider md phone date time completed by,"{
""Diagnoses"": [""STEMI"", ""Hypertension"", ""Cardiac catheterization"", ""Bare metal stent"", ""Proximal and distal right coronary artery occlusion""],
""Medications"": [""Atenolol"", ""Penicillins"", ""Levophed"", ""Asa"", ""Dopamine"", ""Atropine""]
}"
77697,admission date discharge date date of birth sex m service medicine allergies ceftriaxone seroquel attending chief complaint altered mental status major surgical or invasive procedure right hemiarthroplasty evacuation of hematoma lateral hip placement of deep drain and superficial vacuum sponge history of present illness this is a year old male with a history of mechanical aortic valve replacement in carbomedics valve with an inr goal on warfarin of parkinson s disease with dementia who was admitted for altered mental status and failure to thrive at home on and was noted to have a right subcapital femoral neck fracture past medical history parkinson s disease with dementia mechanical aortic valve replacement on coumadin hypertension prostate ca s p resection with dr fistula seeing applying bacitracin social history uses a walker intermittently married lives with wife who is primary caretaker denies tobacco smoke drinks coffee times per day family history brother died of mi age physical exam vs ra general frail man in nad occasionally speaks waxing and orientation heent patient holds his neck in forward flexion chin almost to chest with effort can extend backward to neutral position can rotate to left and right without difficulty eomi sclerae anicteric oropharynx clear heart s s no murmurs auscultated audible click appreciated lungs cta bilaterally good air movement resp unlabored abdomen soft nt nd no masses or hsm no rebound guarding extremities warm well perfused radial and pedal pulses ecchymosis over r hip and r flank improving wound c d i lymph no cervical lad neuro drowsy not oriented knows name but thinks it is and he is in 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 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 pt ptt inr pt 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 brief hospital course assessment plan the patient is a year old man with a history of parkinson disease and falls who is presenting with changes in behavior at home and a newly discovered right hip fracture right subcapital femoral neck fracture pt was not in pain prior to operation fracture was found due to fall at home and inability to ambulate his inr was reversed with po vit k and he was bridged to heparin prior to procedure on he went to the or for a right hip hemiarthroplasty postoperatively he had difficulty with extubation and required a course in the ticu during his post op course coumadin was restarted and the pt developed a large hematoma in the wound bed requiring prbcs and surgical evacuation on cardiology was consulted at this point and recommended waiting days prior to restarting coumadin he was transferred to the medical service on after restarting coumadin he worked with pt and was able to stand with assistance although at his baseline he can ambulate on his own with a walker he will need aggressive pt and will need follow up with orthopedics altered mental status the patient s baseline is aox per the wife he was altered at home the day after his fall more confused not taking pos on admission to medicine originally he was aox although he was quite alert post operatively he was still aox but less alert and as his course continued he became progressively more alert but still remained aox infectious workup was negative throughout his course he remained afebrile blood cx ucx were negative and he never developed a leukocytosis or penia sputum culture during his ticu stay he had a sputum culture from an ett that was positive for mrsa it is unclear why this culture was performed as he had no signs of infection throughout his course cxr after this sample was obtained were negative for infiltration the pt never developed a fever or leukocytosis he was not treated in the ticu and by the time he arrived on the medical floor it was determined that he was d after the culture was obtained and that in all likelihood he was not infected he was not treated for this culture during this course aortic valve replacement anticoagulation started after his hematoma evacuation he was restarted on coumadin by the ortho team it is unclear why he did not resume his old dose however he was resumed on qd on the medical floor with inrs in the low s not consistently therapeutic above he will be discharged on mg qd and will need follow up inrs to ensure that he is within the therapeutic window of it is important that he be above for his valve and be less than as his risk of bleeding and hematoma development in the wound site would be quite high parkinson disease and dementia continuing home regimen of selegiline carbidopa levidopa exelon and clozapine on admission his citalopram was held due to his ams and citalopram s interaction with his selegiline it was felt prior to receiving general anesthesia that it would be best to d c his citalopram low dose unlikely to cause withdrawal it was not restarted afterwards and should be left to his pcp to restart at some point in the future hypotension on midodrine since last admission no episodes of hypotension during this admission anal fistula unclear etiology continued bacitracin ointment medications on admission selegiline hcl mg capsule sig one capsule po qam once a day in the morning selegiline hcl mg capsule sig one capsule po noon at noon atorvastatin mg tablet sig one tablet po daily daily citalopram mg tablet sig one tablet po daily daily warfarin mg tablet sig tablets po qtuthsa tu th sa warfarin mg tablet sig two tablet po qmowefrsu carbidopa levodopa mg tablet sig one tablet po q h every hours clozapine mg tablet sig tablets po daily daily exelon mg hour patch hr sig one transdermal daily bacitracin zinc unit g ointment sig one appl topical times a day midodrine mg tablet sig one tablet po tid times a day take during waking hours not before bed disp tablet s refills discharge medications selegiline hcl mg capsule sig one capsule po bid times a day once in am and once at noon atorvastatin mg tablet sig one tablet po daily daily bacitracin zinc unit g ointment sig one appl topical times a day acetaminophen mg tablet sig one tablet po q h every hours as needed for pain docusate sodium mg ml liquid sig one po bid times a day exelon mg hour patch hr sig one transdermal q h every hours bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for constipation cholecalciferol vitamin d unit tablet sig two tablet po daily daily midodrine mg tablet sig one tablet po tid times a day carbidopa levodopa mg tablet sig one tablet po q h every hours clozapine mg tablet sig tablets po daily daily multivitamin tablet sig one cap po daily daily calcium carbonate mg calcium mg tablet sig one tablet po tid times a day sodium chloride flush ml iv q h prn line flush peripheral line flush with ml normal saline every hours and prn warfarin mg tablet sig one tablet po once a day discharge disposition extended care facility discharge diagnosis right femoral neck fracture right hip wound hematoma post operative blood loss anemia post operative fluid volume deficit 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 mr it was a pleasure taking care of you at you were admitted for confusion and found during your workup to have a right hip fracture which was repaired by orthopedic surgery on after the operation you had bleeding into the surgical site which required a return trip to the or for drainage afterwards you had a wound vacuum placed over the incision to help facilitate healing which was removed prior to discharge you also had continued confusion during your hospital course that was originally due to your hip fracture and afterwards was due to the anesthesia from your operations this is common please make the following changes to your medications please stop citalopram please stop your previous warfarin dosing please start warfarin mg everyday this will likely have to be changed in the future but your dose was lowered due to the risk for further bleeding into your operation wound care keep incision dry do not soak the incision in a bath or pool keep pin sites clean and dry sutures staples will be removed at your first post operative visit activity continue to be weight bearing on your left right arm leg you should not lift anything greater than pounds elevate right left arm leg to reduce swelling and pain other instructions resume your regular diet avoid nicotine products to optimize healing followup instructions name a specialty internal medicine address nd fl phone please discuss with the staff at the facility the need for a follow up appointment with your pcp when you are ready for discharge department orthopedics when wednesday at am with ortho xray scc building sc clinical ctr campus east best parking garage department orthopedics when wednesday at am with np building campus east best parking garage,"{
""Diagnoses"": [""altered mental status"", ""failure to thrive"", ""right subcapital femoral neck fracture""],
""Medications"": [""ceftriaxone"", ""seroquel""]
}"
22004,admission date discharge date service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint infected left av graft major surgical or invasive procedure excision of infected left av graft history of present illness yo male who presented with chills at dialysis he was noted to have a fever to at that time while at dialysis he was noted to have a ulceration over his left av graft site with bleeding he was transferred to for further evaluation and work up of a likely infected left av graft past medical history ckd stage iv disease baseline in patient has one kidney per the family lost to f u with nephrology after discharge from in for similar symptoms family and family refused dialysis at that time o hyperparathyroidism o anemia htn hyperlipidemia gout hernias s p repair social history greek only speaking lives with daughter in law and son in jp substance abuse history unknown family history his parents lived to their s no known cancer history physical exam vitals ra gen a ox mild distress heent nc at no lad no bruits cv tachycardic mrg chest ctab abd soft nt nd ext bleeding from ulceration over left av graft site with likely associated infection no edema 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 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 glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap am blood vanco am blood type art po pco ph caltco base xs pm blood type art po pco ph caltco base xs brief hospital course after presentation the patient was taken to the operating room where he underwent excision of his infected left av graft post operatively he was taken to the icu because of difficulty weaning off the vent after the procedure he was given vancomycin and levofloxacin as well at that time the following day he was extubated without difficulty his wound cultures grew coag staph aureus from the or the following day he was given hemodialysis through his right sided tunnelled line he was transferred to the floor following dialysis and his foley was discontinued he was able to void after this was removed wet to dry dressing changes were used over his infected wound site he was discharged home to continue dialysis with vancomycin for weeks and with vna for continued wet to dry dressing changes he was discharged in good stable condition medications on admission labetalol mg tablet sig one tablet po bid times a day pantoprazole mg po qd aspirin mg tablet sig one tablet po once a day discharge medications labetalol mg tablet sig one tablet po bid times a day pantoprazole mg po qd aspirin mg tablet sig one tablet po once a day vancomycin mg recon soln sig one gram intravenous with dialysis for weeks disp grams refills discharge disposition home with service facility homecare discharge diagnosis infected left av graft discharge condition good stable discharge instructions please continue on all of your medications that you were on prior to coming to the hospital and please take any new medications as prescribed please continue on your regular dialysis schedule at dialysis you will be given vancomycin g iv an antibiotic with your dialysis for your left arm wound for weeks after discharge a home nurse will help you with your wet to dry dressing changes on your left arm please follow up as scheduled if you develop fevers chills nausea vomitting diarrhea shortness of breath or chest pain please contact a physician if you have any questions or concerns regarding your dialysis access please call followup instructions provider md phone date time,"{
""Diagnoses"": [""infected left av graft"", ""likely infected left av graft""],
""Medications"": [""antibiotics"", ""pain medication""]
}"
53024,admission date discharge date date of birth sex m service cardiothoracic allergies penicillins heparin agents lovenox adhesive bandages attending chief complaint left fibrothorax major surgical or invasive procedure left thoracotomy and total pulmonaryn decortication including parietal pleurectomy flexible bronchoscopy with bronchoalveolar lavage history of present illness mr is a year old gentleman who has had bilateral recurrent pleural effusions he had a decortication on the right to address this which revealed significant fibrothorax and trapped lung he has had this same process affecting his left hemithorax and therefore we consented him for decortication to prevent recurrent effusion he also has significant dyspnea and it was unclear whether relief of his fibrothorax may improve his dyspnea though that was a possibility though not guaranteed past medical history bicuspid aortic valve status post st mechanical aortic valve replacement in atrial fibrillation diagnosed since currently on coumadin therapy social history significant for the absence of current tobacco use daily etoh drinks per day family history there is no family history of premature coronary artery disease or sudden death grandfather with mi and dm physical exam vs t hr afib sbp sats ra general walking in halls in no distress heent normocephalic mucus membranes moist neck supple no lymphadenopathy card irregular good click resp decreased breath sounds on right faint crackles lll gi benign extr warm no edema incision left thoracotomy site clean mild erythema around margin cool no discharge neuro non focal pertinent results wbc rbc hgb hct plt ct wbc rbc hgb hct plt ct wbc rbc hgb hct plt ct glucose urean creat na k cl hco glucose urean creat na k cl hco calcium phos mg culture pleural fluid no growth cxr there is a minimal millimetric apical medial pneumothorax signs of tension are not present small left basal pleural effusion that is unchanged also unchanged is the right sided pleural effusion the preexisting rib fracture is less well recognized than on the previous exam the size of the cardiac silhouette is unchanged persistent small bilateral pleural effusion mild left basal atelectasis and costal pleural thickening but no pneumothorax impression left lower lobe new retrocardiac opacity consistent with interval development of atelectasis that might be accompanied by pleural effusion interval improvement of subcutaneous air the left fifth posterior rib fracture is most likely post surgical am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood plt ct am blood pt inr pt brief hospital course mr was admitted on for left thoracotomy and total pulmonary decortication including parietal pleurectomy flexible bronchoscopy with bronchoalveolar lavage he was transferred to sicu intubated pulmonary he was extubated on he required aggressive pulmonary toilets and nebs and diuresis his oxygen saturation on lites high s which dropped to the high s with ambulation his oxygenation improved over the course of his hospitalization ra saturations ra he continued on his home cpap at night chest tubes french chest tubes basilar posterior anterior apical remained on suction until then placed to water seal the drainage was serousanguiounous they were removed on he was followed by serial chest films which revealed atelectasis sm effusion cardiac he was hypotensive immediately postop with a good response to neo and volume he was started on his home medications for atrial fibrillation heme we was restarted on his fondaparinox on for his mechanical valve he chest tube drainaged was monitored for bleeding which none occurred he was then restarted on his warfarin for a goal inr renal administered lasix with liter output renal function remained normal fen electrolytes were repleted as needed he tolerated a regular diet pain his epidural was managed by acute pain with good pain control which was removed on his pain was well controlled via dilaudid pca converted to po pain medication disposition plan home with vna he will follow up with dr as an outpatient medications on admission atenolol mg daily folic acid mg daily furosemide mg probenecid mg isosorbide mononitrate mg daily warfarin mg alternating discharge medications atenolol mg tablet sig one tablet po bid times a day folic acid mg tablet sig one tablet po daily daily cyanocobalamin mcg tablet sig tablet po daily daily docusate sodium mg capsule sig one capsule po bid times a day furosemide mg tablet sig one tablet po bid times a day probenecid mg tablet sig one tablet po bid times a day isosorbide mononitrate mg tablet sustained release hr sig tablet sustained release hr po daily daily warfarin mg tablet sig one tablet po as directed goal inr fondaparinux mg ml syringe sig one injection subcutaneous daily daily stop when inr hydromorphone mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills discharge disposition home with service facility hospice and vna discharge diagnosis left fibrothorax discharge condition stable discharge instructions call dr office if experience fever or chills increased shortness of breath cough or sputum production chest pain incision develops drainage chest tube site remove dressing saturday and cover with a bandaid until healed you may shower on saturday no tub bathing or swimming for weeks no driving while taking narcotics walk times a day for mins increased to goal of mins daily warfarin take fonadarinux until inr or greater warfarin continue home dose as previous followup instructions follow up with dr pm on the clinical center report to the radiology department for a chest x ray minutes before your appointment follow up with dr for further warfarin doses inr goal please have your blood drawn on monday and call dr for further warfarin doses completed by,"{
""Diagnoses"": [""cardiothoracic"", ""allergies"", ""penicillins"", ""heparin"", ""lovenox"", ""adhesive bandages""],
""Medications"": [""bronchoalveolar lavage"", ""coumadin"", ""atrial fibrillation""]
}"
47919,admission date discharge date date of birth sex f service medicine allergies penicillins gadolinium containing agents attending chief complaint benzodiazepine overdose major surgical or invasive procedure endotracheal intubation intubated extubated history of present illness ms is a year old woman with a history of depression anxiety who was brought to the ed after taking a handfull of xanax following an argument with her partner to him they were home at his apartment where she has also been staying for the last few months they had a few beers before dinner ate dinner around pm and were later preparing to go to bed and watch when they began to argue over something stupid the partner suggested she just go back to her own house where she has not stayed in several weeks at which point she became upset she told him she was taking several pills he thinks maybe xanax though it may have been more though he did not actually see exactly what she took she then went to the kitchen and took a knife and began trying to cut her wrists he went to her and was able to wrestle the knife away he held her wrists and maneuvered her to the sofa after several minutes of holding her still she began to weaken and then became somnolent at which time he called he states there was never any trauma or injury other than that self inflicted to her wrists she is followed by dr prescribing psychiatrist and therapist at for mental health issues as far as her partner is aware she has never been hospitalized for psychiatric reasons or had a prior suicide attempt she is seen approximately monthly as an outpatient partner is not aware of any recent physical complaints or symptoms though does note that since her bypass surgery she is only able to eat very small amounts at a time and occasionally has stomach problems including cramping vitals on arrival to the ed were not recorded on ed dash but per verbal signout she had normal bp hr and rr of she was found to be obtunded and was intubated for airway protection she received a dose of narcan after which she was mildly roused but then became somnolent again she received activated charcoal x dose through og tube she received td shot given wrist injury and lacerations to left wrist were sutured she received ivf on nd l ns she was started on propofol after intubation vitals prior to transfer to the micu were t bp hr rr on ventillator review of systems could not be obtained as patient intubated somnolent additional history obtained post extubation patient now reports that she was not intending to kill herself by taking the pills or using a knife on her wrists she says that her depression has generally been under fair to good control but on the night of admission she was very upset and felt like she just snapped she now reports two prior hospitalizations approximately yaers ago for depression past medical history history of dm prior to gastric bypass now off meds history of htn prior to gastric bypass now off meds allergic rhinitis asthma possible urticaria seeing allergist chronic lbp for which she has been getting injections gastric bypass in for obesity hysterectomy depression anxiety followed by dr psych and therapist at g p s with stable simple right adnexal cyst osteoarthritis small right insula meningioma and a pineal cyst social history has been with her partner for years and living in his apartment for the past several months though she maintains her own separate address tobacco ppd etoh occasional typically beers on weekends illlicts none family history non obtainable physical exam admission vs t bp hr rr on fio gen somnolent making some spontaneous movements but not rousable not following commands or opening eyes to voice heent pupils reactive neck supple pulm referred upper airway noises from ventillator no wheeze rales card rrr no m r g abd soft non distended no apparent tenderness on exam ext dp pulses fine linear excoriations on r wrist small laceration on l wrist sutured skin no urticaria noted neuro not able to follow commands at this time psych somnolent discharge gen alert oriented no acute distress heent sclera anicteric moist mucous membranes cv s s rrr no m r g pulm ctab no wheezes rhonchi or rales abd soft non tender non distended ext warm no edema neuro face symmetric moves all extremities psych denies suicidal ideation mood and affect appropriate pertinent results labs on admission urine am urine hours no urine i am urine hours random am urine bnzodzpn pos barbitrt neg opiates neg cocaine neg amphetmn pos mthdone neg am urine color yellow appear clear sp am urine blood neg nitrite neg protein tr glucose neg ketone neg bilirubin neg urobilngn ph leuk tr am urine rbc wbc bacteria none yeast none epi trans epi renal epi am urine hyaline am urine mucous occ blood am ph comments green top am glucose lactate na k cl tco am freeca am urea n creat am alt sgpt ast sgot alk phos tot bili am lipase am asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg am wbc rbc hgb hct mcv mch mchc rdw am pt ptt inr pt am plt count am fibrinoge ecg sinus rhythm j point elevation with early repolarization in precordial leads is probably a normal variant no previous tracing available for comparison cxr frontal chest radiograph a transesophageal catheter extends to at least the level of the stomach possibly post pyloric an et tube terminates cm above the carina the lungs are underinflated the heart size is normal the hilar and mediastinal contours are within normal limits the central pulmonary vessels appear prominent with no evidence of overt edema there is no pneumothorax or pleural effusion impression et tube terminating cm above the carina recommend pull back cm transesophageal catheter extending to at least the level of the stomach possibly post pyloric cxr findings as compared to the previous radiograph there is no relevant change the tip of the endotracheal tube is still abutting the carina and should be pulled back by approximately cm the course of the nasogastric tube is unchanged and in correct status low lung volumes with developing left retrocardiac atelectasis no larger pleural effusions no focal parenchymal opacity suggesting pneumonia or aspiration brief hospital course hospital summary w with a history of depression anxiety who took a handful of xanax after argument with her partner and attempted to slit wrists with a kitchen knife intubated on arrival to ed for airway protection but successfully extubated the next day seen by psychiatry for evaluation of worsening depression who recommended transfer to an inpatient psychiatric facility once medically stable patient is now medically stable for transfer active issues benzodiazepine overdose urine toxicology screen was positive for benzodiazepines and amphetamines serum toxicology screen was negative she received naloxone in the ed in addition to activated charcoal her case was evaluated by the toxicology team who recommended holding off on flumazenil given the risk of precipitating withdrawal remainder of electrolytes and lfts were normal repeat acetaminophen level after hours was negative as well this is likely an isolated benzodiazepine overdose given her characteristic presentation of cns depression with normal vital signs though ultimately exact ingestion remains unclear she was extubated on the afternoon following admission and recovered uneventfully airway protection patient was intubated on arrival to ed for airway protection she was successfully extubated the afternoon following admission without complication she was maintained on propofol for sedation while intubated following extubation she was able to maintain o sats on room air with no subjective shortness of breath depression anxiety patient acknowledges two prior psychiatric admissions for depression she was evaluated by the psychiatry consulting team who recommended wellbutrin mg daily and lamictal mg nightly she was also seen by sw rn specializing in issues of substance abuse she had a sitter during this admission for safety once medically cleared she was transferred to an inpatient psychiatric facility for continued management leukocytosis possibly secondary to ingestion or aspiration however an elevated white count has been present in the online medical record since cxr showed no pneumonia urinalysis was negative for infection differential revealed a neutrophil predominance but no bands she remained afebrile and had no localizing symptoms concerning for infection this should be further evaluated in the outpatient setting by her primary care physician inactive issues allergies stable continued on fluticasone nasal spray and cetirizine as needed for urticaria has a follow up appointment scheduled with her allergist asthma stable continued on albuterol inhaler code status full code contact partner to do primary care physician should pursue additional work up of leukocytosis should it persist after discharge medications on admission xanax mg po tid wellbutrin mg po daily lamictal mg qhs cetirizine mg po times daily ranitidine mg po bid trazodone painkillers dulcolax prn omeprazole mg po daily calcium discharge medications omeprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day zantac mg tablet sig one tablet po twice a day as needed for indigestion cetirizine mg capsule sig one capsule po once a day as needed for allergy symptoms albuterol sulfate mcg actuation hfa aerosol inhaler sig one puff inhalation every hours as needed for shortness of breath or wheezing fluticasone mcg actuation aerosol sig one puff inhalation times a day lamotrigine mg tablet sig one tablet po at bedtime please take with mg tab to make a total of mg nightly lamotrigine mg tablet sig one tablet po at bedtime please take with mg tab for a total of mg nightly multivitamin tablet sig one tablet po daily daily calcium carbonate mg mg tablet chewable sig one tablet chewable po bid times a day cholecalciferol vitamin d unit tablet sig one tablet po bid times a day 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 acetaminophen mg tablet sig two tablet po q h every hours as needed for fever pain cepacol sore throat coating mg lozenge sig one mucous membrane every four hours as needed for sore throat nicotine mg hr patch hr sig one patch hr transdermal daily daily wellbutrin sr mg tablet extended release sig one tablet extended release po once a day discharge disposition extended care discharge diagnosis benzodiazepine overdose depression anxiety asthma allergic rhinitis leukocytosis of unclear etiology discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mrs you were initially admitted to the intensive care unit after you overdosed on medication and were intubated for respiratory support once you were stabilized you were transferred to a medicine floor you did well and now you are medically stable and ready to be transferred to a different inpatient hospital for continued psychiatric help we are making a few changes to your outpatient medication regimen these medications may change again at your next facility please stop xanax followup instructions please schedule a follow up appointment with your primary care physician dr at when you are discharged the following appointments were scheduled prior to your admission department div of allergy and inflam when tuesday at pm with rnc building one place ma campus off campus best parking parking on site department radiology when thursday at am with radiology building sc clinical ctr campus east best parking garage,"{
""Diagnoses"": [""Benzodiazepine overdose""],
""Medications"": [""Xanax"", ""Gadolinium containing agents"", ""Penicillins""]
}"
71143,admission date discharge date service medicine allergies lipitor corgard attending chief complaint septic shock major surgical or invasive procedure ercp ij central line placement history of present illness f with hx of newly diagnosed pancreatic ca s p palliative cbd stent presents with persistent vomitting diarrhea fevers the pt reports her symptoms began at am tuesday night during which she had episodes of emesis diarrhea and shaking chills these symptoms continued into wednesday where she reported decreased po per the pt on thursday she developed confusion and subsequently was brought to an osh ed upon arrival to the osh initial vitals tm l fs the pt received a dose of zosyn mg kcl meq l ns and the pt was subsequently transferred to for presumed ascending cholangitis upon arrival initial vitals on ra looked well appearing clear lungs ruq tenderness wbc tb cr lactate ua neg ruq revealed stent remains in cbd and a dilated intrahepatic duct the pt was noted to be hypoglycemic and subsequently received an amp d kcl ercp consulted pending subsequently the pt sbp dropped to received l of ns meq kcl foley with cc uop morphine mg iv x rij placed prior to transfer to the floor vitals ra on of levophed upon arrival to the floor the pt is resting comfortably she states she feels improved she denies headache shaking chills chest pain shortness of breath she reports mild right upper quadrant pain and yellowing of the eyes past medical history iddm for five years myopathy s p statin years ago continues with methotrexate and prednisone taper hypertension anxiety social history lives with her husband in no history of smoking drinking or recreational drug use family history no history of pancreatic or liver cancers history of dm otherwise non contributory physical exam t bp levophed hr rr o l physical exam general pleasant well appearing eldery female in nad heent normocephalic atraumatic no conjunctival pallor mild scleral icterus perrla eomi dry mmm neck rij in place supple no lad no thyromegaly cardiac regular rhythm normal rate normal s s no murmurs rubs or lungs clear anteriorly abdomen tenderness to palpation in ruq soft nt nd no hsm extremities no edema or calf pain dorsalis pedis posterior tibial pulses skin no rashes lesions ecchymoses neuro a ox psych listens and responds to questions appropriately pleasant pertinent results pm wbc rbc hgb hct mcv mch mchc rdw pm neuts bands lymphs monos eos basos atyps metas myelos pm plt smr normal plt count pm pt ptt inr pt pm urine blood mod nitrite neg protein glucose neg ketone neg bilirubin sm urobilngn neg ph leuk neg pm urine rbc wbc bacteria few yeast none epi pm alt sgpt ast sgot alk phos tot bili pm lipase pm glucose urea n creat sodium potassium chloride total co anion gap pm lactate am blood cortsol ekg sinus rhythm at upper limits of normal rate with sinus arrhythmia borderline low voltage q waves in leads v v consider septal myocardial infarction since the previous tracing of the rate is faster cxr left basilar atelectasis unlikely pneumonia ruq u s stent within the cbd measuring cm intrahepatic biliary ductal dilation to mm stones and sludge within a slightly distended gallbladder but no wall thickening or pericholecystic fluid the patient was not tender over the gallbladder if there is concern for a pancreatic mass cta would be recommended ercp a plastic stent placed in the biliary duct was found in the major papilla the stent appeared to be clogged and there was no bile draining through or around the stent the previously placed plastic biliary stent was removed with a snare successfully after the stent was removed pus and sludge drained from the common bile duct evidence of a previous sphincterotomy was noted in the major papilla cannulation of the biliary duct was performed with a sphincterotome after a guidewire was placed contrast medium was injected resulting in complete opacification a single irregular stricture of malignant appearance that was cm long was seen at the lower third of the common bile duct there was moderate post obstructive dilation a cm by mm covered metal wallflex lot biliary stent was placed successfully discharge day laboratories wbc rbc hgb hct mcv plt ct glucose urean creat na k cl hco brief hospital course f with hx of pancreatic ca s p biliary stenting presenting with ascending cholangitis septic shock pt with fever leukocytosis increased lfts in setting of dilated cbd thus infected source likely biliary consistent with ascending cholangitis patient received ivf but remained hypotensive so was started on levophed cvl placed in ed initial lactate trended down to patient underwent ercp with replacement of her temporary biliary stent with a permanent stent frank pus was drained from the cbd with decompression of cbd sepsis resolved and patient was weaned off pressors pt was covered with zosyn vanco initially cultures remained no growth to date she was weaned to zosyn alone successfully which was transitioned to augmentin several days prior to discharge to complete a total of ten days of antibiotics ascending cholangitis pt with elevated transaminases alk phos tb in setting of a stent cm in the cbd ultrasound revealing dilated intrahepatic ducts at mm and radiographic findings suggestive of small stones and sluge in the gb no evidence of acute cholecystitis treatment for her infection occurred as per above gap metabolic acidosis bicarb of on initial labs with gap of lactate slightly elevated at diarrhea non gap may also be contributing to decreased bicarb patient received large amount ns and hyperchloremic metabolic acidosis was also a contributor to her acid base picture anion gap improved over hours dmii hypoglycemia pt hypoglycemic to while in ed received amp of d ddx included sepsis decreased po in setting of regular insulin dosing patient was re started on her home lasix when transferred to the general medicine floor which she tolerated well arf cr at presentation from baseline to pt with uop at osh bun at up from ddx pre renal from hypoperfusion in the setting of septic shock less likely post renal intrinsic improved with ivf hydration to a baseline of prior to discharge myositis pt was on long term steroids and methotrexate pt currently on mg prednisone am cortisol was wnl she was given stress dose steroids which were weaned back to her baseline of prednisone mg daily and she remained hemodynamically stable she should resume her methotrexate as an outpatient oncology patient without a tissue diagnosis and interested in knowing her options she was seen by oncology in the icu she underwent ct a p with contrast to discern if mass had grown or spread she obtained follow up in oncology clinic for further assessment rad onc was also consulted for potential palliative xrt in the future ca was pending at discharge she was noted to have a right adnexal mass on abdominal ct follow up pelvic ultrasound was non diagnostic this should be further discussed at her oncology follow up appointment diarrhea patient complained of loose stools upon resumption of her diet after stent placement differential diagnosis includes antibiotic associated diarrhea malabsorption in setting of recent biliary manipulation c diff was negative x patient was able to maintain adequate po s with no electrolyte abnormalities would continue to follow as she advances to a regular consistency diet and completes her antibiotics lower extremity edema secondary to fluid repletion in the icu patient had trace bilateral edema at the time of discharge and was given teds and advised to elevate her feet and ambulate frequently she had no respiratory complaints throughout her stay medications on admission prednisone mg po daily methotrexate mg po friday aspirin mg po daily hydrochlorothiazide mg po daily lisinopril mg po qhs folic acid mg po daily fosamax mg po once a week insulin glargine unit ml solution sig four units subcutaneous after breakfast calcium d ergocalciferol vitamin d oral multi vitamin hp minerals capsule oral omega fatty acids oral discharge medications ranitidine hcl mg tablet sig one tablet po daily daily hydrochlorothiazide mg capsule sig two capsule po daily daily lisinopril mg tablet sig one tablet po bid times a day prednisone mg tablet sig one tablet po daily daily amoxicillin pot clavulanate mg tablet sig one tablet po q h every hours for days to be completed on disp tablet s refills lantus unit ml cartridge sig four units subcutaneous at bedtime discharge disposition home with service facility vna assoc of discharge diagnosis cholangitis biliary obstruction pancreatic cancer myositis hypertension benign hypokalemia 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 with an infection in your biliary tree cholangitis you underwent repeat metal stenting to open the obstruction you were also treated with iv antibiotics which were changed to oral antibiotics at discharge please take your antibiotic as prescribed to complete a course on you also underwent further evaluation of your pancreatic cancer with oncology consultation and ct scan you must follow up closely with them for further care other than the addition of your antibiotic no other changes were made to your home medications followup instructions md phone pcp at md phone date time,"{
""Diagnoses"": [""Septic shock"", ""Ascending cholangitis""],
""Medications"": [""Lipitor"", ""Corgard"", ""Zosyn"", ""Kcl"", ""Ns"", ""Foely"", ""Morphine"", ""Iv X"", ""Rij""]
}"
80259,admission date discharge date date of birth sex f service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint worsening fatigue major surgical or invasive procedure cardiac catheterization aortic valve replacement utilizing a mm st tissue valve history of present illness this is a year old female with known aortic stenosis who has been followed closely with serial echocardiograms by dr her most recent echocardiogram showed cm and a mean gradient of mmhg peak gradient of mmhg the patient now presents for aortic valve replacement past medical history aortic stenosis hypertension hyperlipidemia osteoporosis macular degeneration receive s injections in right eye h o basal cell ca shoulder and back old myocardial infarction and rbbb patient denies s p tonsillectomy s p cataracts s p d c s social history occupation retired sales clerk last dental exam upper dentures lives with husband caucasian tobacco quit yrs ago etoh approx glasses wine wk family history no premature coronary artery disease physical exam pulse resp bp left height weight lbs general wd wn female in nad skin dry x intact x heent perrla x eomi x neck supple x full rom x chest lungs clear bilaterally x heart rrr x irregular murmur x sem abdomen soft x non distended x non tender x bowel sounds x extremities warm x well perfused x edema varicosities none bilateral superficial varicosities neuro grossly intact x pulses femoral right cath site left dp right left pt left radial right left carotid bruit right left transmitted murmur pertinent results wbc rbc hgb hct mcv mch mchc rdw plt ct pt ptt inr pt glucose urean creat na k cl hco angap alt ast ck cpk alkphos amylase totbili hba c cardiac cath selective coronary angiograhpy in this right dominant system demonstrated no flow limiting lesions the lmca lad cx and rca had no angiographically apparent disease limited resting hemodynamics revealed slightly elevated right and left sided filling pressures with a rvedp of mmhg and a mean pcwp of mmhg there was mild pulmonary artery hypertension with a pasp of mmhg the central aortic pressure was mmhg echocardiogram 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 ascending aorta is mildly dilated the aortic valve leaflets are severely thickened deformed there is critical aortic valve stenosis valve area cm mild to moderate aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse trivial mitral regurgitation is seen there is borderline pulmonary artery systolic hypertension there is no pericardial effusion carotid ultrasound there is antegrade right vertebral artery flow there is antegrade left vertebral artery flow right ica stenosis left ica stenosis am 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 brief hospital course mrs was admitted and underwent cardiac catheterization which confirmed severe aortic stenosis and showed normal coronary arteries preoperative evaluation was otherwise uneventful and she was cleared for surgery on dr performed an aortic valve replacement mm st tissue valve for further surgical details please refer to dr operative note she was intubated sedated and required pressor support in critical but stable condition when transferred to the cvicu for invasive monitoring within hours she awoke neurologically intact and was extubated without incident pressors were weaned off all lines and drains were discontinued in a timely fashion beta blocker aspirin statin diuresis was initiated she continued to progress and pod was transferred to the step down floor for further monitoring physical therapy evaluated and consulted pod her rhythm went into rapid atrial fibrillation she was treated with amiodarone and beta blocker and subsequently converted to normal sinus rhythm the remainder of her postoperative course was essentially uneventful she continued to do well and was cleared by dr for discharge to home with vna on pod all follow up appointments were advised medications on admission metoprolol mg lipitor mg daily fosamax mg once a week asa mg daily mvi tb daily lisinopril hydrochlorothiazide mg mg daily flaxseed oil 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 ranitidine hcl mg tablet sig one tablet po bid times a day disp tablet s refills 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 tramadol mg tablet sig one tablet po q h every hours as needed for pain 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 metoprolol tartrate mg tablet sig one tablet po tid times a day disp tablet s refills lisinopril mg tablet sig one tablet po daily daily 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 aortic stenosis s p avr hypertension dyslipidemia discharge condition stable discharge instructions no driving for one month no lifting more than lbs for at least weeks from the date of surgery please shower daily wash surgical incisions with soap and water only do not apply lotions creams or ointments to any surgical incision please call cardiac surgeon immediately if you experience fever excessive weight gain and or signs of a wound infection erythema drainage etc office number is call with any additional questions or concerns followup instructions dr in weeks call for appt dr in weeks call for appt dr or in weeks call for appt completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex f service cardiothoracic allergies patient recorded as having no known allergies to drugs attending addendum ms was hyponatremic postop her sodium was electrolytes were corrected discharge disposition home with service facility vna md completed by,"{
""Diagnoses"": [""cardiothoracic"", ""aortic stenosis"", ""hypertension"", ""hyperlipidemia"", ""osteoporosis"", ""macular degeneration""],
""Medications"": [""mm st tissue valve"", ""injections in right eye"", ""basal cell ca"", ""shoulder"", ""back"", ""myocardial infarction"", ""rbbb"", ""s p tonsillectomy"", ""s p cataracts"", ""s p d c"", ""wine""]
}"
14306,admission date discharge date date of birth sex f service history of present illness the patient was the now three day old lb oz product of a week gestation born to a year old primigravida mother born via spontaneous vaginal delivery here at the delivery was after an apparently uncomplicated gestation maternal history is notable for treatment with lovenox for antithrombin deficiency prenatal screens were complete and unremarkable agars were and at delivery the patient did well in the delivery room and in the nursery breastfeeding discharge weight was lb oz she was discharged on the patient did well at home waking for feeds she was breastfeeding well she was given supplements on several occasions the night prior to delivery she was brought to the pediatrician and the day of admission for weight and color check bilirubin at that time was found to be it had been on the day of discharge the patient was sent to for admission physical examination pink jaundice active nondysmorphic infant she was well perfuse and saturated activity was normal she had a normal cry skin was without lesions heent examination was within normal limits cardiac examination showed a normal s and s without murmurs lungs were clear abdomen was benign lungs were clear neurological examination was nonfocal and age appropriate hips were normal spine was intact anus was patent hospital course cardiovascular respiratory the patient remained comfortable in room air throughout her hospital stay there was no murmur fluids electrolytes and nutrition the patient was breast feeding well at the time of admission admission sodium showed to be her weight was at loss from birth weight she was given cc per kilogram of normal saline as well as her blood pressure was normal she was begun on intravenous supplementations while awaiting decreases in her bilirubin hematologic admission hematocrit was reticulocyte count was maternal blood type was o positive as well as the baby s coomb status was negative gastrointestinal bilirubin on admission here at was she was treated with intensive phototherapy where as her bilirubin decreased to the range within hours of admission she was continued on phototherapy through the morning of when he bilirubin was in the range phototherapy was discontinued and a rebound bilirubin needs to be checked if the bilirubin is below she will be discharged to home with follow up with dr in the morning routine health care maintenance hearing screen is suggested in the coming weeks she passed an initial hearing screen at the time of her newborn hospitalization she has not had a repeat screen since her episode of hyperbilirubinemia discharge diagnoses hyperbilirubinemia full term newborn dehydration weight loss discharge disposition discharged to home with parents follow up with dr office on saturday m d dictated by medquist d t job dd,"{
""Diagnoses"": [""Lovenox for antithrombin deficiency""],
""Medications"": [""Lovenox""]
}"
68145,admission date discharge date date of birth sex m service medicine allergies imitrex biaxin attending chief complaint hemoptysis major surgical or invasive procedure rigid bronchoscopy ir embolization of bleeding pulmonary vessels history of present illness y om with stage iv lung ca on home l transferred from osh with hemoptysis x week and resultant hct drop from baseline to patient first started coughing up dark clots of blood on friday states last hemoptysis was day prior to transfer to and was about a tablespoon of blood patient had not required mechanical ventilation and was saturating well on room air in per patient also c o dyspnea on mild exertion of note dyspnea has been a longterm complaint and patient was recently admitted for removal of y stent in first placed mo ago per report op oncologist who did not want to repeat bronchoscopy patient also with recent chemo of gemcitabine last dose on and had radiation to lung in patient also c o rib and right hip pain in radiographs revealed new lytic lesions in ribs and new right femur lytic lesion finally per patient also c o dysphagia x several days and states he can t take liquids solids the team was concerned that the large mass in lungs may be compressing the esophagus so gi consulted for feeding tube also with pound weight loss per note at osh transfused uprbc on ct scan of chest no active source of hemorrhage or pe given concern for large volume bleed patient was transferred to for further evaluation and treatment upon arrival to initial vs l nc able to be weaned to on ra physical exam notable for scattereed rales and trace guiac positive rectal exam repeat hct had risen appropriate to and hct has been stable throughout stay because ip wanted to use a rigid bronch to see if they can coagulate and localize source of bleeding patient was transferred west for or during bronchoscopy found to be tumor invasion into both left and right proximal invasion into the carina ip able to obtain hemostasis coagulate much of it but areas are still oozing and will need ir angioembolization patient intubated in or and comes to micu intubated past medical history lung cancer poorly differentiated adenocarcinoma occluding r main stem bronchus s p rigid bronchoscopy tumor excision and y stent medical oncologist and rad onc doctors removed in hyperlipidemia bph migraines vertigo social history recently quit smoker py history no etoh no drugs lives alone family history mother pancreatic cancer maternal uncle lung cancer siblings sister diabetes physical exam gen thin fragile nad occassionally labored breathing heent eomi perrla no supraclavicular or cervical lymphadenopathy resp rhonchorus breath sounds throughout cv rrr s and s wnl systolic murmur abd nd b s soft nt no masses or hepatosplenomegaly ext no c c e skin no rashes no jaundice no splinters ext limited rom of right hip minimal pain on palpatition of right trochanter neuro ii xii intact no sensory deficits pertinent results admission pm hgb calchct am hct am wbc rbc hgb hct mcv mch mchc rdw am neuts lymphs monos eos basos am plt count am ret aut am pt ptt inr pt am glucose urea n creat sodium potassium chloride total co anion gap am alt sgpt ast sgot ld ldh alk phos tot bili micro respiratory culture final commensal respiratory flora absent staph aureus coag heavy growth of two colonial morphologies oxacillin resistant staphylococci must be reported as also resistant to other penicillins cephalosporins carbacephems carbapenems and beta lactamase inhibitor combinations rifampin should not be used alone for therapy this isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance acinetobacter baumannii complex rare growth note for amp sulbactam higher than standard dosing needs to be used since therapeutic efficacy relies on intrinsic activity of the sulbactam component sensitivities mic expressed in mcg ml staph aureus coag acinetobacter baumannii complex ampicillin sulbactam s cefepime s ceftazidime s ciprofloxacin s clindamycin r erythromycin r gentamicin s s imipenem s levofloxacin r s oxacillin r rifampin s tetracycline s tobramycin s trimethoprim sulfa s s vancomycin s imaging ct chest no aortic dissection pulmonary embolism persistent tumor encasing the posterior mediastinum carina and right hilum the overall extent of this tumor appears to have decreased from the previous study with resultant improved patency of the airways and resolution of right upper lobe and lower lobe atelectasis new bilateral lytic rib lesions consistent with metastatic disease there is also a new pathologic left posterior eighth rib fracture tumor involvement in the posterior mediastinum is inseparable from the esophagus and there is a large volume of ingested material seen in the proximal esophagus this finding raises concern for aspiration emphysema unchanged thickening of both adrenal glands bone scan impression multiple osseous metastatic lytic foci involving the thoracic ribsthe right femoral neck with associated pathologic fracture involvingthe left posterior th rib as can be correlated on recent ct radiographs ct pelvis impression innumerable lytic lesions throughout the sacrum bilateral iliac bones and proximal femurs the largest lesion is in the right intertrochanteric region of the femur which is not completely imaged there is rarefaction of the medial aspect of the right femur medially at the site of the lesion which is at risk for pathologic fracture interval development of ascites in the abdomen ct chest impression overall progression of subcarinal and paraesophageal mass with occlusion of the distal unstented portions of the right middle and lower lobe bronchi subtotal occlusion of the esophageal stent in its mid portion with associated distention of the proximal esophagus marked interval enlargement of bilateral pleural effusions and associated compressive atelectasis at the lower lobes brief hospital course metastatic lung cancer during this hospitalization the was tumor found to be increasingly aggressive in nature with continued growth despite active chemotherapy continued growth resulted in esophageal compression as well as invasion into the bronchial tree furthermore patients additional presenting complaint of right hip weakness found to result from tumor infiltration of right intertrochanteric space on admission patient optimistic and eager for treatment underwent angioembolization to treat bleed underwent tracheal and esophageal stenting in hopes of improving the dysphagia unfortunately the force of the surrounding tumor resulted in near occlusion of esophageal stent hours after placement the severity of the situation was relayed and after several discussions with the family primary outpatient team as well as inpatient team patient changed code status to dni dnr with wish to proceed with hospice care at time of discharge antibiotics tpn were stopped picc line pulled and comfort measure were applied patient with plan to be discharged with home hospice provided with prescriptions to minimize pain decrease nausea decrease anxiety and improve work of breathing hemoptysis secondary to endobronchial tumor burden invasion of tumor into right and left proximal and also into carina arrived in micu intubated for airway protection now s p rigid bronch with ip pt with continued slow bleeding initially embolized by ir s p ir procedure no further episodes of active hemopytsis esophageal obstruction tumor was found to be compressing espogeal resulting in near occlusion after reviewing imaging decision made to first stent tracheal stent to protect airway prior to esophageal stent placement unfortunately ct scan on day following stent placement revealed subtotal occlusion of distal esphagus no further interventions performed patient able to tolerate liquid diet at time of discharge pelvic lesion spoke with both ortho onc as well and radiation oncology initially discussion of possible operative intervention vs xrt however after much discussion decision made to treat pain with and forego additional treatment measures pneumonia patient developed worsening post obstructive pneumonia after esophageal stent placement treatment with antibiotics discontinued after code discussion finalized medications on admission atorvastatin mg daily tamsulosin mg capsule sust release hr qhs menthol cetylpyridinium mg lozenge prn guaifenesin mg tablet sustained release tabs omeprazole mg capsule delayed release e c daily docusate sodium mg capsule albuterol sulfate mg ml solution q hrs prn acetylcysteine mg ml solution q hrs amoxicillin pot clavulanate mg tablet x weeks benzonatate mg capsule tid cyclobenzaprine mg tablet tid oxycodone mg tablet q hrs prn acetaminophen mg q hrs prn lidocaine diphenhyd mag mg ml ml qid codeine sulfate mg tablet qid prn discharge medications fentanyl mcg hr patch hr sig one patch hr transdermal q h every hours disp patch hr s refills lorazepam mg tablet sig one tablet po q h every hours as needed for anxiety disp tablet s refills guaifenesin mg ml syrup sig mls po q h every hours as needed for cough morphine mg ml solution sig one po q h every hours as needed for pain disp bottle refills albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q h every hours as needed for wheezing disp inhalers refills albuterol sulfate mg ml solution for nebulization sig one inhalation q h every hours as needed for shortness of breath disp cartridges refills ondansetron mg tablet rapid dissolve sig one tablet rapid dissolve po q h every hours as needed for nausea disp tablet rapid dissolve s refills acetaminophen mg ml solution sig po every six hours as needed for fever for doses discharge disposition home with service facility hospice of discharge diagnosis primary metastatic lung cancer discharge condition mental status clear and coherent unable to bear weight on left leg discharge instructions you were transferred to for continued treatment of your lung cancer with associated complications of trouble swallowing coughing up blood and hip pain to address the bleeding the team of interventional pulmonologists were able to a perform a bronchoscopy a procedure which allows visualization of your airways during this procedure they were able identify the source of the bleed and apply thermal energy to stop it you had not further episodes of coughing up large volumes of blood while hospitalized you also noted difficulty swallowing it was discovered that the tumor was compressing your esophagus making it difficult for you to swallow the decision was made to place an esophageal stent in hopes of making swallowing easier a tracheal stent was placed prior to the esophageal stent to ensure airway protection unfortunately the force of the tumor on the esophageal stent caused the area of the stent to lessen only allowing passage of liquids prior to discharge you were able to swallow liquids with limited difficulty imaging was taken of your hip ultimately it was determined that your increased pain was due to tumor involvement in the bones of the hip your pain was controlled with morphine and physical therapy worked with you to optimize your strength and ability to transfer during your hospitalization ongoing discussion took place between your primary care physician primary oncologist as well as your inpatient medical team and consult services after much discussion you determined that you would rather return home with hospice care rather than proceed with ongoing hospital care your ongoing goals of care will be optimizing comfort mr it was an honor taking care of you you will be discharged with medications to control pain decrease nasuea and improve breathing morphine mg po every hours as needed for the pain zofran mg tablets take one tablet every hours as needed for pain albuterol inhaler puffs as needed for shortness of breath albuterol nebulizer treatment every hrs as needed for shortness of breath lorazapam mg sl q h as needed for anxiety guaifenesin ml po ng every four hours for cough followup instructions please follow up with dr and dr as needed and contact your hospice program with any questions or difficulties completed by,"{
""Diagnoses"": [""Hemoptysis"", ""Lung Cancer"", ""Stage IV Lung Cancer""],
""Medications"": [""Imitrex"", ""Biaxin"", ""Atemol""]
}"
29390,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint s p ft fall major surgical or invasive procedure splenectomy vats procedure with empyema tube placement history of present illness year old gentleman s p fall approx ft onto a large post which snapped in half who broke several left sided ribs and also ruptured his spleen etoh he was transported to where he was takne to the operating and underwent a splenectomy social history etoh family history noncontributory pertinent results pm glucose lactate na k cl 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 urine bnzodzpn neg barbitrt neg opiates neg cocaine neg amphetmn neg mthdone neg ct chest w contrast impression resolving contusion in right apex and basal segment of right lower lobe interval resolution of loculated effusion in left apex anteriorly chest tube in situ with left pleural effusion noted the patient is status post splenectomy multiple rib fractures on the left small fluid collection in intercostal muscles on the left side at the site of a rib fracture ct head w o contrast impression no intracranial hemorrhage or fracture ct c spine w o contrast impression no acute alignment abnormality or fracture partial demonstration of patient s left pneumothorax brief hospital course he was admitted to the trauma service once stabilized in the trauma bay he was taken to the operating room for an exploratory laparotomy and splenectomy there were no intraoperative complications he remained in the trauma icu for several days for close monitoring given his injuries he was noted to have dyspnea and increased oxygen requirements chest imaging revealed a loculated left sided effusion thoracic surgery was consulted and he was taken to the operating room on for left vats decortication cultures of the pleural fluid and of his chest wound were sent which revealed a staphylococcal infection it was recommended by infectious disease that he be treated with a week course of nafcillin a picc line was placed and plans were made or discharge home with iv antibiotics he was given the appropriate vaccinations due to the splenectomy prior to his discharge follow up is needed in both trauma and thoracic clinic discharge medications bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for constipation docusate sodium mg capsule sig one capsule po bid times a day as needed for constipation oxycodone mg tablet sig tablets po 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 nafcillin in d w g ml piggyback sig two gm intravenous q h every hours for weeks disp qs gm refills sodium chloride syringe sig ten ml injection daily daily flush picc line before and after use and prn disp qs ml s refills central line dressing kit change picc line dressing as directed discharge disposition home with service facility critical care systems discharge diagnosis s p ft fall left pneumothorax multiple left sided rib fractures grade iii splenic laceration wound staphylococcal infection discharge condition stable discharge instructions you will need to continue with the iv antibiotics for a total of weeks return to the emergency room if you develop any fevers chills shortness of breath chest discomfort redness or thick drainage from picc lie site abdominal pain nausea vomiting diarrhea and or any other symptoms that are concerning to you followup instructions follow up with dr in week call for an appointment follow up in clinic in weeks call for an appointment completed by,{}
24782,admission date discharge date date of birth sex m service neurosurgery allergies patient recorded as having no known allergies to drugs attending chief complaint brain mass major surgical or invasive procedure right craniotomy for tumor mass resection history of present illness y o male tx from with h a today starting two weeks ago with less intensity ct today at osh significant for r parietal mass cm w with mm of shift mr states he has occasional h a s relieved with otc meds only recent change was two weeks ago past medical history htn anxiety niddm diet controlled dyslipidemia prostatitis in past anxiety congenital bicuspid valve leak treated with meds mal seizures as teenager until age when he was declared not to have them by a neurologist social history pt currently employeed by a collection comapany yr work hx with same co as sole financial support for his wife and two children ages and physical exam gen appears anxious when answering questions appears slightly unkempt appearance heent normocephallic eyes equidistant nose and mouth midline mucous membranes pink and moist cv pv soft systolic murmor auscultated over erb s point pulses palpable good capillary refill respiroatory chest expansion symmetrical and even lung sounds clear gi abdomen distended soft non tender positive bowel sounds all four quads gu deferred skin intact neuro alert oriented x perrla cranial nerves intact no pronator drift but slight left arm tremor on exertion naned of items in minutes names of objects reflexes all four extremities motor strength in all four extremities sensation intact toes upgoing pertinent results pm pt ptt inr pt pm glucose urea n creat sodium potassium chloride total co anion gap pm crp pm phenytoin 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 sed rate operative report m principal diagnosis right sided temporal tumor principal procedure right sided craniotomy for resection microscopic dissection for intraoperative image guidance duraplasty using pericranial autograft mra brain w o contrast am impression large right superior temporal lobe and deep white matter mass with surrounding edema most likely representing neoplasia ct head w o contrast am impression minimal improvement in the post surgical changes in the right frontotemporal region minimal improvement in the midline shift and mass effect since the prior examination from brief hospital course the patient is a year old male who recently presented with a newly diagnosed right sided contrast enhancing multilobulated mass the patient has significant mass effect and swelling from that lesion a full work up did not reveal a primary tumor anywhere in his body the patient does need a tissue diagnosis as basis for further treatment options he was therefore counseled for open resection he consented he was taken electively to the operating room on he did well post operatively intially was awake alert and orientated x no true deficits noted a follow up head mri showed the resection cavity in the right superior temporal lobe is unchanged in appearance with air and blood products within it there is mild peripheral enhancement and enhancement extending along the dural surface in the location of the right craniotomy defect a deeper rounded cm enhancing mass located between the right posterior thalamus and internal capsule is unchanged there is vasogenic edema around the surgical site which is not significantly changed in the interval since the previous study he was monitored in the recovery room overnight and transferred to the floor on post op day on post op day he was found to be more lethargic a stat head ct showed right uncal herniation from edema he was given gm of mannitol lasix steroids mg and increased to mg q and tranferred to the sicu the following morning he became more awake alert and orientated x perrla language was fluent visual fields full and had equal stength in all extemeties he was transferred to the step down unit on post op day his mannitol was weaned to off on post op day and steroids weaned very slowly to a goal of mg post discharge a head ct on showed minimal improvement of edema and midline shift he was tolerating a regular diet has periods of headaches relieved with percocet and noted to have some edema at surgical site felt to be appropriate by dr no redness or drainage at site physical therapy felt he would benefit from a course of acute rehab he should continue on the lamigotrine with a increase in mg q week until goal of mg is reached medications on admission lisinopril mg po daily lipitor mg po daily baby asa mg po daily clonipin mg in am and mg qhs doxazosin mg po daily discharge medications lisinopril mg tablet sig one tablet po daily daily atorvastatin mg tablet sig one tablet po daily daily clonazepam mg tablet sig one tablet po qam once a day in the morning clonazepam mg tablet sig one tablet po qhs once a day at bedtime doxazosin mg tablet sig two tablet po hs at bedtime acetaminophen mg tablet sig tablets po q h every to hours as needed docusate sodium 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 insulin regular human unit ml solution sig one injection asdir as directed senna mg ml syrup sig one tablet po daily daily lamotrigine mg tablet sig one tablet po bid times a day 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 injection tid times a day phenytoin sodium extended mg capsule sig two capsule po bid times a day oxycodone acetaminophen mg tablet sig one tablet po q h every to hours as needed dexamethasone mg tablet sig tablets po q h every hours continue until dilantin mg capsule sig one capsule po once a day give between dose dexamethasone mg tablet sig one tablet po three times a day start on continue until brain tumor follow up discharge disposition extended care facility health alliance rehabilitation center discharge diagnosis brain mass discharge condition good discharge instructions if any fever greater than wound swelling more than current redndess or increasing pain please call dr office if you experienc any increased headache neck pain or fever please all dr office no driving until foloow up at brain tumor clinic followup instructions follow up at brain tumor clinic at pm building completed by,"{
""Diagnoses"": [""brain mass"", ""tumor mass"", ""neurosurgery""],
""Medications"": [""otc meds"", ""meds"", ""mal seizures""]
}"
53973,admission date discharge date date of birth sex m service cardiothoracic allergies lisinopril attending chief complaint acute onset back pain and syncope major surgical or invasive procedure emergency repl ascending aorta mm gelweave graft avr mm ce pericardial valve history of present illness yo man presented to osh er with one day history of acute onset back pain and syncope with a witnessed collapse at work cta showed acute type a dissection at the level of the aortic root to the left common iliac artery as well as moderate hemopericardium hypotensive in er transferred intubated and sedated by emergently to past medical history htn obesity cri s p pancreatitis prostate ca anemia diverticulosis cva left caudate adrenal hyperplasia s p adrenalectomy hypertriglyceridemia pre diabetic social history unknown family history unknown physical exam admission ht wt kg intubated sedated skin unremarkable ctab rrr with murmur obese abd soft nt nd cool extremities no peripheral edema unable to assess neuro status pe on discharge vs t p r a o sat kg general a o x nad cvs rrr lungs b crackles abd benign extr edema rue superficial thrombus of r cephalic b le edema wound sternal incision c d i stable neuro continues to have rt sided weakness with lower extremity weakness more pronounced than upper extremity facial droop largely resolved passed swallow on pertinent results pm urea n creat potassium pm hct pm wbc hct pm glucose lactate pm alt sgpt ast sgot ld ldh alk phos tot bili pm glucose lactate k am glucose na k am urea n creat chloride total co am wbc rbc hgb hct mcv mch mchc rdw am plt count am pt ptt inr pt am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood plt ct am blood pt inr pt am blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos amylase totbili mri scan of the brain with mr angiography of the head history status post aortic valve replacement following an aortic dissection with a period of hypotension technique multiplanar t and t weighted brain imaging was obtained as well as mr angiography of the circle of and its tributaries utilizing a three dimensional time of flight imaging protocol with multiplanar reconstructions comparison study on pacs archive ct scan of the head from findings there are numerous largely subcentimeter foci of elevated t signal scattered throughout the brain including the centrum semiovale bilaterally this region is more extensively involved on the left side additional foci of restricted diffusion are noted within the right occipital lobe left thalamic region anteriorly the left side of the pons which was suspected on the prior ct scan as well as the inferolateral aspect of both cerebellar hemispheres as these abnormalities also manifest elevated t signal they are likely subacute infarctions there are no areas of abnormal susceptibility demonstrated there is no hydrocephalus or shift of normally midline structures the principal vascular flow patterns are identified there is near complete loss of aeration of the right maxillary sinus and to a moderate degree within the left maxillary sinus extensive mucosal thickening and possibly fluid is noted within the ethmoid sinuses with moderate sphenoid sinus mucosal thickening seen and lastly minimal frontal sinus mucosal thickening the sinus abnormalities could represent the effects of intubation as well as an inflammatory process mr angiography of the circle of and its tributaries shows no overt sign of an area of hemodynamically significant stenosis or within the limitations of this technique an aneurysm conclusion multiple small areas of subacute infarction given the history of protracted hypotension as well as recent aortic valve surgery both hypotensive and embolic sources for the infarctions need to be considered comment i discussed this case with ms the nurse practitioner who requested this study immediately after the examination was completed via telephone dr approved fri am tee conclusions pre bypass the left atrium and right atrium are normal in cavity size no atrial septal defect is seen by d or color doppler regional left ventricular wall motion is normal overall left ventricular systolic function is normal lvef right ventricular chamber size and free wall motion are normal the aortic root is markedly dilated at the sinus level the ascending aorta is moderately dilated the aortic arch is mildly dilated a mobile density is seen in the ascending aorta consistent with an intimal flap aortic dissection a mobile density is seen in the aortic arch consistent with an intimal flap aortic dissection a mobile density is seen in the descending aorta consistent with an intimal flap aortic dissection there are three aortic valve leaflets there is no aortic valve stenosis moderate to severe aortic regurgitation is seen mild mitral regurgitation is seen there is a small pericardial effusion post bypass an aortic valve tissue prosthesis is in good position with good leaflet excursion the mean gradient is appropriate there is a trace paravalvular leak that improved with protamine mr is now trace right and left ventricular function is preserved the remainder of the study is unchanged dr was notified in person of the results at the time of the examination i certify that i was present for this procedure in compliance with hcfa regulations electronically signed by md md interpreting physician radiology report chest pa lat study date of pm csurg fa a sched chest pa lat clip reason eval pleural effusions final report chest pa and lateral indication status post aortic valve replacement evaluate chest findings the patient s condition does not permit standard chest technique and the patient is examined in ap projection in semi erect position a lateral view was obtained with the patient barely sitting up comparison is made with the next previous similar study of status post sternotomy is unchanged and the position of the metallic components of a porcine aortic valve prosthesis is a identified in unchanged position cardiac enlargement persists and the left diaphragmatic contour and lateral pleural sinuses are obliterated comparison with the next preceding study suggests that the amount of effusion has increased mildly size quantification however is difficult considering patient s position and examination technique can however identify pleural effusions in the posterior pleural sinuses of the left side as seen on the lateral view no evidence of pneumothorax the patient is extubated and the previously identified ng tube has been removed a left subclavian approach central venous line persists and terminates overlying the svc at the level of the carina no pneumothorax has developed impression persistent left sided pleural effusion possibly increased slightly no pneumothorax new infiltrates or other complications dr approved pm renal scan clip reason yr old man with s p acute dissection and renal failure eval for flow split final report radiopharmaceutical data mci tc m mag history y o male s p acute type a dissection extending to common iliac bifurcation and left common iliac artery involvement of renal arteries is unknown patient is presenting for evaluation of renal failure interpretation flow and dynamic images were obtained after intravenous administration of tracer blood flow images show symmetric perfusion to both kidneys renogram images show delayed excretion of tracer bilaterally the differential function obtained by analysis of tracer concentration in the parenchyma from to minutes post tracer injection shows the left kidney to be performing of the total renal function and the right kidney performing impression symmetric renal function markedly delayed tracer excretion bilaterally findings consistent with poor parenchymal function which may reflect acute tubular necrosis in the setting of recent hypotensive insult or chronic medical renal disease repeat assessment could be performed as clinically indicated findings discussed with dr on the afternoon of by dr over the telephone m d brief hospital course admitted directly to the or after from emergency room was hypotensive on arrival to or underwent surgery with dr please see or report for details in summary he had an ascending aorta replacement with an aortic valve replacement he tolerated the operation and was transferred to the cvicu in fair conditiion following surgery vascular surgery and general surgery both consulted for rising lactate and abdominal distention renal service also consulted for acute renal failure he remained critically ill and very volume overloaded and therefore remained intubated and sedated for several days post operatively drips titrated for bp and glucose control neuro consult obtained for inability to respond appropriately and right sided weakness ct obtained and then subsequent mri showed multiple areas of small infarcts tube feedings started on pod pancultured for fever and cipro started for gram negative rods in sputum ot eval done he was extubated pod patient had intermittant episodes of atrial fibrillation and was started on amiodarone he initially failed a swallow evaluation however a repeat eval was done pod which he passed diet was advanced as tolerated coumadin was discontinued with rhythm remaining in sinus antihypertensives optimized pod renal ultrasound performed showed no eveidence of hydronephrosis with symetric flow to both kidneys pt continued to progress and on pod he was ready for discharge to rehab all follow up appointments were advised medications on admission atenolol discharge medications aspirin mg tablet chewable sig one tablet chewable po daily daily ranitidine hcl mg tablet sig one tablet po once a day docusate sodium mg capsule sig one capsule po twice a day heparin porcine unit ml solution sig units injection tid times a day amiodarone mg tablet sig two tablet po daily daily mg qd x days then mg qd insulin regular human unit ml solution sig sliding scale injection qac hs fluticasone mcg actuation aerosol sig two puff inhalation times a day allopurinol mg tablet sig one tablet po daily daily ipratropium bromide mcg actuation aerosol sig two puff inhalation qid times a day terazosin mg capsule sig one capsule po hs at bedtime calcium acetate mg capsule sig two capsule po tid w meals times a day with meals atorvastatin mg tablet sig one tablet po daily daily atenolol mg tablet sig as directed tablet po twice a day mg qam mg qpm norvasc mg tablet sig one tablet po once a day lasix mg tablet sig one tablet po once a day hydromorphone mg tablet sig tablets po every hours as needed hydralazine mg tablet sig one tablet po prn for sbp albuterol sulfate mg ml solution for nebulization sig one tx inhalation q h every hours as needed acetaminophen mg tablet sig two tablet po q h every hours as needed discharge disposition extended care facility discharge diagnosis type a aortic dissection s p avr replacement ascending aorta cva postop a fib htn obesity cri s p pancreatitis prostate ca anemia diverticulosis cva left caudate adrenal hyperplasia s p adrenalectomy hypertriglyceridemia pre diabetic discharge condition stable discharge instructions no lotions creams or powders on any incision call for fever greater than redness or drainage no driving for at least one month and until off all narcotics no lifting greater than pounds for weeks shower daily and pat incisions dry followup instructions see pcp in weeks see dr for dr for postop visit in weeks at call for appt md completed by,"{
""Diagnoses"": [""acute onset back pain"", ""syncope"", ""dissection of aortic root"", ""hemopericardium"", ""hypotension""],
""Medications"": [""lisinopril""]
}"
57390,admission date discharge date service medicine allergies penicillins sulfa sulfonamide antibiotics furosemide attending chief complaint right ankle pain major surgical or invasive procedure none history of present illness m with history of schf non ischemic cardiomyopathy ef severe pulmonary htn and right sided heart failure recent worsening of lower extremity edema presenting now with week history of purplish toes and acute onset right medial ankle pain patient has had recent worsening of bilateral lower extremity edema with associated weeping is followed by dr in cardiology and plan was for him to see an advanced heart failure specialist outpatient diuretic regimen of ethacrynic acid recently increased to mg daily last night around pm developed pain in the medial aspect of his right ankle pain came on suddenly and was sharp cramping in nature extending mid way up his calf he denies any preceding injury or history of gout given severe pain called ems and was brought to ed for evaluation in the ed initial vs were ra on exam his bilateral hands were cool bluish w blue discoloration of the nails had lower ext edema with blue discoloration of distal aspects of toes sec cap refill with dopplerable pt dps bilaterally l r noted to have of erythema over the right medial malleolus tracking upwards to the mid calf no crepitus noted labs notable for wbc n inr cr k lactate while in ed bp dropped to s s s baseline sbp in s received cc ns r ij placed and he was started on norepinephrine cvp was no alteration in mental status also received broad antibiotic coverage with vanc clindamycin and pain control with morphine x ray of right tib fib negative for subcutaneous air per prelim report was concern for septic joint vs cellulitis vs nec fasciitis ed deferred vascular consult or cta of aorta with runoff due to and bilateral distribution with dopplerable pulses on arrival to the micu patient reports pain has improved to vs on arrival ra review of systems per hpi reports recent chills sweating in his legs has chronic dyspnea with minimal exertion seconds of activity has intermittent nausea and diarrhea no recent antibiotic use reports purplish discoloration of digits is not new denies fever headache cough wheezing chest pain chest pressure palpitations orthopnea pnd denies constipation abdominal pain dark or bloody stools denies dysuria frequency or hematuria denies arthralgias or myalgias other than in rle past medical history atrial flutter on anticoagulation hyperlipidemia aortic stenosis nonischemic cardiomyopathy ef w symmetric hypertrophy chf pulmonary arterial hypertension lbbb w prolonged qrs duration s p crt placement tia remote colon polyps cataracts s p bilateral surgery s p prostatectomy s p tonsillectomy social history lives alone wife recently passed away son lives in nephew lives in the area former smoker quit in denies any significant etoh use no recreational drugs plans to move to tx to be closer with family family history father had mi in his s physical exam admission exam vitals ra general awake alert oriented x no acute distress heent pupils constricted and minimally reactive to light eomi sclera anicteric mmm oropharynx clear neck supple r ij in place jvd to mandible cv tachycardic irregular normal s s possible systolic murmur distant heart sounds lungs ctab no wheezes rales rhonchi abdomen soft non tender non distended bowel sounds present no organomegaly no rebound or guarding gu foley draining clear yellow urine ext cool dopplerable pts bilaterally pitting extending beyond knees bilaterally skin bilateral lower extremities with serous weeping from skin and scattered excoriations abrasions erythema overlying medial aspect of right ankle calf without warmth induration fluctuance or crepitus exquisitely tender to light touch digits with deeper erythematous purplish tint msk passive and active rom right ankle limited secondary to pain though patient is able to minimally dorsiflex right ankle tender to palpation over right medial malleolus difficult to appreciate if joint effusion present in right ankle given degree of lower extremity edema but no warmth neuro cnii xii intact strength upper lower extremities grossly normal sensation gait deferred discharge vitals ra general awake alert oriented x no acute distress heent pupils constricted and minimally reactive to light eomi sclera anicteric mmm oropharynx clear neck supple jvp flat cv irregular rhythm normal s s iii vi holosystolic murmur best heard at apex lungs ctab trace bibasilar rales no wheezes or rhonchi abdomen soft non tender non distended bowel sounds present no organomegaly no rebound or guarding ext with compression stockings pitting edema to knees bilaterally much improved sincea admission neuro cnii xii intact strength upper lower extremities grossly normal sensation gait deferred pertinent results admission 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 alkphos totbili pm blood albumin calcium uricacd pm blood lactate k discharge 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 cpk am blood calcium phos mg micro blood cultures no growth imaging right tib fib x ray no evidence of soft tissue gas no suspicious bony lesions no fracture calcification of the anterior tibial artery and the superficial femoral artery are seen right ankle x ray three views of the right ankle demonstrate medial soft tissue swelling however the alignment is normal and there is no fracture or dislocation cxr moderate cardiomegaly and vascular congestion left pleural effusion has improved compared to the right ij central line ends at the mid svc no pneumothorax echo impression moderately dilated left ventricle with severe global hypokinesis markedly dilated right ventricle with moderate hypokinesis calcified aortic valve with probable moderate aortic stenosis the gradient is relatively low due to poor systolic function mild aortic regurgitation directed towards the anterior leaflet of the mitral valve mild mitral regurgitation moderate tricuspid regurgitation with moderate pulmonary artery systolic hypertension compared with the prior study images reviewed of left ventricular systolic function has worsened the other findings are similar r heart cath final diagnosis mild elevation in right sided and severe elevation in left sided filling pressures severe pulmonary hypertension with a moderately elevated pvr severely reduced cardiac output index pa catheter secured in place for continued hemodynamic monitoring in the ccu the pa catheter balloon should not be inflated without fluroscopic guidance as the catheter tip may migrate brief hospital course brief course m with history of schf non ischemic cardiomyopathy ef severe pulmonary htn right sided heart failure recent worsening of lower extremity edema presenting now with acute onset right medial ankle pain acute on chronic schf exacerbation ef etiology is non ischemic cardiomyopathy likely idiopathic echo from this admission shows worsening ef of with dilated left and right ventricles with global hypokinesis current clinical picture most c w right sided heart failure given jvd and lower extremity edema with minimal evidence of left sided heart failure at present lungs ctab cxr w o effusions or pulm edema we held metoprolol given hypotension and lisinopril given we restarted his home ethacrynic acid given net positive fluid status cath in showed normal coronoaries at age on exam pitting edema appreciated to right and left knee and lungs with crackles b l pt required inotropes on admission to maintain sbps weaned off lactate improved to from and patient mentating well with good uop during entire admission in ccu we initiated diuresis which significantly decreased oxygen requirement back to baseline of room air swelling in legs improved chf team consulted and recommended swan ganz with milrinone trial which was done and showed significant improvement decreased ra rv pa pressures increased co ci with milrinone swan removed picc placed and plan is for patient to have milrinone pump as an outpatient to provide better cardiac output patient plans to move to where he will have all future cardiology care on d c pt was on mcg kg min of milrinone via picc and ethacrynic acid mg qdaily in addition we recommended pt have supplemental oxygen during long plane ride to pre milrinone hemodynamic measurements ra rv pa pcwp co ci hemodynamic measurements with milrinone at mcg kg min cvp pap ci atrial fibrillation hr was well controlled in the s s during this admission pacer firing irregularly initially ep interrogated pacer yesterday atrial lead was not properly sensing afib so pt was only being intermittently paced increased sensitivity of lead and now pt is paced every beat while in afib working properly given loading doses of amiodarone and digoxin which helped to control his tachycardia we continued both digoxin and amiodarone initially but stopped amio on pt was initially on heparin gtt without problems then switched to home regimen of warfarin alone when inr inr on discharge was cardioversion considered and tee done which unfortunately showed a left atrial thrombus so cardioversion was not pursued discharged on dig warfarin mg and milrinone as mentioned above r ankle pain erythema differential diagnosis includes cellulitis gout septic arthritis dvt much less likely septic arthritis given his rom now without pain and per rheumatology and ortho will not pursue tap given low likelihood and also overlying cellulitis with fear for introducing infection from skin less likely gout given he did not receive the steroids as rec d by rheum and is doing much better most likely cellulitis given concern for possible cellulitis we continued vancomycin day completed full day course holding colchicine for now given lower suspicion of gout and clinical improvement with abx blood cx were negative pt was afebrile and wbc remained wnl and stable pt was also seen by dr who recommend specific wraps to the patient on day of discharge the patient legs were significantly improved as compared to his admission pt was discharged with instructions to use special support stockings cr on admission cr on discharge baseline of ddx includes pre renal azotemia in setting of sepsis atn secondary to hypotension poor forward flow in setting of chf overdiuresis we trended cr electrolytes renally dose meds and held lisinopril his kidney function improved and his cr was on discharge transitional left atrial thrombus continue warfarin monitoring with goal inr cont picc line care and milrinone monitoring lisinopril was held and not restarted during this admission due to and softer pt needs to address with next provider whether to restart in order to optimize chf regimen metoprolol also held during admission due to softer pressures pt is to readdress with next provider regarding when to restart to optimize chf regimen medications on admission preadmission medications listed are correct and complete information was obtained from patientfamily caregiver ethacrynic acid mg po daily lisinopril mg po daily metoprolol succinate xl mg po daily potassium chloride meq po daily duration hours hold for k potassium chloride meq po daily duration hours hold for k simvastatin mg po daily warfarin mg po daily mg s t t mg other days vitamin d unit po daily ferrous sulfate mg po daily discharge medications milrinone mcg kg min iv infusion ferrous sulfate mg po daily outpatient lab work please check chem and inr on thursday with results to dr at phone fax and dr at fax or phone icd simvastatin mg po daily vitamin d unit po daily warfarin mg po daily mg s t t mg other days tramadol ultram mg po q h prn pain rx tramadol mg one tablet s by mouth every hours disp tablet refills ethacrynic acid mg po daily rx ethacrynic acid edecrin mg tablet s by mouth daily disp tablet refills digoxin mg po daily rx digoxin mcg one tablet s by mouth daily disp tablet refills discharge disposition home with service facility home solutions infusion therapy discharge diagnosis right lower leg cellulitis acute on chronic chf exacerbation ef atrial fibrillation aortic stenosis severe pulmonary hypertension hyperlipidemia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions mr you were admitted to for right ankle pain and hypotension the right ankle pain was likely due an infection of the skin called cellulitis which we treated with a full course of antibiotics you were also found to be fluid overloaded causing shortness of breath likely due to your congestive heart failure the extra fluid was removed using diuretics water pill due to the progressive worsening of your congestive heart failure you were started on a medication called milrinone which is given into your vein using your picc line your symptoms improved and swelling decreased we have made appointments for you with cardiologist who will follow your response to the milrinone see appointment information below followup instructions if you are not still in the area for these appointments please call and cancel so that another patient can have your appointment time department cardiac services when tuesday at pm with md building sc clinical ctr campus east best parking garage department cardiac services when wednesday at pm with device clinic building sc clinical ctr campus east best parking garage department cardiac services when wednesday at pm with md building sc clinical ctr campus east best parking garage,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""service medicine"", ""allergies"", ""penicillins"", ""sulfa"", ""sulfonamide"", ""antibiotics"", ""furosemide""],
""Medications"": [""ethacrynic acid""]
}"
16545,admission date discharge date service orthopaedics allergies patient recorded as having no known allergies to drugs attending chief complaint right hip pain major surgical or invasive procedure right tha history of present illness yo male with long standing hx of right hip pain difficulty with ambulation and adls limited rom and function no recent illness no recent fever chills nausea vomiting no recent chest pain no sob past medical history prostate ca avn tia htn hypothyroid hemachromatosis social history no known toxic habits family history non contributory pertinent results pm plt count pm wbc rbc hgb hct mcv mch mchc rdw pm freeca pm hgb calchct pm glucose lactate na k cl tco pm type art po pco ph total co base xs assist con intubated intubated pm freeca pm hgb calchct pm glucose lactate na k cl pm type po pco ph total co base xs intubated intubated brief hospital course patient was admitted and underwent rtha he tolerated the procedure well initially there was some difficulty in foley placement pt had voided before the case and no urine was seen after immediate placement of the foley throughout the case there was no urine production and several cc s of bloody fluid was noted in the foley tubing urology services was consulted during the case they were able to remove the foley catheter after the case with some difficulty it was felt that the foley catheter had folded back onto itself during placement another catheter was placed and pt produced approx cc of clear urine this catheter was to be maintained for days instead of the usual protocol of removing the catheter on pod otherwise the case was without incident please see the separately dictated operative report for details regarding the surgery post operatively he was stable he received peri operative ancef started on gentamycin due to the urologic issues and was also started on iron celebrex bowel regminen appropriate prn medications and appropriate preadmission medications on pod he was made wbat and his drain was removed his cbc and chemistry were checked and noted to be in acceptable range he transferred from bed to chair w assist and worked with physical therapy he was continued on ivf and encouraged to take in fluids the orthopedic ho was called the night of pod for marginal urine output he received a cc bolus with improvement there was some staining of his dressing as well and this was reinforced on pod he progressed with physical therapy his dressing was changed in the am he was tolerating regular diet tolerating po pain medications and otherwise feeling well he had his hct rechecked and it was noted to be he was transfused u prbc he had an xr done of his hip which showed good positioning of the hardware without any dislocations fractures on pod his surgical dressing was changed and his incision was noted to be clean dry and intact he had no erythema and no purulent drainage he was otherwise neurovascularly intact distally and moving his extremity well he was tolerating regular diet progressing well with physical therapy and otherwise doing well on pod his foley was removed and he was voiding but with some hematuria urology was reconsulted and their recommendations received this hematuria was not unexpected and he was cleared for discharge he will be discharged to rehabilitation with the following orders and recommendations medications on admission pantoprazole levothyroxine lisinopril hctz discharge medications enoxaparin sodium mg ml syringe sig one subcutaneous daily daily for weeks x weeks ferrous sulfate mg tablet sig one tablet po daily daily docusate sodium mg capsule sig one capsule po bid times a day pantoprazole sodium mg tablet delayed release e c sig one tablet delayed release e c po q h every hours levothyroxine sodium mcg tablet sig one tablet po daily daily lisinopril mg tablet sig one tablet po daily daily hydrochlorothiazide mg tablet sig tablet po daily daily oxycodone acetaminophen mg tablet sig tablets po q h every to hours as needed for pain senna mg tablet sig one tablet po bid times a day as needed for constipation discharge disposition extended care facility care center discharge diagnosis right total hip arthroplasty discharge condition stable discharge instructions discharge to rehabilitation please call your pcp or report to ew if you have any nausea vomiting fever increased pain redness drainage from incision sites numbness tingling or any other concerning symptoms contact pcp and notify him her of recent admission take stool softener while on narcotics keep incision clean and dry you can shower but should not tub bath ort submerge incision take all medications as prescribed physical therapy wbat posterolateral hip precautions treatments frequency dry dressing daily followup instructions please call dr office to make an appt in days completed by,"{
""Diagnoses"": [""right hip pain""],
""Medications"": [""rtha""]
}"
10100,admission date discharge date date of birth sex m service nb history of present illness is the former kg product of a and week gestation pregnancy born to a year old g p now woman prenatal screens blood type a positive antibody negative rubella immune rpr nonreactive hepatitis b surface antigen negative group beta strep status unknown the mother s medical history is significant for ulcerative colitis she is status post colectomy performed in she also has decreased t levels and is treated with synthroid her prior pregnancies were notable for infants born at to weeks gestation who both presented with severe thrombocytopenia requiring platelet transfusions and treatment the mother has undergone intensive hematologic work up this is not pla antibody mediated thrombocytopenia there is some alpha ba antigen noted but this is not generally consistent with significant low platelets the supposition is that there is some other platelet antibody or other blood group antigen during this pregnancy the mother received intravenous gamma globulin twice weekly normal fetal surveys were performed at and weeks the infant was delivered by planned cesarean section emerged vigorous at delivery and had apgars of at minute and at minutes he was admitted to the neonatal intensive care unit for treatment of prematurity and respiratory distress physical examination physical examination upon admission to the neonatal intensive care unit showed weight kg th percentile head circumference cm th to th percentile length cm th percentile general nondysmorphic appropriate for gestational age infant in moderate to severe respiratory distress heent anterior fontanel open and flat palate intact positive red reflex bilateral chest moderate to severe intercostal retractions breath sounds coarse bilaterally cardiovascular regular rate and rhythm no murmurs normal s and s femoral pulses abdomen soft nontender nondistended extremities well perfused genitourinary normal male testes descended bilaterally skin pink no petechiae noted neurologic tone and reflexes consistent with gestational age summary of hospital course by systems respiratory was placed on continuous positive airway pressure shortly after admission ot the neonatal intensive care unit his respiratory distress resolved over the next hours and he weaned to room air he continued in room air for the remainder of his neonatal intensive care unit admission he did not have any episodes of spontaneous apnea or bradycardia during admission at the time of discharge he was breathing comfortably to times per minute cardiovascular has remained normotensive with normal heart rate no murmurs have been noted baseline heart rate is to beats per minute recent blood pressure is mm hg with a mean arterial pressure of fluids electrolytes and nutrition was initially npo and maintained in intravenous fluids enteral feeds were started on day of life no and gradually advanced to full volume at the time of discharge he was breast feeding or feeding breast milk fortified to calories per ounce with similac powder discharge weight is kg with a length of cm head circumference of cm serum electrolytes were sent on day of life no and were normal infectious disease due to the unknown etiology of the respiratory distress and unknown group beta stress status of the mother was evaluated for sepsis white blood cell count was with differential of percent polymorphonuclear cells percent band neutrophils blood culture obtained prior to starting intravenous ampicillin and gentamycin showed no growth at hours and the antibiotics were discontinued hematological hematocrit at birth was platelets were his platelets were repeated on day of life no and and were to most recent platelet count was on and was gastrointestinal was started on treatment for unconjugated hyperbilirubinemia with phototherapy peak serum bilirubin was day of life no with a total of mg dl over mg dl direct he received phototherapy for approximately hours rebound bilirubin on day of life no was total of mg dl over mg dl neurological maintained a normal neurological examination during admission there were no neurological concerns at the time of discharge sensory audiology hearing screening was performed with automated auditory brain stem responses passed in both ears condition on discharge good discharge disposition sent home with the parents name of primary pediatrician dr pediatrics phone no fax no care recommendations feedings ad lib breast feeding or breast milk po fortified to calories per ounce with calories by similac powder medications ferrous sulfate mg per ml dilution ml po once daily vi daylin ml po once daily car seat position screening was performed was observed for minutes in his car seat without any episodes of oxygen desaturation or bradycardia state newborn screens were sent on and no notification of abnormal results to date immunizations received hepatitis b vaccine was administered on immunizations recommended synagis rsv prophylaxis should be considered from through for infants who meet any of the following three criteria a born within weeks b born between and weeks with two of the following daycare during the rsv season a smoker in the household neuromuscular disease airway abnormalities or school age siblings with chronic lung 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 follow up appointment scheduled appointment with dr on tuesday at p m discharge diagnosis prematurity at and weeks gestation transitional respiratory distress rule out thrombocytopenia unconjugated hyperbilirubinemia rule out sepsis status post circumcision md dictated by medquist d t job,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""service"", ""nb history of present illness"", ""former kg product of a and week gestation pregnancy"", ""born to a year old g p now woman"", ""prenatal screens"", ""blood type"", ""positive antibody"", ""negative rubella immune"", ""rpr nonreactive"", ""hepatitis b surface antigen"", ""negative group beta strep status"", ""unknown""],
""Medications"": [""synthroid"", ""intensive hematologic work up""]
}"
92954,admission date discharge date date of birth sex f service medicine allergies benadryl attending chief complaint transfer from hospital for concern for hrs major surgical or invasive procedure therapeutic paracentesis with removal of liters of ascites blood transfusions multiple diagnostic paracenteses history of present illness ms is a year old female with pmh of alcoholic cirrhosis and admitted to on with weight gain increasing abdominal distension and abdominal pain found to have arf thought to be hrs she recently underwent an umbilical hernia repair during which time l of fliud were removed from her abdomen she had been drinking a half pint of hard liqour daily but had been sober for the last month until a week ago when she started drinking again due to familial stress she identifies the alcohol use as occuring before the weight gain her labs were notable for a creatinine of most recent nadir of in early na of hct of platelets of and wbc of she underwent an ultrasound guided paracentesis with cc of blood tinged fluid removed she was seen by gi and renal consults who felt she would benefit from transfer to per the renal consult note she has had intermittent hepatorenal syndrome type i but during this admission there was concern for type ii hrs so she was started on octreotide midodrine and albumin she was also transfused units of prbc she was transferred on vancomycin however there is nothing in the discharge summary regarding why this was started and she denies any focal infectious symptoms of note osh records from with note of abdominal ct with rectus sheath hematoma as well as liver mass and omental masses suspicious for metasteses she denies any knowledge of intraabdominal or liver masses other than cirrhosis currently she denies symptoms denies current abdominal pain dyspnea chest pain fevers she did have significant nausea and vomiting earlier today but has felt better since the paracentesis review of systems per hpi denies fever chills night sweats recent weight loss or gain denies headache sinus tenderness rhinorrhea or congestion denies chest pain or tightness palpitations denies cough shortness of breath or wheezes no dysuria denies arthralgias or myalgias no numbness tingling in extremities no feelings of depression or anxiety all other review of systems negative past medical history etoh cirrhosis complicated by recurrent ascites and hx of hepatic encephalopathy known portal gastropathy etoh abuse dependence denies a history of alcohol withdrawal multiple epsisodes of arf due to prerenal azotemia versus hrs type ii anemia s p umbilical hernia repair on psoriasis social history single has son unemployed ppd x years etoh heavy alcohol use half a pint daily illicits denies family history negative for family history of liver disease physical exam exam on admission vs t bp hr rr sat on ra admission weight kgs lbs gen middle aged female lying in bed in nad heent sclerae icteric white coating present on her tongue cv rrr systolic murmur heard best at the lusb pulm breathing comfortably crackles present b l up to the mid lung fields abd bs distended fluid wave slightly tender to palpation throughout no rebound or guarding well healed surgical incision across the lower abdomen limbs no peripheral edema skin erythematous scaling plaques scattered on her arms and legs spider angiomas present on her chest neuro alert and oriented to person place and date no asterixis pertinent results labs on admission wbc rbc hgb hct mcv mch mchc rdw plt ct pt ptt inr pt glucose urean creat na k cl hco angap alt ast ld ldh alkphos totbili albumin calcium phos mg lactate other labs tsh normal labs on discharge am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood neuts lymphs monos eos baso am blood hypochr anisocy poiklo macrocy microcy normal polychr normal ovalocy target burr acantho am blood plt ct am blood am blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos totbili am blood albumin calcium phos mg am blood tsh am blood pt ptt inr pt micro all bcx no growth peritoneal culture no growth final mrsa screen negative peritoneal cx no growth c diff negative peritoneal cx ngtd ucx ngtd bcx ngtd bcx pending x peritoneal culture ngtd ucx ngtd ua negative throat culture r o b strep pending viral cx pending c diff negative peritoneal fluid no growth peritoneal fluid no growth afb pending imaging cxr heart is upper limits of normal in size and is slightly increased compared to the previous study a few minimal interstitial opacities are present at the lung bases no confluent areas of consolidation are observed and there are no pleural effusions or concerning skeletal findings mildly distended loops of bowel in the upper abdomen are incompletely evaluated on this radiograph abd us continued reversal of main portal vein flow consistent with portal hypertension but it remains patent with no evidence of clot patent hepatic artery cirrhosis large amount of ascites continued wall thickening of gallbladder likely due third spacing no hydronephrosis ct abdomen pelvis w o contrast there is ascites with layering hyperdensity compatible with superimposed intraperitoneal hemorrhage there is thickening of the left rectus abdominis muscle compatible with rectus hematoma there are healing right rib fractures and left rib fractures which may be acute echo impressoion normal regional and global left ventricular systolic function ef the right ventricle is mildly dilated and hypokinetic with moderate tricuspid regurgitation and at least mild pulmonary hypertension mild mitral regurgitation abdominal us there is a moderate amount of free fluid within the abdomen a site in the right lower quadrant was marked reference is made to previous ct dated and the location of the site of collateral vessels was noted color doppler was applied at the site marked for paracentesis and no vessels were visualized in this region cxr slight worsening of left lower lobe opacity underlying left rib fracture which suggests atelectasis cxr in comparison with the study of there is little overall change continued low lung volumes with a patchy opacification at the left base the findings are most consistent with atelectasis though in view of the clinical history the possibility of supervening pneumonia cannot be unequivocally excluded abd us nodular liver in keeping with cirrhosis moderate ascites splenomegaly with interval increase in size compared to pulsatile flow in the portal vein can be seen in chf and chronic liver disease similar appearance to gallbladder compared to multiple prior studies with wall thickening likely due to third spacing and irregularity at the fundus likely due to adenomyomatosis if clincal concern for cholecystitis hida scan may be contributory ct pelvis w po contrast only cirrhotic liver with splenomegaly and large ascites splenomegaly is again noted to be larger than on ascites little changed in amount ascites currently of simple fluid density with interval resolution of high density blood since left rectus sheath hematoma mildly decreased in size since distended gallbladder is unchanged in appearance with wall thickening along the fundus probably due to adenomyomatosis and a punctate calcified stone small bilateral pleural effusions with adjacent atelectasis aelectasis slightly improved on the right from diag paracentesis removed l fluid sent for requested studies diag paracentesis removed cc fluid sent for requested studies diag paracentesis sent for requested studies brief hospital course year old female with pmhx of alcoholic cirrhosis and admitted to on with weight gain increasing abdominal distension and abdominal pain found to have arf thought to be hrs on admission to due to concern for possible hrs and as no fluid was sent for analysis at osh she had a diagnostic paracentesis that was very concerning for hemoperitoneum with bloody appearing fluid rbcs not enough for spun hct with wbc past para rbcs albumin less than assay cbc in the morning had dropped points so she was transfused an addition u prbc ct abdomen performed and suspicious for hemoperitoneum also notable for rectus sheath hematoma transplant surgery consulted recommended micu observation and continued transfusion support she was transfused total of units prbc bag platelets units ffp and ddavp anemia of acute blood loss rectus sheath hematoma hemoperitoneum bleeding from rectus sheath hematoma in setting of coagulopathy in combination with paracentesis may have contributed to blood loss notes suggest hematoma was present in at previous hospitalization pt was given blood ffp ddavp and platelets in the icu with improvement and stabilization of hematocrit her hct remained stable at on the floor without recurrence of hemoperitoneum she completed days of ceftriaxone for possible sbp subsequent paracentesis were done in spot marked by radiology in area with few collateral blood vessels on ct rectus hematoma was slightly smaller and ascites as of simple fluid density with interval resolution of high density blood since however paracentesis still demonstrated high red cell count although decreased from admission indicating resolving hemoperitoneum hypoxia the patient required liters of oxygen while in the icu since being given multiple blood products for dropping hematocrit in the setting of renal failure and minimal urine output cxrs showed atelectasis without pna echo with normal systolic function mod tr rv dilation hypoxia likely ascites volume overload and atelectasis she did not have any episodes of respiratory distress the patient was taken out of bed her hypoxia resolved by the time she arrived on the floor without recurrence during the rest of her hospitalization acute renal failure renal team considered pre renal vs atn as etiology of her renal failure abdominal us without hydronephrosis hepatorenal a possibility but a diagnosis of exclusion per icu team the patient had low uop on the night of admission and was given lasix mg iv with a fair response renal suggested albumin g in order to increase her oncotic pressure uop rose to cc per hour on the day of transfer to the floor on the floor she was treated for hepatorenal syndrome and her cr slowly improved peak albumin and octreotide were eventually stopped with continuation of midodrine given sbp s pt s creatinine increased again to with fevers raising concern for worsening hrs in setting of infection renal was consulted and felt that urinary sedimentation was most consistent with atn although prerenal problems and hrs could contribute she was midodrine was continued and octreotide restarted she again received albumin mg iv bid from to for hrs in setting of presumed sbp see fevers below her kidney function improved and cr was on discharge she will require close outpatient follow up of kidney function and has labs ordered for which will be followed up by her pcp pcp can decide based on her cr whether she can restart her diuretics her inr had also trended up during her hospitalization to she was given mg p o vitamin k prior to discharge for reversal and her inr should be followed up by her pcp on her labs of monday altered mental status the patient had altered mental status on admission possible etiologies included hepatic encephalopathy uremia and delirium due to metabolic causes she was started on rifaxamin in addition to her lactulose her mental status improved on the day of transfer to the floor she continued to have minor asterixis on the day of transfer but was more alert and oriented on the floor her asterixis resolved and she remained aox without recurrence of encephalopathy she was continued on lactulose and rifaximin alcohol induced hepatitis hepatic cirrhosis acute decompensation likely precipitated by relapsed alcohol abuse her lfts improved since admission hepatic encephalopathy resolved egd with erosive gastritis and portal hypertensive gastropathy but no varices she was continued on lactulose and rifaximin diuretics were held given her renal failure and can be restarted as outpatient nadolol held as she was hypotensive and can be started as outpatient although she may not need it as no varices on most recent egd done prior admission of note splenomegaly increased cm cm on ct from to should be followed up as outpatient pt had low grade fevers early in her hospitalization attributed to alcoholic hepatitis cultures negative and fevers resolved later in her hospitalization she again developed low grade fevers with tmax these were attributed to viral uri para negative for sbp by cell count but given fevers increased wbc in peritoneal fluid and hemoperitoneum which is risk factor for infection she began empiric treamtment sbp started cipro mg day with albumin x wbc in peritoneal fluid on improved from and cultures negative on she developed increased fevers with t with new leukocytosis with left shift id was consulted and felt this was possible superinfection of her known rectus hematoma or hemoperitoneum antibiotics were broadened to vanc flagyl cefepime day she was given albumin x on and for presumed sbp to prevent hrs imaging was negative for pneumonia loculation in abdomen or cholecystitis cultures were negative her fevers improved and leukocystosis and differential normalized she was discharged on sbp prophylaxis with bactrim as she developed fever during treatment for sbp on cipro etoh abuse actively drinking prior to admission later in hospitalization pt denied drinking prior to hospitalization and stated she became ill because she was weak pt continued on mvi folic acid and thiamine social work discussed alcohol use with patient she will require close outpatient follow up for relapse prevention liver mass and omental masses noted on a consult note from osh sister has been told of this at osh films from osh and current studies were obtained and reviewed with radiology these masses are not apparent on cts all without contrast nor mri in our system afp negative in pt will require mri with contrast as outpatient to definitely evaluate this rib fractures noted on imaging pt denies falls trauma abuse unclear chronicity pt will require outpatient follow up and bmd testing code full code confirmed with patient medications on admission aldactone mg po bid lasix mg po daily folic acid mg po daily thiamine mg po daily oxycodone prn lactulose ml prn corgard mg po daily prilosec mg po bid k dur meq po daily mvi daily compazine mg po prn discharge medications omeprazole mg capsule delayed release e c sig one capsule delayed release e c po bid times a day disp capsule delayed release e c s refills folic acid mg tablet sig one tablet po daily daily disp tablet s refills thiamine hcl 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 two tablet po tid times a day disp tablet s refills midodrine mg tablet sig tablets po three times a day disp tablet s refills lactulose gram ml syrup sig fifteen ml po twice a day this medication makes you have bowel movements and prevents you from becoming confused you should increase or decrease this medication to ensure you have bowel movements a day disp ml s refills outpatient lab work chem and inr please fax results to dr at please perform on dx acute renal failure sulfamethoxazole trimethoprim mg tablet sig one tablet po x week tu we th sa disp tablet s refills oxycodone mg tablet sig one tablet po every twelve hours please do not drink alcohol or perform activities requiring fast reaction time while taking this medication cause sedation disp tablet s refills discharge disposition home with service facility home health of discharge diagnosis alcoholic hepatitis alcoholic cirrhosis hepatorenal syndrome hemoperitoneum alcohol abuse discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions ms you were admitted to for evaluation of your worsening abdominal distention during the procedures to evaluate the fluid in your belly you had some bleeding you were given blood with improvement in your blood counts you also had inflammation of your liver due to alcohol use alcoholic hepatitis which occurred on top of your known scarring of the liver alcoholic cirrhosis which is what led to the collection of fluid you had some injury to your kidneys which improved you had some low grade fevers and were treated for a possible infection of the fluid in your abdomen just before you were set to leave you had a higher fever requiring a longer course of stronger antibiotics while you have become better in the hospital continued improvement will be dependent on you it is very important that you do not drink alcohol you had extensive nutrition counseling in the hospital you should continue to eat high calorie and high protein meals with supplements such as ensure changes to your medications stop aldactone until your doctors tells it is ok to restart this stop lasix until your doctor tells you it is ok to restart this stop corgard until your doctor tells you it is ok to restart this stop k dur stop compazine increase prilosec to mg twice a day decrease lactulose to ml twice a day this medication makes you have bowel movements and prevents you from becoming confused you should increase or decrease this medication to ensure you have bowel movements a day start rifaximin mg three times a day if you are unable to get this medication or it is too expensive please tell dr during your visit with him start midodrine mg three times a day continue folic acid thiamine multivitamin it was a pleasure taking care of you during your stay followup instructions pcp medical associates date time tuesday pm phone fax it is very important that you see a liver specialist dr at is happy to see you if you cannot find a specialist in your area you have the following appointment with him below if you choose not to see him please call the number below to cancel your appointment provider md phone date time lm liver center,"{
""Diagnoses"": [""alcoholic cirrhosis"", ""hepatorenal syndrome""],
""Medications"": [""Benadryl"", ""blood transfusions"", ""paracentesis""]
}"
19163,admission date discharge date date of birth sex m service nb history of present illness this is a full term infant boy born to a year old g p to mother at gestational age weeks via a planned c section for a prenatal diagnosis of fetal ventriculomegaly the mother s prenatal labs were as follows blood type o hep b surface antigen negative rpr nonreactive antibody negative rubella immune the mother was also gbs negative the pregnancy was complicated by a prenatal diagnosis of fetal ventriculomegaly made by prenatal ultrasound at approximately weeks gestational age the findings was followed with serial fetal mris in addition there was also a history of spousal abuse resulting in abdominal trauma to the mother at approximately weeks gestational age but there was no change in fetal movement noted thereafter the baby s apgars at birth were and the birth weight was grams as noted above the mother was gbs negative and there were no sepsis risk factors to the baby with regard to the prenatal diagnosis of ventriculomegaly the baby underwent a fetal ultrasound on which showed a mild ventriculomegaly on the right side measuring mm as well as a few septations in the area of the frontal of the ventricles she had a fetal mri on which showed borderline ventriculomegaly of mm on the right side as well as the same finding of frontal septations head ultrasound on and fetal mri on were all consistent with the prior findings physical examination on admission the baby had no visible dysmorphisms he was pink without any skin lesions anterior fontanelle was open and flat the palate was intact chest was clear to auscultation the heart rate was regular with a normal s s there was a systolic murmur along the left sternal border nonradiating he had femoral pulses abdominal exam was benign without any masses his hips were stable and symmetric testicles were descended bilaterally his anus was patent he had good tone with positive suck palmar and plantar reflexes summary of hospital course by system respiratory the baby remained stable on room air throughout the newborn nursery admission cardiovascular the baby underwent a cardiac evaluation on due to persistence of the systolic murmur which included an ekg which showed right axis deviation and right ventricular hypertrophy appropriate for age four extremity blood pressures within normal limits chest x ray wnl baby passed a hyperoxia test cardiology was called to see the baby who felt the murmur on auscultation was consistent with a muscular vsd and recommended outpatient followup in weeks following discharge with cardiology clinic fen gi the baby was taking good p o throughout the hospital admission id due to the prenatal diagnosis of ventriculomegaly the baby was worked up for possible torch infections with a cmv shell vial test and culture pending as of discharge toxoplasmosis will be tested for on the baby s newborn screen we held on evaluation of any infection with hsv in light of the negative maternal history and no findings on the baby s physical skin exam neurology the baby underwent a head ultrasound postnatally which was consistent with the prenatal finding of mild to moderate dilatation of the lateral ventricles with mild dilatation of the third ventricle multiple septations were present raising the possibility of prior infection or hemorrhage prompting the above noted infectious workup on the recommendation of neurology there was a questionable finding on the head ultrasound of thinning of the corpus callosum neurology was consulted on the baby followed prenatally by dr on their recommendation a postnatal head mri was performed that showed dliated lateral ventricles with septations with no definite periventricular edema and no evidence of acute hemorrhage there were several punctate periventricular foci of low signal on gre images genetics a karyotype was sent on the baby in light of the neurological findings psychosocial social work was involved with the family who can be reached at discharge disposition to home discharge cond wt good lbs oz g primary pediatrician dr in care recommendations continue ad lib feeds a state newborn screen was sent on the baby passed hearing screen was performed with automated auditory brain stem responses hepatitis b vaccine was received on immunizations recommended 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 follow up appointments scheduled recommended f u with pmd within days of discharge clinic with dr on at p m in the building th floor phone number cardiology clinic appointment to be made for weeks following discharge at discharge diagnoses full term appropriate for gestational age male ventriculomegaly along with septations impinging on the frontal horns murmur consistent with a muscular ventral septal defect md dictated by medquist d t job,"{
""Diagnoses"": [""fetal ventriculomegaly""],
""Medications"": []
}"
66481,admission date discharge date date of birth sex f service cardiothoracic allergies cephalosporins tetanus demerol attending chief complaint chest pain major surgical or invasive procedure cardiac cath aortic valve replacement with mm biocor apical tissue valve history of present illness year old female with history of aortic stenosis followed by serial echocardiograms she has been doing well until an episode earlier this year where she experienced tenderness in her chest and upper arm area she underwent an echocardiogram which revealed worsening aortic stenosis with increase velocity and gradients compared to echo done just months prior she presents today for surgical evaluation past medical history aortic stenosis rheumatic fever hypertension hyperlipidemia obesity hypercholesterolemia asthma hypothyroidism c radiculopathy colon polyps occular migraines atrial fibrillation svt osteoarthritis elevated ferritin levels sleep apnea lichen planus urinary incontinence social history race caucasian last dental exam last year lives with daughter contact cell home occupation retired cigarettes smoked no yes x last cigarette hx yr pyhx other tobacco use none etoh drink week drinks week x drinks week illicit drug use none family history no premature coronary artery disease none father died of ruptured aortic aneurysm physical exam pulse resp o sat b p right left height weight lbs general nad obese skin dry x intact x heent perrla x eomi x anicteric sclera op unremarkable neck supple x full rom no jvd chest lungs clear bilaterally x heart rrr irregular murmur x holosystolic abdomen soft x non distended x non tender x bowel sounds x no hsm cva tenderness extremities warm x well perfused x edema trace ble varicosities none x neuro grossly intact x mae strengths nonfocal exam pulses femoral right left dp right left pt np left np radial right left carotid bruit murmur radiates to b carotids discharge exam vs t hr sr bp sats ra wt general year old female in no apparent distress heent normocephalic mucus membranes moist neck supple no lymphadenopathy card rrr normal s s no murmur resp clear breath sounds throughout gi benign extr warm no edema incision sternal incision clean dry intact neuro awake alert oriented moves all extremities pertinent results cath selective coronary angiography of this right dominant system demonstrated no angiographically significant coronary disease the lmca and rca were patent the lad had a ostial lesion and the lcx had a ostial lesion limited resting hemodynamics revealed normotension echo pre cpb the left atrium is mildly dilated no thrombus 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 size is normal overall left ventricular systolic function is normal lvef 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 the aortic valve leaflets are severely thickened deformed there is severe aortic valve stenosis valve area cm there is mild ai mild mitral regurgitation is seen post cpb there is a bioprosthetic valve in the aortic position the valve is well seated with normally mobile leaflets there are no paravalvular leaks and there is no ai the left ventricular systolic function remains normal ef there is no evidence of dissection cxr there is a small right pneumothorax small right pleural effusion is new or newly apparent right lower lobe atelectasis has increased there are low lung volumes post operative mediastinal widening is unchanged moderate cardiomegaly is stable right ij catheter tip is in the upper svc left lower lobe retrocardiac opacity a combination of atelectasis and pleural effusion is stable wbc rbc hgb hct mcv mch mchc rdw plt ct wbc rbc hgb hct mcv mch mchc rdw plt ct wbc rbc hgb hct mcv mch mchc rdw plt ct wbc rbc hgb hct mcv mch mchc rdw plt ct wbc rbc hgb hct mcv mch mchc rdw plt ct pt inr pt pt ptt inr pt glucose urean creat na k cl hco glucose urean creat na k cl hco urean creat na k cl brief hospital course mrs underwent a cardiac cath on and following cath she was admitted for surgical work up on she was brought to the operating room where she underwent an aortic valve replacement please see operative note for surgical details following surgery she was transferred to the cvicu for invasive monitoring in stable condition within hours she was weaned from sedation awoke neurologically intact and extubated beta blockers and diuretics were initiated and she was diuresed towards her pre op weight on post op day two she was transferred to the step down floor for further care chest tubes and epicardial pacing wires were removed per protocol chest x ray post chest tube removal revealed small right pneumothorax on post op day three she was started on antibiotics for a urinary tract infection she worked with physical therapy for strength and mobility she made good progress and was discharged to rehab on post op day for with the appropriate medications and follow up appointments medications on admission asa mg daily multivitamin daily calcitrate vit d mg units atenolol mg daily simvastatin mg daily enalapril mg daily levothyroxine mcg daily citalopram mg daily estradiol vaginal cream discharge medications docusate sodium mg capsule sig one capsule po bid times a day ranitidine hcl mg tablet sig one tablet po bid times a day aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily multivitamin tablet sig one tablet po daily daily simvastatin mg tablet sig one tablet po daily daily levothyroxine mcg tablet sig one tablet po daily daily citalopram mg tablet sig one tablet po daily daily tramadol mg tablet sig one tablet po every hours as needed for pain disp tablet s refills sulfamethoxazole trimethoprim mg tablet sig one tablet po bid times a day for days atenolol mg tablet sig one tablet po once a day start enalapril maleate mg tablet sig one tablet po daily daily disp tablet s refills acetaminophen mg tablet sig two tablet po q h every hours as needed for pain fever furosemide mg tablet sig one tablet po once a day for days disp tablet s refills discharge disposition home with service facility discharge diagnosis aortic stenosis s p aortic valve replacement past medical history rheumatic fever hypertension hyperlipidemia obesity hypercholesterolemia asthma hypothyroidism c radiculopathy colon polyps occular migraines atrial fibrillation svt osteoarthritis elevated ferritin levels sleep apnea lichen planus urinary incontinence 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 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 clinic phone date time in the building surgeon dr on phone date time in the building cardiologist dr please call for a follow up appointment 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 completed by,"{
""Diagnoses"": [""aortic stenosis"", ""rheumatic fever"", ""hypertension"", ""hyperlipidemia"", ""obesity"", ""hypercholesterolemia"", ""asthma"", ""hypothyroidism"", ""radiculopathy"", ""colon polyps"", ""ocular migraines"", ""atrial fibrillation"", ""SVT"", ""osteoarthritis"", ""elevated ferritin levels"", ""sleep apnea"", ""lichen planus"", ""urinary incontinence""],
""Medications"": [""cephalosporins"", ""tetanus"", ""demerol"", ""attending""]
}"
24009,admission date discharge date date of birth sex f service medicine allergies latex nickel attending chief complaint left main stem bronchus obstruction major surgical or invasive procedure bronchoscopy to be done history of present illness yo woman with hypothyroidism who due to a loss of medical insurance had not been taking her thyroid replacement for six months prior to her admission to an osh on with a pound weight gain over the past four months and two weeks of fatigue weakness anorexia and fevers chills and night sweats she was found to have a tsh of greater than and a t level of less than consistent with severe hypothyroidism and associated myxedema she also reportedly had a tender pruritic purpuric papular eruption over her upper and lower extremities for two weeks prior to admission this included some large vesiculobullous lesions with central clearing two days into her admission blood culture bottles were positive for gram postive cocci that were ultimately speciated as streptococci oralis a presumptive diagnosis of endocarditis was made with the presumed source a broken tooth several weeks prior to admission she was started on penicillin g million units every four hours as well as gentamicin mg iv every eight hours performed demonstrated an ef of mild moderate mr and no obvious vegetations although scalloping of the mitral valve with an eccentric mitral jet was noted on she developed sudden worsening of her baseline dyspnea and concurrently had to cup hemoptysis with clots she was transferred to the icu fiberoptic exam performed by ent showed no source of the hemoptysis she had a v q scan that was low probability for pe with no perfusion defects but there was no ventilation of the left lung subsequent cxr showed complete white out of the left hemithorax she developed severe hypoxemia and was intubated on and a bedside bronchoscopy subsequently demonstrated the appearance of a mass blocking the left main stem bronchus the lesion was not bleeding and was thought to possible represent a blood clot thoracic surgical intervention for rigid bronchoscopy was considered but deferred due to the risk of severe hypotension that would be unresponsive to pressors given her profound hypothyroidism on her hct fell to and she was transfused two units of prbc a picc was placed and tube feeds were started she is transferred here for bronchoscopy for further characterization of the lesion in her left main stem bronchus past medical history hypothyroidism off thyroid meds x mos prior to osh admit a hashimoto s thyroiditis chronic anemia social history she is separated from her husband and lives in an apartment adjacent to her parents home she is currently unemployed she formerly worked as a data analyst at smokes cigarettes daily drinks wine occasionally no illicit drug use family history non contributory physical exam temp bp hr rr vent ac x peep fio gen intubated sedated heent perrl bilaterally ett in place neck soft supple palpable thyroid cv rrr normal s and s prominent iii vi holosystolic murmur loudest at the apex and radiating to the axilla no r g pulm cta on the right no breath sounds on the left abd soft tender over the ruq and epigastrum non distended active bowel sounds ext minimal edema skin multiple well circumscribed thinly roofed easily unroofable vesicles filled with serosanguinous fluid over the bilateral lower extremities below the knees vasc carotid radial femoral and dp pulses bilaterally lymph no palpable adenopathy pertinent results osh labs wbc hct mcv plt pt ptt inr na k cl bicarb bun cr gluc ca mg phos r o mi complete by enzymes bnp alt ast alk phos tbili alb free t tsh greater than on admission fe tibc b haptoglobin hcv negative rpr nr esr c c complement c anca and p anca less than less than iga anti gbm phospholipids u a small protein large blood rbc no wbc many fine muddy granular casts and a few coarse granular casts urine na cr tp blood cultures strep oralis pcn sensitive blood cultures ng sputum culture ngtd urine culture ng tte ef mild lvh normal rv mild ar mild eccentric mr scalloping of the anterior leaflet of the mitral valve with two eccentric mitral regurgitant jets ekg nsr at bpm normal axis prolonged pr interval normal intervals otherwise no ischemic st segment changes cxr white out of the left hemithorax not seen on admission chest ct poor visualization of the left mainstem bronchus consistent with obstruction patchy lingular infiltrate cm subcarinal ln head ct negative renal u s normal sinus ct negative abd pelvic ct negative per report operative report not reviewed by attending procedure performed flexible bronchoscopy therapeutic aspiration of the left main and left upper lobe assistant md consent informed consent was obtained from the patient the indications as well as the possible complications of the procedure were explained to her preoperative diagnosis airway obstruction postoperative diagnosis well organized blood clot in left main as well as left upper lobe procedure in detail the patient was brought to the operating room she was already intubated therapeutic aspiration of secretions was done with the yankauer while the patient still had the eg tube afterwards the rigid scope was advanced next to the eg tube through the subglottic area at that moment the tube was removed and the rigid scope was advanced into the subglottic area and secured in the trachea the flexible scope then was used and thorough examination of the tracheal bronchial tree was done flexibly findings the trachea was normal the carina was normal the right mainstem was completely patent the left mainstem was completely obstructed by a very well organized clot at that moment using the rigid forceps tumor excision was done as well as of the well organized blood clot and therapeutic aspiration was also done the airway was completely opened the right upper lobe as well as the left upper lobe and the left lower lobe were patent there was evidence of mild oozing in the left upper lobe bronchus the patient was reintubated and she was transferred to the icu impression pulmonary hemorrhage the patient needs frequent bronchoscopies for clean up complications none brief hospital course yo woman with endocarditis and hypothyroidism transferred from osh for rigid bronchoscopy for removal of lesion obstructing the left main stem bronchus left sided white out patient has known obstruction of the left main stem bronchus seen on bronchoscopy two days ago the lesion is believed to be a blood clot as the patient had a clear cxr on admission to the osh and her left sided white out followed an episode of hemoptysis her hypoxemia likely is a result of this obstruction given the acuity of the lesion other more worrisome processes such as malignancy seem highly unlikely underwent bronchoscopy with dr with successful removal of blood clot obstructed the left main bronchus subacute bacterial endocarditis etiology unclear although per osh records initial source of her strep oralis bacteremia and presumptive diagnosis of endocarditis although tte and were negative for vegetation has been attributed to recent broken tooth wbc has not normalized despite what are reportedly appropriate antibiotics no blood culture data are currently available she was continued on penicillin grams iv q h based on renal failure renal failure etiology reportedly believed to be from septic emboli from the presumptive endocarditis vs a post streptococcal glomerulonephritis although the initial u a did not have evidence of glomerulonephritis she now has at least mild gross hematuria and she has acute renal failure so her strep oralis infection seems a likely cause of her renal failure it s unclear what other work up of her renal failure has been performed no known prior history of renal disease skin lesions punch biopsy performed at osh results unavailable lesions could certainly be consistent with septic emboli from endocarditis other possibilities include systemic vasculidites although serologic work up for such has been negative to date wound care was performed with dry dressings to lesions hemoptysis per report patient had transient small volume hemoptysis a few days ago this may well be a complication of her recent strep infection causing concurrent pulmonary hemorrhage and acute renal failure as discussed above given the presence of concurrent renal failure the possibility of a vasculitis affecting the lungs and kidneys goodpasture s is compelling the negative anti gbm serology and the reported absence of findings consistent with glomerulonephritis on urinalysis make goodpasture s less likely though wegener s or a related disorder is unlikely given the negative p anca and c anca no clear source of bleeding was identified by ent or on bronchoscopy although the left sided airways were not visualized given the obstructed left main stem bronchus hypothyroidism patient presented to the osh with severe hypothyroidism in the setting of not having taken her levothyroxine for the past six months due to the lack of medical insurance she was seen by endocrinology at the osh she was continued on levothyroxine mcg iv as per osh dosing anemia reportedly chronic suspect hypothyroidism as major contributor hematocrit was stable during this admission f e n patient appeared euvolemic on admission she was given maintainance fluids overnight electrolytes were followed prophylaxis lansoprazole pneumoboots no heparin given hemoptysis code full dispo the patient returned to osh after bronchoscopy was performed medications on admission penicillin million units iv every four hours started gentamicin mg iv every hours started levofloxacin mg iv once daily started levothyroxine mcg iv once daily pantoprazole mg iv once daily ferrous sulfate mg once daily midazolam gtt at mg hour fentanyl gtt combivent mdi puffs every hours calcium carbonate mg pogt three times daily jevity tube feeds kcal at ml hour discharge medications penicillin g potassium mu iv q h levothyroxine sodium mcg iv daily start in am albuterol mcg actuation aerosol sig two puff inhalation q h every hours lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily fentanyl citrate pf mg ml solution sig mcg hr injection titrate to titrate to desired clinical effect please specify as needed for comfort midazolam hcl mg ml solution sig mg hr injection titrate to titrate to desired clinical effect please specify as needed for comfort discharge disposition extended care facility tcu discharge diagnosis bronchial obstruction hypoxemic respiratory failure hypothyroidism discharge condition stable unchanged from time of admission discharge instructions continue with management prior to admission followup instructions none md,"{
""Diagnoses"": [""hypothyroidism"", ""myxedema"", ""endocarditis""],
""Medications"": [""penicillin g"", ""thyroid replacement""]
}"
58653,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 major surgical or invasive procedure coronary artery bypass grafting x left internal mammary artery graft left anterior descending reverse saphenous vein graft to the marginal branch of the posterior descending artery history of present illness this is a year old male who presents with exertional dyspnea and chest tightness recent stress test was positive for ischemia subsequent cardiac catheterization revealed severe three vessel coronary artery disease he was referred for surgical revascularization cardiac catheterization right dominant mid lad ramus circumflex rca origins of the pda and plv lvef mean wedge pressure of mmhg cardiac echocardiogram lvef trivial mr aortic root and ascending aorta measuring about cm past medical history hypertension dyslipidemia chronic renal insufficiency preop creatinine hypothyroidism past surgical history lumbar surgery left hand surgery social history race caucasian last dental exam n a lives alone occupation retired tobacco denies etoh social family history mother with mi in late s physical exam pulse resp o sat b p right left height weight 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 abdomen soft x non distended x non tender x bowel sounds x extremities warm x well perfused x edema varicosities superficial neuro grossly intact x pulses femoral right left dp right left pt left radial right left carotid bruit right left pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood fibrino am blood glucose urean creat na k cl hco angap pm blood alt ast ld ldh alkphos amylase totbili pm blood albumin brief hospital course the patient was admitted to the hospital and brought to the operating room on where the patient underwent coronary artery bypass grafting x left internal mammary artery graft left anterior descending reverse saphenous vein graft to the marginal branch of the posterior descending artery 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 on no inotropic or vasopressor support beta blocker was initiated and the patient was gently diuresed toward the preoperative weight the patient was transferred to the telemetry floor for further recovery chest tubes and pacing wires were discontinued without complication 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 visiting nurse services in good condition with appropriate follow up instructions medications on admission diltiazem daily lisinopril daily simvastatin daily gemfibrozil twice daily aspirin daily levothyroxine mcg daily omeprazole mg daily bupropion mg tid glucosamine vitamin e allergies nkda discharge disposition home with service discharge diagnosis coronary artery disease s p cabg hypertension dyslipidemia chronic renal insufficiency preop creatinine hypothyroidism discharge condition alert and oriented x nonfocal ambulating with steady gait incisional pain managed with oral analgesics 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 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 pm cardiologist dr on at am 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 completed by,"{
""Diagnoses"": [""coronary artery disease"", ""three vessel coronary artery disease"", ""ischemia"", ""severe coronary artery disease""],
""Medications"": [""aspirin"", ""lisinopril"", ""metoprolol"", ""atenolol"", ""statins""]
}"
83381,admission date discharge date date of birth sex f service medicine allergies sulfa sulfonamide antibiotics attending chief complaint gib major surgical or invasive procedure ir angiography history of present illness f with a history of hypertension and hyperlipidemia who was seen yesterday at hospital for colonoscopy given her family history mother had polyps at age grandfather died of colon cancer she was told to get colonoscopy before age and this was her first screening study during colonoscopy yesterday she underwent polypectomy x per gi note one polyp was mm and one was mm in the hepatic flexure and the trasverse colon both were removed with a hot snare today she developed brbpr at around pm bleeding was initially abrupt in onset and brisk filling the toilet with bloody bm every minutes bleeding slowed to minutes over the next hour or so but she retained a sense of urgency with bowel movements some periumbilical abdominal cramping and rectal tensing but no associated pain no nausea or vomiting she went to hospital where initial hct was and repeat hct was she was therefore transferred to for further management given access to ir services here upon arrival to the ed vitals were t hr bp rr on l she received less than l ivf no medications gi surgery and ir teams were called with a plan for ir to come in to evaluate patient in the night in the ed here she reported lh with oob to commode she continues to have bloody bowel movements orthostatics were not assessed given patient s normal hr and taking bb hct on arrival to was t s and crossmatch sent for units vitals prior to transfer to the micu were afebrile hr bp rr o sat on ra past medical history hypertension hyperlipidemia s p tah for bleeding fibroids age s p deviated septum repair age s p wisdom teeth removal in high school social history lives with her year old daughter who is currently with her mother mother will serve as her emergency contact full time as an accountant quit smoking years ago drinks alcohol times per year no recreational drug use including no ivdu family history mother with colonic polyps age grandfather passed away of colon cancer maternal grandmother with brain cancer lung cancer mi maternal grandfather with lung cancer diabetes father died of hodgkins lymphoma physical exam admission gen awake alert nad heent dry mm neck supple pulm cta bilaterally card rrr abd soft nt nd nabs no organomegaly ext swelling in hands bilaterally has bilateral antecubital fossa pivs trace ankle edema skin intact neuro oriented no focal deficits pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood hct pm blood hct 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 alt ast ld ldh alkphos totbili am blood calcium phos mg ir no active bleed brief hospital course f with a history of hypertension hyperlipidemia who underwent colonoscopy with polypectomy x at osh yesterday now transferred to and admitted to the medical icu with brbpr lower gastrointestinal bleed in setting of polypectomy at hospital hemostasis chieved with ir angiography unable to localize source of hemorrhage patient received units prbc during admission with stabilization of hct discharged with instructions to follow up with outpatient gi this week hypertension anti hypertensives initially held on admission but restarted prior to discharge medications on admission metoprolol succinate mg po bid triamterene hydrochlorothiazide mg mg po once daily pravastatin mg po daily vitamin supplements discharge medications toprol xl mg tablet extended release hr sig one tablet extended release hr po twice a day triamterene hydrochlorothiazid mg tablet sig one tablet po once a day pravastatin mg tablet sig one tablet po once a day discharge disposition home discharge diagnosis primary post polypectomy gastrointestinal bleed discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted for a gastrointestinal bleed which was likely due to your recent colonsocopy with polypectomy you received a blood transfusion during your admission and your blood counts were stable at the time of discharge you will need to follow up with your outpatient gastroenterologist this week you may have some continued black or tarry stools for several days which is old blood if you have new bright red blood with your stools call your gastroenterologist and go to your local emergency department immediately you should restart all of your home medications as taken prior to admission it is very important that you take your medications as prescribed it is very important that you make all of your doctor s appointments followup instructions follow up with your gastroenterologist this week you should call for an appointment tomorrow morning follow up with your pcp in weeks completed by,"{
""Diagnoses"": [""Colon cancer"", ""Hypertension"", ""Hyperlipidemia"", ""Polyps""],
""Medications"": [""Medicine"", ""Sulfa"", ""Sulfonamide"", ""Antibiotics""]
}"
10060,admission date discharge date date of birth sex m service surgery allergies penicillins attending chief complaint s p fall found down major surgical or invasive procedure tracheostomy peg placement history of present illness yo male found down fall etoh he was taken to an area hospital where he was found to have bilatral subarachnoid hemorrhages he was intubated for airway protection prior to this his gcs was he was transferred to for further care past medical history mi cardiomyopathy chf copd left ventricle thrombus etoh abuse social history etoh family history noncontributory pertinent results am glucose urea n creat sodium potassium chloride total co anion gap am wbc rbc hgb hct mcv mch mchc rdw am plt count pm urea n creat pm asa neg ethanol acetmnphn neg bnzodzpn pos barbitrt neg tricyclic neg chest portable ap reason airspace disease atelectatsis medical condition year old man with peep of then bedside trach placement today now with sats of worse than prior when on endotracheal tube atelectasis reason for this examination airspace disease atelectatsis examination ap chest indication hypoxia a single ap view of the chest was obtained on at hours and is compared with the radiograph performed the prior evening at hours the patient has had removal of an et tube and a tracheostomy placed when allowing for technical differences there likely has been no significant change in the appearance of the chronic pulmonary disease together with superimposed mild interstitial edema and small bilateral pleural effusions impression stable appearance to the chest following tracheostomy echo conclusions the left atrium is mildly dilated the estimated right atrial pressure is mmhg left ventricular wall thickness cavity size and systolic function are normal lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded right ventricular chamber size is milldy increased with normal free wall motion the aortic valve is not well seen there is no aortic valve stenosis no aortic regurgitation is seen the mitral valve is not well seen no mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion brief hospital course he was transferred to the tsicu once stabilized in the ed and admitted to the trauma service neurosurgery was consulted because of his subarachnoid hemorrhage the injury was non operative serial head ct scans were followed and were stable he remained in the tsicu and initially was difficult to wean from the ventilator the decision to perform a tracheostomy and placement of a peg tube was made he underwent both procedures without any complications he was eventually weaned from the ventilator because of his head injury there were initially some behavioral problems complicating this was his history of etoh use he was placed on a ciwa protocol for alcohol withdrawal this was discontinued after days haldol was started to help control his intermittent episodes of agitation this was found to be very helpful his mental status and behavior improved over the next several days physical and occupational therapy were consulted and have recommended rehab after hospital stay he will need a speech and swallow evaluation once at rehab for passy muir and swallowing eval he will follow up with dr in clinic in weeks for possible removal of his trach and peg if he passes the speech and swallow evaluation medications on admission coumadin vasotec qd coreg asa discharge medications therapeutic multivitamin liquid sig five ml po daily daily heparin porcine unit ml solution sig one ml injection times a day bisacodyl mg suppository sig one suppository rectal hs at bedtime as needed for constipation docusate sodium mg ml liquid sig ten ml s po bid times a day nicotine mg hr patch hr sig one patch hr transdermal daily daily metoprolol tartrate mg tablet sig tablet po tid times a day hold fro hr sbp clonidine mg tablet sig one tablet po tid times a day aspirin mg tablet chewable sig one tablet chewable po daily daily acetaminophen mg ml solution sig ten ml s po q h every hours albuterol sulfate mg ml solution sig one ml inhalation q h every hours as needed for sob wheeze ipratropium bromide solution sig one neb rx inhalation q h every hours as needed for sob wheeze magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed for constipation oxycodone mg tablet sig tablets po q h every to hours as needed for pain insulin regular human unit ml solution sig one injection four times a day as needed for per sliding scale see attached haloperidol mg tablet sig one tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day swish spit discharge disposition extended care facility discharge diagnosis s p fall bilateral subarachnoid hemorrhages oral candidiasis discharge condition stable followup instructions follow up in clinic in weeks canll for an appointment inform the office that you will need arepeat head ct scan fo this appointment follow up with dr in trauma surgery clinic in weeks call for an appointment completed by,"{
""Diagnoses"": [""bilateral subarachnoid hemorrhages"", ""hypoxia"", ""atelectasis"", ""airspace disease""],
""Medications"": [""penicillins"", ""tracheostomy"", ""peg placement""]
}"
13590,admission date discharge date service neurology allergies haldol attending chief complaint lethargy garbled speech major surgical or invasive procedure none history of present illness this is an yo rhm with cerebral amyloid angiopathy left temporal hemorrhage atrial fibrillation now off coumadin htn seizures and previous strokes recently discharged from the stroke service at for treatment of above mentioned hemorrhage he was discharged to where he has been convalescing until last night when he had a fairly acute onset of garbled speech to the point where he would just be mumbling his daughter notes that he also has left sided weakness however she attributes this to previous strokes he was sent to for evaluation in the ed he had a head ct and received iv levaquin after he was found to have a uti past medical history cerebral amyloid angiopathy left temporal hemorrhage htn atrial fibrillation stroke with resultant left sided deficits stroke with left eye blindness seizures started in s last years ago hypercholesterolemia bph s p turp social history worked as tv repairman and janitor smoked for five years in his s no etoh family history non contributory physical exam t hr bp rr sat l nc pe gen ill appearing heent at nc mouth dry neck supple no thyromegaly no chest cta b cvs irregularly irregular ii vi sem abd soft ntnd bs ext no c c e no rashes or petechiae no asterixis neuro ms lethargic awake responds to name knows name disoriented to place and condition speech garbled seemingly fluent less than intelligible there is significant l r confusion there is left sided neglect of the face arm and leg patient shows left thumb on command moves right body when stimulated on left unlikely secondary to weakness alone definite left gaze preference possible right hemianopsia cn perrl bilat left eye blind left gaze preference can cross midline face sensation intact to lt pp masseters strong symmetrically left face weak left palpebral fissure widened voice normal palate elevates symmetrically uvula midline scm trapezii bilat tongue protrudes midline motor strength formal testing limited by mental status no adventitious movement delt tri we ff fe r l ip quad ham ta r l coord cannot test secondary to mental status refl tri brachio pat toe r up l up withdraws right side to left sided tactile stimulation pertinent results wbc rbc hgb hct mcv mch mchc rdw plt ct neuts lymphs monos eos baso macrocy glucose urean creat na k cl hco angap calcium phos mg pt ptt inr pt pm blood ck cpk ck mb ctropnt am blood ck cpk ck mb notdone ctropnt am blood ck cpk ck mb notdone ctropnt albumin phenoba lactate urine color yellow appear clear sp blood sm nitrite neg protein tr glucose neg ketone neg bilirub neg urobiln ph leuks sm rbc wbc bacteri few yeast none epi uric ax mod studies pcxr left lower lobe atelectasis head ct unusual appearance of a bihemispheric process involving the left temporal and right temporoparietal lobes the latter appears more acute as there was no evidence of such a process on the mr examination obtained less than two weeks ago there is a suggestion of matter involvement this may represent edema related to relatively acute infarction the persistent vasogenic edema in the contralateral temporal lobe may relate to evolving hematoma at that site given the lack of enhancement of underlying lesions on the interval mr study the process is most consistent with infarctions of different ages perhaps with hemorrhagic conversion on the left and the bilaterality is most suggestive of embolic events from a central perhaps cardiac source ekg atrial fibrillation with rapid ventricular response probable right arm left arm reversed right bundle branch block st t wave changes since previous tracing rate increased qrs wider suggest repeat tracing and clinical correlation intervals axes rate pr qrs qt qtc p qrs t head ct resolving hematoma in the left temporal lobe with vasogenic edema low attenuation in the right temporoparietal lobe also likely represent a subacute infarct with possible petechial hemorrhage versus gelatinous proteinaceous material these likely represent infarcts of different ages followup is recommended to evaluate for hemorrhagic conversion echo markedly dilated atria in the setting of atrial fibrillation severe symmetric left ventricular hypertrophy with preserved regional global biventricular systolic function mild mitral regurgitation at least moderate pulmonary hypertension small pericardial effusion ekg atrial fibrillation premature beat ventricular or aberrant left axis deviation rbbb with left anterior fascicular block since previous tracing the rate has decreased limb leads probably correct premature beat new intervals axes rate pr qrs qt qtc p qrs t brief hospital course in summary yo man with amyloid angiopathy s p left temporal hemorrhage with recent d c from on neuro service afib not anticoagulated htn seizures cvas who presented with left sided neglect hemiparesis found to have a subacute stroke event likely last night in right posterior mca territory also with uti neuro patient initially presented with report of left sided neglect hemiparesis head ct with an area of new edema in right posterior mca territory c w subacute infarct and left temporal hemorrhage old neurologic exam was signficant for inattentiveness mumbling speech left gaze preference and right hemianopsia repeat head ct at hours was unchanged patient was started on aspirin mg qd given new stroke kept hob degrees and autoregulated sbp goal history of seizure continued phenobarbitol trough level was continue outpatient po dose pgt also will recommend speech therapy and re evaluation speech and swallow when more stable and rehabilitated from stroke cv patient was in atrial fibrillation with rvr in ed that was responsive to fluids continued beta blocker increased to tid dosing also responded well to ivf resuscitation elevated troponin likely afib and worry of an acute ischemic event is low no changes on ekg will check set in am only given likely embolic stroke will control bp to goal sbp titrate up metoprolol as tolerated continued outpt fenofibrate for hypercholesterolemia id likely uti started levaquin at rehab however was spiking through with leukocytosis switched to iv ceftriaxone x day course urine culture at was contaminated resent ua and urine culture which were pending at discharge patient remained afebrile since switching to ceftriaxone he was discharged on cefpodoxime to complete the day course wound care place pt on st step select mattress pressure relief per pressure ulcer guidelines turn and reposition pt q hours when sitting in chair use foam cushion and limit sitting to hour at a time cleanse coccyx skin with wound cleanser pat dry apply allevyn foam dressing change q days and prn gu cri b l monitored closely fen riss fs qid continue folic acid thiamine zinc vitamin c electrolyte checked and repleted on jevity at we do not carry that here nutrition consulted for tube feeding recommendations and started on fs probalance cc hr adv to goal cc hr checking residuals q hr hold tfs if cc monitored i os ppx pneumoboots eye drops per outpt bowel regimen per outpt code status full code discussed with hcp daughter h c medications on admission phenobarbital mg tablet sig one tablet po bid times a day fenofibrate micronized mg tablet sig one tablet po q day docusate sodium mg capsule sig one capsule po bid times a day brimonidine drops sig one drop ophthalmic travoprost drops sig one drop ophthalmic daily folic acid mg tablet sig one tablet po daily daily acetaminophen mg tablet sig tablets po q h metoprolol tartrate mg tablet sig tablets po bid chlorhexidine gluconate mouthwash ascorbic acid mg tablet po bid zinc sulfate mg capsule thiamine hcl mg ml discharge medications phenobarbital mg tablet sig one tablet po bid times a day brimonidine drops sig one drop ophthalmic q hours folic acid mg tablet sig one tablet po daily daily ascorbic acid mg tablet sig one tablet po bid times a day zinc sulfate mg capsule sig one capsule po daily daily thiamine hcl mg tablet sig one tablet po daily daily as needed for peg acetaminophen mg tablet sig tablets po q h every to hours as needed insulin regular human unit ml solution sig per sliding scale unit injection asdir as directed travoprost drops sig one gtt ou ophthalmic daily daily fenofibrate micronized mg tablet sig one tablet po daily daily docusate sodium mg ml liquid sig one hundred mg po bid times a day aspirin mg tablet sig one tablet po daily daily heparin porcine unit ml solution sig unit injection tid times a day metoprolol tartrate mg tablet sig three tablet po tid times a day hold for sbp hr ceftriaxone dextrose iso osm g ml piggyback sig one gram intravenous q h every hours until midline care midline care per protocol diltiazem hcl mg tablet sig one tablet po qid times a day cefpodoxime mg tablet sig two tablet po q h every hours until discharge disposition extended care facility rehab center discharge diagnosis primary diagnosis subacute right temporoparietal lobe stroke urinary tract infection atrial fibrillation with rapid ventricular response sacral skin breakdown secondary diagnosis cerebral amyloid angiopathy left temporal hemorrhage hypertension stroke with resultant left sided deficits stroke with left eye blindness discharge condition neurologically stable left sided weakness face arm leg mumbling and incoherent speech but is able to follow commands discharge instructions please take medications as prescribed please keep follow up appointments if you have any change in mental status worsening fevers chills worsening weakness or any other worrying symptoms please call your primary care physician or return to the emergency room followup instructions provider md phd date time please follow up with your primary care physician weeks of discharge md completed by,"{
""Diagnoses"": [""Cerebral amyloid angiopathy"", ""Left temporal hemorrhage"", ""Atrial fibrillation"", ""Hypercholesterolemia"", ""BPH"", ""Turp""],
""Medications"": [""Haldol"", ""Levaquin"", ""Coumadin"", ""HTN"", ""BPH"", ""Etoh""]
}"
24723,admission date discharge date date of birth sex m service trauma surgery the patient is a year old male who was an unrestrained driver in a high speed motor vehicle crash the passenger was side t boned by report the patient self extricated took a few steps and collapsed he was unable to be intubated in the field and was only responding to pain initially his systolic blood pressure was he was transferred to and intubated successfully evaluation there he has a blown pupil a large pelvic fracture a negative c spine series and negative chest x ray while at that hospital he dropped his blood pressure into the s iv was started red blood cells was started and the patient was transferred to for further management the patient arrived at hemodynamically unstable he was fluid and volume resuscitated with packed red blood cells plasma products as part of his initial trauma workup the patient had numerous injuries discovered and these included multiple rib fractures bilateral pneumothoraces and hemothoraces subarachnoid hemorrhage with interventricular extension lateral mass fractures of c c and lamina fractures of c and c pneumomediastinum multiple pelvic fractures which included the iliac in the inferior superior pubic rami because of the patient s hemodynamic instability and pelvic fractures the patient was taken immediately to angiography following his initial trauma resuscitation and imaging workup his coagulopathy was corrected and at angiography a right inferior epigastric vessel was embolized successfully following angiography the patient was transferred to the trauma sicu from hospital day one to hospital day two overnight the patient developed an abdominal compartment syndrome for this he returned to the operating room for an exploratory laparotomy with dr no frank bleeding was discovered within his abdomen there was however a large stable retroperitoneal hematoma the patient s abdomen was left abdomen he was returned to the trauma intensive care unit additionally during this procedure the neurosurgical service was consulted for intraoperative placement of a ventricular catheter the following day on hospital day two the neurosurgery service again saw the patient and performed a cerebral angiogram there is no evidence of carotid injury the patient remained intubated and sedated in the intensive care unit following these procedures on the patient had a mri which demonstrated evidence of cortical hemorrhages consistent with diffuse axonal injury and no enlarged infarction the patient remained intubated and sedated in the intensive care unit without change in his neurologic examination until the date of when his abdomen was again closed for the next week the neurosurgery service continued to see the patient daily there was really very minimal resolution in his neurologic examination he is noted to have at times decerebrate posturing some spontaneous eye opening but was never able to follow commands he is also noted to be moving on his left side throughout his hospitalization the neurosurgical service felt that his prognosis for recovery was very poor from a trauma surgical standpoint the patient remained relatively stable requiring minimal amounts of blood products was maintained on maintenance fluid as well as antibiotics and tpn throughout his hospital course on following discussions with the family which had been ongoing for several days with the neurosurgery service s feeling that there is very minimal chance of recovery the family at this point decided to withdraw care on tube feedings and supportive care were stopped the patient expired shortly thereafter the patient was pronounced dead at by trauma sicu staff approximately one hour after extubation m d dictated by medquist d t job,"{
""Diagnoses"": [""Trauma"", ""Motor vehicle crash"", ""Side impact"", ""Pelvic fracture"", ""Blown pupil"", ""Cervical fracture"", ""Pneumothorax"", ""Hemothorax"", ""Subarachnoid hemorrhage"", ""Lateral mass fracture"", ""Pneumomediastinum"", ""Multiple pelvic fractures""],
""Medications"": [""Oxygen"", ""Pain medication"", ""Antibiotics"", ""Corticosteroids"", ""Pain medication"", ""Anti-seizure medication"", ""Blood transfusion"", ""Plasma products"", ""Fluids"", ""Volume resuscitation""]
}"
16247,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint witnessed cardiac arrest major surgical or invasive procedure cabgx lima lad svg om cardiac catheterization with placement of an iabp history of present illness mr is a year old gentleman who at am on with chest pain paramedics were called and he subsequently sustained a cardiac arrest he was cardioverted for ventricular tachycardia sedated and intubated and taken to the he was treated with aspirin betablockade aggrestat and heparin mr was urgently transferred to the for a cardiac catheterization which revealed an stenosed left main and a stenosed left anterior descending artery an intra aortic balloon pump was placed for coronary perfusion and the cardiac surgical service was consulted for surgical revascularization past medical history hypercholesterolemia hypothyroidism social history retired engineer lives with wife in ma denies smoking history or excessive alcohol use family history unavailable physical exam gen pt in cath lab bed intubated and sedated iabp in place vitals sr pa heent jvd cm oropharynx benign no audible carotid bruits bilaterally anicteric sclera cardiac rrr no murmur lungs clear abdomen soft nontender nondistended no hepatosplenomegally extremities no clubbing cyanosis or edema neuro intubated and sedated pupils equal pulses femoral radial dorsalis pedis and posterior tibial bilaterally pertinent results am wbc rbc hgb hct mcv mch mchc rdw am alt sgpt ast sgot alk phos tot bili am glucose urea n creat sodium potassium chloride total co anion gap am type art rates tidal vol peep po pco ph total co base xs intubated intubated electrocardiogram performed on atrial activity is not clearly discernible the rhythm appears to be atrial flutter with a v conduction at intraventricular conduction delay prior anteroseptal and lateral myocardial infarction there is much baseline artifact st segment elevations in leads i avl and v v consistent with active anterolateral ischemia followup and clinical correlation are suggested no previous tracing available for comparison echocardiogram impression severely depressed lv systolic function lvef with regional wall motion abnormalities c w cad normal rv systolic function at least mild mitral and aortic regurgitation echocardiogram mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction c w cad mild aortic regurgitation compared with the prior study tape reviewed of global left ventricular systolic function is improved mild aortic regurgitation is also now seen cardiac catheterization selective coronary arteriography of this right dominant system revealed severe lmca disease demonstrating an distal stenosis the lad had a long lesion involving the proximal and mid vessel as well as the d branch the lcx and rca were free of flow limiting stenoses hemodynamic evaluation after angiography revealed normal right sided pressures mean ra was and rvedp was mmhg moderately elevated left sided pressures mean pcw was mmhg and moderately elevated pulmonary pressures pa was mmhg the cardiac index was supranormal at l min m on dopamine infusion during intra aortic balloon counterpulsations and using an assumed oxygen consumption an intra aortic balloon pump was placed via the right femoral arteriotomy site with appropriate diastolic augmentation and systolic unloading cxr an endotracheal tube terminates is slightly proximal in location pulmonary parenchymal opacity is present within the left lung base obscuring the left hemidiaphragm with an associated small left sided pleural effusion brief hospital course mr was admitted to the medical center on for a cardiac catheterization he was found to have an stenosed left main and a stenosed left anterior descending artery an intra aortic balloon pump iabp was placed for coronary perfusion and the cardiac surgical service was consulted for surgical evaluation mr was worked up in the usual preoperative manner and taken urgently to the operating room where he underwent coronary artery bypass grafting to two vessels postoperatively he was taken to the cardiac surgical intensive care unit for monitoring his iabp was weaned and removed on postoperative day one without complication on postoperative day two mr neurologically intact and was extubated amiodarone was continued for prevention of ventricular arrythmias he was placed on a course of zosyn for thick yellow bronchial secretions on postoperative day three he was transferred to the cardiac surgical step down unit for further recovery he was gently diuresed towards his preoperative weight his epicardial pacing wires and drains were removed per protocol the physical therapy service was consulted for assistance with his postoperative strength and mobility given his history of a ventricular tachycardia arrest and low ejection fraction the electrophysiology service was consulted a repeat echocardiogram revealed improvement in his left ventricular ejection fraction from to roughly it was recommended to add betablockade and follow up in weeks with his cardiologist for a repeat echocardiogram with possible referral to the electrophysiology service for further testing mr continued to make steady progress and was discharged home on postoperative day six he will follow up with dr his cardiologist and his primary care physician as an outpatient medications on admission aspirin mg once daily synthroid mcg once daily lipitor mg once daily discharge medications furosemide mg tablet sig one tablet po q h every hours for days disp tablet s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule 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 levothyroxine sodium mcg tablet sig one tablet po daily daily disp tablet s refills amiodarone hcl mg tablet sig two tablet po bid times a day for days then decrease to mg po daily for days then decrease to mg po daily disp tablet s refills potassium chloride meq capsule sustained release sig two capsule sustained release po q h every hours for days disp capsule sustained release s refills atorvastatin calcium mg tablet sig one tablet po daily daily disp tablet s refills discharge disposition home with service facility nursing services discharge diagnosis coronary artery disease discharge condition good discharge instructions follow medications on discharge instructions you may not drive for weeks you may not lift more than lbs for months you should shower let water flow over wounds pat dry with a towel followup instructions make an appointment with dr for weeks make an appointment with dr for weeks make an appointment with dr for weeks completed by,"{
""Diagnoses"": [""cardiothoracic"", ""allergies"", ""present illness"", ""coronary artery disease"", ""stenosed left main"", ""stenosed left anterior descending artery"", ""intra aortic balloon pump""],
""Medications"": [""aspirin"", ""betablockade"", ""heparin"", ""intra aortic balloon pump""]
}"
16733,admission date discharge date date of birth sex m service nsu history of present illness the patient is a year old man with nonsmall cell ca of the lung diagnosed over two years ago and status post chemotherapy and radiation he presented in with bronchitis a workup included an mri of the head which showed a right frontal and cerebellar lesion consistent with metastasis a follow up scan of the right frontal lesion showed an increase in size with a significant amount of swelling he was started on decadron he was noted to have some problems with slurred speech and weakness in the left hand and since the start of decadron these symptoms have improved physical examination general on examination he was awake alert and fully oriented heent the pupils were mm and sluggishly reactive the eoms were full no nystagmus no diplopia smile is symmetric tongue was midline uvula elevates in the midline hearing is decreased bilaterally outstretched arms without drift rapid alternating movements performed well on the right slightly decreased on the left the patient is able to walk independently although he prefers to walk with a cane hospital course he was admitted status post a right frontal craniotomy for excision of metastatic tumor without intraoperative complications postoperatively his vital signs were stable he was afebrile he was monitored in the recovery room overnight where he remained neurologically stable he did have a left drift he did have a decreased left nasolabial fold on the left his right eye was slightly swollen his pupils were equal round and reactive to light eoms were full visual fields were intact his strength on the right was on the left his grasp was biceps and triceps ip at and gastrocnemius on the left his dressing was clean dry and intact he was monitored closely overnight in the pacu on postoperative day number one he was awake alert and oriented times three his eoms were full he continued to have decreased nasolabial fold on the left and left drift his strength on the right was still he was transferred to the regular floor on postoperative day number one he had an mri scan which showed good excision of the tumor he was seen by physical therapy and occupational therapy and safe for discharge to home he was discharged to home on in stable condition with follow up in the brain clinic in one week and in ten days for staple removal medications on discharge colace mg p o b i d amoxicillin clavulanic acid p o b i d decadron to wean down to b i d over ten days pantoprazole p o q d metoprolol p o b i d percocet one to two tablets p o q hours p r n condition on discharge stable dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service omed allergies patient recorded as having no known allergies to drugs attending chief complaint sob major surgical or invasive procedure none history of present illness yo m with h o nonsmall cell lung cancer metastatic to chest wall spinal cord and brain p w d h o sob fever and vough productive of yellow sputum pt is s p a recent right frontal craniotomy and resection of metastatic tumor he is currently on taxotere chemotherapy most recent dose on the patient says that he has been recovering well since the surgery over the last two days he developed the above symptoms plus intermittent chills no n v cp dysuria no abd pain no headache no neck pain no change in mental status upon arrival to ed patient was noted to be hypoxic with an o sat of on r a up to on non rebreather mask he was febrile to and tachycardic with a heart rate of a chest x ray revealed a persistent opacities in the rul and rll the pt is s p xrt to rul the rll infiltrate was noted to be suspicious for pneumonia past medical history nonsmall cell lung cancer dx d metastatic to chest wall also causing cord compression s p steroid tx chemotx and xrt s p right frontal craniotomy on for metastatectomy pud hearing loss secondary to perforated tympanic membrane copd social history shx tob ppd x years quit two years ago etoh retired painter lives with wife has three children physical exam pe v s t bp p spo on nrb rr gen elderly male temporal wasting in respiratory distress taking rapid shallow breaths heent op dry mm perrl eomi neck no jvd pulm coarse bronchial breath sounds with expiratory wheezes bilaterally prolonged i e ratio cor tachycardic s s no murmurs appreciated abd s nd nt bs ext no cce pertinent results pm glucose urea n creat sodium potassium chloride total co anion gap pm po pco ph total co base xs am wbc rbc hgb hct mcv mch mchc rdw brief hospital course imp yo male with h o nsclc with clinical pneumonia shortness of breath hypoxia fever productive cough likely postobstructive given lung masses plan hypoxia most likely secondary to combination of poor lung substrate copd lung cancer added insult of infection pneumonia will provide supplemental o to keep sp but less than given h o copd would check abg pneumonia likely postobstructive would treat with levofloxacin as well as provide anaerobic coverage with metronidazole obtain sputum for gram stain and culture obtain blood cultures to monitor for dissemination lung cancer disseminated current plans are for head xrt continue steroids brain mets s p recent surgery pt to be seen by neurosurgery copd underlying lung disease would provide nebs prn patient already on antibiotics and steroids ppx hep sc ppi steroids code dnr dni had long discussion with the patient his wife and his son cell they do not want his life dependent on a ventilator should it come to that hospital course transferred from icu chest ct showed increased ground glass opacities and interstitial infiltrates bilaterally did well through the day no issues off respiratory precautions improved likely d c to rehab tomorrow medications on admission meds on admission decadron mg po qd as part of taper oxycontin mg po hs prn percocet prn feso tab mg po qam discharge medications levofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills metronidazole mg tablet sig one tablet po tid times a day for days disp tablet s refills oxycodone hcl mg tablet sustained release hr sig one tablet sustained release hr po qpm prn as needed for pain disp tablet sustained release hr s refills oxycodone acetaminophen mg tablet sig tablets po q h every to hours as needed disp tablet s refills discharge disposition extended care facility courtyard discharge diagnosis pneumonia discharge condition stable discharge instructions rehab facility followup instructions please follow up with dr completed by [NEW_RECORD] admission date discharge date date of birth sex m service omed allergies fentanyl attending chief complaint sob with cough x days major surgical or invasive procedure none history of present illness yo m with h o nonsmall cell lung cancer metastatic to chest wall spinal cord and brain p w d h o sob cough productive of yellow sputum pt is s p a recent right frontal craniotomy and resection of metastatic tumor he is currently on taxotere chemotherapy most recent dose on which is cycle for him and continued whole brain xrt for his brain mets was recently admitted to omed service on for days with exact similar presentation of cough and shortness of breath and had just completed his steroid taper for brain mets when symptoms recurred there does not seem to be increasing exertional dyspnea or a h o orthopnea pt also notes some chest pressure at rest which he has experienced before he took oxycodone which relieved the sx pt says his sx improved yesterday pm and today am without any intervention pt denies fever chills orthopnea pnd current chest pain pressure n v d in ed hypoxic to on ra on face mask b c known copd started on levo flagyl and solumedrol cxr confirmed lll opacity seen on previous study one month ago with simlar presentation also tachycardic to and with low grade temps on admission to ed past medical history nsclc as above copd hearing loss pud social history pt smoke ppd x years quit two years ago he s a retired painter living with his wife and has three kids used to drink drinks day now just occasional etoh use family history non contributory physical exam t bp hr rr spo l nc gen elderly male temporal wasting in respiratory distress taking rapid shallow breaths heent perrl eomi slight scleral icterus op clear with dry mm neck no jvd no lad pulm tachypneic with use of accessory muscles no paradoxical breathing lung sounds are diffusely diminished wheezes and diffuse ronchi cor tachycardic s s no murmurs abd firm nontender nondistended nabs ext no cce neuro cn ii xii intact motor prox and distal in all extrm sensation intact 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 am blood neuts bands lymphs monos eos baso atyps metas myelos am blood plt ct am blood glucose urean creat na k cl hco angap am blood ld ldh ck cpk am blood calcium phos mg brief hospital course pt was admitted to omed from the ed pt was started on bactrim in addition to his ceftriaxone and azithromycin as it was felt that his recent steroid taper might have predisposed him to pcp albuterol ipratropium nebs were started for copd relief however steroids were initially held given possible immunosuppressed state recent steroids possible pcp on the day following admission in the am pt looked better less respiratory distress and tachypnea however as the day progressed mr became increasingly dyspneic and experienced desaturations into the mid low s and the patient was admitted to the icu where his nebs were continued steroids added on inhaled and systemic the latter for a week course and antibiotics changed to ceftriaxone metronidazole and vancomycin given possible postobstructive pneumonia with sputum cx growing out coag staphylococci pt stabilized in the icu and was called out to the floor where he remained tachypneic but appeared less symptomatic with main complaint being copious sputum production that was difficult to clear the results came back from the sputum cx showing pcn resistance so vancomycin was continued final culture results revealed mrsa and no pcp vancomycin was continued and pt was placed on mrsa precautions for sputum started aggressive chest pt guaifenisen and mucomyst pt continued to require l o by nasal cannula but appeared clinically improved from a respiratory standpoint aggressive chest pt was pursued which also helped per report of pt a picc was placed in anticipation of pt s dispo to a pulmonary rehabilitation facility to finish vancomycin course medications on admission oxycontin mg po hs prn percocet prn feso tab mg po qam discharge disposition extended care facility courtyard discharge diagnosis pneumonia methicillin resistant staph aureus chronic obstructive pulmonary disease non small cell lung cancer discharge condition currently on o l nasal cannulatolerating po diet well ambulating discharge instructions please call dr with fevers increasing shortness of breath or chest pain followup instructions provider mri where phone date time provider m d where neurology phone date time provider rn where hematology oncology phone date time completed by,"{
""Diagnoses"": [""Nonsmall cell ca of the lung"", ""Metastasis""],
""Medications"": [""Decadron""]
}"
99674,admission date discharge date date of birth sex f service neurology allergies novocain attending chief complaint left sided weakness major surgical or invasive procedure iv tpa before arrival at this hospital history of present illness yo rhf with past medical history of afib off coumadin for past week for colonoscopy htn hl ar chf p w acute onset left sided weakness at p m she was in usoh till p m today and was seen by her son at p m while eating to have acute onset weakness on the left side noticed due to her food dribbling down on the left side of her face ems was called and she was taken to at p m and was found to have dense left hemiplegia hemineglect and left visual field cut head ct showed a dense rmca m thrombus extending up to m she received iv tpa starting at p m and received the full dose she then started complaining of mild right sided headcahe which persisted she was then transferred to for evaluation for possible neurointerventional procedure on neuro ros the pt denies headache loss of vision blurred vision diplopia dysarthria dysphagia lightheadedness vertigo tinnitus or hearing difficulty denies difficulties producing or comprehending speech denies focal weakness numbness parasthesiae no bowel or bladder incontinence or retention denies difficulty with gait 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 afib previously on coumadin but held for colonoscopy on for week now htn hl moderate aortic regurgitation pda chf ef h o syncope hypothyroidism polymylagia rheumatica social history lives independently and is fully functional at baseline retired secretary drives a car has very involved children denies tobacco occasional alcohol family history father died at age of cad mother died at of chf brothers with cancer daughter with lymphoma physical exam vitals t af p afib r bp sao ra general eyes closed arouses to voice 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 irregularly irregular abdomen soft nt nd extremities wwp skin bruises ecchymoses noted in bilateral arms with large skin tear on left elbow neurologic if applicable 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 to name month and drowsy and dozes off when not being questioned speech is fluent in conversation there were no paraphasias only able to report chair and read the word room on stroke card which are the farmost right items demonstrating dense neglect vs hemianopia speech was not dysarthric able to follow both midline and appendicular one step commands dense visual sensory and auditory neglect cranial nerves i olfaction not tested ii perrl to mm and brisk does not btt in left visual field in either eye funduscopic exam deferred iii iv vi forced gaze deviation to r that does not cross midline no nystagmus noted v facial sensation intact to light touch vii left facial paresis w nlf and inability to close l eye 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 decreased tone on left moves lle in plane of bed but is unable to lift antigravity withdrawal response to pain in lue right sided extremities are antigravity sensory senses light touch reliably on right sometimes when left side is touched she states she feels it on the right othertimes she does not feel it at all again sensory neglect is profound dtrs tri pat ach l r plantar response was upgoing on the left coordination no gross dysmetria when reaching out w right hand gait deferred laboratory data pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap am blood ck mb ctropnt am blood triglyc hdl chol hd ldlcalc am blood hba c eag am blood digoxin ct cta ctp no acute intracranial hemorrhage ct perfusion study suggests acute infarctions in the superior right middle cerebral artery territory and in the right posterior cerebral artery territory these are not yet detectible on the conventional ct images with only a small focus of mild cytotoxic edema noted in the right anterior insula large thrombus extending from the distal right common carotid artery into the proximal right internal carotid artery with stenosis this thrombus also extends into and completely occludes the proximal right external carotid artery which demonstrates distal reconstitution most likely via retrograde filling through its branches occlusion of the superior division of the right middle cerebral artery bilateral fetal configuration of posterior cerebral arteries the posterior communicating arteries appear patent bilaterally enlarged and multinodular thyroid this may be further evaluated by if not previously performed elsewhere mri mra head and neck large acute infarctions involving the right frontal lobe insula and temporal lobe in the middle cerebral artery territory and the right occipital lobe in the posterior cerebral artery territory focal hemorrhagic transformation in the posterior right temporal lobe motion limited mras of the head and neck demonstrate no appreciable change from the preceding ctas of the head and neck there is a large thrombus extending from the distal right common carotid into the proximal right internal carotid and external carotid arteries with stenosis of the right internal carotid artery better demonstrated on the cta and complete occlusion of the proximal external carotid artery with reconstitution via retrograde filling persistent occlusion of the superior division of the right middle cerebral artery bilateral fetal posterior cerebral arteries with bilateral patent posterior communicating arteries echocardiogram patent ductus arteriosus mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function moderate to severe tricuspid regurgitation pulmonary artery hypertension mild aortic valve stenosis mild aortic regurgitation dilated ascending aorta cta neck interval decrease in size of the thrombus in the right common carotid artery extending into both the internal and external branches a small amount of thrombus is still present the previously seen occlusion of the superior division of the right mca is not completely included in the field of view of today s study given that the study is a neck cta if there is any clinical concern for continued occlusion recommend a dedicated cta of the head for further evaluation worsening pulmonary edema with bilateral pleural effusions brief hospital course the patient is an y o with past medical history of afib off coumadin for pastweek for colonoscopy htn hl ar chf p w acute onset left sided weakness and found to have left hempiplegia and profound neglect consistent with r mca syndrome neuro at a dense mca sign was seen on imaging and the pt received iv tpa at min after onset of symptoms nihss was slightly improved here to from at the patient had a cta head and neck here which revealed recanalization of the r mca with cutoff seen at r m superior division and evidence of thrombus at the r cca occluding extending to r eca and r ica with recanalization distally endovascular intervention was discussed with the neurointerventional attending as well as stroke attending dr and the decision was made that the risk of attempting recanalization of the r cca thrombus could potentially outweigh the benefit given the risk of distal embolization with manipulation and relatively intact blood supply currently to circle of the patient had a mri head which showed large acute infarctions involving the right frontal lobe insula and temporal lobe in the middle cerebral artery territory and the right occipital lobe in the posterior cerebral artery territory as well asa focal hemorrhagic conversion the patient was briefly placed on a heparin drip despite this due to concern for the right carotid occlusion this was later discontinued when the patient had a headache due to concern for bleed ct head was obtained hours after tpa and showed no progression of hemorrhagic conversion noted on mri the previous day the patient remained in the icu overnight and then was transferred to the floor the following day she was started on aspirin and then restarted on coumadin the patient regained some left sided strength and her left sided neglect improved slightly while on the floor she began to open her eyes spontaneously and answered questions appropriately a repeat cta of the neck showed decreased thrombus of the right common carotid cardiac the patient was monitored on telemetry and remained in atrial fibrillation her cardiac enzymes were negative she was continued on metoprolol at lower doses initially and home antihypertensives were held to allow for autoregulation her heart rate trended up and her metoprolol was increased to her home dose as above she was started on aspirin bridge to coumadin echocardiogram revealed a pfo endocrine her fingersticks were checked and she was placed on sliding scale insulin glycohemoglobin was normal and ldl cholesterol was fen the patient was not able to swallow safely so a ng tube was placed and tube feeds begun on on the patient was cleared to start ground solids and nectar thickened liquids her tube feeds were held during the day and the plan is to continue nightly tube feed until she is able to take in an adequate number of calories infection the patient was noted to be delerious on and ua came back positive she was started on ceftriaxone for uti urine culture pending at this time once antibiotics were started her delerium cleared dysphagia screening before any po intake x yes no dvt prophylaxis administered x yes no antithrombotic therapy administered by end of hospital day x yes no ldl documented x yes intensive statin therapy administered for ldl yes x no if ldl reason not given smoking cessation counseling given yes no reason x non smoker unable to participate stroke education given x yes no assessment for rehabilitation x yes no discharged on statin therapy x yes no if ldl reason not given discharged on antithrombotic therapy x yes type x antiplatelet x anticoagulation no discharged on oral anticoagulation for patients with atrial fibrillation flutter x yes no n a medications on admission preadmission medications listed are correct and complete information was obtained from family caregiver simvastatin mg po daily lisinopril mg po daily warfarin md to order daily dose po daily mg as directed digoxin mg po daily levothyroxine sodium mcg po daily metoprolol tartrate mg po bid prednisone mg po daily tabs daily docusate sodium mg po bid clobetasol propionate ointment appl tp discharge medications digoxin mg po daily docusate sodium mg po bid levothyroxine sodium mcg po daily prednisone mg po daily tabs daily metoprolol tartrate mg po bid simvastatin mg po daily aspirin mg po daily stop when inr nystatin cream appl tp clobetasol propionate ointment appl tp nitrofurantoin macrodantin mg po q h please continue through warfarin mg po daily discharge disposition extended care facility hospital discharge diagnosis right frontal temporal and occipital lobe stroke patent foramen ovale discharge condition oriented to date does not believe we are at thinks she s in hospital in opening eyes answers questions appropriately naming intact left facial droop l hemineglect l hemiparesis antigravity increased tone in left arm localizes to pain on the left arm withdraws to pain in left leg toes up on left and down on right bibasilar crackles in lungs improved discharge instructions dear ms you were admitted for a stroke this was thought to be secondary to your atrial fibrillation you were restarted on coumadin for stroke protection your stroke risk factors were checked you should continue to not smoke your ldl cholesterol was you were continued on a statin you had a cardiac echocardiogram which demonstrated no cardioembolic source but did show a patent foremen ovale you were checked for blood glucose control with a hgb a c the level was which is normal you need to continue your blood pressure control you should continue to eat a low fat healthy diet and follow up with your primary care physician and stroke neurology as detailed below it was a pleasure taking care of you followup instructions please follow up provider date time provider neurology md phone date time provider md phone date time md,"{
""Diagnoses"": [""Neurology"", ""Allergies"", ""NovoCain"", ""Attending Chief Complaint"", ""Left Sided Weakness"", ""Major Surgical or Invasive Procedure"", ""IV TPA"", ""Acute Onset Left Sided Weakness"", ""Dense Left Hemiplegia"", ""Hemineglect"", ""Left Visual Field Cut"", ""CT Showed Dense RMCa Thrombus""],
""Medications"": [""Coumadin"", ""TPA""]
}"
11101,admission date discharge date date of birth sex m service history of present illness the patient is a year old male with history of atrial fibrillation chronically infected fistula tract in his left hip who presents with three to four day history of fatigue malaise tachypnea anorexia decreased po intake and watery diarrhea of six to seven bowel movements per day he was in his usual state of good health until approximately one week prior to admission when he noted watery diarrhea without cramping blood melena however he did complain of dry heaves and anorexia two to three days prior to admission he noted increasing dyspnea cough production of yellow nonbloody sputum and subjective fevers he did not document his fevers he denies night sweats he attempted to keep up with his fluid loss by a po intake however on the day of admission complained of dry mouth and decreased urine output on arrival to the emergency room he was hypoxic with oxygen saturation in the mid on ten liters nonrebreather he was hypotensive at however he responded to intravenous fluids and oxygen initial electrocardiogram showed atrial bigeminy but repeat was in sinus tachycardia review of systems patient denies exertional chest pain melena bright red blood per rectum hematuria obstructive voiding symptoms denies recent increase in drainage of his left hip sinus past medical history significant for hypertension basal cell carcinoma of his right anterior shin atrial fibrillation motor vehicle accident in complicated by left hip fracture status post rod placement chronic methicillin sensitive staphylococcus aureus infection on suppressive dicloxacillin last documented in to be methicillin sensitive staph aureus echocardiogram showed mild left atrial enlargement ejection fraction greater than mild aortic regurgitation mild mitral regurgitation normal pulmonary artery pressures hypercholesterolemia and status post appendectomy medications he is on coumadin trandolapril mg amiodarone q d and prn viagra allergies no known drug allergies social history quit tobacco ten years ago two or more packs a day lives with his wife in he is a publisher physical examination vitals temperature maximum pulse decreased to after fluid resuscitation blood pressure after fluid bolus breathing saturating on ten liters in general he is tachypneic on nonrebreather head eyes ears nose and throat showed pupils equal round and reactive to light and accommodations extraocular muscles were intact sclerae are anicteric oropharynx clear without lesions mucous membranes were dry neck was supple there was no lymphadenopathy cm jugular venous distention lungs left lung showed rhonchus breath sounds but good air movement right lung decreased breath sounds at the bottom one half of lung fields positive e a changes at right base heart was normal s s distant heart sounds abdomen was obese soft nontender nondistended extremities showed no edema and cyanosis distal pulses were bilaterally left hip fistula drainage tract was draining serosanguinous fluid there was no odor no pus no erythema neurological exam was nonfocal laboratories white blood cell count of with neutrophils bands lymphocytes monocytes hematocrit of mcv of platelets of pt of ptt of inr of sodium potassium chloride bicarbonate bun creatinine baseline creatinine glucose acetone was negative legionella urinary antigen was negative urinalysis was amber cloudy small blood greater than protein small bilirubin urobilinogen was with no cells arterial blood gases were pco of pa of bicarbonate lactate was first electrocardiogram showed sinus tachycardia at left axis deviation qrs at poor r wave progression persistent s in v t wave inversion in v v nonspecific intraventricular conduction delay chest x ray showed large right lower lobe infiltrate with volume loss small pleural effusion on right patchy infiltrates in the left lower lobe however could still see the left hemidiaphragm this year old male was admitted to the medical intensive care unit with severe community acquired pneumonia hospital course by systems hematology the patient was noted to be in mild dic as evidenced by elevated ptt on admission however his platelets were fine there was no evidence of consumptive coagulopathy coumadin was held ptt normalized over the course of stay pulmonary patient with tobacco history and severe community acquired pneumonia sputum cultures were repeatedly sent which did not grow out a predominance of any specific respiratory pathogen early on the morning of his third hospital stay he desaturated to the s and then began to fatigue with arterial blood gases of he was intubated and sedated at that point his chest x ray was unchanged his small right side effusion was tapped which was shown to be exudative with a ph of grams of total protein glucose ldh serum ldh at that time was had white blood cells with polys bands lymphocytes monocytes red blood cells gram stain was unrevealing patient on the following day patient was stable on the ventilator still requiring mechanical ventilation chest x ray unchanged a bronchoscopy was performed which showed normal airways sputum in the right lower lobe and right middle lobe bal was negative for acid fast bacilli pcp and rsv there was positive gram stain showed polys squamous cells oropharyngeal flora on the fifth hospital day the patient required increased fio to to maintain oxygenation at this point there was some concern given his low p f ratio that he had possibly progressed to acute lung injury and or adult respiratory distress syndrome however it was likely he remained just with significant community acquired pneumonia on the fifth hospital day infectious disease consult recommended a ct to evaluate further for processes as he remained without microbiological diagnosis this showed extensive alveolar consolidation involving nearly the entire right lung and to a lesser degree the left lower lobe heterogeneous enhancement attenuation suggested necrotizing pneumonia though no abscesses are evident at this time multiple predominantly ill defined nodules throughout the remaining irradiated lobes most likely areas of early consolidation however follow up ct after appropriate antibiotic therapy and serial chest x ray are recommended to exclude true lung nodules parapneumonic effusion small on the left moderate on the right pleural calcification on the left lower hemithorax and tiny right posterior pleural calcification question of history of asbestosis exposure right adrenal lesion measuring cm possibly an adenoma recommended follow up mri patient was again bronched on the fifth hospital day which showed edematous airway culture data was still unrevealing at this point and so on the th the sixth hospital day the patient underwent open lung biopsy preliminary frozen section was likely to be infectious etiology versus malignancy however on the seventh hospital day the pathology came back showing definite adenocarcinoma as well as alveoli polymorphonucleocytes lymphocytes and atypical cells infectious disease the patient was started on vancomycin and levofloxacin for community acquired pneumonia and concern that it was colonized to the methicillin resistant staphylococcus aureus given his chronic methicillin sensitive staphylococcus aureus infection and suppressive dicloxacillin despite two bronchoscopies with bal and culture and multiple blood cultures sputum cultures no microbiologic diagnosis was ever made however the pleural fluid grew out presumptive peptostreptococcus rare growth two colonies infectious disease consult on the third hospital day recommended addition of imipenem to his regimen which is done patient tolerated antibiotics without difficulty however the microbiologic diagnosis is still unclear at the time of death cardiovascular the patient was in atrial fibrillation with stable ventricular response throughout the hospitalization until the night of intubation the third hospital night when he went to atrial fibrillation with rapid ventricular response which broke easily with mg of diltiazem echocardiogram obtained the next day showed mild left atrial enlargement however showed global left ventricular hypokinesis with an ejection fraction of where as it had been greater than in also noted on the second echocardiogram was a focal apical right ventricular akinesis on the sixth hospital day the patient underwent a swan ganz catheterization to estimate his cardiac status and fluid status his cardiac output was found to be index svr pulmonary capillary wedge pressure was his peep was set at based on this it was felt that patient was not in fact fluid overloaded and congestive heart failure was not a component to his poor oxygenation at this point patient was fluid bolused patient remained on increasing doses of levophed from the fifth hospital day until his death on the seventh hospital day disposition day of death patient s family was concerned of lack of response to antibiotics when the pathology from the lung biopsy came back positive for adenocarcinoma of the lung the family made the patient do not resuscitate and approximately three hours later patient had a decreased response to pressors on fio and he passed away at p m on he was pronounced dead by dr consent for postmortem examination was obtained by the family date of death m d dictated by medquist d t job,"{
""Diagnoses"": [""atrial fibrillation"", ""chronic fistula tract infection"", ""dehydration"", ""malnutrition"", ""pneumonia""],
""Medications"": [""furosemide"", ""ondansetron"", ""metoprolol"", ""aspirin"", ""ceftriaxone""]
}"
16481,admission date discharge date date of birth sex m service history of present illness this year old male with a ten year history of progressive parkinson s disease tripped over his own feet and fell down approximately seven steps he states for a few seconds he was stunned and felt tingling in all four extremities he also noted pain in his legs left greater then right and in his right chest he was taken to hospital where he was reportedly neurologically intact he was in a cervical collar a ct scan of the cervical spine was obtained this showed a fracture of the anterior arch of c there was a moderately displaced comminuted odontoid fracture extending through the base which moderately narrowed the spinal canal the dens and c were displaced approximately mm the patient was able to void spontaneously times two before a foley catheter was placed the patient has been followed by dr in neurology for his movement disorder past medical history the patient has a history of bipolar disorder and parkinson s syndrome allergies he is allergic to haldol medications sinemet folate valproic acid seroquel amantadine laboratories on admission white blood cell count of hematocrit platelet count amylase sodium potassium chloride co bun creatinine glucose lactacid physical examination the patient is alert and oriented times three he is complaining of a headache posterior neck pain and right chest pain he has a marked resting tremor primarily effecting his left upper extremity and left lower extremity there is cogwheel rigidity of both upper extremities his cranial nerves are intact he describes altered sensation and pain to light touch and pin prick over his left occiput and right chest at approximately the t to t levels there is no clear sensory level to pin prick light touch position direction or vibration the patient s cervical collar fits well his toes are upgoing his reflexes are his strength is good in his upper extremities and lower extremities hospital course the patient s management was greatly complicated by his multiple medical problems it was difficult to reduce his fracture and apply a halo because of his movement disorder he was initially kept in a cervical collar an mri scan of the cervical spine was obtained to rule out an epidural hematoma this showed no evidence of any significant cord compression or epidural bleeding he was placed in a halo traction he was noted to have severe dyskinesias from his sinemet which made it difficult to maintain him in halo traction therefore he was seen once again by the neurologist who recommended decreasing his sinemet and continuing the amantadine the patient was taken to radiology where he was placed in halo traction under fluoroscopy once again this was greatly limited by his dyskinesias and his inability to remain still during the procedure the patient was noted to have multiple episodes which seemed to be aspiration he began spiking fevers up to and the patient s chest x ray showed an infiltrate consistent with an aspiration pneumonia he was kept on levaquin his white count was as high he was pan cultured with no other source apparent by the patient had two plain films which showed excellent alignment and reduction of the c c subluxation the patient was placed in the halo vest on a post procedure film once again showed excellent alignment the patient was intubated for his inability to clear his secretions a second post reduction film showed a bit more displacement approximately mm at the c c level however at this point the patient was intubated and sedated there is no evidence of any spinal cord compression on the films it was felt safer to leave the patient intubated and sedated with the halo in that position rather then attempting to realign the fracture without the patient being monitored by his neurological examination the patient would open his eyes at times he periodically would get dilaudid to mg and ativan he was inconsistently following commands he continued to have high fevers up to and a ct scan of the abdomen was unremarkable the patient was again seen by neurology it was felt that his obtundation was likely due to his fevers a follow up ct scan of the head and cervical spine were obtained this showed no evidence of any intracranial masses or infection the patient had no evidence of infection at the site of his fracture because of the need for continued ventilation the patient had a tracheostomy and g tube placed these were well tolerated he continued having fevers ranging from to his white count remained in the to range he really was not responsive a lumbar puncture was recommended however the patient s wife felt strongly she did not want this procedure done the patient was continued on oxacillin ceftriaxone and flagyl his sputum cultures grew out methicillin sensitive staph aureus pneumococcus and strep viridans a ct scan once again reconfirmed a dense right lower lobe infiltrate the infectious disease consultant suggested the differential included a c diff colitis metastatic infection with mmsa a possible meningitis a drug fever or a line infection the patient s lines were changed at this point his white blood cell count began to come down however he still had nightly fevers there was no improvement in his mental status the patient s family felt strongly they would like him to go to rehab plans were made for this final discharge diagnoses parkinson s disease c c fracture aspiration pneumonia fever of unknown origin condition on discharge the patient is obtunded he is in a halo he will need to remain in the halo for a minimum of three months if he improves neurologically and is awake the halo should be readjusted m d dictated by medquist d t job [NEW_RECORD] name unit no admission date discharge date date of birth sex m service this is an addendum to a previously dictated discharge summary the patient was evaluated for transfer to the hospital from to there is absolutely no change in his neurologic status the patient remained obtunded he was tolerating his tube feeds he periodically had temperatures from degrees his pin sites were clean his chest x ray showed no new infiltrates plans were made to transfer the patient to the on final discharge diagnoses cervical spine fracture parkinson s disease fever altered mental status condition on discharge poor follow up plans patient is being transferred to the for further care m d dictated by medquist d t job cclist,"{
""Diagnoses"": [""Parkinson's disease"", ""Fracture of the anterior arch of C""],
""Medications"": [""Haldol"", ""Sinemet"", ""Folate"", ""Valproic acid"", ""Seroquel"", ""Amantadine""]
}"
22056,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint bradycardia status post ablation for atrial fibrillation major surgical or invasive procedure pulmonary vein isolation and ablation placement of temporary pacer wire history of present illness this is a year old gentleman with long standing atrial fibrillation status post two pulmonary vein isolation procedures he initially diagnosed with atrial fibrillation approximately years ago and had been treated therapy for his atrial fibrillation included digoxin sotalol and for the last years flecainide for apprxomiately the first years he had atrial fibrillation only paroxysmally in however mr went into a period of atrial fibrillation that lasted months this prompted an atrial fibrillation ablation on in the procedure was unsuccessful and he reverted to atrial fibrillation mr was subsequently evaluated at the clinic and in underwent a second pulmonary vein isolation procedure of note he reports he was bradycardic after this procedure but eventually returned to a normal heart rate pacemaker placement was therefore deferred he remained in sinus rhythm for only four days post procedure reverting back to af he underwent dc cardioversion but several days later again reverted to af mr had an episode of shortness of breath middle of necessitating admission to an osh he was found to be in atrial fibrillation with rvr and treated with an iv medication the name he cannot recall another dc cardioversion was performed in howevever he has remained in atrial fibrillation and or atrial flutter for the past several months for this reason it was decided by his cardiologists at to reattempt ablation for the past few months the pt continues to have shortness of breath with exertion he denies chest pain palpitations or any peripheral swelling no lightheadedness or syncopal episodes no recent fevers chills or nausea no vomiting or diarrhea the procedure was performed on day of admission he was noted to be bradycardic to rate of for this reason a temporary pacer wire was placed and he was admitted for observation and possible permanent pacemaker placement the patient denies any lightheadedness or dizziness at this time no nausea no cp or dizziness past medical history atrial fibrillation s p pulmonary isolation x hyperlipidemia depression appendectomy removal of benign cysts social history patient is married with adult children he works as a dentist family history a younger brother also has atrial fibrillation his father passed away of mi at physical exam vs t p paced bp r o on l gen wd wn male caucasian nad no apparent shortness of breath speaks in full sentences mouth mmm no lesion neck jvp to cm lungs clear to auscultation bilaterally heart s s are normal no audible murmurs abd soft with no hepatosplenomegaly non tender bowel sounds groin pacer instrumentation in place on r sheath in place on l no hematoma or bruit evident extremities normal dp pulses no edema tel sinus paced with rate of pertinent results imaging cardiac mr lvef effective forward flow mild mr mild tr mild atrial enlargement no evidence of pulmonary vein anomalies per pt a tee done in the clinic in that showed no abnormalities of the pulmonary veins wbc hct mcv plt ct pt ptt inr pt glucose urean creat na k cl hco calcium phos mg ekg prior to ablation supraventricular tachycardia with block with a ventricular rate qrs and q t interval is prolonged post ablation ekg sinus bradycardia rate pr prolonged brief hospital course this is a year old gentleman with long standing atrial fibrillation that has been symptomatic at times characterized by fatigue and shortness of breath he has undergone pulmoanry vein isolation procedures and was admitted for what was his third pulmonary vein isolation and ablation procedure was successful and mr remained in sinus rhythm for the duration of his stay post procedural course was characterized by bradycardia to s requiring temporary transvenous pacing the following morning his pacer wire was discontinued and his resting hr in s increasing to s with exertion based on this it was decided the patient does not now require placement of a permanent pacemaker he was restarted on lower dose toprol xl mg po daily flecanide was not restarted he was discharged home with instructions to restart his coumadin he has an appointment with dr on and may be set up for a tee and mri to assess for pulmonic stenosis he was also sent out with a koh monitor and will have further rhythm monitoring arranged by dr office other issues bph continued avodart per outpatient regimen depression continued escitalopram code status remains full medications on admission avodart mg daily every morning lexapro mg daily every morning zyrtec mg daily every morning toprol xl mg daily every morning flecanide mg twice a day lipitor mg daily every evening coumadin mg monday s and friday s mg all other days last dose discharge medications atorvastatin mg tablet sig one tablet po daily daily escitalopram mg tablet sig two tablet po daily daily cetirizine mg tablet sig one tablet po once daily every morning warfarin mg tablet sig one tablet po hs at bedtime as needed for atrial fibrillation take mg every day until inr is then back to your previous regimen avodart mg capsule sig one capsule po every morning as needed for benigh prostatic hyperplasia ropinirole mg tablet sig two tablet po hs at bedtime metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po daily daily disp tablet sustained release hr s refills aspirin mg tablet sig one tablet po daily daily disp tablet s refills discharge disposition home discharge diagnosis atrial fibrillation discharge condition good discharge instructions you were admitted for a pulmonary vein isolation and ablation your course was complicated by transient bradycardia and you had a temporary pacemaker wire placed you are also being sent home with of hearts monitor and should follow up with dr as arranged you should return to the ed with dizziness lightheadedness palpitations or for any other problems that concern you followup instructions provider m d phone date time,"{
""Diagnoses"": [""atrial fibrillation"", ""bradycardia"", ""status post ablation for atrial fibrillation"", ""major surgical or invasive procedure"", ""placement of temporary pacer wire""],
""Medications"": [""digoxin"", ""sotalol"", ""flecainide""]
}"
84838,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint epigastric pain major surgical or invasive procedure ercp history of present illness pcp address phone fax yo gentleman with little pmhx was admitted from ercp suite with history epigastric pain he was initially admitted to lgh days ago with acute on chronic epigastric pain and diagnosed with pancreatitis additional review of systems is notable for the following intermittent epigastric pain and anorexia over last months he denies fevers or jaundice at lgh labs were notable for leukocytosis with wbc increasing serum and fluid amylase levels with serial fluid amylase readings of s imaging was notable for the following abdominal ct with peripancreatic and ascitic fluid mri which revealed an amorphous pancreatic head suggestive of hemorrhagic pancreatitis a paracentesis was performed on and fluid total protein was elevated a saag was near zero and fluid cell count revealed wbc with neutrophilic predominance for treatment he was started empirically on unasyn on and then changed to zosyn on he also had a drain placed into one of his abdominal fluid collections additional issues include the following malnutrition he was started on tpn in the setting of being npo and with marked hypoalbuminemia with alb anemia he received unit prbcs atrial fibrillation he developed rapid afib on he was initially started on diltiazem with minimal improvement and he was then transitioned to amiodarone a pigtail drain was placed to drain ascitic fluid he was transferred to assessment for ercp and possible transpapillary drainage with stenting finger stick glucose was elevated to this afternoon ros constitutional no weight loss fatigue fevers chills night sweats anorexia for months neuro no headaches confusion numbness of extremities dizziness or light headedness vertigo weakness of extremities tremor parasthesias psychiatric no depression no suicidal ideation eyes no blurry vision diplopia loss of vision photophobia ent no dry mouth oral ulcers bleeding nose or gums tinnitus sinus pain sore throat cardiac no chest pain doe syncope pnd orthopnea palpitations chronic bilat lext peripheral edema pulmonary no shortness of breath cough hemoptysis pleuritic pain gi intermittent epigastric abd pain especially last days none now no nausea vomiting diarrhea constipation hematemesis melena hematochezia heme no easy bleeding bruising lymphadenopathy gu no dysuria hematuria increased frequency urgency chronically but no incontinence endocrine no changes in hair skin heat or cold intolerance change in hat or glove size weight changes change in energy skin new rash mild today no pruritis or lacerations musculoskeletal no myalgias arthralgias back pain allergy no seasonal allergies drug allergies as above past medical history cirrhosis by recent mri no known prior eval pt not aware new onset rapid afib recently at lgh in setting of fluid overload started on amiodarone now resolved chronic diastolic congestive heart failure benign hypertension bph prior prostate biopsy negative for cancer per pt has urgency frequency no incontinence no recent hydro social history home lives alone downstairs from brother in law and nieces childless widower was in the service occupation former shipping department worker for box company tobacco never smoked etoh occasional etoh in past drugs denies family history no cancers or genetic diseases physical exam elderly gentleman pleasant slightly hard of hearing in no distress t bp hr regular rr spo ra heent anicteric op mildly dry no thrush no lesions neck jvp not elevated no neck is supple cor rrr nl s s no mrg normal pmi lungs scant crackles at bases otherwise cta bilaterallly abd distended with ascites non tender no guarding cannot evaluate for organomegaly given fluid ext chronic venous stasis hemosiderosis bilat symmetric lext edema neuro alert oriented x mild sensory hearing loss no focal abnormalitis skin mild blanching rash on chest back arms pertinent results osh labs na k cl co bun cr bg alb ca tb alk phos ast alt amylase lipase wbc hct plt n l m esr wbc hct plt ca wbc hct plt n bands l m na k cl co bun cr bg alt ast alk phos amylase lipase bnp wbc hct plt n bands l m e na k cl co bun cr alb tb db alk phos alt ast amylase lipase na k cl co bun cr ca phos mg alb alk phos tb ast alt amylase lipase inr wbc hct plt peritoneal fluid wbc rbc alb amylase glucose no malignant cells increased pmns with fibrinopurlent debris microbiology blood cx x pending negative ascites fluid cx pending negative afb smear negative osh studies peritoneal fluid no malignant cells ct abd cirrhosis with moderate ascites high density soft tissue pancreatic head abnormality c w hemorrhagic fluid no air within the focus to suggest perforation fluid collection within central mesentary probable ileus marked enlarged prostate hiatal hernia kub moderat ileus no obstruction cxr low lung volumes with atelectasis and small bilat effusions mrcp pancreatic head mass secondary to acute hemorrhagic pancreatitis need to r o underlying mass secondary mild diation of main pd mm unchanged from prior ct no intra extra hepatic biliary dilation mild gb distention w o stones cirrhosis and moderate ascites u s abdominal ascites with septations heterogeneous liver nl spleen no hydronephrosis small bilat effusions echo mild lvh nl lv size ef grade diastolic dysfunction nl rv mod lae minimal aortic stenosis w peak grad mmhg tr tr no pericardial effusion labs admission labs wbc hct plt na k cl co bun cr bg ca mg phos alt ast amylase lipase alk phos ldh tb alb igg hbsag negative hbsab negative hbcab negative hepatitis a antibody negative negative hepatitis c antibody negative discharge labs microbiology c diff toxin positive urine cx negative blood cx prelim gpc in clusters studies ercp edematous major papilla the bile duct was not dilated the distal bile duct filled poorly most likely due to extrinsic compression from the pathology at the pancreatic head no filling defects were noted contrast was injected into the pancreatic duct which appeared to terminate abruptly in the pancreatic head with no filling beyond that point this is in keeping with the reported mrcp findings and is concerning for an obstructing pancreatic mass endoscopic ultrasound a cm x cm discrete anechoic lesion consistent with a cyst was noted in the head of the pancreas the walls of the cyst were thick measuring cm layering debris was noted in the dependent part of the cyst a pseudoaneurysm was noted on the lateral wall of the cyst the cyst appeared to obstruct the main pancreatic duct which was dilated distally the cyst was also noted to compress the portal vein a single perigastric lymph node was noted which measured x cm otherwise normal egd to third part of the duodenum cta abd pelvis multiple areas of fluid collection throughout the abdomen including the large bilobed pseudocyst above and below the pancreas in the right paracolic gutter transverse mesentery and within anterior abdominal wall mm pseudoaneurysm located within the pseudocyst at the level of the pancreas there is also a mm aneurysm at the origin of the common hepatic artery dilatation of the main pancreatic duct due to compressive effect of the pseudocyst brief hospital course yo male with history of bph was transferred from an osh for evaluation of pancreatitis evaluation was notable for large pancreatic pseudocyst with multiple intra abdominal fluid collections thought related to his pseudocyst his course was complicated by unexplained pea arrest the patient had an icu course s p resuscitation wherein he did not regain mental faculties or responsiveness his family chose comfort measures and mr on pea arrest unclear precipitant patient never regained mental faculties pancreatititis pancreatic pseudocysts intra abdominal fluid collections on ercp patient was found to have bile duct filling defect suggestive of external compression he underwent follow up eus which revealed a large pancreatic pseudocyst cta pancreas was also performed which confirmed the large pseudocysts but also noted multiple large abdominal fluid collections he was evaluated by our general surgery team who thought his abdominal process of pancreatic pseudocyst and associated inflammation was relatively immature and that surgical intervention or drainage at this time was not indicated he developed a bleeding gda aneurysm and was taken to ir for embolization before which he developed pea arrest this gda was ultimately embolized clostridium difficile infection within hours of admission patient developed increased diarrhea and marked leukocytosis from to he was c diff positive and started on flagyl on with improvement in his diarrhea he was recommended to continue flagyl for weeks from hepatic cirrhosis imaging from abdominal ct and mrcp revealed hepatic cirrhosis although patient has no history of this in the past atrial fibrillation patient was diagnosed with atrial fibrillation at the osh and was started on diltiazem before being transitioned to amiodarone upon transfer to his picc line was noted to be advanced into the right atrium and it was thought that this may have been triggering his atrial fibrillation during his hospitalization at he remained in sinus rhythm and with excellent rate control his amiodarone was discontinued acute renal failure during his admission at the osh his creatinine was as high as and then remained stable between malnutrition patient was started on tpn at the osh and was continued on this during his hospitalization he was npo during this hospitalization and was npo on discharge at rehab we recommend that he remain npo for the first week he could take sips for comfort after this time anemia unknown baseline his hematocrit has remained stable during this admission from hyperglycemia he was started on insulin during his hospitalization at and was continued on insulin during his hospitalization at family contact patient s family contact is the patient s niece her home number is work number is cell number is medications on admission transfer medications amiodarone mg nitroglycerin ointment ss qid sbp in in in wipe off octreotide mcg iv q hr pantoprazole mg po q zosyn iv q hr day tamsulosin mg po daily neutra phos pack po bid bacitracin ointment top daily prn demerol mg im q h prn pain demerol mg im q hr zoldipem mg qhs prn tpn per nutrition home medications lasix tamsulosin discharge medications deceased discharge disposition discharge diagnosis deceased discharge condition deceased discharge instructions deceased followup instructions deceased md completed by,"{
""Diagnoses"": [""pancreatitis""],
""Medications"": [""unasyn"", ""zosyn"", ""drain""]
}"
56364,admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint difficulty extubating after pvi major surgical or invasive procedure pulmonary vein isolation intubation extubation placement and removal of arterial line history of present illness patient intubated history from omr and wife yo m with atrial fibrillation s p pvi and flutter ablation on s p redo pvi today now in sinus rhythm but still intubated patient has a long history of atrial fibrillation see below he came in today for a scheduled redo pvi after which he was initially extubated he complained of shortness of breath and had poor mental status due to sedation abg at the time on cpap was but then improved to after re intubation he received x mg iv lasix cxr at the time was suggestive vascular congestion he was thus transferred to the ccu for weaning of sedation and ventillation in terms of patient s cardiac history he has had hypertension for the past years he developed atrial fibrillation years ago which initially paroxysmal but progressed to continous since he was evaluated in by dr and started on amiodarone he had a pvi here on with isolationof all pulmonary veins with extensive lines in the left atrium mitral isthmus coronary sinus and also the right atrial isthmus he organized into slow regular atrial tachycardia and then was cardioverted into sinus rhythm at follow up on his ekg showed narrow complex tachycardia at bmp subsequently he underwent several cardioversions at but reverted to a fib his amiodarone was cut down to mg qd in and admitted to redo pvi ros per wife increased sob and fatigue no palpitations syncope or orthopnea has had an uri over the past week with cough and scant yellow phlegm but no fever ros otherweise negative past medical history hypertension afib s p pvi and prior cardioversions anxiety hepatitis with mononucleosis as a teen ulcers gastritis pud on vioxx s p egd with cautery of ulcer shoulder surgery bilaterally right knee surgery bph patient had mild hematuria for several days after foley insertion for pvi tia cva gib sleep apnea not diagnosed but pt suspects he has social history retired lives with wife and has grown children never smoked or used recreational drugs drinks wine occasionally family history no family history of cad mis sudden death physical exam on admission general intubated sedated in no distress heent ncat sclera anicteric perrl conjunctiva were pink no pallor or cyanosis of the oral mucosa neck jvp difficult to assess cardiac regular rhythm rate normal s s no m r g no thrills lifts no s or s lungs et tube in place on a c support unlabored no accessory muscle use no obvious wheezes scattered crackles abdomen soft ntnd no hsm or tenderness extremities edema up to mid calf bilaterally skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid femoral popliteal dp pt left carotid femoral popliteal dp pt on discharge general extubated speaking in full sentences nad heent ncat sclera anicteric perrl conjunctiva were pink no pallor or cyanosis of the oral mucosa neck jvp difficult to assess cardiac regular rhythm rate normal s s no m r g no thrills lifts no s or s lungs et tube in place on a c support unlabored no accessory muscle use no obvious wheezes scattered crackles abdomen soft ntnd no hsm or tenderness extremities edema up to mid calf bilaterally skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid femoral popliteal dp pt left carotid femoral popliteal dp pt pertinent results admission labs 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 pm blood calcium phos mg pm blood triglyc pm blood type art rates tidal v peep po pco ph caltco base xs assist con intubat intubated pm blood freeca pm blood hgb calchct 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 abg studies tee left atrium moderate la enlargement no spontaneous echo contrast or thrombus in the la laa or the ra raa good cm s laa ejection velocity right atrium interatrial septum no asd by d or color doppler left ventricle overall normal lvef aortic valve normal aortic valve leaflets no as no ar no masses or vegetations on aortic valve mitral valve normal mitral valve leaflets no mass or vegetation on mitral valve mild mr tricuspid valve normal tricuspid valve leaflets mild tr 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 monitored by a nurse throughout the procedure the patient was monitored by a nurse in throughout the procedure the patient was under general anesthesia throughout the procedure no glycopyrrolate was administered no tee related complications results were reviewed with the cardiology fellow involved with the patient s care conclusions the left atrium is moderately dilated no spontaneous echo contrast or thrombus is seen in the body of the left atrium left atrial appendage or the body of the right atrium right atrial appendage no atrial septal defect is seen by d or color doppler overall left ventricular systolic function is normal lvef the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation no masses or vegetations are seen on the aortic valve the mitral valve leaflets are structurally normal no mass or vegetation is seen on the mitral valve mild mitral regurgitation is seen trivial physiologic pericardial effusion impression no intracardiac thrombus preserved left ventricular function no significant valvular regurgitation cxr overlying defibrillator pads limit this evaluation and there are low lung volumes endotracheal tube is appropriately positioned there is vascular crowding likely secondary to the low lung volumes although an element of vascular congestion cannot be entirely excluded a retrocardiac opacity may represent atelectasis cxr findings a previously placed nasogastric tube has been removed in the interval moderate cardiomegaly without evidence of pulmonary edema no pleural effusions no focal parenchymal opacity suggesting pneumonia moderate tortuosity of the thoracic aorta brief hospital course yo m with atrial fibrillation s p pvi and flutter ablation and subsequent conversion s p pvi redo on complicated by respiratory failure atrial fibrillation pt underwent pvi on this is the second pvi the patient has had here he is also s p multiple cardioversions as well as failed trials of norpace and dronedarone in the past and currently on amiodarone tee was done pre procedurally showing no thrombus following the pvi he remained in sinus rhythm with hr in the s overnight and maps breifly requiring neo he was continued on amiodarone mg daily as well as his home coumadin regimen remained therapeutic overnight and was discharged on his home regimen he was also discharged on a prophylactic antibiotic regimen of keflex mg qid x days post procedurally respiratory distress patient developed shortness of breath after extubation in the ep lab and had one abg which showed hypoxemia he was re intubated as a result and restarted on phenylephrine for pressure support on transfer to ccu he was on a c peep of and fio of on propofol gtt likely etiology included large body habitus sedation for procedure and also an underlying uri that started about a week ago cxr from the ep lab was of poor quality but did show signs of fluid overload which resolved on subsequent x ray after mg iv lasix his respiratory status and oxygenation improved markedly and he was extuabated early in the morning following his procedure without complication anxiety patient has anxiety at baseline and this might have played a role in the difficult extubation as he is was weaned off sedation he was controlled with prn ativan without complication gerd gastritis continued on home regimen of omeprazole mg po daily hypertension not currently on any antihypertensives he was weaned off neo and his bps remained stable gout renal function was intact with cr of the morning of discharge he was continued on home regimen of colchicine and allopurinol bph continued home regimen of tamsulosin mg daily of note pt with difficulty voiding on day of discharge likely secondary to not receiving his tamsulosin the night before he did receive it the morning of discharge and subsequently voided later in the afternoon cad prevention patient does not have documented cad though he is on primary prevention with aspirin and atorvastatin which was continued medications on admission allopurinol mg daily amiodarone mg daily atorvastatin mg daily colchicine mg tablet tabs daily omeprazole mg daily tamsulosin flomax mg daily warfarin mg m w f mg all other days aspirin mg daily discharge medications aspirin mg tablet chewable sig one tablet chewable po daily daily allopurinol mg tablet sig three tablet po daily daily disp tablet s refills amiodarone 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 colchicine mg tablet sig two 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 disp capsule delayed release e c s refills tamsulosin mg capsule sust release hr sig one capsule sust release hr po hs at bedtime disp capsule sust release hr s refills warfarin mg tablet sig one tablet po mon wed fri please take one mg tablet and one mg tablet for a total of mg on mondays wednesdays fridays disp tablet s refills warfarin mg tablet sig one tablet po mon wed fri please take one mg tablet and one mg tablet for a total of mg on mondays wednesdays fridays disp tablet s refills warfarin mg tablet sig one tablet po sun sat disp tablet s refills keflex mg capsule sig one capsule po every six hours for days please take from through for a total of days disp capsule s refills discharge disposition home discharge diagnosis atrial fibrillation gout anxiety benign prostatic hyperplasia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions mr you were admitted to the cardiac icu at the because after the procedure to help stop your atrail fibrillation you had difficulty coming out of sedation and breathing on your own we were able to take you off of the breathing machine by the morning your heart rhythm was regular after the proceudre and your blood pressure stable we did not make any changes to you medications however you should take keflex antibiotic as directed below you should follow up with your cardiologist dr at the time listed below followup instructions department cardiology dr when thursday at pm,"{
""Diagnoses"": [""atrial fibrillation"", ""pulmonary vein isolation"", ""flutter ablation"", ""atrial fibrillation (paroxysmal)"", ""atrial fibrillation (continous)"", ""hypertension""],
""Medications"": [""amiodarone"", ""lasix"", ""cpap"", ""iv""]
}"
48771,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint s p fall from window major surgical or invasive procedure suturing of lid laceration history of present illness yo male s p fall out of a window at home prior report of assault contradicted by parents etoh and cocaine he was transferred to for further care past medical history alcohol drug abuse right leg venous insufficiency social history admits to drinking beers per weekend he has been arrested for driving under the influence x is a member of alcoholics anonymous and has been in a substance abuse rehab program previously family history noncontributory physical exam upon admission nasal cannula somnolent male in nad aaox person hospital swelling noted over left supraorbital and malar areas periorbital ecchymosis on the left cm laceration down to calvarium through frontalis muscle on the lateral left brow eomi perrla no icterus or scleral hemorrhage no proptosis or enopthalmos no palpable supraorbital or infraorbital fxs midface stable nose stable nares clear no septal hematoma teeth grossly intact anteriorly upper and lower no obvious intraoral lacerations exam limited by patient s agitation no zygomatic arch stepoffs sensation intact over v distributions cn ii xii intact pertinent results am glucose urea n creat sodium potassium chloride total co anion gap am wbc rbc hgb hct mcv mch mchc rdw am plt count am pt ptt inr pt am asa neg ethanol acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg ct head impression multiple facial fractures described in detail in the concurrent facial bone ct report no evidence of acute intracranial abnormalities ct cervical spine impression no fracture or malalignment in the cervical spine ct sinus mandible impression left zygomaticomaxillary complex fracture pattern extraconal hematoma in the inferior left orbit contiguous with the left inferior rectus extraconal gas in the left orbit possible left lamina papyracea fracture brief hospital course he was admitted to the trauma service he was transferred to the trauma icu for close monitoring and was immediately placed on ciwa protocol orthopedics was initially consulted for right anterior ring pelvic fracture which was managed in a conservative manner plastics was consulted for facial fractures which were initially managed non operatively with plans for elective repair at a future date the left brow laceration sustained was irrigated and sutured closed ophthalmology was also consulted to rule out entrapment or other globe injuries none were identified on he developed respiratory distress and was started on vancomycin and zosyn for lll infiltrate noted on chest cta imaging he remained in the icu for several days intermittently agitated requiring use of the ciwa protocol he was also evaluated by the chronic pain service who recommended scheduled ibuprofen tid if no contraindication discontinue dilaudid discontinue scheduled tylenol and start oxycodone acetaminophen tabs po q hr prn on it was recommended to increase percocet tabs q h prn he eventually was stable enough to be transferred to the regular nursing unit it was noted on his right leg an area of erythema concerning for cellulitis and it was decided to initiate iv kefzol this was later changed to oral keflex as patient had been tolerating oral s at this point because of the erythema and swelling lower extremity ultrasound was performed which showed a partial thrombosis of the right popliteal vein with the remainder of the venous structures intact discussions took place as to whether or not to anticoagulate patient and the decision not to was made based on patient s alcohol and drug history and concern for high noncompliance of taking such medications and following up for inr monitoring the information and feedback from social work who had been following patient throughout his hospital stay and patient s family regarding patient s lack of follow through were also factored into the decision to not anticoagulate social work spent many hours with patient providing support and counseling surrounding his alcohol and drug use he was offered inpatient drug and alcohol treatment on several occasions and declined each time discussions between social work and his family took place on multiple occasions and it was made clear by family that patient could not come to any of his family members home after hospital discharge social work presented patient with possibility of going to a shelter and he declined this as well patient ultimately came up with a plan between he and a friend and decided that he would go and stay with this friend after hospital discharge he was evaluated by physical therapy and was cleared for discharge to home with crutches for ambulation medications on admission unknown discharge medications docusate sodium mg capsule sig one capsule po bid times a day cephalexin mg capsule sig one capsule po q h every hours for days disp capsule s refills milk of magnesia mg ml suspension sig thirty ml s po twice a day as needed for constipation oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills discharge disposition home discharge diagnosis s p fall supraorbital laceration left inferior wall orbital fracture right acetabular fracture right ischial pubic rami fracture right popliteal thrombus right lower extremity cellulitis discharge condition hemodynamically stable tolerating a regular diet pain adequately controlled discharge instructions avoid alcohol and or any other illicit drugs while you are taking narcotics prescribed for your pain keep your right leg elevated on pillows when at rest you may bear weight as tolerated on both of your legs using crutches for assistance with ambulation it isi importnathat you walk at least several times daily to avoid developing further blood clot formation adhere to a soft diet because of your facial fractures do not blow your nose or drink through a straw becasue of your facial fractures please complete your entire keflex antibiotic course as prescribed return to the emergency room if you develop any fevers chills headache shortness of breath increased pain swelling redness in your legs abdominal pain nausea vomiting diarrhea and or any other symptoms that are concerning to you followup instructions follow up in weeks in clinic with dr for your pelvic fractures call for an appointment follow up next week with in clinic for your facial fractures call for an appointment follow up in trauma clinic for pain medication prescription refill authorization call for an appointment completed by,{}
2001,admission date discharge date date of birth sex m service history of present illness this is a year old male with no significant past medical history who presented with the sudden onset of left sided abdominal pain radiating to both the back and the left scrotum the patient had noted fever and nausea and had vomited eight or nine times over the few the patient contact his primary care doctor who had him come into the office and when the patient was evaluated at the office a blood pressure of was obtained and the patient was sent to the emergency department while in the emergency department a urinalysis and ct urogram with perinephric stranding with pyelonephritis since the patient was hypotensive he was treated with intravenous fluids and was seen by surgery and urology and the plan was to treat the patient with ceftriaxone also while in the emergency department a blood sugar was checked and the patient s glucose was in the s the diagnosis was diabetic ketoacidosis and the patient was sent to the medical intensive care unit on an insulin drip on further questioning the patient admitted to symptoms of polyphagia polyuria and polydipsia for the several months prior to presentation past medical history none medications on admission the patient took motrin and pepto bismol allergies there were no known drug allergies social history the patient works as a correction s officer he smokes approximately five to six cigarettes per day for the last years occasional alcohol use no drug use family history family history is positive for diabetes on the mother s side of the family physical examination on presentation on physical examination temperature maximum was blood pressure was heart rate was respiratory rate was saturating on room air head eyes ears nose and throat revealed pupils were equal round and reactive to light extraocular muscles were intact anicteric mucous membranes were dry the neck was supple the chest was clear to auscultation the heart was first heart sound and second heart sound tachycardic but regular the abdomen was soft and nondistended mild left lower extremity tenderness no rebound no right sided tenderness and no rebound was noted there was left costovertebral angle tenderness rectal examination was guaiac negative extremities revealed there was no clubbing cyanosis or edema pertinent laboratory data on presentation laboratories on admission with a white blood cell count of hematocrit of and platelets were pt was ptt was inr was sodium of potassium of chloride of bicarbonate of blood urea nitrogen of creatinine of blood glucose of urinalysis was positive for blood protein greater than glucose and trace ketones radiology imaging an echocardiogram was performed that showed an ejection fraction of to with nonfocal hypokinesis a ct showed no obstruction and a left renal calculous with left perinephric fat stranding hospital course the patient was initially admitted to the medical intensive care unit for management of diabetic ketoacidosis and urosepsis with nephrolithiasis for his diabetes the patient was maintained on an insulin drip and treated with fluids his glucose was monitored and the patient was switched from an insulin drip to nph while in the intensive care unit blood cultures and urine cultures came back positive for citrobacter the patient has initially been treated with ceftriaxone and this was switched to levofloxacin while on antibiotics the patient s hemodynamic status improved urology was following the patient while on the unit the decision was for no intervention until the patient was more stable on the patient was transferred to the floor to the service endocrine the patient with new onset diabetes presenting with diabetic ketoacidosis the patient was off insulin drip and on nph was consulted and followed the patient regarding the new onset diabetes and made recommendations regarding the home dose of nph and humalog blood sugars were monitored and adjustments were made accordingly the patient received learning center training for glucometer and teaching for insulin administration genitourinary while on the floor the patient still had not passed his kidney stone urology made the decision on to take the patient to the operating room for a possible ureteral stent placement with stone retrieval at this time no stent was performed and the stone was retrieved the patient s pain improved dramatically the following day and the patient was told to follow up with urology in two to four weeks for the pyelonephritis the patient was maintained on the levofloxacin and is currently completing a day course for acute renal failure the elevated blood urea nitrogen and creatinine on admission after the patient received hydration this resolved with follow up blood urea nitrogen and creatinine at blood urea nitrogen of and creatinine of cardiovascular while in the medical intensive care unit the patient had a echocardiogram showing biventricular dysfunction thought to be secondary to sepsis the patient had a repeat echocardiogram done while on the floor which showed posterior hypokinesis while this study was much improved from the previous one it was felt that the patient still would require a follow up transthoracic echocardiogram as an outpatient in two weeks the patient had blood pressures that ranged in the s to s s to s while in the hospital and on the floor and the patient may need followup regarding diastolic hypertension fluids electrolytes nutrition the patient s electrolytes were monitored while on the floor and repletion of potassium and magnesium were done on an as needed basis on the day of discharge the patient s potassium had normalized to discharge disposition the patient was discharged on condition at discharge condition on discharge was stable discharge status the patient was discharged to home with multiple follow up appointments discharge diagnoses diabetic ketoacidosis nephrolithiasis urosepsis status post ureteral stone removal on medications on discharge levofloxacin mg p o for seven days to complete a day course humalog sliding scale nph units at breakfast and units at bedtime alcohol swabs insulin syringes and glucose tester and glucometer prescriptions discharge followup the patient was to follow up with primary care provider this week to repeat urinalysis and also to check blood pressure to follow up with cardiology for a repeat echocardiogram scheduled on at p m at the building on the seventh floor the patient is also to follow up with urology dr in two to four weeks the patient was given the telephone number to call and make an appointment the patient was instructed to follow up at and to call the day after his discharge to make an appointment for a new patient appointment classes on nutrition and insulin adjustments m d dictated by medquist d t job cc,"{
""Diagnoses"": [""pyelonephritis"", ""diabetic ketoacidosis""],
""Medications"": [""ceftriaxone""]
}"
91044,admission date discharge date date of birth sex f service medicine allergies penicillins morphine vicodin attending chief complaint chest pain major surgical or invasive procedure cardiac catheterization with stent placement history of present illness y o f with no signficant pmhx who presented to the ed with chest pain that started this morning the patient reports that she was in her usoh until around this mroning when she was walking up to go to a meeting at that time she began to feel unwell and diaphoretic with pain in her l arm she drank some water and ate something but this did not help she also developed a feeling of indigestion and tried antacids with slight relief throughout the day her left arm pain continued advil relieved the pain somewhat later in the afternoon when her pain did not resolve she called for an appointment she developed crushing substernal chest pain at her md s office she reports her ecg showed changes she was given asa and sl ntg she was referred to the ed at for further evaluation she was given ntg spray enroute to the ed initital ed vitals were f her ekg showed precordial q waves mm ste in v mm in v she had continued chest pain with development of biphasic t waves cards was heparin gtt was started and she was taken to the cath lab in the cath lab she was found to have a large mid lad thrombus with non flow limiting disease in the other vessels she underwent thrombectomy and she was loaded with prasugrel mg and received integrillin during the procedure of note her arterial stick was relatively high so small possibility she could develop an rp bleed on arrival to the ccu the patient s vs were t bp hr rr o sat on ra she complained of some slight l sided chest discomfort which she attributed to musculoskeletal pain she stated that this pain is different from her previous pain she also complained of some chronic back pain she denied any shortness of breath or other complaints on review of systems she denies any prior history of stroke tia deep venous thrombosis pulmonary embolism bleeding problems myalgias joint pains cough hemoptysis black stools or red stools she denies recent fevers chills or rigors cardiac review of systems is notable for absence of dyspnea on exertion paroxysmal nocturnal dyspnea orthopnea ankle edema palpitations syncope or presyncope she does reports some slight chest discomfort with exertion in the past most recently during a vigorous walk this past weekend all of the other review of systems were negative past medical history anxiety social history she works for the department of developmental disabilities of the state of of note her son getting married on saturday tobacco history remote smoked ppd x years quit years ago etoh a couple of glasses of wine per week illicit drugs denies family history father developed heart disease in his s and had cabg in his s father also had hypertension denies any further family history of heart disease hypertension or diabetes physical exam vs t bp hr rr o sat on ra general wdwn y o f in nad mood affect appropriate heent nc at perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthalesma appreciated neck supple with no jvd noted no carotid bruits cardiac rrr normal s s no m r g no s or s appreciated lungs resp were unlabored no accessory muscle use ctab anteriorly no crackles wheezes or rhonchi abdomen soft ntnd no hsm or tenderness no abdominial bruits extremities no c c e no femoral bruits r cath site intact with no hematoma skin no stasis dermatitis ulcers scars or xanthomas pulses right dp pt left dp pt pertinent results pm k pm glucose urea n creat sodium potassium chloride total co anion gap pm ck cpk pm ctropnt pm ck mb mb indx pm calcium phosphate magnesium pm wbc rbc hgb hct mcv mch mchc rdw pm neuts bands lymphs monos eos basos pm plt smr normal plt count pm hypochrom normal anisocyt normal poikilocy normal macrocyt normal microcyt normal polychrom normal pm pt ptt inr pt ecg pm sinus rhythm possible inferior myocardial infarction of indeterminate age st segment elevation in leads v v with biphasic t waves and q waves in leads v v consider anterior wall myocardial infarction which could be recent acute compared to the previous tracing done earlier the same day the biphasic t waves are more pronounced in leads v v consistent with an evolving myocardial infarction cardiac cath comments selective coronary angiography of this right dominant system revealed single vessel disease the lmca was free of critical stenoses the lad had a large thrombus in the mid vessel with timi slow flow the lcx had a stenosis in the om branch the rca had a stenosis in the rpl branch vessel successful pci of the mid lad with thrombectomy followed by a x mm promus des post dilated to mm in the proximal and mid segments femoral arteriography revealed a high arteriotomy site without extravasation this was successfully closed with a f angioseal device final diagnosis one vessel coronary artery disease anterior stemi successful pci of the lad with thrombectomy and des echocardiogram the left atrium is normal in size the estimated right atrial pressure is mmhg left ventricular wall thicknesses and cavity size are normal there is moderate to severe regional left ventricular systolic dysfunction with akinesis of mid to distal septum and anterior wall severe hypokinesis of the distal left ventricle and apex overall left ventricular systolic function is moderately depressed lvef no masses or thrombi are seen in the left ventricle 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 mild aortic regurgitation is seen mild to moderate mitral regurgitation is seen there is borderline pulmonary artery systolic hypertension there is a trivial physiologic pericardial effusion impression regional left ventricular systolic dysfunction consistent with mid lad territory infarction mild to moderate mitral regurgitation brief hospital course assessment and plan y o f with no signficant pmhx who presented to the ed with chest pain and ecg chages now s p cardiac cath with des to the lad stemi the patient presented with day of chest pain and with ecg showing q waves and st elevations in precordial leads consistent with anterior mi she was given full dose asa as well as ntg at her md s office as well as ntg en route to the ed she was ultimately brought to the cath lab which revealed large thrombus in mid lad she is now s p thrombectomy and des to the lad the echocardiogram revealed moderate to severe regional left ventricular systolic dysfunction consistent with mid lad territory infarction her cardiac enzymes on admission were ctropt ckmb which peaked the next morning tropt ckmb and trended downwards she was put on asa prasugrel statin and metoprolol she had an episode of chest pressure with nausea and headache while in the hospital without any further ekg changes which spontaneously resolved she was clinically stable otherwise and was discharged on prasugel which will need to be continued for at least a year aspirin indefinitely metoprolol and high dose lipitor her pharmacy did not have prasugrel immediately available so she was discharged with a day supply of plavix and will take prasugrel from then on she was not started on lisinopril as she was borderline hypotensive although asymptomatic the need for lisinopril can be revisited as an outpatient she was seen by physical therapy who cleared her to go home she will need cardiac rehabilitation approximately weeks following her discharge as an outpatient which should be orchestrated by her cardiologist pump the echocardiogram showed moderate to severe regional left ventricular systolic dysfunction with akinesis of mid to distal septum and anterior wall severe hypokinesis of the distal left ventricle and apex with lvef which are consistent with mid lad territory infarction mild to moderate mitral regurgitation was also seen given her hypokinesis she was discharged on a lovenox bridge as well as coumadin she will have her inr checked at her pcp s office on monday and her pcp will follow up these results and adjust her medications accordingly she also has follow up with her cardiologist on and her pcp on thursday headache she complained of a headache during which she experienced some chest pain there were no ekg changes her headache and chest pain resolved with ativan she had a history of anxiety and endorsed feelings of anxiety at the possibility of missing her son s wedding due to her hospitalization she continued to take her home klonopin with good effect and did not need further ativan rhythm remained in sinus rhythm no reported history of arryhthmias or palpitations medications on admission clonazepam mg prn anxiety 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 metoprolol succinate mg tablet sustained release hr sig tablet sustained release hrs po once a day disp tablet sustained release hr s refills enoxaparin mg ml syringe sig one injection subcutaneous times a day disp injection refills clonazepam mg tablet sig one tablet po every hours as needed for anxiety please do not drink alcohol or perform activities that require a fast reaction time while taking this medication cause sedation warfarin mg tablet sig one tablet po once daily at pm disp tablet s refills clopidogrel mg tablet sig one tablet po once a day disp tablet s refills prasugrel mg tablet sig one tablet po once a day disp tablet s refills discharge disposition home discharge diagnosis primary diagnosis myocardial infarction s p drug eluting stent to left anterior descending artery 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 because you had a heart attack you had a drug eluting stent placed in one of the major blood vessels to your heart which was found to have a clot you are being discharged with cardiology follow up you will have your blood checked on monday th dr knows about this and will follow up on your blood test results the following changes were made to your medications start atorvastatin mg daily start metoprolol mg xl once a day start clopidogrel mg once daily to be taken until monday at which time you will change over to prasugrel start prasugrel mg once daily on monday when it is available at your pharmacy this should be taken in place of clopidogrel start lovenox mg twice daily x days start coumadin mg daily it was a pleasure taking part in your medical care followup instructions appointment md dr specialty internal medicine primary care date time am location ma phone number appointment md dr specialty cardiology date time am location phone number,"{
""Diagnoses"": [""Chest pain"", ""Indigestion"", ""Heart attack""],
""Medications"": [""Advil"", ""Asa"", ""Ntg"", ""SlnTg""]
}"
53771,admission date discharge date date of birth sex f service medicine allergies penicillins attending chief complaint mssa endocarditis nafcillin desensitization major surgical or invasive procedure pars plana vitrectomy intravitreal antibiotic injection transesophageal echocardiogram history of present illness f w esrd on hd dm she was transferred from osh icu for further management of endocarditis and mssa bacteremia very limited historian and most of history obtained from osh records she was at hd when developed t which grew bottles mssa she was intiially at and was started on vanc gent and tte revealed thickened mitral valve with vegetation she then became hypotensive to requiring a low dose levophed and was transferred to icu on at icu she was desensitized to pcn and started on nafcillin id consult recommended against continuing gent she had some loose stools was empirically started on flagyl but then c dif neg x and flagyl stopped u s of avf negative for abscess however renal felt that if she peristantly spiked temps then she should have tagged wbc scan to rule out avf infection upon arrival to she has no complaints answering only yes no answers she denies pain sob palpitations fever chills n v diarrhea past medical history esrd on hd t th sat cad s p imi dm htn hyperlipidemia s p ccy social history lives at home independently never smoked no etoh no drug use family history father with prostate ca physical exam admission physical exam vs afebrile sbp s general very flat affect nad heent normocephalic atraumatic mm dry op clear cardiac reg rate nl s s ii vi holosystolic murmur at apex lungs ctab abdomen nabs soft nt nd no hsm extremities no edema or calf pain skin no splinters oslers neuro oriented to being in a hospital and name does not know date decreased le strength right left psych listens and follows only simple commands but answers mainly only yes or no stares off blankly pertinent results osh micro bottles mssa blood cx negative pm stool consistency loose source stool final report clostridium difficile toxin a b test final reported by phone to a clostridium difficile feces positive for c difficile toxin by eia reference range negative a positive result in a recently treated patient is of uncertain significance unless the patient is currently symptomatic relapse rpr non reactive osh echo lvef mv thickened with densities which prolapse into la mr trace ar and thickening of leaflets pi present tr pa pressure ra pressure cardiology report ecg study date of pm sinus rhythm left axis deviation inferior wall myocardial infarction probably old poor r wave progression cannot rule out old anteroseptal myocardial infarction compared to the previous tracing of there is no significant diagnostic change tee no atrial septal defect is seen by d or color doppler there is mild global left ventricular hypokinesis lvef right ventricular chamber size and free wall motion are normal there are complex mm atheroma in the descending thoracic aorta the aortic valve leaflets appear structurally normal with good leaflet excursion no masses or vegetations are seen on the aortic valve no aortic valve abscess is seen no aortic regurgitation is seen the mitral valve leaflets are moderately thickened there is a large vegetation with calcifications on the mitral valve cm in length extending from the anterior mitral annulus no mitral valve abscess is seen moderate mitral regurgitation is seen moderate tricuspid regurgitation is seen there is no pericardial effusion impression large mitral valve vegetation consistent with endocarditis moderate mitral regurgitation is present no abscess was apparent ct with contrast of head impression no acute intracranial process specifically no evidence of abscess or enhancing mass ill defined low attenuation in right more than left periventricular white matter likely representing chronic microvascular infarction no pathologic focus of enhancement ct with contrast of torso impression slowly progressive patchy and nodular consolidations predominating in the right upper lobe most likely represent an indolent granulomatous process possibly sarcoidosis though granulomatous infection bronchiolitis are other diagnostic considerations prominent retroperitoneal and pelvic lymph nodes more prominent compared to but of unclear etiology massive right hydronephrosis and cortical thinning likely secondary to chronic right upj obstruction findings raising the question of chronic pancreatitis anasarca with bilateral small effusions and small ascites doppler le impression no evidence of dvt in the bilateral lower legs mra mri of brain impression multiple infra and supratentorial foci of restricted diffusion as described in detail above likely consistent with thromboembolic ischemic events mra of the head there is evidence of vascular flow in both internal carotids the left vertebral artery is patent and also the basilar artery the right vertebral artery is not completely visualized and possibly ends in pica however occlusion secondary to arteriosclerosis cannot be completely excluded diffuse lack of signal is visualized in the distal branches also possibly representing atherosclerotic disease this is a limited examination secondary to motion artifacts therefore the distal branches of the circle of are not completely evaluated tee on no thrombus is seen in the left atrial appendage there is moderate regional left ventricular systolic dysfunction with inferior and inferolateral hypokinesis overall left ventricular systolic function is moderately depressed lvef there are complex mm atheroma in the aortic arch and descending thoracic aorta the aortic valve leaflets appear structurally normal with good leaflet excursion no masses or vegetations are seen on the aortic valve the mitral valve leaflets are moderately thickened there are large vegetations cm and cm in lengths and a third smaller vegetation cm arising from the base of the anterior mitral valve leaflet also seen is a possible small vegetation associated with the right cusp of the aortic valve moderate mitral regurgitation is seen due to acoustic shadowing this study was not adequate to exclude an abscess there is a small pericardial effusion no definite abscess seen but cannot be excluded with certainty compared with the findings of the prior study images reviewed of the mitral valve vegetations appear larger and left ventricular contractile function is more depressed along with inferolateral hypokinesis impression large vegetations consistent with endocarditis of the mitral valve this study was not able to exclude the presence of an abscess tagged wbc scan impression normal white blood cell study no abnormal tracer uptake ct abd pelvis without contrast impression massive right hydronephrosis and cortical thinning consistent with a classic longstanding ureteropelvic junction obstruction dating back to at least pelvic nodes are unchanged possible chronic pancreatitis anasarca with unchanged effusions mr head w o contrast findings again multiple areas of slow diffusion are identified in the white matter in the periventricular region including involvement of the corpus callosum the areas are seen in both frontoparietal lobes as well as in the temporal lobe small focus of signal abnormalities seen in the right cerebellum and also in the left side of the brain stem overall the foci have evolved since the previous study and no definite new abnormalities are seen there is no midline shift noted mild brain atrophy identified impression evolution of previously noted acute subcortical infarcts in the supra and infratentorial regions no new signal abnormalities are seen eeg impression this is an abnormal routine eeg recording in the awake and sleeping states due to the slow background suggestive of a mild encephalopathy metabolic disturbances medications and infections are among the most common causes there were no lateralized or epileptiform features seen brief hospital course methicillin senstive staph aureus mitral valve endocarditis osh blood cultures showed high grade mssa bacteremia and echo demonstrated mitral thickening with mr densities prolapsing into the left atrium la ultrasound and tagged wbc scan did not reveal a source of infection in the lue av graft she was had transient hypotension requiring levophed prior to transfer she was desensitized to nafcillin in the icu tee showed a cm mitral valve vegetation moderate mr but no apparent abscess repeat tee showed vegetations cm cm cm on the mitral valve but could not definitively exclude an abscess nafcillin was changed to vancomycin on out of concern for drug fever daily surveillance blood cultures remained negative daily ekgs and telemetry monitoring did not show any evidence of conduction abnormality the patient expressed an unequivocal desire to forego valve replacement surgery her family agreed given their preferences as well as high operative morbidity that the patient defervesced on antibiotic therapy and that a repeat mri did not show further evidence of cerebral septic emboli the medical team agreed to continue with weeks of antibiotic therapy through she underwent repeat nafcillin desensitization on in the micu without complication she may benefit from surveillance cultures and repeat tee at the conclusion of her antibiotic course she will follow up with her pcp and id as an outpatient endogenous staph aureus endophthalmitis right eye the patient was evaluated by ophthalmology for right eye visual complaints she was found to have evidence of endophthalmitis on exam and was treated immediately with intravitreal vancomycin and then with ppv on she will follow up with ophthalmology as an outpatient cerebral septic thromboembolic disease mri of the brain on showed multiple infra and supratentorial foci of restricted diffusion consistent with thromboembolic ischemic events there were no focal neurological findings on examination repeat mr on showed evolution of these previously noted acute subcortical infarcts but no new signal abnormalities eeg showed mild non specific encephalopathy she will follow up with neurology as an outpatient clostridium difficile colitis started on flagyl to be continued for week beyond the course of nafcillin maintained on contact precautions end stage renal disease on hemodialysis continued hd tu th sa with vancomycin given per hd protocol diabetes mellitus type ii well controlled on an insulin sliding scale hypertension well controlled on reduced dose of metoprolol mg which was started when the patient was hemodynamically stable therefore amlodipine and benicar were discontinued transaminitis alt ast on patient did not have fever nausea abdominal pain or tenderness therefore planned to monitor expectantly and repeat lft s medications on admission home medications pantoprazole daily calcium acetate tid amliodipine daily metoprolol benicar daily asa medications on transfer nafcillin iv q h ppi calcium acetate discharge medications aspirin mg tablet sig one tablet po once a day pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours insulin lispro unit ml solution sig one inj subcutaneous asdir as directed per attached sliding scale senna mg tablet sig one tablet po bid times a day metoprolol tartrate mg tablet sig tablet po bid times a day hold for sbp hr trazodone mg tablet sig tablet po hs at bedtime as needed for insomnia bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for constipation please give if no bm in days bacitracin unit g ointment sig one appl ophthalmic qid times a day acetaminophen mg tablet sig one tablet po q h every hours as needed for pain fever ondansetron mg iv q h prn nausea nafcillin g iv q h heparin porcine unit ml solution sig one injection injection injection tid times a day acetaminophen mg tablet sig one tablet po q h every hours as needed for pain fever polyvinyl alcohol povidone dropperette sig drops ophthalmic prn as needed as needed for irritation metronidazole mg tablet sig one tablet po tid times a day please administer after hemodialysis on tuesday thursday saturday last dose prednisolone acetate drops suspension sig one drop ophthalmic q h every hour scopolamine hbr drops sig one drop ophthalmic times a day bacitracin unit g ointment sig one appl ophthalmic qhs once a day at bedtime ciprofloxacin drops sig one drop ophthalmic qid times a day sodium chloride flush ml iv q h prn line flush peripheral line flush with ml normal saline every hours and prn 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 discharge disposition extended care facility tba discharge diagnosis primary methicillin senstive staph aureus mitral valve endocarditis endogenous staph aureus endophthalmitis right eye cerebral septic thromboembolic disease clostridium difficile colitis secondary end stage renal disease on hemodialysis diabetes mellitus type ii hypertension discharge condition clinically improved with stable vital signs discharge instructions you were admitted to the with endocarditis an infection on one of the heart valves your infection caused damage to your right eye as well as small strokes in the brain your infection was partially treated with antibiotics you will need to complete a total of weeks of antibiotics through the following medication changes were recommended nafcillin grams every hours through metoprolol was decreased to mg twice daily eye drops were started after your right eye surgery amlodipine was discontinued benicar was discontinued calcium acetate was discontinued please attend all of your follow up appointments please call your physician or return to the emergency department if you experience fever chills sweats dizziness lightheadedness passing out chest pain palpitations cough wheezing shortness of breath abdominal pain back pain leg swelling rash vision changes numbness weakness tingling or other worrisome symptoms followup instructions please follow up with at the clinic on wednesday at am please call if you wish to reschedule please follow up with the department of infectious diseases on at thursday at am please call if you wish to reschedule please call the office of dr at for an appointment at your earliest convenience provider dpm phone date time provider m d phone date time provider d phone date time completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex f service medicine allergies penicillins attending addendum nafcillin to be substituted with oxacillin grams iv q h through discharge disposition extended care facility hospital md completed by,"{
""Diagnoses"": [""Endocarditis"", ""MSSA bacteremia"", ""Tuberculosis""],
""Medications"": [""Vanc-Gent"", ""TTE"", ""Nafcillin"", ""Levophed"", ""Pcn"", ""Flagyl"", ""Ciprofloxacin"", ""Ampicillin""]
}"
19785,admission date discharge date service surgery allergies clonidine aquaphor codeine attending chief complaint f presenting through th ed with week history of increasing abdominal pain and bloating major surgical or invasive procedure lysis of adhesions tracheostomy open g tube history of present illness f presented to ed with week of history of bloating ct scan consistent with partial small bowel obstructoin aprox year followng partial colectomy carcinoma past medical history cad chf htn hypothyroid chronic back pain dvt l hip replacement tah partial colectomy carcinomoa s pp open ccy social history daughter actively involved has been at hospital since has not left hospital social worker encouraged her to leave daughter angry with this physical exam afvss patient described as a somehat frail appearing older woman a ox perrl cn ii xii intact contusion noted over right eye lungs clear reduced breath sounds at bases abdomen distended diffusely tender tympanetic no bowel sounds no peritoneal signs no evidence of herniation rectal exam guiac pertinent results ptt heparin drip up to u hr at noon inr up to coumadin mg last eve to get mg tonight pm blood alt ast ck cpk alkphos amylase totbili pm blood alt ast ck cpk alkphos amylase totbili pm blood glucose urean creat na k cl hco angap 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 brief hospital course after presentation to the ed patient had a ct scan this showed several very dilated loops of small bowel a high grade obstruiction and a completely decompressed colon after agressive resuscitation including ng suction and crytalloid she was taken to the operating room on for lysis of adhesions post operative course was complicated by acute on chronic co retention poor oxygenation and hypotension on pod patient was transferred to the floor on pod patient became hypercarbic has baseline co retention with increasing respiratory distress while preparing to electively intubate patient had a pea arrest intubation was completed and the patient was quickly resuscitated post intubation status was gaurded patient continued to have a fib she was lowly diuresed on a natrecor drip but required a swan ganz and drip for worsening chf days later patient had a repeat arrest again requiring cpr but was succesfully resuscitated on she was cardioverted for stable a fib but ultimately reverted back to a fib on she uder went operative trachesotomy and placement of g tube all without event hospital course thereafter was uneventful responding well to pt and tolerated tfs well discharge medications albuterol sulfate solution sig puffs inhalation q h every hours as needed puffs bisacodyl mg suppository sig one suppository rectal hs at bedtime as needed albuterol ipratropium mcg actuation aerosol sig puffs inhalation q h every hours as needed levothyroxine sodium mcg tablet sig one tablet po daily daily lansoprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily insulin regular human unit ml solution sig per insulin sliding scale units injection asdir as directed fluticasone propionate mcg actuation aerosol sig two puff inhalation times a day acetaminophen mg tablet sig tablets po q h every to hours as needed glutamine g packet sig packet po tid times a day therapeutic multivitamin liquid sig one cap po daily daily miconazole nitrate powder sig one appl topical prn as needed miconazole nitrate cream sig one appl topical times a day zolpidem tartrate mg tablet sig one tablet po hs at bedtime as needed artificial saliva solution sig one ml mucous membrane prn as needed spironolactone mg tablet sig one tablet po daily daily folic acid mg tablet sig one tablet po daily daily cyanocobalamin mcg tablet sig tablet po daily daily ferrous sulfate mg ml liquid sig one capsule po daily daily thiamine hcl mg tablet sig one tablet po daily daily docusate sodium mg ml liquid sig one container container po bid times a day lisinopril mg tablet sig three tablet po daily daily amiodarone hcl mg tablet sig one tablet po daily daily furosemide mg tablet sig one tablet po bid times a day senna mg tablet sig one tablet po bid times a day as needed warfarin sodium mg tablet sig one tablet po once once titrate to inr of dolasetron mesylate mg ml solution sig one intravenous q h every hours as needed magnesium sulfate solution sig one injection prn as needed as needed for mg calcium gluconate mg ml solution sig one intravenous prn as needed as needed for ioca morphine sulfate mg ml syringe sig two mg injection q h every hours as needed for pain potassium chloride meq ml piggyback sig one intravenous prn as needed hydralazine hcl mg ml solution sig ten mg injection q h every hours as needed for sbp heparin sod porcine in d w unit ml parenteral solution sig titrate to ptt intravenous asdir as directed discharge disposition extended care facility discharge diagnosis s p prolonged icu course s p llysis of adhesions partial small bowel obstruction respiratory arrest failed video swallow sever copd pulmonary hypertension a fib hypothyroid cad chf htn chronic back pain dvt l hip replacement colectomy for cancer s p cholecystectomy discharge condition good discharge instructions md s physical therapy pas directed will need trach downsized in next weeks currently on a heparin drip will need to get coumadin therapeutic for a fib before stopping drip followup instructions follow up with surgery as needed completed by,"{
""Diagnoses"": [""adhesions"", ""obstructoin"", ""partial colectomy"", ""carcinoma"", ""hypothyroid"", ""back pain"", ""DVT"", ""hip replacement"", ""social history""],
""Medications"": [""clonidine"", ""codeine"", ""Aquaphor"", ""tracheostomy"", ""G-tube"", ""Cad"", ""Chf"", ""Htn"", ""Tah"", ""Coumadin""]
}"
85901,admission date discharge date date of birth sex f service medicine allergies codeine latex attending chief complaint shortness of breath hypoxia major surgical or invasive procedure none history of present illness year old female with known pulmonary fibrosis cervical cancer years prior seizure disorder presenting from outside hospital with concern for dyspnea and hypoxia of note the patient is on l of oxygen at baseline she has had days of gradually increasing shortness of breath exacerbated by today relieved partially with spironolactone and increased oxygen utilization patient was started on cellcept about a month ago as a measure to try to improve her ipf she endorses a pound unintentional weight gain over the past week she also endorses some headaches abdominal pain which she attributes to the cellcept she also says her weight gain correlates with the time that she started her cellcept her predominate complaint on presentation today was mostly her weight gain and fluid overload in the ed initial vs were nrb labs were performed which were ntoable for a lactate of a u a with leuks wbc and bacteria tropinin negative x probnp and inr in the ed she was given written for nitropaste in tp q h as well as ceftriaxone g a cxr was performed which on my read appeared diffuse to show pulmonary edema ekg in the ed showed twave flatting in v v as compared to on transfer her vitals were bipap notably at osh she was given mg iv lasix and put out l she has made l since arrival to our ed she has been diagnosed with ipf a rheumatologic panel as well as a hypersensitivity panel and a careful history did not detail any obvious etiology for her pulmonary fibrosis and therefore it was felt that she may have had idiopathic pulmonary fibrosis although the upper lobe predominance of her infiltrates is not classic an echo done showed an normal lvef and normal pasp she also had a right heart catheterization performed which showed pcwp and a pa read as mild pulmonary hypertenstion on with elevation of pvr normal filling pressures and preserved cardiac output a ct scan of the chest on that day which was notable for subpleural reticular markings that were increased as well as areas of honeycombing consistent with pulmonary fibrosis her case of ipf had previously been discussed at case conferences and given the extensive fibrosis and lack of ground glass or other abnormalities the consensus was that she was unlikely to respond to cytotoxic therapy such as azathioprine cellcept she was initiated on letairis around an attempted to refer her for a lung transplantation evaluation did not procede forward given her prohibitive bmi of she had self dc ed her letairis in she is on liters o with exertion and has become quite sedentary a letter from dr on indicated that she had recently started cellcept in addition to having been recently treated for a uti with bactrim doxycycline on arrival to the micu she is on bipap but is very pleasant alert and oriented review of systems per hpi denies fever chills night sweats recent weight loss or gain denies headache sinus tenderness rhinorrhea or congestion denies cough shortness of breath or wheezing denies chest pain chest pressure palpitations or weakness denies nausea vomiting diarrhea constipation abdominal pain or changes in bowel habits denies dysuria frequency or urgency denies arthralgias or myalgias denies rashes or skin changes past medical history hypertension pulmonary hypertension osteoarthritis in her s with multiple joint replacements pulmonary fibrosis high cholesterol fibromyalgia gerd s p right total knee replacement in l s disectomy x complicated by nerve damage and a foot drop she uses a brace cholecystectomy home l turns it up to l with exertion gib secondary to medication hypothyroidism cervical cancer s p conization at the age of tubal ligation social history she is married she has grown sons that do not live with her she previously worked as a nurse at the she drinks alcohol extremely rarely she did smoke from the age of to up to packs per day she has never used marijuana cocaine or heroin she has never been exposed to asbestos that she knows of she has lived in the northeast her entire life she does have a dog at home but no birds she has not had any recent farm animal exposure although she did live on a farm when she was younger family history mother with arthritis which does not require treatment she does have a brother with lung cancer diagnosed at the age of he was a heavy smoker in addition she also has another brother age with emphysema he also was a smoker physical exam exam on admission general alert x heent sclera anicteric eomi perrl neck supple jvp elevated to the mandible cv regular rate and rhythm normal s s no murmurs rubs gallops lungs crackles to the midline bilateally abdomen soft non tender non distended bowel sounds present no organomegaly gu foley ext warm well perfused pulses non pitting edema in the thigh neuro cnii xii intact pertinent results labs on admission am glucose urea n creat sodium potassium chloride total co anion gap am alt sgpt ast sgot alk phos tot bili am ctropnt am probnp am albumin am wbc rbc hgb hct mcv mch mchc rdw am neuts lymphs monos eos basos am plt count am pt ptt inr pt transthoracic echocardiogram the left atrium is mildly dilated the right atrium is markedly dilated the estimated right atrial pressure is at least mmhg there is mild symmetric left ventricular hypertrophy with normal cavity size overall left ventricular systolic function is low normal lvef the right ventricular cavity is moderately dilated with moderate global free wall hypokinesis there is abnormal systolic septal motion position consistent with right ventricular pressure overload the aortic arch 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 left ventricular inflow pattern suggests impaired relaxation moderate tricuspid regurgitation is seen there is severe pulmonary artery systolic hypertension there is no pericardial effusion impression borderline left ventricular systolic function with abnormal systolic septal motion consistent with right ventricular pressure overload moderately dilated right ventricle with moderate global free wall hypokinesis severe pulmonary hypertension mildly dilated aortic arch moderate tricuspid valve regurgitation compared with the findings of the prior study images reviewed of there is now severe pulmonary hypertension moderate dilation and moderate dysfunction of the right ventricle moderate tricuspid regurgitation and borderline left ventricular systolic function cxr impression probable moderate interstitial pulmonary edema superimposed upon background pulmonary fibrosis the ddx could include fibrosis with superimposed interstital pneumonia though this is considered less likely brief hospital course hospital summary f with a history of idopathic pulmonary fibrosis recently noted to worsen clinically who presented from an outside hospital with worsening hypoxia and dyspnea she initially required nrb oxygen and was placed on bipap and admitted to the medical icu she was started on antibiotics to cover possible cap and placed on a furosemide gtt given volume overload on exam oxygen requirement improved with these measures and she was transitioned back to nasal cannula oxygen and called out to the general medical on hospital day active issues hypoxia the patient s worsening hypoxia is likely multifactorial but was felt most likely due to worsening underlying pulmonary fibrosis leading to a spiral effect of worsening pulmonary hypertension cor pulmonale and fluid retention given the degree of fibrosis present at baseline her chest x ray is difficult to interpret specifically with regard to excluding infiltrate so she was started on ceftriaxone and azithromycin to cover possible cap despite being afebrile with no convincing sputum data she received days of ceftriaxone azithro but given her lack of cough or leukocytosis to suggest pneumonia antbx were narrowed to ciprofloxacin only for her uti when sensitivities returned in addition she was treated with a furosemide gtt to reduce volume overload with brisk urine output associated with improvement in her oxygen requirement transthoracic echocardiogram was done shortly after admission which demonstrated severe pulmonary hypertension with pressure estimates of mmhg it should be noted that the patient was still volume overloaded at the time this study was obtained on the medical floor she was given more iv lasix for diuresis and was discharged home on mg po lasix ipf progression of underlying disease is likely as above her cellcept was recently increased and may have contributed to some of her pulmonary edema and peripheral edema symptoms cellcept was held in house though bactrim prophylaxis was continued steroids were felt unlikely to offer significant benefit in this clinical scenario and were therefore not initiated uti urine culture grew klebseilla which was bactrim resistant she was treated with iv ceftriaxone concurrent with cap treatment as above and transitioned to ciprofloxacin upon discharge to complete a day course goals of care the patient s primary pulmonary team fellow dr and attending dr were contact regarding this admission and expressed concern for limited treatment options in the setting of underlying disease their current feeling is that if her disease continues the current trajectory of rapid progression the only remaining avenue may be palliative care gentle attempts were made to broach this topic with the patient however it was apparent that she does not currently feel mentally or emotionally ready for this discussion it was explained to her that if her respiratory status were to deteriorate to the point of intubation weaning from the ventillator may not be feasible nonetheless she elected to remain full code while she continues to think about her condition and prognosis inactive issues hypothyroidism thyroid studies were checked given her history of hypothyroidism and worsening lower extremity edema but returned unremarkable at tsh and free t no changes were made to her home dose of levothyroxine at mcg po daily gerd continued on omeprazole mg po bid arthritis pain control per patient she has seen two different specialists who disagree on whether her arthritis is sero negative ra or osteoarthritis she has not had significant improvement with increased dose of cellcept which was held during this admission she was restarted on home tramadol mg po bid prn nsaids were held in the setting of diuresis but was started on nambutone on discharge hypertension continued on lisinopril mg po daily hyperlipidemia continued rosuvastatin mg po daily transition of care code full contact medications on admission confirmed with pharmacy spironolactone mg daily levothyroxine mcg daily mycophenolate mofetil mg qam mg qpm omeprazole mg tramadol mg lisinopril mg daily bactrim ss daily rosuvastatin mg daily albuterol mcg q h prn dyspnea acetaminphen mg q h pnr calcium carbonate vitamin d daily coenzyme q mg folic acid multivitamin niacin mg omega fatty acids mg capsule sennosides dosage uncertain discharge medications spironolactone mg tablet sig one tablet po daily daily levothyroxine mcg tablet sig one tablet po once a day omeprazole mg capsule delayed release e c sig one capsule delayed release e c po bid times a day tramadol mg tablet sig one tablet po bid times a day lisinopril mg tablet sig one tablet po daily daily bactrim mg tablet sig one tablet po once a day rosuvastatin mg tablet sig one tablet po daily daily albuterol sulfate mcg actuation hfa aerosol inhaler sig puffs inhalation q h every hours as needed for sob acetaminophen mg tablet sig two tablet po q h every hours as needed for pain calcium carbonate vitamin d mg mg unit tablet sig two tablet po once a day coenzyme q mg capsule sig one capsule po twice a day folic acid mg tablet sig one tablet po once a day multivitamin tablet sig one tablet po daily daily niacin mg tablet sig one tablet po twice a day senna mg tablet sig one tablet po bid times a day as needed for constipation nabumetone mg tablet sig two tablet po bid times a day ciprofloxacin mg tablet sig one tablet po twice a day for days disp tablet s refills furosemide mg tablet sig one tablet po once a day home oxygen l via nasal cannula titrated to o sat diagnosis pulmonary fibrosis discharge disposition home with service facility vna inc discharge diagnosis pulmonary fibrosis pulmonary edema urinary tract infection discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions ms you were admitted to the hospital with worsening shortness of breath thought to be related to pulmonary fibrosis and fluid in your lungs we gave you lasix to reduce the amount of fluid medication changes please start lasix mg daily please start ciprofloxacin mg twice daily for two days for urinary tract infection followup instructions name np address phone appointment tuesday pm department pulmonary function lab when wednesday at am with pulmonary function lab building campus east best parking garage department medical specialties when wednesday at am with dr dr building sc clinical ctr campus east best parking garage,"{
""Diagnoses"": [""Shortness of breath"", ""Hypoxia"", ""Pulmonary fibrosis"", ""Cervical cancer"", ""Seizure disorder""],
""Medications"": [""Codeine"", ""Latex"", ""Spironolactone"", ""Cellcept"", ""Nitropaste""]
}"
89634,admission date discharge date date of birth sex f service surgery allergies lisinopril aspirin attending chief complaint fever shortness of breath major surgical or invasive procedure operations exploratory laparotomy right colectomy hand sewn layer side to side ileotranverse colostomy exploratory laparotomy loa drainage and washout of abdomen diverting loop ileostomy evacuation of pelvic hematoma abdominal closure procedures and thoracic ultrasound and thoracentesis right chest ct guided drainage of abdominal fluid collection ct guided drainage right abdominal fluid collection ct guided aspiration of left lower quadrant fluid collection history of present illness f pod s p right colectomy for cecal mass was discharged home and returns with fever chills and shortness of breath patient reports doing after discharge yesterday however awoke this morning with fever she otherwise has no complaints and denies nausea vomiting diarrhea denies having any bowel movements or passage of blood dizziness or lightheadedness past medical history type diabetes with no known nephropathy neuropathy or retinopathy hypercholesterolemia hypertension status post tubal ligation status post benign breast biopsy and cataract social history married lives at home with her husband she has children son lives on her floor in the same building she never was a smoker and does not drink alcohol she and her husband are both retired she formerly worked as a hairdresser family history cardiac disease otherwise non contributory no heme malignancies or cancers physical exam on day of admission vs t p bp rr o l pe gen alert and oriented times no acute distress cv tachycardia regular rhythm pulm clear to ascultation bilaterally abd soft mild right flank tenderness to palpation nondistended no rebound guarding incision clean dry intact ext no edema at discharge vitals on room air gen nad a ox cv rrr no m r g resp lungs clear abd soft nontender nondistended ostomy functioning penrose drain stitched in place incision healing well extrem no c c e pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood hct 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 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 pt ptt inr pt pm blood fibrino pm blood fibrino d dimer 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 amylase totbili pm blood alt ast ld ldh alkphos amylase totbili dirbili indbili pm blood ld ldh dirbili am blood lipase pm blood lipase am blood lipase am blood calcium phos mg am blood albumin calcium phos mg iron am blood albumin calcium phos mg am blood caltibc ferritn trf pm blood hapto pm blood hapto am blood triglyc brief hospital course the patient was admitted on to the surgical service due to her prolonged hospital course her summary will be done by systems operations exploratory laparotomy right colectomy hand sewn layer side to side ileotranverse colostomy exploratory laparotomy loa drainage and washout of abdomen diverting loop ileostomy evacuation of pelvic hematoma abdominal closure neuro she required prn narcotics for pain on her pain medications were discontinued due to increased lethargy her pain improved and was well controlled on tylenol she did appear depressed at times but as her strenght improved so did her affect and willingness to ambulate and participate in her care cardiovascular she required vasopressor support post operatively this was able to be weaned to off after a couple of days she did remain tachycardic in the low s during her entire hospital stay she was started on a beta blocker and her heart rate improved pulmonary a right thoracentesis was performed on post operatively she required ventilatory support after her third operation she was volume overloaded and remained on the ventilator while she was aggressively diuresed when she was back to her dry weight she tolerated extubation and has remained stable from a respiratory standpoint since due to her persistent tachycardia a cta of her chest was obtained which revealed no pulmonary embolus gastrointestinal she underwent a right colectomy with a hand sewn ileotransverse colostomy on her clinical status improved initially but then slowly began to deteriorate this decline along with a substantial leukocytosis prompted a ct scan on which revealed a large abdominal fluid collection surrounding the anastomotic site ct guided drainage of this collection was performed a repeat ct scan was obtained on and showed two smaller intra abdominal fluid collections that were percutaneously drained a repeat ct scan on showed a new llq fluid collection which was percutaneously drained with a pigtail catheter and the current ruq drain was exchanged her clinical condition failed to improve so on she returned to the operating room for an exploratory laparotomy diverting ileostomy and penrose placement around the anastamotic site the diverting ileostomy began to function on on she became increasingly oliguric a ct scan showed a large hematoma compressing both ureters and causing hydronephrosis she was taken back to the operating room for a hematoma evacuation she returned to the operating days later for abdominal packing removal and abdominal closure with mesh she required tpn support for nutrition she developed pancreatitis and an elevated bilirubin the elevated bilirubin was attributed to tpn and cholestasis and has been trending down to near normal due to her pancreatitis a dobhoff tube was placed and tube feeds started her lipase remain elevated for a number of days and has since trended back down towards normal her tpn was able to be weaned off she is currently tolerating tube feeds cycled overnight her staples were removed and her incision is healing nicely the penrose drain was backed out cm and restitched to the ostomy appliance this will remain to ostomy bag drainage genitourinary on her serum creatinine rose to and she was bolused with ivf for low urine output after her nd operation her creatinine continued to rise a renal consult was obtained and they felt that her acute renal failure was due to atn on she became increasinly oliguric and was transferred back to the icu a repeat ct scan showed a large pelvic hematoma which was compressing the ureters and causing hydronephrosis this hematoma was evacuated and her renal function has returned to while she was in acute renal failure her medications were renally dosed fen she was advanced to a regular diet post operatively when she was found to have an anastomotic leak she was made npo a picc line was placed and tpn was started on she became hypernatremic on which was treated with d w to replace her free water deficit due to increased ostomy output at times she has required free water boluses per her dobhoff tube these free water boluses can be continued as needed imodium may also be added to her medication regimen to help control her ostomy output heme she has had recurrent issues of leukocytosis anemia and thrombocytopenia her initial leukocytosis was attributed to sepsis which resolved with antibiotics and drainage of abscess collections her recurrent bouts of leukocytosis were thought to be consistent with a leukemoid reaction her wbc is trending downward and is now at a low of k she has ongoing problems with anemia secondary to her myelodysplastic syndrome she received transfusions of packed rbcs when necessary id after the initial operation she had a persistent leukocytosis so she was started on empiric zosyn and flagyl vancomycin was added on when a peri anastomotic collection was found with her impressive leukocytosis multiple stool samples were sent for c diff which all were negative fluconazole was added on a day course of vancomycin was complete for coag negative staph isolated from a blood culture a day course of meropenem was completed for enterobacter that was grown from the pigtail catheter medications on admission vicodin and colace no other routine medications discharge medications albuterol mcg actuation aerosol sig four puff inhalation q h every hours as needed for wheezing nystatin unit ml suspension sig five ml po qid times a day as needed symptoms of oral thrush sertraline mg tablet sig one tablet po qpm once a day in the evening metoclopramide mg tablet sig one tablet po qid times a day loperamide mg tablet sig one tablet po qid times a day as needed for increased ostomy output for ostomy output cc hrs pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours acetaminophen mg ml solution sig ml po q h every hours as needed for pain ha do not exceed mg in hrs metoprolol tartrate mg tablet sig tablet po bid times a day hold for sbp hr lantus unit ml solution sig units subcutaneous at bedtime insulin regular human unit ml solution sig per sliding scale injection before meals and at bedtime or every hours regular insulin sliding scale insulin sc sliding scale breakfast lunch dinner bedtime regular regular regular regular glucose insulin dose insulin dose insulin dose insulin dose mg dl oz juice and gm crackers oz juice and gm crackers oz juice and gm crackers oz juice and gm crackers mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units discharge disposition extended care facility tcu discharge diagnosis primary anastamotic leak abdominal fluid collections managed with ct drainage renal insufficiency related to iv contrast hypervolemia managed with iv lasix hypovolemia managed with iv fluid anasarca acute blood loss anemia secondary aml dm hyperlipidemia htn discharge condition stable tolerating a regular diet adequate pain control with oral medication discharge instructions please call your doctor or return to the er for any of the following you experience new chest pain pressure squeezing or tightness 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 see blood or dark black material when you vomit or have a bowel movement your skin or the whites of your eyes become yellow your pain is not improving within hours or becoming progressively worse or inadequately controlled with the prescribed pain medication 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 incision care you may shower pat incision dry avoid swimming and baths until further instruction at your followup appointment please call the doctor if you have increased pain swelling redness or drainage from the incision sites right upper quadrant ostomy appliance penrose inserted into hepatic flexure the drain is sutured to the stoma wafer to prevent from falling out the penrose drain site will be re assessed per dr at the follow up appointment on monitoring ostomy output prevention of dehydration keep well hydrated replace fluid loss from ostomy daily avoid only drinking plain water include gatorade and or other vitamin drinks to replace fluid try to maintain ostomy output between ml to ml per day if ostomy output liter take mg of imodium repeat mg with each episode of loose stool do not exceed mg hours followup instructions please follow up with dr on tuesday please call to confirm appointment time follow up with pcp as needed,{}
23950,admission date discharge date date of birth sex f service medicine allergies penicillins sulfonamides attending chief complaint nausea vomiting post cath major surgical or invasive procedure cardiac catheterization w to cardiac catheterization w to history of present illness per admission cmi note as pt too somnolent to give hx mrs is a yo f with known cad prior vessel cabg in who presented to on with chest pain patient reports that approximately months ago she began to notice chest tightness radiating to her left arm with exertion and at rest these symptoms worsened over the past week and she noticed an increase in palpitations over the past week as well she describes the pain as midsternal chest pressure radiating to her left arm and back the pain is associated with sob mild dizziness and nausea she took sl ntg on one occasion which did relieve her cp she reported her symptoms to her pcp who instructed her to go to the ed she was admitted to and ruled out for an mi by serial enzymes an ett done depressions and t wave flattening she was transferred to today for cath on arrival she was chest pain free past medical history cad s p cabg x lima diag svg lad svg om svg rca htn lipid disorder seen in cardiac and clinic at asthma gerd diverticulosis ibs sensitive stomach per her family social history lives with boyfriend grown children she does not drink etoh upsets her stomach no tobacco family history for cad physical exam vs t bp hr rr sats on l nc gen wdwn f lying in bed somnolent breathing comfortably heent sclera anicteric pupils dilated to mm bilaterally equally rxtive neck supple jvp exaggerated cv rr normal s s no m r g resp lungs clear anteriorly abd soft ntnd bs no masses ext right groin no ooze no hematoma no bruit dp pt pulses bilaterally no c c e neuro somnolent skin no rashes pertinent results labs on admission wbc hct mcv plt inr pt na k cl hco bun cr glu alt ast alkphos amylase tbili pm blood ck cpk ck mb mb indx ctropnt am blood ck cpk ck mb mb indx ctropnt pm blood ck cpk ck mb mb indx ctropnt am blood ck mb labs 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 ck cpk am blood calcium phos mg micro h pylori negative urine culture negative imaging cardiac cath lmca ostial lad to mid lcx to mid rca to prox svg rca widely patent svg lad mid prox svg om distal prox today s p des cypher x svg d ct head no acute intracranial hemorrhage or mass effect ecg sr normal axis twi v v no change from pre procedure cardiac cath comments the mid graft lesion was predilated with a x mm voyager baloon at atm and under distal filter protection we then deployed a x mm cypher stent at atm the proximal graft lesion directly stented with a x mm cypher stent at atm and post dilated using a x mm power sail balloon at atm twice the final angiogram showed timi iii flow with no residual stenosis in the mid graft stent residual stenosis in the proximal graft stent with no dissection and no embolisation the patient left the lab in a stable conditio see ptca comments final diagnosis successful stenting of the mid svg to lad lesion successful stenting of the proxsimal svg to lad lesion brief hospital course patient is a year old female with known cad initally presented to outside hospital with chest pain at the outside hospital patient was ruled out for an mi with sets of negative cardiac enzymes had a positive ett and was subsequently transferred to for cardiac catheterization at patient initally underwent cardiac catheterization where she was found to have a mid lesion and a proximal lesion of the svg to lad graft had and a distal lesion and a proximal lesion of the svg to om she had cypher stents placed in the svg to om lesion with plans to return to the cath lab for stenting of the svg to lad lesion her first post cath course was complicated by severe nausea and vomiting which was eventually relieved with antiemetic medication due to her gi upset she was also started on protonix which helped to alleviate her symptoms and had h pylori test sent which was negative otherwise her cr cpk and ekg remained normal post cath prior to return for her nd catheterization the patient underwent pre medication with famotidine benadryl and solumedrol in case her post cath nausea vomiting was secondary to dye allergy and received only versed no fentanyl for sedation peri cath in her second cardiac catheterization patient had cypher stents placed in the svg to lad lesion this post cath course was not complicated by nausea vomiting and again her cpk cr and ekg remained normal post cath the patient was otherwise managed medically continuing her outpatient anti hypertensive medications imdur which was decreased from mg to mg qd due to low blood pressures diltiazem and quinapril she was also maintained on aspirin mg qd was started on plavix mg qd the hospital course was also notable for some hematuria which developed following foley catheter placement and was thought to be secondary to traumatic foley placement a urine culture was sent which was negative and her hematocrit remained stable and the hematuria resolved upon removal of the foley catheter the patient was discharged on her outpatient medication regimen although her aspirin dose was increased to full strength and her imdur was decreased to daily along with new medications including plavix and protonix she was discharged with appointments to follow up with both her primary care physician and her cardiologist within the next couple weeks medications on admission imdur mg twice a day accupril mg once a day cartia xt mg once a day folic acid micrograms once a day asa mg once a day pulmacort puffs once a day flonase puff each nostril once daily ntg sl prn tums mg prn discharge medications clopidogrel 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 quinapril mg tablet sig tablet po daily daily diltiazem hcl mg capsule sustained release sig one capsule sustained release po daily daily pirbuterol mcg inhalation aerosol breath activated sig one puff inhalation prn as needed calcium carbonate mg tablet chewable sig one tablet chewable po qid times a day as needed indigestion isosorbide mononitrate mg tablet sustained release hr sig one tablet sustained release hr po daily daily disp tablet sustained release hr s refills beclomethasone diprop monohyd aerosol spray sig one spray nasal qd pantoprazole 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 fluticasone mcg actuation aerosol sig two puff inhalation times a day nitroglycerin mg tablet sublingual sig one tablet sublingual every minutes as needed for chest pain place under tongue every minutes as needed for chest pain x contact physician immediately if need to take discharge disposition home discharge diagnosis coronary artery disease discharge condition good patient asymptomatic stable ambulatory without complaints discharge instructions please contact physician if you experience chest pain pressure shortness of breath dizziness lightheadedness any other questions concerns please take medications as directed please follow up with appointments as directed please refrain from heavy lifting or strenuous activity for weeks followup instructions please follow up with dr on monday at am please follow up with dr on tuesday at am,"{
""Diagnoses"": [""Chest pain"", ""Nausea"", ""Vomiting"", ""Mild dizziness""],
""Medications"": [""SL NTG""]
}"
10346,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint pain left chest sob major surgical or invasive procedure mvrepair annuloplasty band history of present illness yo m with history of myxomatous mitral valve and moderate to severe mvp past medical history social history unemployed current tobacco quit cigs day approx year ago etoh x year family history nc physical exam thin man in nad skin unremarkable heent unremarkable neck supple full rom chest ctab heart rrr abd benign extrem warm no edema no varitcosities pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood plt ct 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 echo pre bypass left ventricular wall thicknesses and cavity size are normal regional left ventricular wall motion is normal the mitral valve leaflets are myxomatous there is moderate mitral valve prolapse mild late systolic mitral regurgitation is seen the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation the aortic root is moderately dilated measuring cm the dilatation normalizes at the sinotubular junction with normal diameter of the ascending aorta small secundom asd seen on color doppler right ventricular chamber size and free wall motion are normal post bypass preserved ventricular systolic function repaired mitral valve is seen no mitral regurgitation mild of the tip of the anterior leaflet without gradient across the lvot no evidence of aortic dissection post de cannulation no evidence of asd on color doppler rest of study is unchanged from pre bypass cxr comparison is made to prior day the patient is status post sternotomy a prosthetic mitral valve is again visualized there is persistent volume loss with atelectasis and effusion at the left lung base which is unchanged a right sided pleural effusion is somewhat smaller the lung fields are otherwise clear there is no pneumothorax ospital course he was taken to the operating room on where he underwent a mitral valve repair annuloplasty band and and asd closure he awoke and was extubated that day he was weaned from his neosynephrine and transferred to the floor on pod he remained tachycardiac with a bp in the s on pod he had a temperature of for which he was panculatured he had a enterobactor uti for which he was placed on bactrim he was seen in consultation by medicine for his weight loss nausea and vomiting they recommended adding boost changing diet to soft solids reglan discontinuing nsaids and changing h blocker to ppi he continued to improve and was ready for discharge on pod he will follow up with dr his cardiologist and his primary care physician as an outpatient medications on admission atenolol mg qd lisinopril mg qd discharge medications docusate sodium mg capsule sig one capsule po bid times a day disp capsule 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 ferrous gluconate mg tablet sig one tablet po daily daily disp tablet s refills ascorbic acid mg tablet sig one tablet po bid times a day disp tablet s refills pantoprazole 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 metoprolol tartrate mg tablet sig one tablet po q h every hours disp tablet s refills trimethoprim sulfamethoxazole mg tablet sig one tablet po bid times a day for days disp tablet s refills ibuprofen mg tablet sig one tablet po q h every hours as needed disp tablet s refills discharge disposition home discharge diagnosis myxomatous mv mod severe mvp mr ectasia gerd l para renal cyst 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 heavy lifting or driving until follow up with surgeon p instructions m d weeks dr as planned prior to surgery dr weeks completed by,"{
""Diagnoses"": [""cardiothoracic"", ""myxomatous mitral valve"", ""moderate to severe mitral valve prolapse"", ""mitral regurgitation"", ""aortic valve prolapse"", ""aortic regurgitation""],
""Medications"": [""none""]
}"
49525,admission date discharge date date of birth sex f service surgery allergies no known allergies adverse drug reactions attending chief complaint ruptured infrarenal abdominal aortic aneurysm major surgical or invasive procedure ultrasound guided puncture of bilateral common femoral arteries bilateral catheter placement into the abdominal aorta abdominal aortogram endovascular repair of abdominal aortic aneurysm with a x x mm main body with x mm ipsilateral extension and an x mm contralateral limb perclose closure of bilateral common femoral arteriotomies history of present illness f presented to with abdominal pain with radiation to back she presented earlier towards the day diagnosed with a uti pyelonephritis and was discharge home with cipro at home she was found in excrutiating pain to her abdomen and back again there was nausea with emesis found at the scene she was taken back to for evaluation sbp found to be unstable at s ed attending performed an ultrasound which revealed a cm aaa she was found diaphoretic and in persistent abdominal flank pain with her unstable clinical course she was immediately medflighted to for emergent repair she was intubated upon arrival for airway protection her blood pressure remained in the s past medical history hypertension hypothyroidism history of coronary artery disease abnormal nuclear stress test anterolateral defect in atrial septal aneurysm paroxysmal supraventricular tachycardia bronchitis social history lives with husband in ma family history n c physical exam vs hr bp rr spo ra general alert and oriented x nad neuro cn ii xii intact cardiac rrr lungs cta bilaterally abd soft nt nd wound cdi extremities no cce bilateral generalized edema pedal signals per doppler 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 neuts lymphs monos eos baso am blood plt ct am blood plt ct 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 ck cpk am blood calcium phos mg am blood calcium phos mg am blood type art po pco ph caltco base xs intubat not intuba pm blood type art po pco ph caltco base xs am blood lactate am blood lactate abdominal cta post op preliminary report wet read status post endovascular repair of abdominal aortic aneurysm with aortobiiliac graft which appears intact without evidence of endoleak maximal aneurysm sac dimensions measure x cm in greatest ap diameter complete details of the aneurysm sac and graft will be reported once reformatted images are processed by the d imaging lab decreased quantity and density of blood products in the aneurysm sac and in the left retroperitoneum patent celiac axis sma and renal arteries there is unchanged attenuation of the left renal artery by left retroperitoneal hematoma and which may fill via retrograde flow unchanged hiatal hernia and hepatic and renal cystic lesions probably simple cysts brief hospital course on the patient was transferred to via med flight from for a ruptured aaa she was hemodynamically unstable and intubated on arrival to the ed she was emergently taken to the or for an endovascular aaa repair she was transfused with a total of units of prbc intra and post operatively for blood loss related to ruptured aaa with a hct of post operatively the patient was transferred to the cvicu she was weaned to extubation overnight she was hemodynamically stable following the endovascular repair she also eceived bicarb infusion post op for renal protection bedrest overnight nitro gtt for blood pressure control on pod the patient was started on lopressor for systolic blood pressure goal she responded to diuresis pulmonary toilet continued and the patient got oob with nursing she was transferred to the vicu on pod the patient continued to progress vitals were stable continued to diuresis with iv lasix tolerating regular diet oob with pt a repeat cta showed no endoleak and no migration of the aortic graft continued to work with pt oxygen weaned to off currently on l nc stable no acute events pt visit recommended home with physical therapy and walker on room air discharged home with physical therapy will follow up with dr in weeks with an abdominal ultrasound medications on admission levothyroxine lopressor xl asa discharge medications sodium chloride aerosol spray sig sprays nasal daily daily as needed for dry nose levothyroxine mcg tablet sig one tablet po daily daily oxycodone acetaminophen mg tablet sig one tablet po q h every hours as needed for pain disp tablet s refills acetaminophen mg tablet sig tablets po q h every hours as needed for pain do not exceed gms of acetaminophen daily simvastatin mg tablet sig one tablet po daily daily call pcp for refills phone fax disp tablet s refills metoprolol tartrate mg tablet sig tablet po bid times a day call pcp md s phone fax disp tablet s refills discharge disposition home with service facility nursing services discharge diagnosis ruputured infrarenal abdominal aortic aneurysm pmh hypertension hypothyroidism coronary artery disease bronchitis 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 division of and endovascular surgery endovascular abdominal aortic aneurysm aaa discharge instructions medications take aspirin mg enteric coated once daily do not stop aspirin unless your surgeon instructs you to do so continue all other medications you were taking before surgery unless otherwise directed you make take tylenol or prescribed pain medications for any post procedure pain or discomfort what to expect when you go home it is normal to have slight swelling of the legs elevate your leg above the level of your heart use pillows or a recliner every hours throughout the day and at night avoid prolonged periods of standing or sitting without your legs elevated it is normal to feel tired and have a decreased appetite your appetite will return with time drink plenty of fluids and eat small frequent meals it is important to eat nutritious food options high fiber lean meats vegetables fruits low fat low cholesterol to maintain your strength and assist in wound healing to avoid constipation eat a high fiber diet and use stool softener while taking pain medication what activities you can and cannot do when you go home you may walk and go up and down stairs you may shower let the soapy water run over groin incision rinse and pat dry your incision may be left uncovered unless you have small amounts of drainage from the wound then place a dry dressing or band aid over the area that is draining as needed no heavy lifting pushing or pulling greater than lbs for week to allow groin puncture to heal after week you may resume sexual activity after week gradually increase your activities and distance walked as you can tolerate no driving until you are no longer taking pain medications call and schedule an appointment to be seen in weeks for post procedure check and cta what to report to office numbness coldness or pain in lower extremities temperature greater than f for hours new or increased drainage from incision or white yellow or green drainage from incisions bleeding from groin puncture site sudden severe bleeding or swelling groin puncture site or incision lie down keep leg straight and have someone apply firm pressure to area for minutes if bleeding stops call office if bleeding does not stop call for transfer to closest emergency room followup instructions provider lab phone date time provider md phone date time do not eat anything past midnight the night before your ultrasound on completed by,{}
15230,admission date discharge date date of birth sex m service this is an interim discharge summary history of present illness the patient is a year old indian male with a past medical history of hypertension who presented to the emergency department on with crushing substernal chest pain radiating to the back approximately minutes later the patient also noted numbness of his lower extremities which lasted approximately minutes the patient received two tablets of sublingual nitroglycerin and aspirin without any significant improvement of symptoms in the emergency department he continued to have crushing pain and received a total of four sublingual nitroglycerin tablets as well as mg of intravenous lopressor times three he also received morphine sulfate mg intravenously and was started on labetalol computerized tomography scan of the abdomen was done and was notable for descending thoracic aorta dissection extending to the bifurcation and into the left common iliac as well as external iliac artery the patient denied dyspnea on exertion paroxysmal nocturnal dyspnea edema shortness of breath he did complain of nausea and vomiting he denied palpitations past medical history hypertension and questionable hypercholesterolemia allergies no known drug allergies medications on admission aspirin atenolol mg once a day family history non contributory social history denies using ethanol or smoking tobacco physical examination heartrate blood pressure respirations oxygen saturation is on room air blood pressure on the right arm left arm in general this is a mildly obese indian male lying in bed in pain alert and oriented times three head eyes ears nose and throat pupils equal round and reactive to light and accommodation bilateral extraocular movements intact sclera anicteric mucosal membranes are moist oropharynx is clear no jugulovenous distension and no thyromegaly cardiovascular regular rate and rhythm ii vi systolic murmur to left upper sternal border lungs clear to auscultation bilaterally abdomen is soft nontender nondistended with positive bowel sounds no organomegaly extremities dorsal pedis posterior tibial pulses bilaterally left radial and right radial pulses neurological examination nonfocal cranial nerves ii through xii were intact laboratory data white cell count hematocrit platelets sodium potassium chloride bicarbonate bun creatinine glucose creatinine kinase troponin less than calcium phosphate magnesium hospital course cardiovascular the patient was transferred to the floor and started on labetalol intravenous drip to control his blood pressures on pm he became agitated and was given haldol intravenously shortly after he experienced an episode of hypotension with pulseless electrical activity arrest the code was called the patient was resuscitated his mean arterial pressures remained in the low s for five minutes he was intubated for hypoxia after intubation his blood pressures soon needed to be controlled with two agents labetalol and nipride to decrease sheer forces nipride drip was stopped a few days after initiation secondary to renal toxicity the patient was initially scheduled for surgery however the surgery was cancelled secondary to mental status changes and later fevers on mr developed another episode of hypotension requiring brief use of dopamine drip echocardiogram was repeated and showed trace aortic insufficiency no vegetations and normal aortic root without dissection and normal left ventricular function at about this echocardiogram was considered to be unchanged from the one done initially on admission on computerized tomography scan of the chest and abdomen were done and showed no change in aortic experience no retroperitoneal collections the patient was started on p o antihypertensives on on the same day magnetic resonance imaging scan was done and showed proximal arch wall thickness to be decreased from mm to mm with decreased hematoma it also showed partial thrombosis in the false lumen without occlusion of the full and normal renal arteries by blood pressures were controlled with p o medications lopressor t i d diltiazem q i d and hydralazine q i d as well as minimal lopressor intravenous drip neurological the patient had mental status change shortly after the administration of mg of morphine sulfate in the emergency department he became disorientated and agitated on the floor he had emesis times three an attempt was made to reverse the action of narcotics with naloxone which resulted in agitation and required the use of benzodiazepines and narcotics neurological consult was obtained on and felt that the patient s symptoms were consistent with toxic metabolic encephalopathy on the patient became agitated again required haldol and was intubated computerized tomography scan of the head was done on and was negative for intracranial bleed or any other abnormalities by at the time of this dictation the patient was fully sedated for hours still minimally responsive with some eye tracking and no other responses he had no focal signs on neurological examination infectious disease shortly after admission the patient developed fever and was started on antibiotics for presumed aspiration pneumonia he was initially started on cefepime vancomycin and levofloxacin however when his respiratory cultures came back positive for guaiac positive staphylococcus and his gram stain was positive for gram negative rods his antibiotic regimen was changed to oxacillin the patient continued to have fevers and infectious disease consult was obtained they recommended getting an abdominal ultrasound and liver function tests abdominal ultrasound showed positive sludge in the gallbladder without any evidence of cholecystitis as well as benign hemangioma of the liver liver function tests showed increased ldh and alkaline phosphatase enzymes mr continued to have fevers on oxacillin and his antibiotics were changed once again to unasyn unfortunately the patient developed a rash to this medication in two days and unasyn was changed to clindamycin and levofloxacin and then to flagyl and levofloxacin at this time his cultures were only positive for coagulase negative staphylococcus from the catheter tip and gram positive staphylococcus in the sputum he finished the course of antibiotics on and remained off of antibiotics since then until the time of this dictation his temperature and white blood cell count remained stable no new positive cultures were detected pulmonary the patient developed increased oxygen requirements shortly after admission the swan catheter was flooded and showed right atrial pressure of right ventricular pressure of pulmonary artery pressure of and capillary wedge at later he developed adult respiratory distress syndrome like picture with multiple bilateral passing opacities and bilateral pleural effusions on chest x ray his ventilation settings were changed to low title volumes and increased positive end expiratory pressure he also developed nonanion gap metabolic acidosis on bronchoscopy was done which showed patchy thick secretions throughout the upper and lower lobes bilaterally without any masses bronchial alveolar lavage results showed pmns on gram stain and no organisms by metabolic acidosis was corrected with bicarbonate infusion chest x ray and clinical examination as well as oxygen requirements improved and the patient was extubated at the time of this discharge mr remained off of the ventilator for hours stable renal the patient s baseline creatinine was on admission he received cc of contrast with first computerized tomography scan angiogram and cc with the second one his creatinine rose up to shortly after the patient continued to be in renal failure over the next three weeks with urine electrolytes consistent with a good renal picture and metabolic acidosis secondary to bicarbonate loss renal consult was obtained on and suggested that acute renal failure was the most consistent with acute tubular necrosis with diarrhea contributing to bicarbonate loss bicarbonate was repleted over the next two days with good results dr dictated by medquist d t job [NEW_RECORD] name unit no admission date discharge date date of birth sex m service ccu addendum this is an addendum to the previously described interim discharge summary please see admission history physical and hospital course through accordingly hospital course continued cardiovascular as of blood pressures continued to remain labile metoprolol mg t i d diltiazem mg q i d hydralazine mg q i d and clonidine mg t i d and labetalol drip on the patient was weaned off the labetalol drip and clonidine dosing was gradually increased to maximum dose of mg t i d the patient was also started on hydrochlorothiazide mg q d with little improvement of blood pressure control with improvement of renal function an angiotensin converting enzyme inhibitor was also added to the regimen on at this time the patient s systolic blood pressure was staying at approximately mmhg and a heart rate between to and a ccu team decided this patient was stable enough to be transferred to the floor within hours of transfer the patient began to experience chest pain with radiation to the back sublingual nitroglycerin was given three times and mg of iv morphine with mild relief the patient was taken for emergent ct scan angiogram of the chest that revealed further increase of thoracic luminal diameter from to cm increase in size of the luminal thrombosis and increase in size of the lumen at the left pulmonary artery to cm cardiothoracic surgery was consulted at this time and stated that there was no indication for surgery at this time the patient was then transferred back to the ccu for more aggressive control of his blood pressure and the patient was restarted on nitroglycerin drip for hours the patient was then started on norvasc mg the following evening the patient again experienced an episode of chest pain but this time without back pain and showed no clinical signs of extension or dissection nor changes on ekg later on that evening the patient experienced a drop in blood pressure to systolic blood pressure of minutes after receiving night time dosages of clonidine and captopril the patient responded to cc bolus of normal saline and maintained him at greater than within the next hours the patient had another episode of substernal chest pain with stable vital signs and no ekg changes the patient had moderate relief with nitroglycerin times two there are no ekg changes at this time repeat ct scan angiogram revealed no progression of dissection again blood pressure remained stable in both arms there are no clinical signs for evidence of progression of dissection given the episode of substernal chest pain the patient was started on aspirin the patient s blood pressure remained well controlled in the unit the patient was again transferred to the floor on between the time of transfer and patient s date of discharge on patient s blood pressure was controlled on blood pressure medication blood pressure medication regimen was adjusted as necessary please see discharge medications for discharge antihypertensive medications infectious disease the patient completed a out of day course of linezolid and aztreonam for mrsa and potential gram negative pneumonia as per infectious disease patient remained afebrile with a stable white blood cell count for the remainder of the hospital stay neurology given patient s somnolence confusion mental status changes status post extubation neurology was consulted given these findings on exam on exam it was noted that the patient also had a left gazed deviation right field right hemiparesis a mri on revealed laminar necrosis with hemorrhage in media left occipital lobe and left thalamus sinus disease neurology recommendations including maintaining systolic blood pressure less than keep head of bed elevated greater than degrees and patient was followed by the neurology for the remainder of the hospital course the patient improved mental status throughout the remainder of the hospital stay with increased speech and movement of all extremities the stroke service was also consulted to evaluate the patient for possible cardiac catheterization given patient s history of substernal chest pain and possible future need of cardiothoracic surgery for aortic dissection a mri showed a left pca involving infarct and thus it was concluded it was best to wait two to three weeks for anticoagulation patient is to follow with clinic as an outpatient condition on discharge good discharge status to rehab facility discharge diagnoses aortic dissection type b cerebrovascular accident hypertension aspiration pneumonia ards acute renal failure methicillin resistant staphylococcus aureus bacteremia discharge medications atenolol mg p o q d lisinopril mg p o q d norvasc mg p o q d clonidine mg p o t i d times one week nitroglycerin sublingual p r n chest pain aspirin mg p o q d vitamin c mg p o b i d zinc sulfate mg p o q d follow up plans follow up with cardiothoracic surgery in one month follow up with dr in one to two weeks for blood pressure management this is the patient s primary care physician follow up with cardiology in one month including outpatient stress test follow up in clinic in two to three weeks occupational therapy and physical therapy dr dictated by medquist d t job,"{
""Diagnoses"": [""Descending thoracic aorta dissection""],
""Medications"": [""Nitroglycerin"", ""Lopressor"", ""Morphine sulfate"", ""Labetalol""]
}"
5693,admission date discharge date date of birth sex f service trauma surgical service history of present illness the patient is a year old female who was involved in a motor vehicle crash as a restrained passenger with airbag deployment unknown if she had loss of consciousness or not who presented to the trauma bay trauma workup of this patient revealed bilateral small subarachnoid hemorrhages right thigh hematoma and right forehead lacerations the patient underwent a computerized tomography scan of her head cervical spine and her abdomen which revealed the injury stated above the patient was admitted to the hospital and transferred to the trauma surgical intensive care unit where she underwent aggressive resuscitation through an episode of hypotension which resulted in a computerized tomography scan of her thigh revealing minor extravasation of blood after adequate resuscitation thigh hematoma was found to begin to resorb her blood pressure became normalized and she was transferred to the floor following extubation throughout the remainder of her stay on the floor she underwent aggressive physical therapy her mental status continued to improve and her hematocrit was stable she was maintained on kefzol for the laceration on her head which was closed by plastic surgery and was deepened down to the galea the patient has been seen by physical therapy and deemed appropriate for rehabilitation and will be discharged condition on discharge stable discharge status to rehabilitation discharge medications protonix mg p o q d tylenol mg p o q hours prn albuterol atrovent metered dose inhaler puffs q hours prn mavik mg p o q day verapamil sr mg p o q day hold for systolic blood pressure of less than lipitor mg p o q day premarin mg p o q day keflex mg p o q i d for three days discharge diagnosis hypertension hypercholesterolemia bilateral small subarachnoid hemorrhages resolving right thigh hematoma resolving right forehead laceration 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 was cleared for discharge to rehabilitation by physical therapy and by the surgical staff however over the next couple of days the patient had trouble finding rehabilitation placement due to insurance issues however on the patient was accepted at a rehabilitation facility and will be transferred directly there through the remaining couple of hospital days the patient remained afebrile with stable vital signs and had no acute surgical issues m d dictated by medquist d t job,"{
""Diagnoses"": [""bilateral small subarachnoid hemorrhages"", ""right thigh hematoma"", ""right forehead lacerations""],
""Medications"": [""unknown""]
}"
49508,admission date discharge date service medicine allergies nsaids bactrim attending chief complaint angioedema major surgical or invasive procedure intubation history of present illness pt is an y o f with a h o gave s p argon treatment last on iron deficiency anemia cirrhosis hepc portal htn grade varices but no hx of bleeding varices cri baseline cr who is transfered from intubated s p angioedema by report the pt has some mild abdominal pain and some irritation in her throat a day prior to admission to the following morning she called her son with complaints of oral swelling son states that her speach was garbled the son reports that the patient denies having had any sob no wheezing no hives he called an abmulance who transported the pt to per omr the patient present to pheresis unit on for blood transfusion for chronic slow upper gi bleeding she had no pretreatment medications given and no adverse events vitals on leaving the unit were she has also been recently treated for a uti with bactrim started on at st elizabeths she was hd stable but had a large edematous tongue she recevied decadron epinephrine benadryl famotidine and hydroxazine in the ed the ed was unable to intubate and she was taken to the or laryngeal edema was noted but the et tube was passed successfully she was then transfered to the ccu she received hydroxazine tid and her tongue swelling improved sbt was attempted early on but failed likely secondary to sedation per report pt did have a cuff leak family requested transfer to as pt receives all her care here on arrival in the micu she passed an sbt and was successfully extubated she did well throughout the day but continued to have an o requirement by the time of transfer to the floor she was on l of nc o satting on the floor she is alert and oriented she does not know what caused her swelling she denies new pills new medications or new foods she feels well and has no sob itching or complaints past medical history gave s p argon treatment last on last on hepatitis c cirrhosis child s class a portal htn grade varices no h o ascites encephalopathy variceal bleeding synthetic function intact dm type ii htn iron deficiency anemia s p r radial nephrectomy for renal cell ca yrs ago hypercholesterolemia osteopenia insomnia angioedema possibly due to bactrim but as yet not proven social history lives alone in in complex is widowed has sons who live nearby no tob in yrs occ etoh at holidays worked in food business in sales family history no family history of allergic diseases physical exam gen pleasant elderly lady in nad speaking comfortably no cyanosis jaundice or dyspnea vs on l nc heent mmm no op lesions tongue nl size neck supple no lad or thyromegaly cv rr nl s s no s s mrg pulm roncherous breath sounds with scattered wheezes and crackles up the lung fields abd bs nt ventral hernia gas on percussion no masses or hsm no fluid wave collaterals and angiomata limsb no le edema clubbing neuro perrla eomi moving all limbs reflexes of the biceps and petellar tendons pertinent results admission 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 alt ast ld ldh alkphos totbili am blood calcium phos mg 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 alt ast ld ldh alkphos totbili am blood albumin calcium phos mg brief hospital course f with a h o gave s p argon laser treatment last on iron deficiency anemia due to chronic ugib cirrhosis hcv portal htn with grade varices but no history variceal bleeding cri baseline cr who is s p prolonged intubatation for angioedema of unknown etiology possibly due to bactrim she is doing very well on s p extubation at this point all antihistamines have been discontinued at this point she was progressively be restarted on her home meds angioedema resoved lack of hives bronchospasm or hypotension suggests that this was not allergic angioedema but rather bradykinin related c and c were low c esterase inhibitor pending neg per allergy consult at prior to transfer non allergic angioedema is due to complement depletion either hereditary or ca related or complement activation infection or transfusion the patient did have a transfusion recently which may be related medications would also be high on the list of etiologies common offenders are nsaids and aceis but arbs have also been implicated it was discovered that the pt was taking bactrim when the reaction leading to her admission this is a possible offender and has been added to her allergy list restarted home meds one by one all but felodipine have been restarted had hives and itching the day prior to discharge which did not generalize and seemed more of a contact dermatitis on the l arm no new medications were started so it is unclear what initiated this responded to hydroxyzine x also of note the patient refused to shower or be washed down this admission which may contribute to her itchiness chronic ugib received regular blood transfusions as an outpatient for any hct in the past she only needed them infrequently but her transfusion requirements have increased lately transfused prior to discharge need outpatient follow up with gi dr has been recommended by her outpatient gastroenterologist wheezes and ronchi related to angioedema and volume overload most likely resolved with diuresis and nebulizers hx hcv complicated by cirrhosis no evidence of encephalopathy now but is at risk continued lactulose continued spironolactone aldactone mg daily continue furosemide lasix mg daily continue nadolol mg daily as ppx against variceal bleeding htn holding home ccb as normotensive on nadolol as above cri baseline was elevated on admission to to at baseline on discharge diabetes iss in house discharged on metformin medications on admission home medications felodipine mg qam and mg qpm folic acid mg daily furosemide lasix mg daily hydrocortisone acetate anusol hc mg daily lactulose gram ml daily metformin mg qam and mg qpm mupirocin ointment nadolol mg daily pantoprazole mg spironolactone aldactone mg daily sucralfate g tid zolpidem mg tablet qhs prn calcium carbonate vitamin d mg unit cyanocobalamin mcg daily ferrous gluconate mg times a day sarna ultra discharge medications calcium with d mg mg unit tablet sig one tablet po twice a day disp tablet s refills folic acid mg tablet sig one tablet po daily daily disp tablet s refills furosemide mg tablet sig one tablet po daily daily disp tablet s refills anusol hc mg suppository sig one suppository rectal once a day disp suppositories refills lactulose gram ml syrup sig fifteen ml po once a day disp ml s refills metformin mg tablet sig two tablet po qam disp tablet s refills metformin mg tablet sig one tablet po qpm disp tablet s refills nadolol mg tablet sig one tablet po daily daily disp tablet s refills pantoprazole 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 spironolactone mg tablet sig one tablet po once a day disp tablet s refills zolpidem mg tablet sig one tablet po hs at bedtime as needed for insomnia disp tablet s refills b dots mcg tablet sig one tablet po once a day disp tablet s refills ferrous gluconate mg tablet sig one tablet po five times a day disp tablet s refills discharge disposition home discharge diagnosis angioedema discharge condition stable vital signs at baseline discharge instructions you were admitted at hospital with angioedema or swelling in your mouth and throat you had a breathing tube placed for this you were then transfered to where you had the breathing tube taken out you improved clinically and were discharged to home please continue to take your medications as ordered because you had a likely medication reaction that led to your angioedema you should throw out your old medications do not take any supplements here is your updated medication list list stop taking felodipine for now calcium vitamin d twice daily vitamin b daily folic acid daily furosimide mg daily anusol daily as needed for hemorrhoids metformin mg pills in the morining and mg pill in the evening lactulose ml daily to bowel movements per day nadolol mg daily pantoprazole protonix mg twice daily spironolactone mg daily zolpidem ambien mg at night as needed for insomnia iron times daily please attend your follow up appointments please call your doctor or come to the emergency room if you experience swelling of you face or tongue chest pain palpitations shortness of breath wheezing bleeding or other concerning symptoms followup instructions md np specialty priamry care date and time at pm location phone number special instructions if applicable booked with russain interpreter completed by,{}
5317,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint yo s p rollover mvc ejected head trauma major surgical or invasive procedure none history of present illness yo male s p mvc rollever with ejection treated at referring facility and transferred to for definitive care was brought to by during which he was combative and aggressive he was intubated and sedated in the ed he had a head ct which showed a subarachnoid hemorrahge within the sulci of the left frontal lobe adjacent to the anterior falx past medical history none social history non contributory family history non contributory physical exam t p bp r combative rrr no m r g ctab ttp over left clavicle abd soft nt nd small abrasion on back and shoulders pertinent results am glucose lactate na k cl tco am urea n creat am amylase am asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg am urine hours random am urine hours random am urine gr hold hold am urine bnzodzpn pos barbitrt neg opiates neg cocaine pos amphetmn pos mthdone neg am wbc rbc hgb hct mcv mch mchc rdw am plt count am pt ptt inr pt am fibrinoge am urine color yellow appear clear sp am urine blood lg nitrite neg protein glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg am urine rbc wbc bacteria occ yeast none epi brief hospital course the patient was admitted to the icu neurosurgery was consulted who recommended observation no additional medications the patient was extubated on hod his c spine was cleared medically and he was moved to the floor on hod hod the patient was perseverating and had imbalance a repeat head ct was ordered which showed decrease in size of sah medications on admission none discharge medications oxycodone acetaminophen mg tablet sig tablets po q h every to hours as needed for pain disp tablet s refills discharge disposition home discharge diagnosis subarachnoid hemorrahage discharge condition good discharge instructions you were brought to the emergency department and tested postive for numerous illicit substances in your urine we highly recommend that you seek treatment for any addictions that you may have rest drink plenty of fluids take medications as prescribed followup instructions follow up with your primary care provider follow up in trauma clinic in weeks call for an appointment follow up with neurosurgery in four weeks please call to schedule an appointment with dr you may also need a repeat head ct scan please call to set that appointment as well,"{
""Diagnoses"": [""subarachnoid hemorrhage""],
""Medications"": [""intubated"", ""sedated"", ""head trauma"", ""major surgical or invasive procedure"", ""none""]
}"
11427,admission date discharge date date of birth sex m service micu history of present illness the patient is a year old caucasian male with no significant past medical history who presents with worsening shortness of breath the patient states that he was in his usual state of health until approximately eight hours prior to admission the patient had watched the super bowl and then went to bed he awoke with right sided chest congestion and pressure along with cough and shortness of breath he was brought to the emergency department where his room air oxygen saturation was noted to be and his blood pressure was lactate level was also drawn which was the patient was entered into a sepsis protocol the patient also notes that he has had a dry cough for approximately one week he states he had an episode of bronchitis several months ago and was given antibiotics by his primary care physician also states there were sick contacts at work and he was recently exposed to a young child who apparently had upper respiratory infection he also complains of mild diffuse myalgias and a mild headache he denies any abdominal pain nausea vomiting or diarrhea he denies any dysuria the patient confirms that he received influenza vaccination this year in the emergency department the patient was given two liters of normal saline for fluid resuscitation he was also given ceftriaxone levaquin and bactrim for antibiotics past medical history hereditary angioedema the patient has swelling in the arms and legs with stress or trauma he denies any history of throat swelling or respiratory involvement medications on admission nyquil p r n allergies no known drug allergies family history noncontributory social history the patient denies tobacco or alcohol use he is in a monogamous homosexual relationship he works as a lawyer was tested for hiv approximately one and one half years ago and was negative physical examination on admission vital signs revealed temperature pulse blood pressure respiratory rate oxygen saturation to on nonrebreather in general the patient is well developed and well nourished in mild respiratory distress head eyes ears nose and throat examination the pupils are equal round and reactive to light and accommodation extraocular movements are intact the oropharynx is clear with moist mucous membranes neck is supple with no jugular venous distention heart examination is tachycardic with normal s and s regular rate lungs the patient has diffuse wheezes bilaterally and decreased breath sounds at the right upper lung there is no egophony the abdomen is benign extremities there is no edema there are no rashes the extremities are warm to the touch with good distal pulses laboratory data on admission complete blood count revealed a white blood cell count with a differential of neutrophils and bands hematocrit was and platelet count was chem is within normal limits lactate was arterial blood gas on nonrebreather showed a ph pco and po chest x ray significant for right upper lobe consolidation electrocardiogram showed sinus tachycardia at beats per minute with left axis deviation hospital course sepsis the patient was involved in the mus protocol for sepsis he was aggressively fluid resuscitated and placed on broad spectrum antibiotics stimulation test was done which showed that he was a nonresponder he was empirically started on hydrocortisone fludrocortisone which was to be continued for seven days in addition to the fluid resuscitation the patient was started on vasopressors for his hypotension he was initially started on vasopressin and levophed and then dopamine was also added the patient was also involved in a double blinded trial with cygris he took the cygris study drug for hours after several days of antibiotic treatment the patient was able to be weaned off his pressors initially the dopamine was discontinued followed by the levophed and vasopressin following discontinuation of pressors the patient maintained normal blood pressure gradually his fluid resuscitation was decreased and he was maintained at an even fluid balance to slightly negative respiratory failure after approximately one day in the hospital the patient had increased respiratory distress as well as increased oxygen requirement at this time he was intubated the patient remained intubated for several days while he was being treated for sepsis and pneumonia he was gradually weaned off mechanical ventilation and extubated six days after the intubation following extubation he required face mask oxygenation however he was not in any respiratory distress pneumonia by chest x ray the patient was seen to have a right upper lobe pneumonia sputum and blood cultures were sent following intubation the patient also had a bronchoscopy with bronchoalveolar lavage this was also sent off for culture the patient was initially started on broad spectrum antibiotics with ceftriaxone levaquin and flagyl blood cultures eventually grew out pneumococcus and sensitivities showed that it was pansensitive at this time the antibiotics were narrowed down to only levaquin this was continued while in the hospital as the patient showed gradual and continual improvement repeat chest x ray showed gradual resolution of the right upper lobe consolidation repeat surveillance blood and sputum cultures remained negative by x ray and cat scan of the chest the patient was also seen to have a right lung pleural effusion as there was concern that this might represent an empyema a chest tube was placed pleural fluid collected was exudative although not consistent with empyema it was likely a parapneumonic effusion chest tube was left in place for approximately three days and then removed without any complications the pleural fluid culture hibernates negative to date cardiovascular the patient had cardiac enzymes drawn to rule out acute myocardial infarction this showed that this troponins were elevated at approximately it is possible that this represented a non q wave myocardial infarction or was related to sepsis induced cardiomyopathy transthoracic echocardiogram was also done which showed a depressed ejection fraction of given that the patient had no known history of cardiac disease this likely represented sepsis induced cardiomyopathy the patient should receive a repeat echocardiogram once he has clinically improved and is ready for discharge to reevaluate his cardiac function if his cardiac function remains below normal he should follow up with a cardiologist as an outpatient anemia while in the hospital the patient also developed decreasing hematocrit it was not clear if this was due to mild bleeding from the chest tube site or from repeated phlebotomy that the patient was receiving he did receive transfusion of one unit of packed red blood cells during the medical intensive care unit course after which his hematocrit remained stable fevers the patient continued to have low grade fevers despite clinical improvement and respiratory status improvement repeat cultures remained negative and a clear source for these fevers was not yet identified the rest of the hospital course and discharge summary will be dictated by another physician who will be taking over his care m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service otolaryngology allergies patient recorded as having no known allergies to drugs attending chief complaint angioedema major surgical or invasive procedure bilateral tonsileectomy history of present illness yo male with history of hereditary angioedema is admitted to the icu for overnight observation after deveoping angioedema post bilateral tonsillectomy he developed right sided tongue swelling post surgery he recieved iv decadron po stanazolol and u ffp he has angioedema since childhood and usuallly develops angioedema in hands and feet in response to stress he developes angioedema about once a month except for one episode of agioedema in his face months ago he had never had laryngeal involvement he also denies urticaria general pruritus syncope hypotension shortness of breath according to him each angioedema episode takes about hours to resolve past medical history hereditary angioedema the patient has swelling in the arms and legs with stress or trauma he denies any history of throat swelling or respiratory involvement recent sepsis he was intubated for d and had chest tube x d for suspected empyema turn out to be parapneumonic effusion he was treated for rll pneumococcus pna bal with levaquin homosexual severe osa from enlarged tonsils social history the patient denies tobacco or alcohol use he is in a monogamous homosexual relationship he works as a lawyer was tested for hiv approximately one and one half years ago and was negative family history strong history of angioedema in maternal side physical exam t p bp on ra gen nad very pleasant caucasian man heent anicteric no conjunctival injection no nasal mucosal swelling right sided tongue swelling oral mucosa looks normal no pharyngeal erythema cv rrr no r m g resp ctab active bs soft nt nd neuro a o x perl cn ii xii intact move all limbs symmetrically skin no other area of erythema swelling brief hospital course patient develops angioedema after biilateral tonsillectomy in the right side of his toungue he recieved decadron stanazolol and unit of ffp in total overnight there had been no further progression of angioedema his vital signs had remained very stable throughout the night he took stanazolol every hours overnight and resumed his usual home regimen the next morning he also had amoxicillin as post surgery prophylaxis he will be discharged home with his usual stanazolol and pain medication the ent team agreed that he was cleared for home he will be followed up by the clinic within one week medications on admission stanazolol mg q d have been taking it qd for days prior to surgery discharge medications stanozolol mg tablet sig two tablet po every seventy two hours disp tablet s refills oxycodone acetaminophen mg ml solution sig mls po q h every to hours as needed for pain disp ml s refills discharge disposition home discharge diagnosis angioedema post tonsillectomy discharge condition stable discharge instructions please return to the hospital if you develop difficulty in breathing if your angioedema gets worse if you develop fever or if there are any concerns at all please take stanazolol as prescribed followup instructions please follow up with the clinic within one week of your discharge completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex service medicine firm addendum this is a discharge summary addendum brief summary of hospital course by issue system continued sepsis issues by the time he arrived on the floor his sepsis issues were stable his blood pressures remained stable off fluid resuscitation and his surveillance blood cultures had remained negative fever curves remained stable and his white count remained stable so far this was resolved the patient s cardiac ejection fraction had improved upon resolution of sepsis initial ejection fraction of during his medical intensive care unit course was greater than following resolution of sepsis pneumonia issues the patient has pan sensitive strep pneumonia he was continued on levofloxacin and was to complete a week course he was status post chest tube for an effusion and these were stable the patient s oxygenation was weaned and continued to be weaned throughout the course of his stay at the time of discharge he did not require oxygen and did not desaturate while ambulating he was to complete a another weeks course of his levofloxacin and was continued with as needed nebulizers while in house he was also given some cough suppressant with guaifenesin to help as a mucolytic otherwise his respiratory status remained stable bradycardia issues unsure source of his bradycardia upon stabilization on the floor this resolved and the patient s heart rate remained stable but low he remained asymptomatic electrocardiograms were stable throughout the course of his stay deconditioning issues deconditioning secondary to a prolonged hospital and intensive care unit stay the patient was slightly deconditioned he was evaluated and followed by physical therapy who recommended some home physical therapy for improved strength and endurance training right sided abdominal pain issues the patient had some right sided abdominal pain the patient had liver function tests which were normal and unchanged otherwise these continued to be followed eventually his pain improved and was likely from musculoskeletal pain this happened after increased physical activity and physical therapy and resolved by the time of discharge discharge diagnoses strep pneumonia pleural effusion sepsis bacteremia medications on discharge levofloxacin mg tablets one by mouth every day times seven days oxazepam mg to mg by mouth at hour of sleep as needed condition at discharge condition on discharge was good the patient was ambulating without difficulty and not requiring oxygen discharge status discharge status was to home with home physical therapy discharge instructions followup the patient was instructed to follow up with his primary care physician to days m d dictated by medquist d t job,"{
""Diagnoses"": [""Worsening shortness of breath"", ""Right sided chest congestion"", ""Right sided chest pressure"", ""Cough"", ""Sepsis""],
""Medications"": [""Oxygen"", ""Blood pressure medication"", ""Lactate level""]
}"
67140,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 major surgical or invasive procedure open cholecystostomy on a tube history of present illness diabetes patient with abdominal pain with acute gangrenous cholecystitis on ct scan past medical history dm alzheimer hyperchol social history russian speaking only lives in a rehab family history nc physical exam russian only speaking patient awake partially oriented resp clear to auscultation bilateral cv regular rate and rythm abdomen soft tender on ruq guarding extre no edema no deformities pertinent results pm urine color appear cloudy sp pm urine blood lg nitrite pos protein glucose ketone neg bilirubin neg urobilngn neg ph leuk mod pm urine rbc wbc bacteria many yeast none epi trans epi pm urine wbcclump occ pm glucose lactate k 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 calcium phosphate magnesium 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 ct reconstruction pm ct abdomen w contrast ct pelvis w contrast reason obstruction field of view contrast medical condition year old russian speaking woman with fever ambdominal distension ruq pain lethargy reason for this examination obstruction contraindications for iv contrast none ct abdomen ct pelvis was also performed clinical history fever abdominal distention right upper quadrant pain technique axial mdct images of the abdomen and pelvis were obtained with iv and oral contrast enhancement sagittal and coronal reformatted images were generated at a separate dedicated workstation ct abdomen findings images of the heart and lung bases demonstrate a hiatal hernia there is subsegmental atelectasis at the bases bilaterally the liver appears normal the gallbladder contains numerous stones one stone is seen residing outside the lumen there is gas present within the gallbladder lumen and in the gallbladder wall there is a large amount of pericholecystic fat the ascending colon lies immediately adjacent to the gallbladder inflammatory changes surround this loop of ascending colon there is no intrahepatic biliary dilatation the common bile duct is not dilated the pancreas spleen adrenal glands and kidneys appear normal the kidneys enhance symmetrically and excrete contrast symmetrically there is aortic atherosclerosis there is a retroaortic left renal vein there is a diverticulum of the third portion of the duodenum there is no abdominal lymphadenopathy there is no intraperitoneal free air there are no dilated bowel loops ct pelvis findings there is a foley catheter balloon in the urinary bladder which is nondistended there is no pelvic lymphadenopathy there is atherosclerosis of the arterial structures of the pelvis degenerative changes are present in the lower thoracic and lumbosacral spine the reformatted images demonstrate gas in the gallbladder lumen and allow better evaluation of the osseous structures of the abdomen and pelvis impression gas within the gallbladder this most likely represents gangrenous cholecystitis given the close proximity of the ascending colon it is also possible but less likely that an inflammatory process in the ascending colon involves the gallbladder secondarily and there is communication between the colon and gallbladder which is much less likely since there is only a small amount of gas within the gallbladder lumen these findings were relayed to the emergency department on shortly after the exam was performed no pneumoperitoneum no biliary dilatation there is cholelithiasis with a gallstone present outside of the gallbladder lumen liver or gallbladder us single organ am liver or gallbladder us singl reason r u leak of cholecystostomy tube medical condition year old woman s p cholecystostomy on tube reason for this examination r u leak of cholecystostomy tube indication status post cholecystostomy evaluate for leak about cholecystostomy tube comparison ct of the abdomen dated technique right upper quadrant ultrasound right upper quadrant ultrasound the hepatic echotexture appears within normal limits there is no evidence of intra or extra hepatic biliary ductal dilatation the common bile duct measures mm the gallbladder is decompressed and contains multiple shadowing structures likely representing a combination of stones as well as the cholecystostomy tube a small curvilinear hypoechoic focus in the region of the gallbladder likely represents edema within the gallbladder wall a small amount of fluid is seen adjacent to the right lobe of the liver impression decompressed gallbladder containing multiple echogenic structures likely representing stones and the cholecystostomy tube edema within the gallbladder wall without evidence of pericholecystic fluid collection small amount of free fluid lateral to the right lobe of the liver brief hospital course patient spent the first night after the operation in the pacu well resucitated she was transfer to the regular floor in the pod and was advance to regular diet in pod with initial poor po tolerance she was able to resume po diet in pod cholecystostomy tube with daily ml output scan jp drain output the patient was discharged to rehab and the family was informed dr will see the patient in the clinic as outpatinet and he will remove the jp drain and evaluate the cholecystostomy tube please record and print a daily output for dr to evaluate medications on admission asa glipizide risperidone avandia zocor discharge medications pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours for weeks disp tablet delayed release e c s refills metoprolol tartrate mg tablet sig tablet po bid times a day for weeks disp tablet s refills amoxicillin pot clavulanate mg tablet sig one tablet po tid times a day for days disp tablet s refills discharge disposition extended care facility for the aged ltc discharge diagnosis acute gangrenous cholecystitis discharge condition good discharge instructions please call dr office for a follow up appointment on friday please record the cholecystostomy bile output daily printed on paper and bring to the clinic in your appointment and keep the tube on gravity please record the jp drain bile output daily printed on paper and bring to the clinic in your appointment if any fever nausea or vomiting please contact office complete antibiotics and resume home medications followup instructions with dr completed by [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint lethargy major surgical or invasive procedure none history of present illness mrs is an yof with a history of severe dementia noninsulin dependent diabetes mellitus type ii hyperlipidemia who is a russian speaking only resident of rehab referred to ed for increased somnolence for one day at her baseline she is minimally communicative though withdrew completely and became unresponsive yesterday found to have an fsg greater than assay with fevers and tachypnea was transferred to for further evaluation initial vitals in the ed were hr sat her respiratory rate and pulse slowed with fluid resuscitation laboratories revealed a glucose of glucosuria hypernatremia to hyperlactatemia to and an anion gap of her cbc appeared severely hemoconcentrated she was aggressively resuscitated with liters ns and began iv regular insulin units followed by insulin gtt she was supplemented potassium her glucose subsequently improved to with closure of the anion gap to her na worsened to however which was likely iatrogenic lactate also worsened to ua with moderate bacteria though a single wbc otherwise with glucosuria and no ketones ct abd pelvis done for llq tenderness showed no pathology but possibly basilar atelectasis versus pneumonia ct head negative she was given vanco and cefepime for a fever to though no source of infection noted yet on arrival to the micu her vs were t hr bp rr sat ra she is nonresponsive does not follow commands and does not alert to voice no review of systems could be elicited past medical history diabetes mellitus type ii end stage alzheimers hypercholesterolemia cholecystectomy social history lives at rehab severe dementia at baseline family history nc physical exam vitals t hr bp rr sat ra general not interactive alert not following commands contracted posture heent mm dry sclera anicteric neck supple jvp flat 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 ext warm well perfused pulses no clubbing cyanosis or edema decubitus ulcers on the sacrum and bilateral elbows pertinent results initial labs pm type art ph pm glucose lactate na k cl tco pm freeca am type comments green top am lactate am glucose urea n creat sodium potassium chloride total co anion gap am ck cpk am ck mb ctropnt am calcium phosphate magnesium am glucose lactate na k cl am po pco ph total co base xs comments green top am freeca am comments green top am glucose am urine hours random am urine gr hold hold am urine color yellow appear hazy sp am urine blood neg nitrite neg protein tr glucose ketone neg bilirubin neg urobilngn neg ph leuk neg am urine rbc wbc bacteria mod yeast rare epi am urine hyaline am urine mucous rare am urine color yellow appear cloudy sp am urine blood sm nitrite neg protein tr glucose ketone neg bilirubin neg urobilngn neg ph leuk mod am urine rbc wbc bacteria many yeast none epi am urine hyaline am urine mucous few pm lactate pm pt ptt inr pt pm glucose urea n creat sodium potassium chloride total co anion gap pm estgfr using this pm alt sgpt ast sgot alk phos tot bili pm ck mb ctropnt pm calcium phosphate magnesium pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count am urine site catheter final report urine culture final mixed bacterial flora colony types consistent with skin and or genital contamination escherichia coli organisms ml predominating organism piperacillin tazobactam sensitivity testing available on request sensitivities mic expressed in mcg ml escherichia coli ampicillin r ampicillin sulbactam r cefazolin s cefepime s ceftazidime s ceftriaxone s ciprofloxacin r gentamicin s meropenem s nitrofurantoin s tobramycin s trimethoprim sulfa s ekg artifact is present sinus tachycardia with atrial ectopy left axis deviation there are q waves in the inferior leads consistent with infarction compared to the previous tracing of these findigs are new ct abd pelvis impression bibasilar left greater than right opacities of the lung likely representing atelectasis less likely left lower lobe pneumonia large amount of fecal debris in the rectal vault small uterine fibroid no appendicitis diverticulitis or colitis ct head impression no acute intracranial hemorrhage or mass effect moderate ventricular dilation parenchymal volume loss correlate clinically for superimposed nph correlate clinically to decide on the need for mri if not contra indicated brief hospital course mrs is an yof with severe dementia and niddm presenting with ams likely due to hyperosmolar hyperglycemia hyperosmotic hyperglycemia she presented a non ketotic hyperglycemic state dominated by profound dehyrdation manifesting as hemoconcentration hypernatremia and acute kidney injury likely driven by an osmotic diuresis from glucosuria causing profound volume and particularly free water loss etiology of this event is unclear possibly related to e coli uti no mi based on ekg cardiac enzymes dehydration was likely a prominent component patient initially placed on insulin gtt d with potassium repletion finger sticks monitored closely with improvement to s with nl anion gap patient then transitioned to sq insulin with maintenance of normoglycemia thereafter she may return to oral medicines at rehab though qid fsg should be continued to ensure euglycemia if hyperglycemia ensues then an insulin sliding scale should be started hypernatremia patient presented with severe corrected hypernatremia to due to free water losses related to osmotic diuresis patient hydrated with d w with gradual improvement in sodium level her na tended to increase when d w was discontinued so adequate po water intake is absolutely essential to preventing further episodes of hypernatremia hyperglycemia altered mental status per daughter patient relatively non communicative at baseline with decreased ability to take in po over preceding weeks due to worsening mental status however on admission daughter noted acute worsening of mental status with decreased arousability likely acute decompensation secondary to gross electrolyte abnl hypernatremia dehydration fever hyperglycemia ct head negative not clear signs of infection mental status slowly improved to near baseline with correction of metabolic disturbances leukocytosis all cell lines likely hemoconcentrated no left shift counts monitored which receiving iv hydration urinary tract infection presented with low grade fevers to likely due to uti as patient grew cephalosporin sensitive e coli uti and began ceftriaxone on and will need bactrim ds tab q hr starting at pm x doses medications on admission sorbitol ml qd asa zinc oxide per rectum glucotrol mg erythomycin ointment for eyes discharge medications sorbitol solution miscellaneous aspirin mg tablet delayed release e c sig one tablet delayed release e c po once a day zinc oxide topical glucotrol mg tablet sig one tablet po twice a day erythromycin ophthalmic bactrim ds mg tablet sig one tablet po every twelve hours for doses to begin at pm for doses discharge disposition extended care facility for the aged ltc discharge diagnosis hyperosmotic hyperglycemia hypernatremia urinary tract infection discharge condition mental status confused always level of consciousness lethargic but arousable activity status bedbound discharge instructions dear ms you were admitted to the hospital due to very high sugar and sodium levels that was probably caused by a urinary tract infection and dehydration you felt better with insulin and intravenous fluids you will finish antibiotics at your rehab facility it is very important that you take in adequate water in your diet otherwise you will need iv water the following changes were made to your meds start bactrim ds tablet q hr x doses on followup instructions please followup with the doctors at your rehab facility,"{
""Diagnoses"": [""acute gangrenous cholecystitis"", ""diabetes"", ""hypercholesterolemia"", ""Alzheimer's disease""],
""Medications"": [""open cholecystostomy on a tube"", ""no known allergies to drugs""]
}"
2021,admission date discharge date date of birth sex f service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint vomiting diarrhea colon cancer major surgical or invasive procedure exploratory lap lysis of adhesions hours resection of fistula and closure of the enterotomy low anterior resection and colorectostomy coloproctostomy takedown of colostomy transverse colostomy and frozen section biopsy history of present illness f with locally advanced rectosigmoid adenocarcinoma s p diverty colostomy and feeding jejunostomy s p ct guided abscess drainage she just finished a course of cemoradiation on capecitabine of note from her previous hspitalization the abscess drain was prematurely removed and she was discharged home on augmentin x days she was schedule dto be admitted for resection of her rectal cancer but presents two days early with mild abdominal pain around ostomy and peri ostomy hernia with vomiting and increased ostomy output x day past medical history obstructing rectosigmoid mass emphysema psh colostomy jejunostomy tube open cholecystectomy social history etoh day tobacco pk yr history no recreational drugs family history mother died in late s of cva father died in mid s of hiatal hernia strangulated hernia physical exam admission physical exam ra neuro axox nad heent perrl eomi cvs rrr no m c r resp ctab no w r r abd soft distended tenderness to percussion around ostomy site and peri ostomy hernia nabs ext no c c e 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 hypochr anisocy poiklo macrocy microcy polychr occasional ovalocy target occasional schisto burr pm blood plt ct pm blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap pm blood alt ast alkphos amylase totbili am blood calcium phos mg pm blood albumin calcium mg pm blood lactate 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 nutrition labs date alb fe tibc trf ct of the abdomen with iv contrast there are new diffuse but patchy tree in and ground glass opacities in the right middle right lower and left lower lobes with sparing of the lingula most consistent with pneumonia the liver appears normal the patient is status post cholecystectomy there are splenic arterial calcifications the pancreas adrenal glands and kidneys are within normal limits the stomach appears normal there is a jejunostomy tube overlying the left upper quadrant in suitable position enteric contrast has been administered via that tube for this study there is marked dilatation of the proximal small bowel to a greater extent than on the prior study a segment of jejunum in the left upper quadrant measures cm in diameter more distally there are several segments of irregular narrowing accompanied by wall thickening of the small bowel these abnormal segments are mostly within or immediately above the pelvis particularly near the residual rectum more distally the terminal ileum is normal in caliber contrast passes freely into the cecum the proximal residual colon is only mildly distended and more distally is almost collapsed near the colostomy site although contrast passes freely throughout the appearance of proximal small bowel dilatation worse than before suggests either a low grade obstruction perhaps related to segments of abnormally thickened distal small bowel or an ileus there are multiple enlarged retroperitoneal and mesenteric lymph nodes which are unchanged as none of these is over cm in shortest dimension however these may be reactive but metastatic disease is also possible there are vascular calcifications in the aorta with mild distal fusiform dilatation up to cm at the aortic bifurcation there is no free air ct of the pelvis with iv contrast there is a persistent collection of fluid in the presacral space of intermediate density with a smooth enhancing wall it is only somewhat smaller than before and measures x cm in axial dimensions the collection contains air which suggests a fistulous connection to adjacent bowel or may be due to abscess formation the rectal stump also contains air and fluid more proximally the residual rectum is markedly thickened throughout suggesting persistent tumor there is also enteric contrast which has passed into the residual rectum which outlines the convex contour of an apparent endoluminal mass more distally there is no pelvic or inguinal lymphadenopathy or free fluid bone windows there are no suspicious lytic or blastic lesions impression increased dilatation of the proximal small bowel with areas of narrowing and wall thickening in the more distal small bowel this appearance may relate to radiation change or involvement with tumor proximal dilatation may be due to an ileus or low grade obstruction although contrast passes freely throughout residual rectum with an overall similar appearance including marked thickening and apparently an endoluminal mass the residual rectum contains contrast proximally implying a fistulous connection to the small bowel there is also air and fluid more distally persistent presacral fluid collection with enhancing rim the presence of air within the collection also suggests fistulous connection to adjacent bowel or may be due to abscess formation mild lymphadenopathy which could be either metastatic or reactive operative note preoperative diagnosis carcinoma of the rectosigmoid with a question of an enterorectal fistula postoperative diagnosis enterorectal fistula question carcinoma of the rectosigmoid indications the patient presented with massive weight loss and total obstruction of her rectum which may have been due to a pelvic abscess which was not seen early on we could not get a histologic diagnosis and at the first operation i did not think that i could extirpate the rectum very well and so we did an end sigmoid colostomy and treated her with radiation and chemotherapy we then brought her back she had recurrent pelvic abscess which we believed probably was the result of an enterorectal fistula at the time of surgery we were able to take down the enterorectal fistula and close the enterotomy and then do a low anterior resection takedown the colostomy and resect it and then do an anastomosis and then because of the situation with the previous radiation then do a protected colostomy the following procedure was carried out operations exploratory lap lysis of adhesions hours resection of fistula and closure of the enterotomy low anterior resection and colorectostomy coloproctostomy takedown of colostomy transverse colostomy and frozen section biopsy assistant dr md res dr procedure under satisfactory general anesthesia the patient was placed supine and prepped and draped in the usual manner we excised the old incision and actually carried this higher on the abdominal wall entering the abdomen cleanly the liver had no disease there were a number of adhesions the principal adhesion however was to a loop of bowel which went down on the right side to the rectum and clearly was an enterorectal fistula this was taken down and the opening in the small bowel was closed in layers with silk transversely and interrupted prolene attention was then turned to lysing all of the adhesions in the small bowel until we actually had a totally free small bowel and this was carried out without difficulty we then started dissecting the rectum which we did by grasping the rectum with silk sutures getting behind it freeing it up from the left ureter which was clearly seen and was intact and there was no hematuria and then gradually working our way down and doing a total mesenteric excision getting below the entrance of the fistula into the rectum and then finally well below the sacral curve irrigation of the rectum revealed that it was entirely open at this point up into the point of the obstruction which the area of radiation at the bottom of which was the enterorectal fistula the most distal after we saw that we could get a reasonable length of rectum up to do the anastomosis we took down the colostomy which had a pericolostomy hernia and then transected it with stapler and then anastomosed it with layers of silk initially by using the rectum as a handle but then dealing with the front and taking it off and then getting a very nice layer silk interrupted anastomosis we then irrigated the pelvis copiously we were happy with the anastomosis the rectal tube had been removed and we then changed gowns and gloves and closed the site of the colostomy which had a pericolostomy hernia and then prepared the transverse colostomy by getting a quarter inch penrose drain under the transverse colon we then changed gowns and gloves to closure kit and closed the peritoneum put the penrose drain which had a tie around it in the peritoneum irrigated the peritoneum checked for the nasogastric tube checked for bleeding which there was very little and then closed the peritoneum with chromic catgut the paramedian incision was then closed as a lateral paramedian incision taking the freed up muscle and placing it in the midline and then vicryl on the fascia after the fascia was closed we then made a transverse incision over the right rectus split the rectus and then brought up a loop of colon through the previous identified colon through and put a bridge underneath this was subsequently matured at the end of the procedure by dividing the anterior wall the closure was completed we had previously closed the area of the colostomy with vicryl the subcutaneous tissue of the incision was closed with vicryl and with monocryl and the same with the area of the previous transverse colostomy estimated blood loss was cc the patient tolerated the procedure well she was slightly acidotic so she was left on the ventilator two sponge counts needle counts and instrument counts were reported as correct by the nursing in charge the patient tolerated the procedure well and was returned to the pacu and will likely go to the icu brief hospital course presented to the emergency department at on her wbc was found to be elevated at an abdominal pelvic ct scan showed increased dilatation of the proximal small bowel with areas of narrowing and wall thickening in the more distal small bowel residual rectum with intraluminal mass implied fistulous connection from residual rectum to the small bowel persistent presacral fluid collection with enhancing rim and mild lymphadenopathy see pertinent results a chest xray was obtained which was negative for acute process or effusion see pertinent results she was admitted to the surgery service under the care of dr for questionable obstructive process and presacral fluid collection she was placed npo tube feeds were held and a foley catheter was inserted vancomycin levofloxacin flagyl were started for empiric coverage at hd a picc line was placed tpn was started her j tube was placed to gravity she was taken to interventional radiology for ct guided aspiration of the presacral fluid collection which revealed ml of purulent then serosanguinous drainage a pigtail catheter was placed a sample of the drainage was sent for culture at hd her abdomen remained distended with question of continued obstructive process she denied pain or vomiting she remained npo and continued nutrition via tpn at hd hibiclens washes and neomycin erythromycin were provided on hd she was taken to the operating room where she underwent an exploratory lap lysis of adhesions resection of fistula and closure of the enterotomy low anterior resection and colorectostomy coloproctostomy takedown of colostomy transverse colostomy and frozen section biopsy she tolerated the procedure well estimated blood loss was ml and she received units of prbcs and ml albumin she remained intubated after surgery and was taken to the icu for further care by pod the presacral fluid culture grew staph aureus susceptible to vancomycin and her levo flagyl were discontinued blood cultures from the emergency department were negative she was doing well urine output and vital signs were stable she was extubated without complication at pod narcotic pain control was weaned and she was receiving tylenol with good control her colostomy was functioning well with good output strength tube feeds were started and tpn was continued her wbc count was elevated at and a repeat abscess culture was sent from the pigtail vancomycin was continued levofloxacin flagyl were restarted her diet was advanced to sips and she was deemed stable for transfer to the floor on pod she was transferred to a regular floor she continued to be afebrile her tube feeds were advanced to cc hr and her tpn was continued she ctoninued to has gas and stool from her ostomy an her pigtail continued to drain cc of serosanguinous fluid she was continued on her vancomycin on pod she continued to be afebrile and stable her tube feeds were advanced to cc hr which she tolerated well she was advanced to sips and her tpn was continued her antibiotics were continued and her pigtail continued to have minimal output on pod she continued to do well and be afebrile she was advanced to a soft diet and her tf were advanced to cc hr cycled overnight her pigtail continued to have minimal output of cc and her tpn was discontinued her metoprolol was increased for an elevated heart rate on pod she was deemed stable for discharge home she remained afebrile and her tube feeds advanced to cc hr cycled overnight with non generic imodium on pod she continued to do well tolerating a soft diet her pigtail was discontinued she was discharged home with nursing services for her tube feeds and iv antibiotics medications on admission megace mg qid metoprolol mg asa mg daily discharge medications ampicillin sodium g piggyback sig one intravenous every six hours for days disp refills metronidazole in nacl iso os mg ml piggyback sig one intravenous every eight hours for days disp refills fluconazole mg tablet sig one tablet po q h every hours for days disp tablet s refills metoprolol tartrate mg tablet sig three tablet po bid times a day disp tablet s refills acetaminophen mg ml solution sig twenty ml po q h every hours for days please flush down j tube disp qs qs refills aspirin mg tablet chewable sig one tablet chewable po once a day disp tablet chewable s refills imodium a d mg ml liquid sig two mg po twice a day give ml liquid down j tube twice daily disp qs qs refills discharge disposition home with service facility home therapies discharge diagnosis enterorectal fistula question carcinoma of the rectosigmoid discharge condition stable discharge instructions please call your doctor greater than nausea vomiting inability to eat wound redness warmth swelling foul smelling drainage abdominal pain not controlled by pain medications or any other concerns please take medications as prescribed please follow up as directed no heavy lifting anything that makes you strain for weeks or until directed otherwise please leave water proof dressing on until follow up with dr followup instructions please follow up with dr in weeks please call his office at to schedule an appointment completed by [NEW_RECORD] admission date discharge date date of birth sex f service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint left hydonephrosis ventral hernia sigmoid stricture major surgical or invasive procedure cystoscopy left retrograde pyelogram attempted left stent placement exploratory laparotomy lysis of adhesions hours rectosigmoid resection and coloproctostomy mobilization of the splenic flexure repair of ventral hernia post colostomy history of present illness f with h o obstructing sigmoid mass of indeterminant pathology s p chemo rads and resection of mass with transverse colostomy since this time she has been relatively stable she has developed a ventral hernia at the site of her old diverting colostomy routine ct scan on showed new onset left hydronephrosis presented for left ureteral stent placement which was unsuccessful and elective resection of strictured sigmoid past medical history obstructing rectosigmoid mass emphysema psh colostomy jejunostomy tube open cholecystectomy social history etoh day tobacco pk yr history no recreational drugs family history mother died in late s of cva father died in mid s of hiatal hernia strangulated hernia physical exam admission pe ra gen alert and in nad ox heent perrl neck supple op clear cv rrr no m g r resp ctab good inspiratory effort abd soft nd nt transverse colostomy with loose brown stool left side ventral hernia soft bs ext mae no c c e pertinent results procedure cystoscopy left retrograde pyelogram attempted left stent placement assistant md complications none anesthesia general indications the patient is a year old woman with a recent ct scan in showing a chronically obstructed left kidney there is a possible calculus along the route of the left distal ureter however this is beyond the level of obstruction procedure the patient was prepped and draped in lithotomy position a french cystoscope was inserted into the urethra which was normal the bladder mucosa appeared slightly atrophic and the ureteral orifices were however normal size and slightly laterally positioned a french tapered catheter was gently inserted into the left distal ureteral orifice and cc of contrast dye was injected which revealed a distal ureter with complete retrograde obstruction beyond the level of obstruction was a very faint calcification roughly mm in diameter possibly consistent with the calcification seen on ct scan a straight sensor wire was attempted to be placed beyond the strictured area but was unable we then moved to an angled glidewire and multiple attempts at passing the glidewire beyond the area of stricture were unsuccessful at this point the decision was made to abort the stent placement rather than continued attempts at the wire placement or ureteroscopy without wire access which can result in ureteral rupture the bladder was emptied and the patient was transferred to the pacu stable plan the patient will likely require a left percutaneous nephrostomy tube and possible antegrade wire access which may allow retrograde access to the stricture and possibly the stone m d procedure exploratory laparotomy lysis of adhesions hours rectosigmoid resection and coloproctostomy mobilization of the splenic flexure repair of ventral hernia post colostomy indications this patient had either diverticulitis or an obstructing carcinoma of the rectum which we could never get close enough to do a valid biopsy she underwent radiation which remedied whatever the lesion was we never found any carcinoma in the specimen and she did have evidence of diverticular disease she underwent resection and then a protective colostomy because of the fact that the anastomosis never seemed to heal and indeed the most recent barium enema revealed that she did not have adequate healing and as a matter of fact had several leaks probably disruptive of the anastomosis either because of tension which i had doubted or because of the previous radiation after preparation the following procedure was carried out procedure in detail under satisfactory general anesthesia the patient was placed supine and prepped and draped in the usual manner we opened up the left paramedian incision and were able to free up of lysis of adhesions in the pelvis which were extensive and which required extensive revision starting with the ligament treitz taking down the previous feeding jejunostomy but in fact we were able to get the entire pelvis freed up without any difficulty upon entering the pelvis there were a number of adhesions that were quite dense these were taken down we actually were able to take down the small bowel there was only one area where there was ballooning out of the serosa which was later repaired with interrupted prolene and we were then able to go to work on the previous rectosigmoid which required rectosigmoid resection in order to get an adequate connection with the anastomosis on the bottom there was a stricture at the previous anastomosis initial attempt at irrigation did not pass any fluid into the pelvis only later when we mobilized the colon and had a hole in it was there any irrigation that came through we mobilized the small bowel extensively in a number of areas that were adherent to the pelvis there was an abscess which was then drained and irrigated with gentamicin we then cultured it as well prior to irrigating with gentamicin finally after mobilizing the splenic flexure a layer silk anastomosis was carried out with some difficulty but finally a good anastomosis was obtained and reinforced with the appendices epiploica in the meantime trying to mobilize the rectum i believe we injured a branch of the internal iliac and we lost about cc controlling this with prolene units were given after this and the anastomosis we then changed gowns and gloves for closure irrigated and then checked for hemostasis in the left upper quadrant as well as around in the pelvis a closure of the hernia was done internally first with approximating the fascia from within with interrupted vicryl sutures and then closing the peritoneum under it with a vicryl suture the wound was closed in layers we decided not to do a feeding jejunostomy because there was no anastomosis between the mouth and the transverse colostomy the wound was closed in layers with chromic catgut on the peritoneum taking the rectus which previously had been separated and sewing it over the midline vicryl on the fascia vicryl on the subcutaneous tissue and monocryl subcuticular closure two sponge counts and needle counts were reported as correct by the nurse in charge the patient tolerated the procedure well estimated blood loss was cc urine output was scanty at about cc for the entire case but it picked up as soon as we took her out of trendelenburg she may need some more volume and we did keep her dry it should be pointed out that we looked at the area of the left ureter and indeed it looked like it was stenotic right at the area with a large ureter above and may have been radiated second assistant m d brief hospital course underwent cystoscopy left retrograde pyelogram and attempted left stent placement after the procedure she was admitted to the surgery service under the care of dr the following day she underwent exploratory laparotomy lysis of adhesions rectosigmoid resection and coloproctostomy mobilization of the splenic flexure and repair of ventral hernia she tolerated the procedure well and was returned to the floor after recovery in the pacu postoperatively she was afebrile hct was stable at urine output was marginal but wnl pain was well controlled via epidural at pod she began to mobilize fluid she was tachycardic and had periods of o desaturation ecg was wnl troponin was negative chest xray showed bibasilar atelectasis and small pleural effusions lasix was provided at pod she had return of bowel function diet was advanced she remained tachycardic despite beta blockade she was afebrile wbc remained elevated at at pod she was made npo due to nausea and gastric distention per kub picc line was placed and tpn started ngt was placed cardiology was consulted for persistent tachycardia she was transferred to the icu repeat ecg cardiac enzymes and echo were wnl tsh was wnl lactate was a moderate amount of clear amber fluid was found draining from her rectum and was creatinine at ct cystogram and ct urogram were completed which showed large left retroperitoneal uroma which appeared to leak from distal left ureter significant right hydronephrosis was noted ct scan of abdomen pelvis chest showed moderate bilateral pleural effusions and bibasilar atelectasis abdominal and pelvic ascites and focal fluid collections in the left abdominal and pelvic retroperitoneal regions and active extravasation of contrast suspicious for ureteral injury there was no evidence of pulmonary embolism there was no evidence of communication of the fluid collections and the bowel fluconazole flagyl were added to the abx regimen later in the evening she was intubated for respiratory distress at pod she underwent percutaneous drain placement in the retroperitoneal fluid collection a left nephrostomy tube was placed with antegrade nephrostogram showing probable transected left ureter with free extravasation of contrast into the pelvis at pod she remained intubated she was transfused for a hct of abdominal drain began to appear bilious fluid was amylase at pod she was extubated she was hemodynamically stable wbc count was from at pod she was febrile to peritoneal fluid was negative for growth blood and urine cultures were sent cxr showed bibasilar pleural effusions and linear opacities she was hemodynamically stable wbc count was at pod a repeat ct scan was completed showing continued abdominal fluid collection the pigtail catheter was exchanged the scan did not reveal a communication between the collection and bowel at pod she was afebrile and doing well wbc count was down to she continued to have a moderate amount of biliious drainage from the pigtail drain at pod she was transferred to the floor she was receiving cbi for hematuria nephrostomy continued to drain clear urine urine cytology was sent which was negative for malignant cells at pod an interval ct scan was performed to evaluate abdominal fluid collection as drain output had greatly decreased the scan showed no new fluid collection with marked resolution of drained collection the urinary catheter was discontinued at pod she was afebrile and doing well the hematuria was much improved since removal of the catheter she had no problems with voiding independently the pigtail catheter drainage was decreased to ml per day with increased ostomy output she remained npo with tpn for nutritional support at pod the fistula output had dropped off significantly to about ml per day a repeat ct scan showed no residual fluid in the area of the pigtail catheter her diet was advanced to clear liquids by hd she was tolerating a regular diet but was not eating adequate calories per calorie count megace was started tpn was continued and cycled over night the pigtail continued with low output nephrostomy remained in place and draining adequately she was afebrile and ambulatory wbc was but repeat ct scan showed no new fluid collection and no interval change in the drain site a picc line was placed and the cvl was removed on she was discharged home a picc line was placed prior to discharge for tpn as she was not taking in adequate calories the pigtail and nephrostomy tubes remained she was to follow up with dr in clinic in weeks medications on admission metoprolol mg discharge medications aspirin mg tablet sig one tablet po daily daily ferrous sulfate mg ml liquid sig five ml po daily daily disp qs refills megestrol mg ml suspension sig ten ml po q h every hours disp qs refills pantoprazole 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 metoprolol tartrate mg tablet sig one tablet po three times a day disp tablet s refills sodium chloride flush ml iv daily prn peripheral iv inspect site every shift pigtail flush normal saline ml syringe flush pigtail abdominal drain with ml ns daily disp refills picc line care picc line care per protocol monitor for signs of infection or misplacement discharge disposition home with service facility vna discharge diagnosis sigmoid stricture hydronephrosis ureteral injury s p attempted stent placement post op urinoma post op abdominal fluid collection enteric fistula w drain post op pneumonia post op anemia discharge condition stable discharge instructions please return or contact for f or chills nausea or vomiting abdominal pain increased output of pigtail drain decreased or no output from ostomy misplacement of drains increased redness or drainage from around tube sites chest pain or shortness of breath any other concerns no showering or tub baths with drains in place no lifting over pounds or abdominal stretching exercises for weeks followup instructions please follow up with dr in clinic in weeks please call for an appointment the number is you may also call this number for any questions or concerns completed by,"{
""Diagnoses"": [""advanced rectosigmoid adenocarcinoma"", ""locally advanced rectosigmoid adenocarcinoma"", ""abscess"", ""ct guided abscess drainage"", ""perforated ulcer"", ""small bowel obstruction"", ""obstructing rectosigmoid mass"", ""emphysema"", ""colostomy"", ""jejunostomy"", ""tube open cholecystectomy"", ""social history (ETOH, day tobacco, yr history of recreational drugs, family history (mother)""],
""Medications"": [""augmentin"", ""capecitabine"", ""augmentin x days"", ""recreational drugs"", ""ETOH"", ""tobacco"", ""family history (mother)""],
}"
32184,admission date discharge date date of birth sex m service medicine allergies shellfish iodine iodine containing attending chief complaint status post arrest at home major surgical or invasive procedure icd placement placement and removal of right internal jugular central venous line placement and removal for right sided picc line through interventional radiology placement and removal of left radial arterial line history of present illness patient is an year old man with history of coronary artery disease status post cabg and stent systolic congestive heart failure and stage chronic renal insufficiency who was admitted to the cardiac intensive care unit after presenting to the emergency room after cardiac arrest he was at home today when his wife heard a loud thump and he was found down unresponsive in the kitchen with the refrigerator door open with his procrit in his hand the wife and then called her daughter who lives close by his daughter is cpr certified and arrived within minutes and started cpr ems arrived a few minutes later the patient was pulseless and leads attached demonstrated monomorphic vt he was cardio verted with a shock with return of a pulse he was intubated in the field and lidocaine drip was started a systolic blood pressure in the s was recorded in the emergency room he was initiated on the arctic sun cooling protocol a right internal juglar central venous line was placed he was hypotensive with a systolic pressure in the s and dopamine mcg kg min was started he was reportedly minimally responsive with some movement at that time past medical history dm type dxed insulin since coronary artery disease s p cabg pci congestive heart failure chronic kidney disease stage hyperlipidemia anemia of chronic illness on procrit urinary retention bladder neck obstruction s p turp secondary hyperparathyroidism cardiac history cabg with anatomy lima lad svg om svg om svg to mid rca jump to pda percutaneous coronary intervention bms x svg to pda bms x distal anastamotic site svg to pda prox pda mid pda cath without intervention social history per his wife patient does not use tobacco or alcohol he lives at home with wife family history non contributory physical exam on transport from ed sbp hr rr vs afib ventilated gen intubated and sedated paralyzed heent normocephalic cv irregular s s no m g r resp cta laterally abd soft nt nd no masses ext cool pulses pertinent results laboratories on admission pm sodium potassium chloride total co urea n creat glucose calcium magnesium phosphate pm wbc hgb hct mcv plt count pm pt ptt inr pt pm asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg pm amylase pm abg glucose lactate na k cl tco hgb calchct o sat cardiac enzymes pm ck cpk ctropnt ck mb pm ck mb ctropnt pm ck mb pm ck cpk ck mb ctropnt laboratories upon discharge am wbc hgb hct mcv plt ct am na k cl hco urean creat glucose calcium mg phos am pt ptt inr pt am blood alt ast ld ldh alkphos totbili am blood albumin am blood tsh am blood c c am blood caltibc hapto ferritn trf ekg telemetry on admission atrial fibrillation telemetry strip from ems shows vt post shock there is a period of asystole followed by a slow wide complex rhythym approximately followed by an accelerated wide complex rhythym which then converts to atrial fibrillation with a narrow qrs complex transthoracic echo conclusions the left atrium is normal in size there is mild symmetric left ventricular hypertrophy the left ventricular cavity size is normal there is moderate global left ventricular hypokinesis lvef there is no ventricular septal defect right ventricular chamber size is normal with depressed free wall contractility the aortic valve leaflets are moderately thickened there is a minimally increased gradient consistent with minimal aortic valve stenosis the mitral valve leaflets are mildly thickened there is no mitral valve prolapse mild to moderate mitral regurgitation is seen due to acoustic shadowing the severity of mitral regurgitation may be significantly underestimated the tricuspid valve leaflets are mildly thickened there is no pericardial effusion compared with the findings of the prior study images reviewed of the left ventricular ejection fraction is slightly lower ct c spine without contrast impression moderately severe djd no definite fracture if there is concern for ligamentous injury mri is recommended there is a mm possible nodule in the left lung apex which is only seen on one image recommend further evaluation with ct of the chest renal ultrasound renal son the right kidney measures cm the left kidney measures cm no stone hydronephrosis or mass is identified there is a simple cyst within the lower pole of the left kidney measuring approximately cm not significantly changed from impression no evidence of hydronephrosis chest x ray impression cardiomegaly and upper zone redistribution but no overt pulmonary edema apparent elevation of right hemidiaphragm probably due to subpulmonic right effusion but right lateral decubitus chest radiograph may be considered for confirmation if warranted clinically persistent small left effusion chest pa and lateral pacer icd device has been placed with leads terminating in the right atrium and right ventricle and no pneumothorax right picc line has been withdrawn and now terminates in the superior right axillary region lateral to the right second rib cardiac silhouette remains enlarged and a moderate sized right pleural effusion appears slightly larger small left pleural effusion is unchanged upper zone vascular redistribution is present but no overt pulmonary edema is evident atelectatic changes persist in the right mid and both lower lung zones sputum culture gram stain final pmns and epithelial cells x field per x field gram negative rod s per x field gram positive cocci in pairs chains and clusters per x field gram positive rod s respiratory culture final sparse growth oropharyngeal flora due to mixed bacterial types colony types an abbreviated workup will be performed appropriate to the isolates recovered from this site stenotrophomonas xanthomonas maltophilia moderate growth identification and sensitivities performed on culture m gram negative rod s moderate growth of two colonial morphologies urine culture no growth final urine culture no growth at time of discharge final results pending blood culture no growth final brief hospital course ventricular tachycardia cardiac arrest patient was without spontaneous circulation for approximately minutes possibly longer cpr was started within minutes after his daughter arrived it is unclear if the patient was in a perfusing rhythm prior to the arrival of assistance his coma scale on arrival to the emergency department was and the arctic sun cooling protocl initiated it is difficult to exclude an acute ischemic event but the monomorphic ventricular tachycarida on rhythm strip and known history of coronary artery disease was suggestive of a scar mediated arrhythmic sudden cardiac death patient tolerated the arctic sun cooling protocol well paralytics were used only for induction of the cooling and he appeared comfortable on sedation for the hours of cooling electrolytes ck lactate coagulation studies and serial arterial blood gases were monitored while he was cooled as he was warmed after completing the cooling protocol he demonstrated purposeful movements and responded appropriately to commands by moving all extremities he was able to be successfully extubated on his c spine was cleared and his hard collar was removed patient initally demonstrated some cognitive deficits especially in short term memory however these improved greatly during his stay physical and occupational therapy worked with the patient and he was eventually felt to be safe for discharge home with continued home physical therapy in regards to his arrhythmia he did have another episode of ventricular tachycardia on evening after he was extubated for approximately minutes during this time he was asymptomatic and his blood pressure remained stable he was started on intravenous amiodarone at that time and transitioned to an oral regimen three days after starting amiodarone it was noted that his liver function tests ast alt ldh and total bilirubin had markedly increased this was felt to be secondary to initiation of amiodarone so it was discontinued his liver function tests trended downward immediately after cessation of the amiodarone based on his presentation low ejection fraction and event noted on telemetry decision was made to place a defibrillator icd to protect against any further events icd placement was deferred until the patient s renal function demonstrated improvement and was ultimately placed on he will complete a short course of prophylatic antibiotics and follow up in device clinic in one week as well as in one month to check the device respiratory failure patient was intubated in the field it was initially it was felt that the patient had evidence of congestive heart failure however on he had an episode of hypoxia a chest x ray at that time revealed rul rml collapse secondary to mucous plugging which likely caused the acute hypoxic event which was responsive to suction he was started on broad spectrum antibiotic coverage vancomycin and zosyn given concerns over possible pneumonia based on imaging studies and hypotension his hypoxia resolved and patient was successfully extubated initially he was diuresed however appeared euvolemic during the remainder of his stay without need for further diuresis he completed a course of antibiotic treatment for pneumonia with sputum cultures ultimately demonstrating stenotrophomonas maltophilia he had no further respiratory complaints and continued to have a normal oxygen saturation on room air coronary artery disease it was not suspected that inciting event was ischemic in nature his cardiac enzymes were followed and remained flat peak troponin ck his ekgs were consistent with his prior ekgs without any findings concerning for acute ischemia he had no symptoms of ischemia during his stay his home medications of metoprolol although at a lower dose and aspirin were continued his statin was also re started however this was held due to the increase his liver function tests his statin can likely be re started at his outpatient follow up visit with his primary care physician cardiologist provided that his liver function tests have returned to baseline atrial fibrillation patient has a history of atrial fibrillation and is on chronic anticoagulation for this during his stay his rhythm alternated mainly between atrial fibrillation and a junctional rhythm his coumadin was initially held given a supratherapeutic inr he was given vitamin k for an increasing inr while undergoing cooling protocol he was kept on a heparin drip during his stay while decisions were being made regarding placement of a defibrillator or other interventions after his defibrillator was placed he was re started on his home doses of coumadin mg all days except mg on tuesday rate control was acheived by metoprolol mg twice a day decreased from home dose of mg he will need an inr pt ptt check on tuesday to follow his inr followed by his primary care physician he will then resume his usual inr checks per his primary provdier hypotension patient initially presented with hypotension after his arrest and required pressor support he was kept on a dopamine drip started in the emergency room until he was able to be weaned days later it was felt his hypotension may have been secondary to his arrest he had no evidence of adrenal insufficiency he was treated with antibiotics for his pneumonia as well his home medication of metoprolol was re started and his blood pressure was at goal at time of discharge chronic systolic congestive heart failure patient per report from family and outpatient cardiologist was functioning well prior to his cardiac arrest he was initially diuresed prior to extubation as he had received a large amount of intravenous fluids while in the emergency room during his stay he continued to appear euvolemic his home diuretics torsemide and chlorothiazide were held during his stay for this reason as well as his renal insufficiency and initially poor urine output he was autodiuresing prior to discharge the hours prior to discharge he was negative liter he was asymptomatic and saturating on room air given the increasing size of the right pleural effusion upon discharge he will likely need diuresis soon however the administration of diuretics must be delicately balanced with his renal insufficiency until his renal function returns to baseline creatinine he was instructed to weigh himself daily limit his sodium intake to grams daily and to monitor for signs of heart failure dyspnea peripheral edema etc a vna was also arranged to go to his home and measure daily oxygen saturations and weights he was instructed to contact his physician if he became symptomatic prior to reporting to dr for his appointment on for renal followup his vna was also his oxygen saturation decreased below diabetes mellitus patient was treated with lantus and a humalog sliding scale he will need continued titration of his regimen on an outpatient basis renal failure patient has chronic stage renal insufficiency his creatinine was initially at baseline during his first few days however his creatinine then began to rise while he concurrently became oliguric the renal team was consulted and it was suspected that the patient had atn secondary to his circulatory arrest and hypotension his urine sediment further supported this his creatinine peaked at and was trending downward at time of discharge it was felt that his renal function would continue to improve and that he had no indications for dialysis a renal ultrasound was unremarkable patient will need basic electrolyte panel including bun and creatinine checked on tuesday to be followed by his outpatient nephrologist he will be closely followed after discharge by his outpatient renal team anemia patient has history of chronic anemia and is on procrit as an outpatient he was given one unit of packed red blood cells during his stay to help replete volume and improve his hematocrit his hematocrit remained stable during his stay ranging mainly in the range while on the heparin drip he had mild epistaxis and bruising but otherwise had no evidence of bleeding code patient remained full code during his admission disposition physical therapy and occupational therapy both felt patient was safe for discharge home where he could continue to work towards returning to his baseline with home physical therapy discussions were held with the family to stress the importance of continued activity upon return home patient will have close follow up with his nephrologist primary care physician cardiologist all of whom were aware of patient s hospitalization medications on admission rosuvastatin mg metoprolol tartrate mg plavix mg asa mg tamsulosin mg qhs senna tablet prn colace mg prn insulin lispro sliding scale qid protonix mg daily warfarin mg tuesday mg m w th f torsemide mg vitamin d mcg capsule chlorothiazide mg minutes prior to torsemide m w f klor con powder packest meq s daily procrit u ml ml x week discharge medications aspirin mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet s refills epoetin alfa unit ml solution sig two injection qmowefr monday wednesday friday continue outpatient regimen cephalexin mg capsule sig one capsule po q h every hours for days disp capsule s refills pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours warfarin mg tablet sig one tablet po tuesday warfarin mg tablet sig one tablet po m w th f sat sun insulin glargine unit ml solution sig twelve units subcutaneous qhs insulin lispro unit ml solution sig sliding scale as directed subcutaneous as directed colace mg capsule sig one capsule po bid prn senna mg capsule sig one capsule po bid prn vitamin d oral tamsulosin mg capsule sust release hr sig one capsule sust release hr po at bedtime outpatient lab work please have inr pt ptt basic electrolyte panel including bun creatinine and liver function tests ast alt alk phos ldh t bili checked on tuesday please fax results to dr office phone and dr office phone plavix mg tablet sig one tablet po once a day discharge disposition home with service facility homecare discharge diagnosis primary diagnosis cardiac arrest secondary diagnoses icd placement ventricular tachycardia chronic renal insufficiency anoxic brain injury diabetes mellitus systolic congestive heart failure anemia coronary artery disease chronic stage renal insufficiency discharge condition stable ambulating with assistance of walker discharge instructions you were admitted to the cardiac intensive care unit after having a cardiac arrest at home you were cooled under the arctic sun protocol and initially intubated you did well post extubation with some cognitive deficits and worsening renal function upon discharge you were functioning mentally near baseline and your renal function was improving a defibrillator was placed to prevent further dangerous continued arrhythmias please weigh yourself every morning and call dr or dr if you note a weight gain of more than lbs please call dr dr or go to the emergency room if you experience any chest pain palpitations difficulty breathing bleeding swelling or redness at site of defibrillator insertion firing of your defibrillator decreased or no urination or other concerning symptoms please follow a low salt diet with no more salt than grams daily please continue to work with physical therapy and ambulate frequently at least several times a day to maintain your strength a few medication changes have been made torsemide has been stopped this medication has been stopped due to your renal function being worse than your baseline as you renal function recovers it will be important to restart this medication after discussing this with your physician is important to understand that this medication helps rid your body of excess fluid due to chronic systolic congestive heart failure or decreased pumping ability of your heart if you develop symptoms of shortness of breath inability to lie flat due to shortness of breath swelling in your feet or ankles or shortness of breath with exertion please contact your physician as these are signs of excess fluid which may be affecting your lungs and other organs you will see dr your kidney doctor on thursday it is also recommended that you followup with your pcp prior to this if possible so he can monitor your volume status as well also please weigh yourself daily as described above and notify your physician if you gain pounds in one day as this may be a sign of fluid gain overload rouvastatin has been stopped this can likely be re started at follow up once your liver function tests are checked metoprolol has been decreased to mg twice a day glargine also called lantus has been decreased to units daily chlorothiazide has been stopped potassium klor con powder has been stopped due to your worsened renal failure continue keflex antibiotics as prescribed to complete a day course after your pacemaker was placed please follow up with your cardiologist dr at the following appointment at am the number for his office is you have an echocardiogram scheduled for that morning at am the number for the echocardiogram lab is please follow up with your primary care physician within one week of discharge his office is aware you have been hospitalized and will be calling you with an appointment please follow up with your kidney doctor dr at an appointment made for you on thursday at pm you will need your labs drawn on tuesday to check your kidney function the results will need to be sent to dr office office phone you will also need to follow up in device clinic in one week as directed to have your icd checked their phone number is followup instructions please follow up with your cardiologist dr at the following appointment at am the number for his office is you have an echocardiogram scheduled for that morning at am the number for the echocardiogram lab is please follow up with your primary care physician within one week of discharge his office is aware you have been hospitalized and will be calling you with an appointment please follow up with your kidney doctor dr at an appointment made for you on thursday at pm you will need your labs drawn on tuesday to check your kidney function the results will need to be sent to dr office office phone you will also need to follow up in device clinic in one week as directed to have your icd checked the device clinic will call you for an appointment you will also need to follow up in one month to have your device checked at that time their is,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""m"", ""service"", ""medicine"", ""allergies"", ""shellfish"", ""iodine"", ""iodine containing"", ""attending"", ""chief complaint"", ""status post arrest"", ""at home"", ""major surgical or invasive procedure"", ""ICD placement"", ""placement and removal of right internal jugular central venous line"", ""placement and removal of left radial arterial line"", ""history of present illness""],
""Medications"": [""procrit""]
}"
13091,admission date discharge date date of birth sex m service procedure elective ileostomy takedown history of present illness the patient is a year old male with the diagnosis of crohn s disease times years the patient had terminal ilial stricture in and exploratory laparotomy was performed with resection of the anastomosis a subphrenic abscess was also drained at the time his postoperative course was notable for tachycardia past medical history crohn s disease postoperative tachycardia depression anxiety past surgical history as per above medications paxil mg po q d allergies nsaids and aspirin which cause swelling social history no tobacco former alcohol abuse now in remission no intravenous drug use patient works at united airlines and is married hospital course the patient was admitted on for elective takedown of his ileostomy he tolerated the procedure well without complication notably his postoperative course was significant for tachycardia his vital signs postoperatively were temperature blood pressure pulse oxygen saturation on room air physical examination the patient was in mild distress head eyes ears nose and throat was normocephalic atraumatic cardiac exam was tachycardia with regular rhythm no murmurs rubs or gallops chest was clear to auscultation bilaterally the dressing was in place without evidence of bleeding or discharge his hematocrit was in the post anesthesia care unit the patient received mg of lopressor for heart rate in the s he subsequently decreased to a heart rate of s the patient was transferred to the unit from the post anesthesia care unit for monitoring of his postoperative tachycardia the patient s heart rate was controlled with lopressor and he was started on kefzol and flagyl times two doses he was also placed on intravenous steroids on postoperative day number one the patient was afebrile with a temperature of alert and comfortable his heart rate was and blood pressure was white blood cell count was hematocrit and platelet count he was continued on npo diet and his pain was controlled with a pca later in the day the patient spiked a temperature to and he was given tylenol and incentive spirometer use was encouraged on postoperative day number two the patient s heart rate had decreased to with a blood pressure of and he was transferred to the floor on postoperative day number three the patient s heart rate was blood pressure was and he was afebrile he was started on sips of clears and intravenous fluids were discontinued rate continued to be monitored on postoperative day number four the patient was advanced to a regular diet and was tolerating po medications he was taking percocet for pain and he was discharged home follow up instructions the patient was instructed to follow up with dr in two weeks and he was given percocet for pain and colace m d dictated by medquist d t job,"{
""Diagnoses"": [""Crohn's disease""],
""Medications"": [""Paxil 20 mg po qd""]
}"
75271,admission date discharge date date of birth sex f service cardiothoracic allergies demerol percocet vicodin cymbalta lisinopril hydralazine hydrochlorothiazid codeine darvon trazodone tramadol attending chief complaint angina major surgical or invasive procedure coronaty artery bypass graft x left internal mammary artery to left anterior decending saphenous vein graft to diag saphenous vein graft to obtuse marginal saphenous vein graft to posterior descending artery saphenous vein graft to obtuse marginal history of present illness year old female who this past developed chest discomfort with exertion followed by nausea and emesis an exercise mibi was performed on which showed septal hypertrophy with inferior wall ischemia an echocardiogram did not reveal any valvular disease a cardiac catheterization was performed on which revealed severe three vessel coronary artery disease given the severity of her disease she has been referred for surgical revascularization past medical history hypertension hyperlipidemia diabetes mellitus type fibromyalgia chronic back pain lumbar spinal stenosis right shoulder and hip bursitis shingles alopecia obesity depression cataract retinopathy neuropathy gastroesophageal reflux disease s p surgery to l l and s for spinal stenosis s p right rotator cuff repair s p total abdominal hysterectomy c b small bowel obstruction s p ex lap lysis of adhesions with nephrectomy social history retired lives alone denies tobacco social drinker family history no premature cad physical exam pulse resp o sat b p right left height weight bsa m general wdwn female in no acute distress skin warm x dry x intact x well healed abd incisions heent ncat x perrla x eomi x neck supple x full rom x chest lungs clear bilaterally x heart rrr x irregular murmur none 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 pulses femoral right left dp right left pt left radial right left carotid bruit right none left none pertinent results echo pre cpb the left atrium is moderately dilated no mass thrombus is seen in the left atrium or left atrial appendage the interatrial septum is aneurysmal a patent foramen ovale is present a left to right shunt across the interatrial septum is seen at rest there is mild symmetric left ventricular hypertrophy overall left ventricular systolic function is normal lvef right ventricular chamber size and free wall motion are normal there is intimal thickening and focal calcifications in the descending thoracic aorta no thoracic aortic dissection is seen the aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic stenosis mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is focal posterior mitral annular calcification mild mitral regurgitation is seen post cpb there is mild symmetric lvh with normal global systolic function estimated ef there is mild ai mild mr mild tr unchanged from pre op there is now evidence by color doppler of directional flow through the pfo there is no evidence of dissection 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 am blood pt ptt 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 calcium phos mg brief hospital course mrs was a same day admit and underwent surgery with dr on following surgery she was transferred to the cvicu in stable condition for invasive monitoring within hours she was weaned from sedation awoke neurologically intact and extubated gently diuresed toward her preop weight and beta blockade titrated on post op day three she was transferred to the floor to begin increasing her activity level she was expereincing right anterior chest breast pain which was managed with a lidoderm patch she continued to make good progress and was cleared for discharge on post op day five to specialty hospital in with the appropriate medications and follow up appointments medications on admission quinine sulfate mg capsule sig two capsule po hs at bedtime aspirin mg tablet chewable sig one tablet chewable po daily daily omeprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily isosorbide mononitrate mg tablet sustained release hr sig one tablet sustained release hr po daily daily amlodipine mg tablet sig one tablet po daily daily toprol xl mg tablet sustained release hr sig one tablet sustained release hr po once a day glyburide metformin mg tablet sig one tablet po once a day simvastatin mg tablet sig one tablet po once a day spironolactone mg tablet sig one tablet po twice a day discharge medications docusate sodium mg capsule sig one capsule po bid times a day for months aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily 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 hydromorphone mg tablet sig tablets po q h every hours as needed for pain metformin mg tablet sig one tablet po daily daily glyburide mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig one tablet po bid times a day lidocaine mg patch adhesive patch medicated sig one topical daily daily acetaminophen mg tablet sig two tablet po q h every hours as needed for fever pain magnesium hydroxide mg ml suspension sig thirty ml po hs at bedtime as needed for constipation bisacodyl mg suppository sig one suppository rectal daily daily as needed for constipation furosemide mg tablet sig one tablet po q h every hours potassium chloride meq tab sust rel particle crystal sig one tab sust rel particle crystal po q h every hours albuterol sulfate mg ml solution for nebulization sig one inhalation q h every hours as needed for wheezing discharge disposition extended care facility tba discharge diagnosis coronary artery disease s p coronary artery bypass graft x past medical history hypertension hyperlipidemia diabetes mellitus type fibromyalgia chronic back pain lumbar spinal stenosis right shoulder and hip bursitis shingles alopecia obesity depression cataract retinopathy neuropathy gastroesophageal reflux disease discharge condition alert and oriented x nonfocal ambulating with steady gait incisional pain managed with oral analgesics incisions sternal healing well no erythema or drainage leg right left healing well no erythema or drainage edema lower extremities 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 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 please call to schedule appointments with your primary care dr in weeks 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,"{
""Diagnoses"": [""cardiothoracic"", ""angina"", ""coronary artery disease"", ""severe three vessel coronary artery disease""],
""Medications"": [""demerol"", ""percocet"", ""vicodin"", ""cymbalta"", ""lisinopril"", ""hydrochlorothiazide"", ""codeine"", ""darvon"", ""trazodone"", ""tramadol""]
}"
54337,admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint jaundice and abdominal pain major surgical or invasive procedure ercp with stent placement history of present illness yo woman from with history of treated tb per pt who presented to osh with jaundice and abdominal pain now transfered from osh for concert for cholangitis and sepsis in the setting of liver cyst the pt was originally admitted to osh on for abdominal pain and jaundice ct scan during that admission showed intra and extrahepatic biliary duct dilatation with a large cystic component in the biliary duct and a suggestion of a choledochal cyst with associated infection inflammation labs were notable for ast alt alk phos hep b surface ag neg hep b surface ab pos hcv neg the pt was treated with antibiotics and evaluated by the osh surgical team and ultimately was discharged home on oral antibiotics with plans to follow up with gi as an outpatient for ercp on on the pt developed abdominal pain which was relieved with percocet on the pt developed nausea and non bloody emesis and presented to osh ed labs at that time were significant for wbc hct plt with eos tbili was ast alt and alk phos chem was normal the pt s symptoms improved with supportive medications but the pt was noted to have sbp s persistently low sometimes in the s and was transfered to the osh icu during the admission from the pt was noted to have poor u o with only l out despite l in during her length of stay the pt was initially started on ertapenem and flagyl for presumed cholangitis and pancreatitis but then it was determined that ertapenem would provide adequate coverage and flagyl was stopped the pt was kept npo and did have an episode of hypoglycemia in the s that responded to an amp of d the pt was transfered to for ercp and hepatobiliary consults on the floor sbp otherwise the pt denies abdominal pain nausea lightheadedness past medical history tb dx per patient took mos kanamycin ethionamide her strain was resistant to rifampin recent dx choledochal cyst social history no tobacco alcohol or drugs stays at home with year old married is from indian but tibetan moved to usa one year ago family history non contributory physical exam admission pe 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 thin soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly liver edge palpable no hsm gu no foley ext warm well perfused pulses trace bilat le edema pitting neuro speech fluent a ox strength in bilat upper and lower extremities gait assessment deferred discharge pe afebrile p ra 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 hypochr anisocy poiklo macrocy normal microcy polychr occasional ovalocy schisto am 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 micro stool o p negative echinococcus ab positive entamoeba pending fasciola negative strongyloides negative schistosoma negative mrcp diffuse irregular intra and extrahepatic biliary dilation with dominant massively dilated biliary structure encompassing the majority of the right hepatic lobe this is felt most likely to represent diffuse choledochal cyst formation todani type postinfectious biliary dilation is felt less likely due to lack of stricturing and lack of intraductal stones appearance is not typical of echinococcal disease as questioned diffuse peribiliary enhancement consistent with superinfection cholangitis and probable chronic right portal venous compression or occlusion with collateralization however short interval follow up after treatment and resolution of symptoms within months is recommended to ensure resolution of enhancement about the cyst in order to exclude an adjacent infiltrative mass in addition consideration of correlation with ercp and brushings is suggested perihepatic and subdiaphragmatic free fluid that could relate to inflammatory or infectious change or prior cyst rupture into the perihepatic space additional left sided intrahepatic biliary dilation and wall enhancement differential includes cholangitis biliary stasis and obstruction by the dominant biliary cyst ercp extensive dilation of the common bile duct common hepatic duct intra and extrahepatic bile ducts extensive stones and sludge throughout the extrahepatic and right intrahepatic biliary system cm biliary stricture noted in the right hepatic duct proximal to this was severe dilation with debris inside consistent with patient s known biliary dilation cyst successful sphincterotomy performed extraction of significant amount of stones debris although extensive debris remains in the right intrahepatic bile ducts at the end of the procedure brushings taken of right hepatic duct stricture successful stent placement across the hepatic duct stricture findings most consistent with oriental cholangiohepatitis ruq u s preliminary report pfi pfi given limitations in comparing cross modalities persisting cystic structure in the right kidney with heterogeneous echogenic material within it similar in size to prior mr and draining into a dilated bile duct findings are nonspecific and as advised on prior mr ercp may be considered for further assessment cxr volume loss left upper lobe probably due to old lung infection but mass effect is present bile duct brushing cytology negative for malignant cells ct chest w contrast study date of impression extensive findings consistent with prior tuberculose exposure no evidence of echinococcal infestation of lungs or mediastinum several noncalcified pulmonary nodules most likely consistent with noncalcified granulomas in the absence of smoking or known malignancy as guidelines no further followup indicated discharge labs wbc hgb hct plt alt ast alk phos tbili lytes bun cr wnl brief hospital course year old tibetan woman with choledochal cyst of unknown etiology transferred from osh for ercp and hepatobiliary surgery consultation presented with hypotension eosinophilia elevated lfts and abdominal pain choledochal hepatic cyst ddx included echinococcus amebic or other parasitic cyst vs simple cyst vs abscess vs tumor parasitic cyst was felt to be most likely due to eosinophilia and recent immigration from serologies for echinococcus was positive at the outside hospital multiple serologies at were sent which confirmed echinococcus positivity note that entamoeba serology remains pending albendazole was started empirically at the outside hospital prior to her transfer due to concern for echinoccal cyst and possible spillage leading to hypotension the surgical service was consulted given communication of this cyst with the biliary tree and they recommended surgical removal of the cyst plan was for pt to return to cha for surgical intervention however pt requested to have procedure done at id was consulted and followed throughout the hospitalization per id pt will need to remain on albendazole for one month following surgical intervention cholangitis ercp was consulted as was hepatobiliary surgery and infectious disease she underwent an ercp on and stones and sludge were removed a sphincterotomy was performed and a stent was placed her lfts improved after ercp though there was no obvious change in the size of her cyst on imaging she received empiric treatment with cipro flagyl given concern for cholangitis bacterial infection she completed a two day course of ivermectin for possible strongyloides her symptoms of nausea and abdominal pain improved she will complete a week course of cipro flagyl per ercp recommendations given the duration of her obstruction and the presence of the cyst hypotension pt was hypotensive on admission however this resolved with fluids and remained stable with careful monitoring throughout her stay in the icu her baseline blood pressure is low per pt this may have been due to cholangitis bacterial infection however given the possibility of an echinoccocal cyst there was initial concern for anaphylaxis however she improved with ivf alone medications on admission on admission to osh colace percocet q h prn augmentin x d on transfer to flagyl mg iv q d c ed heparin u tid ertapenem g q h protonix iv daily albendazole mg one dose at pm on discharge medications albendazole mg tablet sig two tablet po bid times a day please continue for month following surgery disp tablet s refills ciprofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills metronidazole mg tablet sig one tablet po q h every hours for days disp tablet s refills discharge disposition extended care discharge diagnosis choledochal hepatic cyst cholangitis hypotension eosinophilia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted with abdominal pain and were found to have blockage in your bile duct this was opened up and stented with drainage of gallstones and sludge you were also found to have a large fluid filled cyst pushing on your liver and liver veins this cyst which communicates with connects to the bile duct system you will need to follow up with surgery to remove the cyst followup instructions surgery please see dr of surgery to discuss your surgical options provider md phone date time pm of the medical building at a plan regarding your bile duct stent from ercp will be made at that time with location cha family health address phone appointment monday at am [NEW_RECORD] name unit no admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending addendum correction pt discharged to home not ecf discharge disposition home md completed by,"{
""Diagnoses"": [""Jaundice"", ""Abdominal pain"", ""Cholangitis"", ""Sepsis"", ""Liver cyst"", ""Choledochal cyst""],
""Medications"": [""Percocet"", ""Antibiotics""]
}"
78325,admission date discharge date date of birth sex f service medicine allergies compazine attending chief complaint cough sob fever transferred from osh for respiratory distress major surgical or invasive procedure left subclavian cvl at osh intubation extubation cvl insertion history of present illness ms is a f smoker with history of copd chronic headaches on narcotics fentanyl patch has increased to recently she also has a history of hld dm pvd s p fem she presented to hospital on with sob fever and chest pain she was having week of sob associated with non productive cough pleuritic chest pain wheezing generalized myalgias and fever chills she was treated with nebs high grade e coli bactermeia and respiratory failure on admission she received a cxr tte and a ct ct was consistent with diffuse nodular ground glass opacities small bilateral effusions cta and lenis negative tte on showed lvef mild mvp and mod mr lae and mild lv dilation she was treated with duoneb xopenex nebs solumedrol mg iv q hrs and dilaudid out bcx positive for pan sensitive e coli she was treated with various abx including ceftazidime levaquin cipro and azithromycin on transfer to she was on levaquin mg iv qday and azithromycin urine and lfts unremarkable she had increased work of breathing requiring bipap nrb mask and eventually required intubation for worsening respiratory acidosis on l she received doses of pancuronium for agitation coughing dysynchrony desaturations and elevating pips she has been having minimal secretions and tracheal aspirations were negative for organisms she received mg iv lasix x and put out l patient cxr showed developing bilateral fluffy bilateral infiltrates she was given mg iv lasix for le edema elevatged bnp and elevated cvp after a subclavian line was placed cvp reduced to after lasix vitals on transfer from osh afberile sinus rhythm at bpm bps s on propofol mcg maps s vent settings cmv peep rr o abg on the floor she arrived intubated on propofol drip stable her vent settings were fio vt rr peep and her vs were afebrile hr bp o rr mid s breathing over vent review of systems patient is intubated and sedated unable to attain ros past medical history past medical history per osh records copd chronic has on narcotics pvd dm hld htn anemia unknown etiology possible ugib social history social history from osh recods tobacco ppd alcohol none illicits none family history family history from osh records nc physical exam on admission to micu from transfer vitals afebrile bp p r s o fio general intubated sedated on propofol drip does not appear in any acute distress heent dry mucous membranes dried blood around nares and lips surrounds et tube neck supple jvp not elevated no lad lungs anterior exam is limiting though she has course rhonchi throuhgout with evidence of crackles worse at bases bilaterally and with end expiratory wheezes apically cv tachycardic s s clear and of good quality though heart exam limited by lound rhonchorous breah sounds abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly gu foley in placve draining moderate large amount of light urine ext warm well perfused pulses no clubbing cyanosis or edema on discharge vitals tmax ra general patient appears well and in nad cardiac rrr s and s no m r g lung diffuse crackles and popping sounds improves with cough abdomen soft nt nd bsx extremeties no calf swelling or tenderness neuro a ox cn ii xii intact moving all extremeties pertinent results lab results on admission 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 bands lymphs monos eos basos atyps metas myelos pm pt ptt inr pt pm type art rates tidal vol peep o po pco ph total co base xs assist con intubated intubated pm urine color straw appear clear sp pm urine blood neg nitrite neg protein tr glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg abgs pm blood type art rates tidal v peep fio po pco ph caltco base xs assist con intubat intubated am blood temp tidal v fio po pco ph caltco base xs am blood triglyc hdl chol hd on propofol drip discharge labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood hgb hct am blood glucose urean creat na k cl hco angap imaging cxr diffuse parenchymal opacification is in keeping with clinical diagnosis of ards endotracheal tube in standard position with tip cm above the carina ct abdomen diffuse patchy opacities within the lung fields along with wedge shaped infarctions along bilateral lung bases raise the possibility of septic emboli no evidence of intra abdominal abscess numerous renal and liver cystic lesions of various size seen in polycystic kidney disease cxr findings in comparison with study of there has been some decrease in the still prominent diffuse bilateral pulmonary opacifications monitoring and support devices remain in good position cxr previously widespread infiltrative pulmonary abnormality improved substantially between and has not changed raising concern for acute pulmonary embolism or other abnormality not detectable on conventional radiographs there is no consolidation or collapse no pleural effusion or pulmonary edema heart size is normal et tube and right internal jugular line are in standard placements and a nasogastric tube passes below the diaphragm and out of view eeg abnormal eeg due to diffuse and prolonged slowing in the delta range with superimposed alpha rhythm both anteriorly and posteriorly the record is consistent with a diffuse mild to moderate encephalopathy without evidence of focality or of increased irritability cxr single ap view of the chest shows an et tube cm above the carina an og tube and ij line are in standard position lung volumes are low however there is no consolidation or collapse no pleural effusion or pneumothorax heart size is normal echo the left atrium is normal in size 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 aortic valve leaflets are mildly thickened there is no aortic valve stenosis no aortic regurgitation is seen the mitral valve leaflets are mildly thickened physiologic mitral regurgitation is seen within normal limits there is no pericardial effusion no vegetation seen cannot definitively exclude cxr as compared to the previous radiograph the lung volumes have slightly increased potentially reflecting improved ventilation the pre existing atelectasis at the right lung base is unchanged in extent no interval appearance of new parenchymal opacities borderline size of the cardiac silhouette no pleural effusion mri head no acute infarction no evidence of other intracranial abnormalities on non contrast mri persistent partial bilateral mastoid air cell opacification possible mucus retention cyst in the nasopharynx if clinically indicated this may be further assessed by direct visualization to exclude other possible etiologies microbiology osh bcx positive in bottles for pan sensitive e coli all bcx negative in house all ucx negative in house sputum cx negative fungal culture preliminary negative brief hospital course hospital course yo f pmhx chronic ha on high dose narcotics who initially presented to osh w cough fevers chills found to have ecoli bacteremia with worsening respiratory distress ards requiring intubation transferred to now status post abx therapy with improvement in respiratory status and extubation e coli sepsis at osh patient with multiple blood cultures positive for pan sensitive e coli treated with azithromycin levofloxacin at osh transitioned to ctx on transfer given persistant fevers source of bacteremia thought to uti with concern for seeding of newly identified pckd cultures at remained negative and fever curve leukocytosis resolved plan for d coverage with antibiotics and completed on ards at osh patient developed increasing hypoxia with bilateral infiltrates consistent with ards requiring intubation underlying etiology was thought to be ecoli sepsis she was maintained on ardsnet ventilation protocol with treatment of underlying bacteremia sedation was complicated by high narcotic and benzo requirements thought to be chronic narcotic usage patient s respiratory status improved and she was successfully extubated on on discharge her respiratory status is stable at on ra tachycardia patient has been tachycardic while on the floor to per pcp baseline is around ekg shows nsr although patient denies any pain aside from her chronic ha the tachycardia does not appear related to dehydration as the patient is tolerating adequate po fluids tachycardia believed to be related to deconditiong in the setting of severe illness and intubation with likely underlying lung disease and bronchodilator medications patient was initially started on metoprolol with good effect but it was discontinued as she did not have indication for beta blockade tsh was checked and was normal her tachycardia has been asmptomatic the patient denies any cp or palpitations the pcp was updated verbally regarding the need for close follow up of this issue chronic has patient with chronic has being treated with fentanyl patch mcg as an outpatient fentanyl patch was stopped in setting of intubation patient was initially transitioned to methadone with prn ultram after extubation in icu on the floor she was transitioned to ms contin given her preference of ms contin to methadone she was also restarted on her home amitriptyline the patient reports her ha pain is under control and would like to be d c on her current regimen the patient was provided a short supply of her opiate regimen enough to reach her follow up appointment with her pcp polycystic kidney disease patient with newly identified pckd on admission with ctap showing multiple cysts in her liver cta of head in setting of intubation did not demonstrate large aneurysms patient with normal renal function at this time will follow up with pcp that source of e coli sepsis may be related to cyst seeeding from a uti as discussed above we suggest considering a renal consultation as an outpatient to clarify this potential diagnosis hypertension held home lisinopril in setting of acute illness patient is being discharged home without lisinopril as her blood pressure is normotensive at the time smoking cessation patient has not smoked x days doing well on nicotine patch without break through cravings will continue as o p and follow up with pcp gerd continued home omeprazole medications on admission medications per osh records lisinopril mg po qday albuterol prn zocor mg po qday prilosec mg po qday amitriptylline mg po qday penicillin since mg po tid fentanyl patch tramadol pills transfer from valler meds azithromycin mg iv day levaquin mg iv qday solumedrol mg iv q hours combivent puffs qid lopressor mg colace mg simvastatin mg qhs omeprazole mg po qday arixtra mg sc discharge medications albuterol sulfate mcg actuation hfa aerosol inhaler sig one puff inhalation every six hours as needed for shortness of breath or wheezing simvastatin mg tablet sig one tablet po daily daily omeprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily amitriptyline mg tablet sig one tablet po at bedtime tramadol mg tablet sig two tablet po q h every hours as needed for pain please do not take more than tablets per day fluticasone salmeterol mcg dose disk with device sig one puff inhalation twice a day morphine mg tablet extended release sig one tablet extended release po every twelve hours as needed for pain please do not drive or operate heavy machinery while taking this medication disp tablet extended release s refills docusate sodium mg capsule sig one capsule po bid times a day as needed for constipation disp capsule s refills senna mg tablet sig one tablet po bid times a day as needed for constipation disp tablet s refills nicotine mg hr patch hr sig one transdermal once a day disp patch refills discharge disposition home discharge diagnosis primary diagnosis acute respiratory distress syndrome secondary diagnosis e coli sepsis polycystic kidney disease discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms it was a pleasure to take care of you at you were transferred here from for management of your e coli infection and acute respiratory distress syndrome you were intubated because of acute respiratory distress syndrome and your breathing was helped by the machines you were treated with antibiotics and were extubated when your respiratory status improved you were transferred to regular medicine floor and did well please note the following changes to your medicaiton regimen stop taking your lisinopril for now because your blood pressure was normal at the time of discharge you may need to restart this medication at later time stop using fentanyl patch start ms contin mg twice daily for your headaches please do not drive while you re taking this medication as it can make you drowsy change zocor to mg daily at bedtime start senna tab twice daily as needed for constipation start mg colace twice daily as needed for constipation followup instructions you have an appointment scheduled with dr your primary care physician fo at pm completed by,"{
""Diagnoses"": [""admission for respiratory distress"", ""pneumonia"", ""sepsis"", ""acute respiratory failure"", ""chronic obstructive pulmonary disease"", ""headache"", ""myalgia"", ""fever"", ""chills""],
""Medications"": [""Compazine"", ""Fentanyl patch"", ""Nebulizers (high-grade E. coli bacteremia)"", ""Solumedrol"", ""Dilaudid"", ""Levaquin"", ""Xopenex"", ""Cipro"", ""Azithromycin""]
}"
27789,admission date discharge date date of birth sex f service cardiothoracic allergies sulfa sulfonamides percocet vicodin adhesive tape attending chief complaint chest pain major surgical or invasive procedure coronary artery bypass graft x lima to lad svg to om svg to pda history of present illness y o female with known cad s p stent to lcx in who presented to osh with progressive chest pain past medical history coronary artery disease s p lcx stent lymphoma s p chemo hyperlipidemia diabetes mellitus social history quit smoking yr ago and pk yr hx denies etoh use family history non contributory physical exam vs gen nad skin unremarkable heent eomi perrl ncat neck supple from jvd chest ctab w r r heart rrr c r m g abd soft nt nd bs ext warm well perfused trace edema superficial varcicosities neuro a o x mae non focal pertinent results echo pre cpb lv systolic fxn appears normal in the face of moderate mr echo contrast is seen in the left atrial appendage right ventricular chamber size and free wall motion are normal there are complex mm atheroma in the descending thoracic aorta the aortic valve leaflets are mildly thickened no aortic regurgitation is seen the mitral valve leaflets are moderately thickened moderate mitral regurgitation is seen there is no pericardial effusion in performing the st graft lad off pump the patient became very ischemic and fibrillated decision made to go on pump for the rest of the grafts post cpb good biventricular systolic fxn mr remains no ai aorta intact 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 pt ptt inr pt am blood urean creat cl hco 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 csurg fa a sched chest portable ap clip reason eval pneumothoraces medical condition year old woman s p cabg reason for this examination eval pneumothoraces final report history cabg to evaluate pneumothoraces findings in comparison with the study of slight decrease in the bilateral pleural effusions the remainder of the examination is unchanged in this patient with midline sternal sutures picc line remains in place dr approved fri am imaging lab brief hospital course ms was a same day admit after undergoing pre operative work up when she had her cardiac cath on on day of admission she was brought to the operating room where she underwent a coronary artery bypass graft x please see operative report for surgical details following surgery she was brought to the cvicu for invasive monitoring in stable condition later on op day she was weaned from sedation awoke neurologically intact and extubated on post op day one she was started on diuretics beta blockers and some pre op medications later on this day she was transferred to the telemetry floor for further care the remainder of her postop course was essentially uneventful and she was ready for discharge to home with vna services on pod she has been advised to follow up with her pcp cardiologist oncologist and dr medications on admission aspirin mg qd plavix mg qd last dose zetia mg qd glyburide mg qd metformin mg qd lopressor mg imdur mg qd lipitor mg qd 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 metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet s refills hydromorphone mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills 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 glyburide mg tablet sig one tablet po daily daily disp tablet s refills furosemide mg tablet sig two 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 once a day for days disp tab sust rel particle crystal s refills fluticasone mcg actuation aerosol sig two puff inhalation times a day disp refills zetia mg tablet sig one tablet po once a day disp tablet s refills ferrous sulfate mg mg iron tablet sig one tablet po daily daily disp tablet s refills ascorbic acid mg tablet sig one tablet po bid times a day disp tablet s refills albuterol sulfate mg ml solution for nebulization sig one inhalation four times a day as needed for shortness of breath or wheezing disp refills ipratropium bromide solution sig one inhalation four times a day as needed for shortness of breath or wheezing disp refills discharge disposition home with service facility vna discharge diagnosis coronary artery disease s p coronary artery bypass graft x pmh lymphoma s p chemo hyperlipidemia diabetes mellitus discharge condition good 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 dr in weeks dr weeks dr in weeks md completed by,"{
""Diagnoses"": [""cardiothoracic"", ""allergies"", ""sulfa"", ""sulfonamides"", ""Percocet"", ""Vicodin"", ""adhesive tape""],
""Medications"": [""chest pain"", ""coronary artery bypass graft"", ""stent"", ""LIMA to LAD"", ""SVG to PDA"", ""history of present illness"", ""y/o female with known CAD"", ""SP stent"", ""lymphoma"", ""chemo"", ""hyperlipidemia"", ""diabetes mellitus""]
}"
43893,admission date discharge date date of birth sex f service obstetrics gynecology allergies morphine attending chief complaint vaginal bleeding major surgical or invasive procedure total abdominal hysterectomy blood transfusion history of present illness yo g p s p svd presents to ed by ems with heavy vb per emt ebl en route cc pt reports that she had been having lochia c w period since discharge it got heavier this afternoon then she began passing large clots with bright red blood per vagina she denies lightheadedness shortness of breath or chest pain she denies fevers chills or other constitutional symptoms she denies headache abd pain blurry vision past medical history pmh fibroid uterus no images here meds tylenol allergies morphine n v shellfish swelling psh lap chole cyst removal l wrist removal of lesion from r ear ob svd term gyn fibroid uterus social history as above family history nc physical exam ra anxious mm dry tachycardic clear abd obese soft nt fundus firm about cm above pubic ramus the perineum is covered in blood there is brb and clot w speculum exam cleared approx cc blood on exam bimanual os cm uterus nontender firm 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 am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood hct pm blood hct 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 hct am blood hct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood fibrino am blood fibrino am blood fibrino 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 alt ast alkphos totbili am blood ck cpk am blood ck mb ctropnt pm blood ck mb ctropnt pm blood ck mb ctropnt pm blood uricacd am blood calcium phos mg am blood calcium phos mg pm blood calcium phos mg am blood calcium phos mg pm blood type art po pco ph caltco base xs intubat intubated vent controlled am blood type art po pco ph caltco base xs intubat intubated vent controlled am blood type art po pco ph caltco base xs intubat intubated vent controlled am blood type art temp po pco ph caltco base xs am blood type art po pco ph caltco base xs brief hospital course ms was admitted after undergoing total abdominal hysterectomy for secondary postpartum hemorrhage please see operative report for full details she was admitted to the icu postoperatively for close monitoring she was transfered out of the icu on post operative day and had an uneventful post operative course social work followed her during her hospital stay she was discharged on post operative day in stable condition she was transfused a total of units of rbc units of ffp and pack platelets medications on admission prenatal vitamins discharge medications docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills ferrous sulfate mg mg iron tablet sig one tablet po bid times a day disp tablet s refills oxycodone mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills motrin mg tablet sig one tablet po every six hours as needed for pain disp tablet s refills discharge disposition home discharge diagnosis secondary postpartum hemorrhage vaginal yeast infection discharge condition stable discharge instructions call your doctor for fever severe abdominal pain difficulty urinating vaginal bleeding requiring pad hr abnormal vaginal discharge redness or drainage from incision nausea vomiting where you are unable to keep down fluids food or your medication general instructions take your medications as prescribed do not drive while taking narcotics no strenuous activity nothing in the vagina no tampons no douching no sex no heavy lifting of objects lbs for weeks you may eat a regular diet incision care you may shower and allow soapy water to run over incision no scrubbing of incision no bath tubs for weeks if you have steri strips leave them on they will fall off on their own or be removed during your followup visit if you have staples they will be removed at your follow up visit followup instructions please call your doctor to make a follow up appointment for staple removal days after your surgery md,"{
""Diagnoses"": [""Lochia"", ""Major surgical or invasive procedure"", ""Total abdominal hysterectomy"", ""Blood transfusion"", ""History of present illness"", ""SVD""],
""Medications"": [""Tylenol"", ""Morphine"", ""N/V"", ""Shellfish"", ""Lap chole"", ""Cyst removal"", ""Wrist removal of lesion from R ear"", ""OB"", ""Fibroid uterus""]
}"
15290,admission date discharge date date of birth sex m service history of present illness the patient is a healthy male who presented to the hospital on with sudden onset of epigastric pain after eating pie the pain persisted through and increased in severity which sought him to treat medical attention he noted a fever of and was referred to the emergency department for workup of gallstone pancreatitis the patient had increased bilirubin which was also concerning for cholangitis with recent fever on physical examination at presentation the patient was middle aged and in mild distress pupils are equal round and reactive to light and accommodation oropharynx is clear scleral icterus was appreciated lungs were clear to auscultation bilaterally heart was regular rate and rhythm there was some epigastric tenderness no rebound no guarding palpable dorsalis pedis pulses were noted no peripheral edema rectal was guaiac negative and no masses the patient does not smoke does not take alcohol has a family history of cholelithiasis allergies no known drug allergies medications protonix occasionally past medical history gastroesophageal reflux disease past surgical history noncontributory admission studies on admission he had right upper quadrant ultrasound that showed numerous stones and mm common bile duct no gallbladder wall thickening admission laboratory white count hematocrit platelets glucose of arterial blood gas was for co for oxygen for bicarb and for base deficit with a lactate of alt was ast amylase was alkaline phosphatase was t bili lipase was assessment the patient is a year old male with gallstone pancreatitis and cholangitis the patient was admitted to the intensive care unit per dr endoscopic retrograde cholangiopancreatography was ordered aggressive intravenous fluids were ordered the patient was npo nasogastric tube was placed if the patient vomited and the patient was on intravenous unasyn the patient was admitted to the intensive care unit and quieted down with pain control his base deficit was reversed with aggressive intravenous fluid therapy the patient was stabilized and on hospital day number two he was further stabilized he underwent an endoscopic retrograde cholangiopancreatography he had an increased o requirement on postoperative day number two his white blood cell count dropped to from admission of the patient was placed on maintenance fluid on hospital day number three the patient was transferred out to the floor and had no events overnight his temperature max that day was his foley was discontinued discharge planning was begun however on it was decided that it would be appropriate for the patient to undergo a laparoscopic cholecystectomy with intraoperative cholangiogram as he was status post endoscopic retrograde cholangiopancreatography with biliary tree drainage please see operative dictation for laparoscopic cholecystectomy the patient had a normal postoperative course on postoperatively day number one his abdomen was soft nontender benign on postoperative day number two the patient was improved and it was decided that the patient met criteria for discharge and was discharged in stable condition of note i have had no clinical contacts with this patient and have dictated this summary from the chart that was found in the medical records discharge diagnoses gallstone pancreatitis choledocholithiasis status post cholangitis status post endoscopic retrograde cholangiopancreatography status post laparoscopic cholecystectomy with intraoperative cholangiogram discharge condition stable m d dictated by medquist d t job,"{
""Diagnoses"": [""gallstone pancreatitis"", ""cholangitis""],
""Medications"": [""protonix""]
}"
7497,admission date discharge date service med history of present illness the patient is an year old man who fell down steps on stairs at home witnessed by his wife was found down the steps unresponsive bleeding profusely from nose as well as his right eye he was cold he was found to be gcs of in field he was intubated brought into emergency room past medical history parkinson s disease urinary incontinence pacemaker history of meningioma resection dementia allergies no known drug allergies medications not available physical examination upon presentation to the emergency room the patient is intubated sedated with pulse of and blood pressure of oxygen saturations percent heent his pupils were fixed and dilated bilaterally he had a large hematoma and bleeding from his right eye socket as well as profuse bleeding from both nostrils his neck was in c collar chest clear to auscultation bilaterally abdomen soft and nondistended rectal guaiac negative with decreased tone extremities well perfused with no deformities neurological she was unresponsive with extension to a pain stimuli laboratory data cbc white blood cell count of hematocrit of platelets of pt ptt inr differential sodium potassium chloride bicarb creatinine amylase lipase of he was positive for blood ct of head showed missing bone on the right parietal region replaced with a mesh large subarachnoid hemorrhage and subdural hematoma with partially obliterated lateral ventricle sphenoid bone fracture with sphenoid and ethmoid sinuses filled with blood occipital fracture c spine was negative ct chest negative ct abdomen evidence of previous surgery partial colectomy no acute process hospital course the patient was evaluated by ophthalmology service who felt that this time although the patient had retrobulbar hematoma he did not need any surgical intervention the neurosurgical service evaluated the patient and concluded that his chance for any kind of meaningful recovery are minimal and his chance of overall any kind of recovery is very minimal as well given his injury the patient was brought to intensive care unit but his coagulopathy was ffp cryoprecipitate his eye was examined by ophthalmology service and covered with the gauze his nasal bleed was controlled with foley which was placed and the balloon injected on the pharynx as well as hemostatic gauze he had peripheral intravenous placed at the same time a discussion was undertaken with the family by senior surgical resident and neurosurgical service and given the patient s extensive injuries as well as what the family stated were the patient s wishes that the patient was made dnr dni and later made comfort measures only fluid replacement was stopped and the patient expired in a matter of hours disposition the case was phoned in to the medical examiner who accepted the case dictated by medquist d t job,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""service med history of present illness"", ""Parkinson's disease"", ""urinary incontinence"", ""meningioma resection"", ""dementia""],
""Medications"": [""intubated"", ""sedated"", ""pulse"", ""blood pressure"", ""oxygen saturations"", ""hematoma"", ""bleeding"", ""neck collar"", ""chest clear"", ""abdomen soft"", ""rectal guaiac negative"", ""decreased tone"", ""neurological"", ""pain stimuli""]
}"
30643,unit no admission date discharge date date of birth sex f service nb history baby girl was born weighing grams and was the product of a and weeks gestation pregnancy born to a year old g p now mother prenatal screens were as follows blood type a positive antibody negative rpr nonreactive rubella immune hbsag negative gbs unknown this pregnancy was complicated by cholestasis of pregnancy irretractable pruritus and hypothyroidism the mother was treated with betamethasone days prior to delivery this infant was born by scheduled c section because of maternal issues she had apgar scores of and at and minutes she voided and passed meconium in the delivery room and was taken to the nicu for further management of prematurity family history additional maternal history includes a history of crohn disease which is treated with imuran and pentasa and type diabetic treated with an insulin pump there is also has histo ry of migraines and gerd with history of h pylori treated with triple therapy raynaud syndrome with retinal detachment treated with surgical buckle repair in eye and pneumopexy in the other eye mom was also week premature infant at birth maternal medications included imuran pentasa insulin nephrocaps iron vitamin c cholestyramine klonopin marinol social history mom denies any illicit drug use she completed year of pediatric residency and is a graduate of in medical school dad is a fourth year medical student at bu parents are married measures at birth birth weight of grams which is th percentile head circumference of cm which is th percentile length of cm which is th to th percentile physical exam at discharge active alert female infant heent anterior fontanelle soft and flat intact palate normal faces bilateral red reflux present supple neck chest breath sounds clear and equal bilaterally with slight retraction comfortable respiratory effort on room air cardiovascular normal s s no murmur pink and well perfused normal pulses abdomen soft and round with active bowel sounds cord dry patent anus no masses gu normal female genitalia musculoskeletal straight spine with no sacral dimple hips intact moves all extremities well good tone neuro active and alert normal cry normal reflexes discharge weight grams length of cm and head circumference of cm done on the day of discharge summary of hospital course by systems respiratory the infant has remained in room air since admission to the nicu with stable oxygen saturations and no apnea or bradycardic episodes she has not required any methylxanthine therapy cardiovascular she has maintained cardiovascular stability since birth with normal blood pressures heart rates and no audible murmurs fluids electrolytes and nutrition the infant was started on p o ad lib feedings on the newborn day she never required any iv fluid her dextrosticks sticks have remained stable she is presently feeding ad lib p o of breast milk or cal per ounce and taking at least ml kg day plus breast feeding she is voiding and stooling normally stools have been heme negative gi she had a peak bilirubin level of on bilirubin on was she has not required phototherapy hematology no blood typing has been done on this infant the hematocrit at birth was and platelet count of infectious disease cbc and blood culture were screened on admission to the nicu the cbc was unremarkable the blood culture remained negative no antibiotics were given neurology the infant has maintained a normal neurologic exam for gestation age sensory audiology a hearing screen was performed with automated auditory brainstem responses and the infant passed in both ears ophthalmology screening ophthalmologic exams for rop are not indicated of note father with a history of macular degeneration at a young age an outpatient assessment for is recommended psychosocial family is active and involved in the infant s care condition at discharge good discharge disposition home with the parents name of primary pediatrician m d pediatrics phone recommendations ad lib p o feedings by breast or supplementing with enfamil calories ounce medications none during her nicu stay however if feedings are eventually provided predominantly by breast milk we recommend iron and vitamin d supplementation 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 international units which may be provided as multivitamin preparation daily until months corrected age car seat position screening this infant was screened in an upright position while in the car seat and the infant passed the screening a state newborn screen was sent on day of life on and results are pending immunizations received the infant received hepatitis b vaccine on the infant does not qualify for synagis per the most current screening with the family prior to discharge immunizations recommended synagis rsv prophylaxis should be considered from through for infants who meet any of the following criteria a born less than weeks gestation b born between and weeks with of the following either daycare during rsv season smoker in the household neuromuscular disease airway abnormalities or school age siblings c chronic lung disease d hemodynamically significant congenital heart disease influenza immunizations as recommended annually in the fall for all infants once they reach months of age before this age and for the first months of 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 follow up appointment is recommended with pediatrician within days of discharge from the nicu vna referral has been made with care group vna discharge diagnosis prematurity born at and weeks gestation now and weeks post conceptual age infant of a diabetic mother sepsis ruled out dictated by medquist d t job cc,"{
""Diagnoses"": [""Cholestasis of pregnancy"", ""Pruritus"", ""Hypothyroidism"", ""Prematurity"", ""Apgar scores of "", ""Maternal issues""],
""Medications"": [""Betamethasone"", ""Imuran"", ""Pentasa"", ""Insulin pump"", ""Triple therapy"", ""Surgical buckle repair"", ""Pneumopexy""]
}"
15211,unit no admission date discharge date date of birth sex f service neonatology please note this infant will go by the last name of graves post discharge history this is a weeks gestational age infant admitted for prematurity maternal history thirty three year old g p woman with past obstetric history notable for spontaneous vaginal deliveries x tab x sab x her past medical history was notable for dvt with pregnancy in she was previously on lovenox but did not take heparin during current pregnancy prenatal screens blood type a positive antibody negative hepatitis b surface antigen negative rpr nr rubella immune gbs unknown antenatal history for ega weeks at delivery on at p m pregnancy was uncomplicated the full fetal survey was normal spontaneous onset of labor led to c section for low lying placenta there was no intrapartum fever or other clinical evidence of chorioamnionitis rupture of membranes occurred at delivery an d yielded clear amniotic fluid intrapartum antibacterial prophylaxis was not administered delivery infant was vigorous at delivery orally and nasally bulb suctioned dried subsequently and in no distress in room air apgars were at minute and at minutes physical examination at discharge weight grams length cm head circumference cm the baby is and comfortable in room air anterior fontanel open and flat cleft not present red reflex present bilaterally heart regular rate and rhythm no murmur strong femoral pulses lungs clear to auscultation no retractions abdomen soft and benign nondistended anus patent genitalia normal external genitalia for a female back straight no hips stable no clicks neuro alert active symmetric tone strong suck skin intact summary of hospital course by systems respiratory the baby was always in room air she never had any episodes of apnea of prematurity upon discharge she was breathing comfortably in room air at rates of s s cardiovascular she has had no murmur she has been well perfused with stable blood pressures fluid electrolytes and nutrition ad lib feeds were started on day of life blood sugars remained stable calories were advanced to neosure cal oz over the course of the hospitalization prior to discharge she was taking all oral feedings for about hours she was discharged home on neosure calories per ounce weight on discharge was grams gi the baby was on phototherapy for about days with a peak total bilirubin of on day of life hematology the baby was never transfused hematocrit at birth was follow up hematocrit prior to discharge was on infectious disease cbc and blood culture were sent on day of life cbc was reassuring blood culture has been no growth to date the baby was never started on antibiotics neurology exam has been appropriate throughout hospitalization sensory hearing screening was performed with automated auditory brainstem responses the baby passed in both ears ophthalmology not examined because the patient s gestation was weeks above our screening limit condition at discharge stable discharge disposition to home name of primary pediatrician the pediatrician dr will be at health center phone number fax number is care recommendations feedings feeds at discharge include neosure calories per ounce ad lib medications none formula will provide mg k day of iron which is adequate for her gestational age and weight no additional supplementation is necessary iron and vitamin d supplementation iron supplementation is recommended for preterm and low birth weight infants until months of corrected age all infants fed predominantly breast milk should receive vitamin d supplementation at international units may be provided as multivitamin preparati on daily until months corrected age car seat position screening the baby passed the car seat position screening prior to discharge state newborn screening within normal limits immunizations received the baby received her hepatitis b vaccine on immunizations recommended synagis rsv prophylaxis should be considered from through for infants who meet any of the following criteria born at less than weeks born between weeks with of the following daycare during rsv season a smoker in the household neuromuscular disease airway abnormalities or school age siblings with chronic lung disease or 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 st months of the child s life immunization against influenza is recommended for household contacts and out of home caregivers this infant has not received 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 scheduled recommended follow up with pediatrician is scheduled for discharge diagnosis late preterm infant hyperbilirubinemia rule out sepsis no antibiotics dictated by medquist d t job,"{
""Diagnoses"": [""prematurity"", ""maternal history of spontaneous vaginal deliveries"", ""history of DVT with pregnancy"", ""notable for spontaneous vaginal deliveries""],
""Medications"": [""Lovenox"", ""heparin""]
}"
9857,admission date discharge date date of birth sex m service csurg allergies patient recorded as having no known allergies to drugs attending chief complaint unstable angina cad major surgical or invasive procedure cabg x lima to lad svg to om rca pda history of present illness mr is a year old male with exertional angina x years which is relieved with rest he had a routine stress in the ett showed mm st depression in inferior and lateral leads with moderated fixd inferior wall defect ef was he was initially reluctant to undergo surgery but has had increasing amounts of chest pain episodes cardiac cath on showed proximal rca mid rca r post lat lm proximal lad distal lad proximal lcx and om past medical history unstable angina cad htn hypercholesterolemia gerd social history retired lithographer pack year history quit years ago drinks day beer wine lives with wife in ma family history dad died at age of mi physical exam on discharge temp hr bp r ra nad rrr incis no soi cta b s nt nd bs le incis c d i no soi brief hospital course mr was taken to the or for his cabg x lima to lad svg to om rca pda total cardiopulmonary bypass time was minutes total cross clamp time was minutes please see dr operative note for greater detail he was transferred to the csru in stable condition on pod he was extubated but was immediately reintubated because of a stridorous airway hewas also hypotensive and levofed was started he was re extubated on pod without incident on pod his chest tubes were removed and he was transferred to the floor while on the floor mr was evaluated by physical therapy and with inpatient treatments they cleared him to go home by pod his pacing wires were also removed on pod on pod his hematocrit was noted to be down from the prior level of mr however was hemodynamically normal and asymptomatic his iron supplements were continued a repeat hematocrit on pod was again mr remained hemodynamically normal asymptomatic and no oozing from his incisions at the time of discharge he was cleared by physical therapy tolerating a regular diet voiding without difficulty and had good pain control he was discharged home in good condition medications on admission lopressor mg qid norvasc mg daily zocor mg daily asa mg daily lisinopril mg daily rolaids discharge medications furosemide mg tablet sig one tablet po q h every hours for weeks potassium chloride meq capsule sustained release sig two capsule sustained release po q h every hours for weeks docusate sodium mg capsule sig one capsule po bid times a day aspirin mg tablet delayed release e c sig one tablet delayed release e c po qd once a day oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain clopidogrel bisulfate mg tablet sig one tablet po qd once a day simvastatin mg tablet sig two tablet po qd once a day ranitidine hcl mg tablet sig one tablet po bid times a day polysaccharide iron complex mg capsule sig one capsule po qd once a day ascorbic acid mg tablet sig one tablet po bid times a day metoprolol tartrate mg tablet sig tablet po bid times a day discharge disposition home with service facility discharge diagnosis status post cabg x hypertension hypercholesterolemia discharge condition good discharge instructions if you experience any chest pain difficulty breathing nausea vomiting or fevers chills please seek medical attention followup instructions please call dr for a follow up appointment in weeks please follow up with your pcp in weeks,"{
""Diagnoses"": [""unstable angina"", ""CAD"", ""HTN"", ""hypercholesterolemia"", ""GERD""],
""Medications"": [""aspirin"", ""clopidogrel"", ""losartan"", ""atorvastatin"", ""metoprolol""]
}"
5374,admission date discharge date date of birth sex f service nb history baby girl was the gram product of a and weeks gestation born to a year old g p mother prenatal screens o positive antibody negative hepatitis surface antigen negative rubella immune rpr nonreactive gbs negative this pregnancy was notable for intrauterine growth restriction and spontaneous onset of labor the infant delivered vaginally with apgars of and she was noted to have dysmorphic features and developed stridor soon after birth on arrival to the newborn intensive care unit the infant with audible stridor and moderate subcostal retractions physical examination weight grams less than th percentile length cm less than th percentile head circumference cm less than th percentile iugr infant with obvious dysmorphic features large long filtrum depressed nasal bridge small chin short stubby hands and feet bilateral single palmar crease and two phalanx each finger anterior fontanel at level sutures normal intact palate neck supple eyes with bilateral red reflex present continues audible stridor even at rest bilateral moderate subcostal retractions with conducted sounds cardiovascular pink well perfused s s normal no murmurs femorals abdomen soft nondistended no hepatosplenomegaly genitourinary normal female genitalia anus patent but anteriorly displaced neurologic tone normal moving all extremities spine with sacral dimple the remainder is normal hips stable summary of hospital course by systems respiratory the baby was admitted to the newborn intensive care unit for observation and management of her iugr status and her respiratory stridor she has remained stable in room air throughout her hospital course and has not required any methylxanthine therapy for apnea bradycardia orl evaluated the infant and discovered severe laryngomalacia plan is to have surgery to correct this issue at on cardiovascular the infant has an audible murmur an echocardiogram was obtained revealing patent foramen ovale small anterior muscular ventricular septal defect small patent ductus arteriosus cardiology was consulted and recommended continued care fluids electrolytes and nutrition birth weight was grams she is currently grams she was initially started on cc per kg per day of d w enteral feedings were initiated on day of life the infant is on full enteral feedings requiring pg feeding she was evaluated by the feeding team at this week and it was recommended to continue offering po feeds every other feed knowing that the infant is at high risk for aspiration at this time plan is to reevaluate the infant following her surgery on thursday she is currently receiving cc per kg per day of breast milk calorie with beneprotein again an average to grams per day gastrointestinal peak bilirubin was on day of life of hematology hematocrit on admission was she has not required any blood transfusions infectious disease cbc and blood culture obtained on admission cbc was benign and blood cultures remained negative at hours at which time ampicillin and gentamycin were discontinued neurologic the infant has been appropriate for gestational age genetics genetics was consulted to evaluate this infant for dysmorphism a chromosome analysis was performed revealing normal xx fish was performed for chromosome and chromosome and those were normal genetics has seen the infant most recently on recommending a signature chip being sent off which has not yet been done audiology hearing screen has not yet been performed but should be done prior to discharge ophthalmology the infant was seen by ophthalmology to rule out ophthalmologic malformations she was seen by dr on to reveal no colobomas normal optic nerves and retina psychosocial the family lives on and are experiencing some financial strains due to housing in area they are interested and involved and loved their daughter condition on discharge stable discharge disposition to name of primary pediatrician dr telephone no care recommendations feeds at discharge she will be npo at the time of transfer to cc per kg per day of d w with of sodium chloride and meq of potassium chloride medications not applicable at the time of transfer but prior to transfer she was on no medications state newborn screens have been sent per protocol and have been within normal limits immunizations received the infant has not received any immunizations to date discharge diagnoses a week infant small for gestational age laryngomalacia dysmorphism patent ductus arteriosus muscular ventricular septal defect dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex f service neonatology addendum summary this is an addendum summary for baby girl to follow the previous surgery done on was born at and weeks gestation her nicu course since is as follows respiratory status on she had a supraglottoplasty for her laryngomalacia she continues to have stridor when agitated although she remains well saturated during those events at rest her respirations are comfortable lung sounds are clear and equal discharge was planned on but she was noted to have bradycardia with spits her total fluids were decreased to cc kg d changed to every hours feedings and she has remained without any events for more than hours cardiovascular she has remained normotensive throughout her nicu stay she continues to have a systolic ejection murmur due to a to mm muscular ventricular septal defect on examination her heart rate runs in the to range systolic blood pressures run from to and diastolic blood pressures run to she will need prophylaxis for subacute bacterial endocarditis for any surgical procedures fluids electrolytes and nutrition at the time of discharge her weight is grams her length is cm head circumference cm her feedings are at ml kg day of calorie per ounce of breast milk made with added neosure powder or neosure powder concentrated to calories per ounce and calories per ounce from corn oil she takes only a few ml p o and the rest is given by gastrostomy tube with feedings every hours on her electrolytes were sodium potassium chloride bicarbonate bun creatinine calcium gastrointestinal status a modified barium swallow study done on was remarkable for extremely abnormal oral phase of swallowing with almost no ability to suck with squeezing a large amount into the pharynx there was a discoordination of swallowing resulting in nasopharyngeal reflux there was no evidence of aspiration as a result of this study and her minimal p o intake an upper gastrointestinal study was done on which revealed normal anatomy on a peg gastrostomy tube was placed the insertion site is healing well there is no erythema or drainage from the site hematology hematocrit on was she has received no blood product transfusions during her nicu stay infectious disease she did receive intraoperative and postoperative routine antibiotics but there are no other active infectious disease issues neurology a head ultrasound on was normal sensory hearing screen was performed with automated auditory brain stem responses and the infant referred in both ears a follow up hearing test is scheduled for ophthalmology the eyes were examined on and revealed no coloboma normal optic nerve and normal retina follow up exam is recommended in months psychosocial the mother has been very involved in the infant s care throughout her nicu stay the father has been able to visit intermittently from the mother s own mother has been here with her for a large percentage of the time the infant s last name after discharge will be genetics has had several genetics tests done due to her growth restriction and dysmorphic features she does have a normal karyotype of xx and she had a fish chromosome study for trisomy and which were both normal she also had a fish for q for cardiofacial syndrome which was normal the most recent genetics recommendation are that her physical findings are most consistent with syndrome at this time the parents have declined testing for that specific syndrome but are aware of its features and prognosis her primary pediatric care provider will be dr telephone number recommendations feedings of calorie per ounce with calories to by neosure and calories from corn oil at approximately ml per kg per day feedings are given every hours infant may attempt oral feedings but feedings will mostly be given by gastrostomy tube medications ferrous sulfate mg per ml ml pg daily goldline baby vitamins m pg daily the infant passed a car seat position screening test last newborn screen was sent on and was within normal limits the infant has received her first hepatitis b vaccine on 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 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 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 follow up she will have an audiology test at audiology department on at p m cape and island early intervention program telephone number home care visiting nurse telephone number her supplies for her gastrostomy tube will come from telephone number gastrointestinal follow up with dr telephone number appointment is on at a m orl otorhinolaryngoscopy dr telephone number appointment is on at p m genetics dr telephone number the parents are to call to plan an appointment to months after discharge cardiology cardiology clinic at parents to call to make an appointment months after discharge discharge diagnoses term female infant status post intrauterine growth restriction failure to thrive laryngomalacia dysfunctional suck swallow reflex rule out genetic syndrome status post gastrostomy tube placement ventriculoseptal defect muscular anemia referred bilateral hearing examination dictated by medquist d t job,"{
""Diagnoses"": [""Intrauterine growth restriction"", ""Spontaneous onset of labor"", ""Dysmorphic features"", ""Stridor"", ""Infant with obvious dysmorphic features"", ""Obvious dysmorphic features"", ""Large long filtrum"", ""Depressed nasal bridge"", ""Small chin"", ""Short stubby hands and feet"", ""Bilateral single palmar crease"", ""Two phalanx each finger"", ""Anterior fontanel at level sutures"", ""Normal intact palate"", ""Supple eyes with bilateral red reflex present"", ""Bilateral moderate subcostal retractions with conducted sounds""],
""Medications"": []
}"
30294,admission date discharge date date of birth sex f service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint obstructive jaundice major surgical or invasive procedure successful placement of an fr internal external biliary drain through an anomalous r biliary duct ptbd placed in the left biliary system internal external drain right ptbd removed ir celiac plexus block exploratory laparotomy history of present illness this is a year old female with a history of t n pancreatc adenocacinoma s p whipple by dr in she is s p chemo and radiation and recently had asecond round of chemo she presents with obstructive jaundice she is s p ercp on but they were not able to cannulate her duct past medical history pancreatic ca s p chemo and radiation hyperlipid asthma smoker chronic cough and mild dyspnea psh bso ankle social history smoked two packs per day quit in no etoh former waitress currently not working family history there is no familial history of pancreatic cancer physical exam avss gen tired a o x normal communication heent slight scleral icterus cv rrr chest diminished at bases crackles heared at bases productive cough abd soft tender to epigastric minimally distended bs previous surgical scar noted ext pulses bilat 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 alt ast alkphos amylase totbili dirbili indbili am blood alt ast alkphos amylase totbili am blood lipase am blood lipase am blood albumin calcium phos mg reason please place ptc and stent impression cholangiogram demonstrates moderate dilation of the intrahepatic biliary ducts as well as partial obstruction at the level of the confluence of an anomalous right bile duct and the right and left hepatic ducts the exact appearance of the obstuction may be better delineated by pull back cholangiography after the ducts have decompressed in days successful placement of an french internal external biliary drain through an anomalous right biliary duct cta abd w w o c recons am impression heterogeneous pancreatic mass extending into the root of the mesentery as above compatible with recurrent pancreatic adenocarcinoma ascites prominent enhancing mesenteric lymph nodes as above tiny bilateral pleural effusions with associated airspace disease likely reflecting atelectasis ir biliary drain biliary obstruction appears to be secondary to narrowed encased roux loop which we were unable to cross distally to stent successful placement of fr left internal external biliary drain with the tip positioned within the roux loop connected to a bag for external drainage this should decompress the left and right bile ducts as well as the obstructed roux loop the previously placed biliary drain through the right anomalous biliary duct was removed and the tract was embolized with gelfoam brief hospital course this is a year old female with recurrence of pancreatic tumor who presented with abdominal and back pain and obstructive jaundice ercp was unsuccessful in cannulating her duct to relieve the obstruction she went to ir for a ptc and had dilated intrahepatic ducts and successful placement of an fr internal external biliary drain through an anomalous r biliary duct a ct showed recurrent pancreatic cancer she then went to ir for stent placement on however the biliary obstruction appears to be secondary to narrowed encased roux loop which we were unable to cross distally to stent successful placement of fr left internal external biliary drain with the tip positioned within the roux loop connected to a bag for external drainage this should decompress the left and right bile ducts as well as the obstructed roux loop the previously placed biliary drain through the right anomalous biliary duct was removed and the tract was embolized with gelfoam chronic pain was consulted for a celiac plexus block she went for this procedure on and had some expectant relief she developed clear evidence of precipitace recurrent disease she has a large at the root of the root of the mesentery on ct scan it is obstructing her full pancreaticobiliary efferent limb rendering her jaundice and bilirubin rising each day she has a mild septic picture and now comes to the operating room on for an attempt to decompress this obstructive pancreaticobiliary rim this is a last ditch effort change in the patient but clear aggressive recurrent pancreatic cancer with a hope at palliation upon opening she had ischemic infarcted small bowel her family was contact and her abdomen was closed she was made cmo and passed away early the next morning medications on admission haldol mg q prn megestrol mg omeprazole mg oxycodone oxycontin paxil mg qd senna prochlorperazine mg prn discharge medications none discharge disposition expired discharge diagnosis pancreatic cancer recurrence obstructive jaundice chronic pain infarcted small bowel death discharge condition death discharge instructions none followup instructions none completed by,"{
""Diagnoses"": [""Obstructive jaundice"", ""Pancreatic adenocarcinoma"", ""Chemotherapy-induced jaundice""],
""Medications"": [""Chemotherapy"", ""Radiation therapy"", ""Erbitux""]
}"
13455,admission date discharge date date of birth sex f service chief complaint nausea vomiting diarrhea history of present illness this is a year old female with a three day history of diarrhea on the day of admission the patient ha four to five bowel movements and weakness her son called ems the patient was being treated for cellulitis at her left antecubital dialysis graft site she was on an antibiotic which name she does not recall for one week the patient began experiencing nausea vomiting diarrhea for three to four days after started antibiotics which is three days prior to admission she denied blood in her vomit no fever or chills patient has reported intermittent chest pain unlike her last mi in she has shortness of breath with walking at baseline no sick contacts raw meat or egg ingestion patient had dialysis today with profound weakness following dialysis the patient has a history of cva with left sided residual weakness also was admitted in status post myocardial infarction past medical history hypertension diabetes mellitus hypercholesterolemia coronary artery disease status post myocardial infarction with stent to lad paroxysmal atrial fibrillation end stage renal disease on hemodialysis patient has port a cath and av fistula placed in her arm hypertension history of cva and patient has left sided weakness cataract medications on admission lisinopril mg p o q d amiodarone mg p o q d elavil q h s p r n lipitor mg p o q d aspirin p o q d prilosec mg p o q d amlodipine mg p o q d lopressor mg p o b i d dulcolax p r n insulin nph q am q pm phos lo three tabs with meals colace mg p o b i d iron sulfate mg p o q d unknown antibiotic for her cellulitis allergies eggs tetracycline iv contrast social history negative for tobacco and alcohol patient has two children and lives with her husband and physical examination on admission temperature f blood pressure heart rate respiratory rate o saturation on room air in general obese female in no apparent distress head eyes ears nose and throat pupils are equal round and reactive to light extraocular muscles are intact mucous membranes dry neck carotid bruits bilaterally heart normal s s there is a ii vi systolic ejection murmur regular rate and rhythm patient has quinton catheter respiratory clear to auscultation bilaterally no rales no wheezes abdomen diffusely tender soft with normoactive bowel sounds neuro there is lower extremity edema bilaterally no clubbing or cyanosis left upper extremity fistula site evident plus redness and warm plus bruit and thrill edema neuro cranial nerves ii through xii intact strength bilaterally laboratory data on admission showed a sodium of potassium chloride bicarbonate bun creatinine glucose of the white count was hemoglobin hematocrit platelets neutrophils lymphocytes monocytes eosinophils alt was ast was amylase lipase total bilirubin was ecg on admission was unchanged from her prior hospitalization hospital course patient was initially admitted to the medicine service her hospital course will be reviewed by system infectious disease patient was started on a two week course of vancomycin for cellulitis of her left upper extremity her vancomycin was dosed based on levels she completed her two week course on cardiovascular a coronary artery disease patient is status post myocardial infarction in with subsequently cardiac catheterization and lad stent on the patient developed substernal chest pain and hemodialysis an ecg was done which disclosed significant changes there were st segment elevations in v through v st segment depressions in ii iii and avf the patient was emergently taken to the cath lab for intervention resting hemodynamics demonstrated elevated right and left sided filling pressures there was a v wave dominance in the pulmonary capillary wedge pressure tracing saturation was elevated with a difference in the svc to ivc and saturations all consistent with known av fistula in the left arm there is severe systemic arterial hypertension and moderate to moderate pulmonary artery hypertension selective coronary angiography of the right dominant circulation demonstrated a proximal lad culprit lesion the lad had a instant restenosis with distal timi ii flow successful ptca of the proximal lad was performed using a cutting balloon there was residual stenosis normal flow and no apparent dissection on the following day the patient underwent brachytherapy she was transferred to the ccu for management following her catheterization she was administered aspirin plavix beta blocker and statin b pump patient has hypertension she continued on beta blocker and was administered norvasc and ace inhibitor a tte done on following her mi showed an ejection fraction of there was mild symmetric lvh c rhythm patient has a history of paroxysmal atrial fibrillation she continued on her amiodarone and beta blocker she was monitored on telemetry she is currently being restarted on her coumadin with lovenox as a bridge to coumadin neurologic patient has a history of cva in and she has left sided residual weakness following her cardiac catheterization the family noted that the patient was demonstrating mental status changes a mri done on disclosed a large subacute infarct involving the left parietal lobe the stroke was believed to be initially ischemia with hemorrhagic conversion the patient was seen by the stroke service who evaluated her and ultimately recommended that she be administered coumadin due to her history of paroxysmal atrial fibrillation following her stroke the patient had demonstrated swallowing deficits on the swallow evaluation in addition she showed some right sided weakness which has improved over this admission a carotid duplex ultrasound disclosed to laminal stenosis at the origin of the right internal carotid artery the patient has been started on coumadin with lovenox as a bridge to coumadin due to her history of paroxysmal atrial fibrillation renal patient has end stage renal disease secondary to diabetes mellitus complicated by contrast nephropathy she undergoes hemodialysis three times a week she is administered phos lo three tablets t i d with meals her nephrologist is dr a fistulogram done on demonstrated a patent av fistula fluids nutrition and electrolytes gi as noted above the patient underwent a swallow evaluation on she failed this evaluation and it was recommended that she be npo with tube feeds patient initially received tube feeds and medications per ng tube on a peg was placed patient is currently being administered tube feeds her goal tube feeds are nepro at cc an hour plus grams of promod per day this will give her kilocalories and grams of protein per day the nutrition service has suggested that the patient be administered nephrocaps and her phosphate should be monitored in addition the patient has chronic constipation a colonoscopy in the past demonstrated melanosis coli the patient has continued on her bowel regimen with senna colace and lactulose p r n endocrine patient has type diabetes mellitus her fingersticks were monitored q i d she was administered regular insulin sliding scale and fixed dose insulin units nph q am units nph q pm vasculature on following the patient s cardiac catheterization it was noted that she had a right femoral artery pseudoaneurysm on the patient underwent thrombin injection to that site on a repeat ultrasound was done which confirmed thrombosis of the right groin and pseudoaneurysm the patient also had doppler ultrasound of the lower extremities done during this hospital which disclosed no evidence of deep venous thrombosis code status the patient is full code discharge diagnoses myocardial infarction status post cardiac catheterization and intervention with balloon thrombectomy and brachytherapy to instant restenosis of lad stent end stage renal disease secondary to diabetic nephropathy hypercholesterolemia hypertension diabetes mellitus type cerebrovascular accident condition on discharge fair discharge medications zestril mg p o q d lovenox mg subcu b i d coumadin mg p o q h s plavix mg p o q d aspirin mg p o q d lactulose cc t i d p r n nephrocaps one tab p o q d prevacid mg per peg q d metoprolol mg p o b i d norvasc mg p o q d colace mg p o b i d regular insulin sliding scale insulin units nph q am units nph q pm senna one tablet b i d p r n tylenol p r n phos lo three tabs t i d with meals atorvastatin mg p o q d amiodarone mg p o q d discharge instructions patient is being discharged on lovenox and coumadin when her coumadin reaches therapeutic range of to the lovenox should be discontinued patient is to undergo dialysis three times per week her nephrologist is dr patient should follow up with her cardiologist and with her primary care physician m d dictated by medquist d t job,"{
""Diagnoses"": [""nausea"", ""vomiting"", ""diarrhea"", ""history of present illness"", ""cellulitis"", ""antibiotic""],
""Medications"": [""antibiotic""]
}"
6918,admission date discharge date service med chief complaint hemoptysis history of present illness patient is an year old male recently diagnosed with squamous cell carcinoma of the lung presents from an outside hospital with shortness of breath hemoptysis and positive post obstructive pneumonia the patient became increasingly short of breath on with complaints of coughing he experienced hemoptysis of approximately cc of bright red blood hemoptysis resolved but shortness of breath and cough continued at outside hospital chest x ray is consistent with right upper lobe collapse patient currently without complaints no fevers chills nausea or vomiting positive for dyspnea on exertion no chest pain or palpitations the patient was transferred to for possible interventional pulmonary procedure of bronchial stent past medical history newly diagnosed endobronchial cancer moderately differentiated invasive squamous cell carcinoma copd cad status post mi paroxysmal atrial fibrillation tia status post appendectomy allergies no known drug allergies medications asa darvocet lasix celebrex glucosamine transferred on solu medrol iv social history lives with wife one pack per day smoker x years quit two months ago drinks approximately drinks per week physical examination afebrile at heart rate irregular breathing at and blood pressure percent on percent ventimask alert and oriented times three in no acute distress diffuse coarse breath sounds with decreased breath sounds in the right upper lobe no egophony irregularly irregular no murmurs rubs or gallops abdomen is soft nontender nondistended normoactive bowel sounds no hepatosplenomegaly on skin exam there is frequent seborrheic keratoses and actinic keratoses on shin and along ear with multiple firm blue black nodules no edema positive for clubbing and cyanosis hospital course patient was admitted to general medicine with post obstructive pneumonia hemoptysis secondary to endobronchial invasive cancer on the floor the patient continued to desat and experienced cc of bright red blood patient was transferred to the micu and stabilized patient went to bronchoscopy on left trachea within normal limits two segmental level on the right right main stem bronchus approximately percent obstructive by fungating tumor emanating from the right upper lobe and tumor was excised and destroyed with microdebrider apc and forceps patent right middle lobe and right lower lobe unable to open right upper lobe a x stent was placed patient tolerated the procedure well and continued to be cared for in the micu hematocrit remains stable and patient was weaned down on o the patient was transferred to the general medicine floor on where he underwent physical therapy and was cleared by physical therapy to go home on home o with exertion the patient is to continue on seven day course of antibiotics of levofloxacin and metronidazole as well as prednisone taper given prescription for albuterol prn as well as home o at this time given atrial fibrillation and hemoptysis anticoagulation agents were held it could be restarted once hematocrit remains stable at time of discharge hematocrit the patient had defervesced and white count had returned to no other laboratory values were abnormal at the time of dictation pathology of excised tumor is still pending in discussion with interventional pulmonary patient was presented at tumor board for possible adjuvant chemotherapy and resection at a later date patient will be followed up in interventional pulmonary to address these issues follow up the patient is to followup with pcp in one week for hematocrit check as well as adjustment of duration of antibiotic therapy if patient does not defervesce or exhibit reobstruction pneumonia patient is to be seen by his primary pulmonologist in weeks dr at this time interventional pulmonary does not feel need for high dosed steroids and will initiate steroid taper follow up with dr at interventional pulmonology will contact patient in the near future for further possible intervention and or chemo adjuvant therapy major surgical procedure bronchoscopy with tumor excision and stent placement of the right main stem bronchus discharge status the patient is discharged to home with home oxygen services and vna services discharge medications albuterol inhaler puffs q prn pantoprazole mg p o q d metronidazole mg p o t i d duration four days levofloxacin mg p o q d duration five days oxygen to be titrated for saturations percent with ambulation prednisone taper mg p o x days mg p o x days mg p o x days and mg p o x days discharge condition the patient is discharged home in satisfactory condition without evidence of further hemoptysis stable on home o md dictated by medquist d t job,"{
""Diagnoses"": [""Squamous cell carcinoma of the lung"", ""Post obstructive pneumonia"", ""Copd"", ""Cad"", ""Moderately differentiated invasive squamous cell carcinoma"", ""Endobronchial cancer""],
""Medications"": [""Asa"", ""Darvocet"", ""Lasix"", ""Celebrex"", ""Glucosamine"", ""Solu medrol"", ""IV""]
}"
88773,admission date discharge date date of birth sex f service cardiothoracic allergies imitrex ambien codeine oxycodone attending chief complaint tbm s p y stent placement and removal in s p stent placement and removal in r mainstem bronchus in with transient alleviation in symptoms major surgical or invasive procedure appendectomy in r knee arthroscopy in y stent placement rmb stent placement history of present illness f with h o tbm who has undergone stenting including y stent and rmb stent in and with transient alleviation in her respiratory symptoms she has met with dr in clinic and has agreed to a surgical intervention on the patient underwent a bronchoscopy right thoracotomy and tracheoplasty with thoracic tracheoplasty with mesh right main stem bronchus bronchus intermedius bronchoplasty with mesh and left main stem bronchus bronchoplasty with mesh past medical history hypercholesterolemia pulmonary emboli x and requiring chronic anticoagulation first was unprovoked treated with coumadin second occurred after coumadin was stopped but again unprovoked crohn s colitis hypothyroidism hashimoto s temporal arteritis dx clinically last year treated with prednisone and mtx social history she is a retired chemist lives with her wife she has kids and grandkids distant tob years ago does not drink and does not use any drugs family history her mother died at of breast cancer her father died at of heart attack her sister is and her brother is both are healthy she has a year old daughter and two sons age and she has three brothers with prostate cancer and one son with type diabetes physical exam at day of discharge ra nad a ox rrr ctab soft nt nd no c c e her right thoracotomy site appears c d i no significant erythema or fluctuance noted pertinent results admit hct discharge hct admit cr discharge cr cpk trend discharge inr cxr right lung base remains elevated due in part to small pleural effusion and atelectasis in the middle lobe brief hospital course the patient underwent a tracheobronchoplasty by dr on the patient was monitored in the sicu from with no significant events she then transferred to the floor on pm and was discharged from the floor on neuro the patient was then started back on her celexa once she was tolerating clears she remained alert and oriented for her entire hospital duration there were no significant events pain the patient s pain was controlled with an epidural initially which was ultimately transitioned to iv dilaudid then po narcotics her pain was well controlled with a po regimen cv she was placed on telemetry after her surgery she had no events resp the patient had no respiratory issues after surgery she was able to produce and clear her own secretions she was transitioned to room air she continued on her nebs her chest tube was transitioned to water seal and she did not develop any respiratory symptoms nor was there a ptx on cxr the chest tube was ultimately taken out and the patient did well she ambulated on room air without difficulties gi her diet was slowly transitioned to a regular diet which she tolerated well renal per labs she did have rhabdomyolosis secondary to prolonged positioning from her operation but her creatinine remained normal throughout her foley was discontinued after her epidural was discontinued and she voided without difficulties heme the patient started on her coumadin once she was able to tolerate clears at the time of discharge her inr was she will continue on her coumadin and follow up with her pcp will not leave with lovenox to bridge her coumadin per dr id she remained afebrile during her hospital course endo she was restarted on her levoxyl immediately after surgery she will taper her prednisone dose at home on discharge she will take mg of prednisone daily for three days and then stop in terms of her mtx she will not be on it until she follows up with her rheumatologist medications on admission benzonate citalopram clonazepam qhs folic acid levothyroxine lovastatin methotrexate qwk omeprazole prednisone warfarin five days two days discharge medications ipratropium bromide solution sig one neb inhalation every eight hours disp vials refills albuterol sulfate mg ml solution for nebulization sig one neb inhalation every eight hours disp nebs refills prednisone mg tablet sig half tablet po once a day x days then stop omeprazole mg tablet delayed release e c sig one tablet delayed release e c po once a day levothyroxine mcg tablet sig one tablet po daily daily coumadin mg tablet sig tablets po at bedtime take mg po and and check inr friday and follow up with dr regarding dose citalopram mg tablet sig one tablet po once a day clonazepam mg tablet rapid dissolve sig one tablet rapid dissolve po at bedtime as needed for insomnia be cautious while on narcotics for pain would avoid folic acid mg tablet sig one tablet po once a day lovastatin mg tablet sig one tablet po once a day calcium carbonate vitamin d mg mg unit tablet chewable sig one tablet chewable po twice a day colace mg capsule sig one capsule po twice a day dilaudid mg tablet sig tablets po every four hours as needed for pain disp tablet s refills home nebulizer equipment dx tracheobronchomalacia s p tracheoplasty discharge disposition home discharge diagnosis tracheobronchomalacia hx of pe hx of colitis hx of temporal arteritis hashimoto s thyroiditis hyperlipidemia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions call dr if you have fevers greater than chills shakes shortness of breath chest pain increasing amount of productive cough with difficult to manage secretions or any questions no driving while taking narcotics take stool softeners to avoid constipation while on narcotics take nebulizers as instructed no submerging in water x weeks but you may shower then remove right chest bandage and keep covered with bandaid until healed followup instructions follow up with dr in weeks with chest xray please call to get the exact appointment date time and location instruction remember to get your chest xray minutes prior to your follow up check you inr on friday early in the am and call dr to check on your coumadin dose for friday night and thereafter call if you have any problems with this completed by,"{
""Diagnoses"": [""cardiothoracic"", ""allergies"", ""imitrex"", ""ambien"", ""codeine"", ""oxycodone""],
""Medications"": [""stent placement and removal in s p stent placement and removal in r mainstem bronchus"", ""transient alleviation in symptoms"", ""major surgical or invasive procedure"", ""appendectomy"", ""r knee arthroscopy"", ""y stent placement"", ""rmb stent placement"", ""history of present illness"", ""f with h o tbm who has undergone stenting including y stent and rmb stent in and with transient alleviation in her respiratory symptoms"", ""she has met with dr in clinic and has agreed to a surgical intervention""]
}"
51485,admission date discharge date service medicine allergies no known allergies adverse drug reactions attending chief complaint nausea vomiting abdominal tenderness major surgical or invasive procedure ercp central venous line placement arterial line placement removal ercp for stent replacement ercp for stent replacement history of present illness the patient rpeorts that he symtpoms began yesterday when she began to experience nausea and had several episodes of vomiting she has also been noticing that he belly has been distended recently she complains of on and off diarrhea every five weeks or so but has not experienced any diarrhea this week the patient says that her abdomen hurts only when people push on it alone and undisturbed her abdomen is non tender the patient has no history of gallbladder or liver disease that she knows of she further denies any ruq pain she has not experienced and hematuria or dysuria per reports from the patient may not have been accurate in my interview there she was brought in with complaints of llq pain and jaundice at the patient received metoprolol iv mg zofran and liters of fluid in the emergency department a ct scan showed severe intra extrahepatic biliary dilatation severe pancreatic duct dilatation with pancreatic atrophy nodular enhancement at ampulla suggests possible malignancy distended gallbladder with wall edema and perihepatic ascites likely severe biliary dilatation stool distending the entire colon distended small bowel likely to the stool l spigelian hernia contains a colon loop and free fluid but no obstruction is seen at the level of the hernia and no bowel wall thickening avn of l femoral head again seen the emergency department had discussed with dr and arranged direct admit to surgical floor and possible ercp evaluation but then they noted that she was in afib rvr s also has mm in lead iii and st depressions in v worse since prior ekg has had a silent nstemi in past cardiology saw the patient and felt that negative stress from months ago made mi very unlikely the patient was given metoprolol both po and iv and a dose of zosyn on the floor the patient was tired but denied any specific abdominal pain she denies being nauseated she also denied feeling any palpitations past medical history hypertension cataracts with a recent iridectomy in hyperreflexic bladder degenerative arthritis of her neck and back and osteoporosis social history lives with her daughter ambulates at home with a cane no smoking or alcohol family history her family history is positive for a stroke in her brother otherwise it is noncontributory physical exam admission physical exam vs t bp hr rr on l general frail elderly woman in no acute distress heent nc at perrl eomi sclerae mildly icteric oropharynx clear neck supple no jvd heart s s no murmurs auscultated lungs cta bilaterally to anterior auscultation abdomen soft distended diffusely tender to palpation no masses or hsm no rebound guarding extremities wwp no edema peripheral pulses skin no rashes or lesions lymph no cervical lad neuro awake a ox cns iii xii grossly intact muscle strength throughout patellar reflexes labs see below discharge physical exam vs ra gen no acute distress heent perrl eomi sclerae anicteric op clear cv rrr nl s s no mrg resp cta bilaterally abd soft mildly distended non tender no rebound or guarding no hsm ext wwp pitting edema to knee no decrease in rom passive or active in right hip no pain on movement of any of the extremities psych calm appropriate a o x neuro cn ii xii grossly intact strength throughout pertinent results admission labs pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm pt ptt inr pt pm glucose urea n creat sodium potassium chloride total co anion gap pm alt sgpt ast sgot ck cpk alk phos tot bili pm ctropnt pm ck mb ctropnt pm magnesium pm urine blood neg nitrite neg protein tr glucose neg ketone neg bilirubin mod urobilngn ph leuk neg pm urine rbc wbc bacteria none yeast none epi am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood hct pm blood hct pm blood hgb hct pm blood hct pm blood hct am blood glucose urean creat na k cl hco angap am blood urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap am blood alt ast ld ldh ck cpk alkphos totbili am blood alt ast alkphos totbili pm blood ck cpk amylase pm blood albumin calcium phos mg am blood alt ast ld ldh ck cpk alkphos totbili am blood alt ast alkphos totbili am blood alt ast alkphos totbili am blood alt ast alkphos totbili am blood alt ast alkphos totbili pm blood alt ast alkphos totbili am blood alt ast alkphos totbili am blood alt ast alkphos totbili am blood alt ast alkphos totbili am blood alt ast alkphos totbili am blood ck mb mb indx ctropnt pm blood ck mb mb indx ctropnt pm blood ck mb mb indx ctropnt am blood type art po pco ph caltco base xs 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 alt ast alkphos totbili am blood calcium phos mg microbiology urine culture negative blood culture negative blood culture negative imaging right upper quadrant ultrasound there is marked intra and extra hepatic biliary ductal dilation as seen on recent ct the common bile duct measures up to cm gallbladder is distended likely reflecting biliary obstruction there are no stones within the gallbladder nor is there sludge identified there is no gallbladder wall thickening or pericholecystic fluid there is trace fluid in morison s pouch without generalized ascites the pancreas could not be well visualized due to significant bowel gas in the midline impression intra and extra hepatic biliary ductal dilation as seen on recent ct further evaluation with ercp or mrcp is recommended distended gallbladder likely reflecting biliary obstruction without cholelithiasis or son evidence of acute cholecystitis ercp impression the major papilla appeared like fish mouth there was copious thick mucin extruding out the minor papilla was bulging there was some thick mucin extruding out immediately below the minor papilla there was a small opening suspicious for fistula a diffuse dilation was seen at the cbd and intrahepatic ducts with the cbd measuring mm copious amount of mucin was extracted successfully using a mm rx balloon spyglass cholangioscope showed large amount of mucin in cbd and no discrete lesion was found pd was cannulated from the major papilla and small amount of contrast was injected there was one filling defect in the proximal main pd suspicious for intraductal neoplasm the guidewire was not able to traverse the santorini duct was cannulated from the minor papilla and small amount of contrast was injected there was one filling defect in the proximal main pd suspicious for intraductal neoplasm cytology samples were obtained for histology using a brush in the cbd because of the severely dilated cbd and large amount of mucin a cm by fr double pig tail biliary stent was placed successfully in the cbd then a cm by fr cotton biliary stent was placed side by side successfully in the cbd otherwise normal ercp to third part of the duodenum kub impression no evidence of obstruction with a large amount of gas in the bowel which may be indicative of ileus cxr findings there is progressive increase in diffuse bilateral parenchymal opacities consistent with rapid accumulation of moderate to severe pulmonary edema more focal areas of opacity including within the right apex may represent asymmetric edema versus superimposed aspiration consolidation elevation of the right minor fissue is suggestive of volume loss atelectasis in the right upper lobe bilateral pleural effusions are present and appear progressed with associated bibasilar atelectasis no pneumothorax is seen the heart size is top normal there are calcifications of the aortic arch a left sided central line is unchanged with tip in the low svc echo the left atrium is mildly dilated no left atrial mass thrombus seen best excluded by transesophageal echocardiography the estimated right atrial pressure is mmhg 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 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 trace aortic regurgitation is seen the mitral leaflets are mildly thickened no mitral valve prolapse is seen an eccentric anteriorly directed jet of severe mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion impression normal biventricular cavity sizes with preserved global and regional biventricular systolic function moderate to severe mitral regurgitation pulmonary artrery hypertension ercp the major papilla appeared like fish mouth there was some thick mucin extruding out the minor papilla was bulging there was some thick mucin extruding out two previously placed biliary stents were seen at the major papilla one stent partially migrated distally both stents were removed with a snare cannulation of the biliary duct was successful and deep with a sphincterotome a straight tip in dreamwire was placed a diffuse dilation was seen at the cbd and intrahepatic ducts with the cbd measuring mm because patient developed obstruction with plastic stents and patient and family agreed with the metal stent placement a cm by mm wallflex fully covered biliary stent ref lot was placed successfully in the cbd the bile flow was good otherwise normal ercp to third part of the duodenum ercp copious amount of mucin was seen at the major and minor papilla the major papilla appeared like fishmouth the previously placed fcse metal stent was seen at the major papilla it largely migrated distally it was removed with a snare cannulation of the biliary duct was successful and deep with a balloon catheter a straight tip in guidewire was placed because of the copious amount of mucin causing obstruction small amount of contrast was injected there was filling defect mucin at the cbd cbd measured mm large amount of mucin was extracted successfully with a balloon because patient has failed plastic stents and fcse metal stent a cm by mm uncovered wallflex biliary stent ref lot was placed successfully in the cbd the bile flow was good otherwise normal ercp to third part of the duodenum brief hospital course y o f with hx dchf recent nstemi presents with cholangitis and new onset a fib with rvr found to have signs of ipmn and adenocarcinoma biliary obstruction cholangitis the patient s ct and ruq ultrasound both suggestive of biliary obstruction she was evaluated via ercp on which revealed substantial obstruction of the bile ducts secondary to copious mucin two plastic stents were placed the patient was given prophylactic antibiotics with zosyn prior to and immediately following the procedure her abdominal distension slowly resolved and her lfts normalized one week following the procedure she was found to have rising lfts and increased abdominal distension on she underwent repeat ercp to replace the plastic stents with a metal stent as the previous stent had slipped this did not successfully stay in place and required replacement on despite this replacement it is possible that the blockage will recur in which case repeat ercp would be indicated to replace the stents on discharge her lfts were stable for hours and abdominal exam remained benign adenocarcinoma the findings on the ercp combined with the papillary mass found on ct were highly suggestive of ipmn cytology brushings revealed adenocarcinoma cells likely malignant the patient indicated prior to the ercp that she would not wish to undertake therapy for any cancer found as a result of the procedure she is not a surgical candidate there may be chemotherapeutic options the patient may also prefer a comfort care hospice approach an appointment with a medical oncologist was set for her following discharge new onset atrial fibrillation on admission the patient was found to be in afib with rvr she was successfully rate controlled with iv and po metoprolol cardiology was consulted and attributed her symptoms to demand ischemia she was monitored and continued on beta blocker throughout her stay as her chads score is she is a candidate for long term anti coagulation however her primary care physician felt that this was not appropriate therapy given her risk of bleeding she will continue metoprolol for rate control hypotension resolved the patient was found to be somnolent and hypotensive on following an episode of coffee ground emesis she was transferred to the micu for pressor support this was thought secondary to afib with bradycardia she was in the icu overnight and on pressors for roughly hours she did not require ventilation report following immediate management she was maintained in nsr with metoprolol and had no recurrence of the hypotension her hematocrit was stable and there was no further sign of bleeding diastolic heart failure the patient has a history of diastolic hf but at home required no oxygen support on admission she was found to have some demand ischemia with troponin her hypoxia responded to diuresis indicating heart failure as the etiology she was resumed on home lasix mg daily and was felt to be euvolemic on discharge delirium with hallucination resolved the patient experienced waxing and orientation following her return from icu she also experienced visual hallucinations this was attributed to hospital associated delirium any exacerbating medications were discontinued and the patient was managed according to the protocol inactive issues cad continued aspirin back pain held home tizanidine hypertension continue home lisinopril urinary incontinence held home oxybutynin glaucoma continue home timolol code dnr dni transitional issues please monitor liver function tests ast alt alkaline phosphatase total bilirubin daily until normalized if there is an increase or if her abdominal exam worsens call the ercp team for follow up as stents may have slipped once liver function tests have normalized you may wish to restart zocor tizanidine and oxybutynin please monitor electrolytes and consider restarting kcl if necessary if respiratory function improves nebulizers can be d c the patient does not have obstructive disease at baseline oncology appointment to review cytology and determine possible treatment options discuss prognosis and select a path forward this may lead to treatment or to a comfort care hospice option medications on admission asa mg daily calcium d tab daily oxybutynin qhs lasix mg qam lisinopril mg daily mvi kcl sr meq daily timolol drops drop to right eye tizanidine mg vit d unit tab daily zocor mg qhs omeprazole mg daily immodium mom prn discharge medications albuterol sulfate mg ml solution for nebulization sig one nebulized inhalation every six hours as needed for sob wheezing ipratropium bromide solution sig one inhalation q h every hours as needed for sob wheezing aspirin mg tablet sig one tablet po daily daily timolol maleate drops sig one drop ophthalmic times a day furosemide mg tablet sig one tablet po daily daily lisinopril mg tablet sig one tablet po daily daily calcium d mg mg unit tablet sig one tablet po once a day multi day tablet sig one tablet po once a day vitamin d unit tablet sig one tablet po once a day omeprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day ampicillin sulbactam gram recon soln sig one recon soln injection q h every hours g q h end on acetaminophen mg tablet sig tablets po q h every hours as needed for pain max g day hydroxyzine hcl mg tablet sig one tablet po q h every hours as needed for pruritis hold for mental status changes metoprolol succinate mg tablet extended release hr sig one tablet extended release hr po once a day senna mg capsule sig one capsule po twice a day colace mg capsule sig one capsule po twice a day outpatient lab work please obtain daily chemistry panel along with daily ast alt alkaline phosphatase and total bilirubin please call results to dr p discharge disposition extended care facility healthcare rehabilitation center discharge diagnosis primary obstructive cholangitis secondary adenocarcinoma likely pancreatic atrial fibrillation diastolic heart failure discharge condition mental status confused sometimes activity status out of bed with assistance to chair or wheelchair level of consciousness alert and interactive discharge instructions dear mrs you came to our with nausea vomiting abdominal pain and jaundice a ct scan showed dilated bile ducts most likely due to an obstruction you were transferred to our hospital for ercp endoscopic retrograde cholangiopancreatography to investigate the cause of this blockage and to relieve it stents were placed to hold open the bile ducts samples of the wall of the bile duct were taken these were shown to be cancerous during your recovery from the ercp you experienced a rapid irregular heart rate on your blood pressure dropped to a dangerously low level and you were transferred to our icu you returned to the medical floor on for several days you needed additional oxygen support due to fluid in your lungs you were given medications to control your heart rate keep your blood pressure in the normal range and reduce any extra fluid in your body as these medications took effect you were able to reduce your need for extra oxygen during your stay on the medical floor you were found to be confused at times and to have some visual hallucinations this is a problem when people are in the hospital and you were able to recover from this confusion as your health improved a week after your ercp we determined that one of the stents had slipped out of place allowing the duct to close you underwent a repeat ercp on to replace this stent you required an additional ercp on to replace the stents once again following this rd procedure the stent appeared to remain in place you will have daily bloodwork at rehab for liver function tests to ensure that everything is stable our physical therapy team worked with you and determined you were weakened from the long hospital stay you were transferred to a rehab facility to build your strength we made the following changes to your medications stop oxybutynin stop potassium chloride may restart depending on electrolyte monitoring stop tizanidine may restart once liver function normalizes stop zocor may restart once liver function normalizes increase lisinopril from mg to mg daily for better blood pressure control start albuterol nebulizer treatments prn to ease breathing start iprotropium nebulizer treatments prn to ease breathing start metoprolol xr mg daily for a fib rate control and blood pressure management start hydoxyzine mg q h prn itching for rash please follow up with your primary care physician when you are discharged from rehab to determine any further medication changes please also follow up with an oncologist to discuss your new diagnosis your treatment choices and how you wish to proceed we have made an appointment for you in on monday followup instructions please follow up with your primary care physician following your discharge from rehab name md specialty hematology oncology location hospital campus ma phone when monday at pm,"{
""Diagnoses"": [""nausea"", ""vomiting"", ""abdominal tenderness"", ""major surgical or invasive procedure"", ""ERCP"", ""central venous line placement"", ""arterial line placement"", ""removal of ERCP for stent replacement"", ""removal of ERCP for stent replacement"", ""history of present illness""],
""Medications"": [""metoprolol"", ""zofran"", ""fluid""]
}"
99712,admission date discharge date date of birth sex f service neurosurgery allergies patient recorded as having no known allergies to drugs attending chief complaint headache major surgical or invasive procedure left craniotomy cranioplasty for excision of skull based mass history of present illness the patient was electively admitted for resection of a skull lesion past medical history unknown social history lives with husband from and speaks cantonese works in a factory family history non contributory physical exam exam upon discharge chinese speaking only but able to follow commands with prompts pupils to mm bilaterally eomi face symetric no drift or droop full strength with motor exam left sided cranial wound c d i closed with sutures pertinent results head ct expected post surgical changes after craniectomy and cranioplasty for a left frontoparietal calvarial lesion mri head since the previous study the patient has undergone resection of left parietal skull mass there is no residual nodular enhancement seen there remains a small left sided subdural collection and meningeal enhancement there is no midline shift or hydrocephalus no acute infarct seen impression status post resection of left parietal skull mass no residual nodular enhancement is seen no acute infarct brief hospital course the patient was electively admitted for resection of a skull based lesion she had a craniectomy and cranioplasty with mesh the procedure went well and the patient was transferred to the icu for monitoring overnight the patient s post operative mri revealed complete resection of the lesion she was neurologically stable and post op imaging was consistent with total resection of the mass the patient was transferred to the floor on she worked with pt and ot but was slow to mobilize she continued to work with pt and ot on and she was re evaluated on and was deemed safe for discharge home on with home services the patient had lesions on her legs when she came into the or dermatology was consulted and felt that she had chronic eczema for which she was discharged home with creams she will follow up with them in clinic medications on admission none discharge medications docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills oxycodone mg tablet sig one tablet po q h every hours as needed for pain no driving while on this medication disp tablet s refills acetaminophen mg tablet sig two tablet po q h every hours as needed for pain ferrous sulfate mg mg iron tablet sig one tablet po daily daily disp tablet s refills levetiracetam mg tablet sig one tablet po bid times a day for days continue for two weeks from the date of your surgery disp tablet s refills cortisone cream sig one appl topical times a day for days disp tube refills triamcinolone acetonide ointment sig one appl topical tid times a day for days disp tube refills discharge disposition home with service facility carecentrix discharge diagnosis left skull based mass preliminary diagnosis is meningioma discharge condition neurologically stable mental status clear and coherent with interpreter level of consciousness alert and interactive activity status ambulatory requires assistance discharge instructions 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 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 unless directed by your doctor do not take any anti inflammatory medicines such as motrin aspirin advil and ibuprofen etc 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 haven been discharged on keppra levetiracetam you will not require blood work monitoring clearance to drive and return to work will be addressed at your post operative office visit make sure to continue to use your incentive spirometer while at home unless you have been instructed not to call your surgeon immediately if you experience any of the following new onset of tremors or seizures any confusion 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 any signs of infection at the wound site redness swelling tenderness or drainage fever greater than or equal to f followup instructions follow up in the brain clinic it is located on the on call your appointment is at pm follow up with dermatology in the clinic call to schedule an appointment within weeks completed by [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies levetiracetam latex attending chief complaint lower gi bleed pelvic pain major surgical or invasive procedure none history of present illness this is a year old woman with a pmhx significant for stage iiia t n mx high grade cervical cancer papillary thyroid cancer seizure disorder and atypical meningioma who is admitted from the ed with fever lower gi bleed and uti patient has been undergoing active treatment for cervical cancer with taxol carboplatin with c on ms has been having trouble with gi bleeding in the setting of constipation and straining as per outpatient notes and has been supported conservatively with blood transfusions no history of egd or colonsocopy in our system ms states the for the last weekshe has noticed increased blood in her stool also endorses fevers chills and abdominal pain in the ed initial vitals were ra hgb was and u a was consistent with uti patient received l of ns and gram of ceftriaxone ct abdomen pelvis showed thickening of the rectum and sigmoid colon with extension to possibly the mid descending colon raise suspicion for a proctocolitis due to an infectious or inflammatory process heterogenous irregular cervical mass appears stable in size but there is more hypodense material endometrial canal suggesting either outlet obstruction by the mass or possibly involvement of the region by the mass left upper lobe nodule has decreased in size vitals on admission were ra past medical history atypical meningioma s p resection md brief seizure disorder given keppra developed rash not taking aed at this time purportedly to undergo radiation therapy but did not undergo therapy chronic eczematous process involving thighs chronic hyperpigmented shins bilaterally seen by dermatology in past g p ab cervical cancer stage iiia dx lung mets and progression in cycle taxol thyroid cancer no treatment social history she lives in the with her husband and works as a tailor no tobacco or etoh use she is originially from and speaks cantonese only family history father lung cancer smoker mother no known medical issues she has sisters brother she has children physical exam admission physical exam vs ra general alert oriented pleasant no acute distress heent mucous membranes moist chest cta bilaterally no wheezes rales or rhonchi cardiac rrr no mrg abdomen bs slightly tender non distended extremities dry skin no edema bilaterally discharge exam tmax c f tcurrent c f hr bpm bp mmhg rr insp min spo general alert oriented nad heent mmm chest cta bilaterally no wheezes rales or rhonchi cardiac rrr s s no mrg abdomen bs soft suprapubic mass is mildly tender non distended hepatic edge palpable no cvat extremities dry skin no edema bilaterally pertinent results admission labs pm urine color yellow appear cloudy sp pm urine blood mod nitrite neg protein glucose neg ketone neg bilirubin neg urobilngn neg ph leuk lg pm urine rbc wbc bacteria mod yeast none epi pm urine mucous mod am type comments added to g am lactate am glucose urea n creat sodium potassium chloride total co anion gap am estgfr using this am alt sgpt ast sgot ld ldh alk phos tot bili am albumin am wbc rbc hgb hct mcv mch mchc rdw am neuts lymphs monos eos basos am plt count am pt ptt inr pt studies ct chest abd pelvis impression proctocolitis which may be due to an infectious or inflammatory process heterogenous irregular cervical mass appears relatively similar compatible with known carcinoma increased hypodense material in the endometrial canal with peripheral irregular enhancement is suggestive of increased endometrial fluid due to cervical obstruction by the mass with endometritis but neoplastic involvement of the endometrium may also be present air within the cervix and vagina is unchanged from the prior studies while no communication is seen between the vagina and rectum if there is concern for a rectovaginal fistula this can better be assessed with rectal contrast interval decrease in size of the left upper lobe nodule heterogeneous hypodense area within the right lobe of the thyroid gland consistent with the patient s known thyroid carcinoma mild dilatation of the ureters without frank hydronephrosis likely due to mass effect upon the distal ureters by the cervical tumor kub findings there is retained contrast within the large bowel there is no dilated bowel there is no free air or pneumatosis impression no gas abnormality microbiology mrsa screen mrsa screen pending inpatient blood culture blood culture routine pending inpatient blood culture blood culture routine pending inpatient urine culture final inpatient blood culture pending blood culture pending 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 am blood lactate brief hospital course this is a year old woman with a history of cervical cancer stage iiia t n mx papillary thyroid cancer atypical meningioma and anemia who is admitted with fever lower gi bleed and likely uti active issues lower gi bleed patient received ivf and an active type screen and crossmatch was maintained she had a ct scan demonstrating colitis given recent chemotherapy chemotherapy induced colitis was high in our differential we also considered infectious colitis and patient was started on antibiotics she was afebrile in the icu and not passing stool so an infectious etiology was felt to be less likely and zosyn was discontinued on ischemic bowel was unlikely given lactate is within normal limits and patient does not appear systemically ill on patient received units prbc for a hct of with hct increasing appropriately to on the morning of while in the patient passed small blood clots through her rectum but did not have frank hematochezia or melena patient was called out of the on but a floor bed was not available on she was stable for discharge home uti patient with evidence of uti on u a on admission asymptomatic she was initially treated with antibiotics however urine studies were felt to represent fecal contamination and her imaging was concerning for possible fistula antibiotics were discontinued on and patient remained afebrile cervical cancer patient currently undergoing chemotherapy with taxol and carboplatin her outpatient oncologist was contact who felt colitis could be secondary to chemotherapy and chemotherapy was not given in house patient will follow up with oncology as outpatient hypotension patient was initially transferred to the with an sbp in the s in spite of aggressive fluid resuscitation and concern for sepsis upon further investigation patient s baseline outpatient sbp is s she denied symptoms of orthostatic hypotension chronic issues thyroid cancer no treatment at this time pain patient was continued on oxycodone and oxycontin ibuprofen was held in the setting of gi bleed transitional issues avoid nsaids determine future chemo regimen medications on admission the preadmission medication list is accurate and complete dexamethasone mg po daily lorazepam mg po q h prn anxiety or insomnia please hold for oversedation or rr ondansetron mg po q h prn nausea oxycodone immediate release mg po q h prn pain please hold for oversedation or rr oxycodone sr oxycontin mg po qam please hold for oversedation or rr oxycodone sr oxycontin mg po qpm please hold for oversedation or rr prochlorperazine mg po q h prn nausea docusate sodium mg po bid senna tab po bid prn constipation polyethylene glycol g po daily prn constipation ibuprofen mg po q h prn pain discharge medications dexamethasone mg po daily docusate sodium mg po bid lorazepam mg po q h prn anxiety or insomnia please hold for oversedation or rr ondansetron mg po q h prn nausea oxycodone immediate release mg po q h prn pain please hold for oversedation or rr oxycodone sr oxycontin mg po qam please hold for oversedation or rr oxycodone sr oxycontin mg po qpm please hold for oversedation or rr prochlorperazine mg po q h prn nausea senna tab po bid prn constipation polyethylene glycol g po daily prn constipation discharge disposition home discharge diagnosis lower gi bleed hypotension anemia 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 dear ms it was a pleasure caring for you at you were admitted for low blood pressure and blood in your stool you had a blood transfusion which improved your blood pressure and your anemia a ct scan showed inflammation of your colon which is most likely due to your chemotherapy you also complained of tongue pain which is also likely due to your chemotherapy we have prescribed a lidocaine mouth rinse to help with the pain in the future please avoid over the counter non steroidal anti inflammatory medications nsaids as they may cause worse bleeding in your gi tract this means you should not take ibuprofen advil motrin aspirin or naproxen it is ok to take tylenol please continue to follow up with your oncologist for care of your cervical cancer followup instructions dr thursday pm department hematology oncology when friday at am with md building sc clinical ctr campus east best parking garage department mri when friday at am with mri building cc campus west best parking garage department radiology when friday at am with cat scan building sc clinical ctr campus east best parking garage md [NEW_RECORD] name unit no admission date discharge date date of birth sex f service medicine allergies levetiracetam latex attending addendum on day of discharge patient was noted to have several enlarged tongue papilliae causing mild mouth pain not consistent with mucousitis per oncology this is commonly seen in chemotherapy discharged home with magic mouthwash and viscous lidocaine prn discharge disposition home md completed by,{}
19478,admission date discharge date date of birth sex m service medicine allergies compazine phenobarbital nsaids aspirin dilantin heparin agents attending chief complaint transferred for biliary sepsis acalculous cholecystitis major surgical or invasive procedure subclavian line placement history of present illness this is a yo m who was transferred for acalculous cholecystitis he had prolonged recent hospitalization with recent c diff with toxic megacolon in surgery deferred because patient refused ostomy sepsis with pseudomonas from urine respiratory failure secondary to pneumonia requiring intubation fungal septicemia peg tube was palced at that time he was eventually discharged to rehabilitation after one month of hospitalization on he developed abdominal discomfort in rehab and was sent to outpatient ct scan raised suspiciaon of cholecystitis patient had alp and direct bili elevation since ultrasound demonstarted sludge in gb ct showed cholecystitis with some pericholecystic fluid and hida scan abnormal he was given cefotetan and zosyn he was in icu and given ivf for mild hypotension he was also given ivf for mild hypotention per d c summary transferred to for futher care and biliary drainage past medical history major depression with recent hospitalization under section seizure disorder osteoporosis c diff colitis vre from rectal swab anemia chronic constipation colonic polyp osteoporosis bilateral pneumonia social history he denies smoking etoh prior to all this he was living home alone physical exam gen sleepy nad a o x heent anicteric oral mucosa dry neck supple cv rrr no r m g resp ctab from anterior exam mild tenderness on right side no rebound no guarding active bowel sounds soft peg tube site clean ext pitting edema pertinent results ct pelvis limited portable exam demonstrating no gross evidence of left hip fracture or dislocation dedicated radiographs of the hip within the department may be helpful for more comprehensive assessment given concern for fracture mrcp minimal central intrahepatic biliary ductal dilatation with a normal appearing common bile duct there is no evidence of intraductal filling defects or central obstructing lesions gallbladder sludge with a small amount of gallbladder wall edema given the presence of abdominal ascites and third spacing of fluid within the visualized subcutaneous soft tissues the significance of this gallbladder wall edema is non specific clinical correlation is recommended bibasilar consolidations consistent with the patient s stated history of aspiration pneumonia gynecomastia liver u s gallbladder sludge without calculi or evidence of acute cholecytitis no evidence of biliary tract obstruction to explain cholestasis cxr increased opacity at the right lung base likely represents developing pneumonia versus aspiration increased atelectasis at the left lung base ct head no evidence of acute intracranial hemorrhage or mass effect mr there is an acute compression fracture of the l vertebral body which likely represents an insufficiency fracture though a pathologic fracture cannot be entirely excluded a chronic compression fracture of l is also noted there is no evidence of cord impingement mr chronic compression fracture of t vertebral body no epidural abscesses are seen liver core biopsy the specimen is small and fragmented but shows changes consistent with submassive hepatic necrosis the changes include parenchymal collapse bile duct proliferation with portal mixed inflammatory cell infiltrate and cholestasis no fatty change is seen trichrome stain shows mild portal fibrosis and collapse the etiology of these changes includes a drug reaction among others knee plain film pa and lateral views of the left knee show mild degree of degenerative changes involving the left knee manifested by mild degree of joint space narrowing involving the medial and the patellofemoral compartments there is no evidence of joint effusion there is mild degree of hypertrophic changes involving the superior aspect of the patella the bony structures show normal bone density and no evidence of fractures or destructive changes or erosions pm lactate 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 hbsag negative hbs ab negative hbc ab negative hav ab negative pm hcv ab negative pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm anisocyt macrocyt pm plt count pm pt ptt inr pt brief hospital course c diff colitis the patient was initially placed on metronidazole due to his prior history of prolonged c diff colitis this was stopped after three days after it was determined that the he had completed a full course of metronidazole at the outside hospital on hospital day the patient spiked to w rigors and tachycardia to the s he was transferred to the micu for a second time for further monitoring his white count rose to he was pancultured and emprically started on vancomycin levaquin and flagyl his stool eventually came back positive for c difficile vancomycin and levaquin were stopped and the patient was maintained on flagyl and po vancomycin his white count returned to and he was no longer febrile the patient was eventually given a day course of flagyl for c diff colitis since the patient had a prior history of c diff toxic megacolon and a history of prior c diff infections was unknown he was treated as a second relapse he will be d c on pulsed taper of po vancomycin for a total six week course elevated lfts the patient was initially admitted to the icu for sepsis he was started on broad spectrum abx due to concern for cholecystitis pt had ruq us and mrcp that illustrated sludging withing the gallbladder but no evidence for acute cholecystitis since the patient did not have a fever and no cholecystitis zosyn was stopped after five days due to concern for hepatotoxicity of his regular anticonvulsants lamictal and valproate both known to be hepatotoxic and conversation with neurology the patients regular anticonvulsants were held and he was started on keppra his lfts then began to normalize however after the patient was called out of the micu for a second time for a recurrence of his c diff colitis his lfts began to rise again hepatology was re consulted and recommended ruling out fungal infections fungal isolator blood cx were sent and found to be negative the patient also had a negative hiv test the patient eventually had a transjugular liver biopsy that showed submassive hepatic necrosis that was most consistent with a drug reaction the patient was not on any hepatotoxic medications during his second episode of transaminitis however this will felt to represent a residual finding from his anti epileptic medications his lfts again began to trend down at the time of d c and the patient was instructed to follow up with hepatology in the next month atrial tachycardia the patient was noted on telemetry to have intermittent bursts of tachycardia to the s and then he would slowly return to a rhythm in the s ecg p waves of a different morphology than his baseline when he became tachycardic on one occasion the patient experienced bradycardia to the s ep was called to see the patient they felt the patient had an episodic atrial atchycardia that emerged due to his acute illness they felt his bradycardia was due to a vagal episode as a result he was placed on a beta blocker for prophylaxis against other vagal episodes as well as a tachycardia induced cardiomyopathy seizures depakote lemectil and zonegram was discontinued due to concern of hepatotpxicity per conversation with neurology the patient was started on keppra for prophylaxis and prn ativan the patient was noted to have a generalized shaking of all extremities which lasted for minutes and resolved with the administration of ativan neurology was consulted and advised that the patient s keppra dose be increased on the morning of the patient had a staring spell and had decreased responsiveness this was felt to be another seizure and neurology advised to increase the keppra again neurology also felt that the patient should be given a sleep aid as abnormal sleep cycles could contribute to breakthrough seizures neurontin was recommended as an additional if needed but was not started as the patient did not have another episode at the time of d c right foot ischemia on hospital day the pt was noted to have a cold right foot with nonpalpable pulse pulse was present by doppler he was started on heparin drip vascular surgery was consulted per their recommendation workup was initiated to rule out source of emboli echocardiogram showed normal ef with no thrombus duplex fem arteries was negative for aneurysm abd u s to r o aaa was negative heparin was eventually changed to lovenox and the patient was started on coumadin with anticipated treatment for six months the patient s platelet count began to steadily decline as a result all heparin products were stopped and a heparin induced thrombocytopenia hit antibody was sent and was found to be positive the patient was placed on lepirudin for his hit this was stopped temporarily for liver biopsy and then started again once the patient s coumadin was therapeutic lepirudin was stopped he was instructed to see vascular surgery in months time serotonin release antibody ultimately returned negative so this anticoagulation can likely be discontinued this information was communicated with the rehabilitation facility tube feeds the patient was given resplor tube feeds and encouraged to take po s as tolerated lower extremity weakness the patient was felt to be deconditioned due to prolonged hospitalization neurology was consulted and recommended an mri spine to evaluate for epidural abscess he was found to have a lumbar compression fracture with no cord compression and no abscess the patient was given calcium and vitamin d medications on admission cymbalta lamictal q zonegran flagyl vanco q valproic acid qid hydrocortisone qd sc heparin cymbalta qam zantac potassium lidoderm for left hip morphine prn guainefesin all compazine aspirin dilantin phenobarbital nsaids tricyclics tegretol succinylcholine discharge medications atenolol mg tablet sig one tablet po daily daily ursodiol mg capsule sig one capsule po bid times a day lidocaine mg patch adhesive patch medicated sig one adhesive patch medicated topical q h every hours right hip lidocaine mg patch adhesive patch medicated sig one adhesive patch medicated topical q left hip miconazole nitrate powder sig one appl topical tid times a day lansoprazole mg susp delayed release for recon sig one po daily daily levetiracetam mg tablet sig three tablet po qam once a day in the morning levetiracetam mg tablet sig four tablet po qpm once a day in the evening trazodone hcl mg tablet sig tablet po hs at bedtime as needed aluminum magnesium hydroxide mg ml suspension sig mls po qid times a day as needed zinc oxide cod liver oil ointment sig one appl topical qd oxycodone hcl mg tablet sig one tablet po q h every to hours as needed cholecalciferol vitamin d unit tablet sig one tablet po daily daily calcium carbonate mg tablet sig one tablet po tid times a day lorazepam mg ml syringe sig mg injection q h every hours as needed for seizure activity vancomycin hcl mg capsule sig one capsule po see instructions pill x days pill qd x days pill qod x days pill q days x days warfarin sodium mg tablet sig one tablet po once a day for months please start again when inr between discharge disposition extended care facility discharge diagnosis drug induced hepatitis heparin induced thrombocytopenia seizures c diff colitis atrial tachycardia depression ischemic foot discharge condition fair discharge instructions please notify a physician or return to the emergency room if you experience fevers chills uncontrolled nausea or vomiting continuous foul smelling diarrhea limb shaking shortness of breath chest pain abdominal pain bloody stool confusion you will take coumadin for the next six months and then follow up with dr of vascular surgery in months time your coumadin is being held for two days until your inr returns between you should have your lfts checked daily in rehab to make sure they normalize followup instructions please follow up with dr of vascular surgery in months for your ischemic foot please make an appointment to be seen in the hepatology clinic in the next month please make an appointment to see your neurologist dr within a week of discharge from rehab,"{
""Diagnoses"": [""accalculous cholecystitis"", ""biliary sepsis"", ""cholecystitis"", ""pericholecystic fluid"", ""hypotension"", ""sepsis"", ""pseudomonas"", ""urine""],
""Medications"": [""Compazine"", ""Phenobarbital"", ""NSAIDs"", ""Aspirin"", ""Dilantin"", ""Heparin"", ""Agents"", ""Zosyn"", ""Cefotetan""]
}"
58329,admission date discharge date date of birth sex f service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint right carotid body tumor major surgical or invasive procedure coil embolization of right carotid body tumor resection of right carotid body tumor history of present illness f with a known right carotid body tumor this was first identified back in when she saw dr for a right sided shoulder and neck pain and he identified a mass in her carotid which proved to be a carotid body tumor she was subsequently seen by dr in and he advised resection of the tumor as it had been enlarging but she had deferred she has recently developed increasing pain in the side and difficulty lying on that side of her neck with some discomfort although no dysphagia and has finally agreed to have surgery past medical history hypothyroidism anxiety social history nonsmoker lives with husband no ivdu no heavy etoh use family history noncontributory physical exam discharge day ra gen nad heent r neck incision site clean dry intact cn intact cv rrr chest ctab abd soft nontender nondistended ext wwp pulses at dp pt b l strength sensation equal and intact bilaterally with the exception of mild r hand grip weakness stable since previous rotator cuff surgery brief hospital course ms was admitted to the vascular surgery service on following embolization of her known right carotid body tumor by the interventional radiology department she was monitored in the cvicu overnight and found to be neurologically intact and stable in the morning of she underwent an uncomplicated resection of the right carotid body tumor postoperatively she complained of chest pain which appeared to be reproducible on palpation an ekg and cardiac enzymes were negative and the chest pain was self limited on the evening of pod she did demonstrate a mild right mouth droop in addition her right hand grip was slightly weak however the patient reported this was her baseline since having had right rotator cuff surgery in she remained otherwise neurologically intact and her pain was well controlled with tylenol on pod she did complain of intermittent mild frontal headaches which were alleviated with tylenol the ent service followed the patient throughout her admission and did a postoperative laryngoscopy see omr for full report she underwent a speech and swallow evaluation and was delared safe for pureed solids and thin liquids on pod the jp drain in her neck was removed she was able to tolerate a diet and swallow her pills without difficulty she denied pain and she was able to ambulate without difficulty she was discharged to home in good condition with scheduled follow up with clinic vascular surgery clinic and speech swallow clinic medications on admission levothyroxine mcg tablet sig one tablet po daily daily trazodone oral cetirizine mg tablet oral omeprazole patient reports not taking discharge medications levothyroxine mcg tablet sig one tablet po daily daily trazodone oral cetirizine mg tablet oral percocet mg tablet sig tablets po every four hours as needed for pain disp tablet s refills docusate sodium mg capsule sig one capsule po bid times a day as needed for constipation use while taking percocet for pain disp capsule s refills discharge disposition home discharge diagnosis right carotid body tumor discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions please call dr office or dr office if you experience fevers chills nausea vomiting chest pain shortness of breath weakness in face or arms difficulty speaking hoarseness or increasing redness or drainage from the incision site you may remove bandages or dressings in hours you may shower and bathe as desired you may resume your normal activities however it is normal to feel somewhat tired for the first several days after surgery do not drive while you are taking percocet narcotic pain medication continue a pureed solids thin liquids diet until your follow up speech and swallow appointment followup instructions provider md phone date time provider md phone date time speech swallow eval call to schedule appointment,"{
""Diagnoses"": [""right carotid body tumor""],
""Medications"": [""coil embolization"", ""resection of right carotid body tumor""]
}"
2719,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint syncope major surgical or invasive procedure egd history of present illness y o male with pmh sig for mult cvas b ica stenosis s p lcea in htn hyperhol type dm of note pt ac since for r ica occlusion today wife found patient slumped over in the bathroom on the toilet after having a bm pt does not recall the event no cp sob but does note intermittent dizziness over past few days also notes some left hand numbess leg weakness seen by neuro in ed see plan in short came to ed where had inr of and hct of melena on exam but no active gi bleeding appreciated pt reports having inr checked in early and it being at goal no new meds abx dietary changes change in coumdain dose in ed initial vs p given l ns u prbc u ffp mg sq k past medical history peripheral disease anxiety htn dm inc lipids left cea stroke social history works as a car salesman sedentary lifestyle ppd x smoking history quit after stroke on wellbutrin h o heavy etoh in the past no illicit drug use lives with wife family history mother had pna father died at secondary to strokes over a year period brother with cad and aicd physical exam gen ra supine standing cv s s no mrg chest exp wheezes throughout no crackles abd normoactive bs nt nd ext no c c e neuro cnii cnxii intact pertinent results egd erosions in the antrum and fundus likely sources of bleeding in the setting of inr of erythema in the fundus compatible with gastritis echo the left atrium is elongated the right atrium is moderately dilated there is mild symmetric left ventricular hypertrophy overall left ventricular systolic function is normal lvef 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 root is mildly dilated 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 mitral regurgitation is seen there is no pericardial effusion pm ck cpk pm ck mb mb indx ctropnt pm hct pm pt ptt inr pt pm urine color straw appear clear sp pm urine blood lg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg pm urine rbc wbc bacteria none yeast none epi pm wbc rbc hgb hct mcv mch mchc rdw pm neuts bands lymphs monos eos basos atyps metas myelos pm hypochrom anisocyt normal poikilocy macrocyt normal microcyt polychrom normal ovalocyt pm plt count pm pt ptt inr pt am glucose urea n creat sodium potassium chloride total co anion gap am alt sgpt ast sgot ck cpk alk phos amylase tot bili am lipase am ctropnt am ck mb am albumin calcium phosphate magnesium am wbc rbc hgb hct mcv mch mchc rdw am neuts lymphs monos eos basos am microcyt am plt count am pt ptt inr pt brief hospital course cc y o male with pmh sig for mult cvas b ica stenosis s p lcea in htn hyperhol type dm presented with inr of and anemia ugib the patient required admission to the micu for management of his anemia and elevated inr he was given mg iv vitamin k his coumadin was held and required u prbcs for management of his anemia he had melanotic stools on admission but did not have active bleeding and did not require emergent egd he was made npo started on a ppi and monitored he was stabilized and transferred to the floors because he had leak of his cardiac enzymes likely secondary to ischemic demand cardiology was consulted to determine if egd would be tolerated cardiology determined that he was low risk for the egd procedure and he underwent an egd which showed erosions in the antrum and fundus likely sources of bleeding in the setting of inr of erythema in the fundus compatible with gastritis gastroenterology felt it was not contraindicated to start aggrenox indigestion there was a mild ck bump with positive troponin as high as he remained chest pain free and the etiology was likely secondary to demand ischemia cardiology was consulted and although he has peripheral disease and history of cvas and likely cardiac disease did not feel this was acs and he was to follow up with outpatient stress test and possible catherization dm ssi neuro sx essentially felt to be to low perfusion state from anemia head ct without new stroke or bleed his neuro exam was monitored without any change or worsening from baseline ppx holding anticoagulation given supertherapeutic inr code full comm with pt medications on admission wellubtrin avandia asa coumadin zocor aggenox altace labetolol advair prn discharge medications simvastatin mg tablet sig two tablet po daily daily ramipril mg capsule sig two capsule po daily daily bupropion mg tablet sustained release sig one tablet sustained release po bid times a day metoprolol tartrate mg tablet sig tablet po bid times a day disp tablet s refills dipyridamole aspirin mg cap multiphasic release hr sig one cap po bid times a day disp caps refills tylenol extra strength mg tablet sig tablets po every six hours as needed for pain disp tablet s refills avandia oral advair diskus inhalation protonix mg tablet delayed release e c sig one tablet delayed release e c po once a day disp tablet delayed release e c s refills discharge disposition home discharge diagnosis gi bleed coagulopathy myocardial damage demand ischemia anemia hx cva s discharge condition afebrile hemodynamically stable with stable hct discharge instructions please take all medications as prescribed please discontinue coumadin now please contact your primary care physician for an appointment this week please contact your physician or return to the emergency department if you have chest pain shortness of breath bleeding lightheadedness weakness or any other worrisome symptoms followup instructions please contact your primary physician for an appointment this week to discuss your hospital stay you must discuss with your physician the option of having a stress test done to evaluate for coronary artery disease please have your blood count hematocrit assessed within the next week to ensure that is remains stable please discuss with him your ongoing use of aggrenox if you continue to have foot pain contact your pcp for possible prednisone or colchicine treatment for gout please keep the following appointments arranged for you by dr office provider nhb date time provider nhb date time provider surgery nhb date time,"{
""Diagnoses"": [""syncope"", ""major surgical or invasive procedure"", ""EGD"", ""history of present illness"", ""hypertension"", ""hyperlipidemia"", ""type 2 diabetes"", ""occlusion"", ""stroke""],
""Medications"": [""melena"", ""inr"", ""hct"", ""Wellbutrin"", ""sedentary lifestyle"", ""PPD"", ""smoking history"", ""lipids"", ""CEA"", ""social history""]
}"
83468,admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint obtundation respiratory distress major surgical or invasive procedure intubation suture of wrist laceration history of present illness all information below is according to mother however patient not able to answer questions no family present i tried to call left for the day m with history of drug abuse who is an osh transfer for obtundation drug abuse and concern for suicide attempt according to mother although per osh she had changed the story several times pt was assaulted at a store yesterday and was choked with the of his sweatshirt by people assaulting him he was also sprayed in the face with mace and wallet stollen later in the day he was apparently cleaning a roasting pan and cut his wrist on a knife that was in the pan while reaching into it mother noticed he was acting different and slurring his speech he seems like he aws on something so she called ems and sent pt to osh ed where he appeared obtunded his initial vitals were bp hr rr ra he was intubated for airway protection while at osh ed he had head ct and cxr ct cervical spine which were unremarkable he was given narcan x with minimal improvement in arrousal trop neg etoh neg lactate he was transfered to our ed for further care in the ed inital vitals were t bp hr assist control tv peep f ppeak glascow initialy in rn report fast neg given bolues of fent versed given l ivf with cc total uo he had ct cervical which was overall unremarkable he had left wrist laceration sp sutures and tetanus vaccine on exam he was found to have ligature mark on neck from likely recent strangulation as well as what appeared to be cigerette burns around his penis ekg and tele notable for sinus bradycardia with hr s he was planned to be given g ca gluconate for possible bb ccb overdose but not given rn urine positive for benzos opiates cocaine he was likely given benzos and opiates for intubation but cocaine is likely recent intoxication recent vent settings assist control fio peep gas on arrival to the icu pt follows commands responds to his name opens his eyes glascow he appears comfortable intubated has bruises blood smear on knees bilaterally neck with sign of recent strangulation left wrist with stitches past medical history hcv drug abuser since age heroin and cocaine in a drug abuse program x mo hospitalized yrs ago for drug overdose nerve damage genital warts social history prior heroin and cocaine use supposedly clean x mo drug abuse x yrs hospitalized yrs ago for overdose spent some time in prison family history denied physical exam admission exam vitals bp p r o ac tv fio peep rate ppeak general responds follows commands and name no acute distress heent sclera anicteric mmm intubated neck with signs of strangulation rope mark neck supple jvp not elevated no lad lungs bilateral breath sounds clear to auscultation bilaterally no wheezes rales ronchi cv regular rate bradycardic 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 foley with urine output cc since arrival to ed has genital warts on penis also with lesions on base of penis and suprapubic area chancre appearance ext warm well perfused pulses no clubbing cyanosis or edema 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 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 lymphs monos eos baso am blood neuts lymphs monos eos baso am blood pt ptt inr pt am blood pt ptt inr pt 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 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 alt ast ld ldh alkphos totbili am blood alt ast ld ldh alkphos totbili am 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 lipase am blood lipase am blood ck mb ctropnt am blood ck mb ctropnt am blood calcium phos mg am blood calcium phos mg am blood calcium phos mg am blood calcium phos mg pm blood calcium phos mg am blood albumin calcium phos mg am blood tsh am blood hbsag negative hbsab positive hbcab negative am blood hiv ab negative am blood digoxin less than am blood lithium less than am blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg am blood hcv ab positive am blood hcv ab positive am blood type art temp fio po pco ph caltco base xs intubat not intuba am blood type art tidal v peep fio po pco ph caltco base xs assist con intubat intubated am blood o sat microbiology sputum acid fast smear final acid fast culture preliminary inpatient prelim neg stool clostridium difficile toxin a b test final inpatient neg sputum acid fast smear final acid fast culture preliminary inpatient prelim neg sputum acid fast smear final acid fast culture pending inpatient prelim neg immunology hiv viral load ultrasensitive final inpatient negative rapid respiratory viral screen culture respiratory viral culture final respiratory viral antigen screen final inpatient negative influenza a b by dfa not processed inpatient urine legionella urinary antigen final inpatient negative sputum acid fast smear final acid fast culture preliminary inpatient prelim neg blood culture blood culture routine pending inpatient rapid respiratory viral screen culture respiratory viral culture final respiratory viral antigen screen final inpatient urine neisseria gonorrhoeae gc nucleic acid probe with amplification final chlamydia trachomatis nucleic acid probe with amplification final inpatient negative sputum gram stain final respiratory culture final streptococcus pneumoniae legionella culture preliminary fungal culture preliminary paecilomyces species stemphylium sp inpatient urine urine culture final inpatient serology blood rapid plasma reagin test final inpatient negative serology blood lyme serology final inpatient negative blood culture blood culture routine pending inpatient mrsa screen mrsa screen final ekg ectopic atrial rhythm low qrs voltage in the limb leads compared to the previous tracing of p wave axis is now altered consistent with an ectopic atrial rhythm cxr impression standard position of lines and tubes no pneumothorax bibasilar consolidation left greater than right possible atelectasis though aspiration or pneumonia should be considered in the appropriate clinical circumstances mild cardiomegaly cta neck impression patent cervical and intracranial vasculature several tiny foci of air external to the trachea these are felt most likely to represent small foci of air within small superficial veins injury to the trachea is felt to be less likely note added at attending review incompletely imaged there appears to be at least partial left lower lobe collapse with air bronchograms this revised finding was discussed by telephone with dr by dr at pm on cxr there are low inspiratory volumes allowing for this there is increased density at the left base suspicious for worsening left lower lobe collapse and or consolidation a small left effusion would be difficult to exclude the cardiac silhouette pulmonary hila and interstitial markings are all prominent while these findings could relate to cardiopulmonary failure they are likely also accentuated by low lung volumes no pneumothorax detected compared with earlier the same day the left base opacity is greater the inspiratory volumes are lower and associated with this and the vascular markings and hila are more prominent ct chest impression complete consolidation of the left lower lobe and the medial base of the right lower lobe consistent with pneumonia multifocal ground glass opacities in the upper lobes indicates spread of infection ekg sinus rhythm within normal limits compared to the previous tracing p wave axis is now consisent with sinus rhythm cxr impression ap chest compared to through large scale consolidation in both lower lobes left greater than right is improving pleural effusion small on the left also decreased heart size normal mild pulmonary edema on has not recurred no pneumothorax brief hospital course m with pmh of hcv is an osh transfer for obtundation cocaine abuse sinus bradycardia and concern for suicide attempt found to have severe strep pneumo pneumonia respiratory distress pna patient was intubated for respiratory distress patient s ct showed dense consolidation of lll and medial rll scattered ground glass opacities suggestive of significant pna sputum grew strep pneumo blood cultures were ngtd patient was initially treated with ceftriaxone azithro and vancomycin d c d on however narrowed to ceftriaxone given culture results in the icu pt required significant amounts of o with high flow mask however improved to l nc satting just prior to transfer to the floor induced sputum for afb smear was negative x urine legionella negative viral culture negative hiv negative pt s symptoms markedly improved upon transfer to the medical floor he was on room air by morning of floor transfer and remained on room air without any signs of respiratory distress during the remainder of his hospitalization on day of discharge strep culture was noted to be resistant to pcn however given his marked improvement on ceftriaxone he was continued on cefopodoxime mg to complete a total of days of therapy hemoptysis developed shortly after extubation possibly due to frequent coughing trauma from recent intubation hemorrhage from pneumonia more often with staph pna but can also see strep pna markedly improved during admission hct remained stable and pt remained on room air afb neg x obtundation drug overdose concern for suicide attempt in young male with signs of neck strangulation wrist laceration and drug abuse however per mother there is concern for assault urine positive for cocaine urine also pos for benzos and opiates although unclear if this is from his sedating meds given during intubation osh records were positive for cocaine and opiates neg for benzos suggesting he probably consumed opiates and cocaine commonly abused drugs include ethyl alcohol acetaminophen opiates benzodiazepines barbiturates salicylates cocaine amphetamines ethylene glycol and methanol patient s only presenting signs include obtundation on trasnfer pt was bradycardic in the s urine and tox screen remarkable for cocaine benzos and opiates remainder all negative intubated for airway protection patient with small osmolar gap normal which has since resolved would expect to see pos gap in methanol ethylene glycol sorbitol mannitol patient was weaned off sedation and extubated without issues on the first day in the icu bradycardia sinus bradycardia on ekg hr s differential includes tox ingestion such as bb ccb methyldopa lithium digoxin clonidine amiordarone antiarrythmics withdrawal from cocaine sick sinus syndrome although unlikely in otherwise health young male with no prior arrythmias vasovagal less likely since that is often self limited and transient hypothermia was of consideration carotid pressure upon strangulation although would expect that to be self limited hypothyroidism increased intracranial pressure cushings reflex although head ct from osh negative for signs of increased pressure inferior infarct in pt with recent cocaine intox although no st changes or twi on ekg severe prolonged hypoxia although pt appeared to have preserved o sat from osh and was intubated for obtundation only infections such as legionella typhoid fever lyme viral myocarditis endocarditis can also present like this although no description of recent febrile uri like illnesses and no clinical signs such as olser janeaway splinter hemorrhage lithium level dig level negative tsh normal troponin ck mb trop neg at osh all normal lyme titer negative patient s bradycardia resolved and upon transfer hr was patient stated that he thinks he took clonidine transient bradycardia most likely due to clonidine overdose benzo opiates or withdrawal from prior stimulants causing excess parasympathetic effect possible suicide attempt initial concern for suicide attempt given signs of neck strangulation wrist laceration and drug abuse on talking to the patient sounds like he was trying to get high by taking all these meds rather than kill himself lesion on neck is from strangulation during mugging rather than suicide attempt cut on wrist was reportedly an accident while washing dishes per him and his mother psych was consulted and saw patient patient was initially section with a sitter however psych spoke with the patient further and decided he does not meet criteria for section sitter was stopped patient was monitored with plan for bentyl mg po q h prn abdominal pain and robaxin mg q hrs prn muscle cramps neither of which were needed and ibuprofen mg q hrs prn muscle pain which may occur if opiate withdrawal develops additionally ciwa used for withdrawal symptoms however never showed signs of etoh benzodiazepine withdrawal psychiatry and social work followed the patient closely during admission to assess for safety and suicidality pt repeatedly reported that he was not trying to harm himself and was simply trying to get high as his girlfriend wanted to party on new year s for her bday repeatedly said that the neck wound was from being strangled when he was trying to get his girlfriend who uses drugs out of a crack house he reported that wrist wound due to accidentally injury at home psychiatry deemed that he was not a candidate for section nor did he warrant inpatient psychiatric admission they believed him to be in the pre contemplative phase he has a scheduled appointment with an outpatient psychiatrist soonest available of note pt has served alot of jail time due to drugs and his long term girlfriend uses drugs recently released from prison anxiety pt reports anxiety as a trigger to his substance use requests clonidine and benzos this was no given given pt s reported history of missuse and overdose on these substances this was explained to patient pt reported he uses his home neurontin for anxiety told patient that best option for him would be an ssri and continued therapy he was not interested in ssri therapy and requested benzos this was not offered anemia hemoptysis was minimal per report guaiac d stools trended hct could be due to pna remained stable during admission hct on day of discharge this can be further followed in the outpatient setting transaminitis mildly elevated alt likely related to chronic hcv no fever or leukocytosis would consider outpatient gi evaluation wrist lac s p suture in ed and tetanus shot pt was given wound care and dressing changes he is to have suture removal in days after placed pcp f u scheduled wrist neuropathy continued neurontin per outpt regimen pt reports followed by a at and prescribed neurontin pt requested rx for this however called pharmacy cvs pt got mg tid neurontin on this was not prescribed upon dc decreased urine output uop initially decreased upon hospital transfer fena consistent with pre renal state cr normal no sign of renal dysfunction uop was trended and responsive to ivfs resolved wrist laceration mother and patient report this was an accident from washing dishes now s p suture in ed and tetanus shot daily dressings applied sutures to be removed days from placement d pt was set up with pcp appointment for this hcv not currently on treatment hiv and hbv negative pt can follow up as an outpatient to consider need for treatment currently unlikely to be a good candidate penile lesions per patient he had genital warts frozen at a health clinic last week urine gonorrhea chlamydia and rpr negative medications on admission neurontin discharge medications neurontin mg tablet sig one tablet po three times a day cefpodoxime mg tablet sig two tablet po twice a day for days disp tablet s refills discharge disposition home discharge diagnosis strep pneumo pneumonia drug overdose heroin cocaine benzodiazepines clonidine l wrist injury with suture repair anemia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted with an unintential overdose of multiple drugs and you were found to have a severe pneumonia due to this you were intubated placed on artifical breathing and admitted to the icu you were monitored by psychiatry social work and infectious diseases your pneumonia improved and you will be discharged to complete your course of antibiotic therapy in addition you were seen by psychiatry and social work to help you with resources for anxiety and substance abuse it is of extreme importance that you stop using drugs in order to avoid further harm to your body including death in addition this will help to keep you out of jail please follow up with your pcp and psychiatry after discharge you reported that you did not intentionally harm yourself or have any plans to harm yourself however should this change call or go to the nearest er immediately you will need to have your stitches removed by your pcp at your scheduled follow up medication changes none your pharmacy reports that you recently received a prescription for neurontin that will be good until your next follow up appointment please follow up with the appointments below and take all of your medications as prescribed followup instructions name e md location community health center address phone appt at pm name md location bu neurology associates address sutie b phone appt at am you have also been placed on the wait list for a sooner appt if you are unable to make this appt please call the office within hours of appt to cancel your prior is no longer at this practice name location community health center address phone appt at pm,"{
""Diagnoses"": [""Obtundation"", ""Drug abuse"", ""Concern for suicide attempt""],
""Medications"": [""None""]
}"
91539,admission date discharge date date of birth sex f service plastic allergies no known allergies adverse drug reactions attending chief complaint left lateral thigh wound major surgical or invasive procedure drainage deep abscess hematoma left hip open biopsy deep left femur application of vacuum assisted closure sponge greater than cm left lower extremity reconstruction with latissimus muscle free flap from left back local advancement flap closure of left thigh wound cm debridement of skin subcutaneous tissue and muscle lower extremity thigh wound cm saphenous vein graft to venous anastomosis history of present illness f with a history of high grade spindle cell sarcoma of the left thigh subsequent pre operative chemotherapy radiation and resection in underwent pre operative chemo xrt her post operative course was complicated by radiation induced femur fracture initially treated with orif plating bone graft in and a left total knee arthroplasty due to recurrent pain from non the plates were removed and she was coverted to an intramedullary rod in she developed a complex abscess of the left lateral thigh wound which was washed out and a vac placed id was consulted at the time she completed a prolonged course of iv vancomycin for mrsa abscess followed by doxycycline and rifampin during this evaluation she is on ancef monotherapy yesterday she underwent repeat washout in or with vac placement we are consulted to assist in wound management past medical history high grade soft tissue sarcoma s p resection pathologic fx l femur s p orif and bone graft excision of benign pulmonary nodules on hypercholesterolemia social history former bookkeeper married to her nd husband has children from a previous marriage lives in ma which is about a hour drive away non smoker non drinker prior to admission ambulatory with a crutch under right arm former bookkeeper retired family history mother is in her s with alzheimer s and h o colon cancer in her s daughter has clotting disorder no bleeding diathesis physical exam on presentation vs t max hr rr ra jp output since serosanguinous cc cc cc cc cc cc gen resting comfortably in chair nad heent eomi perrl mmm op clear pale conjuntiva anicteric sclera neck no jvd no lad back two jp drains in place near latissimus dorsi flap resection small mildly tender mass without overlying ecchymosis at inferior portion of flap cv regular rate and rhythm no murmurs normal s s resp ctab no wheezes or crackles gi soft ntnd no hsm bs ext no c c e left thigh with small degree of ecchymoses at border of flap two jp drains in place without drainage neuro cnii cnxii intact strength and sensation intact throughout psych a ox slightly blunted affect pertinent results am wbc rbc hgb hct mcv mch mchc rdw plt ct am wbc rbc hgb hct mcv mch mchc rdw plt ct am wbc rbc hgb hct mcv mch mchc rdw plt ct am wbc rbc hgb hct mcv mch mchc rdw plt ct am pt ptt inr pt am pt ptt inr pt am ret aut am glucose urean creat na k cl hco angap am glucose urean creat na k cl hco angap am calcium phos mg am calcium phos mg pm caltibc hapto ferritn trf pm vanco brief hospital course the patient was admitted to the plastic surgery service on for repair of her left lateral thigh defect status post washout of her an abscess of her left femur and vacuum placement of the defect by the orthopedics service neuro post operatively the patient received dilaudid iv pca with good effect and adequate pain control when tolerating oral intake the patient was transitioned to oral pain medications she did not require additional pain medication by prescription upon discharge cv the patient received one unit of prbc peri operatively given the length and complexity of the procedure and was transfused again with units pod for a hematocrit of the patient responded appropriately and has since maintained hematocrit levels consistently in the range however medicine was consulted given her anemia and baseline hematocrit of please refer to hematology below otherwise the patient remained hemodynamically stable and asymptomatic vital signs were routinely monitored pulmonary the patient was stable from a pulmonary standpoint vital signs were routinely monitored she was successfully weaned off of oxygen via nasal cannula and maintained oxygen saturations in the high s prior to discharge gi gu post operatively the patient was given iv fluids until tolerating oral intake her diet was advanced when appropriate which was tolerated well intake and output were closely monitored on pod however she was found to have an elevated creatinine of with a baseline of at this point it is unclear whether it is pre renal or renal secondary to possible nephrotoxicity to ciprofloxacin which was recently discontinued urine osmolality creatinine eosinophil smear urine analysis and urine culture were ordered as well as serum osmolality electrolytes random vancomycin level and c diff toxin given the patient s expressed desires to go home today with vna and vna arrangements to draw and send these respective labs with follow up by the patient s pcp dr and office for weekend coverage id peri operatively the patient received vancomycin and ciprofloxacin for broad coverage based on her history of coagulase negative staph by previous bone biopsy her wound cultures were found negative for organisms as were her cultures id recommended sending a s rna pcr which returned on as positive for staph epidermidis the recommendations at this time are to continue vancomycin at her current dose of mg iv q hours and discontinuing her ciprofloxacin to tailor her coverage heme as discussed earlier medicine was consulted for the patient s anemia iron studies were consistent with iron deficiency anemia and the patient was placed on daily iron supplements she does have a history of guiac positive stools with recent colonoscopy in the last year with unremarkable findings recommendations at this time are to start ppi therapy daily and follow up with her pcp for elective egd to investigate an upper gi source for her guiac positive stools the patient was advised to stay on her aspirin therapy as well as month of subcutaneous lovenox for dvt prophylaxis prophylaxis the patient received subcutaneous heparin during this stay and will be discharged home on mg daily for month msk vascular the patient had consistent vioptix saturations in the mid s s for her graft the graft appeared healthy with clean incision lines and dopperable signals on discharge at the time of discharge on pod the patient was doing well afebrile with stable vital signs tolerating a regular diet ambulating with crutches voiding without assistance and pain was well controlled medications on admission simvastatin mg qd aspirin mg qd acetaminophen mg q h prn fever pain mvi tablet qd vitamin d units qd calcium carbonate mg po q h docusate mg tablet discharge medications vancomycin mg recon soln sig five hundred mg intravenous q h every hours disp iv bags refills aspirin mg tablet chewable sig tablet chewables po daily daily for days disp tablet chewable s refills acetaminophen mg tablet sig tablets po q h every hours as needed for fever pain max day do not exceed gms mg of tylenol per day oxycodone mg tablet sig tablets po q h every hours as needed for pain loperamide mg capsule sig one capsule po qid times a day as needed for loose stool over the counter medication for loose stool ferrous sulfate mg mg iron 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 bid times a day disp capsule delayed release e c s refills calcium carbonate mg calcium mg tablet chewable sig one tablet chewable po tid times a day as needed for indigestion heartburn take tums over the counter replacement lovenox mg ml syringe sig one subcutaneous once a day for days disp refills discharge disposition home with service facility community nurse care inc discharge diagnosis chronic left lateral thigh wound 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 personal care you may keep your incisions open to air clean around the drain site s where the tubing exits the skin with soap and water strip drain tubing empty bulb s and record output s times per day a written record of the daily output from each drain should be brought to every follow up appointment your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount be careful that your bra does not disrupt or put pressure on your left posterior incision site you may consider wearing a camisole until your follow up visit with dr you may shower daily with assistance as needed be sure to secure your upper body drains to a laniard that hangs down from your neck so they don t hang down and pull out you may secure your leg drains to your waist by tying a pair of old stockings around your waist and attaching the drains to the panel of the stockings no pressure on your left thigh flap site okay to shower but no baths until after directed by your doctor you may dangle left lower extremity minutes tid you should not be bearing any weight on her left lower extremity touch down weight bear only but patient unable to walk with walker and not partial wt bear on her lle patient should elevate her left lower extremity when not dangling activity you may resume your regular diet do not lift anything heavier than pounds or engage in strenuous activity for weeks following surgery medications resume your regular medications unless instructed otherwise and take any new meds as ordered you may take your prescribed pain medication for moderate to severe pain you may switch to tylenol or extra strength tylenol for mild pain as directed on the packaging please note that percocet and vicodin have tylenol as an active ingredient so do not take these meds with additional tylenol take prescription pain medications for pain not relieved by tylenol take colace mg by mouth times per day while taking the prescription pain medication you may use a different over the counter stool softener if you wish do not drive or operate heavy machinery while taking any narcotic pain medication you may have constipation when taking narcotic pain medications oxycodone percocet vicodin hydrocodone dilaudid etc you should continue drinking fluids you may take stool softeners and should eat foods that are high in fiber call the office immediately if you have any of the following signs of infection fever with chills increased redness swelling warmth or tenderness at the surgical site or unusual drainage from the incision s a large amount of bleeding from the incision s or drain s fever greater than of severe pain not relieved by your medication return to the er if if you are vomiting and cannot keep in fluids or your medications if you have shaking chills fever greater than f degrees or c degrees increased redness swelling or discharge from incision chest pain shortness of breath or anything else that is troubling you any serious change in your symptoms or any new symptoms that concern you drain discharge instructions you are being discharged with drains in place drain care is a clean procedure wash your hands thoroughly with soap and warm water before performing drain care perform drainage care twice a day try to empty the drain at the same time each day pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup record the amount of drainage fluid on the record sheet reestablish drain suction followup instructions infectious disease provider md date time located on the basement level plastic reconstructive surgery dr at located on the completed by,{}
87344,admission date discharge date date of birth sex f service medicine allergies gluten attending chief complaint asystolic in home arrest s p resuscitation major surgical or invasive procedure endotracheal intubation central venous line in right internal jugular vein atrial line foley catheterization cardiac catheterization history of present illness f with pmhx of htn found down at home at roughly am on the day of admission non responsive by husband who called ems patient was found to be asystolic and then subsequently vfib epinephrinex atropinex shocks x and started on amiodarone with return of sinus rhythym at this time a large anterior territory stemi was revealed on ekg and she was brought to in ed code stemi called and patient was brought to cath lab at cath a tortuous lad with distal lad lesion was found but determined to be unintervenable disease and medical management was undertaken lv gram showeeef with apical dyskinesis and non infarct zone hyperkinesis she was given aspirin plavix mg lopressor and intergrillin she was continued on amiodarone gtt and started on dopamine gtt on arrival to the ccu cooling protocol was undertaken review of systems could not be obtained as patient was intubated and sedated however according to her husband the day prior to the event the patient had been more fatigued than usual she told him at am that she was having a hard time sleeping and got up to take a buspar and lay on the couch he heard a loud moan around in the morning that woke him from sleep at which point he got up to find her unresponsive of note patient s mother is currently hospitalized in the at past medical history cardiac risk factors hypertension cardiac history cabg none percutaneous coronary interventions none pacing icd none other past medical history anxiety medications atenolol fosamax busbar social history tobacco history none etoh unknown illicit drugs unknown family history pt lives in with husband has multiple family and friend supports physical exam vs t bp hr rr o sat vented ac x fio general wdwn 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 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 skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid femoral popliteal dp pt left carotid femoral popliteal dp pt decorticate posturing pertinent results admission labs am freeca hgb calchct o sat carboxyhb met hgb glucose lactate na k cl tco pt ptt inr pt plt count wbc rbc hgb hct mcv mch mchc rdw asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg tsh hba c caltibc ferritin trf albumin calcium phosphate magnesium iron ck mb mb indx ctropnt lipase alt sgpt ast sgot ck cpk alk phos tot bili glucose urea n creat sodium potassium chloride total co anion gap urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg urine bnzodzpn neg barbitrt neg opiates neg cocaine neg amphetmn neg mthdone neg cardiac catheterization comments coronary angiography in this right dominant system demonstrated single vessel disease the lmca had no angiographically apparent disease the lad was a tortuous vessel and had a distal occlusion with faint collaterals the cx and rca were without angiographically apparent disease resting hemodynamics demonstrated mildly elevated systemic arterial pressures with sbp mm hg and dbp mm hg there was no transaortic valvular gradient left ventriculography revealed no mitral regurgitation the lvef was estimated at with focal apical dyskinesis final diagnosis one vessel coronary artery disease mild systolic ventricular dysfunction acute anterior myocardial infarction managed by medical therapy cxr single frontal view of the chest there is an endotracheal tube with the tip approximately cm away from the carina bilateral interstitial thickening especially in bilateral upper lobes and perihilar areas are noted the heart and mediastinal are normal there is no pleural effusion or pneumothorax impression bilateral upper lung and perihilar interstitial thickening likely representing pulmonary edema non contrast head ct findings there is no intracranial hemorrhage edema mass effect or vascular territorial infarction white matter differentiation is well preserved the ventricles and sulci are normal in size and configuration there is no fracture the included paranasal sinuses reveal an air fluid level dependently in the maxillary sinus on the right the included mastoid air cells are clear impression no acute intracranial process with preservation of white matter differentiation and no evidence of cerebral edema mr head final report mri of the brain with and without contrast dated clinical history year old woman status post cardiac arrest now with neurological recovery but had questionable findings on the eeg that suggests mini seizures please evaluate for any changes that suggest ischemia technique mri of the brain was performed both before and after the administration of intravenous contrast with imaging sequences including sagittal t axial t axial gradient echo axial t propeller axial flair propeller sagittal t post contrast axial t post contrast and axial diffusion weighted imaging comparisons head ct dated findings image quality is markedly degraded by patient motion especially on the post contrast imaging there is no decreased diffusion to indicate an acute infarct multiple t and flair hyperintense foci are noted in the periventricular and subcortical white matter a nonspecific finding the ventricles sulci and cisterns are age appropriate there is no midline shift there is no definite evidence of hemorrhage although there is marked degradation of image quality on the gradient echo sequence there is no extra axial fluid collection the flow voids of the major vessels are grossly unremarkable minimal mucosal thickening is noted in the maxillary sinuses and ethmoid air cells the orbits and soft tissues are grossly unremarkable impression grossly unremarkable mri without evidence of acute intracranial pathology or acute infarct although image quality is markedly degraded by patient motion scattered white matter hyperintensities are a nonspecific finding however given the patient s age the findings likely reflect the sequela of chronic microangiopathy eeg findings routine time sampling showed mixed theta frequencies which at times became rhythmic and semi rhythmic for periods of several seconds at times there were intermixed sharp features as the recording progresses the overall background frequency appears to increase slightly from an average of hz to hz there are occasional phase reversing sharps and spikes noted at t p and f these were most notable at t spike detection programs there were entries in these files these contained periods of rhythmic theta activity as described in the routine sampling portions there were also occasional phase reversing sharps and spikes at t p and f seizure detection programs there were entries in these files these contained periods of rhythmic theta activity occasionally with sharper features concerning for potential seizure activity there were also isolated phase reversing sharps and spikes at t p and f these were most frequent at t they were occasionally followed by seconds of higher voltage sharp theta activity lasting two to four seconds there were also independently occurring bursts of sharp rhythmic more generalized theta activity of varying length concerning for possible seizure activity there were no clear clinical correlates with any of these findings on video pushbutton activations there were no entries in these files sleep no normal sleep architecture was noted on the study cardiac monitor showed a generally regular rhythm impression this telemetry captured no pushbutton activations routine sampling showed a moderate encephalopathy consisting of mixed theta frequencies at times there were bursts of generalized sharp rhythmic theta activity lasting several seconds which are concerning for potential seizure activity though no obvious clinical correlate is observed on video there were also infrequent isolated phase reversing sharps and spikes occurring at t p and f as described above tte the left atrium is normal in size left ventricular wall thicknesses and cavity size are normal there is mild regional left ventricular systolic dysfunction with distal lv and apical akinesis lvef the remaining segments are hyperdynamic 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 there is no aortic valve stenosis no aortic regurgitation is seen the mitral valve leaflets are moderately thickened mild mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened moderate tricuspid regurgitation is seen there is moderate pulmonary artery systolic hypertension there is no pericardial effusion brief hospital course f with pmhx of htn found unresponive at home s p stemi from distal lad lesion that was not intervened upon who underwent artic sun cooling procedure with subsequent cardiac recovery and persistent neurologic impairment coronaries patient presented apparently asystolic and then with vfib from anterior stemi with distal lad lesion which could not be intervened only known risk factor was hypertension cardiac enzmes elevated on admission peaked at ck ckmb trop she was managed medically with integrellin gtt aspirin statin betablocker repeat tte on showed ef of apical akinesis and no lv clot or thrombus hba c was she was initially on mg atorvastatin at half dose while on amio gtt which was increased to mg po daily prior to discharge pump no known history of heart failure only htn patient had ef on lv gram with apical dyskinesis and non infarct zone hyperkinesis she did well after coming off cooling and was normal tensive for the most of her hospitalization beta blockers were started acei held mild orthostasis pt should start this once orthostasis resolved rhythm patient s arrest was asystole and then vfib she presented to the hospital in sinus brady on amiodarone gtt she continued to be bradycardic during the cooling process which resolved with rewarming the electrophyisology team was consulted who felt that she did not require further amiodarone for prophylaxis of a a ventricular arrhythmia and would not require icd placement at this time but will follow with her as an outpatient respiratory patient was intubated in the field she was initiatlly treated empirically for aspiration pnemonia with cefepime flagyl cxr performed on admission showed no evidence of infiltrate she continued without any significat pulmonary secretions no fevers and had no difficulty with oxygenation antibiotics were discontinued and she was extubated after rewarming on metabilic anion gap met acidosis present on admission with elevated lactate likely from cardiogenic shock and hypoperfusion resolved with return of perfusion neuro patient was decorticate posturing on admission to ccu concerning for poor prognosis even with cooling patient tolerated hours of artic sun cooling protocol and upon rewarming patient was noted to have improvement in neurologic status head ct performed after rewarming was unremarkable for bleed or edema continuous eeg monitoring revealed questionable spikes that were suggestive of seizure activities these spikes were significantly reduced with low dose ativan and she was started on keppra for seizure prophylaxis mr was performed that was largely unremarkable she will require outpatient neurologic follow up as well as intensive neurologic rehabilitation transaminitis likely elevated in setting of arrest hypoperfusion also started on amio which is unlikely to cause transaminitis so acutely lfts trended down on discharge normocytic anemia no history of anemia no signs of bleeding during this hospital stay no clear source of bleeding hct was trended and remained stable iron studies with nl b and haptoglobin high ferretin and low tibc with low reticulocyte index likely anemia of chronic disease with inappropriate bone marrow responses she will need outpatient follow up with regard to this condition htn on atenolol as outpatient for management of htn now on hold with start of bb and acei medications on admission atenolol unknown dose fosamax mg weekly busbar unknown dose calcium and vitamin d discharge medications aspirin mg tablet sig one tablet po daily daily levetiracetam mg tablet sig one tablet po bid times a day potassium sodium phosphates mg powder in packet sig one powder in packet po bid times a day acetaminophen mg tablet sig two tablet po q h every hours as needed for pain fever metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po once a day hold for sbp hr atorvastatin mg tablet sig one tablet po once a day discharge disposition extended care facility discharge diagnosis st elevation myocardial infarction ventricular fibrillation hypertension discharge condition ambulating with one assist on fall precautions because of memory and judgement issues poor short term memory needs ot and supervision discharge instructions you had a heart attack and your heart stopped for a short time before the emt s revived you a cardiac catheterization was done to look at your coronary arteries and found a total blockage in your left coronary artery the cardiologists were unable to place a stent or open the artery you have been managed with medicines since then and have been stable with no further chest pain or irregular rhythms your heart function is weak because of the heart attack but hopefully will improve in the next few months you need to monitor yourself for signs of fluid retention information regarding this was reviewed with you you had an eeg that showed some mild seizures you were started on a medicine to prevent this medication changes stop taking atenolol start taking an aspirin daily to prevent another heart attack start taking metoprolol to lower your hear rate and prevent help your heart recover from the attack start taking atorvastatin to lower your cholesterol start taking keppra to prevent any seizures start taking neutrophos to replete your phospate levels weigh yourself every morning md if weight goes up more than lbs in day or pounds in days adhere to gm sodium diet followup instructions ep md phone date time pm cardiology md phone date time at pm primary care md p unit phone date time at pm neurology dr phone date time please call the office to make an appt on completed by,"{
""Diagnoses"": [""asystolic"", ""vfib"", ""htn"", ""non responsive"", ""aneurysm""],
""Medications"": [""epinephrine"", ""atropine"", ""shocks"", ""amiodarone"", ""aspirin"", ""plavix"", ""lopressor"", ""dopamine"", ""cooling protocol""]
}"
75023,admission date discharge date service medicine allergies no known allergies adverse drug reactions attending chief complaint altered mental status major surgical or invasive procedure intubation history of present illness the patient is a yo man with h o htn hl dm cri baseline creatinine of who presented from home with hypothermia bradycardia and ams as the patient is altered the majority of the history was obtained from the patient s daughter and medical records in brief the patient was reportedly in his normal state of health until last week when he had several days of diarrhea and anuria per his daughter she gave him his night medications last night and then this morning he was noted to be more lethargic given this constellation of symptoms she called and the patient was brought to the ed in the ed his initial vs were t hr np rr sat l nc he kept repeating to the ed staff that he was having diarrhea and hadn t urinated he was in sinus rhythm and normotensive until he was taken to the ed room per ed resident there he was noted to become intermittently hypotensive to the s in the setting of bradycardia to the s he was given iv mg atropine x with his pressures reponding to increases in his hr he was also given ivf rescusitation of l his ekg was noted to ste inferiorly v v with q waves inferiorly std depression in avl flat twaves in lead i and lateral leads stemi team was called at as well as toxicology and he was started on a heparin gtt and was given asa mg pr he was found to have hyperkalemia and and an initial lactate of for which he was given calcium gluconate and albuterol nebs a cxr was obtained which showed low lung volumes but no pneumonia vascular congestion or pleural effusion a kub ct abd was also obtained given the bradycardia hypotension elevated lactate with a prelim read showing no acute intrabdominal process he was started on vancomycin and flagyl per discussion with his daughter the patient s code status was reversed from dnr dni to full code given his ams he was intubated in the ed he was induced with rocuronium and etomidate and was noted to go into asystole chest compressions were started and he was given round of epinephrine atropine a pulse was noted after minutes of compression his bps were noted to be in the s following epi administation during placement of his femoral line the pt s systolic pressures were noted to drop in the s with hr still in the s he was then started on dopamine pressor support with an increase in bp to last sbp recorded was s he was then admitted to the ccu for further evaluation per report the ed resident called his previous pcp and was informed that the patient had been lost to follow up since and was fired for non compliance there was also reportedly a question of narcotics abuse in the past between the patient and his daughter a message was also left with the patient s pcp in the ccu renal was consulted and recommended a fluid challenge with l of ns and l of sodium bicarbonate rather than immediately starting cvvh his repeat potassium was elevated to so he was given another dose of calcium gluconate insulin and dextrose he was placed on artic sun and attempts to place an a line were unsuccessful given the patient s complex medical issues he was transferred to the micu for further management on the floor the patient opens his eyes to voice but otherwise is unable to contribute to the history ros unable to obtain secondary to patient sedation past medical history type diabetes hyperlipidemia hypertension oa of the shoulder gout chronic kidney disease peripheral neuropathy gerd social history he occasionally smokes and drinks but not to a significant degree he is a retired maintenance worker at he emigrated from family history n c physical exam general pt currently intubated not responding to verbal commands or withdrawing from pain heent mm b l minimally reactive pt just received atropine cardiac normal s s rate in the s no m r g lungs cta b l abdomen soft no facial grimacing with palpation no bowel sounds noted extremities no edema pertinent results tte 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 is unusually small regional left ventricular wall motion is normal left ventricular systolic function is hyperdynamic ef there is no ventricular septal defect the right ventricular cavity is mildly dilated with moderate global free wall hypokinesis there is sparring of the apical rv sign suggestive of acute rv strain from pulmonary embolism there is abnormal septal motion position consistent with right ventricular pressure volume overload the aortic root is mildly dilated at the sinus level the aortic valve leaflets are moderately thickened the study is inadequate to exclude significant aortic valve stenosis trivial 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 no pericardial effusion impression acute rv strain suggestive of pulmonary embolism ct abdomen no acute intra abdominal or pelvic pathology left renal cyst and bilateral renal hypodensities that are too small to characterize am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap am blood alt ast ld ldh ck cpk alkphos totbili am blood ck mb mb indx ctropnt am blood type art po pco ph caltco base xs am blood lactate k brief hospital course mr was a yo man with h o dm htn and hl who presented from home with lethargy and ams he was intubated for worsening mental status in the ed sustained a pea arrest and he was transferred from the ccu to the micu for further management of multi organ failure he became hypotensive during his course in the icu and the family had decided that they did not want to proceed with resusitation or escalation in care he was given more liters of fluid however he did not respond patient expired at pm on s p pea arrest the patient reportedly went into pea arrest with inducation for intubation with rocuronium and etomidate he received atropine epi x and mins of chest compressions before a pulse was detected pt s bp was noted to be in s following resuscitation he was started on the arctic sun protocol with core temperatures reaching degrees celsius at pm ddx for pea arrest at this time is long and includes hypotension in the setting of anesthesia induction v hyperkalemia v pe v acs echo showed severe right heart strain concerning for pe hyperkalemia the patient s k on presentation was which decreased to with two doses of insulin calcium gluconate and glucose his hyperkalemia is likely secondary to acute on chronic renal insufficiency and exacerbated by his lisinopril renal is aware and had discussed starting cvvh if needed complete heart block per pt would become bradycardic in the ed to the s with resulting hypotension to the s pt received atropine mg iv x with improvement in his heart rate and bps his ekgs in the ccu appeared to be in heart block with a junctional escape ddx includes beta blocker toxicity v metabolic acidosis v hyperkalemia pt s current ventricular rate is in the s on dopamine pacer pads in place hypotension pt was reportedly normotensive in triage following his arrest his bps were noted to be in the s per ed during placement of the femoral central line he became hypotensive to the s and required approximately l of ivf was started on dopamine which was uptitrated to mcg will titrate dopamine for goal maps hypotension may be hypovolemia given his diarrhea at times he was noted to be hypotensive when he became bradycardic however his last episode of hypotension occured in the setting of his heart rate in the s s sepsis needs also to be considered given the leukocytosis hypothermia diarrhea diarrhea pt reported diarrhea over several days unfortunately pt is intubated and daughter is a poor historian making history of the diarrhea difficult to clarify will monitor stool output to eval bloody vs watery pt had ct abd pelvis performed will await final read to look for colitis diarrhea could be infection ischaemic colitis metabolic acidosis pt noted to have a significant anion gap acidosis with ag hco ranging suspect this is due to the elevated lactate although elevated bun could be contributing he was started on a bicarb gtt and his hco improved to transaminits on arrival to the ed the patient was noted to have transaminitis with ast alt of it appears that these labs were drawn prior to the time of the cardiac arrest though this history is uncertain his elevated transaminases are likely secondary to shock liver in the setting of significant hypotension dispo expired pm medications on admission omeprazole mg daily gabapentin mg lisinopril mg daily colchicine mg daily allopurinol mg daily metoprolol xr mg calcium citrate mg humulin n u qhs discharge medications n a discharge disposition expired discharge diagnosis expired discharge condition expired discharge instructions n a followup instructions n a md,"{
""Diagnoses"": [""hypothermia"", ""bradycardia"", ""altered mental status"", ""hypotension"", ""anuria"", ""diarrhea""],
""Medications"": [""iv atropine""]
}"
89721,admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint observed syncope at pcp major surgical or invasive procedure endotracheal tube placement history of present illness mr is a year old homeless male with hx of polysubstance abuse cocaine recent diverticulitis and seizure disorder presenting from pcp s office with witnessed syncope as per admission note pt went to pcp to pick up methadone prescription and felt light headed with slight left sided chest pain relieved with nitroglycerin of note pt denied seizure activity but has seizure history on dilantin last seizure a few days ago recently found to have diverticulitis on bactrim and flagyl ct abdomen pelvis in ed did not show diverticulitis on the floor pt was initially complaining of whole body pains from his fibromyalgia and peripheral neuropathy and was requesting methadone around pm pt had a visitor who smelled of marijuana was walking around floor but then at pm nurse found the patient unresponsive code blue was called pt was satting well fsg normal bp subsequently had seizure o sats dropped into s decision made to intubate to protect airway pt then had another episode of seizure vs combative behavior then proceeded to vomit after already being intubated on arrival to the micu the patient was intubated and sedated required multiple propofol boluses for agitation also had an episode of maroon vomitus guaic positive ros could not obtain patient sedated past medical history psychotic disorder seizure disorder substance abuse substance dependence syncope and collapse injury of head coronary artery disease mitral valve prolapse peptic ulcer asthma chest pain osteomyelitis s p left th toe amputation peripheral neuropathy fibromyalgia social history has been homeless for months living at alewife station previously had worked in landscape currently using nicotine lozenges to stop smoking denies alcohol use does not wish to disclose recreational drug use denies iv drug use family history none physical exam admission physical exam general intubated sedated heent sclera anicteric neck supple cv regular rate and rhythm normal s s no murmurs rubs gallops lungs clear to auscultation bilaterally no wheezes rales ronchi abdomen soft non tender non distended bowel sounds present ext warm well perfused pulses no clubbing cyanosis or edema discharge physical exam t bp hr rr o sat ra exam unchanged from admission except agitated and with emotional lability from happy to angry 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 plt ct pm blood pt ptt inr pt am blood glucose urean creat na k cl hco angap am blood alt ast ck cpk alkphos totbili am blood lipase am blood ck mb pm blood ck mb ctropnt am blood albumin calcium phos am blood phenyto pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg am blood lactate am urine color yellow appear clear sp am urine blood neg nitrite neg protein neg glucose neg ketone tr bilirub neg urobiln neg ph leuks tr am urine rbc wbc bacteri few yeast none epi pm urine bnzodzp neg barbitr neg opiates neg cocaine pos amphetm neg mthdone pos pending labs at dishcarge h pylori serology imaging ct abd pelvis technique mdct images were obtained from the lung bases to the pelvic outlet after administration of intravenous contrast coronal and sagittal reformats were obtained comparison none findings ct of the abdomen there is moderate to severe centrilobular emphysema in the lung bases a mm pulmonary nodule is noted in the left lower lobe the visualized portions of the heart and pericardium are unremarkable the liver enhances homogenously and there are no focal liver lesions the gallbladder pancreas spleen and adrenal glands are unremarkable there is a low density mm well circumscribed lesion in the upper pole of the left kidney most likely representing a simple cyst the kidneys enhance symmetrically and excrete contrast without evidence of hydronephrosis or stones the stomach and small bowel are unremarkable there is no free air or free fluid abdominal aorta is normal in caliber ct of the pelvis though the appendix is not definitely visualized a candidate structure for the appendix is air filled and appears normal scattered diverticula without evidence of diverticulitis are noted in the sigmoid colon the remaining portions of the colon are unremarkable the rectum urinary bladder prostate and seminal vesicles are unremarkable there is no pelvic free fluid osseous structures sacralization of the l vertebra is noted on the left there are no suspicious osseous lytic or blastic lesions impression centrilobular emphysema with a mm left lower lobe pulmonary nodule followup with a dedicated ct of the chest is recommended no acute intra abdominal abnormality diverticulosis without evidence of diverticulitis brief hospital course mr is a year old homeless male with history of polysubstance abuse cocaine and seizure disorder presenting from pcp s office with witnessed syncope while on the floor he was found unresponsive so a code blue was called for possible seizure activity and he was intubated for airway protection he ultimately left ama seizures the patient was first found to be unresponsive then had seizure at this time he was intubated for airway protection has known history of seizure disorder reported to take dilantin at home on admission dilantin level negligible and was also low with pericode labs however a spot eeg was negative for epileptiform activity also on home benzodiazepines could be benzo withdrawal finally he had a visitor who the nursing staff identified as possible drug user directly before the seizure activity and the patient admitted to using something while in the hospital but did not specify what urine tox positive for cocaine bloody vomitus patient with multiple episodes of guaic maroon vomiting after his seizure no known liver disease unclear what drinking history is but patient is polysubstance abuser he underwent an egd which found only clean based ulcers and no explanation for the bleeding h pylori serologies were sent but were not resulted when he left ama he was kept on a ppi while in house after he was extubated he was complaining of abdominal pain and was preoccupied with his home opiod and benzo doses it is possible that he was withdrawling from opiods chronic methadone at home and had repeated emesis prior to seizure which then caused small tear polysubstance abuse utox positive for cocaine and methadone prescribed once he was extubated and off sedation he was restarted on his home doses of methadone and clonazepam after about days off these meds but he was still agitated and ultimately left ama also two drug pipes were found in his belongings and given to the hospital police code full transitional issues please follow up h pylori serologies and start therapy for gastric ulcers please reassess his needs for housing and substance abuse counselling medications on admission clonazepam mg tid last filled phenytoin mg daily bactrim ds tab x days flagyl mg q h x days dilantin mg daily nicotine mg lozenges q h prn methadone mg tablets tid prn last filled for tablets for days pharmacy discharge medications left ama discharge disposition home discharge diagnosis primary diagnosis seizure disorder not otherwise specified gastric ulcers polysubstance abuse discharge condition left ama discharge instructions left ama followup instructions left ama,"{
""Diagnoses"": [""syncope"", ""polysubstance abuse"", ""diverticulitis"", ""seizure disorder""],
""Medications"": [""methadone"", ""nitroglycerin"", ""dilantin"", ""bactrim"", ""flagyl""]
}"
3603,admission date discharge date date of birth sex m service csu history of present illness this year old male was admitted to on the day prior to admission after experiencing a syncopal episode at the donuts with associated nausea and vomiting he has no recollection of the event he was brought to the patient stated that he took a sublingual nitroglycerin just prior to the event for feeling woozy post procedure the patient was diaphoretic and had a vagal episode with dropped saturations treated by the cardiology fellow at he had a stat chest x ray also which showed chf past medical history hypertension coronary artery disease with a history of myocardial infarction in a ct scan of his head was negative by report on the morning of glaucoma non insulin dependent diabetes mellitus right eye trauma from fall with small lacerations and sutures around the area of his right orbit which was swollen and ecchymotic hypercholesterolemia myocardial infarction with positive troponins cardiac catheterization showed a lad lesion a diagonal one lesion a circumflex an om lesion a rca lesion a acute marginal lesion and a lesion of the pda obesity with a weight of pounds height of feet inches medications glucophage mg p o twice a day glyburide mg p o twice a day protonix mg p o once a day zocor mg p o once a day enteric coated aspirin mg p o once a day lisinopril mg p o once a day atenolol mg p o once a day hydrochlorothiazide mg p o once a day the patient was also on vitamin c and vitamin e and additional eye drops pilocarpine drop once a day left eye only xalatan drop in each eye every evening alphagan drop each eye times a day allergies he has no known drug allergies laboratory data prior to admission hematocrit of platelet count of sodium of k of bun of creatinine of magnesium of blood sugar that morning prior to transfer was physical examination on exam he was in a normal sinus rhythm with a heart rate of to on o nonrebreather at to a blood pressure of to and a respiratory rate of to breaths per minute hospital course he was transferred to from on the th in preparation for coronary artery bypass grafting surgery and was referred to dr on exam on admission he was in no apparent distress with a blood pressure of in sinus rhythm at with a right eye abrasion he was alert and oriented no jvd or bruits his heart was regular in rate and rhythm with no murmurs his lungs were clear bilaterally his abdomen was soft and nontender he had no edema in his extremities and no groin hematoma at his cath site he was not allergic to any medicines he has no history of prior surgery the patient was seen and evaluated by dr it was determined the patient should have a carotid duplex ultrasound and a neurology consult as well as obtaining the final read of the ct of his head vascular laboratory performed a carotid ultrasound on which showed a to narrowing of his right internal carotid artery and less than on the left with normal antegrade flow of vertebral s please refer to the official report dated on house day he was seen by neurology to evaluate the neurologic event of syncope which was prior to admission at they determined it was probably a cardiogenic syncopal event and they recommended repeating a head ct if no sign of any bleed then he cultured be anticoagulated and put on a heart lung machine and have his operation which was planned he was evaluated in the icu that day and then transferred out to two on the th on house day he also had a ct of the chest which showed a cm ascending aorta and prior right rib fractures x which was associated with his syncopal fall he remained in a sinus rhythm at his creatinine remained up slightly from to his k was stable at with a hematocrit of his exam was unremarkable he was given additional potassium for a k of with a plan to check his creatinine again in the morning to evaluate the trend in preparation for surgery on tuesday the st he remained in sinus bradycardia on house day his creatinine remained stable at he was saturating percent on room air with a blood pressure of he was given hydralazine for his blood pressure he remained in sinus bradycardia with occasional pvc preoperatively he was receiving tylenol for his shoulder pain and rib pain from his fall he was seen again by dr on the th and consented for surgery his baseline creatinine was noted to be approximately by dr his creatinine was on that day he was seen and evaluated on the floor by case management on the day prior to his surgery on house day his creatinine still remained and it was determined to delay his surgery another day his exam was otherwise unremarkable the patient was also consented by dr for the cabg study he was also seen by dr preoperatively on the st in the morning who evaluated the plan and agreed for a cabg x on the st the patient underwent a cabg x by dr with a lima to the lad a vein graft to the ramus a vein graft to the diagonal a vein graft to the plv he was transferred to the cardiothoracic icu in stable condition on a nitroglycerin drip at mcg kg per minute a propofol titrated drip and an insulin drip at units per hour on postoperative day the patient was on cpap at fio he remained on an insulin drip at units an hour a lidocaine drip at with a cardiac index of he was in sinus rhythm at he was on a natrecor drip at and a nitroglycerin drip at he was in no apparent distress he was moving all extremities his sternum was stable a levophed drip at this was weaned off during the course of the day lasix diuresis was begun the chest tubes were discontinued and he was extubated on the nd on postoperative day he continued with diuresis his exam was unremarkable he started beta blockade with lopressor his chest tubes were discontinued his jp drain in his leg was discontinued and his natrecor drip was discontinued he was seen and evaluated by physical therapy and transferred out to the floor after he was extubated and stabilized on the he was switched over to percocet for pain but was refusing it at the time and had no complaints of pain after his transfer he had pedal edema his pacing wires were grounded he had good urine output his foley was discontinued that evening he was encouraged to ambulate with the nurses and the physical therapist he was also started back on heparin subcutaneously i d he had an episode of rapid afib in the morning the lopressor was increased to b i d but maintained a good blood pressure of he was encouraged to ambulate and increase his p o intake his creatinine was stable at with a hematocrit of and a white count of he was saturating on liters nasal cannula he was started back again also on his oral diabetes medicines on the th he removed in afib with a rate of he was also encouraged to use the incentive spirometer his left leg incisions were clean dry and intact his sternum was stable and clean dry and intact of note the patient did continue to have bilateral lower extremity edema he continued with lasix diuresis he was encouraged to keep his legs elevated when he was not ambulating his chest dressing was intact his pacing wires were discontinued and he was seen and evaluated by dr who noted his continued pitting edema in his lower extremities his blood sugar was slightly elevated this was covered by a sliding scale regular insulin he was ambulating on the unit with assist his creatinine decreased to on the th he was also back in a sinus rhythm in his usual sinus bradycardia between the s and s his epicardial pacing wires were discontinued on the th his lungs were clear bilaterally without any shortness of breath and he was saturating on room air he was speaking in full sentences and was alert and oriented he was encouraged to ambulate which he did he was moving all extremities and was ambulating with minimal assist without any difficulty discharge status on he was discharged to home with vna services with the following discharge diagnoses discharge diagnoses status post coronary artery bypass grafting x hypertension myocardial infarction glaucoma non insulin dependent diabetes mellitus right eye and right rib trauma from syncopal event hypercholesterolemia discharge instructions the patient was instructed to follow up with dr his primary care physician in approximately to weeks post discharge telephone number he was to make an appointment to see dr in the office in weeks for his postoperative surgical visit telephone number medications on discharge potassium chloride meq p o twice a day for days enteric coated aspirin mg p o once a day colace mg p o twice a day zocor mg p o once daily protonix mg p o once daily brimonidine tartrate ophthalmic drops drop q h latanoprost ophthalmic drop at bedtime pilocarpine hydrochloride drops drop ophthalmic q h tylenol no to tablets p o q h as needed for pain glyburide mg p o twice a day metoprolol mg p o twice a day amiodarone mg p o twice a day for days then amiodarone mg p o once a day for days then decrease to amiodarone mg p o once a day lasix mg p o times daily for days glucophage mg p o twice a day discharge disposition the patient was discharged to home with vna services on condition on discharge in stable condition m d dictated by medquist d t job,"{
""Diagnoses"": [""syncopal episode"", ""hypertension"", ""coronary artery disease"", ""myocardial infarction"", ""glaucoma"", ""non-insulin dependent diabetes mellitus"", ""right eye trauma"", ""hypercholesterolemia""],
""Medications"": [""sublingual nitroglycerin""]
}"
51834,admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint hemoptysis major surgical or invasive procedure bronchoscopy with bronchoalveolar lavage history of present illness patient is a year old male with a history of cad s p mi s p cabg x and icd af on warfarin and a pack years of smoking stopped in who was admitted to the icu for continued monitoring after brochoscopy revealed diffuse alveolar hemorrhage three or four months ago the patient coughed up something that in retrospect he believes to have been blood though he did not appreciate it at the time he did not notice shortness of breath or any other associated symptoms even with exertion he continued his normal activity which involved exercising one hour minutes cardio minutes weights five times per week without incident his cough occurs occasionally and is only rarely productive though he usually swallows anything he coughs up without spitting it out about two months ago his wife noticed that he coughed up a dark clot and he began to notice a heaviness in his chest when tired but did not follow up approximately three weeks ago he began to notice worsening shortness of breath primarily when walking outside in the cold and felt concerned enough to contact his pcp in retrospect he first noticed this several weeks earlier under similar circumstances he reports some lightheadedness or mild dizziness concurrent with the onset of shortness of breath but denies any other syptoms including chest pain or tightness or sensory changes additionally he recalls increased work of breathing when climbing stairs but no other incidents except those involving vigorous activity walking rapidly shoveling snow outside in the cold in particular he denies dyspnea at rest after seeing his pcp was referred to a pulmonolgist who he saw on a ct was ordered and he was sent to see dr on followed by flexible bronchoscopy the next day after repeated bal revealed increasing blood he was sent to the micu for continued observation he denies fever chills night sweats unintentional weight loss change in appetite malaise fatigue change in energy level recent travel contact with fresh water or time in wilderness areas animal contact beyond his cat known sick contacts tuberculosis exposure exposure to abestos or inhaled toxins arthritis joint pain muscle pain kidney disease skin changes or rashes recent use of medications other than those listed with the possible exception of antibiotics nitrofurantoin use immunosuppression or valvular disease in the micu initial vitals were temp hr bp rr o sat ra exam notable for diffuse fine crackles and wheezing labs notable for wbc hgb hct esr crp gluc the pt underwent continuous monitoring and serial cbcs which detected a drop in hematocrit from to at which point he was transfused with two units of prbcs which raised his hematocrit to vitals prior to transfer hr bp rr o sat ra currently he is afebrile with vss and is feeling well on the floor ros as above plus denies headache vision or other sensory changes rhinorrhea congestion sore throat chest pain abdominal pain nausea vomiting diarrhea constipation brbpr melena hematochezia dysuria or hematuria past medical history cad s p mi s p cabg x and icd in atrial fibrilation diagnosed in after mi on warfarin infected blister in late which resolved s p i d and antibiotics pinched nerve in neck not currently symptomatic distant knee injury pvd with occassional atypical claudication no significant disability hypertension hyperlipidemia social history lives in with wife and one cat retired pscyhologist years ago and property assessor years ago smoked two packs a day from since drinks alcohol very rarely cups of coffee a day distant history of marijauna exercised hours five days a week until a month ago regularly played basketball until no special diet though he avoids red meat and rarely uses salt his most recent travel was to a year ago family history no lung disease cad stroke dm depression anxiety hld arthritis autoimmunity thyroid disease hypertension in parents kidney disease requring nephrectomy in mother prostate cancer in father breast cancer in two sisters physical exam physical exam on transfer vs temp f bp hr r o sat ra general well appearing man in nad comfortable appropriate heent nc at perrla eomi sclerae anicteric mmm op clear neck supple no thyromegaly no jvd no carotid bruits chest well healed scar from median sternotomy lungs cta bilat in upper lungs crackles audible at bases good air movement resp unlabored no accessory muscle use heart rrr no mrg nl s s abdomen nabs soft nt nd no masses or hsm no rebound guarding extremities wwp no c c e peripheral pulses radials dps skin no rashes or lesions lymph no cervical lad neuro awake a ox cns ii xii grossly intact rectal normal and guiac negative per dr physical exam on discharge afebrile vss as above except basilar crackles now much fainter than previously slightly decreased breath sounds at right base no wheezes or rales audible pertinent results imaging studies procedures outside ct per ip on diffuse bilateral pulmonary ground glass infiltrates without mediastinal hilar lymphadenopathy cxr there are no old films available for comparison a pacemaker is visualized with leads projecting over the expected locations of the heart the heart is mildly enlarged sternal wires and mediastinal clips are seen there is hazy bilateral vasculature and some areas of patchy alveolar infiltrate it is unclear if this is due to the known alveolar hemorrhage or if there is an overlying element of fluid overload or infection ip operative report impression blood in the trachea blood diffusely in the bilateral bronchial tree dependently but with worsening blood on seserial labage indicative of diffuse alveolar hemorrage otherwise normal mucosa and airways to tracheobronchial tree with no evidence of endobronchial lesion ecg sinus rhythm with a v conduction delay intra atrial conduction delay consider prior inferior myocardial infarction although it is non diagnostic and may be within normal limits st t wave abnormalities are non specific clinical correlation is suggested no previous tracing available for comparison echocardiogram the left atrium is moderately dilated left ventricular wall thicknesses and cavity size are normal there is moderate regional left ventricular systolic dysfunction with hypokinesis of the basal inferior wall and septum the remaining segments contract normally lvef the estimated cardiac index is normal l min m no masses or thrombi are seen in the left ventricle the right ventricular cavity is mildly dilated with moderate global free wall hypokinesis the aortic root and ascending aorta are 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 mild to moderate mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion impression normal left ventricular cavity size with regional systolic dysfunction c w cad mild moderate mitral regurgitation dilated ascending aorta pulmonary artery hypertension clinical implications the left ventricular ejection fraction is a threshold for which the patient may benefit from a beta blocker and an ace inhibitor or based on aha endocarditis prophylaxis recommendations the echo findings indicate prophylaxis is not recommended clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data cxr indication diffuse alveolar hemorrhage desaturation overnight comparison findings diffuse bilateral alveolar infiltrates are not significantly changed since the prior study no effusion or pneumothorax is present the heart and mediastinal contours are normal sternotomy wires are intact vascular clips from prior cabg are seen pacemaker leads are seen in the expected positions overlying the right atrium and right ventricle impression no change in bilateral diffuse alveolar opacities ct history year old man with diffuse alveolar hemorrhage of unknown etiology query change technique volumetric multidetector ct acquisition of the chest was performed without intravenous or oral contrast images are presented for display in the axial plane at and mm collimation a series of multiplanar reformations were also submitted for review comparison reference ct chest findings the visualized portions of the thyroid gland and supraclavicular regions are unremarkable in appearance there are small mediastinal lymph nodes which do not meet ct size criteria for pathologic enlargement the largest is an mm pre tracheal node a small hiatus hernia is seen the patient has had a previous coronary artery bypass graft and there are multiple surgical clips in the mediastinum as well as calcification of the coronary arteries calcification of the aortic annulus is also noted there is a dual lead pacemaker in situ otherwise non contrast examination of the heart and great vessels are unremarkable no pleural effusion no pericardial effusion the airways are patent to a subsegmental level on review of the lung windows there has been further progression of the diffuse bilateral ground glass opacities with progression in some areas to frank consolidation this is most apparent in the superior segment of the right lower lobe at the right apex and left apex this appearance may be the end point of resorption of hemorrhage however superimposed infection cannot be excluded and cryptogenic organizing pneumonia is also a possibility superimposed on these abnormalities there is mild interlobar septal thickening with mild vascular congestion this study is not tailored for evaluation of the subdiaphragmatic organs the adrenal glands are unremarkable in appearance calcification of the splenic artery is noted the spleen is borderline enlarged measuring cm otherwise the visualized portions of the liver spleen and kidneys are unremarkable in appearance bony structures degenerative changes noted in the left shoulder no destructive lytic or sclerotic bony lesions are seen impression further interval progression of the diffuse bilateral ground glass opacities with areas of frank consolidation seen in the apices bilaterally and superior segment of the right lower lobe appearances could be consistent with resorption of intra alveolar hemorrhage however superimposed infection cannot be excluded and cryptogenic organizing pneumonia is also a possibility labs at admission chem am glucose urea n creat sodium potassium chloride total co anion gap ca phos mg cbc with diff am wbc rbc hgb hct mcv mch mchc rdw am neuts lymphs monos eos basos am plt count other am sed rate am crp am alt sgpt ast sgot alk phos tot bili am tot prot albumin globulin iron am caltibc ferritin trf viral and antibody serology am hbsag negative hbs ab negative am hcv ab negative pm negative urinalysis am urine color straw appear clear sp am urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg am urine rbc wbc bacteria none yeast none epi bal fluid pm other body fluid polys lymphs monos eos macrophag other pm other body fluid polys lymphs monos eos macrophag other pm other body fluid polys lymphs monos eos basos macrophag other trended labs complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct added i hos addon basic coagulation pt ptt plt inr pt ptt plt ct inr pt added i hos addon chem gluc bun cr na k cl hco angap moderately hemolyzed specimen addon additional chem ca phos mg at discharge chem glucose bun creat na k cl hco angap cbc wbc rbc hgb hct mcv mch mchc rdw plt retic count coags pt ptt inr pt hba c eag anca anti gbm antibodies and c still pending cultures mrsa screen final no mrsa isolated pm rapid respiratory viral screen culture bronchial lavage final report respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus detection of viruses other than those listed above will only be performed on specific request please call virology at within week if additional testing is needed respiratory viral antigen screen final negative for respiratory viral antigen specimen screened for adeno parainfluenza influenza a b and rsv by immunofluorescence refer to respiratory viral culture for further information pm bronchoalveolar lavage bronchial lavage gram stain final per x field polymorphonuclear leukocytes per x field columnar epithelial cells no microorganisms seen respiratory culture final no growth cfu ml fungal culture preliminary no fungus isolated acid fast smear final no acid fast bacilli seen on direct smear no acid fast bacilli seen on concentrated smear acid fast culture preliminary pending at discharge brief hospital course the patient was admitted to the hospital after bronchoscopy with bal which showed diffuse alveolar hemorrhage for monitoring in the micu bal fluid cultures for bacteria and fungi were sent and home medications were stopped in the micu simvastatin was restarted and a number of tests including antibody panels viral cultures and serologies were sent his hematocrit dropped significantly from to and he was transfused with two units of packed red blood cells restoring it to after this he remained stable and was transferred to the general medicine floor the next day the most likely etiology of his dah was thought to be from concurrent coumadin and aspirin treatment given his clinical stability and lack of other organ system involvement other etiologies such as vasculitis were considered less likely although anti gbm ab anca c were all sent on the medicine floor his inr declined from on to on off of coumadin given his history of sudden cardiac arrest and cad his aspirin was continued at mg his hematocrit was largely stable at discharge cbc iron studies and reticulocyte count index on indicated that his anemia was most consistent with acute blood loss overnight his o desaturated to requiring l o but recovering to on ra by morning a cxr and ct scan were ordered to rule out bleeding the cxr showed no change from previously and the ct showed only a small amount of increased hemorrhage and was reassuring overall echocardiogram showed a reduced ejection fraction of mild pulmonary hypertension and some mitral regurgitation consistent patient s history of myocardial infarction on his oxygen saturation fell to while climbing stairs and he continued in the hospital in order to assess his stability on his resting saturation increased to ra which was his highest since admission saturation during a six minute walk test remained above and it stayed above while climbing four flights of stairs and subsequently thereafter when ambulating pulmonary followed the patient throughout his hospital course and given his dramatic improvement felt that he was safe to discharge home with close follow up the following week once the remainder of his test results became available at the time of discharge all cultures and serologies were negative except for the acid fast culture which showed no growth to date but was not yet final was negative but anca and anti gbm antibody and c studies were still pending based on persistently high fasting blood sugars we ordered a hemoglobin a c measurement and obtained previous records from the a c was however his historical fasting glucose measurements have remained above since based on this we made a diagnosis of type ii diabetes mellitus we prescribed a glucometer and taught him and his wife how to use it instructing him to keep a diary of glucose levels to share with his pcp also prescribed metformin to help improve his glucose control at home his lisinopril was restarted at a reduced dose of mg prior to discharge he was instructed not to restart warfarin without consulting with his cardiologist and pulmonologist as it was the most likely cause of his hemoptysis though other etiologies may also have been involved given his chads score of history of hypertension and new diagnosis of diabetes he is considered at intermediate risk and aspirin only anticoagulation is acceptable medications on admission levoflxacin mg daily started on lisinopril mg daily metoprolol mg daily simvastatin mg daily aspirin mg daily warfarin mg times per week mg twice a week fish oil mg qid glucosamine mg discharge medications glucometer free style freedom lyte glucometer diagnosis diabetes mellitus metformin mg tablet sig one tablet po twice a day disp tablet s refills glucometer supplies lancets for monitoring blood sugar sig please check blood sugar daily disp refills glucometer supplies test strips sig please check blood sugar daily disp refills aspirin mg tablet chewable sig one tablet chewable po daily daily simvastatin mg tablet sig one tablet po daily daily 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 disp tablet s refills discharge disposition home discharge diagnosis diffuse alveolar hemorrhage most likely secondary to warfarin anticoagulation diabetes mellitus type ii 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 at you were admitted to the hospital after your bronchoscopy which showed diffuse alveolar hemorrhage for monitoring in the micu bal fluid cultures for bacteria and fungi were sent and your home medications were stopped in the micu your simvastatin was restarted and a number of tests including antibody panels viral cultures and serologies were sent your hematocrit dropped significantly and you were transfused with two units of packed red blood cells after this you were stable and were transferred to the general medicine floor the next day on the medicine floor we continued to monitor you within several days your inr declined to off warfarin indicating decreased risk of bleeding you were generally well but on your oxygen saturation dropped leading us to order an x ray and ct scan to rule out bleeding the ct showed only a small amount of increased hemorrhage and was reassuring overall we also performed an echocardiogram that showed a reduced ejection fraction of mild pulmonary hypertension and some mitral regurgitation this is consistent with your history of myocardial infarction we monitored your oxygen saturation levels closely during your stay the day before discharge your oxygen saturation fell to while climbing stairs but on the day of discharge your saturation remained above while climbing four flights of stairs and subsequently when ambulating additionally your resting oxygen saturation was increased to on room air these results suggested that your lung function had improved since admission and we felt that you could return home without oxygen we also found that you have elevated fasting blood sugars and a mildly elevated hemoglobin a c on the basis of your previous records from we made a diagnosis of type ii diabetes mellitus we prescribed you metformin to start after discharge and a glucometer which we taught you how to use and asked you to keep a blood sugar diary please check blood sugars once a day you should share this with your pcp assist him in dosing the metformin and selecting the proper glucose control regimen for you you should also try to reduce your consumption of foods high in sugar and simple carbohydrates persistently high blood sugar can put you at increased risk for cardiovacular disease so it is important to work with your pcp to find the regimen that works best for you at the time of discharge all of your cultures and serologies were negative except for the acid fast culture which showed no growth to date but was not yet final was negative but anca and anti gbm antibody and c studies were still pending over the course of your stay we restarted all of your home medications except warfarin coumadin though we restarted you on a lower dose of lisinopril this dose may be adjusted up by your doctor as needed after you leave the hospital please do not restart warfarin without consulting with your cardiologist and pulmonologist since along with other factors it is the most likely cause of your hemoptysis your pcp should continue to follow your blood counts and electrolyte levels as well as your metformin as needed please seek medical care immediately if you begin to have difficulty breathing your hemoptysis worsens you are feeling weak lightheaded or you have other symptoms that concern you please take all your medications as prescribed we made the following changes in your medications stop warfarin coumadin decrease dose of lisinopril to mg daily please speak with your doctor this dose after you leave the hospital start monitoring blood sugars on a daily basis and recording them for review with your pcp metformin mg twice a day this medicine may cause diarrhea followup instructions name np specialty internal medicine when tuesday at am address phone dr has nothing available so you will see his nurse practitioner at this visit you will follow up with dr at the center for chest diseases your appointment will be next thursday someone from the clinic will call you with a definite time likely pm if you do not hear from anyone by monday please call the clinic at,"{
""Diagnoses"": [""Diffuse alveolar hemorrhage""],
""Medications"": [""Warfarin"", ""Aspirin"", ""Pain medication""]
}"
50142,admission date discharge date date of birth sex m service cardiothoracic allergies pollen extracts attending chief complaint dyspnea on exertion major surgical or invasive procedure s p coronary artery bypass grafting x left internal artery grafted to left anterior descending aortic valve replacement mm tissue valve on history of present illness this is a a year old male with dyspnea on exertion and history of aortic stenosis while being evaluated for radical prostatectomy he had a stress test showing subendocardial ischemia and underwent cardiac cath which showed coronary artery disease and aortic valve pathology he is now referred for surgical evaluation past medical history coronary artery disease aortic stenosis hyperlipidemia prostate cancer sclerotic rib lesion not metastatic per urology arthritis bilateral cataract surgery social history race asian american last dental exam months ago lives with wife occupation retired electrical engineer tobacco denies etoh denies family history notable for lung cancer in his father history of premature coronary artery disease or valve disease physical exam admission pulse resp o sat ra b p right left height weight kg general nad well appearing 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 sem radiates to carotids abdomen soft x non distended x non tender x bowel sounds x extremities warm x well perfused x edema none ecchymosis right groin thigh at cath site varicosities none neuro grossly intact nonfocal exam mae strengths pulses femoral right left dp right left pt left radial right left carotid bruit murmur radiates to carotids pertinent results intraop tee pre cpb the left atrium is mildly dilated no thrombus is seen in the left atrial appendage no atrial septal defect is seen by d or color doppler there is moderate 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 there are simple atheroma in the ascending aorta there are simple atheroma in the aortic arch there are simple atheroma in the descending thoracic aorta there are three aortic valve leaflets the aortic valve leaflets are severely thickened deformed there is severe aortic valve stenosis valve area cm moderate to severe aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen post cpb well seated bioprosthetic valve in the aortic position preserved biventricular systolic function aortic contour normal post decannulation 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 pm blood urean creat na k cl hco angap am blood urean creat na k cl brief hospital course mr was admitted and underwent single vessel coronary artery bypass grafting and aortic valve replacement surgery by dr for surgical details please see operative note following the operation he was brought to the cvicu for invasive monitoring within hours he awoke neurologically intact and was extubated without incident his cvicu course was uneventful and he transferred to the floor on postoperative day one he experienced a brief bout of atrial fibrillation but converted back to a normal sinus rhythm with the administration of iv amiodarone and then oral dosing he was begun on a beta blocker diuresed towards his preoperative weight and progressed well chest tubes were removed on post op day one and pacing wires on post op day physical therapy worked with him for mobility and strength he appeared to be doing well on post op day and was discharged home with vna services medications on admission zocor mg daily aspirin mg daily amoxicillin prn dental 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 simvastatin 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 lisinopril mg tablet sig one tablet po daily daily disp tablet s refills metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet s refills docusate sodium mg tablet sig one tablet po twice a day disp tablet s refills furosemide mg tablet sig one tablet po once a day for weeks 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 weeks disp tab sust rel particle crystal s refills amiodarone mg tablet sig two tablet po bid times a day take to two mg tablets twice daily for week then one mg tablets twice daily for week then mg tablet daily until stopped by cardiologist disp tablet s refills discharge disposition home with service facility homecare discharge diagnosis coronary artery disease and aortic stenosis s p coronary artery bypass grafting x lima lad aortic valve replacement mm tissue valve past medical history hyperlipidemia cataracts s p bilateral cataract surgery prostate cancer sclerotic rib lesion not metastatic per urology arthritis discharge condition alert and oriented x nonfocal ambulating with steady gait incisional pain managed with incisions sternal healing well no erythema or drainage edema none 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 surgeon dr on at pm cardiologist dr on at pm please call to schedule appointments with 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 completed by,{}
84505,admission date discharge date date of birth sex m service surgery allergies no known allergies adverse drug reactions attending chief complaint abdominal pain major surgical or invasive procedure patch repair history of present illness mr is an year old male who has been in his usual state of health until about a week ago when he experience some abdominal pain he described pain began in lower abdomen then migrated to periumbilical he also endorsed nausea and emesis in the mid week his appetite has also been poor pt reported that he was seen in nc days ago with a normal ct scan however the pain continues to persist and got worse today patient was worked up for possible aortic dissection given his intense abdominal pain in the ed cta showed no evidence of aortic dissection but free air with stranding around the duodenum patient denied any history of nsaid use but reported taking aspirin for about a month he denied any history of abdominal pain in the past except history of gib more than yrs ago at the present patient denied any abdominal pain he has been given mg of morphine mg dilaudid prior to being examined by surgery team past medical history rotator cuff injury mass left long finger gerd bph hx of uti hx of gib yrs ago hearing loss pshx rotator cuff repair social history lives alone engineer has flown a single engine plane across the into europe middle east and no tobacco very rare etoh no illicits family history mother deceased from cva in s father cad with ami deceased from cva in s physical exam on admission physical exam vitals ra gen a ox nad heent no scleral icterus mucus membranes moist cv rrr no m g r pulm clear to auscultation b l no w r r abd tense nondistended mild tenderness at periumbilical region no rebound guarding no palpable masses dre normal tone no gross or occult blood ext no le edema le warm and well perfused pertinent results agap n l m e bas pt ptt inr cta abd w w o c reconstruction moderate pneumoperitoneum and complex fluid within the abdomen focal stranding and mucosal hyperemia involving the distal stomach and duodenal bulb likely represents the source of perforation possibly from a perforated ulcer colonic diverticulosis with no evidence of diverticulitis cholelithiasis no aortic aneurysm or dissection small bilateral pleural effusions with adjacent atelectasis hepatic capsular enhancement compatible with perihepatitis due to bowel perforation helicobacter pylori antibody test final positive by eia ecg atrial fibrillation with rapid ventricular response early r wave progression st t wave abnormalities echo the left atrium and right atrium are normal in cavity size no left atrial mass thrombus seen best excluded by transesophageal echocardiography left ventricular wall thickness cavity size and regional global systolic function are normal lvef tissue doppler imaging suggests a normal left ventricular filling pressure pcwp mmhg right ventricular chamber size and free wall motion are normal the aortic root is mildly dilated at the sinus level the aortic arch is mildly dilated the mitral valve appears structurally normal with trivial mitral regurgitation the estimated pulmonary artery systolic pressure is high normal there is an anterior space which most likely represents a prominent fat pad impression suboptimal image quality normal biventricular cavity sizes with preserved global and regional biventricular systolic function dilated thoracic aorta compared with the prior study images reviewed of the findings are similar ecg sinus rhythm borderline a v conduction delay non specific anterolateral t wave flattening ct abd pelvis with contrast there are two complex fluid collections in the right upper abdomen with an appearance suspicious for abscesses the collections would be amenable to percutaneous drainage 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 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 brief hospital course mr was admitted on under the acute care surgery service for management of perforated viscous he was taken emergently to the operating room and underwent patch repair for pyloric channel perforated ulcer on please see operative report by dr for details of this procedure post operatively he was admitted to the floor and did well initially requiring fluid boluses for hypotension and then developed afib with rvr of note he does have a history of afib but was in sinus rhythm prior to the operation he was transferred to the tsicu for a fib with rvr associated with hypotension in the icu he remained tachycardic and was started on a diltiazem drip he ruled out for mi and cta chest was obtained given tachycardia and mild hypoxia with an a a gradient which showed no evidence of pe he did not convert to sinus rhythm on diltiazem and so was subsequently started on a heparin drip and ultimately converted to sinus rhythm with amiodarone the heparin drip was then stopped his h pylori test was positive and antibiotics were changed to levofloxacin and zosyn for appropriate iv coverage of this organism on pod gastrograffin swallow showed no evidence of leak from the patch repair site and he was started on a diet he was seen by cardiology who made recommendations for his care he was transitioned to oral amiodoarone and he remained stable so was transferred to the floor on on the floor he was monitored on telemetry and his vital signs were monitored routinely he remained hemodynamically stable however his wbc began to rise and on a ct scan was performed which showed two complex fluid collections in the right upper abdomen these fluid collections were drained on gram stain and cultures were sent from the fluid and had no growth his white blood cell count was monitored and it slowly decreased to he is afebrile and his vital signs are stable he is tolerating a regular diet without nausea or vomitting he is voiding without difficulty he is preparing for discharge with the abdominal drains in place he has an appointment to follow up with the acute care service in weeks he also has folow up with his cardiologist to determine the best management of his paf of note aspirin is still on hold upon discharge medications on admission metoprolol er mg po daily ranitidine mg po bid aspirin mg po daily discharge medications oxycodone mg tablet sig tablet po q h every hours as needed for pain tramadol mg tablet sig tablet po q h every hours as needed for pain acetaminophen mg tablet sig two tablet po q h every hours as needed for pain amiodarone mg tablet sig one tablet po bid times a day continue until then start mg daily dosing amiodarone mg tablet sig one tablet po daily daily please begin on bismuth subsalicylate mg ml suspension sig thirty ml po tid times a day last dose clarithromycin mg tablet sig two tablet po q h every hours last dose amoxicillin mg capsule sig four capsule po q h every hours last dose protonix mg tablet delayed release e c sig one tablet delayed release e c po twice a day albuterol sulfate mg ml solution for nebulization sig one neb inhalation q h every hours as needed for wheezing sob ipratropium bromide solution sig one neb inhalation q h every hours as needed for sob fluconazole mg tablet sig two tablet po q h every hours for weeks started on heparin porcine unit ml solution sig units injection tid times a day tramadol mg tablet sig tablet po q h every hours acetaminophen mg tablet sig two tablet po q h every hours discharge disposition extended care facility discharge diagnosis pyloric channel perforated ulcer 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 came to the hospital with abdominal pain and you were found to have a perforated ulcer you were taken to the operating room and had patch placed to repair the perforation you are recovering well from the procedure and are now being discharged to rehab with the following instructions followup instructions department general surgery when thursday at pm with md with acute care clinic building lm bldg campus west best parking garage name md specialty internal medicine location address phone please discuss with the staff at the facility a follow up appointment with your pcp when you are ready for discharge they can call the number listed above you also have an outpatient cardiology appointment at the center on with dr at pm it is important that you keep this appointment the telephone number is completed by,"{
""Diagnoses"": [""abdominal pain"", ""nausea"", ""emesis"", ""poor appetite""],
""Medications"": [""morphine"", ""dilaudid""]
}"
14709,admission date discharge date service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint colon cancer major surgical or invasive procedure sigmoid colectomy and partial small bowel resection history of present illness mr is a year old gentleman with a month history of not feeling well associated with weight loss of an unknown amount and diarrhea on workup he was found to have a sigmoid colon cancer at cm and ct scan showed a possible adherent matted loop of small bowel which may have a small bowel fistula he presents now for resection past medical history st degree av block social history denies etoh or tobacco family history nc physical exam at time of discharge alert oriented x self only perrl eomi rrr ctab abdomen soft nt nd bs no masses well healing incision ext without c c e pertinent results pathology results from segmental resection of colon sigmoid mucinous adenocarcinoma arising in a villous adenoma the carcinoma extends through the colonic wall and invades the full thickness of an adjacent segment of small bowel forming two fistula tracts wbc rbc hgb hct mcv mch mchc rdw plt ct hct pt ptt inr pt glucose urean creat na k cl hco angap glucose urean creat na k cl hco angap glucose urean creat na k cl hco angap alt ast ld ldh alkphos amylase totbili lipase probnp probnp ck mb notdone ctropnt ck mb notdone ctropnt ck mb ctropnt calcium phos mg tsh brief hospital course on mr was admitted to the surgery service under the care of dr he was taken to the or for resection for details of the operation please see dr operative report postoperatively he was admitted to the icu and placed on an amiodarone drip due to rapid atrial fibrillation his pain was well controlled with an epidural cardiology and eps were consulted pod for assistance in controlling mr tachycardia once stable mr was transferred to the floor on hd his diet was slowly advanced on the night of hd he was found to be increasingly somnolent difficult to arouse and unable to follow commands his abg was and he was hypernatremic he was transferred back to the icu for close monitoring due to increasing agitation mr d to pull out his foley dobhoff that had been placed for tube feeding and his iv geriatrics was consulted for his mental status changes and felt that his pain medication may have contributed to his confusion his pain was now well controlled with tylenol only he was transferred back to the floor on pod with a sitter he gradually became slightly more alert and oriented as his hypernatremia was corrected his diet was advanced to regular however his po intake was poor supplements and tpn were initiated on hd tpn picc and foley were d c d pts po intake remained poor his bun and creatinine continued to rise on hd ivf were reinitiated hd substantial increase of k to with increase bun to and creatinine urine lytes were ordered along with stat ekg renal was consulted gerientology continued to follow pt and provide recs notable decline in mental status and increase in agitation pts state continued to decline with increased creatinine and bun multiple boluses were adminsitered on hd urine output noted to have decreased to less than hr oxygen level had diminshed to on room air and was placed on a fask mask with which he had sats of pt transferred to the unit continued decline in respiration and patient foudn to be acidotic as per abg pt intubated and ngt placed renal team spoken with and dialysis begun as the hospitalization progressed his overall status began to improve neurologically all hiss sedation was minimized we were able to wean all of his pressor support in terms of the ventilator he was weaned to nasal cannula gradually tube feeds were initiated via a g tube placed and advanced to goal rate with good urine output he finished a course of meropenum for enterobacter in the blood the patient was being screened for rehab when on the morning of he acutly went into bradycardia then cardiac arrest patient was intubated and acls protocol was initiated the attending surgeon was present at that time and after a short period of time the code was called and the patient expired medications on admission none discharge disposition extended care facility discharge diagnosis colon cancer discharge condition expired md,"{
""Diagnoses"": [""Sigmoid colon cancer"", ""Major surgical or invasive procedure"", ""Partial small bowel resection""],
""Medications"": [""None known""]
}"
41469,admission date discharge date date of birth sex f service orthopaedics allergies penicillins latex morphine sulfa sulfonamide antibiotics codeine attending chief complaint nonunion c major surgical or invasive procedure stage exploration of spinal fusion c c removal of hardware c c open deep biopsy bone c partial corpectomy c vertebral body partial excision removal of intrinsic lesion allograft for fusion c c arthrodesis stage exploration of spinal fusion c c c c c c c c bilateral hemilaminotomy posterior cervical fusion c c instrumentation c to c allograft for fusion iliac crest bone graft for fusion history of present illness in summary she is a year old female who underwent anterior cervical discectomy and fusion for treatment of disc segment disease she developed postoperative infection osteomyelitis requiring suppressive antibiotics for that reason in part she wants to become a candidate for hardware removal with a goal of eradicating her infection we did perform a ct scan for her on to assess the status of her fusion she also want flexion and extension radiographs both her ct scan and flexion and extension radiographs are most consistent with a nonunion since she did not have a healed spinal fusion revision surgery treatment will require a two staged approach we discussed at length the surgical strategy and also the rationale for surgery we discussed the alternatives risks and benefits of both surgical and ongoing nonsurgical care with the goal of eradicating infection ultimately hopefully desisting the use of antibiotics she has elected to undergo surgical treatment this would be a two staged approach the first stage would be anterior cervical hardware removal at c c with debridement of the surgical site this would then allow cultures to also be taken and first to follow her inflammatory markers as an inpatient following that surgery she would then be treated with postoperative antibiotics if postoperative antibiotics offer to have a normal decline in her crp trend we may then pursue posterior spinal fusion with iliac crest bone graft in the same hospitalization if further antibiotics are required with infectious disease consultation as an inpatient then we would do a second staged surgery for her some weeks in the future after the goals of sepsis have been achieved in order to decrease the risk of potential wound infection in her posterior cervical spine past medical history htn hl past surgical history s p revision acdf c and s p washout s p acdf c c and c c years ago tubal ligation lithotripsy cholecystectomy partial hysterectomy salivary gland removal social history nc family history nc physical exam intact neuro brief hospital course patient was admitted to the spine surgery service and taken to the operating room for the stage 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 per id recommendations initial postop pain was controlled with a pca code blue for unresponsive apneic episode o sat but with poor wave form pt never lost pulse arousable by sternal rub alert after dose of narcan transferred to sicu for close monitoring transferred to floor without event stage surgery was done posterior cerivcal fusion overnight temp from to hvac drain was remioved pca and foley were discontinued change antibiotic to vancomycin per id tmax picc line was placed vanco trough low dose adjusted increased vanco trough diet was advanced as tolerated the patient was transitioned to oral pain medication when tolerating po diet physical therapy was consulted for mobilization oob to ambulate on the day of discharge the patient was afebrile with stable vital signs comfortable on oral pain control and tolerating a regular diet medications on admission gabapentin toprol xl omeprazole zofran prn seroquel hs simvastatin cetirizine colace prn minocycline vitamin d qweek levothyroxine mcg cymbalta lasix tomapax hs terazosin mg hs zoloft sertraline lorazepam discharge medications docusate sodium mg capsule sig one capsule po bid times a day senna mg tablet sig tablets po qhs once a day at bedtime as needed for constipation omeprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily acetaminophen mg tablet sig tablets po q h every hours as needed for fever pain oxycodone mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills prochlorperazine maleate mg tablet sig one tablet po q h every hours as needed for nausea disp tablet s refills metoprolol succinate mg tablet extended release hr sig one tablet extended release hr po daily daily prazosin mg capsule sig two capsule po hs at bedtime fexofenadine mg tablet sig one tablet po bid times a day sertraline mg tablet sig one tablet po daily daily topiramate mg tablet sig one tablet po hs at bedtime furosemide mg tablet sig one tablet po daily daily duloxetine mg capsule delayed release e c sig one capsule delayed release e c po bid times a day levothyroxine mcg tablet sig one tablet po daily daily simvastatin mg tablet sig one tablet po daily daily quetiapine mg tablet sig one tablet po hs at bedtime gabapentin mg capsule sig three capsule po tid times a day vancomycin mg recon soln sig three recon soln intravenous q h every hours disp recon soln s refills heparin porcine pf unit ml syringe sig two ml intravenous prn as needed as needed for line flush disp qs ml s refills outpatient lab work weekly tests esr crp cbc diff bun cr vanco trough results fax to id rns at discharge disposition home with service facility vna discharge diagnosis c c suspected nonunion c c suspected osteomyelitis retained hardware discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions 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 in a car or chair for more than minutes without getting up and walking 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 isometric extension exercise in the collar x day x times perform extension exercises as instructed swallowing difficulty swallowing is not uncommon after this type of surgery this should resolve over time please take small bites and eat slowly removing the collar while eating can be helpful however please limit your movement of your neck if you remove your collar while eating cervical collar neck brace you need to wear the brace at all times until your follow up appointment which should be in weeks you may remove the collar to take a shower limit your motion of your neck while the collar is off place the collar back on your neck immediately after the shower 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 call the office at that time if you have an incision on your hip please follow the same instructions in terms of wound care 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 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 narcotic oxycontin oxycodone percocet prescriptions to the 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 o we will then see you at weeks from the day of the operation at that time we will most likely obtain flexion extension x rays and often able to place you in a soft collar which you will wean out of over week please call the office if you have a fever degrees fahrenheit drainage from your wound or have any questions physical therapy see discharge instructions treatments frequency see discharge instructions followup instructions provider md phone date time provider md phone date time opat attending visit and all questions regarding antibiotics please call please call above number for id fu appointment,{}
44303,admission date discharge date date of birth sex m service medicine allergies no drug allergy information on file attending chief complaint multisystem failure major surgical or invasive procedure intubation central line placement history of present illness y o m who presented to the hospital emergency room after being found unresponsive by his mother was spoke to his mother at pm the night previously the following morning she was unable to reach him by phone and so activated ems on arrival patient was found unresponsive on the floor he was noted to have shallow agonal breathing with bp of intubated at the site on the second attempt to to vomiting and a seizure with first attempt at the osh he was noted to be in acute liver failure with elevated tylenol level and was given activated charcoal and started on mucomyst gtt he was then transferred to the icu icu course by system hypotension ivf s given started on levophed and vasopressin for hypotension he was given decadron for refractory hypotension and stim was performed zosyn empirically bp at time of transfer was reportedly in s with hr renal cr was at time of transfer he was given amps of bicarb and started on a bicarbonate gtt ml per hour cardiac bedside echo was reportedly notable for euvolemic ivc and hyperdynamic lv liver transaminases mildly elevated with ast alt inr pt he received charcoal and mucomyst as described and last tylenol level was was given low dose vitamin k for elevated inr mental status patient was essentially flacid w o dtr s or corneal reflexes his pupils were fixed and dilated however he was spontaneously breathing on occasion and intermittently reponsive by report from osh head ct showed no evidence of acute intracranial process ct c spine also interpreted negative in med flight patient was hypertensive so levophed was weaned to off but hypotension recurred patient was bag ventilated and chest tube was on suction in med flight but off suction in transport to icu on arrival to the icu patient had a pea arrest with return of spontaneous circulation perfusing rhythm after minutes he received amps bicarbonate and had a needle decompression of his chest performed by dr past medical history depression social history lives alone in apartment for last months working in a supermarket in the meat department father recently deceased was a non smoker with occasional etoh use family history depression physical exam s p arrest hr low s bp rr t gen calm non responsive pupils fixed and dilated post code heent ncat face puffy chest symmetric breath sounds coarse heart irregularly irregular abd no bowel sounds soft non distended overweight ext wwp no le edema good le pulses neuro pupils fixed and dilated no gag no corneal reflexes no dtr s agonal breathing 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 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 am blood pt ptt inr pt am blood pt ptt inr pt pm blood pt ptt inr pt pm 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 k 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 alt ast ld ldh ck cpk alkphos totbili pm blood alt ast ld ldh ck cpk alkphos totbili am blood alt ast ld ldh ck cpk alkphos totbili pm blood ck mb mb indx ctropnt am blood ck mb mb indx ctropnt am blood ck mb mb indx ctropnt pm blood albumin calcium phos mg am blood albumin calcium phos mg pm blood acetmnp am blood acetmnp pm blood acetmnp am blood acetmnp pm blood type art po pco ph caltco base xs am blood lactate brief hospital course mr was medflighted to after he overdosed on tylenol and developed multisystem failure including acute hepatic failure ards and acute renal failure he required maxed out pressors to maintain a bp but even with this his bp slowly dropped by hd he remained intubated with fixed dilated pulils and no signs of cerebral function he expired on medications on admission klonopin lexapro discharge medications n a discharge disposition expired discharge diagnosis multiorgan dysfunction due to tylenol overdose discharge condition expired discharge instructions n a followup instructions n a,"{
""Diagnoses"": [""acute liver failure"", ""hypotension"", ""renal failure"", ""intubation"", ""vomiting"", ""seizure"", ""multisystem failure""],
""Medications"": [""activated charcoal"", ""mucomyst"", ""levophed"", ""vasopressin"", ""decadron"", ""zosyn"", ""bicarb""]
}"
82754,admission date discharge date date of birth sex m service medicine allergies peanut attending chief complaint admitted with gi bleed called out of icu major surgical or invasive procedure egd on history of present illness mr is a year old male with a history of abdominal pain and hemetemesis with a inflammatory gastric polyp resected two days prior to admission who presents with melena lightheadedness and new anemia he was admitted from the er to the on after an episode of presyncope associated with melena in addition he had extreme thirst in the ed initial vs were pain t hr bp rr o sat ra exam was notable for dark guaiac stool per rectum labs were notable for hct down from baseline of cxr was unremarkable ekg was sinus tach at with t wave inversions in the lateral leads patient was given protonix mg iv bolus and protonix gtt as well as l ns and unit of blood vital signs on sign out were bp hr rr ra afebrile in the icu the patient underwent an egd which revealed a deep ulcer no vessel was seen no active bleeding his hct was relatively stable hemodynamically stable so called out to the medical floor in the p m on he underwent transfusion of units prbc last at a m on he ruled out for an mi currently feeling well tolerating a regular diet no nausea abdominal pain diaphoresis lightheadedness episode of melena the day prior but none since no brbpr no chest pain or sob rest of ros is negative past medical history genital herpes gastric polyp s p ex lap for abdominal stab wound social history works as an anesthesia tech at formerly was in the military smokes cigarettes daily used to drink bottle of beer or hard liquor once or twice on the weekends but has cut back last drink was of oz bottle of beer on family history unknown adopted physical exam vs t hr bp rr o on ra gen nad aox heent mmm unable to assess jvp card rrr no m r g pulm ctab abd soft nt nd no masses or organomegaly ext wwp no c c e neuro aox grossly normal 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 am blood hct pm 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 pm blood glucose urean creat na k cl hco angap pm blood ck cpk am blood ck cpk pm blood ck cpk pm blood ck mb ctropnt am blood ck mb ctropnt pm blood ctropnt am blood calcium phos mg am blood wbc rbc hgb hct mcv mch mchc rdw plt ct chest x ray no acute cardiopulmonary process no significant interval change egd ulcer in the pylorus otherwise normal egd to duodenal bulb egd a esophagitis was seen in the ge junction a small size hiatal hernia was seen an approximately cm erythematous nodule was seen in the prepyloric antrum along the greater curvature a mucosal resection was performed and the lesion was totally removed using a band emr otherwise normal egd to third part of the duodenum eus a esophagitis a cm prepyloric antral nodule was noted eus nodule showed ill defined expansion of the superficial and deep mucosal layer with normal appearing submucosa and muscularis this appearance was suggestive of a mucosal based polyp e g inflammatory hyperplastic or adenomatous polyp eus appearance was not typical for gist carcinod or lymph node egd performed for dyspepsia friability erythema and congestion in the antrum compatible with gastritis biopsy nodule in the pylorus biopsy otherwise normal egd to third part of the duodenum brief hospital course this is a year old male with a history of recently ressected inflammatory gastric polyp who presents with melena presyncope and hct drop concerning for upper gi bleed upper gi bleed likely etiology of melena presyncope and hct drop to from baseline of likely related to recently ressected gastric polyp the patient was treated with high dose ppi and will continue for at least weeks pathology of gastric polyp pending at the time of discharge hct stable at the time of discharge in total the patient rec d units of prbc ekg changes likely related to tachycardia no complaints of chest pain or shortness of breath ruled out for mi medications on admission home medications prednisone mg daily from omeprazole mg po bid transfer medications protonix mg iv bid discharge medications omeprazole mg capsule delayed release e c sig one capsule delayed release e c po twice a day disp capsule delayed release e c s refills discharge disposition home discharge diagnosis primary diagonsis peptic ulcer disease gastrointestinal bleeding anemia of acute blood loss discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted with bleeding from your stomach you should continue your medications as prescribed and make your follow up apointments please continue to take omeprazole twice daily for at least weeks unless instructed otherwise by your gastroenterologist please avoid alcohol aspirin and ibuprofen or naproxen for the next weeks followup instructions please follow up with your primary care physician for check up and to have your blood counts checked hematocrit within week of discharge from the hospital,"{
""Diagnoses"": [""gi bleed"", ""anemia"", ""melena"", ""lightheadedness"", ""new anemia""],
""Medications"": [""Protonix"", ""LNS"", ""blood"", ""units PrBC""]
}"
70608,admission date discharge date service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint dyspnea on exertion major surgical or invasive procedure aortic valve replacement mm st porcine valve and three vessel coronary artery bypass grafting lima to lad svg to obtuse marginal svg to posterior descending artery history of present illness mr is an year old male with known aortic stenosis and long standing dyspnea on exertion recent cardiac catheterization showed severe three vessel coronary artery disease including a left main disease given his severe aortic stenosis and multivessel coronary artery disease he was referred for cardiac surgical intervention past medical history aortic stenosis coronary artery disease non insulin dependent diabetes mellitus dyslipidemia obesity benign prostatic hypertrophy spinal stenosis history of herpes zoster appendectomy lumbar laminectomy umbilical hernia repair carpal tunnel repair hemorrhoid surgery social history pack year history of tobacco quit years ago no prior etoh abuse drinks wine with dinner married lives with wife family history denies premature coronary artery disease physical exam discharge exam vs t hr sr bp rr ra awake and alert mae some dysphagia to thin liquids receiving tube feedings lungs slightly dece reased bs at bases no rales rhonchii cor rrr no murmur crisp heart sounds exts warm palpable pulses trace edema wounds clean and dry with stable sternum pertinent results pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm glucose na k pm urea n creat chloride total co 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 glucose urean creat na k cl hco angap pre bypass the left atrium is moderately dilated 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 overall left ventricular systolic function is normal lvef right ventricular chamber size and free wall motion are normal there are simple atheroma in the descending thoracic aorta there are three aortic valve leaflets the aortic valve leaflets are severely thickened deformed there is moderate to severe aortic valve stenosis area cm mild aortic regurgitation is seen the mitral valve leaflets are moderately thickened there is mild valvular mitral stenosis area cm mild to moderate mitral regurgitation is seen there is no pericardial effusion post bypass the patient is in sinus rhythm left and right ventricular function is preserved an aortic valve replacement tissue is in good position there is no ai the av peak and mean gradients are and mmhg mitral regurgitation is now mild the aorta is intact otherwise the examination is unchanged dr was notified in person of the results at the time of study i certify that i was present for this procedure in compliance with hcfa regulations electronically signed by md interpreting physician m radiology report chest portable ap study date of am medical condition year old man with s p cabg reason for this examination evaluate for infiltrates and effusion final report history cabg findings in comparison with the study of there is little change the aberrant dobbhoff tube is again seen and there is consistent increased opacification at the left base dr approved sun am brief hospital course the patient was admitted and underwent avr cabg x with dr as noted he was transferred to the cvicu in stable condition on titrated phenylephrine and propofol the evening of surgery he developed facial twitching and benzodiazepines were started head cts were done twice in the postop period with no evidence of cva a neurology consultation was obtained and this was felt to not clearly represent seizure activity as confirmed by continuous eeg monitoring keppra was started however seizures did not resolve dilantin was added to his treatment and a mri of head done on pod showed multiple areas of infarction repeat eegs were done again inconsistent with seizures the facial twitching slowly resolved the keppra was discontinued and the patient had slow neurologic advancement over the next few days hemodynamically he remained stable and pressors were weaned and discontinued over several days he continued to improve neurologically and was extubated there is some dysphagia and because of this a dobhoff tube was placed and tube feeds begun speech and swallowing will need to be reassessed as he continues to rehabilitate he remained stable and his respiratory status stabilized with some need for suctioning he was kept in the icu setting prior to transfer to rehab to optimize his care he is ready for transfer at this time discharge medications and follow up appointment requirements are as noted in the discharge paperwork medications on admission coreg detrol qd flomax qd simvastatin qd aspirin qd calcium discharge medications acetaminophen mg tablet two tablet po q h every hours as needed for temperature docusate sodium mg ml liquid two po bid times a day magnesium hydroxide mg ml suspension thirty ml po daily daily as needed for constipation simvastatin mg tablet two tablet po hs at bedtime tamsulosin mg capsule sust release hr one capsule sust release hr po hs at bedtime polyvinyl alcohol povidone dropperette drops ophthalmic prn as needed heparin porcine unit ml solution one injection tid times a day bisacodyl mg suppository one suppository rectal daily daily aspirin mg tablet chewable one tablet chewable po once a day amiodarone mg tablet one tablet po once a day lansoprazole mg tablet rapid dissolve dr one tablet rapid dissolve dr daily daily metoprolol tartrate mg tablet one tablet po tid times a day albuterol sulfate mg ml solution for nebulization three ml inhalation q h every hours as needed furosemide mg tablet one tablet po daily daily insulin glargine unit ml solution thirty five units subcutaneous once a day give at hours insulin regular human unit ml insulin pen see sliding scale subcutaneous ac hs units sq units sq units sq units sq discharge disposition extended care facility discharge diagnosis aortic stenosis coronary artery disease s p aortic valve replacement coronary artery grafting non insulin dependent diabetes mellitus dyslipidemia obesity benign prostatic hypertrophy spinal stenosis postop cva discharge condition good discharge instructions no lifting more than pounds for weeks no driving for weeks and off all narcotics report any drainage from or redness of incisions report any temperature greater than report any weight gain greater than pounds a day or pounds a week shower daily no simming or baths no lotions creams or powders to incisions take all medications as directed followup instructions dr in weeks dr in weeks dr in weeks please call for appointments completed by,"{
""Diagnoses"": [""cardiothoracic"", ""aortic stenosis"", ""dyspnea on exertion"", ""coronary artery disease"", ""multivessel coronary artery disease"", ""severe aortic stenosis""],
""Medications"": [""porcine valve"", ""three vessel coronary artery bypass grafting"", ""lima to lad svg to obtuse marginal svg to posterior descending artery""]
}"
66130,admission date discharge date date of birth sex m service emergency allergies no drug allergy information on file attending chief complaint altered mental status major surgical or invasive procedure none history of present illness the patient is a yom w h o bipolar disorder presenting with mania and delerium sent in from his psychiatrist s office the patient is currently providing an unreliable history however per his brother in law and his sister the patient has had recent poor adherence to his medications and is has had erratic bizarre behavior x months since then he has stopped taking his meds per his sister he seems like he was on speed and never sleeps the patient was evaluated by psychiatry in the er who thought the patient had delerious or psychotic mania and had some catatonic features such as echolalia he has hallucinations as well given delerium not oriented to place or time he was admitted to medicine service to rule out toxic metabolic cause prior to psychiatric inpt admission in the ed initial vs t hr bp rr o sat ra in the er he rec d valium mg iv and mg iv ativan x doses he also was combative in the er and jumped out of bed ran into the hallway and attempted to grab a nurse by the neck due to low grade temp there was a plan for lp but given his combativeness was unable so he was given vanc ceftriaxone and acyclovir prior to his transfer to the floor his vs were hr bp rr o sat on ra currently the patient has complaints of low back pain x days no other complaints he is asking for food from legal sea foods and occasionally yells non sense phrases out but during other times is sleeping heavily he is unable to provide adequate history past medical history psychiatric history include prior hospitalizations outpatient treatments medication ect history response to treatment history of homicidal suicidal assaultive behavior diagnosed in teens major downturn in college has been stabilized on lithium in the past adhd no previous psychiatric hospitalizations no previous sa past medical history include history of head trauma seizures or other neurologic illness s p assault in hs skull fracture severed ulnar nerve s p repair social history per omr lives alone is a nd year law student at ne likes to go to bars frequent barfights had arrest for assaultive behavior while at u mich had arrest for assault within the past year case dismissed after community service no history of physical or sexual abuse h o cocaine heroin per family no known h o ivdu and etoh abuse family history per omr brothers both with with schizophrenia father depression paternal aunt depression s p ect physical exam vitals t bp hr rr sat ra general sleeping aox person thinks he is at the and thinks it is he is unaware of why he is in the hospital heent op clear jvp cm cardiac rrr no m r g lung ctab abdomen bs soft nt nd no masses or organomegaly ext wwp no c c e neuro somnolent occasionally yells out phrases that are non sense answers questions appropriately sometimes aox occasional agitation perrl mm mm able to follow commands grip stregnth bilaterally le stregnth no spinous process tenderness no myoclonus unable to cooperate with rest of neuro exam derm flush bilateral hand abrasions with dorsal surface erythema blanching blanching erythema of the knees bilaterally pertinent results am urine bnzodzpn neg barbitrt neg opiates neg cocaine neg amphetmn neg mthdone neg am urine color yellow appear clear sp am urine blood neg nitrite neg protein neg glucose neg ketone tr bilirubin neg urobilngn neg ph leuk neg am urine rbc wbc bacteria rare yeast none epi pm lactate 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 lipase pm albumin calcium phosphate magnesium pm tsh pm asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count hand a p no acute fracture dislocation or foreign body of the left or right hand cxr no acute intrathoracic abnormality head ct no acute intracranial hemorrhage or edema brief hospital course the patient is a yom w h o bipolar disorder presenting with mania and delerium altered mental status patient was not oriented on presentation and was very aggressive he became oriented to person and place over the first hours but his alertness has waxed and waned with the the administration of sedating medications patient remained significantly agitated and aggressive due to his aggression and attempted assault of hospital staff he was maintained in four point restraints initial disorientation was concerning for delirium patient s subsequent infectious and metabolic work up was negative head ct was also negative for evidence of brain trauma his serum and urine toxicology screens were negative making acute intoxication less likely he was monitored closely for evidence of withdrawal patient s disorientation most likely represented psychosis related to his underlying psychiatric illness family reports recent history of mania in the setting of not adhering to his bipolar medication regimen psychiatry was consulted per their recommendations he was started on zyprexa cogentin and haldol his home psychiatric medications of ambien lexapro and seroquel were held he required several boluses of haldol for extreme agitation he was medically cleared and discharged for further psychiatric treatment to an inpatient psychiatric facility fever low grade temp of on admission with normal wbc count and normal differential etiology unclear likely secondary to agitation or intoxication as his infectious work up remained negative and temperatures returned to due to erythema of bilateral hands with several small abrasions he was started on clindamycin for possible cellulitis after hours erythema resolved and showed no evidence of active infection antibiotics were discontinued chronic back pain per patient and family he does not use iv drugs making osteomyelitis less likely and does not need to be worked up immediately mild transaminse elevation unclear baseline reports of increased etoh use in the last week recommend out patient work up including hepatitis serologies code full contact mother icu consent signed dispo psychiatric inpatient facility medications on admission seroquel ambien lexapro discharge medications clonazepam mg tablet sig one tablet po qid times a day benztropine mg ml solution sig one mg injection times a day as needed for when he receives haldol olanzapine mg tablet rapid dissolve sig two tablet rapid dissolve po bid times a day haloperidol lactate mg ml solution sig one mg injection iv drip via continous iv drip mg per hour multivitamin injection thiamine mg iv once per day banana bag particularly while not taking po discharge disposition extended care discharge diagnosis bipolar disorder with acute mania psychosis nos discharge condition hemodynamically stable altered alertness oriented to person and place discharge instructions you presented to the emergency department with extreme agitation and confusion because of your aggressive behavior you required significant sedation and the decision was made to monitor you in the icu during your icu admission you were evaluated for underlying illness and infection to account for your altered mental status no underlying infection or metabolic abnormality was identified the psychiatry team was consulted and they recommended admission to a psychiatric facility for further management of your symptoms and titration of medications followup instructions please follow up with your primary care provider within two weeks of discharge to have your liver function monitored [NEW_RECORD] name unit no admission date discharge date date of birth sex m service emergency allergies no drug allergy information on file attending addendum question of hand cellulitis given bilateral hand erythema and several abrasions erythema was likely secondary to patient s struggle against restraints as the erythema resolved with sedation he was treated with clindaymycin for hours and then discontinued as no active sign of infection recommend close monitoring of hands and abrasions would restart a day course of clindamycin should patient develop signs of infection etoh abuse per patient and family he has been binge drinking recently in the setting of his manic symptoms but they deny any history of etoh dependence or withdrawal symptoms so unlikely to have withdrawal and low risk for wernicke s however would continue to monitor withdrawal and provide daily banana bags with thiamine particulary if patient remains too sedated agitated to tolerate po diet discharge disposition extended care md completed by,"{
""Diagnoses"": [""Bipolar Disorder"", ""Mania"", ""Delirium"", ""Psychotic Mania"", ""Catatonia"", ""Hallucinations""],
""Medications"": [""Valium"", ""Ativan""]
}"
77276,admission date discharge date date of birth sex f service orthopaedics allergies percocdan nylon sutures attending chief complaint back pain major surgical or invasive procedure l s anterior fusion anterior fusion and decompression of t l posterior decompression and fusion t s w instrumentation and bone graft history of present illness ms has a long history of scoliosis she has attempted conservative treatment but has failed she now presents for surgical intervention past medical history hld gerd barrett s esophagus asthma migraines scoliosis anxiety mitral valve prolapse social history denies family history n c physical exam a o x nad rrr cta b abd soft nt nd bue good strength at deltoid biceps triceps wrist flexion extension finger flexion extension and intrinics sensation intact c t dermatomes reflexes symmetric at biceps triceps and brachioradialis ble good strength at hip flexion extension knee flexion extension ankle dorsiflexion and plantar flexion fhl sensation intact l s dermatomes clonus reflexes symmetric at quads and achilles 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 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 pm blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap brief hospital course ms was admitted to the spine surgery service on and taken to the operating room for l s interbody fusion through an anterior approach please 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 given per standard protocol initial postop pain was controlled with a pca on hd she returned to the operating room for a scheduled t l decompression with psif as part of a staged part procedure please refer to the dictated operative note for further details the second surgery was also without complication and the patient was transferred to the pacu in a stable condition postoperative hct was stable on hd she returned for a scheduled t s posterior fusion with instrumentation a bupivicaine epidural pain catheter placed at the time of the posterior surgery remained in place until postop day one she developed a post operative ileus and an ng tube was placed the ileuse was slowly resolving and ng tube was removed with diet advanced she developed acute distension and was transferred to the ticu for monitoring there an ng tube was placed and her abdomen was decompressed ct scan showed no sign of blockage she was subsequently transferred out of the ticu and monitored she was kept npo until bowel function returned then diet was advanced as tolerated the patient was transitioned to oral pain medication when tolerating po diet foley remained in place due to post op urinary incontenance this will be managed by her pcp was fitted with a tlso brace for ambulation 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 medications on admission pravastatin mg tablet sig two tablet po daily daily citalopram mg tablet sig one tablet po daily daily nortriptyline mg capsule sig one capsule po hs at bedtime bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for contipation magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed for constipation aspirin mg tablet sig one tablet po daily daily calcium carbonate mg calcium mg tablet chewable sig one tablet chewable po qid times a day as needed for dyspepsia ranitidine hcl mg tablet sig one tablet po bid times a day diltiazem hcl mg capsule extended release sig one capsule extended release po daily daily discharge medications pravastatin mg tablet sig two tablet po daily daily citalopram mg tablet sig one tablet po daily daily nortriptyline mg capsule sig one capsule po hs at bedtime bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for contipation magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed for constipation aspirin mg tablet sig one tablet po daily daily calcium carbonate mg calcium mg tablet chewable sig one tablet chewable po qid times a day as needed for dyspepsia ranitidine hcl mg tablet sig one tablet po bid times a day oxycodone mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills diltiazem hcl mg capsule extended release sig one capsule extended release po daily daily discharge disposition home with service facility care discharge diagnosis scoliosis urinary incontenance post op ileus acute post op blood loss anemia discharge condition good discharge instructions you have undergone the following operation anterior posterior thoracolumbar decompression with fusion 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 getting up and walking 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 olimit 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 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 while 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 call the office you should resume taking your normal home medications no nsaids 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 please call the office if you have a fever degrees fahrenheit and or drainage from your wound physical therapy activity activity ambulate with brace treatment frequency please perform leg bag teaching inspect the incision for drainage daily followup instructions with dr in days completed by,{}
10209,admission date discharge date date of birth sex m service nsu addendum mr is being discharged to an acute rehab facility no significant changes have been made to his medical care as reported in the previous discharge summary he is currently being treated with vancomycin mg iv q h for a staph aureus coag positive blood culture from per id recommendations he needs to receive two weeks of iv vanco which would end on for those blood cultures he had a picc line placed in order to receive iv antibiotics his dilantin level need to be followed closely discharge instructions he will have aggressive physical therapy and occupational therapy he should call dr office if he has any decreased level of consciousness he should have a helmet when out of bed at all times or being transferred he should monitor his dilantin as previously mentioned discharge medications colace mg ml one po bid bisacodyl mg tablet delayed release two tablets qd tylenol prn prevacid mg one po bid oxycodone solution q h as needed labetalol three tablets po bid insulin sliding scale ferrous sulfate mg one po qd fluconazole mg one po q h dilantin mg tablets to take six tablets po tid keppra mg two tablets po bid heparin units subcu metoprolol mg po bid vancomycin mg iv q follow up he should follow up with dr with a head ct prior to appointment he will also need his craniectomy replaced and his flap put back on in the next one to two months he should call dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service nsu history of present illness the patient is a year old gentleman who was struck in the head with a baseball bat the patient was found combative at the scene he was intubated sedated and transported to where a head ct revealed a large subarachnoid hemorrhage with no shift or mass effect and a possible small right parietal subdural hematoma the patient was given gm of mannitol and transported to for further management on arrival the patient s pupils were pinpoint he had right upward gaze he was intubated and sedated his blood pressure was pulse sat s percent repeat head ct showed largely unchanged positive right parietal skull fracture right sided longitudinal temporal bone fracture air in the soft tissue a large subarachnoid hemorrhage past medical history unknown at the time of admission later from his wife found that the patient was recently given meds for hypertension no other past medical history physical exam the patient was afebrile blood pressure pulse the patient also had a large laceration of the right occipital area he was in a cervical collar labs white count crit platelet count gas was and he had a lactate level of on admission the patient s gcs was at the scene the patient had a ventricular drain placed on admission icp was after a drain was placed other imaging on admission ct of the maxillary sinuses was negative ct of the c spine and abdomen were also negative his chest x ray was clear his kub was also negative hospital course icp s were a problem for the first week of patient s admission to the icu up as high as the patient was given gm of mannitol q h on exam he opened his eyes and moved all extremities the patient had a repeat head ct done on which showed vent drain in place a small right temporal extraaxial hematoma which was unchanged from previous a small punctate hemorrhagic contusion in the temporal lobe also a tiny contusion of the basal right frontal lobe and left hemispheric cortex on the patient had a stat head ct for increased icp ct showed right frontoparietal and left frontal matter the patient had sudden desaturation chest x ray showed lingular atelectasis the patient continued to have persistent high icp s the patient was put in a pentobarbital coma chest x ray showed bilateral pleural effusions despite being in the pentobarbital coma the patient s icp s elevated to the patient reached his maximum for mannitol given high sodium and osm the patient was given lasix which brought icp s down into the s the patient had lower extremity doppler s on that showed no evidence of dvt head ct on showed increase in the ethmoid sinus opacity possibly contusion of the right frontal lobe via the right mca and continued effacement of the sulci and ventricles from edema on despite being in a pentobarbital coma with burst suppression and functioning vent drain the patient s icp s became uncontrollable into the s to s the patient was taken emergently for a right anterior temporal lobectomy for removal of the contused brain and a decompressive craniectomy the patient tolerated the procedure well there were no complications his pupils were mm and nonreactive his incision was clean dry and intact his vital signs were stable on the patient had an acute onset of desaturation he had a cta of his chest which confirmed a left upper lobe pe he had an ivc filter placed on general surgery was consulted for question of ischemic bowel secondary to high lactate levels ct of the abdomen on suggested partially or early small bowel obstruction with decreased caliber of celiac axis increased bibasilar consolidation in the lungs head ct showed changes otherwise stable the patient continued to be in pentobarbital coma as no discernable exam and despite that continued to have small spikes in his icp requiring treatment with mannitol and lasix vital signs were otherwise stable and his lactic acid levels were trending down by on the patient spiked to on the patient had a head ct that showed bilateral frontotemporal encephalomalacia right greater than left but midline was improved the patient had cerebral blood flow study scan after being weaned off pentobarbital it did show blood flow but his exam was consistently poor pupils were small in diameter and nonreactive he had no movement in his extremities his icp was chest x ray on showed development of left lower lobe collapse and consolidation and left pleural effusion kub on the showed the tip of his og tube postpyloric however the patient was not tolerating tube feedings secondary to high residuals tube feeding was discontinued and the patient was started on tpn the thought being that still with lactic acid level high he was not absorbing his tube feedings and it would give him bowel rest and put him on tpn due to his consolidation and pneumonia the patient s ventilatory support needed to be increased and the patient was not a candidate for trach at this point the patient had repeat head ct on which was stable and stable chest ct there was an improvement in the bilateral consolidation his abdominal ct showed left lower quadrant thickening thick bowel versus collapsed lumen he spiked to the patient showing evidence of pancreatitis from his tpn he was started on flagyl for loose stool to date csf cultures have been negative blood cultures were negative sputum grew citrobacter and the patient was started on levaquin neuro exam slightly improved on the patient was moving his right arm spontaneously and tracking with his eyes when off sedation his peep was being weaned his pancreatitis was slowly resolving drain was increased to cm and clamped the patient tolerated clamping of the vent drain head ct after clamping the drain showed slight enlargement of the right frontal on the patient was trach d the patient was bronched which showed thick but clear secretions sputum grew out acinetobacter and was given a dose of meropenem he was also on levaquin flagyl and cefazolin for the vent drain prophylaxis the patient s vein drain was removed on he continued to have low grade fevers on a chest x ray continued to show bibasilar infiltrates and increased on the right his head ct from was stable with no changes on the patient had a stable head ct with no change in the ventricular size the patient was off propofol with minimal neuro exam opening his eyes some spontaneous movement on the right side his condition remained stable and he was transferred to the step down unit on he has been seen by physical therapy and occupational therapy he did grow out staph coag positive mrsa from his blood on and was started on vancomycin gm iv q h latest sputum from continued to show acinetobacter in his sputum on he had a tonic clonic seizure and was reloaded on dilantin on he also had flexion extension films of his c spine under fluoro which cleared his c spine the collar was removed he had a repeat echo on that was essentially unchanged from previous with an ef of percent there was no pfo and no evidence of clot in either chamber of the heart causing emboli the patient was seen by physical therapy and occupational therapy and found to require acute rehab his vital signs have remained stable he is on iv antibiotics which finish on condition on discharge stable neurologically his condition remains unchanged he opens his eyes he has some spontaneous movement on the right side and is tracking intermittently otherwise his neuro exam is unchanged no movement on the left side discharge medications dilantin mg po q pm mg po q am fluconazole mg po q h for yeast in his urine ferrous sulfate po qd metoclopramide mg po qid before meals insulin sliding scale heparin u subcu tid labetalol mg po bid percocet elixir ml po q h prn miconazole powder percent application topically prn artificial tears drops ou prn vancomycin mg iv q h which was started on he was transferred to rehab and is to follow up with dr in month with a repeat head ct dictated by medquist d t job,{}
3150,admission date discharge date service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint right femur fracture after fall at facility major surgical or invasive procedure right femur fracture repair history of present illness year old female who was admitted with a midshaft right femur fracture after a mechanical fall she did not have vertigo chest pain shortness of breath loss of consciousness or head trauma per the facility the patient was unable to give a coherent history due to her dementia past medical history pmh atrial fibrillation on coumadin hypothyroid hypertension mitral regurgitation dementia likely alzheimer s severe h o r hip fracture intertrochanteric with subtrochanteric extension h o tia x h o pacemaker placement social history lives in widowed has children denies tobacco occasional alcohol no ivdu family history noncontributory physical exam pe gen awake alert conversant pleasant elderly woman in nad heent pupils mildly responsive r surgical pupil cv rrr nl s s no murmurs pulm ctab no wheezes abd soft nondistended hypoactive bowel sounds no masses ext r leg brace in place r foot somewhat cool to touch pulses sensed by doppler pertinent results n l m e bas band pt ptt inr ua dipstick negative rbc wbc bact occ yeast none epi hip and femur plain films severely comminuted fracture of the distal metadiaphysis of the right femur no other acute fractures identified interval fixation of proximal right femur fracture with intact metallic hardware brief hospital course r femur fracture she was found to have a distal right femur fracture she received fresh frozen plasm for reversal of inr prior to surgery she had an orif on the day of admission without complication during the immediate post operative period her right lower extremity was slightly cool but the pulses were sense by doppler therefore there was some concern for compartment syndrome over the course of the next day both of her extremities were warm well perfused and had pulses that were detectable by doppler she had a drain in place that was removed on post operative day she received hours of prophylactic antibiotics her coumadin was restarted on post operative day for dvt prophylaxis her pain was managed with morphine she was tolerating touch down weight bearing on the right leg at the time of discharge she was fitted for a brace prior to being discharged atrial fibrillation with rapid ventricular rate during the peri operative period she became tachycardic to the s she was started on a diltiazem drip for rate control she was not extubated immediately post operatively given her tachycardia her heart rate came down to the s and she was weaned off of the diltiazem in the pacu she remained stable during an overnight observation in the micu and was extubated in the morning once she was extubated she was restarted on her outpatient metoprolol which was titrated up for rate control she was also maintained on her coumadin she was subterapeutic so her coumadin was increasedd to on the day of discharge she had three sets of cardiac enzymes post operatively hypotension she had peri operative hypotension that was attributed to hypovolemia given her intra operative blood loss she initially required pressors in the pacu but the her blood pressor stabilized within the first hours she also received units of red cells her antihypertensive medications were restarted with adequate blood pressure control dementia after extubation she quickly returned to her baseline she was not oriented but she was conversational and responsive at night she sometimes required haldol and zyprexa for agitation her outpatient donepezil was continued throughout the admission hypothyroidism her outpatient levothyroxine was continued throughout the admission fen she was initially npo for her surgery upon extubation she didn t tolerate thin liquids with her medications a speech and swallow evaluation cleared her for pureed foods and nectar thick liquids her electrolytes were repleted prophylaxis she was maintained on a ppi and coumadin communication communication was with her son code her code is dnr dni which was reversed for the operation medications on admission hydrochlorothiazide mg po qd lisinopril mg po qd donepezil mg po qd synthroid mg po qd coumadin mg po qhs discharge medications levothyroxine sodium mcg tablet sig one tablet po daily daily donepezil mg tablet sig one tablet po hs at bedtime lisinopril mg tablet sig tablet po daily daily metoprolol tartrate mg tablet sig tablets po tid times a day calcium carbonate mg ml suspension sig five ml po tid times a day cholecalciferol vitamin d unit tablet sig one tablet po daily daily morphine mg ml syringe sig one injection q h every hours as needed coumadin mg tablet sig one tablet po at bedtime discharge disposition extended care facility discharge diagnosis right femur fracture discharge condition stable she is tolerating touch down weight bearing on the right leg her blood pressure and heart rate are stable discharge instructions please take all medications as prescribed call your doctor or return to the emergengy room if you have numbness tingling coldness in your right foot or if the surgical wound becomes red swollen or drains puss followup instructions please follow up in the orthopedics clinic for your fracture provider m d where orthopedics phone date time completed by,{}
6871,admission date discharge date date of birth sex m service chief complaint back pain retroperitoneal mass on ct history of present illness the patient is a hospital transfer to our emergency room who is a diabetic with peripheral vascular disease hypertension and hypercholesterolemia who one week ago developed moderate to severe lower back pain the patient denied any sprain trauma falls or lifting the back pain was without radiation numbness weakness nausea or vomiting the patient denied dysuria or hematuria the patient was seen at a local hospital where abdominal ct was obtained that showed a retroperitoneal mass the patient was given bactrim and discharged the patient requested evaluation at past medical history diabetes mellitus type x years hypertension hypercholesterolemia peripheral vascular disease chronic renal insufficiency with baseline creatinine of history of svt status post surgery history of hemorrhoids past surgical history orthopedic surgery for leg fracture and toe amputations allergies the patient has no known drug allergies medications zocor mg q d zestril mg q d oxycontin for pain advil for pain and insulin social history the patient is married and lives with his wife has occasional alcohol use occasional cigar use he is a retired bricklayer physical examination vital signs temperature blood pressure pulse rate respiratory rate oxygen saturation on room air general he was a morbidly obese white male in no acute distress heent examination was unremarkable neck supple with no lymphadenopathy cardiac regular rate and rhythm with normal s and s lungs clear to auscultation bilaterally abdomen obese soft and nontender nondistended with bowel sounds present back no costovertebral angle tenderness or muscle spasm rectal normal tone no masses guaiac positive extremities there was edema with chronic venous stasis changes with right foot charcot foot changes femoral pulses were palpable bilaterally popliteal pulses were palpable bilaterally pedal pulses were nonpalpable neurological examination was unremarkable laboratory data white count hematocrit platelet count neutrophils bands lymphocytes pt inr and ptt were normal bun creatinine k recheck outside ct scan showed a x x x mass at the level of l hospital course a repeat ct of the abdomen was obtained which demonstrated contained leak in the abdominal aorta cm distal to the right renal artery positive node enlargement multiple blood and urine cultures were obtained which were all no growth and negative abf staining negative fungal staining negative to date but not finalized abf and fungal cultures the patient was transferred to the surgical intensive care unit for continued monitoring and care he had a foley catheter placed by the urology service he was placed with two large bore gauge needles nitroglycerin to maintain his systolic blood pressure at less than n p o intravenous hydration serial hematocrits mucomyst was begun dr was consulted by consulted by dr to consider placing a stent graft in the aortic pseudoaneurysm secondary to tumor invasion the patient underwent endovascular aortic stent placement on he remained intubated and was stable and was transferred to the surgical intensive care unit for continued care serial hematocrits were obtained he was transfused two units of packed red blood cells post transfusion hematocrit was the patient s examination remained unremarkable and he continued to require nipride drip and beta blockade to maintain a systolic blood pressure of less than or equal to he was weaned to extubate on postoperative day two the patient required aggressive diuresis for volume overload secondary to third spacing the patient was extubated without difficulty his post transfusion hematocrit was bun creatinine k abdominal examination remained unchanged and pulse examination remained unchanged his hematocrit remained stable the patient was transferred to the vascular intensive care unit for continued monitoring and care a renal consultation was requested because of continuing elevation in his creatinine they felt the etiology of the creatinine bump was secondary to acute tubular necrosis which was caused by a combination of contrast induced hypotension on the patient returned to ct scan and underwent a ct needle biopsy and aspiration tissue and fluid were sent for culture the culture results demonstrated pmns abf stain was negative so far the culture has shown no growth and the abf is not finalized but no growth with these results the patient was placed on vancomycin levofloxacin and flagyl his medications were renal dosed the patient required intravenous hydration for low urinary output per renal infectious disease was consulted to determine length of therapy and antibiotic agents that should be utilized for this patient s care recommendations were to continue current antibiotic therapy and adjust according to culture results the patient returned to ct on for further specimens for culture he tolerated the procedure without complications his acute renal failure slowly resolved his peak creatinine was he returned to baseline of general surgery continued to follow the patient awaiting further anticipation of intra abdominal surgery podiatric surgery saw the patient for left foot callus protection the patient s antihypertensives required redosing with improvement in his renal function ace inhibitor was restarted zestril mg q d on discussion ensued regarding intra abdominal intervention with axillofemoral bypass graft cardiology consultation was requested for perioperative risk assessment echocardiogram demonstrated left atrial dilatation mild right atrial dilatation mild left ventricular and right ventricular dilatation with global hypokinesis pulmonary hypertension valves were without stenosis or regurgitation ejection fraction was calculated at although the patient s persantine mibi was negative for ischemic changes but because of the low ejection fraction and global hypokinesis cardiac catheterization was recommended the patient underwent cardiac catheterization on which demonstrated multivessel disease right coronary artery stenosis main trunk stenosis left anterior descending coronary artery stenosis main circumflex coronary artery stenosis the patient did not require any cardiac intervention or surgery continue on medical therapy after rediscussion and reconsideration it was decided that the patient would be at a very high risk for open procedure and that for the present time we would continue conservative treatment with long term antibiotics monitor the patient and then determine if any other surgical intervention is required the following day post catheterization the patient had an episode of vague anterior chest discomfort described as a heaviness burning ekg was obtained which showed st depressions in v and the patient was transferred to a monitoring unit to rule out myocardial infarction his cpks and troponin levels were flat his ekg returned to baseline general surgery was consulted on to do an open biopsy the patient underwent exploratory laparotomy retroperitoneal dissection phlegmon drainage and biopsy on he tolerated the procedure well and was transferred to the postanesthesia care unit in stable condition postoperatively the patient did well the patient s culture from the operating room on the st grew out gram positive cocci the patient was continued on vancomycin the patient will require a total of eight weeks of antibiotics physical therapy and occupational therapy did evaluate the patient for potential rehabilitation the right picc line initially was felt not to be positioned correctly after reevaluation it was felt that it was in the correct position and did not require any adjustment the patient s hematocrit was noted to be recommendations of cardiology to maintain his hematocrit greater than included transfusion this will be discussed with the attending and decision made before patient discharge with a repeat hematocrit if transfused at the time of discharge the patient was afebrile his wounds were clean dry and intact discharge instructions recommendations were to continue antibiotics for a total of eight weeks starting from he would require abdominal and pelvic ct with intravenous contrast at two weeks post discharge and four weeks post discharge this request will be called to dr office and arranged for the patient the patient should have per infectious disease weekly complete blood counts sma s and vancomycin troughs we will clarify with the infectious disease service whether he will require serial esrs to be done on an outpatient basis the laboratory findings should be called to the infectious disease clinic the infectious disease clinic number is follow up a follow up appointment in two weeks with dr and dr which is thursday clinics or dr which is friday clinics should be arranged along with his abdominal ct arrangements should be made for the patient to be seen on follow up by dr of the renal service at the same time he has his initial follow up visit with dr and the infectious disease service discharge medications dulcolax tablets mg q d p r n aspirin mg q d vancomycin mg intravenous q hours with trough levels q week levofloxacin mg intravenous q hours flagyl mg intravenous q hours zantac mg b i d metoprolol mg b i d hold for systolic blood pressure of less than heart rate less than lisinopril mg q d percocet tablets q hours p r n for pain epogen units subcutaneous q sunday and wednesday heparin subcutaneous units q hours surgical pathology the periaortic lymph node was reactive with fragments of fibrinous connective tissue with marked chronic and active inflammation and focal abscess formation the retrocaval phlegmon showed fibrinous and fibroadipose tissue with abscess formation reactive lymph nodes there was no malignancy identified in either specimen discharge diagnoses retroperitoneal mass i e abscess status post exploratory laparotomy retroperitoneal approach abdominal aortic aneurysm status post aortic endovascular stenting chronic renal insufficiency with episode of acute tubular necrosis resolved coronary artery disease with ejection fraction of status post cardiac catheterization mild triple vessel disease left foot deformity stable hypertension controlled picc line placement for long term antibiotics m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service addendum discharge instructions picc line care as per institutional protocol left foot dressing dsd qd monitor cbc sma vanco trough weekly call results to dr office and infectious disease clinic number monitor esr and crp at two weeks and four weeks postdischarge and call those to infectious disease antibiotics will be continued for a total of eight weeks starting from the date please call and arrange for abdominal pelvic ct with contrast iv at two weeks and at four weeks correlate these with follow ups with dr give the patient mucomyst mg doses prior to planned ct and two doses after planned ct dates monitor glucose by fingersticks before meals and at bedtime follow up visits dr at two weeks and at four weeks with abdominal pelvic ct with iv contrast please call for arrangements for the procedure and follow up visit the patient should also be seen by the infectious disease clinic dr or dr and their number is the patient also should be seen by dr of nephrology department with the initial visit postdischarge his number is discharge diagnoses abdominal aortic aneurysm status post endovascular stenting on retroperitoneal mass abscess status post ct needle aspiration on and open laparotomy retroperitoneal approach with biopsy on coronary artery disease with an ejection fraction of with global hypokinesis and negative stress test status post cardiac catheterization on chronic renal insufficiency with acute tubular necrosis corrected secondary to contrast induced resolved chronic anemia stable m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service medicine history of present illness the patient is a year old male with a history significant for hypertension type diabetes hypercholesterolemia coronary artery disease and an aortic aneurysm status post endovascular repair in who presents with left groin swelling the patient had been in his usual state of health until two weeks prior to admission when he complained of this left groin swelling he denied any fever or chills nausea or vomiting or any other complaints patient presented to hospital where the left groin swelling where the abscess was was spontaneously drained he was then transferred to the emergency room at where he was started empirically on vancomycin levofloxacin and clindamycin for probable groin abscess he is also treated for his hyperkalemia as his potassium on admission was he was also transfused unit of packed red blood cells for his hematocrit of and fluid resuscitated past medical history aortic aneurysm status post endovascular repair with an infrarenal vena cava reconstruction in hypertension type diabetes x years peripheral vascular disease hypercholesterolemia coronary artery disease status post catheterization and stress test in congestive heart failure with an ejection fraction of chronic renal insufficiency with a baseline creatinine of history of supraventricular tachycardia status post radiofrequency ablation hemorrhoids past surgical history endovascular graft repair of triple aortic aneurysm with infrarenal vena cava reconstruction status post open reduction internal fixation of left leg multiple toe amputations medications on admission humalog humulin q h s zestril mg p o q d zocor mg p o q d percocet tablets p o q h prn pain oxycontin levofloxacin mg p o q d synthroid mcg p o q d allergies no known drug allergies family history noncontributory social history the patient is married and lives with his wife in he reports occasional alcohol and occasional cigar use he is a retired bricklayer but now is out on disability physical exam on admission temperature heart rate blood pressure oxygen saturation on room air respiratory rate general the patient is alert and oriented lying flat on the stretcher heent anicteric mucous membranes moist extraocular muscles are intact cardiovascular regular rate and rhythm positive s and s grade systolic ejection murmur at the left upper sternal border without radiation abdomen soft nontender positive bowel sounds extremities left greater than right groin swelling bilateral lower extremity edema no asterixis pedal pulses neurologic alert and oriented times three cranial nerves ii through xii are grossly intact laboratory values on admission white blood cell count with neutrophils and lymphocytes hematocrit platelets sodium potassium chloride bicarb creatinine glucose pt ptt inr patient had urinalysis which revealed protein but no ketones or urobilinogen chest x ray no congestive heart failure ct scan of the pelvis no bleed bilateral groin fluid collection graft present below the renal arteries impression the patient is a year old caucasian male with underlying renal disease likely secondary to hypertension diabetes who presents with left groin abscess hospitalization course by systems infectious disease patient had incision and drainage performed of his left groin he was found to have staphylococcus aureus that was sensitive to vancomycin and thus he was started on vancomycin gram iv q he was also initially on levofloxacin and clindamycin which were discontinued and zosyn was begun on in addition a debridement was performed by podiatry of the left foot ulcer this also grew out staphylococcus aureus which is sensitive to vancomycin this is likely the source of his left groin abscess a mri was performed of the foot which was negative for osteomyelitis and thus the zosyn was discontinued and the vancomycin was continued the patient remained afebrile and his white blood cell count was within normal limits local wound care was performed for his left foot ulcer and left groin abscess blood cultures and urine cultures were negative for any signs of infection patient was also continued on oral pain medication for his pain associated with the abscess and ulcer vascular vascular surgery followed the patient while he was in house pulse volume recordings were obtained on which revealed significant left tibial disease however the pvrs were and the patient should follow up with vascular surgery as an outpatient fluids electrolytes and nutrition the patient was followed closely for his hyperkalemia during his stay he was given one dose of kayexalate with improvement in his potassium from to he was maintained on a low potassium renal prudent diet he was also started on sodium bicarbonate mg p o b i d for correction of his hyperkalemia cardiovascular the patient was continued on metoprolol hydralazine and isordil norvasc was added on for long term blood pressure control he was continued on his simvastatin at his current dose for hypercholesterolemia gu patient has chronic renal insufficiency he improved nearly to his baseline creatinine with hydration he will follow up with nephrology in as an outpatient endocrine the patient was continued on sliding scale insulin with adequate control of his blood sugars pulmonary patient did well with incentive spirometry after his left groin abscess was incised and drained an interval chest x ray showed improvement in atelectasis podiatry as above the patient was fitted with a felted foam pad to allow ambulation upon discharge condition on discharge good discharge status rehab facility discharge medications humalog units humulin units q h s zocor mg p o q d percocet tablets p o q h prn metoprolol mg p o b i d protonix mg p o q d hydralazine mg p o q norvasc mg p o q d isordil mg p o t i d synthroid mcg p o q d vancomycin mg iv q h bicarbonate mg p o b i d ferrous sulfate mg p o q d epogen units per week discharge diagnoses left groin abscess left foot ulcer type diabetes hypertension hyperkalemia followup the patient was instructed to followup with his nephrologist as an outpatient in he is also instructed to call his primary care physician for an appointment within weeks m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service vascular chief complaint left groin swelling and pain with spontaneous drainage history of present illness the patient was hospitalized on to for bilateral fluid collections on the right was x and on the left was x seroma versus hematoma was the thinking the patient developed low back pain with radiation to the groin the patient went to an outside hospital and then was referred to us he underwent a noncontrast computed tomography which revealed a right groin fluid collection which was stable infectious disease felt at that time there was no clinical or radiological evidence of abscess worsening their recommendations were that the patient complete an week course of vancomycin levofloxacin and flagyl at the time of admission he had two more weeks of antibiotics the hospital course was unremarkable except for a low hematocrit of for which he was transfused the patient s hematocrit was the patient returns now with two weeks of left groin swelling he did not seek medical attention he denied constitutional symptoms the pain continued to progress until when the patient sought medical attention and was seen at hospital and admitted the groin spontaneously drained a computed tomography was done there report of the findings were not available to us the patient was transferred to our institution for further evaluation and treatment past medical history abdominal aortic aneurysm status post endovascular repair history of bilateral groin fluid collections history of hypertension history of type diabetes history of hypercholesterolemia history of chronic renal insufficiency with a baseline creatinine of history of supraventricular tachycardia past surgical history endovascular abdominal aortic aneurysmal repair and open reduction internal fixation of a leg fracture brief summary of hospital course the patient was initially assessed in the emergency department and the vascular service was consulted complete blood count revealed white blood cell count was with neutrophils of and lymphocytes of and his hematocrit was the patient was afebrile with a temperature maximum of the patient s electrolytes showed a potassium of with a creatinine of which was elevated from his baseline of the patient was given kayexalate and normal saline intravenous solution with intravenously regular insulin and d ampules times one was given the patient was also begun on levofloxacin mg and vancomycin gram intravenous fluids were changed to half normal saline with ampules of bicarbonate per liter and he received a second dosing of units of insulin with ampule of d the patient was to the operating room and underwent an urgent incision and drainage of the left groin cultures were obtained at that time the intraoperative findings were an abscessed cavity the artery was not exposed the patient was then transferred to the postanesthesia care unit for controlled monitoring and care the patient remained on ventilator support secondary to episodes of hypotension which responded to fluid boluses his blood gas was the patient s postoperative hematocrit was his white blood cell count was his blood urea nitrogen was his creatinine was the patient received units of packed red blood cells intraoperatively the patient was kept sedated overnight and remained in the postanesthesia care unit the renal service was consulted for management of the patient s acute renal failure recommendations were to continue to monitor his urine output maintain his systolic blood pressure at greater than maintain his hematocrit at greater than hold ace inhibitors and to avoid lasix and diuretics and nonsteroidal medications recommendations were since his urine output was good there would be supportive care and dose medications for a glomerular filtration rate of to podiatry was also consulted for severe soft tissue swelling and charcot changes of the midfoot with barouk button deformity recommendations were to continue current therapy the patient remained intubated and was transferred to the intensive care unit for continued monitoring and care the patient initial wound cultures grew gram positive cocci the foot wound culture grew gram positive cocci gram positive rods and gram negative rods the patient was seen by the cardiology service and a transesophageal echocardiogram was done the valves were without changes there were no vegetations noted his ejection fraction was calculated at greater than there was no pericardial effusion and no atrial septal defect the infectious disease service was consulted regarding evaluation of infection antibiotic and length of therapy their recommendations were to continue vancomycin and to dose when levels were less than the levofloxacin should be discontinued since the patient had been on it previously and change him to zosyn for gram negative rod coverage discontinue the clindamycin repeat blood cultures times two sets to rule out bacteremia length of therapy to depend on clinical course the patient was extubated on postoperative day one and the patient was transferred to the vascular intensive care unit for continued monitoring and care the nitroglycerin was weaned off he remained hemodynamically stable his hematocrit was with a total white blood cell count of his blood urea nitrogen was his creatinine was liver function tests were unremarkable the patient s blood cultures were no growth but not finalized at the time of this dictation the initial wound culture grew oxacillin resistant coagulase positive staphylococcus intraoperative tissue cultures were the same a repeat wound culture grew the same organisms the patient remained in the vascular intensive care unit the pa catheter was changed to a central venous line ambulation with a healing sandal was instituted his diet was advanced as tolerated his fluids were hep locked his wound dressing changes were continued three times per day the patient underwent pulmonary vascular resistance studies which demonstrated noncompressible vessels with mild left tibial arterial disease the dopplerable signals at popliteal posterior tibialis and dorsalis pedis were all triphasic the pulse volume metatarsal was on the right and on the left ankle brachial index could not be calculated secondary to elevated noncompressible vessels the patient s renal status continued to show improvement over the next hours with management by the renal service the patient underwent excisional debridement at the bedside on by the podiatry service their recommendations were to continue current therapy and the patient was to follow up with dr or dr one week status post discharge the patient was transferred to the medicine service on under the care of dr the remaining hospital course will be dictated by the medicine service the patient should follow up with dr one week status post discharge m d dictated by medquist d t job [NEW_RECORD] name unit admission date discharge date date of birth sex m service medicine firm hospitalization course please refer to the prior dictated discharge summary for a complete account of this patient s hospitalization course up through due to the need for a picc line placement as well as a repeat x ray to assess the positions of the patient s stent he was hospitalized for another day he was also evaluated by physical therapy who felt that he was safe to discharge home with services rather than to a rehabilitation facility podiatry evaluated the patient and fitted him with a felted foam on the bottom of his left foot for facilitating ambulation an abdominal x ray revealed that the endo graft was in the correct position as per vascular the patient s zosyn was discontinued and he was continued on vancomycin only his blood pressure medications were also slightly adjusted for more adequate control of his hypertension condition on discharge good discharge status home with services discharge diagnoses left groin abscess left foot ulcer hyperkalemia type diabetes mellitus hypertension medications on discharge epogen units per ml one injection per week synthroid mcg tablet per day simvastatin mg p o q day metoprolol mg p o b i d percocet to tablets p o q to hours p r n pain protonix mg p o q day hydralazine mg p o q hours sodium bicarbonate mg p o b i d norvasc mg p o q d ferrous sulfate mg p o q d aspirin mg p o q d vancomycin gram intravenously q hours times cays levofloxacin mg p o q d isordil mg p o q day humalog units in the morning units in the afternoon units in the evening as well as humulin units q h s prescription for outpatient laboratory work to include a chem cbc liver function tests vancomycin trough every wednesday was given follow up the patient was instructed to call his nephrologist and podiatrist in for appropriate follow up he was also instructed to call his primary care physician at for follow up appointment in one to two weeks he was also to follow up with dr on at p m the patient was also to follow up with dr on at a m at the patient was given instructions for appropriate dressing changes to be followed by the visiting nurses m d dictated by medquist d t job,"{
""Diagnoses"": [""back pain"", ""retroperitoneal mass"", ""hypertension"", ""hypercholesterolemia"", ""diabetes mellitus"", ""peripheral vascular disease"", ""chronic renal insufficiency""],
""Medications"": [""Bactrim"", ""Zocor"", ""Zestril"", ""Oxycontin"", ""Advil"", ""Insulin""]
}"
76826,admission date discharge date date of birth sex m service surgery allergies erythromycin base attending chief complaint m presents after possible assault in jail and reported seizure intubated at osh for airway protection it is not clear if seizure was secondary to assault or etoh withdrawl major surgical or invasive procedure none history of present illness pt is a yo m transf d from osh s p unknown trauma per ems pt was arrested on saturday for dui possible mvc associated w arrest but pt was not taken to hospital pt was withdrawing in jail and was found having a seizure there is a vague report he may have been assaulted while in jail but this has not been confirmed he was brought to the osh intubated and transf d to physical exam vs ra pupils equal rrr chest chear abdomen soft pertinent results pm asa neg ethanol neg acetmnphn neg bnzodzpn pos barbitrt neg tricyclic neg brief hospital course patient was noted to be tremorous when propofol was turned down it was thought that he likely had alcohol withdrawal seizures he was weaned from the ventilator and extubated he has a subdural hematoma and a c facet fracture he was seen by physical therapy who thought he was deconditioned and week he was transferred to the floor where magnesium and potassium were repleted on he was discharged discharge medications phenytoin sodium extended mg capsule sig one capsule po tid times a day for days disp capsule s refills discharge disposition home discharge diagnosis alcoholic withdrawal syndrome seizure disorder c facet fracture subdural hematoma discharge condition stable discharge instructions you had some bleeding in your head called a subdural hematoma ct scans show that the bleeding has stabilized you should take dilantin for a total of days to be completed because of your bleeding you are at increased risk of seizures the dilantin will help to prevent these no driving for months call your doctor s office or come to the emergency room if you have fevers above f nausea vomiting that doesn t stop headaches or changes in your vision blackouts followup instructions please follow up with dr in weeks you will have another ct scan of your head on this visit please call to have this arranged,{}
92415,admission date discharge date date of birth sex m service medicine allergies oxycodone attending chief complaint non healing rle wound major surgical or invasive procedure irrigation and debridement of skin subcutaneous tissue muscle and tendon of right lower extremity free latissimus dorsi muscle flap reconstruction split thickness skin graft x cm irrigation and debridement of right back wound history of present illness yom w h o with chf afib wpw s p ablation high grade right le sarcoma s p xrt and multiple excisions hemochromatosis c b cirrhosis hypertension gerd and asthma his rle sarcoma is s p resection x and rads w last one covered w stsg has since had breakdown of wound that required free flap past medical history sarcoma rle s p excision and wks ago late an elective wide excision of the tumor bed wound healing well per surgery note here in ed today atrial fibrillation on chronic a c warfarin status post ablation for parkinson white syndrome in congestive heart failure cirrhosis hemochromatosis diagnosed two to three years ago hypertension gerd asthma depression hypothyroidism int hemorrhoids social history irish scottish ancestry speaks english with accent speaks gaelic lived in and ca previously the patient works as a housecleaner he previously owned his own cleaning concession and did both household as well as commercial cleaning works and does chores from a p at baseline recent changes post op with difficulty sleeping tobacco he is currently a nonsmoker and reports years of nonsmoking prior history was one pack per day x years etoh prior intake beers and a nip of soco whiskey wife says he hides intake from her so may be more says he stopped drinking for surgery none since denies illicits family history significant for alcoholism he has a brother who has hepatocellular carcinoma and there is a history of breast cancer in both his mother and a sister physical exam admission pe vs s s ra gen lying comfortably in bed awake alert oriented appropriate heent no conjunctival iceterus or pallor mmm op clear face symmetric neck supple no jvd or lad cv irregularly irregular not tachycardic no murmurs or rubs pmi nondisplaced abd soft nt nd nabsx no rebound or guarding ext rle with large leg lesion right foot has pitting edema which patient says is chronic neuro sensation to light touch intact over all extremities other than posterior r thigh aaox speech fluent thought process clear discharge pe vitals t p s ss bp r o sat ra general alert oriented no acute distress heent sclera anicteric mmm oropharynx clear neck supple no lad cvl on r anterior neck lungs jp drains in r lower thorax draining bloody fluid no adventicious sounds b l cv irregular 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 ext rle wrapped with ace bandage no le noted b l neuro le sensation intact plantar and dorsiflexion noted b l pertinent results pertinent labs 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 pt ptt inr pt am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap pm blood ck cpk pm blood ck mb ctropnt am blood calcium phos mg am blood tsh am blood digoxin pm blood type art rates tidal v fio po pco ph caltco base xs intubat intubated vent controlled pm blood type art po pco ph caltco base xs pm blood glucose lactate na k cl pm blood freeca pm blood freeca 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 micro blood culture routine final no growth blood culture routine final no growth mrsa screen final no mrsa isolated chest pre op pa lat study date of pm impression copd cardiomegaly small left effusion new compared with of uncertain etiology no chf bilat lower ext veins study date of pm impression no bilateral lower extremity dvt complex right cyst knee views left study date of pm impression moderate to large suprapatellar joint effusion is new since prior study persistent severe tricompartmental osteoarthritis and chondrocalcinosis pathology examination name birthdate age sex pathology male report to dr description by dr mtd specimen submitted right leg sarcoma procedure date tissue received report date diagnosed by dr dr ch previous biopsies anterior tumor bed right leg right lower extremity sarcoma deep tissue overlying right ankle mass diagnosis skin and subcutaneous tissue right leg a p skin and subcutaneous tissue with fibrosis acute and chronic inflammation focal necrosis focal calcification and foreign body giant cell reaction consistent with prior procedure treatment effect no sarcoma is identified multiple tissue levels examined chest portable ap study date of am impression ap chest compared to preoperative chest radiograph moderate to severe cardiomegaly is comparable to the preoperative appearance opacification of the base of the left hemithorax is probably a combination of severe left lower lobe atelectasis and pleural effusion i do not see pulmonary edema no pneumothorax chest portable ap study date of am findings as compared to the previous radiograph the lung volumes have increased likely reflecting improved ventilation there is unchanged borderline size of the cardiac silhouette but the diameter of the vasculature in the lungs has decreased reflecting decrease in pulmonary edema moderate atelectasis at the left lung bases no newly occurred parenchymal opacities chest portable ap study date of am findings mild and hazy opacities in right lower lung is either atelectasias or combination of small effusion and atelectasis unchanged over last hours pleural effusion if any is minimal on the left side and stable mildly increased retrocardiac density reflecting atelectasis is similar moderately enlarged heart size is stable mediastinal and hilar contours are unremarkable upper lungs are clear chest portable ap study date of pm findings in comparison with the earlier study there has been placement of an endotracheal tube with its tip at the clavicular level approximately cm above the carina retrocardiac opacification persists there has been interval placement of a right ij catheter that extends to lower portion of the svc chest portable ap study date of am impression ap chest compared to through moderate to severe cardiomegaly and pulmonary vascular congestion and small right pleural effusion have worsened left lower lobe atelectasis is relatively unchanged following extubation right jugular line ends in the region of the superior cavoatrial junction no pneumothorax brief hospital course m with chf afib wpw s p ablation high grade right le sarcoma s p xrt and multiple excisions hemochromatosis c b cirrhosis hypertension left atrial thrombus seen on tee in who was admitted after elective debridement and split thickness skin graft reconstruction of radiated sarcoma defect immediately post op his course was complicated by severe pain for which he had a sciatic nerve catheter placed by the acute pain service and atrial fibrillation with rvr after several liters of fluid and better pain control his rates returned to the low s with metoprolol double home dose he was taken back to the or on for a large skin graft and flap surgery post operatively he was in afib to the s hypotensive started on a diltiazem gtt and neo gtt and transferred to the tsicu he was also agitated and received haldol and ativan with improvement in his mental status in the tsicu he remained on a neo and dilt gtt both weaned off on the am of he was then rate controlled on q po dilt and metoprolol tartrate he has been on heparin gtt for anticoagulation while his coumadin is being held on he continued to have afib with rvr into the s with a hct drop to and a developing flank bacl hematoma he was taken back to or for hematoma evacuation transfused units prbcs the hematoma drained cc and patient transferred back to tsicu he remained in afib to s metoprolol doubled to tid dilt dc ed started on verapamil tid on hcts stable and rates better controlled with pressures in s s heparin gtt was discontinued after bleed placed on aspirin and heparin subq he was transferred to medicine for optimaztion of rate control and anticoagulation on the medicine service the pt was placed on po diltiazem and metoprolol succinate was continued his persistent tachycardia was noted to be vagally responsive digoxin was initiated and within hrs his hr was well controlled with resting rates in the s s from s s prior to digoxin after discussion with plastic surgery it was determined that because he is a chads score warfarin would be held until the two jp drains in his back are removed he will be continued on just mg of aspirin daily plastic surgery recommended that he continue antibiotic coverage with both bactrim ds and augmentin daily until the jp drains are removed from his thorax or dr from plastic surgery recommends they be stopped the rehab facility was given instructions to restart his home dose of valsartan and furosemide with careful monitoring of his kidney function and blood pressure transitional please schedule a primary care appointment within weeks of discharge from the hospital furosemide mg daily and valsartan mg daily should be restarted in days with careful monitoring if his renal function and blood pressure daily he has a follow up appointment with dr regarding his flap post discharge please continue bactrim and augmentin until jp drains are removed or instructed by dr warfarin should continue to be held until jp drains are removed medications on admission lasix d gabapentin tid vicodin anusol levothyroxine metrop bid pantoprazole diovan coumadin ambien verapamil discharge medications levothyroxine mcg tablet sig one tablet po daily daily metoprolol succinate mg tablet extended release hr sig one tablet extended release hr po daily daily tramadol mg tablet sig one tablet po q h every hours as needed for pain pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours venlafaxine mg capsule ext release hr sig one capsule ext release hr po daily daily docusate sodium mg capsule sig one capsule po bid times a day digoxin mcg tablet sig one tablet po daily daily lidocaine mg patch adhesive patch medicated sig one adhesive patch medicated topical daily daily as needed for back pain aspirin mg tablet chewable sig one tablet chewable po daily daily diltiazem hcl mg capsule extended release sig two capsule extended release po daily daily amoxicillin pot clavulanate mg tablet sig one tablet po q h every hours please continue to take until drains are removed from back sulfamethoxazole trimethoprim mg tablet sig two tablet po bid times a day continue until both jp drains are removed discharge disposition extended care facility maristhill nursing rehabilitation center discharge diagnosis non healing leg wound atrial fibrilation with rapid ventricular response successful skin flap surgical site infection 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 mr it was a pleasure taking care of you at you were admitted on for surgical debridements of a chronic right lower extremity wound followed by repair with a free right latissimus flap to your clean wound site with skin graft coverage on please follow these discharge instructions you may continue to move along with your right lower extremity dangle protocol and fully weight bear on your right leg when you reach minutes three times a day you should continue this for days and then you may progress to an hour a day three times a day remember that after your dangles you should elevate your right leg to allow for the swelling to go down and give your leg a proper rest period dr will let you know at your follow up appointment when it is appropriate to progress to greater than hour dangles three times a day you also experienced atrial fibrilliation with a rapid ventricular rate during this admission as well we increased the dose of two medications to help decrease your heart rate and added a medicine called digoxin for heart rate control as well we recommend that you not restart warfarin until the drains in your back are removed the following changes have been made to your medications stop verapamil warfarin valsartan furosemide hydrocodone acetaminophen oxycodone start diltiazem for blood pressure and heart rate control digoxin for heart rate control lidocaine patch as needed for pain control aspirin to help thin your blood change increase dose of metoprolol succinate to mg daily please see below for follow up appointments that have been made on your behalf followup instructions you should follow up with your primary care physician with in weeks of discharge from the hospital please follow up with dr for management of your right lower extremity flap repair at md on the building in the spine center if you cannot keep this appointment then please call his office to re schedule,{}
15283,admission date discharge date date of birth sex m service chief complaint the patient presented with a perforation in his left anterior descending artery just distal to occluded saphenous vein graft during percutaneous transluminal coronary angioplasty for coronary artery disease history of present illness he is a year old man with history of coronary artery disease including two prior coronary artery bypass grafts myocardial infarction in and a lung nodule he had presented for catheterization because of an abnormal imaging study of his heart in preoperative work up for removal of a lung mass in catheterization all the grafts were occluded except for the saphenous vein graft to the right posterolateral artery however his saphenous vein graft to the left anterior descending was occluded and as the attempt was made to open up occluded vessel the distal part of the catheter perforated the left anterior descending coronary artery and led to a small amount of extravasation of dye after the procedure he remained hemodynamically stable an echocardiogram was done which did not reveal any effusion he was brought up to the ccu for further monitoring and management of his hemodynamics in the ccu he became hypotensive with systolic blood pressure to after a brief period of tachycardia he became bradycardiac also the concern was that there was diffuse pericardial tamponade echocardiogram was done which m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m history of present illness the patient is a year old man with history of coronary artery disease including two prior coronary artery bypass grafts myocardial infarction in and a lung nodule who had presented for catheterization pre operative work up for lung mass resection in the catheterization all the grafts were occluded except for the saphenous vein graft to his right posterolateral artery however when attempt was made to open the saphenous vein graft to the lad perforation occurred in the left anterior descending artery just distal to the saphenous vein graft he remained hemodynamically stable echocardiogram was done the patient was brought up to the ccu for monitoring and management of his hemodynamics past medical history significant for coronary artery disease with two prior coronary artery bypass grafts in and a saphenous vein graft to his left anterior descending artery saphenous vein graft to his posterior descending artery in a left internal mammary artery to his diagonal and saphenous vein graft to his left anterior descending and saphenous vein graft to his left circumflex he had a catheterization in which revealed a patent saphenous vein graft to his left anterior descending and a saphenous vein graft to his posterior descending artery myocardial infarction in hypercholesterolemia abdominal aortic aneurysm lung nodule and emphysema medications on presentation aspirin mg po q d colestid gm lopressor mg po bid captopril mg po q d darvocet gm q hours prn allergies to statins which cause swelling in legs penicillin shellfish and dye family history noncontributory social history the patient is widowed lives in alcohol approximately beers per week tobacco he quit smoking in after his mi physical examination in general he was awake and anxious his vitals were temperature pulse respirations blood pressure heent mucus membranes slightly dry no jugulovenous distension clear to auscultation bilaterally chest no wheezes crackles or rales heart was regular rate and rhythm with distant heart sounds no appreciable murmurs rubs or gallops abdomen was tender in his lower abdomen bilateral groin hematomas were tender but no bruits were present palpable pedal pulses bilaterally laboratory data upon admission his white blood count was hematocrit with baseline of platelet count chem with baseline of creatinine and inr was cks have been and and ekg on admission revealed atrial fibrillation at a rate of with left bundle branch block no left bundle branch block had been noted on previous ekgs chest x ray revealed no cardiomegaly no pneumothorax with mild to moderate chf but no effusions hospital course the patient arrived in the ccu and after approximately minutes became severely hypotensive with systolic blood pressures in the s to s he also became tachycardic initially and then bradycardic code was called and his pressure was stabilized on pressors and finally on epinephrine the concern was that he had developed pericardial tamponade echocardiogram was done which did not reveal any effusion second concern was that of hemodynamic status and a swan ganz catheter was passed from his left femoral sheath which revealed a central venous pressure of right ventricular pressure of and a wedge pressure of consistent with mild hypovolemia his pressures again had increased with dopamine and epinephrine he was sedated and intubated and an abdominal ct scan was done because of the concern of enlarging bilateral groin hematomas the abdominal ct revealed stranding of right groin consistent with small hematoma but no retroperitoneal hematoma was found he received two units of packed red blood cells the next concern was that he was hypovolemic and he remained stable overnight the next day he was able to be weaned off the dopamine after one cc normal saline bolus after having received two units of packed red blood cells he converted to sinus rhythm and remained in sinus rhythm for the rest of his hospital course and was extubated after a successful trial of pressure supports again the next morning on he had no further complications was transferred to the floor on was evaluated by physical therapy and then again on physical therapy cleared him for discharge with cardiac rehab follow up he tolerated po well and had good urine output after foley was removed he was able to be restarted on regimen of mg po bid of lopressor and mg po tid of captopril discharge status the patient is stable plan discharge to daughter s home for a few days until he gains more strength and is able to live on his own again he will be discharged on his outpatient medication except for questran instead of colestipol discharge medications lopressor mg po bid captopril mg po tid aspirin mg po q d questran gm po bid and darvocet prn plan he should follow up with dr in about one week call for appointment he should also follow up in cardiac rehab and our plan would be to increase his captopril dose to mg po bid and possibly mg po bid if his blood pressure tolerates it m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service cardiothoracic surgery history of present illness this year old gentleman who presented with a right lower lobe tumor on a recent ct scan the scarring of his lung had been followed two years prior from a chest x ray he had some complaints of back pain this year with loss of balance occasionally his ambulation had been reduced to approximately one half mile which brought on angina in addition to any exertion like walking up a he had a recent cardiac catheterization which showed an ejection fraction of approximately with multiple blocked arterial vessels past medical history myocardial infarction in coronary artery bypass graft in redo coronary artery bypass graft in angioplasty in the patient still occasionally has angina he had several angioplasties in a very recent smoking history chronic obstructive pulmonary disease allergies penicillin which caused a question of hyperthermia and statins which cause leg cramps he also listed methanol as giving him a rash medications on admission his medications prior to admission were aspirin colestid captopril and lopressor physical examination on admission on examination his lungs were clear bilaterally his heart was regular in rate and rhythm his abdominal examination was soft laboratory data on admission preoperative laboratory work showed a white blood cell count of a hematocrit of platelet count of glucose bun creatinine sodium potassium chloride bicarbonate anion gap of radiology imaging preoperative chest x ray showed calcified mediastinal lymph nodes and a vague opacity only seen on the ap view the ill defined opacity was in the right base the examination was otherwise unremarkable please refer to his final chest x ray report electrocardiogram showed sinus bradycardia with some supraventricular extra systoles and a left bundle branch block plan the plan was for him to have a mediastinoscopy and thoracoscopy with a question of a right lower lobectomy dr did note his increased risk of operation and discussed it with dr of cardiology who recommended that it would reasonable to go ahead with monitoring although the risk was increased hospital course on he underwent a bronchoscopy mediastinal thoracoscopy and a right left lower lobectomy by dr he was transferred to the cardiothoracic intensive care unit in stable condition he was seen by the acute pain service for follow up of his epidural on postoperative day one he was extubated he had been on a little bit of neo synephrine his central venous pressure line was changed he was in sinus rhythm with premature contractions in the s with a temperature maximum of he was satting reasonably well on liters of nasal cannula he had no pleural leak and had cc from his chest tube his hematocrit was he was neurologically intact he had decreased breath sounds at the right lower lobe but was clear on the left his examination was otherwise unremarkable he started pulmonary toilet his epidural remained in place his calcium and magnesium were down slightly his electrolytes were repleted his neo synephrine was weaned to off he started p o as tolerated his foley remained in place he was transferred to the floor after weaning of his neo synephrine he was followed by the acute pain service for his epidural he was seen by physical therapy for help with his ambulation he was seen by case management on postoperative day two he was hemodynamically stable his lungs were clear his heart was irregularly irregular his chest tubes had a small air leak his abdominal was benign his extremities were warm a chest x ray was checked to see if there was a pneumothorax with plans to pull his chest tubes if there was no pneumothorax as there was minimal chest tube output he continued to work with physical therapy on the floor on postoperative day three he was sitting up comfortably he was afebrile with good vital signs his urine output was good his lungs were clear his heart was regular in rate and rhythm his abdominal examination benign with minimal swelling in his extremities his chest tubes had been pulled the evening prior his foley catheter was removed in the morning his epidural was removed he was ambulating well his central line was discontinued with plans for discharge in the morning and he was discharged to home on with the following discharge diagnoses discharge diagnoses chronic obstructive pulmonary disease status post right lower lobectomy bronchoscopy mediastinoscopy mediastinal fluoroscopy status post myocardial infarction status post coronary artery bypass graft status post redo coronary artery bypass graft status post multiple angioplasties in angina medications on discharge captopril mg p o q d lopressor mg p o b i d aspirin mg p o q d tylenol p r n percocet one to two tablets p o q h p r n for pain milk of magnesia p o q d p r n albuterol meter dosed inhaler p r n discharge status the patient was discharged to home on m d dictated by medquist d t job cclist,"{
""Diagnoses"": [""perforation in left anterior descending artery"", ""occlusion of saphenous vein graft""],
""Medications"": [""none""]
}"
77217,admission date discharge date service surgery allergies cipro quinolones attending chief complaint s p fall major surgical or invasive procedure pelvic arteriogram history of present illness f s p mechanical fall at home taken to osh where ct showed right superior and inferior pubic rami fractures with an associated hematoma tracking up the rectus sheath measuring x x the patient was hypotensive with low bp s in the s s at the osh she was given blood for a hct and transferred to for further management head ct at the osh was negative past medical history pmh crohn s bell s palsy htn glaucoma psh unknown social history no tobacco no etoh lives alone family history non contributory physical exam temp hr bp resp o sat constitutional awake alert and oriented heent normocephalic atraumatic pupils equal round and reactive to light there is no tenderness to palpation of the posterior cervical c spine chest clear to auscultation cardiovascular regular rate and rhythm pelvic tenderness to palpation over the anterior pelvis extr back distal sensation and capillary refill are intact in both lower extremities neuro speech fluent psych normal mood pertinent results imaging cta torso right superior pubic ramus fracture with associated complex fluid collection seen along the anterior abdominal wall and within the right side of pelvis consistent with hematoma findings are stable and unchanged when compared to prior imaging no evidence of active arterial extravasation on this study however this is within the limits of suboptimal iv bolus timing and acute extravasation cannot be fully excluded however given that the size of the hematomas have not changed significantly since the prior examination these are likely stable there is infrarenal abdominal aortic aneurysm measuring maximum in anterior posterior diameter and cm in transverse diameter there is infrarenal abdominal aortic aneurysm measuring maximum in anterior posterior diameter and cm in transverse diameter pelvic arteriogram unsuccessful right common femoral artery access successful left common femoral artery access with a pelvic arteriogram performed ap and oblique projections did not demonstrate evidence of active contrast extravasation at this time no further intervention was performed the patient tolerated the procedure well and there were no early complications cxr pulmonary vasculature previously engorged on is now normal to slightly increased in caliber there is no pulmonary edema pleural effusion is small on the left if any heart size normal left subclavian line ends close to the superior cavoatrial junction no pneumothorax or mediastinal widening brief hospital course the patient was admitted to the acs service was taken for urgent ir angio given that there was active extravasation seen on her cta torso however they did not visualize any active bleeding and no intervention was performed post procedure the patient was admitted to the tsicu for close monitoring serial hcts were checked these initially remained stable but then began trending down during the latter part of the day on post procedure day to a nadir of she was transfused two units of blood and one unit of platelets for a platelet count of and her post transfusion bumped appropriately to hemodynamically the patient remained stable her diet was liberalized and she tolerated a regular diet without problems she transferred to a regular floor bed on pt did spike a fever up to once on the floor on pt continued to be hd stable hct remained stable pt did begin to show sign of delirium and agitation which was addressed with zyprexa cultures and cxr were obtained and pt was started on empiric vanc zosyn on pt continued to wax and wane a geriatric consult was obtained and seroquel was started instead of zyprexa her blood cultures were preliminarily negative as was her urine culture a sputum culture could not be obtained but the working diagnosis was pneumonia based on a slightly elevated wbc and increased opacity of the left lower lobe on chest xray she developed atn on possibly from the dye load from the angiogram her urine output was adequate with additional iv hydration and gradually it declined her admission creatinine actually was but it decreased to a low of her vancomycin was stopped in order to eliminate nephrotoxic drugs and she continued to improve the physical therapy service recommended short term rehab to try to increase her mobility and endurance medications on admission macrobid pepcid vitc combigan gtt each eye proair caltrate vitd timoptic mg eye gtt gtt each eye miabalicin spr spray daily per nostril alternating discharge medications tiotropium bromide mcg capsule w inhalation device sig one cap inhalation daily daily docusate sodium mg capsule sig one capsule po bid times a day timolol maleate drops sig one drop ophthalmic daily daily both eyes oxycodone mg tablet sig tablet po q h every hours as needed for pain acetaminophen mg tablet sig two tablet po q h every hours vitamin c mg tablet sig one tablet po once a day pepcid mg tablet sig one tablet po once a day ipratropium albuterol mcg actuation aerosol sig puffs inhalation q h every hours as needed for shortness of breath or wheezing discharge disposition extended care facility care center discharge diagnosis s p fall right superior inferior rami fracture pneumonia acute blood loss anemia delirium acute renal failure atn 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 were admitted to the hospital after falling and you have a pelvic fracture your blood count has been stable and the orthopedic doctors to bear weight as long as the pain is tolerable you also have been treated with antibiotics for pneumonia continue to eat well and stay hydrated your kidney function wasa bit abnormal in the hospital probably from the contrast dye used during some of your xrays it is getting better and actually is back to normal you are being transferred to rehab to try to increase your mobility and endurance prior to returning home followup instructions call the acute care clinic at for a follow up appointment in weeks call the clinic at for a follow up appointment in weeks completed by,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""service"", ""surgery"", ""allergies"", ""Cipro"", ""quinolones""],
""Medications"": [""blood"", ""hct"", ""further management"", ""head CT"", ""negative""]
}"
81535,admission date discharge date date of birth sex f service neurosurgery allergies vicodin hp sulfa sulfonamide antibiotics attending chief complaint head bleed transfer from osh major surgical or invasive procedure right evd placement cerebral angiogram with coiling left mca aneurysm left craniotomy evacuation of left intraparenchymal hemorrhage icp monitor insertion cerebral angiogram right evd replaced stent assisted coiling of left mca aneurysm history of present illness pt is a f who was found down in a parking lot she was intubated at the scene and taken to osh where ct head showed a left temporal bleed with mm of midline shift she was transferred to for further evaluation past medical history migraines cva at age social history unknown family history unknown physical exam on admission bp hr r o sats gen wd wn heent pupils perla mm intubated no eye opening localizes lue withdraws briskly lle minimal withdrawal rle flexion rue on discharge eo spont follows commands expressive aphasia full motor pertinent results ct head w o contrast interval craniotomies coiling of mca aneurysm and placement of ventriculostomy catheter with improvement in extensive previously seen subarachnoid hemorrhage post operative pneumocephalus ct head w o contrast post left craniotomy changes with unchanged subarachnoid blood products within the left frontoparietal temporal and right frontal lobes unchanged position of a right frontal approach ventriculostomy catheter terminating at the right lateral ventricle no evidence of new hemorrhage or mass effect since the study ct head increasing areas of low attenuation and loss of white and white matter differentiation in the territory of the left mca may be secondary to evolving infarction or evolving edema adjacent to the hematoma stable appearance of subarachnoid blood without evidence of new hemorrhage slight enlargement of the left frontal extra axial collection beneath the left craniotomy changes unchanged mass effect with mm of rightward shift of the normal midline structures no evidence of uncal herniation ct abd pelvis no retroperitoneal hematoma as clinically questioned indeterminate mm hypodense lesion within the left lobe of the liver ultrasound is recommended for further evaluation non emergently small bilateral pleural effusions with associated atelectasis cta head no evidence of vasospasm with symmetric patent bilateral mcas metallic coil in unchanged position at the bifurcation of the m and m segments a small residual aneurysm is likely present in this region unchanged appearance of subarachnoid intraparenchymal and intraventricular hemorrhages no new foci of hemorrhage are visualized stable areas of low attenuation in the territory of the left mca are most likely due to vasogenic edema from the surrounding hematomas although an underlying evolving infarction cannot be totally excluded unchanged position of the right frontal ventriculostomy catheter without evidence of hydrocephalus unchanged post surgical changes in the left frontal lobe cxr ap single view of the chest has been obtained with patient in sitting semi upright position comparison is made with the next preceding similar study of the patient remains intubated ett in unchanged position a right sided picc line has now been adjusted and its tip is seen to terminate in the mid portion of the svc nasogastric tube reaches well into the stomach where it is curled up as before no interval changes are seen in the normal appearing cardiovascular pulmonary status on this portable chest examination cxr in comparison with the study of the endotracheal tube appears to have been removed other monitoring and support devices remain in place little change in the appearance of the heart and lungs cta no evidence of vasospasm bilateral mca are patent a coil pack is present in the left mca bifurcation of m and m with a mm dilatation just medial and superior to the coil pack likely representing residual aneursym subarachnoid blood mildly decreased since the prior exam stable left frontal intraparenchymal and intraventricular hematomas as well as stable left frontal subdural collection causing a stable mass effect with mm midline shift to the right stable areas of low attenuation in the territory of the left mca are most likely due to vasogenic edema from the surrounding hematomas although an underlying evolving infarction cannot be totally excluded stable position of the right frontal ventriculostomy catheter without evidence of hydrocephalus ct head right common carotid artery arteriogram shows widely patent right internal carotid artery middle cerebral artery and anterior cerebral artery with no evidence of spasm left common carotid artery arteriogram shows that the left internal carotid artery left anterior cerebral artery and left middle cerebral artery are patent with no evidence of spasm the aneurysm is still patent with coils at the tip where the rupture site was left vertebral artery arteriogram shows that both pcas are patent underwent cerebral angiography which showed that there was no vasospasm we did not treat the aneurysm on this setting since she would require plavix for the stent and she still had a ventricular catheter in after the ventricular catheter is removed she will be brought back for definitive treatment of this aneurysm cxr previous mild pulmonary edema has almost resolved heterogeneous opacification in the infrahilar right lower lung could be residual edema and atelectasis or early pneumonia pleural effusion on the right is small if any heart size top normal nasogastric feeding tube ends in the stomach right pic line ends close to the anticipated location of the superior cavoatrial junction no pneumothorax cxr the right lower lobe opacity is again redemonstrated concerning for infectious process in the right lower lobe dobbhoff tube tip is in the stomach the right picc line tip is at the cavoatrial junction no pleural effusion or pneumothorax is demonstrated cxr tip of the right pic line projects over the upper right atrium and would need to be withdrawn cm to confidently place it in the low svc no endotracheal tube seen below c the upper margin of this film feeding tube is looped in the stomach minimal pulmonary edema has developed in the right lower lobe and the heart though still normal size is slightly larger no pneumothorax pleural effusions small if any ct head decrease in residual intraparenchymal subarachnoid and intraventricular hemorrhage with no new foci of hemorrhage slight decrease in edema surrounding the left temporoparietal hematoma although residual sulcal effacement and rightward shift of the normal midline structures persist small amount of post surgical pneumocephalus around the right ventriculostomy catheter without evidence of hemorrhage stable post craniotomy changes with a decrease in size of the adjacent subdural and subgaleal hematomas lens no evidence of right or left deep vein thrombosis ct head findings there is a right sided ventriculostomy catheter through a right frontal burr hole approach the catheter appears to course through the frontal of the right lateral ventricle but terminates just lateral to the ventricle itself a small amount of postoperative pneumocephalus is adjacent to the catheter and unchanged the ventricles are unchanged in size there is no evidence of hydrocephalus there is trace if any residual intraventricular hemorrhage again noted is a left temporal intraparenchymal hemorrhage which is unchanged in size with surrounding edema there is mild rightward shift of the normal midline structures measuring mm this is unchanged from the prior exam residual subarachnoid hemorrhage is present in the left hemisphere persistent edema and cortical swelling of the left frontal and parietal lobes is noted as before no new foci of blood are visualized hypodense areas in the left temporal lobe are again seen and may relate to a combination ischemic changes and edema post surgical left frontal craniotomy changes are stable there is a small post surgical subdural hematoma which is unchanged in size mineralization of the membrane is present the small post surgical subgaleal hematoma appears to be slightly smaller in comparison to the prior exam there is mucosal thickening in the left maxillary sinus and an air fluid level in the sphenoid sinus these are unchanged the mastoid air cells and middle ear cavities are clear impression no evidence of hydrocephalus right ventriculostomy catheter courses through the right lateral ventricle but terminates just lateral to the ventricle correlate with catheter function and if the position is desirable appropriate followup closely as clinically indicated unchanged appearance of left intraparenchymal and subarachnoid hemorrhage without evidence of new bleeding stable post surgical changes after left frontal craniotomy ct findings since the prior study approximately hours earlier there has been no change in size of the ventricles there is no evidence of hydrocephalus no intraventricular hemorrhage is identified a ventriculostomy catheter through a right frontal burr hole is unchanged in position it appears to course through the frontal of the right lateral ventricle with the tip terminating just lateral to the ventricle within the parenchyma this is unchanged since the prior exam a small amount of postoperative pneumocephalus is adjacent to the catheter tract and also unchanged the left temporal parenchymal hemorrhage and surrounding vasogenic edema is unchanged from the recent exam there is effacement of the adjacent sulci and mild mm stable rightward shift of the normal midline structures there is no evidence of uncal herniation the basal cisterns are patent residual subarachnoid hemorrhage is present in the left hemisphere no new foci of hemorrhage is identified a metallic coil is present in the region of the left mca with a slight amount of metallic streak artifact post surgical changes from a left frontal craniotomy are unchanged there is a small residual subdural hematoma with mineralization of the membrane no fracture is identified mucosal thickening is present in the left maxillary sinus the remainder of the paranasal sinuses mastoid air cells and middle ear cavities are clear impression unchanged size of the ventricles without evidence of hydrocephalus unchanged position of the right ventriculostomy catheter which appears to terminate just lateral to the right lateral ventricle unchanged appearance of left temporal parenchymal hemorrhage subarachnoid hemorrhage and post surgical changes from left frontal craniotomy cerebral angiogram final report diagnosis subarachnoid hemorrhage from ruptured left middle cerebral artery aneurysm indication the patient had large hematoma of the left temporal lobe the aneurysm was partially coiled and the hematoma evacuated following this she was brought back for elective stent assisted coiling procedure performed left internal carotid artery arteriogram left mca stent assisted coiling of left bifurcation aneurysm right common femoral artery arteriogram anesthesia general bilat lower ext veins no evidence of deep vein thrombosis in either leg brief hospital course ms was admitted to the neurosurgery service and an emergent evd was placed for developing hydrocephalus she was then taken emergently for cerebral angiogram where preliminary embolization of the left mca aneurysm was performed post angiog she was taken emergently to the operating room for a left craniotomy for evacuation of the left temporal clot post procedure she remained intubated on pod the patient remained in the icu for close neuro monitoring her subgaleal drain was removed and staples were placed at the drain site a repeat head ct was orderred secondary to a rise in her icps which showed post surgical changes and stable hemorrhage mannitol was given x and a icp bolt was placed overnight she had an increase in her icp to low s which resolved independently on off sedation patient was purposeful in all extremities l r icps remained stable she was stable into and on morning rounds on she was purposeful with her lue and w d in the other three lle rle on morning rounds on she was more awake with eye opening and otherwise her exam was stable she underwent a cta of the head which showed no vasospasm tcd was repeated and also showed no vasospasm patient was weaned to extubate and bolt was removed she was extubated on the evening of and her tube feeds were restarted she was also febrile to and she was pancultured on the morning of was doign well off the ventilator and csf was sent from her evd for culture and lab testing tcds were performed that showed slower velocities and little evidence of vasospasm she was taken off of neo and her blood pressure was liberalized seroquel was started around the clock for delerium she was agitated overnight and her evd was dropped from to she also received a unit of prbc s patient went to angio to rule out ongoing vasospasm her evd was clamped afterwards but icp s were elevated overnight and the drain was opened she was extubated on she had stridor that improved with nebulizer tm and ciprofloxacin mg iv q h started for sputum she continued to be restless and was aggitated on she was very alert nicotene patch was strated for request for cigarretes evd to was at and she seemed to be seems to be dumoping csf fluid when moving and restless in bed the icu was weaning the seroquel due to ekg changes with qtc elevation there was scant serous drainage from staple insertion site around the evd cath evd was clogged and she was taken to the or sunday night to change out evd on she was neuologically stable and the evd was clamped sutures staples were removed she was seen by speach and swallow and was cleared for thin liquids and ground solids she had low icp s with a clamped drain on ct head was stable on and the evd was removed on she remained stable and was returned to the angiography suite on for completion of coil of left mca aneurysm with stent assist this was uneventful and she was started on asa and plavix she remained in the icu one more day and was transferred to floor status on she was impulsive and required supervision to prevent her from leaving the hospital her sutures and antibiotics were discontinued on sceening lens on were negative seroquel was being weaned due to ekg changes keepra was stoppedo n ua was done for dysuria but was negative she was denied coverage for acute rehab by she was being screened for a on seroquel was added for impulsive and aggressive behavior patient continued to attempt to leave hospital she was denied and it was decided that patient is safe for discharge home with hr supervision her nimodipine was discontinued and patient was discharged home with daughter medications on admission unknown discharge medications atorvastatin mg tablet sig one tablet po daily daily aspirin mg tablet sig one tablet po daily daily disp tablet s refills nicotine mg hr patch hr sig one patch hr transdermal daily daily disp patch hr s refills multivitamin tablet sig one tablet po daily daily clopidogrel mg tablet sig one tablet po daily daily for days disp tablet s refills oxycodone mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills discharge disposition home with service facility discharge diagnosis left mca aneurysm hydrocephalus cerebral edema left intracerebral hemorrhage delerium elevated intracranial pressure anemia requiring blood transfusion stridor h flu pneumonia dysphagia discharge condition level of consciousness alert and interactive activity status ambulatory independent mental status confused always discharge instructions 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 and or staples 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 unless directed by your doctor do not take any anti inflammatory medicines such as motrin aspirin advil and ibuprofen etc you are to continue plavix for month and continue aspirin until seen in follow up with dr 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 clearance to drive and return to work will be addressed at your post operative office visit make sure to continue to use your incentive spirometer while at home unless you have been instructed not to call your surgeon immediately if you experience any of the following new onset of tremors or seizures any confusion 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 any signs of infection at the wound site redness swelling tenderness or drainage fever greater than or equal to f 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 you will also need to be seen in months with an mri mra completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex f service neurosurgery allergies vicodin hp sulfa sulfonamide antibiotics attending addendum patient was discharged home with home vna services discharge disposition home with service facility md completed by,{}
26969,admission date discharge date date of birth sex f service neurology allergies sulfamethoxazole attending chief complaint seizure major surgical or invasive procedure lp history of present illness the patient was last seen in clinic by dr on she continues to have nocturnal seizures about once every three months consisting of a generalized convulsion in her sleep and then gets up and wanders around or runs in the home in the daytime also approx once monthly she sometimes has brief auras characterized by a tremendous sense of fear for which she takes mg lorazepam has had prior episodes of status epilepticus most recently at and as well in usually in the context of infection such as uti or sinusitis compliant with meds no recent changes in aeds no cough chest pain dysuria headache or head trauma she fell a few weeks ago slipped on cellar stairs and has ecchymosis of l shoulder her husband reported to osh that overnight she had three mins gtc seizures around am and at approx h am had mins gtc sz at home she was given ativan mg po as per husband ems arrived and still gtc sz when arrived in ed at she was given ativan iv mg at h am and again at h am then dilantin mg kg mg iv at h after level measured to be last dilantin level in was she had a nasal trumpet inserted pertinent findings on neurological exam documented in osh notes were vertical nystagmus r eye gaze deviation and r facial twitching past medical history r temp lobectomy status epilepticus social history no tobacco excessive etoh illicit drugs married children family history unknown physical exam vitals t hr nsr bp rr so ra gen kg heent mmm neck no lad no carotid bruits full range neck movements but meningismus as tending to hold knees flexed upward lungs clear to auscultation bilaterally heart regular rate and rhythm normal s and s no murmurs gallops and rubs abdomen normal bowel sounds soft nontender nondistended extremities no clubbing cyanosis ecchymosis or edema mental status obtunded opened one eye once to voice but mostly withdraws and grimaces to noxious stimuli symmetrically no speech cranial nerves ii did not blink to threat positive corneal reflex bilat r pupil round pinpoint and sluggishly reactive l pupil pinpoint and irregular not obviously reactive iii iv vi no oculocephalic reflex no nystagmus vii facial grimace symmetrical to jaw thrust no facial droop xii tongue protrudes in midline no fasciculations motor system normal bulk and tone bilaterally withdraws all extremities symmetrically to noxious stim reflexes dtrs and symmetric plantars downgoing bilat sensory system withdraws to noxious stim symmetrically pertinent results pm lactate pm urine rbc wbc bacteria few yeast none epi pm urine blood mod nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg pm wbc rbc hgb hct mcv mch mchc rdw pm phenytoin pm haptoglob pm calcium phosphate magnesium pm ld ldh pm glucose urea n creat sodium potassium chloride total co anion gap pm lactate pm plt count pm wbc rbc hgb hct mcv mch mchc rdw pm hgb calchct pm pt inr pt pm voidspec qns to run pm pt inr pt pm plt count pm neuts lymphs monos eos basos pm hgb calchct pm glucose urea n creat sodium potassium chloride total co anion gap head ct limited examination but no hemorrhage or mass effect eeg this is an abnormal portable eeg due to slightly increased waveform amplitudes and frequencies over the right frontocentral region perhaps due to a breach rhythm related to the patient s prior history of craniotomy in addition there were frequent bursts of generalized mixed frequency slowing in the setting of a slow and disorganized background together these findings are consistent with a mild diffuse encephalopathy suggesting bilateral subcortical or deep midline dysfunction no clearly epileptiform features were noted no electrographic or clinical seizures were noted brief hospital course ms was admitted on due to a minute generalized tonic clonic seizure which resolved with mg iv ativan she then developed a fever to while her initial ua was negative her urine culture contains aureus furthermore csf revealed wbc with normal protein and glucose she had a transient episode of severe thrombocytopenia which appears spurious but forwhich she was transfered to the icu for closer monitoring her hospital course by problem is as follows seizure presumably her episode of status epilepticus was due to the fever and infection likely meningitis she was loaded with dilantin and treated with atc ativan her home regimens of zonegran lamictal and dilantin were also maintained her eeg revealed an initially mild encephalopathy which resolved over the recording to a hz posterior predominant rhythm she demonstrated a mild slowing over the right frontocentral region likely related to subcortical dysfunction in this region due to prior temporal lobectomy pt conitnued to do well with her at home aed doses ativan was d c d without seizure activity with reduction of dilantin to home doses and subsequent drop in dph level to by discharge her mental status improved significantly possible meningitis she was treated with vancomycin ceftriaxone and acyclovir while we are awaiting csf and blood cultures a picc was placed on cultures negative throughout hospital stay but csf was pretreated sample hsv pcr resulted negative and acyclovir was stopped prior to discharge pt received days of iv abx prior to discharge gi pt with epigastric pain after transfer from icu pt with history of gi bleeding when ngt placed in ed with guaiac stools ekg was performed without abnormality gi was consulted and egd was performed which demonstrated gastritis pt s protonix increased to upon discharge medications on admission dilantin mg alternating with mg once daily lamotrigine mg zonisamide mg generic form since asa once daily ativan prn discharge medications zonisamide mg capsule sig three capsule po bid times a day lamotrigine mg tablet sig four tablet po bid times a day phenytoin mg ml suspension sig two y mg po every other day every other day phenytoin mg ml suspension sig two y mg po every other day every other day ceftriaxone dextrose iso osm g ml piggyback sig two g intravenous q h every hours as needed for meningitis for days please continue for days until disp qs refills vancomycin in dextrose g ml piggyback sig one g intravenous q h every hours for days disp qs refills pantoprazole mg recon soln sig forty mg intravenous twice a day disp refills discharge disposition home with service facility care centrix discharge diagnosis meningoencephalitis seizure disorder discharge condition stable discharge instructions please call pcp neurologist return to ed if worsened seizures fever chest pain bloody stools ha weakness increased confusion or for any other patient concerns pt will need more week of iv antibiotics vancomycin g iv q until ceftriaxone g iv q until followup instructions please follow up with dr on am tuesday please follow up with your pcp will need to have a colonoscopy with history of guaiac positive stools during your inpatient stay completed by,"{
""Diagnoses"": [""Neurology"", ""Seizure disorder"", ""Status epilepticus"", ""Prior episodes of status epilepticus""],
""Medications"": [""Sulfamethoxazole"", ""Lorazepam"", ""Ativan"", ""Dilantin""]
}"
23477,admission date discharge date date of birth sex f chief complaint hematemesis history of present illness the patient is a year old female with a history of alcohol abuse with gastrointestinal bleed on the patient has a history of grade iii varices and portal hypertensive gastropathy status post banding on two week prior to admission the patient resumed alcohol use on the patient presented with emesis that was bright red and later became coffee grounds on the day of and lightheadedness in the emergency room heart rate was blood pressure of which decreased to with continued hematemesis the patient received octreotide mcg per hour drip ciprofloxacin mg intravenously protonix mg intravenously units of packed red blood cells and units of fresh frozen plasma on a repeat esophagogastroduodenoscopy showed grade iii varices with active bleeding the patient was then referred for transjugular intrahepatic portosystemic shunt the patient received more units of packed red blood cells and more units of fresh frozen plasma transjugular intrahepatic portosystemic shunt was inserted on the patient remained hemodynamically stable and was transferred to the floor for further monitoring the patient was in the medical intensive care unit from to past medical history alcoholic cirrhosis presumed complicated by variceal bleeds a admission for variceal bleeding treated with band ligation in new onset ascites thought secondary to portal hypertension but no paracentesis for confirmation the patient was treated with diuretics in esophagogastroduodenoscopy grade ii nonbleeding varices with mm ulcer status post injection and sclera therapy on esophagogastroduodenoscopy revealed grade iii nonbleeding varices and portal hypertensive gastropathy status post sclera therapy on grade iii varices portal hypertension gastropathy mm ulcer status post banding hypertension hypothyroidism vitiligo allergies no known drug allergies medications on admission propanolol mg p o b i d levoxyl mcg p o q d spironolactone mg p o q d hydrochlorothiazide mg p o q d omeprazole mg p o b i d medications in medical intensive care unit regular insulin sliding scale levoxyl spironolactone hydrochlorothiazide octreotide mcg per hour drip ciprofloxacin mg p o q d lactulose mg p o t i d serax mg p o t i d and ciwa scale sucralfate g q i d protonix mg p o q d folic acid thiamine and multivitamin family history family history negative for liver disease positive for alcohol abuse social history she lives alone and works as a travel physical examination on presentation heart rate of and systolic blood pressure of in general the patient was edematous lying in bed in no apparent distress head eyes ears nose and throat revealed positive icterus extraocular movements were intact positive periorbital edema heart was normal tachycardic normal first heart sound and second heart sound lungs revealed decreased breath sounds at the bases otherwise clear to auscultation right subclavian nontender some blood under dressing the abdomen was soft and nontender positive bowel sounds positive ascites extremities revealed right groin with no hematoma to pitting edema pertinent laboratory data on presentation laboratory data revealed hematocrit trended from to to platelets trended from to inr of fibrinogen of fdp of to d dimer of greater than chem was unremarkable alt of ast of total bilirubin of ldh of alkaline phosphatase of lipase of albumin of thyroid stimulating hormone of ins calcium of urine culture was no growth radiology imaging liver ultrasound revealed cirrhotic liver with a large amount of ascites hepatic and portal veins were patent electrocardiogram from showed sinus tachycardia at hospital course in summary this is a year old female status post acute variceal bleed due to presumed alcoholic cirrhosis status post transjugular intrahepatic portosystemic shunt transferred from the medical intensive care unit for further monitoring alcoholic cirrhosis complicated by variceal bleed status post transjugular intrahepatic portosystemic shunt the patient s hematocrit was monitored status post transjugular intrahepatic portosystemic shunt and ultrasound confirmed patency of the transjugular intrahepatic portosystemic shunt octreotide drip was discontinued protonix was changed to p o and propanolol was discontinued hydrochlorothiazide was also discontinued and spironolactone was continued the patient was continued on ciprofloxacin as well lactulose cc t i d was also continued and the patient continued her serax mg p o t i d with ciwa scale for ethanol withdrawal the patient s hematocrit remained stable and she did not require any further transfusions hypoxia it was noted that on hospital day three the patient was hypoxic especially with exertion with oxygen saturation decreasing to a chest x ray was done which showed bilateral effusions but no overt congestive heart failure however the patient was diuresed with mg of p o lasix the patient responded to diuresis and oxygen saturations increased glucose intolerance it was noted that the patient was glucose intolerant during this admission an insulin sliding scale was started and fingersticks q i d code status the patient wished to be full code but if she is permanently debilitated with irreversible condition she did not want continued aggressive care discharge disposition physical therapy was consulted and recommended rehabilitation however the patient preferred to discharged to home and this was done discharge diagnoses alcoholic cirrhosis complicated by acute variceal bleed causing hemodynamic instability status post transjugular intrahepatic portosystemic shunt coagulopathy most likely secondary to liver disease alcohol withdrawal hypoxia most likely secondary to fluid overload secondary to liver failure medications on discharge levoxyl mcg p o q d spironolactone mg p o q d ciprofloxacin mg p o q d lactulose mg p o t i d protonix mg p o q d multivitamin thiamine folate sucralfate g q i d discharge status to home discharge followup follow up with dr on md dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex f chief complaint hematemesis history of present illness this is a year old female with alcoholic cirrhosis who was recently status post shunt who was discharged from on saturday and has had dark stool since then with bright red blood per rectum on the morning of admission and one episode of hematemesis approximately one cup she also complains of lightheadedness and dizziness she contact ems and arrived in the emergency department at p m at that time her temperature was f blood room air she denied chest pain or use of nonsteroidal anti inflammatory drugs she did complain of shortness of breath she was given three liters of intravenous normal saline in the emergency department her blood pressure increased to and her heart rate was the patient was also given mg of intravenous ranitidine in the emergency department of note the patient was recently admitted to on for a variceal bleed at which point she has sodium morrhuate sclerotherapy and trans jugular interhepatic portal systemic shunt procedure tips she was discharged after a right upper quadrant ultrasound showed a patent tips on and she went home on spironolactone and lactulose past medical history alcoholic cirrhosis status post tips as above for recurrent variceal bleed after multiple instances of sclerotherapy and banding last sclerotherapy alcohol abuse for many years quit in but had recurrent alcohol abuse in after the death of a loved one she has now been sober for two weeks hypertension hypothyroidism vitiligo negative for hepatitis a b and c in pneumovax in admission medications lactulose synthroid micrograms q day spironolactone mg q day allergies no known drug allergies social history ethanol abuse last drink was two weeks ago lives alone works as a travel lives in an apartment never married no children no tobacco family history no liver disease alcoholism in multiple family members physical examination temperature f oral heart rate blood pressure respiratory rate oxygen saturation on room air the patient is lying flat and is not dyspneic or uncomfortable her skin is icteric she has vitiligo on her hands and forehead she has good capillary refill her sclerae are icteric she has a very pale conjunctivae her oropharynx is dry her neck is supple with no jugular venous distention noticed her heart is tachycardia with a ii vi systolic ejection murmur noted at the left upper sternal border heart sounds are otherwise normal lungs are clear to auscultation on anterior examination abdomen is obese soft nontender and nondistended liver edge is not palpable extremities demonstrate one plus pitting edema in both ankles palmar erythema is noted laboratory data white blood cell count hematocrit platelet count prothrombin time and international normalized ratio of activated partial thromboplastin time sodium potassium chloride carbon dioxide blood urea nitrogen serum creatinine glucose serum calcium serum magnesium serum phosphate alt ast lipase albumin alkaline phosphatase amylase ammonia total bilirubin electrocardiogram sinus tachycardia at a rate of with normal axis and no st segment or t wave abnormalities noted hospital course the patient was admitted with presumed recurrent variceal bleed she received intravenous octreotide micrograms per hour drip intravenous protonix and packed red blood cells and platelet transfusion for hemodynamic support she received a total of four units of packed red blood cells four units of fresh frozen plasma and one unit of mixed platelets esophageal gastroduodenoscopy was performed on the evening of this showed a large esophageal ulcer with necrotic tissue at the sclerotherapy sites from there was organized clot with no sign of current bleeding the patient did have esophageal varices but no fundal varices indicating that the tips has probably not closed the patient was started on sucralfate in addition to pantoprazole after transfusion the patient s hematocrit returned at the patient was hemodynamically stable and was transferred to the general medicine wards on the seventh floor of the clinical center due to peripheral edema her spironolactone was increased to mg from and furosemide mg was added to her regimen the patient remained stable on this regimen for the remaining two days of her hospitalization her hematocrit was unchanged and her vital signs remained stable she was rapidly advanced to a full diet without complications and was able to walk about the medicine wards without symptoms of note it was difficult to draw blood from her peripheral veins and she required two femoral venous blood draws for routine laboratory monitoring the second of these two on was complicated by femoral artery puncture with a gauge needle however after pressure was held for minutes and the patient remained in bed rest for two hours there were no complications of this bleed the patient was felt to be stable for discharge on the afternoon of discharge condition stable disposition transfer to home discharge medications spironolactone mg p o q day furosemide mg p o q day levothyroxine micrograms p o q day sucralfate suspension cc p o four times a day pantoprazole mg p o q day magnesium oxide mg p o twice a day ciprofloxacin mg p o q day times seven days magnesium oxide mg p o twice a day times seven days lactulose cc p o three times a day titrated to two soft stools multivitamin discharge instructions the patient is to follow up with either dr or dr she will call to schedule an appointment and see whoever who has the first available clinic appointment md dictated by medquist d t job,"{
""Diagnoses"": [""Hemorrhagic shock"", ""Gastrointestinal bleed"", ""Grade III varices"", ""Portal hypertensive gastropathy"", ""Alcohol abuse""],
""Medications"": [""Octreotide"", ""Ciprofloxacin"", ""Protonix"", ""Packed red blood cells"", ""Fresh frozen plasma""]
}"
69776,admission date discharge date date of birth sex m service medicine allergies penicillins tegretol spironolactone attending chief complaint heart failure major surgical or invasive procedure attempted right heart catheterization history of present illness yo m h o severe dchf ef as s p mechanical avr afib on coumadin pulmonary htn cad s p cabg rd degree heart block s p ppm and transferred from osh for further management of chronic diastolic congestion heart failure the patient was recently admitted to from to for altered mental status and failure to thrive the hospital course was complicated by healthcare associated pneumonia which was treated with ceftriaxone and vancomycin the patient was discharged to life care center of at the time his weight was documented as lb at rehab the patient was initially doing well he was even able to walk with a walker beginning around however the patient s family began to notice increasing fatigue along with intermittent confusion agitation poor sleep and poor appetite the family also described second periods of tachypnea occurring at minute intervals the family also describes increased swelling in the patient s face and belly in the early morning of the patient was noted to be more confused leading him to present to hospital at wincester his initial weight was pounds the patient was started on cefepime and linezolid for hcap although there was no evidence of pneumonia there was no documented fever or leukocytosis ct chest showed mediastinal adenopathy and bilateral pleural effusions but no infiltrate the patient was diuresed with lasix mg iv for presumed chf in the ambulance on the way to the hospital but did not receive further diuresis in house due to concern for renal failure there was an episode of desaturation to with confusion bronchodilators and iv steroids were given for copd the patient was noted to have mildly elevated bilirubin and alk phos ruq u s was negative coumadin was held and a heparin gtt was started for consideration of thoracentesis which was not done prior to transfer the patient was transferred directly to the ccu at on arrival initial vital signs were t bp hr rr sat l weight pounds review of systems was not reliable due to altered mental status however patient denied pain dyspnea or other symptoms past medical history cardiac risk factors diabetes dyslipidemia hypertension cardiac history cabg vessel cabg percutaneous coronary interventions pacing icd ppm placed for rd degree av block other past medical history as s p avr with mechanical valve s p avr in atrial fibrillation on coumadin copd on spiriva and flovent htn cad s p cabg vessel s p cva with seizure d o on lamictal last sz year ago diastolic chf ef pulmonary htn dm diet controlled chronic lethargy and confusion with concern for dementia focal disection of abd aorta noted ct abdomen unchanged from bph no difficulty voiding s p l orif and thr s p pacemaker for rd degree av block has had seasonal and h n vaccinations social history lives with wife son family lives in same town house children total retired newpaper journalist he moved to the u s a in but returned to to work he returned here for good in tobacco history quit years ago pack years chewed tobacco until approximately mo ago etoh quit long time ago unclear how much pt drank in past illicit drugs never family history cad in family with hx of cabg everyone including all sisters and brothers who have all died before him as well as his mother and father physical exam vs t bp hr rr sat l weight kg general frail elderly gentleman in no acute distress though he does appear uncomfortable when he moves heent ncat sclera anicteric neck supple with jvp elevated to ear with patient upright cardiac rrr normal s mechanical s s present no m r g no thrills lifts lungs speaking in work sentences but denies dyspnea diffusely wheezy and rhonchorous abdomen distended non tender exam limited by distention extremities poor capillary refill skin skin breakdown on lower extremities neuro sleepy but arousable oriented to hospital can state his occupation cn ii xii intact asterixis present no pronator drift strength throughout pulses right radial dp doppler pt doppler left radial dp doppler pt doppler pertinent results admissions labs pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood ptt pm blood glucose urean creat na k cl hco angap pm blood alt ast ld ldh alkphos totbili pm blood probnp pm blood albumin calcium phos mg pm blood type art po pco ph caltco base xs pm blood lactate cxr portable ap cardiac silhouette has slightly increased in size and is accompanied by worsening pulmonary vascular engorgement and increasing predominantly interstitial edema additional areas of coalescing opacities in the infrahilar region could reflect progression to alveolar edema bilateral pleural effusions have increased in size right greater than left brief hospital course mr is a year old man with a history of dchf ef as s p avr af pulmonary htn cad s p cabg rd degree heart block s p ppm transferred from hospital for consideration of vasodilator therapy for pulmonary hypertension in the setting of severe diastolic biventricular heart failure acute on chronic diastolic heart failure the patient presented with predominantly right sided heart failure with peripheral edema hepatic congestion poor appetite weight gain and elevated jvp he was diuresed with po torsemide without effect the patient was then successfully diuresed with lasix mg iv bid metolazone was added however the family warned that this can cause bumps in the creatinine which we have not noted however today s creatinine was the patient s heart failure was thought to be end stage class diastolic and pt has a poor prognosis palliative medicine consult was considered however the family was not interested in this route and was more interested in aggressive medical treatment more than symptom control metolazone mg minuntes prior to lasix affords improved diuresis but has in the past resulted in renal failure this should be done cautiously when he approaches dry weight of just over lbs he can be converted to an oral regimen of torsamide altered mental status this was thought to be related to chf encephalopathy or poor forward flow in setting of heart failure however asterixis also suggested a toxic metabolic cause hypercarbia was ruled out by abg neurology was consulted and ruled out seizures by negative eeg observation has revealed that mental status is improved when pt is not fluid overloaded it is very helpful his family to be present to assist with orientation particularly at night lateral abdominal hematoma the patient developed a lateral wall abdominal hematoma most likely from trauma by leaning or hitting his flank on the bed rail in the setting of agitation delerium and supratherapeutic inr the patient s hct dropped nearly points from to and ct confirmed an extraperitoneal musculoskeletal hematoma ir was notified but favored conservative management by correcting coaggulopathy and transfusing the patient received a total of units of prbcs and his hct stabilized once the underlying coaggulopathy corrected the patient s hct remained stable for the remainder of the admission in the low s chronic kidney disease the patient s creatinine remained at his recent baseline of to even with diuresis copd the patient was noted to be rhonchorous and wheezy on exam he was treated with inhaled fluticasone and nebulized albuterol and ipratropium status post mechanical aortic valve the patient s coumadin was initially held the patient was kept on a heparin drip this was discontinued during the acute bleed then restarted once patient s hct stabilized and bridged pt to coumadin dm the patient was started on an insulin sliding scale bph continued flomax at home dose medications on admission meds on transfer cefepime g iv q h linezolid mg iv q h methylprednisolone mg iv q h received and heparin gtt at lasix mg iv prn unclear how many doses he received lopressor mg daily enalapril mg daily on hold flomax mg qhs zocor mg qhs lamictal mg calcium carbonate mg mvi daily coumadin on hold vitamin d iu daily spiriva inh daily duoneb qid fluticasone inhaler puffs colace mg trusopt xalatan eye drops drop at night both eyes discharge medications albuterol sulfate mg ml solution for nebulization sig one inhalation q h every hours as needed for wheeze ipratropium bromide solution sig one inhalation q h every hours lamotrigine mg tablet sig tablets po bid times a day simvastatin mg tablet sig two tablet po hs at bedtime multivitamin tablet sig one tablet po daily daily tamsulosin mg capsule sust release hr sig one capsule sust release hr po hs at bedtime dorzolamide drops sig one drop ophthalmic times a day cholecalciferol vitamin d unit tablet sig two tablet po daily daily acetaminophen mg tablet sig one tablet po q h every hours as needed for pain latanoprost drops sig one drop ophthalmic hs at bedtime insulin lispro unit ml solution sig one subcutaneous asdir as directed sliding scale insulin dextromethorphan poly complex mg ml suspension sust release hr sig one po q h every hours as needed for cough benzonatate mg capsule sig one capsule po tid times a day docusate sodium mg capsule sig one capsule po bid times a day as needed for constipation acetylcysteine mg ml solution sig one ml miscellaneous q h every hours as needed for cough wheeze warfarin mg tablet sig one tablet po once daily at pm senna mg tablet sig one tablet po bid times a day aspirin mg tablet chewable sig one tablet chewable po daily daily sildenafil mg tablet sig two tablet po tid times a day as needed for diastolic dysfunction metoprolol tartrate mg tablet sig tablet po bid times a day furosemide mg ml solution sig one hundred mg injection times a day sodium chloride flush ml iv q h prn line flush peripheral line flush with ml normal saline every hours and prn sodium chloride flush ml iv q h prn line flush midline flush with ml normal saline every hours and prn before and after use heparin flush units ml ml iv prn use of midline daily and after each use heparin porcine in d w unit ml parenteral solution sig per sliding scale units intravenous continuous discharge disposition extended care facility hospital discharge diagnosis nyha class acute on chronic diastolic congestive heart failure secondary mechanical avr pulmonary hypertension chronic obstructive pulmonary disease diabetes mellitus diet controlled atrial fibrillation s p pacemaker seizure disorder discharge condition mental status confused sometimes level of consciousness lethargic but arousable activity status bedbound discharge instructions it was a pleasure to take care of you here at you were admitted for acute on chronic heart failure we used a water medicine called lasix to remove the fluid from your lungs and your body your heart failure is end stage and for this reason it is critically important that you follow a low sodium diet take all your medications as prescribed and contact your doctor if your weight increases lbs in day or pounds in days medication changes stop taking linezolid cefepime methylprednisolone and fluticasone inhaler start taking acetylcysteine benzonatate and dextromethoraphan for your cough restart coumadin to prevent blood clots start tylenol for pain as needed start aspirin for heart protection increase lasix to mg twice daily decrease metoprolol to mg twice daily start sildenafil to treat your heart failure start insulin sliding scale to keep your blood sugars under control start heparin iv to prevent blood clots until the coumadin level is therapeutic start senna to prevent constipation stop methylprednisolone and fluticasone inhaler start calcium to prevent bone loss followup instructions cardiology md phone date time primary care b phone date time please make an appt to be seen after you get out of rehabilitation completed by [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies penicillins tegretol spironolactone attending chief complaint urinary retention x week fevers x days major surgical or invasive procedure left septic hip wash out intubation extubation thoracentesis history of present illness year old male with diastolic heart failure avr af on coumadin cad pulmonary hypertension chb s p ppm and severe copd admitted with weight gain urinary retention and fever son at bedside provides majority of history famiy noted weight up to be up by approximately lb yesterday morning baseline discussed with patient s pcp recommended metolazone mg iv x with lasix also difficulty with lasix administration time receiving doses hours apart rather than every hours over past week patient with no salt diet and strict fluid restriction to liter per day over past day had increasing difficulty with urination yesterday took attempts at a time before he was able to urinate and then only small amounts also with fever to this morning decreased po intake today patient presented to ed for further evaluation of note inpatient with copd exacerbation and acute on chronic diastolic heart failure received steroids antibiotics lasix mg iv bid continued at discharge medication changes included adding prednisone taper azithromycin and ipratropium in the ed l nc physical examination notable for midline site without erythema well appearing male sons at bedside laboratory data significant for creatinine hematocrit wbc with left shift lactate ua within normal limits urine culture blood culture x sent cxr v with with fluid overload rll pneumonia ekg with v paced similar to prior discussed with cardiology troponin elevation likely related urinary retention recommend no intervention at this time foley placed with cc l output received lasix mg iv per home regimen vancomycin iv and levofloxacin iv on transfer to medicine service l on the floor patient able to participate in full review of systems reports feeling relief after foley placement he is without night sweats headache visual changes sinus congestion cough sore throat chest pain palpitations abdominal pain nausea vomiting dysuria he has constipation no skin rashes past medical history cads p v cabg htn hld severe diastolic chf ef pulmonary hypertension a fib on coumadin hx of rd degree block s p ppm currently v paced hx of as s p avr with mechanical valve copd hx of cva c b seizure do on lamictal diet controlled dm chronic kidney injury chronic lethargy and confusion with concern for dementia focal disection of abd aorta noted ct abdomen unchanged from bph no difficulty voiding s p l orif and thr social history he currently lives with wife and son in a two story home he is a retired newpaper journalist he moved to the u s a in but returned to to work he returned here permanently in he does not currently smoke but quit years ago with an pack year history family history there is a family history of cad all sisters and brothers are deceased physical exam admission pe l general alert comfortable at times with pain when moving left leg he and son report chronic after hip surgery last year heent sclera anicteric dry mucous membranes neck supple flexion extension without difficulty bounding venous pulsation lungs crackles to mid lung fields bilaterally no wheezes or rhonchi appreciated cv irregularly irregular normal s pronounced s no murmurs appreciated abdomen hypoactive bowel sounds soft nontender and not distended ext thin venous stasis changes faint lower extremity pulses no lower extremity edema no erythema or swelling noted at left hip neuro no facial droop noted squeezes both hands equally reduced moves lower extremities skin no erythema drainage noted at rue midline site discharge pe bps ranging from high s systolic to s with diastolics ranging from s s hr s rr pox l nc general confused at times a ox person and sometimes place pertinent results pertinent 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 am blood vanco echo the left atrium is markedly dilated the right atrium is markedly dilated the estimated right atrial pressure is mmhg there is mild symmetric left ventricular hypertrophy the left ventricular cavity size is normal the right ventricular free wall is hypertrophied the right ventricular cavity is mildly dilated with depressed free wall contractility a bileaflet aortic valve prosthesis is present the transaortic gradient is higher than expected for this type of prosthesis the mitral valve leaflets are mildly thickened the left ventricular inflow pattern suggests a restrictive filling abnormality with elevated left atrial pressure the tricuspid valve leaflets are mildly thickened moderate tricuspid regurgitation is seen there is moderate pulmonary artery systolic hypertension there is no pericardial effusion left shoulder and elbow x ray clinical information limited shoulder motion after extubation findings four total images are obtained including the humerus and elbow there are mild degenerative changes of the acromioclavicular joint and glenohumeral joint no fracture is identified in the humerus within the elbow there are mild degenerative changes without fracture noted cxr findings in comparison with the study of there is again a tiny right apical pneumothorax the overall appearance of heart and lungs is essentially unchanged the nasogastric tube has been removed brief hospital course medical floor course mrsa bacteremia mr was started on vancomycin and cefepime on arrival to the floor infectious source was considered pna vs sacral and le ulcers he was found to have high grade mrsa bacteremia with positive blood cultures from the ed and id was consulted and the midline was pulled on hospital day daily blood cultures were drawn for evidence of clearing of infection bacteremia was thought to be due to a transietn bacteremia likely from his sacral stage iv decubitus ulcer or other cutaneous entry point with the midline serving as a nidus for rapid replication pneumonia was considered to be another less likely source of bacteremia on the evening of cefepime was stopped due to low suspicion for pneumonia and he was started on gentamycin at mg kg normal dose due to chronic kidney disease for empiric endocarditis treatment tee was performed on to look for valvular vegetations and showed no vegetations and left atrial appendage thrombus could not be ruled out ct chest was performed to look for evidence of pneumonia given back and hip pain plain xray of his hip was performed on admission and showed no obvious fracture though could not rule out fracture of greater trochanter ct back and hip were performed to look for evidence of osteomyelitis or spinal cord compression given urinary retention and back pain though neuro exam showed intact symmetric reflexes and strength and normal perianal sensation or florid abnormality of hip prosthesis as mr was not a candidate for mri due to pacemaker and not considered candidate for joint aspiration given multiple medical comorbities fragile skin and florid bacteremia vancomycin was continud for the mrsa left hip pain mr reported intermittent left hip and leg pain and muscle spasms plain x ray on admission negative for fracture though left trochanter could not be evaluated ct on no obvious fluid collection unable to evaluate hip given streak could not get mr due to pacemaker on he was evaluated by his orthopedic surgeon dr and his team and it was decided that he should undergo emergent aspiration of his left hip joint due to concern for septic joint his left hip was aspirated under ir guidance on and showed mrsa he was taken to the or by orthopedic surgery for prosthetic hip replacement on and tolerated the procedure but was unable to be extubated and was transferred to the icu please see micu course below urinary retention u a and urine culture were negative known bph retention likely precipitated by ipratropium new med as of month prior admission and lasix dosing every instead of hours continued on home flomax hold anticholinergics foley placed home lasix cr and bun bump with diuretics ctm decompensated diastolic heart failure lasix mg iv bid goal cc to l daily beta blocker aspirin statin cad s p v cabg troponin above baseline at admission trending down decreased clearance atrial fibrillation s p ppm placement for rd degree chb mr was maintained on coumadin and heparin gtt drip for coumadin b blocker held due to sbps in s she was seen by electrophysiology on who interrogated his pacemaker and reset it so that it would have decreased variation with activity as it had detected his tremors and artificially elevated his heart rate on the morning after it was reset creatinine improved to from despite aggressive diuresis with lasix and an increase in his sodium to a max of tte was performed on to look for preliminary signs of endocarditis while awaiting tee and also to assess for improvement in ef s p pacemaker adjustment aortic stenosis s p avr inr subtherapeutic on admission heparin gtt was started with goal ptt copd o was weaned o sats ranged from on room air holding anticholinergics micu course respiratory failure he was intubated for his left septic hip washout and could not be extubated after the surgery for several reasons the cause was likely bacteremia with ards as well as multifocal pneumonia diastolic heart failuure volume overload and copd vancomycin was continued ceftazidime and metronidazole were added sputum also grew mutli drug resistant pseudomonas initially susceptible to ceftazidime he was intermittently able to tolerate pressure support ventilation but his poor mental status remained a barrier to extubation later his daily cxr started to improve and his mental status cleared he remained net quite positive for his length of stay in the icu so aggressive diuresis with a lasix drip was begun to improve his chances for a successful extubation he was extubated on without difficulty with good o sats on l nc he was also changed lasix mg iv dosing he completed a day course of the ceftazidime which was then stopped hypotension while intubated on a lasix gtt norepinephrine gtt was started to support blood pressure he continued to require this after extubation while on a lasix gtt but it was discontinued once the lasix drip was stopped when the lasix drip was titrated off he continued to have ample urine output on lasix iv bolus doses despite systolic blood pressures that occasionally fell into the s prevotella bacteremia he grew blood cultures positive for prevotella flagyl was continued for a total day course and then stopped acute renal failure baseline creatinine to bun high acei held on admission creatinine slowly climbed to renal was consulted and felt that this was likely atn from his previous hypotension he was started on levophed to increase maps while on lasix gtt he put out copious amounts of urine and creatinine downtrended on the lasix gtt and continued to trend down after it was stopped creatinine was down to upon discharge and has been improving slowly with diuresis his vanco levels should be monitored frequently given his improving renal function and his vanco should be dosed to keep his levels between aortic stenosis s p avr inr subtherapeutic on admission heparin gtt was started with goal ptt later he was bleeding slightly into his lung and into his gi tract and his ptt goal was adjusted to when he stabilized coumadin was restarted at a lower dose with a goal inr his goal ptts on his heparin drip should remain in the range until his inr becomes therapeutic copd he was given a steroid course for the copd component of his respiratory failure these were tapered and stopped upon discharge his home inhaled steroids were restarted goals of care after extensive discussions mr family decided that he would be dnr but ok to re intubate medications on admission metolazone mg iv prn last dose yesterday morning aspirin mg po daily dorzolamide one drop ophthalmic times a day fluticasone mcg actuation aerosol sig two puff inhalation times a day furosemide sig mg intravenous twice a day lamotrigine mg tablet sig tablets po bid times a day potassium chloride meq packet sig two po twice a day sildenafil mg tablet sig two tablet po tid times a day warfarin mg tablet sig one tablet po once daily at pm please alternate with mg dosing varies with inr guaifenesin mg tablet sustained release sig two tablet sustained release po bid tamsulosin mg capsule sust release hr sig one capsule sust release hr po hs at bedtime cholecalciferol vitamin d unit tablet sig two tablet po daily daily tiotropium bromide mcg capsule w inhalation device sig one cap inhalation daily daily multivitamin oral ipratropium bromide mcg actuation hfa aerosol inhaler sig puffs inhalation four times a day as needed for shortness of breath or wheezing has not used over past hours travatan z drops sig one drop ophthalmic at bedtime into each eye calcium carbonate mg mg tablet chewable sig one tablet chewable po bid times a day simvastatin mg tablet sig one tablet po once a day docusate sodium mg capsule sig one capsule po bid senna mg tablet sig one tablet po bid times a day as needed for constipation metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po once a day ferrous sulfate mg mg iron tablet sig one tablet po bid times a day discharge medications bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for constipation docusate sodium mg capsule sig one capsule po bid times a day folic acid mg tablet sig one tablet po daily daily latanoprost drops sig one drop ophthalmic hs at bedtime sildenafil mg tablet sig two tablet po tid times a day lamotrigine mg tablet sig one tablet po bid times a day aspirin mg tablet chewable sig one tablet chewable po daily daily dorzolamide drops sig one drop ophthalmic 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 as needed for constipation polyethylene glycol gram dose powder sig seventeen g po daily daily as needed for constipation albuterol sulfate mg ml solution for nebulization sig one neb inhalation q h every hours as needed for sob wheeze famotidine mg tablet sig one tablet po q h every hours warfarin mg tablet sig one tablet po once daily at pm quetiapine mg tablet sig one tablet po hs at bedtime as needed for insomnia agitation furosemide mg iv bid heparin drip please continue at units per hour and adjust for goal ptt insulin please use attached humalog sliding scale labs please do cbc with differential and basic metabolic panel faxed to on two days prior to his infectious disease appointment vancomycin mg recon soln sig five hundred mg intravenous every other day please adjust dosing for goal level this will continue at least until he follows up with infectious disease clinic on flovent hfa mcg actuation aerosol sig one inhalation twice a day vitamin d unit tablet sig two tablet po once a day tiotropium bromide mcg capsule w inhalation device sig one inhalation once a day multivitamin tablet sig one tablet po once a day ipratropium bromide mcg actuation hfa aerosol inhaler sig one inhalation four times a day as needed for shortness of breath or wheezing calcium mg mg tablet sig one tablet po twice a day simvastatin mg tablet sig one tablet po once a day discharge disposition extended care facility discharge diagnosis primary mrsa and prevotella bacteremia pseudomonas pneumonia mrsa prosthetic joint infection s p surgical washout copd exacerbation diastolic chf secondary atrial fibrillation pulmonary hypertension cad s p cabg type ii diabetes mellitus chronic kidney injury discharge condition mental status confused sometimes level of consciousness lethargic but arousable activity status out of bed with assistance to chair or wheelchair discharge instructions you came to the hospital because of an infection in your hip and your blood you were treated with antibiotics and required a surgery to wash out the infection from your prosthetic hip after the surgery you were unable to be extubated for a prolonged period of time until your lung status was optimized from an infection fluid and copd perspective your kidneys also suffered injury due to your infections which continues to improve slowly followup instructions please follow up with all of your outpatient medical appointments listed below cardiology dr phone date time infectious disease dr phone medical building basement at pm please do cbc with differential and basic metabolic panel faxed to two days prior to this appointment orthopedics ortho xray scc phone date time then follow up with provider date time [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies penicillins tegretol spironolactone attending chief complaint hip pain major surgical or invasive procedure hip reduction history of present illness this is a year old male with pmh of diastolic heart failure with an ef as s p mechanical avr af on coumadin cad s p cabg pulmonary hypertension rd degree heart block s p ppm and severe copd who was discharged to ltac yesterday after a month long hospitalization for mrsa bacteremia secondary to a picc line complicated by left prostethic hip seeding requiring or washout and prolonged intubation after the procedure who now presents with worsening left hip pain and evidence of dislocation on an x ray taken at his ltac the patient was delirious at time of discharge and unable to effectively communicate that he was having pain in his left hip according to the patient s son his mental status quickly cleared at the ltac and he was able to report severe pain in his left hip this provoked the ltac to obtain x rays of the hip which showed dislocation necessitating transfer back to for ortho evaluation he remains on vanco for mrsa bacteremia to complete a week course per id recommendations and still has his midline in place in the emergency department initial vital signs were l nc he was later noted to have a fever of but his son says that he did not feel as though the patient had a fever because he did not feel warm and his temperature resolved quickly to although he was given gm of tylenol he received cc of ivfs for sbp in the s and his sbp climbed to s he also received zosyn gms as a cxr in the ed could not r o pna and his vanco level was checked at an ekg showed atrial fibrillation and no changes from his prior orthopedics was consulted and his hip was reduced under conscious sedation with propofol repeat films after the hip manipulation showed successful relocation of the hip he was admitted for documented fever on vanco in the setting of low sbp to the s on arrival in the icu the patient was alert pleasant and conversational the son notes that the patient s mental status improved dramatically after his hip was put back into place by ortho and postulates that his delirium was likely related to pain otherwise the patient has no complaints and did not feel febrile in the ed he feels as though he is improved from the time he was discharged past medical history cad s p v cabg htn hld severe diastolic chf ef pulmonary hypertension a fib on coumadin hx of rd degree block s p ppm currently v paced hx of as s p avr with mechanical valve copd hx of cva c b seizure do on lamictal diet controlled dm chronic kidney injury chronic lethargy and confusion with concern for dementia focal disection of abd aorta noted ct abdomen unchanged from bph no difficulty voiding s p l orif and thr social history he currently lives with wife and son in a two story home he is a retired newpaper journalist he moved to the u s a in but returned to to work he returned here permanently in he does not currently smoke but quit years ago with an pack year history family history there is a family history of cad all sisters and brothers are deceased physical exam vs t hr bp rr pox on nc gen comfortable pleasant heent dry mm eomi perrl neck supple pulm ctab with crackles noted at the bases card irregularly irregular abd soft nt nd bs ext no clubbing or edema skin multiple ecchymoses and wounds unchanged from previous admission neuro a ox diminished range of motion of left shoulder and elbow left hip range of motion not assessed given recent ortho manipulation to reset hip in socket pertinent results admission labs am wbc rbc hgb hct mcv mch mchc rdw am glucose urea n creat sodium potassium chloride total co anion gap am calcium phosphate magnesium brief hospital course please see previous discharge summary for full details of recent course this brief admission is summarized below assessment and plan this is a year old male with pmh of diastolic heart failure with an ef as s p mechanical avr af on coumadin cad s p cabg pulmonary hypertension rd degree heart block s p ppm and severe copd who was discharged to ltac yesterday after a month long hospitalization for mrsa bacteremia secondary to a picc line complicated by left prostethic hip seeding requiring or washout and prolonged intubation after the procedure who now presents with worsening left hip pain and evidence of dislocation on an x ray taken at his ltac the dislocated hip was reduced under conscious sedation in the ed fever the patient was asymptomatic and it is unclear if this was a real fever all of his labs his urinalysis and his chest xray appeared improved from prior his blood pressure was also systolic an improvement from his recent baseline there was no evidence of new infection vancomycin was continued for the recent mrsa bacteremia this was redosed for his improved renal function left prosthetic hip dislocation the patient was having significant pain that was relieved by manipulation of his hip joint back into proper alignment ortho recommended continuing the abduction pillow between his legs until his follow up appointment on he may weight bear as tolerated by taking the pillow off temporarily and using posterior hip precautions aortic stenosis s p avr inr was subtherapeutic at on admission heparin gtt was continued with a goal ptt of his inr goal remains on the lower side with a goal inr of given his propensity for bleeding heparin drip was continued and coumadin increased to mg daily acute kidney injury previous baseline creatinine was to his creatinine peaked at his last admission secondary to atn his creatinine was improved to this admission copd continue home flovent albuterol ipratropium and tiotropium fen regular diet code status dnr no chest compressions but ok to intubate emergency contact son hcp at disposition icu for now medications on admission vancomycin mg qod goal cont through id appnt sildenafil mg tab po tid aspirin mg tab daily furosemide mg iv bid warfarin mg tab po q pm heparin drip u hr adjust ptt bisacodyl mg tab tabs prn docusate sodium mg folic acid mg tab po daily latanoprost gtt qhs lamotrigine mg po bid dorzolamide gtt acetaminophen mg q h prn senna mg tab prn polyethylene glycol gram dose prn albuterol sulfate mg ml neb q h prn famotidine mg tab po q h quetiapine mg tab qhs prn insomnia agitation humalog insulin sliding scale flovent hfa mcg actuation aerosol vitamin d unit tablet po daily tiotropium bromide mcg inh daily multivitamin po daily ipratropium bromide mcg actuation hfa inh qid prn calcium mg mg po bid simvastatin mg tab po daily discharge medications sildenafil mg tablet sig two tablet po tid times a day aspirin mg tablet chewable sig one tablet chewable po daily daily bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for constipation docusate sodium mg capsule sig one capsule po bid times a day folic acid mg tablet sig one tablet po daily daily latanoprost drops sig one drop ophthalmic hs at bedtime lamotrigine mg tablet sig tablets po bid times a day dorzolamide drops sig one drop ophthalmic times a day acetaminophen mg tablet sig one tablet po q h every hours as needed for pain fever senna mg tablet sig one tablet po bid times a day as needed for constipation polyethylene glycol gram dose powder sig one dose po daily daily as needed for constipation g albuterol sulfate mg ml solution for nebulization sig one neb inhalation q h every hours as needed for sob wheezing famotidine mg tablet sig one tablet po daily daily quetiapine mg tablet sig one tablet po hs at bedtime as needed for insomnia agitation fluticasone mcg actuation aerosol sig two puff inhalation times a day cholecalciferol vitamin d unit tablet sig two tablet po daily daily tiotropium bromide mcg capsule w inhalation device sig one cap inhalation daily daily multivitamin tablet sig one tablet po daily daily ipratropium bromide solution sig one nebulizer inhalation q h every hours as needed for sob wheezing calcium carbonate mg mg tablet chewable sig one tablet chewable po bid times a day simvastatin mg tablet sig two tablet po daily daily warfarin mg tablet sig one tablet po once daily at pm goal inr please stop heparin drip when at goal furosemide mg iv bid heparin porcine in d w unit ml parenteral solution sig eight hundred units intravenous asdir as directed units hour currently titrate to ptt goal stop when inr vancomycin in d w gram ml piggyback sig one gram intravenous q h every hours please adjust as needed for goal trough level this will continue at least until he follows up with infectious disease clinic on lab work please do cbc with differential and basic metabolic panel and fax to on two days prior to his infectious disease appointment insulin please resume insulin humalog sliding scale discharge disposition extended care facility hospital discharge diagnosis primary dislocated hip discharge condition mental status confused always level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions you came to the hospital because of a dislocated hip this was fixed your warfarin was increased because of a low inr and your vancomycin was increased because of improved kidney function otherwise none of your medications was changed followup instructions cardiology provider phone date time infectious disease provider id west sb phone date time orthopedics xray on appointment with provider in ortho clinic completed by [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies penicillins tegretol spironolactone attending chief complaint fever reason for micu transfer ams major surgical or invasive procedure cvvhd history of present illness this is a year old male with pmh of diastolic heart failure with an ef as s p mechanical avr af on coumadin cad s p cabg pulmonary hypertension rd degree heart block s p ppm severe copd with recent prolonged hospitalization for mrsa bacteremia who was sent in from clinic with fevers his most recent medical course dates back to when the patient was admitted with mrsa bacteremia secondary to a picc line hospital course complicated by left prostethic hip seeding requiring or washout and prolonged post op course of intubation that was complicated by several infections pseudomonal pneumonia upper resp tract infection prevotella bacteremia and tunneling sacral wound hospital course also c b arf with cr peaking at eventually the patient was extubated and d ced to ltac with plan to continue vancomycin iv x weeks and then a prolonged oral course of antibiotics rehab course was c b worsening l hip pain with evidence of dislocation on an x ray taken at his ltac he was hospitalized again briefly for relocation of hip with recommendations to continue an abduction pillow between his legs until his follow up appointment on the patient was at a routine follow up appointment at clinic when found to have fever tachypnea and ams per id fellow vancomycin should be changed to linezolid with addition of colisitin and doripenem in the ed initial vs hr bp resp o sat cxr showed volume overload and worsening b l patchy infiltrates c w volume overload vs infection past medical history cad s p v cabg htn hld severe diastolic chf ef pulmonary hypertension a fib on coumadin hx of rd degree block s p ppm currently v paced hx of as s p avr with mechanical valve copd hx of cva c b seizure do on lamictal diet controlled dm chronic kidney injury chronic lethargy and confusion with concern for dementia focal disection of abd aorta noted ct abdomen unchanged from bph no difficulty voiding s p l orif and thr social history prior to admission he lived with wife and youngest son in a two story home he is a retired newpaper journalist and english professor he moved to the u s a in but returned to to work he returned here permanently in he does not currently smoke but quit years ago with an pack year history family history per omr there is a family history of cad all sisters and brothers are deceased physical exam physical exam on arrival to temp bp hr rr o sat gen cachectic heent perrl eomi anicteric very drymm poor dentition no supraclavicular or cervical lymphadenopathy neck vein engorged but flatten with inspiration resp no accessory muscle use mildly tachypneic good air movement throughout rhonchi laterally at r base cv mechanical heart sounds regular rate no m r g abd nd b s soft nt no masses or hepatosplenomegaly ext warm no clubbing or edema skin tunneling sacral ulcer venous stasis changes on bilateral distal legs neuro drowsy arousable to verbal stimuli follows commands slowly inattentive is oriented to person and hospital cn ii xii intact strength throughout no sensory deficits to light touch appreciated no pass pointing on finger to nose dtr s patellar and biceps rectal guaiac negative pertinent results 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 alkphos totbili pm blood lipase pm blood ctropnt am blood ck cpk am blood ck mb ctropnt pm blood ck cpk pm blood ck mb ctropnt pm blood calcium phos mg pm blood type art po pco ph caltco base xs pm blood lactate k pm blood lactate pm urine color straw appear clear sp pm urine blood neg nitrite neg protein glucose neg ketone neg bilirub neg urobiln neg ph leuks neg pm urine rbc wbc bacteri none yeast none epi microbiology blood cx urine cx negative urine legionella negative imaging cxr semi upright ap view of the chest the patient is status post median sternotomy and aortic valve repair left sided single lead pacemaker device is noted with lead terminating in the region of the right ventricle a left picc tip terminates within the left distal subclavian brachiocephalic vein the heart remains moderately enlarged worsening perihilar opacities with vascular indistinctness is again noted compatible with congestive heart failure moderate in severity worsening bibasilar opacities are also noted with small bilateral pleural effusions no pneumothorax is present there are no acute osseous findings impression worsening congestive heart failure worsening bibasilar airspace opacities which may reflect atelectasis but infection is not excluded small bilateral pleural effusions left picc tip terminates within the distal left subclavian proximal brachiocephalic vein unchanged brief hospital course year old male with pmh of diastolic heart failure with an ef as s p mechanical avr af on coumadin cad s p cabg pulmonary hypertension rd degree heart block s p ppm severe copd recent mrsa bacteremia prolonged post surgical intubation presents after recent discharge with persistent fevers and altered mental status he was admitted to the icu for these symptoms his heart failure continued to worsen while in the icu and he began to undergo multiorgan failure as his condition was refractory to treatment his family decided to place mr on a morphine drip he expired on the morning of medications on admission patient expired discharge medications patient expired discharge disposition expired discharge diagnosis patient expired discharge condition patient expired discharge instructions patient expired followup instructions patient expired,{}
24708,admission date discharge date date of birth sex m service neurosurgery allergies patient recorded as having no known allergies to drugs attending chief complaint blown pupil major surgical or invasive procedure right craniectomy and evacuation sdh history of present illness hpi m reportedly fell last night in yard after etoh crawled into house and spent part night on floor this morning not arousable went to found to have large r sdh with shift and herniation right pupil fixed and dilated on coumadin for st jude s valve intubated given ffp and vitamin k and medflighted here of tremor vs seizure activity enroute stopped with ativan past medical history pmhx valve all unknown social history social hx unknown family history noncontributory physical exam physical exam gen wd wn intubated in hard collar heent pupils r mm fixed and dilated l mm nonreactive neck hard collar extrem warm and well perfused neuro intubated tremors no movement ues triple flexion bilat upgoing bilaterally pertinent results ct large right sdh approx mm along convexity with shift and herniation pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm urine color yellow appear clear sp pm urine blood sm nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg pm urine rbc wbc bacteria rare yeast none epi pm pt ptt inr pt pm urea n creat pm fibrinoge brief hospital course pt was evaluated in the ed and brought emergently to the or where under general anesthesia a right craniectomy with evacuation of subdural hematoma was performed pt tolerated this procedure and was transferred to the ticu for close monitoring post op ct scan showed improvement he began leaking csf from his head the head was oversewn and was reddened he was started on triple antibiotics after a day course of antibiotics they were stopped with the exception of a vancomycin for staph in his urine culture which grew out staph on we were planning a full days of vanco for that infection he did have staph also grow out of his sputum he had a lumbar drain placed for approximately days which stopped further drainage from his head wound his sutures were removed and the redness in the wound decreased on daily basis he has slight erythema but it is greatly improved there were focal seizures during early hospitalisation the patient was treated with dilantin and transitioned to levetiracetam he has no further seizures peg and trach were placed on discharge from the peg site has been noted but no erthyema was noted our surgical team was consulted and they felt it was normal drainage and they would only become concerned if it developed erythema the patient was covered with heparin for drain removal and coumadin restarted for anticoagulation in view of valve his goal inr is he is being bridged from heparin to coumadin on his last inr was he had a picc line placed for heparin and iv vancomycin on he was transferred to the floor on the patient was reviewed by pt and ot he has been interactive with staff following intermittent commands spontaneously moving right side very briskly sponteously he does move the left side with some weakness in both arm and leg he appears more responsive engaging with family on discharge he was started on a bladder clamping training program the patient had a craniectomy and must wear helmut whenever out of bed medications on admission medications prior to admission coumadin asa zantac discharge medications acetaminophen mg ml solution sig po q h every to hours as needed docusate sodium mg ml liquid sig po bid times a day bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed ipratropium bromide mcg actuation aerosol sig puffs inhalation q h every hours as needed for when on vent levetiracetam mg tablet sig three tablet po bid times a day artificial tear with lanolin ointment sig one appl ophthalmic prn as needed senna mg tablet sig one tablet po bid times a day as needed oxycodone acetaminophen mg ml solution sig mls po q h every to hours as needed albuterol mcg actuation aerosol sig puffs inhalation q h every hours as needed metoprolol tartrate mg tablet sig three tablet po tid times a day warfarin mg tablet sig two tablet po daily daily heparin lock flush porcine unit ml syringe sig one ml intravenous daily daily as needed heparin lock flush porcine unit ml syringe sig one ml intravenous daily daily as needed heparin porcine in d w unit ml parenteral solution sig one intravenous asdir as directed vancomycin in dextrose g ml piggyback sig one intravenous q h every hours discharge disposition extended care facility discharge diagnosis right sdh discharge condition neurologically stable discharge instructions discharge instructions for craniotomy head injury have a 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 excessive bending you may wash your hair only after sutures and or staples have been removed you may shower before this time with assistance and use of a shower cap increase your intake of fluids and fiber as pain medicine narcotics can cause constipation unless directed by your doctor do not take any anti inflammatory medicines such as motrin aspirin advil ibuprofen etc if you have been prescribed an anti seizure medicine take it as prescribed and follow up with laboratory blood drawing as ordered clearance to drive and return to work will be addressed at your post operative office visit watch for drainage out of head wound slight drainage noted from g tube our surgery service feels it is normal drainage and would not be worried unless it becomes cellulitic looking must wear helmut at all times when out of bed call your surgeon immediately if you experience any of the following new onset of tremors or seizures any confusion 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 any signs of infection at the wound site redness swelling tenderness drainage fever greater than or equal to f followup instructions follow up with dr in weeks with head ct call for an appointment completed by,{}
8402,admission date discharge date date of birth sex m service history of present illness the patient is a year old male with known history of coronary artery disease status post myocardial infarction with angioplasty in he has a history of increased cholesterol family history of heart disease and states he has had angina symptoms for many years he said within the last year his symptoms have increased with concomitant shortness of breath the patient stated that he was golfing roughly four days prior to admission and had episodes of left sided chest pains which radiated to the shoulder and arm the patient on presented to an emergency room for rule out myocardial infarction and the myocardial infarction was ruled out with enzymes and electrocardiogram on the patient started exercising had increased chest pains for roughly seven minutes which resolved the patient was then worked up for a myocardial infarction once again and was transferred to a catheterization lab for possible angioplasty past medical history coronary artery disease status post myocardial infarction in status post angioplasty of the left circumflex in gastroesophageal reflux disease hypertension hypercholesterolemia benign prostatic hypertrophy dupuytren contractures admitting medications include lipitor mg cardizem mg q day aspirin mg q day flomax mg q day ambien mg hs and ativan mg tid prn allergies include contrast dye physical examination on initial examination vital signs blood pressure heart rate neck negative jugular venous distention chest is clear to auscultation heart regular rate and rhythm abdomen soft nontender positive bowel sounds extremities dorsalis pedis and posterior tibial laboratory data sodium potassium chloride co bun creatinine white blood cell count hemoglobin hematocrit platelets electrocardiogram showed normal sinus rhythm at and abnormal hospital course the patient was admitted on and was worked up for coronary artery disease on the patient also had a cardiac catheterization which showed left main coronary artery normal left anterior descending long to after s lcm occluded major marginal and collaterals to distal vessels right coronary artery distal occlusion with left coronary collaterals on cardiothoracic surgery was consulted and was assessed to have significant three vessel disease and a coronary artery bypass graft was planned for the following monday the patient s course between that time and the surgery was uneventful on the patient was brought to the operating room with an initial diagnosis of coronary artery disease the patient had a coronary artery bypass graft times four with an left internal mammary artery to the left anterior descending saphenous vein graft to the obtuse marginal artery and diagonal and saphenous vein graft to the am the patient tolerated the procedure well and was transferred to the post anesthesia care unit in stable condition on postoperative day one the patient was extubated and was doing well the patient was transferred to the floor on postoperative day two the patient continued to do well increased his physical therapy level and was tolerating a regular diet the patient stated that he lived with his wife and most likely would like to return home after the hospital stay on postoperative day three the patient continued to do well and increased his physical therapy level to a iii on postoperative day four the patient s physical therapy level was a v his hematocrit was stable and he was discharged home his discharge physical examination maximum temperature f heart rate respirations blood pressure o saturation on room air plus kg physical therapy was level v cardiovascular was regular rate and rhythm respiratory clear to auscultation bilaterally abdomen was soft nontender nondistended extremities was negative peripheral edema the incisions were clean dry and intact complications significant events none discharge medications lasix mg po q twelve hours potassium chloride supplements meq po q twelve hours aspirin mg po q day lipitor mg po q hs flomax mg po q day lopressor mg po bid niferex mg po q day percocet mg one to two tablets po q four to six hours prn discharge condition good and stable to home discharge status to home follow up follow up with dr in three to four weeks m d dictated by medquist d t job,"{
""Diagnoses"": [""Coronary artery disease"", ""Myocardial infarction"", ""Gastroesophageal reflux disease"", ""Hypertension"", ""Hypercholesterolemia""],
""Medications"": [""Aspirin"", ""Lipitor"", ""Plavix"", ""Protonix""]
}"
11941,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint right facial pain hypotension major surgical or invasive procedure none history of present illness mr is an year old gentleman with a history notable for cad hypertension afib off coumadin pvd s p left and right carotid end arterectomy and type ii dm who came to the ed on with a chief complaint of right sided facial pain and hypotension problem trigeminal neuralgia the patient has had pain from right sided trigeminal neuralgia for the past several years he began experiencing this pain in after he underwent right and left sided cea the pain occurred in the morning though it would not wake him up from sleep and would not be elicited by chewing over the past year the pain has increased in frequency to approximately once per day occurring in primarily the morning the pain is in the high right upper jaw near the tm joint in a v distribution the pain is shooting and he rates it as mr and his pcp report that his pain has become much worse over the last month in terms of the frequency in that they began occurring every few minutes i spoke with the patient s pcp who says that he began ramping up the patient s tegretol up to the most recent dose of mg of tegretol sr the patient s pain improved with more tegretol but he began experiencing gait instability attributed to the tegretol as well as several falls the pcp discontinued the patient s coumadin for afib as a result of these falls despite initial improvement with tegretol the patient s right facial pain again worsened this led to his recent hospitalization at he was discharged on monday from nwh on mg tegretol sr as well as a neurontin mg po tid the patient reports that since returning home on monday the pain has been occurring every few minutes the patient has not been taking in good po s as a result and has been extremely uncomfortable in addition to the neurontin he has been taking percocet q hours to manage his pain problem hypotension mr was at home yesterday when his vna nurse came in and woke him up the patient had taken percocet that morning he felt dizzy and dopey the nurse felt that the patient was not himself and was concerned enough to call ems at that time the patient had no chest pain sob visual changes palpitations or headache ems found him to hypotensive with sbp of ed course in ed mr was hypotensive with vital signs of hr bp and lethargic after l ivf bolus his bp improved to sbp and another l ns of fluid were given and bp stabilized at a bedside ultrasound performed did not show evidence of effusion or tamponade in addition an ekg was performed initially thought to be avb but in review with cardiology it was interpreted at afib and the recommendation was made to rule out mr for mi he otherwise had a negative head ct for ich and became more orientated during his ed course but he continued to complain of his right sided facial pain his cardiac enzymes were negative times review of systems no n v f d no weight loss no abdominal pain no hematochezia no hematuria no visual changes past medical history coronary artery disease with angina pvd s p bilateral cea with residual right sided facial numbness type dm arthritis bilaterally in his hands hypertension carpal tunnel syndrome status post release s p turp for benign prostatic hypertrophy s p knee surgery for cartilage tear social history widowed years ago the patient lives alone positive tobacco times years but quit years ago and has approximately one glass of wine per week family history mother with cad sister with dm and niece with ovarian cancer physical exam vs l gen in bed nad heent perrl eomi no lad mmm no jvd cv irreg irreg no m r g chest cta b l no w r r abd normoactive bs soft nt nd no organomegaly per ed guaiac neg ext lower extremity edema neuro aaox no focal deficits motor throughout sensation intact pertinent results cbc am blood wbc rbc hgb hct mcv mch mchc rdw plt ct lytes am blood glucose urean creat na k cl hco angap am blood calcium phos mg cardiac enzymes pm blood ctropnt am blood ck mb ctropnt pm blood ck mb ctropnt metabolic pm blood caltibc vitb folate ferritn trf pm blood tsh pm blood lactate tegretol level pm blood carbamz chest pa lateral left lower lobe opacities which may represent atelectasis but the possibility of infection is also possible in the appropriate clinical setting mild congestive heart failure brief hospital course altered mental status this patient was felt to have altered mental status on the day of admission by his vna likely explanations included med effect hypotension bradycardia infection metabolic cva hemorrhage the patient had no signs of infection and his head ct was negative for mass or bleed there was a question of an opacity on portable chest x ray but f u pa and lateral films were more suggestive of atelectasis than infection and the patient had no clinical evidence of infection his b folate and tsh were all found to be normal suggesting against a metabolic cause mi was considered a possible explanation as well but the patient ruled out during his ed course with negative cardiac enzymes the patient had taken percocet on the morning of presentation and this provided a very likely explanation in addition the patient s hypotension with sbp was considered another likely contributor to his altered mental status the patient s mental status returned to baseline confirmed by pcp on the morning following admission and remained stable during the entire hospital stay hypotension this patient presented with hypotension sbp the patients family expressed concern that he has not been taking his medications correctly and so med effect was considered a possible cause furthermore the patient was taking in poor po intake and was likely dehydrated this was supported by the fact that his bp rose nicely with ivf mi and tamponade were considered but the patient ruled out in the ed and had a bedside u s negative for tamponade in the ed his low bp responded well to fluid and the patient has been taking good po s recently as such dehydration is a likely contributor endocrine causes seemed unlikely and the patient s tsh was normal he was followed on telemetry and did not show evidence of a new arrythmia the patient s bp was stable during his entire admission he was maintained on his home bp med regimen during this admission with a change in his metoprolol to toprol xl mg daily tachycardia the patient had difficulty with tachycardia during this admission and had heart rates in the s and s at times as such his metoprolol was increased to toprol xl mg daily and cardizem sr mg these were held for low blood pressure or heart rate trigeminal neuralgia the patient was admitted with severe right facial pain from his trigeminal neuralgia he came in on tegretol neurontin and percocet for control of his pain the patient was continued on his mg day of tegretol without neurontin and percocet and his pain improved dramatically on the first day the neurontin and percocet were discontinued due to mental status changes on admission however the patient continued to have pain as such neurology was called to see the patient they felt that no additional w u was needed and recommended that the patient be started on lyrica pregabalin which was titrated up to mg he can hold these medications for increased sedation afib this patient came in to the hospital with afib not on coumadin his pcp discontinued the coumadin b c the patient had been falling recently as such we will leave the decision about restarting coumadin up to the pcp the patient will taper off of tegretol and this will make dosing the coumadin easier his rate was controlled with metoprolol and diltiazem as outlined above and he should continue on the long acting forms of these medications after discharge as detailed dm the patient s glyburide and metformin were held and he was started on an insulin sliding scale on discharge his oral agents were restarted dispo the patient was discharged to a medications on admission aspirin mg qd isosorbide mononitrate mg hydrochlorothiazide mg qd metoprolol succinate mg qd pravastatin sodium mg qd amlodipine besylate mg qd metformin mg qd glyburide mg qd lisinopril mg qd tegretol sr percocet discharge medications aspirin mg tablet sig one tablet po daily daily isosorbide mononitrate mg tablet sig two tablet po bid times a day hydrochlorothiazide mg tablet sig one tablet po daily daily pravastatin mg tablet sig one tablet po daily daily amlodipine mg tablet sig one tablet po daily daily lisinopril mg tablet sig one tablet po daily daily carbamazepine mg tablet sustained release hr sig one tablet sustained release hr po twice a day tablet sustained release hr s metoprolol tartrate mg tablet sig one tablet po q h every hours glyburide mg tablet sig one tablet po once a day metformin mg tablet sig one tablet po once a day lyrica mg capsule sig one capsule po twice a day please start taking lyrica at mg twice a day and if you tolerate this with good relief of the pain increase by mg every two to three days to a final dose of mg a day you can hold the increase for increased sedation or enough effect at a lower dose discharge disposition extended care facility discharge diagnosis trigeminal neuralgia atrial fibrillation with rvr secondary diagnoses degenerative disk disease anemia diabetes mellitus discharge condition stable with stable vitals afebrile and pain better controlled discharge instructions please contact your pcp or return to the hospital if your facial pain gets worse or if you have any concerning symptoms please follow up with your pcp when you are discharged from rehabilitation please follow up with neurology at the phone number there is and you should schedule an appointment with dr you will be taking a new medication called lyrica at the rehabilitation facility for your facial pain at mg twice a day please note that your dose of metoprolol has been changed and you should continue on the new dose followup instructions please contact your pcp or return to the hospital if your facial pain gets worse or if you have any concerning symptoms please follow up with your pcp when you are discharged from rehabilitation please follow up with neurology at the phone number there is and you should schedule an appointment with dr you will begin taking a new medication called lyrica at the rehabilitation facility at a dose of mg please note that your dose of metoprolol has been changed from mg once per day to mg three times per day this change was made to achieve better control of your heart rate following discharge you can continue taking all of the medications that you took prior to you admission completed by [NEW_RECORD] name r unit no admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending addendum gait disturbance the gait disturbance was not attributed to spinal cord compression the c spine mri did show the following impression multilevel degenerative changes including mild impression on the cord at the c c and c c levels related to degenerative changes however cervical stenosis is mild and the signal intensities within the cord are normal per neurosurgery there was no surgically correctable problem evident the patient will benefit from rehabilitation discharge disposition extended care facility md completed by [NEW_RECORD] name r unit no admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending addendum medication change addendum discharge medications aspirin mg tablet sig one tablet po daily daily pravastatin mg tablet sig one tablet po daily daily lisinopril mg tablet sig one tablet po daily daily carbamazepine mg tablet sustained release hr sig one tablet sustained release hr po twice a day tablet sustained release hr s glyburide mg tablet sig one tablet po once a day metformin mg tablet sig one tablet po once a day lyrica mg capsule sig two capsule po twice a day please hold for sedation toprol xl mg tablet sustained release hr sig one tablet sustained release hr po once a day cardizem sr mg capsule sust release hr sig one capsule sust release hr po twice a day docusate sodium mg capsule sig one capsule po bid times a day as needed for constipation senna mg tablet sig one tablet po bid times a day as needed for constipation insulin regular human unit ml solution sig per sliding scale injection asdir as directed pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours ipratropium bromide solution sig one inhalation q h every hours as needed albuterol sulfate solution sig one inhalation q h every hours as needed tramadol mg tablet sig two tablet po q h every hours isosorbide mononitrate mg tablet sig one tablet po twice a day morphine mg tablet sig one tablet po every six hours as needed for pain please only use if other medications not working tablet s discharge disposition extended care facility md completed by,"{
""Diagnoses"": [""trigeminal neuralgia"", ""hypotension"", ""facial pain"", ""hypertension"", ""cad"", ""afib"", ""pvd"", ""coumadin allergy"", ""carotid endarterectomy"", ""type ii dm""],
""Medications"": [""coumadin"", ""afib"", ""pvd"", ""type ii dm""]
}"
12763,admission date discharge date service csu history of present illness this is an year old man admitted being discharged today who has a past medical history significant for coronary artery disease hypertension hypercholesterolemia prostate cancer status post a radical prostatectomy ten years ago with chronic urinary tract infections status post hernia repair times two and status post bilateral knee repairs preoperative medications procardia xl mg p o q d imdur mg p o q d lescol mg p o q d aspirin mg p o q d ditropan mg p o q d macrobid mg p o q h s allergies no known drug allergies social history history of a pack per year history of smoking quitting years ago denying alcohol use hospital course the patient had a known history of coronary artery disease with a history of percutaneous transluminal coronary angioplasty to his left circumflex coronary artery in he presented to an outside hospital with complaints of chest pain and was found to have an elevated troponin he was then transferred to on for cardiac catheterization at which time he continued to complain of intermittent mild chest pain cardiac catheterization was performed that day which revealed severe two vessel coronary artery disease with a fifty percent distal stenosis of his left main coronary artery percent stenosis of his left anterior descending coronary artery percent stenosis of his left circumflex coronary artery with moderate left ventricle dysfunction with an ejection fraction of percent the patient underwent coronary artery bypass grafting times two with the left internal mammary artery to left anterior descending coronary artery and saphenous vein graft to the obtuse marginal on total cardiopulmonary bypass time was minutes total cross clamp time was minutes the patient was discharged in stable condition to the cardiac surgery recovery unit on propofol and phenylephrine the patient was extubated the evening of surgery without complication the patient continued to be constipated during his course however stating that he had been constipated four days prior to his admission to the hospital he was transferred to two in stable condition the patient went into atrial fibrillation on postoperative day three with a heart rate in the s he was administered lopressor with good effect and he was converted back to sinus rhythm with a heart rate in the s the patient s foley catheter was discontinued on postoperative day two and his own condom catheter was placed secondary to incontinence which he had been wearing at home prior to admission the patient was found to have a urinary tract infection urine cultures were sent out which grew out e coli for which he was treated with ceftriaxone gm intravenously b i d on postoperative day four he was also found to have a hematocrit of for which he was transfused one unit of packed red blood cells the patient continued to remain in normal sinus rhythm his heart rate was in the s to s progressing to level five for physical therapy on postoperative day six and was ready to be discharged to a rehabilitation facility on physical examination the patient s examination on discharge revealed the patient to be neurologically intact the chest was clear to auscultation bilaterally with no wheezing rhonchi or rales the sternum was stable the incision was clean dry and intact his heart was regular with no murmurs rubs or gallops abdomen was soft nontender and nondistended extremities were warm with pedal edema bilaterally vital signs was his current temperature blood pressure heart rate respirations saturation percent on room air chest x ray performed revealed a small left pleural effusion otherwise unremarkable discharge medications potassium chloride meq p o q d for two weeks lasix mg p o q d for two weeks colace mg p o b i d protonix mg p o q d aspirin mg p o q d acetaminophen mg two tablets p o q four hours p r n plavix mg p o q d for three months ditropan mg p o q d lipitor mg p o q d multivitamin p o q d ascorbic acid mg p o b i d iron complex mg p o q d metoprolol mg p o b i d ceftriaxone gm intravenously b i d for ten days darvon for pain mg p o q six hours p r n disposition the patient was discharged in good condition to a rehabilitation facility with discharge instructions to follow up with dr in weeks and dr in weeks discharge diagnosis coronary artery disease status post coronary artery bypass grafting times two dictated by medquist d t job,"{
""Diagnoses"": [""coronary artery disease"", ""hypertension"", ""hypercholesterolemia"", ""prostate cancer"", ""status post radical prostatectomy""],
""Medications"": [""Procardia XL"", ""Imdur"", ""Lescol"", ""Aspirin"", ""Macrobid""]
}"
41393,admission date discharge date date of birth sex m service surgery allergies tetanus attending chief complaint esophageal carcinoma major surgical or invasive procedure laproscopic esophagogastrectomy j tube placement history of present illness year old man who has had barrett s esophagus with some dysplasia he has had biopsies recently which have been read here as intramucosal carcinoma he has had no symptoms of esophageal obstruction he is being admitted to the for esophagectomy anf j tube placement past medical history pmh gerd prostate ca psh turp umbilical hernia repair tonsillectomy excision of a vocal cord polyp social history ex smoker quit smoking yrs ago occasional alcohol drinker family history father emphysema mother kidney failure physical exam vitals t hr bp rr sat nc gen nad aox heent mmm anicteric eom i cvs reg no m r g pulm no resp distress ctabl abd soft mildly distended mildly tender j tube in place le no c c e wound c d i no erythema or ecchymosis 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 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 plt ct am blood plt ct am blood plt ct 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 brief hospital course the patient was admitted to the for esophagectomy and j tube placement for esophageal carcinoma the procedure went as planned the patient was taken to the icu as per pathway his postop check was normal his pain was well controlled on dilaudid pca chest tube was to suction and showed no leak on pod chest tube was put to water seal he remained npo and tube feeds were started via the j tube on pod his abdomen felt distended and his j tube was clamped and the patient s tube feeds were restarted in the evening the patient s ng tube was d ced on pod on pod the patient was put on roxicet for pain control and pca was d ced foley was d ced and the patient voided without any difficulty on pod the patient underwent a barium swallow study which showed no leak at the anastomosis the patient s diet was advanced to sips and then to clears on pod which he tolerated well his chest tube was removed the chest xrays showed a stable pneumothorax on pod the patient s jp drain and staples were taken out on the day of discharge the patient s tube feeds were being cycled to goal he was tolerating clears voiding normally ambulating with assistance and his pain was well controlled he will follow up in dr clinic in weeks medications on admission pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po once a day mvi zocor mg po tab once a day discharge medications camphor menthol lotion sig one appl topical tid times a day as needed for rash on back disp tubes refills metoprolol tartrate mg tablet sig one tablet po tid times a day oxycodone acetaminophen mg ml solution sig mls po q h every hours as needed for pain disp ml s refills pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po once a day menthol cetylpyridinium mg lozenge sig one lozenge mucous membrane prn as needed as needed for throat irritation discharge disposition extended care facility renaissance garden discharge diagnosis esophageal ca discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions please call dr office or call the er if you have any of the following symptoms fever greater than chills abdominal pain abdominal swelling nausea and vomiting vomiting blood difficulty swallowing diarrhea constipation blood in stool black stool shortness of breath pain with breathing coughing up blood wheezing opening of incission redness around incission or bleeding you may take all your home meds you are also being discharged on pain meds which cause drowsiness please donot drive or operate heavy machinery while you are on them please keep your incission dry at all times it is ok to shower please donot take a tub bath till your first clinic visit followup instructions please call dr for an appointment in weeks ph completed by,"{
""Diagnoses"": [""Esophageal carcinoma"", ""Major surgical or invasive procedure (laparoscopic esophagogastrectomy)"", ""J-tube placement""],
""Medications"": [""Tetanus"", ""Allergies"", ""Prostate CA"", ""Psh"", ""Turp"", ""Umbilical hernia repair"", ""Tonsillectomy"", ""Excision of a vocal cord polyp""]
}"
66200,admission date discharge date date of birth sex m service emergency allergies no known allergies adverse drug reactions attending chief complaint mesenteric ischemia major surgical or invasive procedure none history of present illness mr is a year old male who was transferred from for concern of possible bowel ischemia mr reports he presented to on with bloodydiarrhea and abdominal pain and was admitted overnight and discharged with antibiotics flagyl he returned to their er with worsening abdominal pain and was admitted for further work up and put on levofloxacin and flagyl he has since had increasing abdominal pain which he describes as intermittent and he describes it as gas pain that is sharp in nature he received several abdominal ct s over the next days that showed progressively worsening edema and thickening of the bowel wall but without evidence of free air he also had leukocytosis to k with a left shift stool cultures were negative as of time of transfer he reports he had a colonoscopy about years ago and told everything was ok he denies having any sick contacts or family history of gi illness of note mr recently had a cva weeks ago on that presented with left facial droop which has resolved but has persistent bladder incontinence he had originally been on coumdin for history of afib and pe but was switched to pradaxa since the cva and begriming about weeks ago he reports the presence of hematuria for which he presented to his pcp but had not had any interventions about week ago he stared experiencing bloody diarrhea as noted above with accompanied incontinence to stool for which he presented to past medical history pmh afib dilated cardiomyopathy resolved pe s p cardiac cath glucose intolerance hyperlipidemia djd gout hypertension cva now with urinary incontinence essential tremor psh none social history retired police officer from married lives with wife non denies alcohol use family history non contributory physical exam pe t hr bp rr sat ra gen nad aox cv irregularly irregular rate controlled nl s and s pulm cta b l no respiratory distress abd soft mildly tender in lower quadrants bilaterally bs non distended no rebound or guarding guiac positive stools good rectal tone rash and stage ii ulcer on left buttock and gluteal cleft ext no c c e mae no gross motor deficit brief hospital course the patient was transferred from on for possible mesenteric ischemia at time of admission the patient was made npo started on intravenous fluids for resuscitation pradaxa was discontinued heparin gtt was started for anticoagulation on hd gastroenterology was consulted stool cultures blood cultures and urine cultures were sent a cmv viral load and c diff pcr were sent as recommended by the gastroenterologists on hd the patient was started on a trial of clear liquids which he tolerated a consult was placed to the infectous disease department on hd multiple stool cultures and tests were sent as recommended by id the patient had one episode of rapid heart rate to the s the patient responded to mg iv lopressor on hd the patient was switched to iv digoxin and iv beta blocker for better rate control of his atrial fibrillation an rpr and anca were sent as per gi recommendations medicine was consulted for work up for patient s diarrhea and gi bleeding patient s care was transferred to the medical service on hd and subsequently to the medical icu the patient was transferred to the micu for closer management of atrial fibrillation with rvr micu green course with afib with rvr dialated cardiomyopathy hld htn s p pe recent stroke who was initially transferred from the medical floor to the micu for management of afib with rvr in the setting of diarrhea enteritiss palpable purpura and petechiae indicative of possible vasculitis subsequently developed intermittent bowl obstruction which improved at times with ng tube started on steroids for suspected gi vasculitis decompensated on with hypoxemic respiratory failure and septic shock requiring mechanical ventilation and pressors he was initially extubated successfully for days before being intubated again given recurrent tachypnea and hypotensive episode he then developed large volume upper gi bleeds requiring units of prbc and then a family meeting took place after the family meeting his health care proxy his wife decided to make the patient cmo and he was extubated the patient passed away shortly thereafter hypoxemic respiratory failure patient intubated twice during the admission differential included aspiration pneumonitis and mucous plugging unlikely to be acute heart failure or pneumonia given clear cxr first extubation failed and the patient was reintubated days later due to persistent tachypnea continued abx coverage with vancomycin and zosyn for presumed hap given fevers sputum cx grew mrsa hypotension at times during the admission the patient became hypotensive to sbp to the s he did grow mrsa from blood cx which was treated with vancomycin he recieved multiple fluid bolus s and at times was breifly on phenylephrine his bp during his admission was mostly stable above sbp without any support ugib sbo kub and ruq consistent with sbo concerning ischemic colitis or mesenteric ischemia at time had high ng output including cofee ground bilious output in the differential is vasculitis mesenteric emboli from atrial fibrillation and atherosclerosis continued iv pantoprazole to mg appreciated gi and surgery recs lactate was never significantly elevated enteritis clinically most likely to be same process as in skin where biopsy shows medium to small vessel vasculitis had ct abdomen which revealed isolated jejunitis and ileitis autoimmune serologies were negative and rheumatology recommended to start steroids for presumed vasculitis thought to be most consistent with lcv vs hsp like process and anca were negative the following tests were negative dsdna ena ro la rnp cryoglobulins rf rpr spep upep lupus anticoagulant anticardiolipin ab and rmsf titers rash leading diagnosis is vasculitis as above largely based on skin biopsy improved in last hours of life unclear what led to improvement but may have been due to high dose pulsed steroids afib rvr difficult to control worsened rvr with fever spikes and episodes of hypotension related to the gi bleed very difficult to control during admission with rvr to s was put on esmolol drip and diltiazam drip and continued digoxin cards recs were appreciated renal failure hematuria proteinuria may be prerenal azotemia but will have to balance with risk of pulmonary edema combination of renal contrast and pre renal during admission which recovered with fluids in last days of life creatinine was trending up in the setting of recent hypotensive episode and intubation renal recs were appreciated elevated lipase in the differential was bowel obstruction as etiology though more likely is pancreatitis no nausea vomiting some epigastric tenderness could be pancreatitis caused by medications or potential autoimmune triglycerides normal level lasix induced pancreatitis was in the differential elevated inr likely secondary to poor nutritional status reversed to with vitamin k nutrition continued tpn hyperglycemia insulin sliding scale continued thrush resolved with nystatin death note mr expired at pm on exam pupils fixed and nonreactive to light no heart sounds no lung sounds no response to nail bed pressure no carotid pulse wife notified attending of record dr and pcp notified autopsy requested by wife pathology documentation filed medications on admission primidone mg allopurinol mg digoxin mg quinapril mg carvedilol mg simvastatin mg qpm lasix mg ubidecarenone co q mg calcium mg mvi pradaxa mg calmoseptine ointment cirpofloxacin mg probiotics hyophen discharge disposition expired discharge diagnosis expired discharge condition expired discharge instructions expired followup instructions expired completed by,"{
""Diagnoses"": [""mesenteric ischemia"", ""bowel ischemia"", ""abdominal pain""],
""Medications"": [""flagyl"", ""levofloxacin""]
}"
6759,admission date discharge date date of birth sex f service medicine allergies biaxin ciprofloxacin procainamide ceftin lipitor latex attending chief complaint shortness of breath major surgical or invasive procedure intubation pleurodesis history of present illness year old f with h o chf critical as s p mvr on anticoagulation severe copd and cryptogenic cirrhosis who presented from osh with hyponatremia and change in mental status transferred to ccu for sob on review of discharge summary from osh she presented on with increasing dyspnea orthopnea and chest tightness cxr showed small left pleural effusion bibasilar scarring and atelectasis per patient pleural effusion is old and mds did not pursue thoracentesis given anticoagulation labs showed bnp mildly elevated alk phos ldh and ast it was felt she was volume overloaded and she was diuresed ekg showed afib with lbbb also old she reportedly improved with initial management and was ruled out for mi echocardiogram was done that reportedly showed borderline lvh dyskinesis of mid to distal intraventricular septum and adjacent anterior wall with preserved contractile function of other segments peak gradient of aortic valve was mild to moderate aortic insufficiency rv hypertrophy severe tr pa pressure mm aortic valve area she was also seen by pulmonary who felt that her pleural effusions were chronic and the her dyspnea was secondary to her aortic stenosis an acute change in mental status was noted on the morning of labs revealed a sodium of urine osmolarity serum osms amonium normal saline was given there are no records of her na level between from to patient was transfered to for further management on arrival she was noted to be dyspneic on l nc abg her mental status declined and repeat abg hours later was her bnp was and cxr looked congested so she was diuresed with lasix her na returned at repeat was and renal was consulted they recommended nacl solution but due to poor iv access she only received hours this this am she again looked distressed and abg was after lasix iv and mso mg iv abg was she was transferred to the ccu for elective intubation after intubation the patient s abg was during attempt at a line placement she received mcg fentanyl and became hypotensive with sbp in the s and hr s she received atropine mg and dopamine gtt was started her pressure responded well and this was quickly weaned off of note after speaking with her pcp in she was hospitalized in for b t le cellulitis she was hyponatremic to at that time and was advised to stop taking chlorthalidone on discharge with na of she was also noted to have delirium during her hospital stay upon traveling to she was worked up in primary care clinic at for mental status changes she had a normal brain mri and work up revealed only elev nh alk phos and ggt and positive past medical history chf preserved ef critical aortic stenosis valve area s p mitral valve replacement inr on coumadin cryptogenic cirrhosis followed in tx no liver bx done with hepatomegaly neg hbv ag neg hcvab of amiodarone induced idiopathic hyponatremia baseline s atrial fibrillation severe obstructive lung disease pfts in with fev predicted non smoker radiation pneumonitis breast cancer age s p left mastectomy cobalt radiation reactive airway disease diverticulitis last cscope yrs prior neuropathy chronic left pleural effusion pulmonary htn social history lives in with her husband she spends every summer here visiting her daughter smoking or alcohol second hand exposure with husband family history non contributory physical exam vitals t p bp ac general intubated occ agitated heent eomi perrl sclera anicteric dry oral mucosa neck jvd to level of jaw carotid pulses pulm decrease breath sounds to left base coarse otherwise cardiac irregularly irregular nl s s systolic ejection murmur at rusb with radiation to neck thorax status post mastectomy abdomen soft non tender liver edge cm below costal margen extremities no edema neurologic intubated sedated mae pertinent results cxr apical pleural capping bilateral pleural effusion interstitial prominence probably due to vascular congestion osh mri brain small lacunar infarcts microangiopathic disease osh echo aortic valve area nl lvef mild ai mod as lae and severe rve mod severe tr with mod pulm htn cxr mild pulmonary edema moderate bilateral pleural effusions question abnormal right hilum cxr a moderate pulmonary edema has worsened accompanied by increasing moderate left and stable small right pleural effusion lobulation of the right hilus and infrahilar consolidation need to be evaluated to exclude mass cxr b et tube tip is mm above the carina ng tube tip is not included in the film below the diaphragm there is no pneumothorax the lungs are more expanded unchanged biapical pleural parenchymal scarring moderate pulmonary edema is less conspicuous unchanged prominence of the right hilus cardiac contour is obscured by the stable bilateral moderate pleural effusions tte la is mildly dilated no asd is seen by d or color doppler the ivc is dilated cm lv wall thicknesses are normal the lv cavity size is normal overall lv systolic function is mildly to moderately depressed ef the apex appears dyskinetic left bbb with abnormal septal activation is also contributing to reduced ef the rv cavity is dilated rv systolic function is borderline normal the aortic valve leaflets are severely thickened deformed there is severe aortic valve stenosis mild aortic regurgitation is seen a bileaflet mitral valve prosthesis is present the mitral prosthesis appears well seated with normal leaflet disc motion and transvalvular gradients trivial mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened moderate to severe tricuspid regurgitation is seen tr gradient there is moderate pulmonary artery systolic hypertension the main pulmonary artery is dilated the branch pulmonary arteries are dilated there is no pericardial effusion brief hospital course yo f with h o chf critical as s p mvr on anticoagulation severe copd and cryptogenic cirrhosis who presented from osh with hyponatremia and change in mental status transferred to ccu for sob and intubated s p extubation patient went into cardiogenic shock and was found to have an occlusion of the left main coronary which was stented iabp was placed for a few days then successfully removed during her hospitalization the following issues were addressed cardiovascular ischemia pt was found to have l main disease by cath with ostial lesion with heavy calcification first cath lca unable to be stented anatomical variation too short that would not accommodate a stent nd cath l cx lad stented her cad was treated medically she was anticoagulated on heparin valves severe as area confirmed on cath mvr in on anticoagulation pump echo with ef pt was thought to be intravascularly depleted given persistent pleural drainage and low bp likely due to intravascular depletion she was given several prbc transfusions ivf and albumin x rhythm a fib continued on digoxin for rate control and anticoagulaiton as above respiratory failure patient was intubated at start of hospitalization for hypercapnic respiratory failure she was successfully extubated but continued to have respiratory difficulty given her pulmonary hypertension obstructive disease pleural effusions chf r hilar consolidation and fullness ct surgery placed bilateral chest tubes which drained large amounts of transudative fluid daily pleurodesis was performed on the r lung on and on hte l lung on arf the patient developed arf on and became oliguric on renal u s was normal likely due to prerenal etiology due to intravascular hypovolemia as well as hypotension causing decreased renal artery perfusion despite ns boluses maintenance ivf albumin prbc as above to maintain intravascular volume and pressors to attempt to maintain bp id the patient was treated with empiric zosyn and vancomycin for leukocytosis and abnormal chest xray cultures were persistantly negative hyponatremia acute on chronic history of hyponatremia likely due to intravascular volume depletion na of on admission improved to baseline of s with hydration h o cryptogenic cirrhosis elevated lfts and biopsy was never done due to anticoagulation on the patient went into bradycardic asystolic arrest acls was performed and the patient was resuscitated after minutes of cpr she was intubated and started on pressors despite this she remained hypotensive a family meeting was held and the family husband and daughter decided to make the patient given her obvious discomfort and poor prognosis a morphine drip was started and other modalities of care including pressors and the ventilator were withdrawn the patient died at am on with her husband and daughter at her side an autopsy was refused medications on admission digoxin in osh records lasix qday clarinex mg day potasium chloride meq day spiriva one inhalation daily advair valsartan vitamin b mg day neurontin mg am at noon bed time coumadin mvi calcium mg each evening albuterol clonidine mg prn discharge medications na discharge disposition expired discharge diagnosis expired discharge condition expired discharge instructions expired followup instructions expired,"{
""Diagnoses"": [""hyponatremia"", ""change in mental status"", ""copd"", ""cryptogenic cirrhosis"", ""severe copd"", ""asthma"", ""critical as"", ""pulmonary edema"", ""mild volume overload""],
""Medications"": [""Biaxin"", ""Ciprofloxacin"", ""Procainamide"", ""Ceptin"", ""Lipitor"", ""Latex"", ""Attending"", ""Chief complaint"", ""Shortness of breath"", ""Major surgical or invasive procedure"", ""Intubation"", ""Pleurodesis""]
}"
29628,admission date discharge date date of birth sex m service neurosurgery allergies patient recorded as having no known allergies to drugs attending chief complaint fall major surgical or invasive procedure right craniotomy with evacuation sdh history of present illness hpi m s p mechanical fall and hit head no loc on cobble stone in on he sustained reported bilateral sdh a follow up ct on at showed bilat sdh in the frontoparietal region there was an interim development of r sdh cm at largest diameter and is new compared to original on without significant mass effect possible l sdh in posterior falx follow up ct was reccomended his follow up today shows right subdural hematoma measuring mm in greatest dimensions overlying the right cerebral hemisphere with mass effect and leftward subfalcine herniation of approx mm past medical history pmhx htm social history social hx drinks socially wk family history family hx nc physical exam physical exam t bp hr r o sats ra gen standing at the doorway comfortable nad heent pupils perrl eoms intact neck supple extrem warm and well perfused neuro mental status awake and alert x cooperative with exam normal affect orientation oriented to person place and date recall objects at minutes language speech fluent with good comprehension and repetition naming intact no dysarthria or paraphasic errors 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 reflexes b t br pa ac right left toes downgoing bilaterally coordination normal on finger nose finger rapid alternating movements pertinent results ct right subdural hematoma measuring mm in greatest dimensions overlying the right cerebral hemisphere with mass effect and leftward subfalcine herniation of approx mm brief hospital course pt was admitted to neurosurgery service and readied for the or he was monitored closely neurologically and remained stable on he was brought to the or where under general anesthesia he underwent right craniotomy with evacuation sdh he tolerated this procedure well was extubated and transferred to icu for close monitoring he remained neurologically stable post op he had jp drain placed intra op that was removed post op day without difficulty his diet and activity were advanced his foley was removed incision was clean and dry with staples he ambulated with pt and was cleared for dc to home with outpatient pt medications on admission medications prior to admission lipitor discharge medications acetaminophen codeine mg tablet sig tablets po q h every hours as needed for headache disp tablet s refills phenytoin sodium extended mg capsule sig one capsule po tid times a day for months disp capsule s refills acetaminophen mg tablet sig tablets po q h every hours as needed colace mg capsule sig one capsule po twice a day for months disp capsule s refills discharge disposition home discharge diagnosis sdh discharge condition neurologically stable discharge instructions discharge instructions for craniotomy please begin daily showers have a 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 excessive bending increase your intake of fluids and fiber as pain medicine narcotics can cause constipation unless directed by your doctor do not take any anti inflammatory medicines such as motrin aspirin advil ibuprofen etc for one month you have been prescribed an anti seizure medicine take it as prescribed call your surgeon immediately if you experience any of the following new onset of tremors or seizures any confusion 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 any signs of infection at the wound site redness swelling tenderness drainage fever greater than or equal to f followup instructions please return to the office in days for removal of your staples sutures please call to schedule an appointment with dr to be seen in weeks you will need a cat scan of the brain without contrast completed by,{}
9206,admission date discharge date date of birth sex m service medicine allergies iodine iodine containing attending chief complaint lethargy nausea vomiting abdominal pain major surgical or invasive procedure intubation x exploratory laparotomy placement of r internal jugular venous catheter placement of femoral line placement of picc line history of present illness pt was brought to the ed with mental status changes lethargy nausea vomiting and abdominal pain he was unable to give much of a history given his mental status he had been vomiting and unable to keep food down for the past several days but cannot give more specific details in the ed he was found to have a bp of with a lactate of with guaiac positive stool and acute renal failure baseline cr cr on admission in addition his wbc count was the must protocol was initiated and pt was intubated as there was concern for intraabdominal infection as source of sepsis pt was taken for an exploratory laparotomy past medical history pituitary tumor now panhypopit seizure disorder hypothyroidism gerd hypercholesterolemia legally blind social history he is single smokes to ppd and abstains after previous problems with alcoholism years ago he is a housing manager family history f died of cva m tb physical exam initial pe pe on transfer to floor vs tm tc l nc gen appears stated age somewhat hoarse voice nad appears fatigued heent perrl eomi mmm op clear neck no cervical lad pulm mainly clear bilaterally good air movement trace bibasilar crackles dullness to percussion at r base cv rrr nl s s no murmurs abd soft nt nd bs no masses midline wound with staples minimally tender at superior edge wound intact without drainage ext distal pulses trace edema pertinent results admission labs cbc wbc rbc hgb hct mcv mch mchc rdw neuts bands lymphs monos eos basos plt smr normal plt count coags pt ptt inr pt electrolytes glucose urea n creat sodium potassium chloride total co anion gap albumin calcium phosphate magnesium am lactate pm lactate pm lactate ct abdomen pelvis impression no evidence of an acute pathologic process in the abdomen or pelvis on extremely limited examination without oral or intravenous contrast evaluation of the bowel for ischemia or other pathologic process is particularly limited dilatation of the proximal small bowel with normal caliber distal small bowel and colon this appearance is nonspecific but may be seen in early ileus ectatic infrarenal aorta with maximal ap diameter of cm diverticulosis probable left renal cyst if there are no outside prior studies to document stability further evaluation may be performed by ultrasound echo conclusions the left atrium is normal in size left ventricular wall thickness cavity size and systolic function are normal lvef the right ventricular cavity is mildly dilated right ventricular systolic function is normal 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 mild pulmonary artery systolic hypertension there is a trivial physiologic pericardial effusion cxr worsening bibasilar atelectasis consolidation and right pleural effusion cxr impression ng tube terminating in right upper quadrant increasing opacity in the left lower lobe which may represent atelectasis however pneumonia cannot be totally excluded cxr bibasilar pulmonary opacities which could be secondary to effusion or atelectasis stable appearance of mild prominence of the central pulmonary vasculature labs on transfer to floor cbc wbc rbc hgb hct mcv mch mchc rdw plt ct electrolytes glucose urean creat na k cl hco angap calcium phos mg micro data multiple blood urine cultures negative sputum cultures gpcs in pairs clusters on gram stain c w contamination mrsa in sputum brief hospital course note hospital course written by floor resident with information gleaned from chart regarding sicu and micu stay but without the benefit of input from caretakers from these units sepsis pt initially presented with fatigue mental status changes hypotension acidosis acute renal failure and a lactate of in the ed the must protocol was initiated and the pt was intubated and transiently placed on levophed lactate decreased over hours to broad spectrum antibiotics were given levo flagyl vanco concern was for peritonitis and pt was emergently taken to or on for an exploratory laparotomy no source of peritonitis was found there was some purulent peritoneal fluid which did not grow any microorganisms and dusky appearing but viable bowel the duskiness was thought to be due to hypoperfusion in setting of sepsis pt was taken to the sicu and followed he was extubated on then reintubated on due to mental status decline and hypoxia as below he was transferred to the micu for the remainder of pt s hospitalization he was hemodynamically stable and did not display further septic physiology respiratory failure extubation was attempted a couple of times which failed sputum cultures were unrevealing pt continued a course of vanc levo flagyl and then vanc ceftaz flagyl vanco was ultimately continued for days levo for about days and flagyl for about days ceftazidime was on board for days pt was noted to have rll collapse on cxr and areas of consolidation vs atelectasis on cxr however no microorganisms were isolated in sputum save for mrsa on sputum thought perhaps to be a colonizer concern for increased secretions prompted consideration of trach placement but pt was able to be extubated successfully he was given an incentive spirometer and pt was placed on nebs since extubation pt has been doing quite well from a respiratory standpoint sats in on room air hyponatremia pt was noted to develop hyponatremic around initially it was thought that he was hypovolemic but with fluids sodium did not correct endocrine was consulted particularly as pt has h o panhypopituitarism urine and serum osms were sent the results of which were consistent with siadh pt was free water restricted and sodium was monitored his mental status remained stable after transfer to the floor on discharge his sodium had improved to pt should continue on fluid restriction to l while he is at rehab seizure disorder pt was placed on iv dilantin starting on this was switched to po dilantin levels were checked and were found to be low however steady state takes about days to reach therefore pt is currently on mg po tid and levels should be checked again on to determine whether an increased dose is needed goal level he will continue on dilantin mg po tid anemia pt s hct remained stable without evidence of gi bleed or other source of bleed workup revealed that this was most consistent with anemia of chronic disease hct was monitored and remained stable panhypopituitarism pt was maintained on low dose prednisone per outpatient regimen of mg po bid also was continued on synthroid of note tsh has been but this was checked in the setting of acute illness pt had repeat tsh checked just prior to discharge but this was still pending this level will need to be followed up while pt is at rehab acute renal failure pt s cr on admission was his baseline is creatinine trended towards normal with ivf arf thought most likely to be due to prerenal azotemia in the setting of shock and hypoperfusion and it corrected easily with ivf s p exploratory laparatomy as mentioned in hpi pt had ex lap for concern of intraabdominal infection which was unrevealing except for some evidence of small bowel ischemia which was thought to be in the context of hypoperfusion due to sepsis pt has had no further abdominal symptoms his staples were removed just prior to discharge he will follow up with surgery dr in weeks medications on admission lipitor protonix ranitidine prednisone fexofenadine discharge medications nystatin unit ml suspension sig five ml po tid times a day as needed for thrush heparin sodium porcine unit ml solution sig one injection injection tid times a day may discontinue if pt walking consistently albuterol sulfate solution sig one nebulizer inhalation q h every hours as needed levothyroxine sodium mcg tablet sig one tablet po daily daily prednisone mg tablet sig one tablet po bid times a day ipratropium bromide solution sig one nebulizer inhalation q h every hours as needed pantoprazole sodium mg tablet delayed release e c sig one tablet delayed release e c po q h every hours ranitidine hcl mg tablet sig one tablet po hs at bedtime metoprolol tartrate mg tablet sig one tablet po bid times a day phenytoin sodium extended mg capsule sig one capsule po tid times a day discharge disposition extended care facility discharge diagnosis septic shock acute renal failure due to prerenal azotemia respiratory failure syndrome of inappropriate antidiuretic hormone panhypopituitarism seizure disorder discharge condition stable tolerating po discharge instructions please tell the staff if you experience chest pain shortness of breath abdominal pain or any other concerning symptom followup instructions provider d where lm ent phone date time please call to make an appointment with dr follow up with surgery for post op check provider md where lm associates phone date time md completed by [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies iodine iodine containing attending chief complaint fatigue major surgical or invasive procedure none history of present illness mr is a yo man with past history of pituitary tumor s p resection and remote seizure disorder who presented from his group home with fatigue he stated that a someone at the home called the ambulance to bring him in but he cannot pinpoint the cause he thought it may have been because he did not get out of bed the day pta he denied fever and sob at home he did have a chronic cough but he has smoked ppd x years with likely chronic bronchitis he denied increased sputum production compared to his baseline in the ed he was initially normotensive and febrile to with hr he then dropped his blood pressures to the s systolic he received a total of l ns with improvement in blood pressure head ct demonstrated an intracranial fluid collection concerning for an infection he received levofloxacin and ceftriaxone he also received dexamethasone mg x for possible meningitis urinalysis was unrevealing labs were notable for cr baseline per old records and lactate he was evaluated by neurosurgery in the ed who felt that his fatigue and presentation was likely not related to his prior pituitary surgery an lp was also performed to rule out cns infection the patient denied headache chest pain nausea vomiting abdominal pain dysuria and shortness of breath he did endorse diarrhea which started in the ed he had had a pruritic rash on his back for months past medical history pituitary tumor now panhypopit seizure disorder hypothyroidism gerd hypercholesterolemia legally blind social history he is single smokes to ppd and abstains after previous problems with alcoholism years ago he is a housing manager family history father died of cva mother had tuberculosis physical exam admission physical exam vs t bp hr rr o sat on l nc gen pleasant elderly male in nad lying in bed heent perrl slight right ptosis eomi anicteric mm slightly dry op without lesions neck no supraclavicular or cervical lymphadenopathy no appreciable jvd while sitting upright no thyromegaly no meningismus neck with full range of motion resp crackles at bilateral bases with expiratory wheeze cv rr s and s wnl no m r g abd nd b s soft nt no masses or hepatosplenomegaly appreciated ext feet hands cool no le edema skin scaly erythematous pruritic rash on right lower back though crossing midline no vesicles appreciated neuro a ox moving all extremities without difficulty face symmetric cn ii xii intact cooperative answering questions appropriately pertinent results admission labs pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts lymphs monos eos baso am blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos amylase totbili am blood albumin calcium phos mg pm blood lactate dilantin levels am blood phenyto am blood phenyto csf analysis pm cerebrospinal fluid csf wbc rbc polys lymphs monos pm cerebrospinal fluid csf totprot glucose ld ldh pm cerebrospinal fluid csf herpes simplex virus pcr negative for hsv and urinalysis am urine color yellow appear clear sp am urine blood neg nitrite neg protein neg glucose neg ketone neg bilirub neg urobiln neg ph leuks neg microbiology blood cultures negative in four vials csf gram stain and culture no growth no viruses isolated no polymorphonuclear leukocytes seen no microorganisms seen sputum gram stain pmns and epithelial cells x field influenza a b dfa negative urine culture organisms ml urine legionella antigen negative stool cultures negative c diff toxin negative imaging cxr no acute cardiopulmonary process cxr new left lower lobe pneumonia tte the left atrium and right atrium are normal in cavity 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 the aortic valve leaflets are mildly thickened but aortic stenosis is not present trace aortic regurgitation is seen the mitral valve leaflets are structurally normal mild mitral regurgitation is seen there is borderline pulmonary artery systolic hypertension there is an anterior space which most likely represents a fat pad impression normal biventricular cavity sizes with preserved global and regional biventricular systolic function borderline pulmonary artery systolic hypertension mild mitral regurgitation with normal valve morphology compared with the prior report images unavailable for review of biventricular systolic function is similar ct head status post remote right frontal craniotomy and right frontal sinus surgery approximately eight years prior high attenuation material seen within the right frontal sinus measuring greater than that would be expected for simple fluid differential diagnosis includes proteinaceous material versus post surgery hematoma although this is considered less likely given the amount of time that has passed versus an underlying infectious process such as a fungal sinusitis new low attenuation areas tracking within the right frontal lobe superiorly are concerning for empyema consideration of mri examination for further characterization is recommended mri head prior right frontal sinus surgery with expected postoperative changes no evidence of hemorrhage edema or infectious process brief hospital course pneumonia mr was found to have a left lower lobe pneumonia likely community acquired he was severely volume depleted on admission with arf see below requiring brief micu admission for hypotension initial cxr did not show an infiltrate however after volume repletion an infiltrate was more evident on repeat cxr two days after presentation to the ed it was thought that the pneumonia was the cause of his fatigue malaise and headache prompting presentation to the ed he was also ruled out for influenza as well as meningitis lp was negative he was started on a ten day course of levofloxacin with improvement in his fevers and symptoms acute renal failure mr creatinine was on admission up from his baseline around this was thought to be secondary to prerenal volume depletion in the setting of his lung infection and his creatinine improved significantly with ivf he was discharged with cr medications on admission lipitor daily prednisone once daily dilantin twice daily prevacid once daily levothyroxine mcg once daily discharge medications levothyroxine mcg tablet sig one tablet po daily daily phenytoin sodium extended mg capsule sig two capsule po bid times a day atorvastatin mg tablet sig one tablet po daily daily levofloxacin mg tablet sig one tablet po once a day for days disp tablet s refills prednisone mg tablet sig one tablet po daily daily prevacid oral discharge disposition home discharge diagnosis left lower lobe pneumonia likely community acquired pneumonia discharge condition stable breathing comfortably on room air with minimal cough afebrile overall feeling much better than on admission discharge instructions please call your doctor if you develop worsening shortness of breath or cough or if you develop fevers again if you cannot reach your doctor you should return to the emergency room the only change to your medications was the addition of an antibiotic for your pneumonia you should take all other medicines as you were taking before you came into the hospital followup instructions please see your primary care doctor at am for a follow up appointment their phone number is,"{
""Diagnoses"": [""acute renal failure"", ""intraabdominal infection"", ""sepsis""],
""Medications"": [""intubation"", ""laparotomy"", ""picc line"", ""crash cart""]
}"
43543,admission date discharge date date of birth sex f service medicine allergies penicillins compazine attending chief complaint abdominal pain major surgical or invasive procedure none history of present illness hpi vitals on arrival to the ed were in ed she complained of abd pain and nausea vomiting her fs was k returned at but was hemolyzed and was on repeat wbc nl at na cl bicarb and gap ktones in urine urine tox for opiates she had a lactate of she received zofran mg iv for her nausea a total of morphine mg iv x for her pain and question of receiving dilaudid mg x she later asked for a diet despite complaining of abd pain she was difficilt to obtain access on initially but eventually a guage and a guage was placed and she was started on her first l of ivf she was given units of regular insulin iv and then started on an insulin gtt at units hr at vitals prior to transfer were t hr bp rr ra she reports that her bs have been greater than assay since she left on she has been taking glargine units qhs and novologu units tid she reports blurry vision and a few seoncds of blacking out while in the ed she reports severe abd pain that can be sharp or a constant ache she s had abdominal pain for many yrs but it has been much worse in the last few weeks the pain is in the upper abd and radiates to the back it occurs without eating but is worse with eating it does not feel like her gastroparesis pain it was worked up at and no etiology was found she became very upset when they changed her from morphine mg iv q hrs to po morphine she has not had a bm for weeks and lost lbs over the last wks she also reports chest pain that she s had since being at she describes it as firey acidy and sharp pain she also gets a feeling of numbness in her entire left arm the pain is worse with inspiration at the patient ruled out for pe had a negative hida scan had a neg lead level had an abdominal u s that showed ascities had an unremarkable ct abd pelvis tsh was pt refused in pt tx for narcotic abuse and was reluctant to switch from iv to po pain meds the d c summary reports she set an alarm to wake up to take her pain meds she reports pain in her head x week the pain is in the back of the right head behind the right ear and behind the right eye the pain is and comes and goes it does go away completely and does not feel like a migraine past medical history ddm and dka chronic abdominal pain and discomfort on daily basis and occasional nausea last hospitalized in and in for upper abd pain anxiety depression psa currently abusing narcotics mild pancreatitis in h o bipolar and personality d o h o tia possible h o eating d o dka h o mi at age cocaine use paranoid schizoid personality d o h o depression s p ect lbp ruptured disc hepatomegaly nash social history h o cocaine abuse tobacco use occ etoh h o benzo abuse divorced remarried presented from psychiatric hospital family history adopted physical exam vs temp bp hr rr o sat gen pleasant comfortable nad heent perrl eomi anicteric mildly dry mm resp cta b l with good air movement throughout cv rr s and s wnl no m r g abd epigastric tenderness mildly distracting no rebound no hsm ext dp pulses intact no edema neuro aaox cn ii xii intact strength throughout ue reflexes pertinent results admission labs pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm glucose urea n creat sodium potassium chloride total co anion gap pm urine blood sm nitrite neg protein glucose ketone bilirubin neg urobilngn neg ph leuk neg pm urine rbc wbc bacteria rare yeast none epi pm urine bnzodzpn neg barbitrt neg opiates pos cocaine neg amphetmn neg mthdone neg pm alt sgpt ast sgot alk phos tot bili pm lipase pm ctropnt cxr no acute processes microbiology blood cx negative urine cx k gpc either streptococcus a or lactobacilli returned after discharge no action necessary 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 a p yo female with h o iddm who presented to the ed with a bs of in dka with a gap of and also complaining of chest pain and abdominal pain dka etiology of dka unknown ua was negative for infection gap in the ed was and bicarb was bs on arrival she was started on insulin gtt at u h bs was checked q h ns was given initially and changed to d ns when fsbg fell below she was given phosporus and potassium repletion anion gap closed within hours of admission she was given u sc lantus and insulin gtt turned off several hours later she was subsequently covered with humalog ss was consulted to assist with outpatient planning lantus was increased to units and continued on sliding scale patient was discharged to follow up with pcp abdominal pain records from outside hospital revealed extensive prior work up for her chronic abdominal pain including negative workup for gastroparesis here lfts lipase were all wnl she was treated with small doses of morphine bowel regimen was started for constipation component on transfer to floor she was transitioned to po pain medication and ultimately tolerated a po diet prior to discharge patient requested discharge on hospital day follow up was arranged for patient with pcp the day after discharge acute renal failure creatinine initially elevated to fell to with iv fluids medications on admission glargine novolog sliding scale trazodone mg qhs discharge medications insulin glargine unit ml solution sig thirteen units subcutaneous at bedtime novolog unit ml solution sig units subcutaneous four times a day per sliding scale as previously prescribed trazodone mg tablet sig one tablet po at bedtime as needed for insomnia discharge disposition home discharge diagnosis diabetic ketoacidosis chronic abdominal pain discharge condition mental status clear and coherent discharge instructions you were admitted to the hospital due to uncontrolled diabetes a state called diabetic ketoacidosis you were in the intensive care until your blood sugars were well controlled you were given medications to control your abdominal pain at discharge you were tolerating an normal diet it is very important that you take your insulin as prescribed to keep your sugars at a safe level even if you aren t eating it is important that you take your lantus becuase your body always needs insulin changes in medication increase lantus glargine to units at night followup instructions the following appointment has been arranged for you at your pcp s office it is very important that you go to this appointment pcp thursday at pm with np who works with dr location holistic family practice address turnpike phone,"{
""Diagnoses"": [""Abdominal pain"", ""Nausea"", ""Vomiting"", ""Hemolysis"", ""WBC count""],
""Medications"": [""Zofran"", ""Morphine"", ""Dilaudid"", ""Insulin"", ""Regular insulin"", ""Novolog"", ""Glargine""]
}"
28742,admission date discharge date date of birth sex f service medicine allergies iodine iodine containing attending chief complaint fever fatigue major surgical or invasive procedure none history of present illness yof with h o breast cancer metastatic to liver lung bones cns s p whole brain xrt on who presents today to the ed with c o wks of fatigue and generalized weakness and day of temperature at home to max of she states she has been feeling exhausted x nearly wks with increased fatigue she has been sleeping most of each day she denies subjective fever but reports her husband recommended taking her temperature today max as above she denies cough shortness of breath chest pain she further denies abdominal pain diarrhea dysuria hematuria no headache nor changes in vision she does however endorse visual hallucinations flies in the room intermittently since her last xrt and steroid taper she reportedly finished steroid taper last week s p whole brain xrt of note her last chemotherapy was late at which time she received oral cmf and did not become neutropenic on a visit with her oncologist her coreg dose was cut in half to significant fatigue and her lasix was discontinued she reports however that she has been eating drinking well at home over the past few weeks although reports feeling chronically thirsty past medical history prior onc hx in pt had a mass noted in her r breast and she underwent mastectomy she had positive ln she was diagnosed with inflammatory breast ca estrogen receptor positive she received cyclophosphamide adriamycin fu and chest xrt she then took tamoxifen for years then changed to arimidex in she developed metastatic disease with rising tumor markers she was taken off arimidex and placed on taxol avastin she has bone liver mets and mediastinal adenopathy bone mets to t iliac crest l l in ct head showed multiple areas of cerebral calcifications however pt in repeat ct of torso showed regression of all of her mets and she had decreased tumor markers she is now receiving weekly taxol which was restarted in after taxol avastin had been held for fatigue and chf additionally is s p brain irradiation pmh cardiomyopathy from adriamycin tte there is severe global left ventricular hypokinesis overall left ventricular systolic function is severely depressed ef bilateral knee replacements one in and another in osteoarthritis lymphedema right arm social history no tobacco etoh or illicit drug use lives with her husband family history father died of rectal cancer physical exam afebrile vital signs stable on room air without hypoxia gen overweight elderly female in nad heent sclera anicteric perrla eomi oropharynx clear alopecia neck supple lad heart regular sem at lusb lungs clear bilaterally abd obese benign bs ext dry skin no edema 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 ld ldh totbili dirbili indbili am blood ck mb ctropnt pm blood ck mb notdone ctropnt am blood hapto pm blood caltibc vitb folate ferritn trf pm blood cortsol am blood cea ca pnd chest plain film the left subclavian cv line is unchanged in position projecting at the level of distal svc heart contour is mildly enlarged venous congestion is noted bilateral linear opacities are visible at lung periphery pulmonary vascular congestion is also noted at both lung hila areas of increased opacity within the right lower lobe is consistent with hostory of pulmonary nodules which are difficult to see due to the interstitial edema small right pleural effusion is also present the deformity of the right chest wall is unchanged brief hospital course fever hypotension initially admitted to the medical icu for concern of sepsis particularly with an indwelling central venous catheter blood cultures were drawn and empiric coverage for staphylococcal bacteremia and community acquired pneumonia with vancomycin and levaquin were initiated a cxr showed new left lower infiltrate she improved without pressor support and was transferred to the general medicine team for further care no obvious infectious source was delineated blood cultures did not grow organisms the vancomycin was discontinued and a full course of levaquin was planned on discharge deconditioning the patient s weakness and fatigue were a large part of her subjective complaints surrounding admission she worked with pt daily and will continue to have daily physical therapy at home cardiomyopathy with lv dysfunction with normalized blood pressures she was instructed to resume her home carvedilol and lisinopril at low doses metastatic breast cancer followed by dr no active issues during her hospitalizations she has no pain complaints on discharge medications on admission percocet tabs q hrs prn paxil mg qam zantac mg po bid ambien cr mg hs prn coreg mg po daily lasix mg po daily d c d on lisinopril mg po daily discharge medications 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 paroxetine hcl mg tablet sig one tablet po daily daily ranitidine hcl mg tablet sig tablet po bid times a day oxycodone acetaminophen mg tablet sig one tablet po q h every hours as needed levofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills coreg mg tablet sig one tablet po once a day lisinopril mg tablet sig one tablet po once a day hickman line care per vna protocol discharge disposition home with service facility discharge diagnosis deconditioning possible community acquired pneumonia metastatic breast cancer discharge condition stable ambulating with assistance discharge instructions you were hospitalized with fever and hypotension this has resolved we are treating you with antibiotics which you will continue after leaving the hospital finish all the antibiotics please call your doctor or return to the hospital with any concerns particularly fever greater than redness or pus around your port headache mental status changes or falls at home followup instructions call your oncologist dr for a follow up appointment at call your primary physician at for a follow up appointment provider phone date time provider phone date time [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint syncope major surgical or invasive procedure central line placement and removal history of present illness y o female with breast cancer metastatic to the liver lung bones cns s p whole brain xrt in who presented to the ed with weakness and lightheadedness of note her last chemo was on and had one shot of neupogen on and she was to return for more doses of neupogen but she did not make it on the day of presentation to the ed she was walking to the bathroom using her walker and felt weak and lightheaded she then had a loc and episode of syncope witnessed by husband for approximately minutes no incontinence no evidence of seizure activity per husband she regained consciouness and felt fine afterwards she decided to come to the ed for further evaluation she also has a known rle dvt and is on coumadin in the ed initial vitals were t hr bp rr o sat l nc she was found to be hypotensive transiently to which improved with bolus of ns she was also given zofran for nausea x dilaudid for pain and vancomycin levofloxacin flagyl for a presumed infection bedside tte revealed no evidence of pericardial effusion a right ij cvl was placed for central access she had a cta which was negative for pe she was c o right le pain and she had a ct which was negative cxr was negative ct abdomen was negative rle u s revealed her known dvt upon arrival to the icu she was normotensive and had an episode of nausea and vomiting ml of undigested food ros denies f c positive for n v x episode after arrival to the icu no diarrhea no cp or sob no rash no urinary or bowel complaints no palpitations no orthopnea or pnd no le edema past medical history prior onc hx in pt had a mass noted in her r breast and she underwent mastectomy she had positive ln she was diagnosed with inflammatory breast ca estrogen receptor positive she received cyclophosphamide adriamycin fu and chest xrt she then took tamoxifen for years then changed to arimidex in she developed metastatic disease with rising tumor markers she was taken off arimidex and placed on taxol avastin she has bone liver mets and mediastinal adenopathy bone mets to t iliac crest l l in ct head showed multiple areas of cerebral calcifications however pt in repeat ct of torso showed regression of all of her mets and she had decreased tumor markers she is now receiving weekly taxol which was restarted in after taxol avastin had been held for fatigue and chf additionally is s p brain irradiation pmh cardiomyopathy from adriamycin tte there is severe global left ventricular hypokinesis overall left ventricular systolic function is severely depressed ef bilateral knee replacements one in and another in osteoarthritis lymphedema right arm social history no tobacco or illicit drug use drinks a glass of wine a day lives with her husband and has visiting pt family history father died of rectal cancer physical exam tmax c f tcurrent c f hr bpm bp mmhg rr insp min spo general appearance well nourished no acute distress overweight obese eyes conjunctiva perrl head ears nose throat normocephalic lymphatic cervical wnl supraclavicular wnl cardiovascular pmi normal s normal s normal murmur systolic rusb peripheral vascular right dp pulse present left dp pulse present respiratory chest expansion symmetric breath sounds clear abdominal soft non tender bowel sounds present obese extremities right trace left trace neurologic attentive follows simple commands oriented to person place and time tone normal rue left pertinent results cxr no acute cardiopulmonary disease rle u s extensive deep vein thrombus within the right lower extremity as detailed above intraluminal thrombus starting from the distal common femoral vein extending throughout the superficial femoral vein and into the popliteal vein right hip films no acute pathology prelim read ct abdomen and pelvis no evidence of pulmonary embolism stable pulmonary nodules improving left lingular opacity representing either infectious or inflammatory etiology non visualized liver lesions likely due to differences in phase of contrast ekg nsr at lad lbbb no acute st changes tte complete done at pm the left atrium is mildly dilated left ventricular wall thicknesses and cavity size are normal there is mild regional left ventricular systolic dysfunction with hypokinesis of the basal to mid inferior septum inferior wall and inferolateral wall there is no ventricular septal defect 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 there is mild pulmonary artery systolic hypertension there is no pericardial effusion impression mild regional left ventricular systolic dysfunction no pathologic valvular abnormality or significant outflow tract gradient seen mild pulmonary artery systolic hypertension compared with the prior study images reviewed of the overall ejection fraction is probably similar the prior echo reported global mild hypokinesis however the inferior and inferolateral segments appeared to have worse function at that time also brief hospital course a p y o female with metastatic breast ca bone liver lungs cns who p w weakness and was found to have transient hypotension initally admitted to the icu for further evaluation of hypotension then transferred to the oncology service for further monitoring hypotension transient and resolved prior to admission to icu fluid responsive denies poor po intake other considerations included infection though no symptoms no data while inpatient or cardiac source ruled out for myocardial infarction no arrhythmia on telemetry normotensive throughout stay after minimal fluid supplementation tte was additionally obtained given her history of known cardiomyopathy and low ef echo results where similar to those of last study thus she was discharged to home with resolution of problem leukocytosis no signs or symptoms of infection during stay patient received neupogen in the week prior to admission which would explain leukocytosis blood urine cultures obtained and negative cxr without evidence of infection thus likely secondary to neupogen syncope upon transfer to the oncology service had effectively been ruled out for pe infection and mi have had mild dehydration though she denies decreased po intake prior to event seizure unlikely though no eeg performed no new neurological deficits concerning for tia arrhythmia possible but none seen while on telemetry in icu echo nondiagnostic for new abnormaliity given history and other negative work up her syncope is most consistent with a vasovagal response metastatic breast ca currently being treated with dr last treatment was and also recieving neupogen resultant leukocytosis as above deferred to outpatient follow up continued megace on d c per outpatient regimen cardiomyopathy adriamycin toxicity continued outpatient blood pressure medications and statin while inpatient including coreg mg po daily lisinopril mg po daily lipitor mg po daily and asa mg daily anemia chronic likely anemia of chronic disease last work up in was notable for iron ug dl tibc ug dl vitamin b pg ml folate ng ml ferritin ng ml transferrin mg dl continued on folic acid daily rle dvt on coumadin as an outpatient intermittently subtherapeutic as an outpatient supratherapeutic on admission therapeutic upon transfer to oncology continued coumadin as outpatient code full confirmed on admission communication husband is hcp medications on admission percocet tabs q h prn coreg mg po daily lasix mg po daily d c d on lisinopril mg po daily albuterol prn folic acid mg po daily hydroxyzine prn lipitor mg po daily megestrol mg po qid mycostatin topical nystatin warfarin mg po daily discharge medications atorvastatin mg tablet sig one tablet po daily daily oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain carvedilol mg tablet sig one tablet po daily daily lisinopril mg tablet sig one tablet po daily daily albuterol inhalation hydroxyzine hcl oral megace oral oral warfarin mg tablet sig one tablet po once a day to start on lasix mg tablet sig one tablet po once a day please do not take if you feel dizzy discharge disposition home discharge diagnosis hypotension nos metastatic breast cancer discharge condition stable discharge instructions you were admitted with hypotension a full workup has been performed and no clear source for your low blood pressure was discovered if you develop dizziness weakness fainting fever chills shortness of breath or chest pain please seek medical attention immediately followup instructions provider md phone date time provider md phone date time provider date time [NEW_RECORD] admission date discharge date date of birth sex f service neurology allergies patient recorded as having no known allergies to drugs attending chief complaint altered mental status major surgical or invasive procedure none history of present illness ms is a year old woman with widely metastatic breast cancer metastases to brain lung bone and liver on coumadin for dvt history of a with right sided deficit who presented with an acute change in mental status weakness and word garbling per her husband now with altered mental status word garbling and weakness per husband per report from her husband patient was doing well until one week ago at that time she developed bilateral sharp shooting pain in her thighs radiating up to her pelvis and inguinal area she spoke with her oncology team and was given a prescription for oxycodone mg which she took she also developed diffuse pruritis around the same time but no rash she has continued to have pain that is responsive to oxycodone yesterday she went for an inr check and felt lethargic and weak her weakness was more notable on her left side which is usually her stronger side she was unable to get out of the car without significant assistance she was noted to be slurring her speech but otherwise was making sense at the clinic the nursing team had a difficult time obtaining blood she then reported she wanted to go home and go to bed she then went to bed and per her husband awoke later than usual in the morning around am he noticed at that time her face was asymmetric especially her mouth she again had difficulty speaking and it was apparently difficult to get the words out she did not want breakfast and her husband fed her breakfast at this time her husband was concerned and brought her in for evaluation he states she has not urinated since yesterday there had been no changes in her urine noted she has poor po intake usually only eating breakfast with poor fluid intake she was also recently started on megace which was stopped about one week ago due to an elevated inr in the emergency department her initial vital signs were temperature of f blood pressure of heart rate of respiratory rate of and oxygen saturation of on room air while in the emergency room her blood pressure flucuated from systolic to systolic she received a total of three liters of ivf for intermittent hypotension with fair response she was given grams of ceftriaxone gram of vancomycin grams of ampicillin mg of benadryl and percocet mg times two she was noted to have a right sided facial droop which per report was old she was guaiac negative a head ct was without a bleed or edema her laboratories were remarkable for thrombocytopenia anemia and new renal failure an urinanalysis was unremarkable she was started on empiric coverage for bacterial meningitis and was given gram of vancomycin and gram of ceftriaxone after recommendations given by the oncology team to the emergency room physicians a lumbar puncture was not pursued as her inr was and it was felt this was no consistent with her goals of care while she was in the emergency room her mental status may have improved somewhat but she is not back to her baseline upon sign out to icu team ampicillin for listeria coverage was discussed and given prior to leaving the ed of note her last gemcitabine therapy was on with neupogen given on and per report from her husband this therapy is no longer working and a different therapy plan will be pursued in the coming weeks upon arrival to the icu patient s blood pressure was she denied any discomfort and would answer some questions appropriately review of systems is otherwise negative for fevers recent illness chills nightsweats nausea vomiting diarrhea constipation chest pain and shortness of breath past medical history she was born at home in without any torch perinatal infections she does not have diabetes hypertension or copd she has cardiomyopathy from adriamycin social history patient does not smoke tobacco or use illicit drugs per omr notes she drinks a glass of wine a few times a week she lives with her husband and mainly bed bound family history father died of rectal cancer physical exam vital signs temperature f pulse blood pressure respiration and oxygen saturation in room air general elderly thin female chronically ill in nad but appearing somewhat confused heent nc at no conjunctival pallor perrl no scleral icterus mucous membranes slightly dry slight asymmetry of nasolabial fold neck supple flat jvp no lad appreciated no meningismus kernig and brudzinski signs negative cardiac regular iii vi sem best heard at rusb no rubs or gallops lungs clear to ascultation anteriorly and posteriorly with very occasional wheeze few rales at bases abdomen soft nt nd bs no dullness to percussion no guarding or rebound tenderness genitourinary rectal tone wnl as assessed by nursing patient appearing uncomfortable when temperature obtained no inguinal masses or tenderness to palpation extremities warm bilateral ecchymoses over tibias right leg slightly more edematous than left some signs of venous stasis right arm fixed in contracted position few excoriations over arms no clubbing cyanosis or edema neurological examination alert oriented to self in but not to date squeezes eyes symmetrically perrl tongue mid line grip on left on right upper extremity on left left leg lifts off bed against gravity plantar flexion left right toe down going on left up going on right pertinent results admission labs pm neuts bands lymphs monos eos basos atyps metas myelos pm wbc rbc hgb hct mcv mch mchc rdw pm glucose urea n creat sodium potassium chloride total co anion gap pm calcium phosphate magnesium pm pt ptt inr pt cxr left lower lobe opacity may represent pneumonia or edema recommend repeat imaging after diuresis to excluded underlying infection minimal chf moderate left and small right pleural effusion head cta no evidence of stenoses in the cervical or intracranial arteries no evidence of intracranial aneurysms no ct signs of an acute infarction mri would be more sensitive for an acute infarction unchanged intracranial calcifications consistent with treated metastases unchanged sclerotic bone lesions in the spine sclerotic lesions in the sternum not previously imaged these are consistent with metastases patchy pulmonary opacities in the imaged upper lungs partially imaged pleural effusions clinical correlation is recommended further evaluation may be performed by dedicated chest imaging brief hospital course assessment and plan ms is a year old woman with past medical history of metastatic breast cancer dvt on coumadin prior cva and cardiomyopathy who presents with altered mental status and feeling of weakness on left side has weakness on right side at baseline altered mental status patient had altered mental status on admission and thru oriented only to self and was combative on her mental status improved dramatically this is thought likely to be toxic metabolic factors in the setting of old cva deficits the toxic metabolic factors could include penumonia oxycodone use and possible small contribution of hypocalcemia there was concern for leptomeningeal disease given her metastatic breast cancer to the cerebellum however lumbar puncture was not persued given patient s mental status cleared and we would not expect it to resolve spontaneously seizure could also be responsible if altered mental status was secondary to seizure ct of the head was negtive for cva or tia bleed or new edema patient still has innumerable calcified metastatic foci and mild edema she refused mri given her severe claustrophobia cta showed no evidence of intracranial thrombosis her oxycodone was discontinued and her calcium was repleted patient did receive antibiotics for bacterial meningitis in the ed but they were not continued given that she had no fever or signs of meningismus patient was also placed on lactulose for concern for hepatic encephalopathy given increased lft s but this was discontinued patient required haldol and benedryl for agitation until when her mental status cleared she was transferred out of the icu and her mental status remained clear and at her baseline per the patient and her family for hours after which she was discharged pneumonia left retrocardiac mild pna she received days of ceftriaxone and vancomycin blood cultures were negative increased liver function tests ruq was done for concern of rising lfts given pt has liver mets some biliary sludge found on ruq ultrasound acute renal failure patient was pre renal fena in setting of poor po intake reported by family and continuation of home bp medications ace i lasix and coreg her baseline creatinine is her creatinine on admission was and fell to when leaving the icu patient had received fluid boluses early on in the admission for hypotension hypotension patient was hypotensive on admission to systolic bp and she received fluid boluses per hematology oncology clinic notes patient s baseline blood pressure over the last several weeks was recorded as patient s home bp meds were held and restarted prior to dischrge thrombocytopenia platelets on presentation she was day of her gemcitabine therapy so this likely represent marrow suppression from that cycle wbc could be disporportionally up secondary to administration of gsc f consistent with severity and timing of prior post chemo thrombocytopenia her coumadin was held her thrombocytonpenia improved to the s on the day of discontinued from the icu anemia hct since in range on presentation hct was and now is we suspect large part of this may be marrow suppression secondary to chemotherapy as has no signs of bleeding guaiac negative in ed her hemolysis labs were negative she has poor reticulocytosis and anemia of chronic disease to account for macrocytosis and microcytosis respectively she received one unit of blood while in the icu and bumped appropriately hct stable at thereafter pruritis per husband and as noted on skin examination this has been a major complaint over the last week prior to admission most likely secondary to oxycodone she was treated with benedryl which was later discontinued due to her ms changes she did not complain of further itching bilateral leg pain this is likely due to compression by known spinal mets she had no signs of cord compresion or cauda equina as rectal tone and sensation in tact she was pain free on day of call out from icu she subsequently had some pain and swelling in the right leg doppler studies were negative for clot she was given ibuprofen for pain on the floor svt patient had episodes of svt while in the icu with hr up to which responded to metoprolol mg iv breast cancer no active patient while an in patient failure to thrive per omr notes and discussion with husband she has lost a significant amount of weight pounds over the last several months and has very poor po intake a trial of megace had been initiated however this was stopped due to interaction with her coumadin and supratherapeutic inr she was seen by nutrition and originally placed on a restricted diet which was later to a regular consistency dysphagia diet she should be supplemented with boost ensure history of dvt patient s inr was supratherapeutic on admission she had no signs of bleeding anticoagulation was held in anticipation of lp coumadin restarted on at mg daily down from home dose of mg daily given that she was supratherapeutic and also on antibiotics rle doppler studies done to evaluate leg pain and swelling were negative for clot she was discharged with this dose and plans to follow up for inr check in days history of cardiomyopathy held ace i lasix and coreg in setting of hypotension they were not restarted prior to being called out from the icu on medications on admission atorvastatin mg po daily carvedilol mg po daily folic acid mg po daily furosemide mg po every other day lisinopril mg po daily zolpidem mg po hs prn aspirin mg po daily guaifenesin mg ml mls po q h prn coumadin mg po once a day oxycodone mg sr qhs prn lactulose ml prn oxycodone acetaminophen mg mg t po q prn discharge medications atorvastatin mg tablet sig one tablet po once a day carvedilol mg tablet sig one tablet po daily daily folic acid mg tablet sig one tablet po once a day furosemide mg tablet sig one tablet po qod lisinopril mg tablet sig one tablet po daily daily aspirin mg tablet chewable sig one tablet chewable po daily daily thiamine hcl mg tablet sig one tablet po daily daily warfarin mg tablet sig three tablet po once daily at pm acetaminophen mg tablet sig tablets po q h every hours as needed ibuprofen mg tablet sig one tablet po q h every hours as needed for pain discharge disposition home with service facility discharge diagnosis primary altered mental status secondary metastatic breast cancer chronic systolic congestive heart failure osteoarthritis hisotry of dvt history of cva discharge condition stable discharge instructions you were admitted to the hospital because you were confused you were treated for a pneumonia and given fluids for your kidneys your confusion improved please make sure to drink plenty of fluids at home we recommend that you not take zolpidem or oxycodone for now as these medications can cause confusion you may take acetaminophen or ibuprofen for pain which worked for you in the hospital if you have ongoing pain that does not improve with acetaminophen you should talk to your doctor about other medications that might help your coumadin dose was decreased in the hospital because your level was quite high you should follow up with coumadin clinic in days please call your doctor or return to the emergency room if you have fevers or chills another episode of altered mental status chest pain shortness of breath or other symptoms that are concerning to you followup instructions please follow up as previously scheduled in the oncology clinic rn phone date time rn phone date time rn phone date time completed by,"{
""Diagnoses"": [""breast cancer"", ""metastatic to liver"", ""metastatic to lung"", ""metastatic to bones"", ""CNS""],
""Medications"": [""iodine"", ""iodine containing"", ""none""]
}"
12531,admission date discharge date date of birth sex m service medicine allergies amoxicillin attending chief complaint found down major surgical or invasive procedure intubation central venous line pa catheter history of present illness yo male w vague pmh of arrhythmia presents after being found down by his family patient was apparently found by family in the basement after being down for an unknown period of time hours they were unable to get him upstairs so they brought a mattress down into the basement the daughter slept down in the basement with him overnight and at around am he was calling out for watter but did not seem to recognize her the family called the scientist nurse advisor who told them that they were legallly bound to call the ambulance in the state of ma ems found him to be unresponsive w gcs and a fs of on the scene he received an amp of d when the patient arrived in the ed his vitals were as follows t f c hr bp rr sat on face mask he was intubated and started on warm o in attempt to warm him he was also noted to be coagulopathic with an inr of he received u prbcs and vit k mg sc x also was started empirically on broad spectrum abx vancomycin ceftriaxone and flagyl and a dose of dexamethasone mg iv x he was started on a levophed gtt for blood pressure support he had a fast exam which noted free fluid in the abdomen but it was unclear if this blood or ascites he also went to the or and was going to get warmed via ecmo since his temp was up to f at that time the surgeons decided against this but a l subclavian cordis was placed swanned in micu and found to have high right sided pressures and waveforms c w severe tr echo confirmed tr past medical history hx of a fib dx in summer not rate controlled or anticoagulated hx of edema testicular attributed to heart failure per wife social history sh patient is originally from the republic has lived in and came to the us about one year ago is retired and lives with his wife and daughter family history fh no hx of liver disease physical exam gen intubated heent periorbital edema pupils reactive lungs clear heart irreg irreg no murmurs appreciated abd no bowel sounds firm ascites could not palpate liver or spleen ext diffuse severe total body pitting edema skin eccymoses under arms bilat skin over feet is also ecchymotic has cracked skin over fingernail beds neuro not responsive to voice commands 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 plt smr very low plt ct pm blood fibrino pm blood esr pm blood glucose urean creat na k cl hco angap pm blood alt ast ld ldh ck cpk alkphos amylase totbili pm blood lipase pm blood ck mb mb indx ctropnt pm blood albumin calcium phos mg am blood hapto am blood tsh am blood hbsag negative hbsab positive hav ab positive igm hbc negative pm blood anca negative b pm blood negative am blood hcv ab negative pm blood glucose lactate na k cl calhco pm blood anti jo antibody pm blood c test range mg dl chagas antibody not detected cxr no evidence of definite parenchymal consolidation unchanged appearance to pleural effusions and interstitial pulmonary edema endotracheal tube approximately cm from carina recommend repositioning swan ganz catheter tip likely within right ventricle ct chest abdomen extremely limited study secondary to artifact free fluid seen throughout the abdomen tracking into the pelvis measuring simple fluid density in most areas some areas of higher attenuation fluid measurements are likely secondary to artifact although hemoperitoneum cannot be totally excluded there is no evidence of layering hematocrit level no active extravasation identified diffuse anasarca large bilateral pleural effusions with associated atelectasis consolidation ct head no evidence of acute intracranial hemorrhage ct c spine no evidence of acute fracture cervical spondylosis bilateral pleural effusions and atelectasis tte the left atrium is dilated the right atrium is dilated there is moderate global left ventricular hypokinesis there is no ventricular septal defect the right ventricular cavity is dilated there is severe global right ventricular free wall hypokinesis and moderate global left ventricular hypokinesis ejection fraction percent the number of aortic valve leaflets cannot be determined there is significant focal thickening of the noncoronary cusp suggestive of a vegetation the aortic valve leaflets are moderately thickened there is no aortic valve stenosis mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse mild mitral regurgitation is seen moderate to severe tricuspid regurgitation is seen there is a trivial physiologic pericardial effusion there are no echocardiographic signs of tamponade compared to previous study of the left ventricular ejection fraction is increased ct head interval development of large wedge shaped area of low attenuation consistent with infarct in the left parietal region numerous other new low attenuation foci bilaterally are also concerning for infarction and do not correspond to any particular vascular territory this pattern raises concern for possible watershed infarction rather than embolic or thrombotic etiology and should be correlated with history of shock hypotension no evidence of intracranial hemorrhage air fluid levels in the paranasal sinuses possibly sequela from intubation and supine positioning ct chest abdomen extremely limited study due to artifact and lack of intravenous contrast slight interval decrease in large bilateral pleural effusions with associated bibasilar atelectasis consolidation large amount of low attenuation fluid throughout the abdomen tracking into the pelvis no definite evidence of retroperitoneal hematoma or acute hemorrhage apparent thickening of the wall of the sigmoid and distal descending colon incompletely characterized due to lack of distention with oral contrast while the rectum appears spared in the appropriate clinical context findings may represent colitis either infectious or ischemic given the segments involved and may be new since the earlier study anasarca as before eeg this is an abnormal eeg due to the low voltage slow background activity and bursts of generalized slowing this suggests a severe encephalopathy which may be seen with infections ischemia medication effect or toxic metabolic abnormalities no epileptiform features were noted a repeat eeg to evaluate for evolution would be recommended if patient remains unresponsive brief hospital course this is a yo male intially admitted after being found down with hypothermia coagulopathy hypotension free fluid in abdomen intubated in the ed shock unclear etiology initially had chracteristics of both cardiogenic shock and vasodilatory shock had increased r sided pressures and r ventricular dysfunction echo w severe biv systolic dysfunction rv not functioning ef mod mr severe tr also had acute systemic illness characterized by hypothermia hypotension coagulopathy diffuse capillary leak no infectious source identified and only localizing complaint prior to admission was three days of increasing abdominal girth and episode of diarrhea on day of admission had considered vasculitis auto immune process dermatomyositis but esr ck anca anti were all unremarkable had been on levophed neosynephrine and vasopressin then weaned to only levophed levophed turned off yesterday after family made pt he received a day course of empiric vancomycin ciprofloxacin and flagyl he also received stress dose steroids during this admission pressor support was discontinued after the patient s family requested that he be made comfort measures only unresponsiveness the patient remained unresponsive for several days off sedation his head ct was consistent with anoxic brain injury demonstrating large ischemic infarcts eeg showed diffuse encephalopathy the neurology service was involved and felt that meaningful neurologic recovery was unlikely given the poor prognosis the patient s family decided to make him comfort measures only this decision was made on respiratory failure initially the patient was intubated for obtundation and hypoxia he required high peep up to but this was later weaned down to and hypoxia improved abg was consistent with metabolic acidosis possibly secondary to acute renal failure and his respiratory rate was set at to compensate for this the patient was extubated after the he was made on rv biventricular failure echo w severe biv systolic dysfunction non functioning rv not functioning ef with mod mr and severe tr biventricular failure could be secondary to acute coronary syndrom pe or severe valvular disease he was initally on a lasix drip which was later discontinued he then proceeded to autodiurese well coagulopathy initally his labs were indicative of dic with low platelets fibrinogen and hapto and elevated ldh inr eventually improved to down from he recieved a total of u ffp u prbcs u plts tachycardia initially thought to be svt vs atrial fibrillation this tachycardia was poorly tolerated resulting in hypotension later patient had atrial bigeminy he was on amiodarone drip which was latered discontinued on given patient s status rhabdomyolysis patient found down and ck was elevated to the s at admission ck s eventually improved renal failure creatinine trended up to from early in admission urine lytes suggested pre renal etiology likely secondary to hypotension elevated liver enzymes unclear etiology possibly secondary to shock liver vs cholangitis vs chronic liver disease with acute exacerbation difficult to ascertain synthetic function in this acute settting lfts slowly improved hepatitis panel negative possible nstemi initially had positive trop and mbi then mbi negative trop peaked at then trended down ekg was without concerning ischemic changes ascites this was thought to be due to iv fluids paracentesis was performed with no growth in culture abdomen continued to drain large amounts of fluid from tap site anemia baseline unknown no obvious source of blood loss likely secondary to hemolysis and phlebotomy transfused as above hyponatremia possibly secondary to chf and cirrhosis this improved throughout his admission likely secondary to diuresis status given the patient s poor prognosis the patient was made on by his family wife and daughter patient s family informed the micu team that this would be consistent with patient s wishes after this decision was made all non comfort medications were discontinued he was given morphine and ativan prn social work followed with the family the patient was extubated on he later expired on at permission was granted by his wife for autopsy medications on admission none discharge medications none discharge disposition expired discharge diagnosis shock unresponsiveness respiratory failure congestive heart failure coagulopathy rhabdomyolysis renal failure ascites discharge condition expired discharge instructions none followup instructions none,"{
""Diagnoses"": [""Down syndrome"", ""Arrhythmia"", ""Coagulopathy"", ""Sepsis""],
""Medications"": [""Amoxicillin"", ""Vancomycin"", ""Ceftriaxone"", ""Flagyl""]
}"
51495,admission date discharge date date of birth sex m service cardiothoracic allergies no known allergies adverse drug reactions attending chief complaint chest pain and shortness of breath major surgical or invasive procedure coronary artery bypass grafting x with left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the posterior descending artery and the obtuse marginal artery history of present illness year old male has a history of an mi about years ago he has been treated with medication since then he has been doing well over the years until about weeks ago when he started to notice some diaphoresis shortness of breath and right sided chest discomfort that has occurred with exertion such as yard work or taking out the trash his symptoms resolve with rest he also had one episode of chest pain diaphoresis and back pain that occurred at rest after a large meal this episode lasted a little longer than the other episodes and prompted the patient to contact dr he was sent for a stress echo which was abnormal and referred for a cardiac catheterization he is was found to have three vessel disease and is now being referred to cardiac surgery for revascularization past medical history diabetes type ii diagnosed controlled on oral agents hyperlipidemia hypertension mi psoriasis social history race caucasian last dental exam lives with wife contact wife phone occupation retired from the fda as a field investigator and consultant cigarettes smoked no yes x hx smoked ppd for years and quit other tobacco use denies etoh drink week x drinks week drinks week illicit drug use denies family history premature coronary artery disease unknown adopted physical exam pulse resp o sat ra b p right left height weight lbs general skin dry x intact x heent perrla x eomi x neck supple x full rom x 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 varicosities l le superficial varicosities neuro grossly intact x pulses femoral right left dp right left pt left radial right left carotid bruit none appreciated pulses right left pertinent results echo pre bypass 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 left ventricular wall thicknesses are normal the left ventricular cavity size is top normal borderline dilated there is mild regional left ventricular systolic dysfunction with hypokinesis of the basal to distal inferoseptal and anteroseptal walls overall left ventricular systolic function is mildly depressed lvef right ventricular chamber size and free wall motion are normal 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 stenosis or aortic regurgitation the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen there is no pericardial effusion dr was notified in person of the results at time of surgery post bypass the patient is in sinus rhythm the patient is on no inotropes biventricular function is unchanged mitral regurgitation is unchanged the aorta is intact post decannulation 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 mg comparison at a m findings as noted previously there is a similar sized left apical pneumothorax the left chest tube has been removed in the interim left basilar atelectasis remains the cardiac silhouette and mediastinal contours are unchanged median sternotomy wires are unchanged impression unchanged small left apical pneumothorax status post left chest tube removal brief hospital course mr yr old male with history of mi developed worsening chest pain underwent cath which revealed significnat cad he was seen by the cardiac surgery service and accepted for cabg he was a same day admit and on was brought directly to the operating room where he underwent a coronary artery bypass graft x please see operative note 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 he was weaned from neo overnight and was started on beta blocker pod he was diuresed towards his preoperative weight pod he transferred to the step down unit for further monitoring he continued to progress well on the floor physical therapy was consulted for evaluation of his strength and mobility the remainder of his postop course was essentially uneventful he was cleared for discharge to home with vna services on pod follow up appts arranged medications on admission atenolol mg daily lipitor mg daily plavix mg daily started on ld diltiazem hcl mg daily enalapril maleate takes mg qam mg qhs hydrochlorothiazide mg daily metformin mg nitroglycerin mg tablet prn aspirin mg daily centrum silver multivitamin tablet daily discharge medications potassium chloride meq tablet extended release sig two tablet extended release po once a day for weeks disp tablet extended release 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 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 fluticasone mcg actuation spray suspension sig two spray nasal daily daily disp refills metoprolol tartrate mg tablet sig one tablet po tid times a day disp tablet s refills metformin mg tablet sig two tablet po bid times a day disp tablet s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills lasix mg tablet sig one tablet po once a day for weeks disp tablet s refills discharge disposition home with service facility vna discharge diagnosis coronary artery disease s p coronary artery bypass graft x past medical history diabetes type ii diagnosed controlled on oral agents hyperlipidemia hypertension mi psoriasis 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 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 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 wound check surgeon dr on pm cardiologist pcp date time please call cardiac surgery office with any questions or concerns answering service will contact on call person during off hours completed by,"{
""Diagnoses"": [""cardiothoracic"", ""anterior descending artery"", ""posterior descending artery"", ""obtuse marginal artery"", ""three vessel disease""],
""Medications"": [""medication""]
}"
92793,admission date discharge date date of birth sex m service neurosurgery allergies no known allergies adverse drug reactions attending chief complaint ataxia falls headache brain lesions major surgical or invasive procedure suboccipital craniotomy with posterior fossa tumor resection history of present illness yo m presents with weeks of difficulty with balance with recent falls and a few near misses ataxia slowed speech and headache he presented to his pcp and after brief workup was sent for an mri of the brain which shows at least two lesions in the brain one x cm lesion in the r cerebellum and a smaller l occipital lobe lesion most consistent with metastasis as well as dilated ventricles concerning for obstructive hydrocephalus he was sent from by ems for neurosurgical evaluation past medical history htn hld pre diabetic h o cataract surgery social history previous smoker approx pack years previous social etoh no illicits family history gm with stroke prostate ca in f and uncle physical exam o t bp hr r o sats ra gen wd wn comfortable nad heent pupils brisk eomi but with mild r nystagmus neck supple lungs cta bilaterally cardiac rrr s s abd soft nt bs extrem warm and well perfused neuro mental status awake and alert cooperative with exam normal affect orientation oriented to person and to date but only after correcting himself recall objects at minutes with prompts language speech fluent with good comprehension and repetition naming intact no dysarthria 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 with mild r beating 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 tremors strength full power throughout no pronator drift sensation intact to light touch bilaterally reflexes b t br pa ac right left toes downgoing bilaterally coordination dysmetria on finger nose finger worse on r as well as decreased performance of on r wide based stance with negative romberg pertinent results ct chest abd pelvis w w o contrast addl sections x x cm homogeneous pleural based mass in the anterior inferior right upper lobe further characterization with biopsy is recommended given concern for malignancy focal hyperdensity near the left ureterovesical junction in the bladder underlying mural lesion cannot be excluded further evaluation with ultrasound or mri should be considered mm pulmonary nodule in the right lung base given concern for malignancy attention on followup is recommended no lymphadenopathy within the chest abdomen or pelvis mri wand enhancing hemorrhagic masses in right cerebellum and left occipital lobe are again demonstrated for surgical planning post op non contrast head ct expected postoperative appearance following right cerebellar mass resection the extent of resection would be better assessed by mri left occipital mass with surrounding edema is again noted better seen on prior mri post op mri the patient is status post partial resection of the right cerebellum for removal of enhancing mass the surgical bed includes blood products thin peripheral rim of restricted diffusion likely representing postoperative ischemia as well as minimal peripheral enhancement also likely postoperative although residual tumor cannot be excluded there remains mass effect upon the surrounding structures with effacement of the fourth ventricle and minimal right to left shift of the right residual cerebellar lobe the ventricular size has decreased with a right ventricular drain in place an enhancing fluid collection is present within the posterior extraaxial space inferior to the surgical bed posterior to the cerebellar tonsils brainstem at and below the foramen magnum as described above this may represent postoperative fluid although the sterility of this collection is indeterminate short interval followup is recommended no change in the left paramedian occipital lobe enhancing lesion with surrounding edema brief hospital course y o m presents with frequent fall and balance instability was found to have a r cerebellar and l occipital mass on examination patient has minimal dysmetria and ataxia but is otherwise intact patient was started on decadron and psa was sent and was elevated at ct torso was done which revealed a mass in both rul and rll on exam remains stable while he awaited the or on he underwent a suboccipital craniotomy and mass resection surgery was without complication and he tolerated it well post op head ct revealed no hemorrhage and good placement of evd on he was neurologically stable but complained of nausea he was cleared for sqh and decadron wean he underwent mri imaging for restaging on his evd was removed and he was transferred to the neurosurgical floor on he remained neurologically intact with only mild dysmetria his pain was well controlled on oral medications he was tolerating a regular diet and ambulated with physical therapy thus he was deemed ready for discharge home on pt was discharged home with home nursing evaluation in stable condition medications on admission nadolol pravastatin daily takes rd medication but unsure of the name discharge medications pravastatin mg tablet sig two tablet po daily daily nadolol mg tablet sig two tablet po daily daily famotidine mg tablet sig one tablet po bid times a day disp tablet s refills senna mg tablet sig tablets po bid times a day docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily dexamethasone mg tablet sig one tablet po bid disp tablet s refills acetaminophen mg tablet sig two tablet po q h every hours as needed for pain fever oxycodone mg tablet sig tablets po every four hours as needed for pain disp tablet s refills oxycodone mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills discharge disposition home with service facility nursing services discharge diagnosis r cerebellar and l occipital mass hypertension hyperlipidemia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions 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 and or staples 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 unless directed by your doctor do not take any anti inflammatory medicines such as motrin aspirin advil and ibuprofen etc clearance to drive and return to work will be addressed at your post operative office visit make sure to continue to use your incentive spirometer while at home call your surgeon immediately if you experience any of the following new onset of tremors or seizures any confusion 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 any signs of infection at the wound site redness swelling tenderness or drainage fever greater than or equal to f followup instructions follow up appointment instructions please return to the office in days from your date of surgery for removal of your staples and a wound check this appointment can be made with the nurse practitioner please make this appointment by calling if you live quite a distance from our office please make arrangements for the same with your pcp you have an appointment with the brain clinic on at am completed by,"{
""Diagnoses"": [""ataxia"", ""headache"", ""brain lesions"", ""obstructive hydrocephalus"", ""metastasis""],
""Medications"": [""""]
}"
9652,admission date discharge date date of birth sex f service cardiothor history of the present illness this is a year old portuguese speaking female with known history of aortic stenosis seen by the primary care practitioner tte was consistent with critical aortic stenosis the patient denies angina tias syncope or claudication there is no history of orthopnea paroxysmal nocturnal dyspnea or lower extremity edema cardiac catheterization revealed critical aortic stenosis with atrial valve area of cm squared and mild three vessel coronary artery disease past medical history hypertension hyperlipidemia hiatal hernia allergies the patient is allergic to flu shots physical examination examination revealed the patient to be afebrile vital signs were stable lungs lungs were clear heart regular rate and rhythm systolic murmur abdomen soft nontender nondistended extremities no edema palpable pulses summary of hospital course the patient was brought to the operating room on the procedure performed was an avr and cabg times three a mm pericardial ce valve was placed the saphenous vein graft went to lad pda and om cvp was minutes xcl minutes the pericardium was left open a swan ganz catheter was placed two atrial and ventricular wires along with two mediastinal and one pleural tube were also placed the patient had an episode of ventricular fibrillation coming off pump and therefore an amioardone drip was started in the icu the patient was rapidly extubated and the levo drip was weaned on postoperative day the patient was observed in the icu and stable on postoperative day she was transferred to the floor on postoperative day due to a low hematocrit two units of packed red blood cells were given she also had a run of atrial fibrillation on postoperative day for which she was started on oral amiodarone due to a low output from the pleural and mediastinal tubes they were removed on postoperative day the patient was tolerating p o diet well the foley catheter was removed on postoperative day the patient was stable for discharge to rehabilitation wires were also removed labs on discharge laboratory data revealed the following white count hematocrit platelet count sodium potassium chloride bicarbonate bun creatinine glucose calcium magnesium and phosphorus condition on discharge stable discharge medications lasix mg b i d times seven days mg b i d times seven days enteric coated aspirin mg q d captopril mg t i d lipitor mg q d lopressor mg b i d amiodarone mg t i d times two days mg b i d times seven days mg q d times days percocet one to two tablets q to h p r n colace mg b i d discharge status the patient is discharged to a rehabilitation facility follow up care the patient will follow up with the primary care provider or cardiologist in three weeks the patient will followup with dr in four weeks diagnosis status post coronary artery bypass graft times three avr m d dictated by medquist d t job [NEW_RECORD] name unit no admission date discharge date date of birth sex f service cardiothor discharge summary addendum on the day prior to discharge developed some nausea she had emesis times one very small amounts ast alt amylase lipase bilirubin were all obtained and they were all normal a kub was obtained which revealed no ileus no gastric dilatation on the day of discharge ms was nausea free and had not vomited for the entire day she was tolerating a regular diet with no problems in addition her blood pressure was still mildly elevated hydralazine was added and her blood pressure was then controlled her discharge vital signs were temperature f heart rate blood pressure respiratory rate and saturation on room air she will be sent home with hydralazine as an addition to her prior discharge medications milligrams qid she will also have visiting nurses for blood pressure checks and wound checks m d dictated by medquist d t job,"{
""Diagnoses"": [""aortic stenosis"", ""critical aortic stenosis"", ""hypertension"", ""hyperlipidemia"", ""hiatal hernia""],
""Medications"": [""flu shots""]
}"
12876,admission date discharge date date of birth sex m service medicine allergies a c e inhibitors attending chief complaint sob major surgical or invasive procedure none history of present illness history obatined from nh notes md and patient patient is poor historian the pt is a year old male with pmh of scc of the tongue s p xrt and nsclc of s p rml and lul resection copd on chronic o l ns and current smoker p w days of increased sob with productive cough from his nh bengamin center has been treated with nebs and levo for presumptive pna over the past days fevers at home no shaking chills no cp n v is npo neck scc but is able to swallow sercretion no odynophagia or dysphagia per nh records patient was noted to be on usual l nc on ems arrival on nrb tachypnic per nh sheets has refused pneumovax in the past he was admitted to the medical intensive care unit in the micu the patient was started on vanco zosyn for presumed pna was maintained on oxygen mask with sating in the low s past medical history copd on home o l dementia squamous cell of the tongue s p xrt chf with ef etoh cm pud nsclc s p rml lul resection status post video assisted left upper lobectomy in and laser ablation plus radiotherapy in peptic ulcer disease status post appendectomy history of alcohol now sober per patient tobacco use ppd currently ppd social history homeless was transferred here from the health care facility he has a pack year history of smoking and continues to smoke he no longer uses alcohol the patient was seen status post a successful peg placement with no complications family history non contributory physical exam vitals t p r bp sao general awake nodding to questions heent perrla eomi without nystagmus no scleral icterus noted mucous membranes very dry neck no jvp or carotid bruits appreciated xrt skin hyperpigmentation no tracheal deviation noted no palpable masses appreciated pulmonary poor air movment throughout prolonged exp phase with end exp wheeze upper airway sounds cardiac tachy regular no m r g noted abdomen soft nt nd normoactive bowel sounds no masses or organomegaly noted peg site is c d i extremities clubbing atrophic limbs dp and pt pulses b l pertinent results ekg st nl axis and intervals prwp lae lvh by mm in precordial leads std in v v c w prwp is new and lvh is more pronounced radiologic data left shirt of mediastinum with tracheal deviation unchanged from prior cxr rul and lll new airspace disease small left pleura effusions on ptx cultures blood pending urine pending brief hospital course the patient was a yo male with severe copd rml lul wedge resection and neck xrt presented with a history of increased sob and cough he had been on ceftriaxone from and then levofloxicin for more days the patient was at risk for resistent organisms and also the risk of aspiration was great and given neck xrt impaired ciliary clearnance increases risk of pseudomonas on admission the patients abg is remarkable for paco of but with a ph of for chronic resp acidosis expect his bicarb to be thus he had a met alk as well patient does not give any history of nausea emesis as one might expect in theoph toxicity the patient had clearly documented dnr dni status at the nursing home and his signed forms were faxed over the patient was initally admitted to the medical intensive care unit he was started on vanco and zosyn for broad coverage and started on methylprednisolone q for management of his copd flare it was unclear if there was a superimposed pna the icu team felt that bipap was not indicated as it could serve only be a bridge to intubation and intubation was against the patient s wishes the patient was maintained on nc and fasemask o he was transferred to the medical floor there was no further intensive interventions he continued to be tachypnic and require increasing amounts of oxygent to maintain o he was given morphine for worsening sob multiple attempts were made to contact family members but none could be reached the nursing home reported that the patient had not had contact with any family member in over year the patient expired on at pm further attempts were made to contact family members without success no autopsy was performed medications on admission tf jevity plus fluoxetine mg po qd protonix mg po qd prednisone mg po taper on and completed this on the th now on baseline mg po qd trazodone mg po mg po bid lasix mg po bid clonazepam mg po bid percocet prn combivent inh puffs qid prn albuterol prn colace senna fleets prn levo from ctx on allergies lisinopril which causes angioedema discharge medications patient expired on at pm discharge disposition expired discharge diagnosis respiratory failure lung cancer discharge condition expired at pm,"{
""Diagnoses"": [""SCC of the tongue"", ""SP XRT"", ""NSCLC of SP RML"", ""LUL resection"", ""COPD"", ""Dementia"", ""Squamous cell carcinoma of the tongue"", ""Chf with EF < 40%"", ""Pud""],
""Medications"": [""Vanco"", ""Zosyn"", ""Levo"", ""Nebs""]
}"
57989,admission date discharge date date of birth sex f service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint dyspnea on exertion major surgical or invasive procedure avr mm mosaic porcine history of present illness year old female with history of hypertension and hyperlipidemia with known aortic stenosis for months who presents for evaluation for aortic valve replacment the patient is limited by dyspnea on exertion that has affected her daily activities past medical history past medical history hypertension hyperlipidemia aortic stenosis history of falls osteoporosis past surgical history s p right hip replacement s p left hip plate and screw s p ths and bso years ago s p tonsillectomy social history family history nc race causasian last dental exam full dentures lives with senior living center estranged from husband has grown sons occupation none tobacco denies etoh denies family history none physical exam pulse resp o sat b p right left height weight lbs general well developed elderly female in no acute distress skin dry x intact x heent 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 non tender x bowel sounds x extremities warm x well perfused x edema varicosities none x neuro grossly intact x pulses femoral right left dp right left pt left radial right left carotid bruit right left transmitted murmur pertinent results echo pre bypass the left atrium is mildly dilated and elongated 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 complex mm atheroma in the aortic root aortic arch and the descending thoracic aorta there are three aortic valve leaflets the aortic valve leaflets are severely thickened deformed there is moderate aortic valve stenosis valve area cm trace aortic regurgitation is seen the mitral valve leaflets are moderately thickened no mitral regurgitation is seen post bypass patient is in sinus rhythm with pac s on phenylepherine infusion preserved biventricular function lvef there is a bioprosthetic valve in the aortic position mosaic per surgeons without ai or perivalvular leaks peak gradient mm hg mean mm hg on aortic valve aortic contours intact remaining exam is unchanged all findings discussed with surgeons at the time of the exam cardiac catheterization clean coronaries brief hospital course ms was admitted to the on for a cardiac catheterization in preparation for an aortic valve replacement her cardiac catheterization revealed clean coronaries and severe aortic stenosis she was worked up in the usual preoperative manner on she was talken to the operating room where she underwent an aortic valve replacement with a bioprosthesis please see operative note for details postoperatively she wastaken to the intensive care unit for invasive hemodynamic monitoring over the next hours she awoke neurologically intact and was extubated she was transferred to the stepdown unit on pod she was started on betablockade and diuresed toward her pre operative weight her chest tubes and temporary pacing wires were removed per protocol she was evaluated by physical therapy for strength and conditioning and rehab was recommended she was cleared for discharge on pod by dr medications on admission fosamax lipitor mg qd lisinopril mg qd discharge medications furosemide mg tablet sig one tablet po daily daily until at pre op weight of kg then chnage to home diuretic hctz potassium chloride meq tab sust rel particle crystal sig one tab sust rel particle crystal po daily daily while on lasix docusate sodium mg capsule sig one capsule po bid times a day 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 bisacodyl mg suppository sig one suppository rectal daily daily as needed for constipation atorvastatin mg tablet sig one tablet po daily daily metoprolol tartrate mg tablet sig one tablet po tid times a day alendronate mg tablet sig one tablet po once a week discharge disposition extended care facility health care center discharge diagnosis as s p avr hypertension hyperlipidemia history of falls osteoporosis discharge condition alert and oriented x nonfocal ambulating gait steady sternal pain managed with percocet prn 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 females please wear bra to reduce pulling on incision avoid rubbing on lower edge followup instructions please call to schedule appointments surgeon dr in weeks primary care dr in weeks cardiologist dr in weeks completed by,"{
""Diagnoses"": [""cardiothoracic"", ""aortic stenosis"", ""hypertension"", ""hyperlipidemia"", ""dyspnea""],
""Medications"": [""""]
}"
11953,admission date discharge date service surgery allergies tetracycline attending chief complaint transfer from to sicu major surgical or invasive procedure s p i d s p debridement history of present illness mr is a yo male transferred from he developed right foot pain the sunday prior to admission and was seen by his podiatrist who diagnosed him with gout he was given colchicine and prednisone mr then developed more pain and warmth to his right foot later in the week and presented to the ed at this hospital he underwent an i d of a right foot infection and subsequently underwent re exploration for developing necrotizing fascitis he was transferred to for further care past medical history pmh prostate ca glaucoma psh rih repair s p turp s p thyroid excision social history etoh physical exam gen nad heent eomi anicteric op pink neck no masses supple cv rrr no m r resp clear gi soft nt nd ext r foot with erythema swelling muscle and tendons exposed with necrotic edges some fibrinous exudate neuro axox pertinent results mri rle cm linear fluid collection running between the anterior and lateral muscle compartments extending from a large area of soft tissue loss seen in the distal lateral foreleg to roughly the mid tibia fibula cm distal to the knee joint line the collection is largest at its most proximal extent measuring x cm in the transverse dimension non specific myositis involving multiple muscle groups in the foreleg most severe in the anterior lateral and posterior deep compartments tendinosis of the posterior tibialis and peroneus brevis tendons no tendon tear no evidence of abnormal bone marrow signal intensity or intraosseous abscess rle angio mild but multifocal atherosclerotic disease involving the infrarenal aorta and iliac arteries with no significant pressure gradient associated significant segmental stenosis approx cm long in the mid right superficial femoral artery high bifurcation of the popliteal artery at the knee level in the proximal calf severe stenosis or occlusion of the two terminal branches arising from this popliteal bifurcation likely the anterior tibial and the peroneal arteries two significant focal stenoses of the distal right anterior tibial artery right posterior tibial artery completely occluded patent medial and lateral plantar arteries filled through collaterals arising mostly from the peroneal artery dorsalis pedis artery not seen brief hospital course mr was admitted to the tsicu he was placed on penicillin g clindamycin for empiric coverage of his wound with group a strep growth from the cultures he was transferred to the floor on hd he continued to undergo dressing changes plastic surgery was asked to evaluate the patient per their recommendations silvadine was applied to the tendons to prevent dessication vascular surgery was also asked to evaluate the patient s right lower extremity blood flow an angiogram on hd showed severe tibial disease and moderate sfa disease no dp artery was seen the vascular team recommended a femoral peroneal bypass for revascularization and performed this operation on hd he tolerated the procedure well please see dr operative note for detail on pod mr received units of prbcs for post op anemia hct mr continued to be followed by infectious disease whose recommendations were to complete a week course of penicillin g and clindamycin after the foot was completely debrided and the skin flaps completed his wound continued to heal well and by pod a vac dressing was placed he received a picc on pod for his long term antibiotic therapy at the time of discharge mr had good pain control was tolerating a regular diet had a well healing wound treated with a vac dressing and was to continue his iv pcn g and clindamycin he was discharged to a rehab facility in fair condition medications on admission timolol discharge disposition extended care facility healthcare discharge diagnosis right lower extremity necrosing fascitis history of prostate cancer s p turp glaucoma discharge condition fair discharge instructions if you have any fevers chills nausea vomiting chest pain foot pain please seek medical attention followup instructions please follow up with dr in one week call for an appointment follow up with dr in weeks call for an appointment,"{
""Diagnoses"": [""gout"", ""infection"", ""necrotizing fasciitis"", ""soft tissue loss""],
""Medications"": [""colchicine"", ""prednisone"", ""antibiotics""]
}"
98295,admission date discharge date date of birth sex f service plastic allergies patient recorded as having no known allergies to drugs attending chief complaint osteoarthritis left knee morbid obesity and scarred fibrosis of the skin late effect of motor vehicle accident left knee major surgical or invasive procedure excision of previous skin graft in preparation of recipient flap site left knee local flap mobilization left knee free vascularized right latissimus dorsi myocutaneous flap to anterior and lateral aspect of left knee application long leg splint primary plastic closure latissimus dorsi donor site greater than cm history of present illness ms is a year old lady with severe osteoarthritis she has had total knee replacement with an excellent result on the right side and wished very much to have one on the left side problem here was soft tissue within the past few years she was involved in a pedestrian motor vehicle accident and sustained a loss of tissue on the anterior and lateral aspect of her left leg this was treated initially with a skin graft i believe at the she has been evaluated by her joint surgeons who correctly noted that a total knee replacement on the left side would be perilous and indeedquite unsuccessful unless she had adequate soft tissue coverage past medical history lv hypertrophy diastolic dysfunction dyslipidemia htn obstructive sleep apnea h o nph s p vp shunt placement obesity s p gastric banding gerd osteoarthritis depression social history tobacco use in the past denies alcohol use family history non contributory physical exam pre procedure pe per anesthesia record wt lbs pulse min b p o sat general wd overweight mental psych a o airway as documented in detail on anesthesia record dental good head neck range of motion free range of motion no carotid bruits heart rrr lungs clear to auscultation abdomen soft obese nt extremities no ankle edema extensive scarring on left knee left pedal pulses non palp but present w doppler other neck supple no cerv lad pertinent results pm glucose urea n creat sodium potassium chloride total co anion gap pm estgfr using this pm calcium phosphate magnesium pm wbc rbc hgb hct mcv mch mchc rdw pm plt count brief hospital course the patient was admitted to the plastic surgery service on and had a right latissimus dorsi myocutaneous free flap to left knee the patient tolerated the procedure well immediately post operative she was admitted to the surgical intensive care unit for flap monitoring the patient did quite well on her first post operative day with good vioptix data and reassuring physical exam she was called out to the floor but had a beat run of non sustained vt in the icu she received magnesium sulfate and remained in a normal sinus rhythm after that she was kept in the icu an additional night and transferred to the floor on pod on postoperative day she was transitioned to oral pain medications she was slow to mobilize and her foley remained in place she worked with physical therapy to get up and out of bed she continued with pt throughout the remainder of her hospitalization her foley catheter was removed on pod prior to discharge she had a thermoplastic splint palced by ot to allow knee to stay in flexion at rest neuro post operatively the patient received dilaudid iv pca with good effect and adequate pain control when tolerating oral intake the patient was transitioned to oral pain medications cv the patient was stable from a cardiovascular standpoint vital signs were routinely monitored pulmonary the patient was stable from a pulmonary standpoint vital signs were routinely monitored gi gu post operatively the patient was given iv fluids until tolerating oral intake her diet was advanced when appropriate which was tolerated well she was also started on a bowel regimen to encourage bowel movement foley was removed on pod intake and output were closely monitored id post operatively the patient was started on iv cefazolin then switched to po cephalexin on pod the patient s temperature was closely watched for signs of infection prophylaxis the patient received subcutaneous lovenox during this stay and was encouraged to get out of bed with assistance as early as possible at the time of discharge on pod the patient was doing well afebrile with stable vital signs tolerating a regular diet ambulating voiding without assistance and pain was well controlled the patient is being discharged to a rehabilitation facility to continue her aggressive physical therapy medications on admission atenolol celexa ranitidine simvistatin valsartan discharge medications aspirin mg tablet chewable sig tablet chewables po daily daily for days acetaminophen mg tablet sig two tablet po q h every hours as needed for pain ha t degrees max mg day simvastatin mg tablet sig two tablet po daily daily citalopram mg tablet sig one tablet po daily daily atenolol mg tablet sig one tablet po daily daily hold if sbp hr valsartan mg tablet sig one tablet po daily daily hold if sbp oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for moderate to severe pain max day max mg tylenol day enoxaparin mg ml syringe sig one syringe subcutaneous q h every hours for days docusate sodium mg capsule sig one capsule po tid times a day famotidine mg tablet sig one tablet 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 magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed for constipation keflex mg capsule sig one capsule po every six hours for days needs keflex for as long as drains remain in discharge disposition extended care facility at discharge diagnosis osteoarthritis left knee morbid obesity scarred fibrosis of the skin late effect of motor vehicle accident left knee 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 followup instructions you should continue taking the antibiotics as prescribed elevate your left leg as much as possible and maintain it in a splint please keep your left leg dry if your left leg begins to worsen after discharge with an acute increase in swelling or pain please call dr office drains you have two drains to care for and to measure output from clean around the drain site s where the tubing exits the skin with hydrogen peroxide strip drain tubing empty bulb s and record output s times per day a written record of the daily output from each drain should be brought to every follow up appointment your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount you may shower daily no baths until instructed to do so by dr drain discharge instructions you are being discharged with drains in place drain care is a clean procedure wash your hands thoroughly with soap and warm water before performing drain care perform drainage care twice a day try to empty the drain at the same time each day pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup record the amount of drainage fluid on the record sheet reestablish drain suction medications resume your regular medications unless instructed otherwise you may take your prescribed pain medication for moderate to severe pain you may switch to tylenol or extra strength tylenol for mild pain as directed on the packaging please note that percocet and vicodin have tylenol as an active ingredient so do not take these meds with additional tylenol take prescription pain medications for pain not relieved by tylenol take colace mg by mouth times per day while taking the prescription pain medication to prevent constipation you may use a different over the counter stool softerner if you wish do not drive or operate heavy machinery while taking any narcotic pain medication you may have constipation when taking narcotic pain medications oxycodone percocet vicodin hydrocodone dilaudid etc you should continue drinking fluids you may take stool softeners and should eat foods that are high in fiber return to the er if if you are vomiting and cannot keep in fluids or your medications if you have shaking chills fever greater than f degrees or c degrees increased redness swelling or discharge from incision chest pain shortness of breath or anything else that is troubling you followup instructions please follow up with dr in week please call his office to schedule an appointment for a follow up visit md completed by,"{
""Diagnoses"": [""osteoarthritis"", ""morbid obesity"", ""scarred fibrosis of the skin"", ""late effect of motor vehicle accident""],
""Medications"": [""none known""]
}"
87239,admission date discharge date date of birth sex m service medicine allergies xray dye iv dye iodine containing contrast media attending chief complaint tremors and fever major surgical or invasive procedure none history of present illness mr is an year old man with a history of essential tremor s p placement of a dbs on he reports initially feeling well following the placement of the dbs however over the last days he has has some shortness of breath fatigue and worsening tremors he describes these tremors as like his essential tremor except much worse and all over his body he did not take his temperature he thought his new dbs was not working properly and called neurosurgery he went to hospital there a chest xray revealed bilateral infiltrates he received ceftriaxone and azithromycin and cc of ivf a head ct was performed which showed the dbs but no acute abnormality he was transferred to for further management in the ed initial vitals l he was initially tachypneic to the thirties he received vancomycin and acetaminophen for a temp of neurosurgery was made aware of his admission the osh films were uploaded vitals on transfer were l on arrival to the micu he appeared comfortable and was conversant he denies any episodes of shortness of breath or chest pain or cough he reports always having a headache since the surgery but no change denies neck stiffness sinus tenderness rhinorrhea or congestion denies nausea vomiting diarrhea constipation abdominal pain or changes in bowel habits denies dysuria frequency or urgency denies arthralgias or myalgias denies rashes or skin changes past medical history essential tremor s p mi with stent in tia hyperlipidemia atrial fibrillation gout hypothyroidism prostate cancer arthritis social history the patient was with his wife is retired but is an active writer he has published five to six novels he quit smoking more than years ago and he states that he does not drink alcohol family history nc physical exam on admission vitals l general alert oriented no acute distress heent sclera anicteric mmm oropharynx clear eomi perrl neck supple jvp not elevated no lad cv regular rate and rhythm normal s s no murmurs rubs gallops lungs clear to auscultation bilaterally no wheezes rales ronchi abdomen soft non tender non distended bowel sounds present no organomegaly ext warm well perfused pulses no clubbing cyanosis or edema neuro cnii xii intact strength upper lower extremities grossly normal sensation reflexes bilaterally gait deferred finger to nose intact on discharge vitals ra bm this am general alert oriented no acute distress heent sclera anicteric mmm oropharynx clear eomi perrl neck supple jvp not elevated no lad cv regular rate and rhythm normal s s no murmurs rubs gallops lungs clear to auscultation bilaterally no wheezes rales ronchi abdomen soft non tender non distended bowel sounds present no organomegaly gu no foley ext warm well perfused pulses no clubbing cyanosis or edema neuro cnii xii intact strength upper lower extremities grossly normal sensation reflexes bilaterally gait deferred finger to nose intact pertinent results labs on admission pm blood neuts lymphs monos eos baso 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 ck cpk pm blood ck mb pm blood ctropnt pm blood calcium phos mg pm blood lactate imaging studies ekg atrial fib compared to tracing of no change rate pr qrs qt qtc p qrs t cxr there is a generator device with a wire seen extending superiorly into the neck unchanged since the previous studies please correlate clinically the heart size is upper limits of normal and there is tortuosity of thoracic aorta there are hazy opacities in both lung fields right side worse than left this may represent infection or asymmetric pulmonary edema there is a small left sided pleural effusion cxr there is a left sided generator with lead tip extending into the neck please correlate clinically there is stable cardiac size without significant enlargement there are hazy densities in the lung fields bilaterally which have improved since the previous study there are no signs of overt pulmonary edema or pneumothoraces no pleural effusions are seen on either side lenis impression no bilateral lower extremity dvt ct head non contrast dbs electrode in the left subthalamic nucleus chronic paranasal sinus disease labs on discharge am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt brief hospital course this is the brief hospital course for an year old man with a recent dbs placement hospitalization who presented this admission with fever and worsening of his baseline essential tremor chest x ray was concerning for pneumonia and the patient was admitted to the icu the following active issues were addressed this admission fever chest x ray per osh read was consistent with a bilateral pneumonia portable chest xray in ed was suggestive of bibasilar consolidation more consistent with atelectasis than pneumonia given that the patient was recently admitted to the hospital he was initially empirically covered with vancomycin and zosyn for hap he looked well by the morning after admission and his coverage was narrowed to levofloxacin mg for a total day course day for cap essential tremor he is continued on his home meds with neurosurgery aware elevated inr inr was super therapuetic to on admission so coumadin was held until when mg was given just prior to discharge vna services will draw inrs on the patient at home starting and occuring every other day those results will be faxed to dr in cardiology at northshore who will adjust the warfarin dose as needed patient s dose of warfarin on admission was mg sun tues thurs and mg mon wed fri sat he is discharged today on mg qday decreased hematocrit there was a drop in baseline hct from noted on admission but there were no signs of bleeding while in house gout continued on home allopurinol cad continued on home aspirin statin and propanolol more for tremor than beta blockade hypothyroidism continued on home medication patient is discharged home with vna services for home physical therapy inr draws and medication management he has adequate follow up vitals stable patient agrees medications on admission allopurinol mg levothyroxine mcg primidone mg propanolol mg simvastatin mg baclofen mg prn daily for back spasms metronidazole on nose prn desonide on forehead prn fluorouracil topical prn on hands and arms vitamin d iu vitamin c mg coq mg b complex with vitamin c mg multivitamin magnesium mg calcium mg krill oil mg acetaminophen mg prn pain discharge medications ascorbic acid mg po bid aspirin mg po daily acetaminophen mg po q h prn pain allopurinol mg po daily baclofen mg po daily prn back spasms hold for sedation or rr calcium carbonate mg po bid levofloxacin mg po daily duration days rx levofloxacin mg daily disp tablet refills levothyroxine sodium mcg po daily primidone mg po bid in the morning and at noon propranolol mg po bid hold for sbp or hr simvastatin mg po daily vitamin d unit po daily warfarin mg po daily outpatient lab work vna services should draw inr on this patient every other day starting and send results to dr cardiology via fax icd magnesium oxide mg po bid co q nf coenzyme q br coenzyme q vitamin e mg oral daily nephrocaps cap po daily multivitamins tab po daily krill oil omega nf krill om dha epa om lip astx mg oral daily discharge disposition home with service facility discharge diagnosis primary pneumonia coagulopathy super therapeutic inr secondary essential tremor atrial fibrillation tia history hyperlipidemia hypothyroidism prostate cancer arthritis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you were admitted for fever and were found to have pneumonia you will receive days of an antibiotic to treatment this your tremor was slightly worse with this pneumonia but neurosurgery believes that your surgical site looks great and that the tremor will improve soon you were on warfarin for atrial fibrillation as an outpatient due to a high inr measurement here in the hospital your warfarin was temporarily held it was restarted on at mg daily this is not your prior dose as i am sure you are aware but you should stick to this new dose until your levels normalize the vna will draw your blood every other day and send the results of the inr to dr so that he can adjust the warfarin dose the following medication changes were made this admission start levofloxacin mg daily for total days take through change warfarin to mg daily until told otherwise by dr continue all other medications as prior we wish you a speedy recovery followup instructions name md specialty primary care location center address center dr phone when tuesday at am name dr specialty cardiology location cardiology phone when tuesday at am department neurology when tuesday at pm with md building campus east best parking garage department neurosurgery when monday at am with md building lm bldg campus west best parking garage completed by,"{
""Diagnoses"": [""Essential tremor"", ""Bilateral infiltrates"", ""Acute respiratory distress syndrome (ARDS)""],
""Medications"": [""Cefotaxime"", ""Azithromycin"", ""Vancomycin"", ""Acetaminophen""]
}"
32335,admission date discharge date date of birth sex m service neurology allergies pentasa mercaptopurine penicillins attending chief complaint change in mental status right sided weakness major surgical or invasive procedure left ica stenting followed by ia t pa and clot retrieval using the merci penumbra devices history of present illness mr is a yo male with a history of hypertension ulcerative colitis and mild depression who presents with decreased responsiveness and r hemiparesis consistent with l mca stroke the patient was last seen normal at am on the day of admission he was found by his wife at am on the day of admission on the floor laying on his side and incontinent of urine his wife reported that he was nonverbal but it was unclear if there was any focal weakness at this time per his wife week prior to admission he had an episode of left sided blurry vision ems was called and took him to ed and was intubated for altered mental status and given lidocaine etomidate succs versed vecuronium iv x and ativan gm iv x neuro exam at the osh am showed the patient was intubated squeezed left hand to command r cn vii paresis motor of left arm and leg r leg at the thigh but cannot elevate the right heel off the bed r arm movement planter reflex was down ct head at osh showed hyperdensity involving the left mca no evidence of ich and subtle hypodensity involving the left cerebral hemisphere consistent with infarction incidental note was also made of an mm hyperdense focus anterior to the sella which is suspicious for an aneurysm of the anterior communicating artery it was determined that he was not an iv tpa candidate because of likely seizure at the onset and he was transferred to patient arrived to the ed and code stroke was called at pm neurology was at the bedside within minutes nihss was for loc motor arm and leg aphasia examination was limited by medications and intubation ct head showed occlusion of left carotid and left mca at origin and hypodensity of left cerebral hemisphere ct perfusion showed decreased blood volume and increased mean transit time with mismatch between the images the family was contact and consented and the patient was taken to the angiography lab for ia tpa and merci cath penumbra past medical history hypertension ulcerative colitis mild depression prozac discontinued on erectile dysfuncion gerd bilateral trigger fingers s p release of trigger finger right long and ring digits excision of retinacular cyst right index finger and trigger release right index finger social history social history per records he is married he does not smoke cigarettes and rarely drinks alcohol the patient has had recent stressors in his life including some health problems of his wife and his son recently being diagnosed with chronic pancreatitis due to alcohol abuse family history family history per records positive for emphysema dementia and cva negative for inflammatory bowel disease or colon cancer physical exam nihss a loc arousable only to painful stimulation b loc questions intubated c commands intubated best gaze forced eye deviation visual field cannot perform do not score facial palsy normal motor arm on right no movement on left some antigravity effort but can t sustain motor leg on right no movement on left some antigravity effort but can t sustain limb ataxia x unable to assess sensory normal best language aphasia dysarthria x intubation extinction neglect x total vitals bp hr rr genl intubated does not open eyes to command neuro the patient is intubated and sedated so much of the exam was deferred no withdrawal to nasal tickle left arm and leg withdraw to nailbed pressure right arm and does not move to noxious stimulus right leg shows triple flexion to noxious stimulus eyes deviated to the left bilaterally plantar relflexes extensor 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 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 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 pm blood hct am blood hct 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 neuts bands lymphs monos eos baso pm blood hypochr normal anisocy normal poiklo macrocy normal microcy normal polychr tear dr pm blood pt ptt inr pt am blood plt ct am blood pt ptt inr pt am blood plt ct am blood plt ct am blood plt ct am blood plt ct am blood plt ct am blood plt ct am blood plt ct am blood plt ct am blood pt ptt inr pt am blood plt ct am blood plt ct am blood plt ct am blood plt ct am blood pt ptt inr pt pm blood plt ct pm blood pt ptt inr pt pm blood pt ptt inr pt pm blood plt smr low plt ct 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 k am blood glucose urean creat na k cl hco angap am blood glucose urean creat na k cl hco angap pm blood na k am blood glucose urean creat na k cl hco angap pm blood na pm blood na k am blood glucose urean creat na k cl hco angap pm blood na am blood glucose urean creat na k cl hco angap pm blood k pm 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 pm blood k pm blood k 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 ck cpk pm blood alt ast ck cpk alkphos totbili am blood ck mb ctropnt pm blood ck mb pm blood ctropnt pm blood albumin am blood calcium phos mg am blood calcium phos mg am blood calcium phos mg am blood calcium phos mg pm blood mg am blood calcium phos mg am blood calcium phos mg pm blood calcium phos mg am blood calcium phos mg pm blood calcium phos mg am blood calcium phos mg am blood calcium phos mg pm blood calcium mg am blood cholest am blood calcium phos mg pm blood calcium phos mg am blood calcium phos mg pm blood calcium mg pm blood calcium phos mg am blood calcium phos mg cholest pm blood calcium phos mg pm blood albumin calcium phos mg am blood hba c am blood hba c am blood triglyc hdl chol hd ldlcalc pm blood osmolal pm blood osmolal am blood osmolal pm blood osmolal am blood osmolal am blood osmolal pm blood osmolal am blood osmolal pm blood osmolal pm blood osmolal am blood osmolal pm blood osmolal am blood osmolal pm blood osmolal pm blood osmolal am blood osmolal am blood osmolal pm blood osmolal pm blood osmolal am blood osmolal pm blood osmolal am blood vanco am blood vanco pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg am 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 am 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 am 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 am blood type art po pco ph caltco base xs pm blood type art po pco ph caltco base xs pm blood type art po pco ph caltco base xs intubat intubated vent controlled pm blood glucose am blood glucose lactate pm blood glucose am blood k pm blood glucose lactate na k cl pm blood hgb calchct pm blood freeca pm blood freeca am blood freeca am blood freeca pm blood freeca am blood freeca pm blood freeca pm blood freeca brief hospital course course in the icu admitted to icu on staph coag treated with vanc did receive a couple of doses of zosyn open tracheostomy and percutaneous endoscopic gastrostomy surgeon for failure to wean poor nutritional status transferred out of the icu to the stroke floor physical and neurological exam remains unchanged pt able to follow some motor commands both midline and appendicular no verbal responses flaccid right ue and le plegia blinks to threat on l some r neglect bed available at hospital for acute rehab and pt transferred medications on admission lisinopril hctz mg mg tablet po qam omeprazole mg po daily sildenafil mg po prn sulfasalazine mg po qid folic acid mg po daily discharge medications artificial tear with lanolin ointment sig one appl ophthalmic prn as needed polyvinyl alcohol povidone dropperette sig drops ophthalmic prn as needed heparin porcine unit ml solution sig units injection tid times a day atorvastatin mg tablet sig one tablet po daily daily clopidogrel mg tablet sig one tablet po daily daily sulfasalazine mg tablet sig one tablet po qid times a day docusate sodium mg ml liquid sig five ml po bid times a day as needed acetaminophen mg ml solution sig five ml po q h every hours as needed for temp famotidine mg tablet sig one tablet po bid times a day chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane times a day lisinopril mg tablet sig one tablet po daily daily oxycodone acetaminophen mg ml solution sig mls po q h every hours as needed dextromethorphan guaifenesin mg ml syrup sig five ml po q h every hours as needed memantine mg tablet sig two tablet po qhs once a day at bedtime discharge disposition extended care facility discharge diagnosis l mca territory infarction discharge condition stable discharge instructions you have had a major stroke on the left side of your brain affecting your language and right sided motor strength in order to prevent future stroke it is important to modify your risk factors including keeping your blood pressure and blood lipids under control including continuing to take lipitor as well as continuing to take plavix which functions to prevent platelets from sticking together and will prevent your carotid stent from re occluding please return to the er if you expereince any sudden weakness headaches vertigo changes in vision senstion or communication non verbal speech followup instructions follow up with dr at provider m d phone date time md completed by [NEW_RECORD] name jr j unit no admission date discharge date date of birth sex m service neurology allergies pentasa mercaptopurine penicillins attending addendum mr had one black stool that was guaiac positive on several hematocrit measurements were stable over the course of the day he had another stool that on visual inspection and guaiac examination was negative for blood he was felt to be appropriate for discharge discharge disposition extended care facility md completed by,"{
""Diagnoses"": [""l mca stroke"", ""hypertension"", ""ulcerative colitis"", ""mild depression""],
""Medications"": [""pentasa"", ""mercaptopurine"", ""penicillins"", ""ia t pa"", ""clot retrieval using the merci penumbra devices""]
}"
40057,admission date discharge date date of birth sex m service surgery allergies keflex attending chief complaint left lower extremity ischemic pain major surgical or invasive procedure left lower extremity angiogram with bilateral common and external iliac arteries stents left common femoral to anterior tibial artery bypass with nonreversed saphenous vein and angioscopy aortogram left lower extremity runoff second order catheterization ultrasound guidance for femoral access history of present illness mr is a m s p right sfa to anterior tibial bypass with saphenous vein who presents with days of progressively worsening left leg pain no change in motor function on presentation he noted worsening discoloration of his distal left foot patient reports sensation is always diminished secondary to neuropathy he denies fevers or chills he was seen by his cardiologist who referred the patient to the ed past medical history diabetes mellitus type ii peripheral vascular disease hypertension hypercholesterolemia prior myocardial infarctions without intervention prior transient ischemic attacks history of alcohol abuse s p right lower extremity sfa to at bypass eith saphenous vein appendectomy laparoscopic cholecystectomy social history lives with wife h o alcohol abuse with withdrawal though reports no alcohol use in years h o tobacco abuse ppd x years though quit years ago denies ivdu family history non contribtary physical exam tmax hr bp rr o sat ra general middle aged male in nad a ox neuro cn ii xii intact lungs cta bilat no resp distress heart nl s s rrr no mrg abd bs x soft nt nd lle surgical wound staples cdi without erythema or drainage lle great toe with dry gangrene eschar extremities no clubbing cyanosis or edema doppler pulses dp pt bilat 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 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 hgb hct 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 pt ptt 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 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 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 ck cpk pm blood ck mb ctropnt pm blood culture final report blood culture routine final no growth pm blood culture final report blood culture routine final no growth right groin u s findings no abnormalities identified in the region of clinical concern in the right groin no fluid collection or evidence of pseudoaneurysm or fistula is seen the right common femoral artery displays normal waveform and compressibility a graft is partially imaged within the right groin impression no abnormality identified at the site of clinical concern no evidence of fluid collection av fistula or pseudoaneurysm formation cxr findings as compared to the previous radiograph there is no relevant change normal appearance of the lung parenchyma normal size of the cardiac silhouette normal hilar and mediastinal contours the previously placed central venous access line has been removed in the interval brief hospital course mr was admitted on with left lower extremity ischemic pain and left great toe ulcer he was started on a heparin drip and given pain medication for his ischemic pain iv antibiotics were initiated for groin cellulitis and continued throughout his admission a picc line was placed for antibiotics given poor peripheral access on mr was consented and taken to the endovascular suite for left lower extremity angiogram the angiogram showed severe calcification of the bilateral external and common iliac arteries complete occlusion of the left superficial femoral artery at its origin with reconstitution below the adductor hiatus from collaterals derived from the profunda femoris artery and complete obstruction of the posterior tibial artery at its origin bilateral common and external iliac arteries were stented at that time with a plan to return to the or to bypass the occluded vessels vein mapping was performed and he underwent evaluation by cardiology for surgical clearance he was given cardiac clearance by dr to proceed with bypass on the patient went to the or for left common femoral to anterior tibial artery bypass with nonreversed saphenous vein and angioscopy intra operatively he was closely monitored and remained hemodynamically stable he tolerated the procedure well without any difficulty or complication post operatively he was extubated and transferred to the pacu for further stabilization and monitoring he was then transferred to the vicu for further recovery while in the vicu he was monitored closely on pod he was delined his diet was advanced and heparin drip was turned off on pod foley was removed he voided and a pt consult was obtained on there was some concern for ischemia of the left great toe so he was taken back to the endovascular suite for repeat angiogram which showed patent bypass and runoff we continued to monitor his left great toe which improved in appearance over the next couple days he remained hemodynamically stable with his pain controlled he progressed with physical therapy to improve his strength and mobility pt recommended home with pt services on the day of discharge his picc line was removed and he was started on bactrim ds for weeks he continues to make steady progress without any incidents he was discharged to home with physical therapy in stable condition of note his creatinine was stable throughout his admission medications on admission aggrenox mg ativan qid metoprolol protonix simvastatin bactrim ds until trazadone qhs lantus humalog ss ativan qid prn anxiety discharge medications oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain take colace to prevent constipation while you are taking percocet for pain disp tablet s refills simvastatin mg tablet sig one tablet po once a day metoprolol tartrate mg tablet sig one tablet po bid times a day lorazepam mg tablet sig one tablet po qid times a day as needed for anxiety docusate sodium mg capsule sig one capsule po bid times a day bactrim ds mg tablet sig one tablet po twice a day for days days start date disp tablet s refills pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours aggrenox mg cap multiphasic release hr sig one cap multiphasic release hr po twice a day insulin glargine unit ml solution sig forty five units subcutaneous qam and qhs humalog unit ml solution sig one subcutaneous with meals resume home humalog sliding scale discharge disposition home with service facility vna discharge diagnosis left lower extremity ischemia peripheral vascular disease diabetes mellitus hypertension hypercholesterolemia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions division of vascular and endovascular surgery lower extremity bypass surgery discharge instructions what to expect when you go home it is normal to feel tired this will last for weeks you should get up out of bed every day and gradually increase your activity each day you may walk and you may go up and down stairs increase your activities as you can tolerate do not do too much right away it is normal to have swelling of the leg you were operated on elevate your leg above the level of your heart use pillows or a recliner every hours throughout the day and at night avoid prolonged periods of standing or sitting without your legs elevated it is normal to have a decreased appetite your appetite will return with time you will probably lose your taste for food and lose some weight eat small frequent meals it is important to eat nutritious food options high fiber lean meats vegetables fruits low fat low cholesterol to maintain your strength and assist in wound healing to avoid constipation eat a high fiber diet and use stool softener while taking pain medication what activities you can and cannot do no driving until post op visit and you are no longer taking pain medications you should get up every day get dressed and walk you should gradually increase your activity you may up and down stairs go outside and or ride in a car increase your activities as you can tolerate do not do too much right away no heavy lifting pushing or pulling greater than pounds until your post op visit you may shower unless you have stitches or foot incisions no direct spray on incision let the soapy water run over incision rinse and pat dry your incision may be left uncovered unless you have small amounts of drainage from the wound then place a dry dressing over the area that is draining as needed take all the medications you were taking before surgery unless otherwise directed what to report to office redness that extends away from your incision a sudden increase in pain that is not controlled with pain medication a sudden change in the ability to move or use your leg or the ability to feel your leg temperature greater than f for hours bleeding new or increased drainage from incision or white yellow or green drainage from incisions lower extremity angiogram discharge instructions medications continue all other medications you were taking before surgery unless otherwise directed you make take tylenol or prescribed pain medications for any post procedure pain or discomfort what to expect when you go home it is normal to have slight swelling of the legs elevate your leg above the level of your heart use pillows or a recliner every hours throughout the day and at night avoid prolonged periods of standing or sitting without your legs elevated it is normal to feel tired and have a decreased appetite your appetite will return with time drink plenty of fluids and eat small frequent meals it is important to eat nutritious food options high fiber lean meats vegetables fruits low fat low cholesterol to maintain your strength and assist in wound healing to avoid constipation eat a high fiber diet and use stool softener while taking pain medication what activities you can and cannot do when you go home you may walk and go up and down stairs you may shower let the soapy water run over groin incision rinse and pat dry your incision may be left uncovered unless you have small amounts of drainage from the wound then place a dry dressing or band aid over the area that is draining as needed no heavy lifting pushing or pulling greater than lbs for week to allow groin puncture to heal after week you may resume sexual activity after week gradually increase your activities and distance walked as you can tolerate no driving until you are no longer taking pain medications what to report to office numbness coldness or pain in lower extremities temperature greater than f for hours new or increased drainage from incision or white yellow or green drainage from incisions bleeding from groin puncture site sudden severe bleeding or swelling groin puncture site lie down keep leg straight and have someone apply firm pressure to area for minutes if bleeding stops call vascular office if bleeding does not stop call for transfer to closest emergency room followup instructions dr cardiology janurary am provider md phone date time completed by [NEW_RECORD] admission date discharge date date of birth sex m service cardiothoracic allergies keflex attending chief complaint chest pain major surgical or invasive procedure emergent coronary artery bypass grafting x on an intra aortic balloon pump with left internal mammary artery to left anterior descending coronary reverse saphenous vein single graft from aorta to ramus intermedius coronary artery reverse saphenous vein single graft from aorta to first obtuse marginal coronary artery history of present illness yo m with dmii htn hld pvd s p fem bypass on the left and iliac stent on the right h o mi without intervention presented to the ed at found to be in dka with glucose in the s per report patient with gradual onset weakness nausea loose stool excessive thirst due to decreased po intake patient omitted several days of insulin therapy progressive symptoms prompted presentation to osh ed found to have a ph and admitted to icu for treatment of dka in the icu patient placed on an insulin gtt overnight and covered empirically with broad spectrum antibiotics vancomycin and flagyl in the am gap had resolved and ph normalized and transitioned to sq lantus antibiotics were stopped as clinical suspicion for infection low later in morning he was noted to develop increased agitation ekg showed st depression v v patient started on arixtra for anticoagulation as unable to start heparin secondary to allergy though pt received hep sq during osh stay without problem and patient refused cxr obtained which was consistent with volume overload he was urgently taken to cath lab per report he was intubated for respiratory stabilization pre procedure but had never been hypoxic in cath lab he was noted to have severe distal left main disease with diffused lad disease rca noted to be chronically occluded there are collateral artery l r and r r pcwp of ef of iabp was placed through right femoral artery and vein in the cath lab he was given mg of iv lasix of dobutamine and of levophed and agumented bp to s of note his prior unaugmented sbp was systolic per med flight patient with uneventful transport he is sedated versed and paralyzed vecuronium on arrival to the ccu patient sbp is augmented with levophed cardiac surgery consulted for coronary revascularization past medical history diabetes mellitus type ii peripheral vascular disease hypertension hypercholesterolemia prior myocardial infarctions without intervention prior transient ischemic attacks history of alcohol abuse s p right lower extremity sfa to at bypass eith saphenous vein appendectomy laparoscopic cholecystectomy social history lives with wife h o alcohol abuse with withdrawal though reports no alcohol use in years h o tobacco abuse ppd x years though quit years ago denies ivdu family history no family history of early mi arrhythmia cardiomyopathies or sudden cardiac death otherwise non contributory physical exam on admission general intubated sedated paralyzed nad heent ncat sclera anicteric perrl eomi conjunctiva were pink ot tube in place with yellow secretions no xanthalesma neck supple cardiac pmi located in th intercostal space midclavicular line rr normal s s sem heard throughout precordium no thrills lifts no s or s no peripheral edema lungs no chest wall deformities scoliosis or kyphosis anterior fields with anterior rhonchi no audible crackles abdomen soft ntnd no hsm or tenderness abd aorta not enlarged by palpation no abdominial bruits extremities cool missing right toes right femoral line in place no groin hematomas skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid femoral dp pt left carotid femoral dopplerable dp dopplerable pt t l d et in place foley iabp in right femoral artery and vein right and left radial artery line on discharge 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 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 glucose urean creat na k cl hco angap am blood urean creat na k cl biomarker trend am blood ck mb mb indx ctropnt am blood ck mb mb indx 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 mb indx ctropnt am blood hba c eag imaging osh cardiac cath lm lad lcx luminal irregularities rca right heart cath ra rv pa pcwp cardiac output l min cardiac index l min m ef no significant mr cxr portable chest findings radiodense tip of an intraaortic balloon pump is at the expected junction of the superior aspect of the aortic knob and left subclavian artery as communicated by telephone to dr on at a m endotracheal tube and nasogastric tube are in standard position heart size is normal bilateral interstitial pulmonary edema is present as well as an asymmetrical left perihilar alveolar process likely reflecting asymmetrical edema tte the left atrium is normal in size 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 severe global left ventricular hypokinesis lvef no masses or thrombi are seen in the left ventricle there is no ventricular septal defect there is no aortic valve stenosis no aortic regurgitation is seen trivial mitral regurgitation is seen the pulmonary artery systolic pressure could not be determined there is no pericardial effusion 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 m indication intraoperative tee for cabg procedure chest pain coronary artery disease left ventricular function preoperative assessment right ventricular function icd codes test information date time at interpret md md test type tee complete son md doppler limited doppler and color doppler test location anesthesia west or cardiac contrast none tech quality adequate tape aw machine u s echocardiographic measurements results measurements normal range left ventricle ejection fraction aorta ascending cm cm findings 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 severe regional lv systolic dysfunction right ventricle normal rv chamber size and free wall motion aorta normal aortic diameter at the sinus level normal ascending aorta diameter normal descending aorta diameter aortic valve normal aortic valve leaflets no as no ar mitral valve mild mr tricuspid valve mild tr 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 no tee related complications the patient appears to be in sinus rhythm results were personally reviewed with the md caring for the patient left pleural effusion regional left ventricular wall motion n normal h hypokinetic a akinetic d dyskinetic conclusions prebypass no atrial septal defect is seen by d or color doppler there is severe regional left ventricular systolic dysfunction with akinesia of the apex and apical portion of the inferior wall there is also hypokinesia of the apical and mid portions of the anterior anteroseptal and inferospetal walls right ventricular chamber size and free wall motion are normal the aortic valve leaflets appear structurally normal with good leaflet excursion there is no aortic valve stenosis no aortic regurgitation is seen mild mitral regurgitation is seen tip of iabp in good position dr was notified in person of the results on at pm post bypass patient is av paced and receiving an infusion of phenylephrine milrinone and epinephrine lvef aorta is intact post decannulation mild mitral regurgitation present i certify that i was present for this procedure in compliance with hcfa regulations electronically signed by md interpreting physician caregroup is all rights reserved brief hospital course year old male with dmii hypertension hyperlipidemia peripheral vascular disease question history of myocardial infarction without intervention initially treated for diabetic keto acidosis but found to have worsening signs of congestive heart failure ekg changes cardiac enzymes ejection fraction of intubated iabp in place and on pressors for treatment of cardiogenic shock transferred via med flight from outside hospital his hospital course was complicated by multiple episodes of vf arrest on he was taken to the operating room and underwent emergent coronary artery bypass grafting x on an intra aortic balloon pump with left internal mammary artery to left anterior descending coronary reverse saphenous vein single graft from aorta to ramus intermedius coronary artery reverse saphenous vein single graft from aorta to first obtuse marginal coronary artery with dr cardiopulmonary bypass time minutes cross clamp time minutes please see operative report for further surgical details he was transferred to the cvicu intubated sedated on pressors he remained intubated on pressors until when he was weaned off and was successfully extubated events he was hypotensive requiring pressors and decreasing renal function an echocargiogram was done and revealed a large pericardial effusion with right ventricular diastolic collapse he was taken to the operating room for subxiphoid pericardial window respiratory aggressive pulmonary toilet chest pt nebs his oxygen requirement improved to lpm via nasal cannula chest tubes were all removed per protocol cardiac intermittent atrial fibrillation amiodarone bolus and drip with low dose beta blocker he converted to sinus rhythm gi aggressive bowel regimen and ppi were continued nutrition he was seen by speech and swallow on who recommended regular diet thin liquid medications whole with water his po intake was poor on he was seen again by speech who recommended a regular diet thin liquid and medications whole pills nutrition recommended cardiac diabetic sugar free carnation instant breakfast his po intake continued to be poor therefore a doboff feeding tube was placed and tube feeds were started nutrition recommended boost glucose control ml x hrs to supplement his po intake id on he was seen by infectious disease for low grade fevers positive bc for strept viridans catheter tip with albicans he completed a week course of vancomycin and fluconazole per id recommendations renal renal function baseline creatnine on his creatnine increased to peak secondary to large pericardial effusion which once treated his renal function returned to his baseline he was gently diuresed his electrolytes were repleted as needed required foley re insertion for urinary retention flomax was started and he was discharged to rehab with his foley he will have a void trial on following a week of flomax therapy endocrine insulin drip was titrated to maintain blood sugars converted to lantus with sliding scale regular once transfer to floor neuro flat affect follows commands pain well controlled with po pain medications disposition he was seen by physical therapy requires max assist for ambulation and lift device on pod he was discharged to rehab hospital in all follow up appointments were advised medications on admission aggrenox cap trazadone mg qhs lorazepam mg q h pantoprazole mg q h metoprolol mg simvastatin mg qd lantus u breakfast bedtime riss discharge medications tamsulosin mg capsule ext release hr sig one capsule ext release hr po hs at bedtime enoxaparin mg ml syringe sig one subcutaneous q h every hours quetiapine mg tablet sig one tablet po bid times a day trazodone mg tablet sig one tablet po hs at bedtime as needed for insomnia amiodarone mg tablet sig two tablet po daily daily mg daily x week then mg daily until further instructed atorvastatin mg tablet sig one tablet po hs at bedtime pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily docusate sodium mg capsule sig one capsule po bid times a day magnesium hydroxide mg ml suspension sig thirty ml po hs at bedtime as needed for constipation oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain bisacodyl mg suppository sig one suppository rectal daily daily as needed for constipation nystatin unit ml suspension sig five ml po qid times a day nystatin unit g cream sig one appl topical times a day as needed for groin yeast indomethacin mg capsule sig one capsule po tid times a day colchicine mg tablet sig one tablet po daily daily carvedilol mg tablet sig one tablet po bid times a day insulin glargine unit ml solution sig twenty subcutaneous at bedtime units at bedtime insulin regular human unit ml solution sig one injection four times a day per attached regular insulin sliding scale furosemide mg tablet sig one tablet po once a day for weeks potassium chloride meq tablet extended release sig two tablet extended release po once a day for weeks acetaminophen mg tablet sig two tablet po q h every hours as needed for pain fever discharge disposition extended care facility hospital discharge diagnosis severe vessel coronary artery disease acute myocardial infarction cardiogenic shock malignant ventricular arrhythmias severe peripheral vascular disease status post bilateral femoral artery to dorsalis pedal bypasses acute respiratory failure requiring intubation history of esophageal varices previous alcoholic previous tobacco user discharge condition alert and oriented x nonfocal deconditioned incisional pain managed with oral analgesia 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 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 provider md phone date time in the provider vascular lab phone date time provider md phone date time please schedule the following appointments on discharge from rehab cardiology dr pcp m completed by,"{
""Diagnoses"": [""Ischemic pain"", ""Left lower extremity ischemic pain"", ""Neuropathy"", ""Peripheral vascular disease"", ""Hypertension"", ""Hypercholesterolemia"", ""Prior myocardial infarctions without intervention"", ""Prior transient ischemic attacks""],
""Medications"": [""Keflex""]
}"
10101,admission date discharge date date of birth sex m service medicine allergies morphine vicodin attending chief complaint fatigue and weakness major surgical or invasive procedure none history of present illness y o male with pmhx of nsclc pe who presented to the ed on with generally increasing fatigue and tachypnea in the ed he underwent cta chest and abdomen which no pe but marked progression of metastatic disease including innumerable new metastases in the lungs and liver and increased size of metastases in the adrenals kidneys mesentary soft tissues he had negative ct head and ekg his hematocrit was from baseline around and inr was on admission he received ffp unit prbc and a dose of cefepime vanc due to slightly low blood pressure the patient was also given steroids and l ns and admitted to the in the icu his hct improved and bp remained stable in the s and hr in the s egd or further gi workup was refused oncology came to meet with the patient and his family and decided that focusing goals of care on comfort was most appropriate he was made dnr dni but medications were continued and he was admitted to omed ros he denies chest pain shortness of breath he does feel somewhat fatigued he reports some right flank back pain before receiving iv dialudid he denies other concerns onc history initially found to have a large right sided mass on cxr in performed for month history of cough ct scan confirmed the mass and biopsy of nodes were suspicious but fna of the primary mass showed likely nsclc pet showed abnormality on the right thyroid he started radiation therapy in and started cycle of cisplatin etoposide in and cycle in he completed xrt he was hospitalized for chest pain and found to have a pe in and started on coumadin pet scan in demonstrated metastatic disease to the adrenals so he was changed to taxotere therapy in which he tolerated reasonably well past medical history pmh nsclc former smoker originally presented to pcp with cough x mo cxr with lg r lung mass ct showed right upper lobe posterior segment mass abutting the chest wall but not invading with an enlarged upper r paratracheal node and lower r paratracheal node s p tbna of mediastinal lad showing highly atypical cells suggestive of nsclc and ct guided biopsy of the lung mass confirming nsclc mri brain negative for met s p cycles of cisplatinum etoposide xrt completed had pet scan htn per son used to be on meds but has been normotensive hypercholesterolemia lbp social history sh born in lives in montreal canadian citizen children who live in the area retired owner of a restaurant primarily speaks greek speaks little english remote tobacco pk yr quit at age extensive passive exposure at the restaurant no asbestos exposure family history fh no history of malignancy physical exam v bp hr r sat l ra gen yo m sitting in a chair nad comfortable heent at nc eomi perrla anicteric mmm neck supple no jvd lungs decreased bs at l base o w ctab no w r r abd soft obese nd nt bs ext trace to pretibial edema wwp good pulses neuro a ox mild intention tremor cn ii xii in tact pertinent results am pt ptt inr pt am wbc rbc hgb hct mcv mch mchc rdw am neuts bands lymphs monos eos basos atyps metas myelos am lactate pm ck mb notdone ctropnt pm glucose urea n creat sodium potassium chloride total co anion gap pm urine osmolal brief hospital course y o m with pmhx of ncslc who presents with increased weakness and fatigue with progressive lung cancer the patient had a brief stay in the and was transferred to the floor after the goals of care were transitioned to a goal for a move to hospice he arrived on the floor on vitals were stable overnight the patient had increased work of breathing and became diaphoretic and tachycardic and with the family and attending s involvement the goal of care became comfort measures only the patient passed away at am on medications on admission home meds pantoprazole docusate sodium mg po bid senna mg po bid acetaminophen mg hydromorphone mg prn q fentanyl mcg hr patch hr coumadin mg mg alternate days qhs florinef decadron qd meds on transfer hydromorphone dilaudid mg po q h prn dexamethasone mg po daily docusate sodium mg po bid pantoprazole mg po q h fentanyl patch mcg hr tp q h senna tab po bid prn fludrocortisone acetate mg po daily discharge medications none discharge disposition expired discharge diagnosis non small cell lung cancer discharge condition expired discharge instructions n a followup instructions n a md,"{
""Diagnoses"": [""NSCLC"", ""Metastatic disease""],
""Medications"": [""Morphine"", ""Vicodin"", ""FFP"", ""PRBC"", ""Cefepime"", ""Steroids"", ""LNS""]
}"
27558,admission date discharge date date of birth sex m service cardiac surgery history of present illness the patient is an year old man with a long history of coronary artery disease who for the past several weeks has experienced increasing chest pain which in retrospect was angina and has taken increased nitroglycerine he was taking care of his ill wife and therefore did not want to come to the hospital the patient has a history of chronic obstructive pulmonary disease peripheral vascular disease and shortness of breath he presented to the hospital and was felt initially to have pneumonia he was admitted to the medical intensive care unit however review of the ekg showed severe ekg changes he was taken for emergent catheterization that showed left main ostial lad stenosis circumflex disease and moderate right coronary artery disease the patient was hypotensive and hemodynamically unstable surgery was consulted because the patient developed cardiogenic shock acidosis and hypotension and intraaortic balloon pump was placed which stabilized his hemodynamics although he continued to be somewhat hypotensive and acidotic on physical examination his bp was on the intraaortic ballon pump with elevated filling pressures hr was bpm he was not intubated lung exam showed bilateral rales abdomen was soft and nontender cardiac exam showed distant heart sounds the patient had non papable distal extremity pulses suggesting peripheral vascular disease neurologic exam was grossly normal he was taken for emergency bypass surgery where coronary artery bypass grafting x was performed the conduits were extremely poor the lima was placed to the om veins were placed to the lad and rca ejection fraction initially was with pulmonary hypertension and mitral regurgitation his mixed venous oxygen saturation was approximately suggesting poor peripheral perfusion and shock his filling pressures were elevated with a cvp of about mmhg he has rather severe pulmonary hypertension prior to surgery mmhg after surgery initially he did feel well with moderate inotropic support and intraaortic balloon pump support however his condition gradually and progressively deteriorated he developed severe episode of ventricular tachycardia prior to chest closure his chest was reopened but his hemodynamics did not significantly change the sternum was left open but the skin was closed his poor hemodynamic condition was felt most likely to be due to poor underlying cardiac function poor bypass targets and poor vein conduit his acidosis may be in part been due to the iabp and peripheral vascular disease he was transported to the cardiac surgical recovery unit he continues to have low cardiac output syndrome and acidosis despite maximal inotropic support and intraaortic balloon pump support consideration for left ventricular assist device was given however because of his advanced age and poor chances for recovery this was not placed the situation was discussed with the family the patient s family were at his bedside when he died final diagnosis acute myocardial infarction cardiogenic shock treated with iabp and emergency cabg x congestive heart failure pulmonary edema mild renal insufficiency peripheral vascular disease moderate chronic obstructive pulmonary disease status post coronary artery bypass grafting death following emergent cabg dictated by medquist d t job,"{
""Diagnoses"": [""cardiac surgery"", ""coronary artery disease"", ""angina"", ""pneumonia"", ""chronic obstructive pulmonary disease"", ""peripheral vascular disease"", ""shortness of breath""],
""Medications"": [""nitroglycerine""]
}"
8008,admission date discharge date date of birth sex f service history of present illness this is a year old white female with a history of presenting with seizures in the fall of which led to a workup and an mri which showed an avm of the right temporal region she was admitted at that time for diagnostic angiogram which confirmed the presence readmitted now for further angiographic embolization treatment of the avm past medical history otherwise unremarkable medications paxil and prilosec social history she is a nonsmoker with a positive alcohol intake history physical examination she was in general a well developed well nourished white female in no acute distress with the entire general physical examination including head eyes ears nose throat heart lungs and abdomen are essentially unremarkable neurological examination showed speech to be fluent she was awake alert and oriented times three face was symmetric visual fields were full to confrontation and she moved all extremities without any evidence of weakness cerebellar examination showed finger to nose to be equal bilaterally and there was no dysmetria and the remainder of the neurological examination was unremarkable hospital course due to the clinical and previous angiographic and mri findings the patient was taken to the angiography suite on the day of admission where under local anesthetic the patient underwent a repeat diagnostic cerebral angiogram as well as a coiling of the cerebral avm of the right temporal region the patient tolerated the procedure well and went to the neurosurgical intensive care unit post procedure for recovery her post procedure hospitalization course was essentially unremarkable she was subsequently discharged home on the with follow up to see dr in the clinic m d dictated by medquist d t job,"{
""Diagnoses"": [""AVM of the right temporal region""],
""Medications"": [""Paxil"", ""Prilosec""]
}"
29299,admission date discharge date date of birth sex m service medicine allergies ceftriaxone attending chief complaint somnolence and fevers major surgical or invasive procedure picc line placement x ng tube placement intestinal tube placement lumbar puncture mechanical ventilation history of present illness mr is a m with a pmh s f morbid obesity type ii dm and osa who presented to hospital with altered mental status after being found by a family member according to the patient s daughter who lives with him he was in his usoh until the night prior to admission to on on he slept in unusually late into the afternoon his daughter finally went into his bedroom to wake him up and reports that patient was too lethargic to arouse completely he would intermittently wake up and speak in meaningful sentances other times he would be non sensical and drift off into sleep she also reports he seemed to have weakness on his left lower extremity and complained of back and left leg pain at he was found to be febrile to hyperglycemic with a fingerstick of hypertensive in the range and somnolent he was treated with units of insulin but did not have an anion gap he reportedly did not respond to narcan a foley was placed and drained cc of urine his o saturations dropped to on ra requiring nrb a head ct showed no evidence of gross ich hypodensities are noted in the bilateral thalami which may represent infarcts of indeterminate age recommend correlation with mri a cxr was negative for any acute pulmonary pathology a d dimer waws elevated to abg on arrival to our ed his inital vital signs were axillary nrb his fingerstick was in the s with no anion gap on his electrolytes his mental status was severely declined he was minimally responsive to painful stimuli and had a reduced gag reflex the ed called anesthesiology who placed a nasotracheal airway a serum tox screen was negative an ekg was wnl as were cardiac enzymes an infectious work up was started including a cxr ua lumbar puncture urine and blood cultures lumbar puncture showed no leukocytes and a mildly elevated protein he had a ct torso with contrast which preliminarily is negative for pe and shows some pelvic lymphadenopathywith asymmetric sclerosis of the sacroiliac joints the patient was empirically started on vancomycin and ceftriaxone for meningitis coverage past medical history type ii dm osa not on cpap fluid overload social history works in real estate and owns several small businesses remote smoking history quit years ago no alcohol or drug use family history no sudden cardiac death mother with a cardiomyopathy and chf physical exam t bp hr rr o on psv pulling tv of fio general morbidly obese intubated sedated heent normocephalic atraumatic no conjunctival pallor no scleral icterus pupils miotic and sluggish bilaterally cardiac regular rhythm normal rate no murmurs or gallops lungs coars ventilated breath sounds anteriorly abdomen obese nabs nt nd extremities bilateral pitting edema to the knees good pulses x skin no rashes lesions ecchymoses neuro pupils sluggish bilaterally and miotic doll s eye equivocal corneal reflexes intact babinski s down going bilaterally responds to noxious stimuli in all four extremities with purposeful movement pertinent results admission labs pm hba c am type art temp po pco ph total co base xs intubated intubated am lactate am voidspec qns am comments green top am lactate am cerebrospinal fluid csf protein glucose am cerebrospinal fluid csf wbc rbc polys lymphs monos am cerebrospinal fluid csf wbc rbc polys lymphs monos am glucose urea n creat sodium potassium chloride total co anion gap am estgfr using this am alt sgpt ast sgot ck cpk alk phos tot bili am lipase am ctropnt am ck mb am albumin calcium phosphate magnesium am tsh am digoxin theophyl am phenobarb phenytoin lithium valproate am asa neg ethanol neg carbamzpn acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg am urine hours random am urine bnzodzpn neg barbitrt neg opiates neg cocaine neg amphetmn neg mthdone neg am wbc rbc hgb hct mcv mch mchc rdw am neuts lymphs monos eos basos am plt count am pt ptt inr pt am urine color yellow appear clear sp am urine blood lg nitrite neg protein neg glucose ketone bilirubin neg urobilngn neg ph leuk neg am urine rbc wbc bacteria mod yeast none epi pertinent 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 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 am blood neuts lymphs monos eos baso am blood pt ptt inr pt am blood pt ptt inr pt am blood esr am blood esr am blood ret aut 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 alt ast ld ldh alkphos totbili pm blood ck cpk am blood ck cpk am blood alt ast alkphos amylase totbili am blood lipase am blood ck mb ctropnt pm blood ck mb ctropnt am blood ck mb ctropnt am blood calcium phos mg am blood calcium phos mg am blood calcium phos mg am blood triglyc hdl chol hd ldlcalc am blood crp am blood crp am blood crp am blood psa am blood vanco am blood vanco am blood vanco am blood digoxin theophy am blood phenoba phenyto lithium valproa am blood asa neg ethanol neg carbamz acetmnp neg bnzodzp neg barbitr neg tricycl neg pm blood type 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 am blood type po pco ph caltco base xs am blood type mix temp po pco ph caltco base xs comment green top pm blood type temp o flow po pco ph caltco base xs intubat not intuba comment nasal am blood type art temp po pco ph caltco base xs intubat not intuba am blood lactate am blood lactate am blood k u a on color yellow clear specgr ph urobil neg bili neg leuk neg bld lg nitr neg prot neg glu ket rbc wbc bact mod yeast none epi osh pertinent imaging ct head osh no evidence of gross ich hypodensities are noted in the bilateral thalami which may represent infarcts of indeterminate age recommend correlation with mri ct torso osh no dissection no central or segmental pe limited by patient size bibasilar consolidations atelectasis vs aspiration vs pna fatty liver asymmetric sclerosis of the sacroiliac joints with multiple enlarged pelvic lymph nodes septic arthritis of sacroiliac joint recommend pertinent imaging mri eeg impression this is an abnormal routine eeg due to slow background activity this finding suggests either a moderate encephalopathy or severe drowsiness medications metabolic disturbances infection and hypoxia are among the most common causes there were no areas of prominent focal slowing and there were no epileptiform features seen ct chest abd pelvis impression bibasilar pulmoanry infiltrates most likely secondary due to aspiration left sacroileiitis head mri mra mrv there are bilateral acute thalamic infarcts left greater than right the left sided infarct extends into the superior mid brain cerebral peduncle and midbrain tegmentum there are no imaging findings of herpes simplex encephalitis there is no pathologic intracranial enhancement scattered ethmoid opacification is noted bilaterally there is also scattered fluid in the right mastoid air cells mrv of the brain demonstrates no evidence of venous sinus thrombosis mra of the brain demonstrates a pica termination of the right distal vertebral artery basilar artery appears to be patent the left pca appears to be supplied via the left pcom in a fetal distribution the left pca appears to be slightly smaller compared to the right but no evidence for acute occlusive lesion is seen a cta can be performed for further evaluation if clinically indicated there is no pathologic intracranial enhancement impression acute bilateral thalamic and left midbrain infarct no significant lesions seen in the remaining brain bilateral lenis there is a normal d grayscale and color doppler appearance of bilateral lower extremity veins including the common femoral superficial femoral and popliteal veins no dvt within either lower extremity tte the left atrium is mildly dilated there is moderate symmetric left ventricular hypertrophy the left ventricular cavity size is normal due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded right ventricular chamber size and free wall motion are normal the aortic root is mildly dilated at the sinus level 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 no vegetation seen cannot definitively exclude neck mri mra the study is moderately motion degraded the origin of the right vertebral artery is not well visualized within limits of the exam no hemodynamically significant stenosis is seen the right vertebral artery is hypoplastic and appears to terminate as the pica the carotid arteries demonstrate no hemodynamically significant stenosis impression technically limited study no definite evidence for high grade stenosis no evidence for dissection pelvic mri mra findings there are prominent signal abnormalities consisting of hypointensity on all sequences involving the anterior inferior si joints bilaterally left greater than right with the sacral aspect appearing more involved than the iliac aspect there is very faint edema involving the more superior aspects and probable faint enhancement though no pre contrast or subtraction sequences are available to confirm ct demonstrates the low intensity areas to correspond to areas of sclerosis there are no definite erosions or joint effusions small osteophytes are noted there are no adjacent focal fluid collections about the si joints or involving the imaged psoas musculature however there is edema involving the left paraspinous musculature only partially imaged at the most superior aspect of the study of uncertain clinical significance prominent subcutaneous edema at this level is also noted several borderline enlarged iliac chain and obturator internus lymph nodes are seen on the left no other focal area of marrow edema no fractures impression bilateral sacroiliitis consisting primarily of sclerosis with faint edema and enhancement about the superior aspect and small osteophytes no erosions or effusions given these findings a degenerative process with altered biomechanics is favored over an inflammatory etiology though correlate with clinical presentation and lab values ill defined edema involving the left paraspinal musculature incompletely imaged on this study of unclear etiology and clinical significance left iliac chain and obturator internus lymphadenopathy tee the left atrium and right atrium are normal in cavity size no spontaneous echo contrast or thrombus is seen in the body of the left atrium left atrial appendage or the body of the right atrium right atrial appendage the interatrial septum is mildly dynamic with color flow evidence of right to left flow with deep inspiration snoring across the area of a secundum asd pfo left ventricular wall thicknesses and cavity size are normal overall left ventricular systolic function is normal lvef the ascending transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to cm from the incisors 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 evidence of any mass or thrombus on the mitral or aortic vavlve the tricuspid valve appears structurally normal with trace trivial regurgitation there is no pericardial effusion impression a small secundum asd with a right to left shunt during deep inspiration snoring no evidence of thrombus or valvular endocarditis right upper extremity venous ultrasound the examination is somewhat limited due to patient body habitus scale color and doppler images of the right internal jugular subclavian axillary brachial basilic and cephalic veins show normal flow compressibility augmentation and waveforms no intraluminal thrombus is identified impression limited examination no deep venous thrombosis identified in right upper extremity intestinal tube placement procedure the right nostril was anesthetized with lidocaine jelly and the throat with hurricane spray an french feeding tube was introduced using fluoroscopic guidance and passed beyond the pylorus and beyond the ligament of treitz an injection of conray confirms the tip placement in the proximal jejunum the patient tolerated the procedure well and there were no immediate complications impression successful placement of french feeding tube into the proximal jejunum bedside swallow evaluations mr appeared with s sx of aspiration on thin liquids as evidenced by throat clearing and delayed cough he appeared with some difficulty with ground solid trial possibly signs and sensation of pharyngeal residue suggest patient begin a po diet of nectar thick liquids and puree consistencies at this time recommend supervision to assist with feeding and monitor swallow safety suggest keeping dobhoff in place as patient begins po to ensure toleration of diet and adequate intake we will continue to follow to see how he is tolerating and if his diet may safely be advanced early next week i do feel he will continue to improve as his overall medical status and alertness continues to improve this swallowing pattern correlates to a dysphagia outcome severity scale doss rating of level moderate dysphagia recommendations continue use of tube feeds as primary means of nutrition and hydration at this time initiate po intake of nectar thick liquids and puree consistencies pills may be crushed with puree or via tube feeds supervision with po alternate bites and sips patient seated upright as much as possible we will continue to follow to see how he is tolerating and if his diet may safely be advanced early next week repeat bedside swallw evaluation history returned today to re evaluate this y o male with h o morbid obesity dm ii osa who initially presented to osh after being found by family member with altered mental status lethargy fever lower extremity weakness and c o back and leg pain at osh patient was found to be hyperglycemic and hypertensive requiring a nrb patient was transferred to on for further management upon arrival to ed patient was noted with worsening mental status and was subsequently intubated nasotracheally further w u revealed acute thalamic stroke bilateral and right pontine infarct resulting in right sided hemiparesis patient being treated for aspiration pna patient was extubated and we were consulted to evaluate patient s oral and pharyngeal swallowing function and r o aspiration while eating and drinking we attempted to see him on however patient was significantly lethargic and unarousable we returned today to reattempt the bedside swallow evaluation on he passed his bedside swallowing evaluation for nectar thick liquids and pureed solids he was seen on and recommended for diet upgrade to thin liquids and continued puree consistencies we returned and the pt had overt coughing with thin liquids and was downgraded to nectar thick liquids and pureed solids he continued to require tube feeds via the dobbhoff as he was too lethargic to take in enough po we returned today to repeat the evaluation and rn reported he had been fully awake all day taking in a good amount po without signs of aspiration evaluation the examination was performed while the patient was seated upright in the chair on cc cognition language speech voice pt was awake alert and oriented x able to stay awake throughout the evaluation language was fluent but speech was mildly dysarthric he was able to follow all commands today but with occasional slow response time teeth wfl secretions wfl in the oral cavity oral motor exam mild right sided weakness and facial droop with reduced rom on the right lip seal was adequate bilaterally tongue was at midline with functional strength and rom palatal elevation was symmetrical gag swallowing assessment the pt was seen with ice chips thin liquids tsp cup thin liquids with a chin tuck nectar thick liquids tsp straw consecutive pureed solids ground solids in apple sauce and small bites of cracker he was awake enough to focus on keeping solid boluses on the left side of the oral cavity and pocketing was minimal with all consistencies he had overt coughing with thin liquids with his head slightly reclined in the chair that was eliminated when he was able to use the chin tuck however he continues to be lethargic and was unable to consistently lift his head to tuck his chin coughing was consistently present when not using the chin tuck and he admitted to the sensation of aspiration o sats remained stable during the evaluation laryngeal elevation was timely and wfl to palpation summary impression mr was significantly more awake today than during previous evaluations and was able to take in larger amounts po he continues to have aspiration with thin liquids but it can be prevented with the use of a chin tuck while up in the chair however most meals are given in bed limited tolerance of sitting in the chair and the risk for aspiration is greater in a reclined position on the bed as such he should remain on nectar thick liquids but can be advanced to moist ground solids he should be encouraged to keep the bolus on the left and will still need to alternate between bites and sips please crush meds and give with purees when most awake and seated fully upright in the chair he can take a small amount of thin liquids using a chin tuck outside of meals he will benefit from continued nutrition follow up to determine if his po intake is adequate now that he is more awake and his diet can be advanced slightly if his intake continues to be poor he may still need to have the peg placed for supplemental nutrition and hydration before d c we will continue to follow him this swallowing pattern correlates to a dysphagia outcome severity scale doss rating of mild to moderate dysphagia recommendations suggest a po diet of nectar thick liquids and moist ground solids continue strict supervision during meals alternate between bites and sips and encourage the pt to keep the bolus on the left side of his mouth check the oral cavity before lying him down between meals and only when seated fully upright in the chair he can take small amounts of thin liquids using a chin tuck continued nutrition input to wean tube feeds as po intake increases if intake continues to be limited he may still need to have a peg placed before d c we will continue to follow during his admission pt will benefit from speech therapy services s p d c social work consult sw met with pt s dtr today for coping support dtr is about to enter her senor year at she reports she has been living at home with pt in their own home in ma dtr reports she is the one who found pt and called dtr reports pt is divorced ex wife lives in az and is supportive to dtr but no contact with pt dtr shares that she and her aunt pt s sister have been making decisions on behalf of pt and that dtr is very grateful for and appreciative of aunt s involvement she shares aunt has experience with hospital system as she was primary care taker for pt s mother dtr reports she is coping well under circumstances she notes understandable difficulty coping with the unknowns of the future particularly wondering to what extent pt will recover she expresses concerns about logistics ie pt owns adn operates a liquor store and she is unsure about the future of this she shares that pt s father lives near them and is handling the logistics but notes he is elderly and wonders how this is impacting him dtr shares she is well supported by her aunt and her fiance but notes limited family support she is hoping that pt will be able to go to rehab near her college she is hoping for ne dtr and aunt also weighing decision re peg dtr wanting this as a last resort option fearing that if he gets one he will never swallow on his own sw explained sw role and function and provided emotional support to dtr a p dtr appears to be coping well under circumstances she is heavily relying on aunt for guidance and is very appreciative and respectful of aunt s input it seems as though pt and aunt could use further education re peg tube placement to help them make their decision they could also benefit from regular updates from team brief hospital course mr is a m with a pmh s f type ii dm who is presenting with acute onset of somnolence in the setting of fevers and hyperglycemia bilateral thalamic cva and left peduncle cva the patient was found at home by a family member and was found to be extremely somnolent the pt presented to an osh and the ct head showed infarcts bilaterally in the thalamus the pt was then transferred to for further work up in the ep and lp was performed and the pt was empirically started on antibiotics to treat bacterial meningitis these were later d c on the basis of csf fluid analysis and culture neurology was consulted an eeg was consistent with a global encephalopathy an mri was obtained which confirmed the above infarcts and in addition diagnosed the patient was a left cerebral peduncle infarct these were thought to be embolic in nature the patient was briefly started on a heparin drip but this was stopped after neurology reviewed the films more closely both tte and tees were obtained that did not demonstrate any valvular lesions his carotid studies did not show evidence stenosis or data compatible with an unstable plaque pt seen repeatedly by speech and swallow details listed above due to difficulty swallowing and questionable aspiration pna on admission in regards to his deficits the patient was discharged able to move both his left upper and lower extremities able to grip with his right hand and able to slightly wiggle his right toes the pt was able to speak was oriented to his daughters name on occasion able to state yes no correctly as to his location but did not know the date the patient worked consistently with pt while as an in patient working on bed mobility balance training transfer training and patient family education fever of unknown etiology the patient spiked fevers throughout his hospitalization from a tm of on admission often as high as f in the pm for a period of over three weeks the patient has also had hrs between throughout his hospital stay without identified etiologies of his sinus tachycardia when patient was first admitted he was empirically treated for bacterial meningitis given a fever and changes in mental status but in light of his csf fluid data the regimen was stopped ct torso at the osh also showed pelvic lymphadenopathy with a question of septic arthritis at the sacroiliac joint he underwent an mri pelvis here which suggested that this inflammation around the sacroiliac joint was chronic in nature and not osteomyelitis several days into admission the patient was started on ceftriaxone and flagyl for presumed aspiration pneumonia he then started to spike fevers almost every day repeat cxr suggested a new infiltrate so his antibiotic regimen was changed to vancomycin and zosyn to treat for hospital acquired pneumonia a picc line was placed for access he also had a cta and le dopplers which were negative for pe and dvt the patient completed a day course of zosyn for presumed hospital acquired pna and a day course for fungal uti the patient also had a full day course of vancomycin plus days at subtherapeutic levels for a suspected line infection from one should note that the bcx from as well as one from were positive bottles for coag neg staph oxacillin resistant from the one with subsequent surveillance all showing no growth to date other etiologies for the patients fuo included drug fevers to vancomycin sacral ileitis and centralized possible hypothalamic involvement of the patients stroke on the final day of admission the patient was noted to have a slight increase in his wbc from to in the setting of a clogged foley catheter u a was negative for bacterial infection see attached results urine cultures were sent and were pending at the time of discharge and will be followed up by the primary team respiratory patient was intubated in ed with a nasopharyngeal tube in place as his mental status improved he was extubated successfully he required cpap at night given his underlying osa the patient remained on cpap at night once transferred to the floor the patient had episodes of somnolence during the day when not on cpap and thus he was desaturate but given a hx of presumed osa the patients saturations would increase once awaken the patient was discharged on type ii dm the patient presented on metformin as an outpatient his hemoglobin a c he was initially started on nph which was titrated up significantly especially given his body habitus the patient initially had very labile sugars given persistently elevated blood sugars he was started on an insulin drip with improvement was consulted to help manage his diabetes given his large insulin requirements the patient was placed on lantus units which was later decreased then and finally upon discharge once tf s were running at hr nutrition patient was unable to take po upon admission due to somnolence and inability to swallow an ng tube was placed for tf was consulted given his labile blood glucose levels the patient was eventually stabilized on tube feeds in conjunction with ground solids and thick purees the patient was initially started on a rate of hr this was decreased to hr with the appropriate changes made to his insulin regimen the team emphasized that a long term solution the patients decreased po intake and need for nutrition would be to place a peg gi consulted and stated that a percutaneous peg could not be placed due to the patients fat pad the family repeatedly stated that they were against placement of a peg on the day of discharge the patient has a peg and or dobhoff tube in place for days the patient had calorie count done on showing gm total of protein gm food gm supplement and calories food supplement uti on the final day of the patients hospital course prior to discharge the patient was noted to have an increase in his wbc from to in the setting of a clogged foley catheter u a was negative for bacterial infection see attached results urine cultures were sent and were pending at the time of discharge and will be followed up by the primary team medications on admission metformin mg insulin lasix mg daily discharge medications docusate sodium mg ml liquid sig one po bid times a day as needed senna mg tablet sig one tablet po bid times a day as needed heparin porcine unit ml solution sig one injection tid times a day simvastatin mg tablet sig one tablet po daily daily aspirin mg tablet sig one tablet po daily daily bisacodyl mg suppository sig one suppository rectal hs at bedtime as needed metformin mg tablet sig two tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day acetaminophen mg ml solution sig one po q h every hours as needed for fever metoprolol tartrate mg tablet sig one tablet po bid times a day insulin glargine unit ml cartridge sig one subcutaneous twice a day discharge disposition extended care facility discharge diagnosis primary diagnosis bilateral thalamic and left peducle cerebrovascular accident hospital acquired pna urinary tract infection central line infection urinary tract infection discharge condition stable patient on tube feeds at hr able to take ground solid po and thicks with dysphagia patient able to move left upper and lower extremity patient able to speak discharge instructions you were admitted to hospital after suffering a stroke while at home while in hospital you were treated for a number of suspected infections including a urinary tract infection pneumonia and a potential line infection in addition your blood sugars were very high and you were seen by the clinic that made a number of recommendations to your diabetes regimen a number of changes have been made to your medications as listed in the discharge summary specifically note the initiation of an insulin regimen that must be followed closely please return to hospital if you experience worsening in your ability to move your left arm and left leg repeated high fevers chills chest pain worsening shortness of breath or loss of consciousness followup instructions follow up at rehabilitation center md [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies ceftriaxone oxycodone attending chief complaint free intraperitoneal air and abdominal pain major surgical or invasive procedure exploratory laparotomy right hemicolectomy end ileostomy and hartmann s pouch history of present illness per initial surgical hpi m recently discharged after work up for bilateral thalamic stroke pna line infection nj feeding tube placement and uti was intubated briefly at that time now presenting as transfer from osh with reports of free air was presumably seen there from rehab unable to answer questions coherently medicine team hpi on upon transfer to floor which partly summarizes hospital course prior to transfer briefly patient is a m with hx of morbid obesity type ii dm osa on bipap with a very complicated month hospital course s p cardiac arrest on transferred to the unit for mrsa hap in the unit patient had jp drain placed in an abdominal abscess he also had a hct drop with no clear source and had a negative abdominal ct his hct has been stable at he also developed a uti and was started on diflucan pt initially presented on with acute change in ms weakness and was found to have bilateral thalamic and l cerebral peduncle infarcts transferred to the floor and discharged to rehab see prior dc summary for details related to initial hospital course pt re admitted on and found to have intra peritoneal air and abdominal pain was taken to the or and found to have perforated cecum thought to be secondary to syndrome he had right hemicolectomy and end ileostomy with hartmann s patch his post op course was complicated by abdominal abscess the pt developed purulence at his op site and wound was opened and cultured he was started on vancomycin on cultures grew mrsa and vre ct abd showed large fluid collection he was intubated on for inability to manage airway secretions and was started on zosyn ct abd on again showed an organizing fluid collection r hepatic flex to pelvis and on the collection was drained fluid grew vre he was continued on antibiotics he also had sputum cultures on and with mrsa in addition ct scan to evaluate his fluid collections showed an smv clot hematology was consulted and hypercoag labs were sent and he was anticoagulated with heparin bridged to coumadin on pt had ct abd w po contrast via dobhoff tube for re eval of abdominal abscess leak that was drained by a pigtail overnight pt triggered for tachypnea and subsequently transferred from east to to the ticu on arrival to the ticu the pt was in respiratory distress he was emergently intubated following intubation he suffered a cardiac arrest with pulseless vt responding to epi x down time estimated at minutes he underwent a bronchoscopy on with cultures growing coag staph he was started on vancomycin and levaquin pt now transferred to the micu for further medical management pt was admitted to micu following transfer from ticu during which he suffered a cardiac arrest the pt was intubated and sedated on arrival for acute hypoxemic respiratory failure thought to be secondary to mucous plugging the patient was weaned off the vent over the course of his first day and was subsequently extubated without complications the pt was placed on scoop mask and subsequently transferred to the floor with a l o requirment the patient was transferred to the floor on during which time his mental status began to clear he had been intermittently oriented to and could discuss the he received multiple debridements of a sacral ulcer that had been present since his original surgery a wound culture from grew e coli and enterococcus and zosyn was added to his regimen on of note his percutaneous drainage tube was removed on after multiple days of cc drainage on the patient developed fevers to standard infectious work up was negative with unchanged cxr negative blood cultures and u a with only yeast id was consulted and zosyn was changed to meropenem out of concern for drug fever on however the patient continued to have fevers the evening of the patient had an episode of tachypnea to the s without new hypoxia or acidosis on abg which resolved by morning later he was sent for a repeat ct torso to evaluate for potential worsening of his abscess this showed a large and worsened phlegmon at the site of the previous pigtail with a new fluid collection upon returning from ct he was tachycardic to the s s sinus and tachypnic with worsened abdominal pain surgery was called but felt his abdomen did not require surgical intervention he received l ns and mg po vit k for a potential ir drainage procedure in the am he denied chest pain worsened sob n v he was not hypotensive and an abg confirmed the lack of acidosis in the micu the patient had jp drain placed in an abdominal abscess he also had a hct drop with no clear source and had a negative abdominal ct his hct has been stable at for two days at time of transfer he also developed a uti and was started on diflucan past medical history bilateral thalamic and left peducle cerebrovascular accident hospital acquired pna urinary tract infection central line infection type ii dm osa not on cpap social history works in real estate and owns several small businesses including liquor store remote smoking history quit years ago no alcohol or drug use family history no sudden cardiac death mother with a cardiomyopathy and chf physical exam initial physical exam vitals t hr bp rr o sat nrb gen nad alert head and neck at nc soft supple no masses heart rrr no murmurs lungs ctab no rhonchi no crackles abd soft distended diffuse abdominal tenderness c peritonitis rectal guiac neg no masses per er ext warm well perfused no edema discharge physical exam t bp hr rr o ra general morbidly obese mildly ill appearing man in nad heent nc at perrl eomi with mild impairment of upward gaze dobhoff tube in place op clear no exudate patient intermittently squints closing alternate eyes double vision neck no jvd appreciated cv distant rrr no m r g resp cta anteriorly abd obese soft ostomy with brown stool ventral incision wound with pink granulation tissue back circular approx by cm sacral decubitus ulcer extending to bone with some surrounding pink granulationt issue with associated skin breakdown at to oc lock ext lue picc r rd digit black nodule stable nontender no c c e neuro aao x cn grossly intact wiggles toes b l can lift lle off bed unable to lift strength rue strength lue pertinent results admission labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap other selected laboratory data tsh t t free t crp crp wbc rbc hgb hct mcv mch mchc rdw plt ct lactate caltibc hapto ferritn trf am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood ck mb notdone ctropnt pm blood ck mb ctropnt negative factor v leiden mutation prothrombin mutation no mutation detected method is pcr amplification and restriction fragment length polymorphism analysis for detection of the g a mutation in the untranslated region of the prothrombin gene discharge laboratory data pt ptt inr pt pt ptt inr pt pt ptt inr pt wbc rbc hgb hct mcv mch mchc rdw plt ct pt ptt inr pt glucose urean creat na k cl hco angap alt ast ld ldh alkphos totbili calcium phos mg microbiology data am tissue source coccyx final report gram stain final per x field polymorphonuclear leukocytes per x field gram negative rod s per x field gram positive cocci in pairs in short chains tissue final escherichia coli moderate growth enterococcus sp moderate growth gram negative rod sparse growth resembling alcaligenes species levofloxacin mcg ml cefepime mcg ml meropenem mcg ml sensitivity testing performed by microscan sensitivities mic expressed in mcg ml escherichia coli enterococcus sp gram negative rod ampicillin s s ampicillin sulbactam s cefazolin s cefepime s s ceftazidime s s ceftriaxone s s cefuroxime s ciprofloxacin s r gentamicin s s imipenem s levofloxacin s linezolid s meropenem s s penicillin g s piperacillin s s piperacillin tazo s s tobramycin s s trimethoprim sulfa s s vancomycin r anaerobic culture final no anaerobes isolated r o vancomycin resistant enterococcus final enterococcus sp moderate growth sensitivities mic expressed in mcg ml enterococcus sp vancomycin r fluid culture final from rlq enterococcus sp isolated from broth media only indicating very low numbers of organisms sensitivities mic expressed in mcg ml enterococcus sp ampicillin r linezolid s penicillin g r vancomycin r pm sputum source induced final report gram stain final pmns and epithelial cells x field per x field gram positive cocci in pairs chains and clusters pm urine source catheter final report urine culture final enterococcus sp organisms ml yeast organisms ml sensitivities mic expressed in mcg ml enterococcus sp ampicillin s linezolid s nitrofurantoin s tetracycline r vancomycin r respiratory culture final oropharyngeal flora absent staph aureus coag heavy growth oxacillin resistant staphylococci must be reported as also resistant to other penicillins cephalosporins carbacephems carbapenems and beta lactamase inhibitor combinations rifampin should not be used alone for therapy sensitivities mic expressed in mcg ml staph aureus coag clindamycin r erythromycin r gentamicin s levofloxacin r oxacillin r penicillin g r rifampin s tetracycline s trimethoprim sulfa s vancomycin s am swab source abdominal wound final report gram stain final per x field polymorphonuclear leukocytes per x field gram positive cocci in pairs wound culture final staph aureus coag moderate growth oxacillin resistant staphylococci must be reported as also resistant to other penicillins cephalosporins carbacephems carbapenems and beta lactamase inhibitor combinations rifampin should not be used alone for therapy please contact the microbiology laboratory immediately if sensitivity to clindamycin is required on this patient s isolate enterococcus sp sparse growth sensitivities mic expressed in mcg ml staph aureus coag enterococcus sp ampicillin r erythromycin r gentamicin s levofloxacin r linezolid s oxacillin r penicillin g r r rifampin s tetracycline s trimethoprim sulfa s vancomycin s r anaerobic culture final no anaerobes isolated pm abscess right lower quadrant final report gram stain final per x field polymorphonuclear leukocytes no microorganisms seen wound culture final no growth anaerobic culture final no growth fungal culture final no fungus isolated c diff negative x blood cultures including mycolytic from x x ngtd all other blood cultures have been negative studies echo the left atrium is normal in size the estimated right atrial pressure is mmhg there is mild symmetric left ventricular hypertrophy the left ventricular cavity is unusually small due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded overall left ventricular systolic function is 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 trace aortic regurgitation is seen the mitral valve appears structurally normal with trivial mitral regurgitation there is no mitral valve prolapse there is an anterior space which most likely represents a fat pad compared with the prior study images reviewed of the findings are similar cxr findings two ap views lung volumes are low comparison is made with the previous study done there is some motion artifact streaky density is again demonstrated at the lung bases consistent with subsegmental atelectasis mediastinal structures are unchanged a feeding tube is again demonstrated and is coiled in the upper abdomen as before terminating in the region of the gastric body or antrum non contrast head ct findings there are thalamic hypodensities and left mid brain hypodensity consistent with the site of the patient s previous infarcts as demonstrated on the previous examination of there is no evidence of acute infarct the remainder of white differentiation is maintained there is no intra or extra axial hemorrhage mass mass effect or midline shift ventricles and cisterns are patent paranasal sinuses mastoids and middle ear cavities are clear globes orbits skull and extracranial soft tissues are unremarkable impression no acute intracranial process previous infarcts as described above ct abdomen pelvis impression large fluid collection extending from the right hepatic flexure into the pelvis discussed with dr by dr on bilateral sacroiliitis ct torso impression right lower quadrant phlegmonous collection at the site of the prior pigtail catheter measuring approximately cm x cm x cm there is central hypattenuation within this phlegmon suggestive of fluid bibasilar atelectasis and a trace right pleural effusion cm exophytic lesion in the interpolar region of the left kidney not fully characterized on this study sacral decubitus ulcer which extends to the level of the underlying bone raising concern for osteomyelitis ct abdomen pelvis impression minimal decrease in size of a right lower quadrant collection no significant change in a collection within the pelvis no new collections identified large sacral decubitus ulcer directly abutting the sacrum although no direct signs of osteomyelitis is seen on this study the sacrum is at high risk for developing osteomyelitis bibasilar consolidation within the visualized lungs may reflect atelectasis tte the left atrium and right atrium are normal in cavity size no atrial septal defect or patent foramen ovale is seen by d color doppler or saline contrast with maneuvers 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 the estimated cardiac index is normal l min m right ventricular chamber size and free wall motion are normal the aortic valve leaflets appear structurally normal with good leaflet excursion 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 no definite valvular pathology or pathologic flow identified brief hospital course mr has had prolonged hospital course and has been cared for by multiple services different parts of hospital course are summarized below by each primary team who cared for the patient at the time i have also summarized hospital course prior to when i assumed care for patient in my initial hpi i have subsequently summarized his medical floor course in the last section below which details events from and initial admission surgical course patient was admitted to dr surgical service on in short the patient is a year old gentleman who was discharged days ago prior after a month long hospitalization for bilateral acute thalamic strokes he has had days of abdominal pain and poor p o intake he now presents after evaluation at an outside hospital that showed a significant amount of free air on an upright chest x ray upon house staff examination decision was made to take patient to the operating room for exploratory laparotomy for probable perforated viscus during operation upon entering the abdomen it was noted that the patient had a distended perforated cecum it was thinned out and ischemic area on the antimesenteric wall of the cecum with his perforation in the ischemic area the cecum itself was large and patulous and the perforation was partially walled off with omentum against the right lateral sidewall there were feculent contents in the peritoneal fluid throughout the abdomen indicating prior free perforation which had walled off there was no evidence of gastric or duodenal injury the sigmoid colon was normal as was the transverse colon and the small bowel the liver on palpation was also normal the decision was then made to continue with a right hemicolectomy end ileostomy and hartmann s pouch blood loss was ml and patient resuscitated with almost liters of crystalloids patient tolerated the procedure and there were no complications to the operation he was immediately transferred to trauma surgical intensive care unit for postoperative monitoring and recovery patient remained intubated at this time major events hypotensive responded to fluids levophed weaned off levophed started tube feeds via dobbhoff cont lasix cont pressure support extubated doing well overnight abx dc d desat overnight low s encouraged to cough spiked temp axillary pan cx possible uti urine cloudy wound grossly purulent minimally opened by primary team and cultured vanc started for gpc clusters cvl changed over wire ct abd no collections po lasix with iv boluses desated likely plug bronch sputum cx with gpc in pt with hx of hosp acquired pna vanc started reintubated secondary to large amount of secretions which patient was unable to clear on vancomycin zosyn for hosptial aquired pneumonia intrabdominal fluid collection tapped by ultrasound diuresis to continue spontaneous breathing trial tolerated for an hour and a half successfully extubated tf hr nacl nebs continue aggressive diuresis no bronch failed swallow eval switched back to po lasix coumadin mg started for smv thrombus therapeutic on coumadin dose decreased to mg tube feeds continued status stable continues with mg of coumadin inr goal transferred to stone icu care not required due to stable status inr coumadin dose decreased to mg status remains stable until transfer as below ticu course on patient was transferred from east to he had respiratory arrest most likely secondary to mrsa pneumonia and mucus plug he developed tachypnea o sats s on bipap s on facemask s nrb and hr s on arrival to unit sats on arrival to unit were on nrb he desatted to low s in icu and was intubated with etomidate and succinylcholine two to minutes later pt went into v tach arrest he was successfully resuscitated on weaned off pressors continued on antibiotics micu course pt was admitted to micu following transfer from ticu during which he suffered a cardiac arrest the pt was intubated and sedated on arrival for acute hypoxemic respiratory failure thought to be secondary to mucous plugging the patient was weaned off the vent over the course of his first day and was subsequently extubated without complications the pt was placed on scoop mask and subsequently transferred to the floor with a l o requirment in addition the patient was also initially treated for a likely mrsa pna given fevers and increased sputum cxr was without supporting evidence sputum cultures grew mrsa however it was felt that this was likely a tracheo bronchitis rather than a true pna the patient had a known intrabdominal abcess for which surgery had placed a drain cultures had previously confirmed vre however the pt had never been treated with antibiotics i d was consulted and in conjunction with surgery a plan was made to continue treating with iv linezolid for a duration of days post the plugging of the surgical drain once it is deemed to no longer be draining adequate ammounts the pt was also noted to have an enterococcal uti in the setting of vancomycin use this was treated concurrently with linezolid the pt has a stage iii iv sacral decub this likely required further imaging and a plastic consult further imaging was not able to be obtained while the patient was intubated in the unit however this information was conveyed to the floor team at the time of transfer the pt has a hx of smv thrombosis the patient presented to the micu with a supratherapeutic inr in the setting of coumadin and levaquin use the patients coumadin was initially held but restarted the date of transfer from the unit the patient has a hx of extremely labile sugars during the patients stay in the micu the pts tube feeds were at sub goal levels the patient had one episode of fs with hypotension to the s and received amps of d the patients fixed lantus and sliding scales were adjused prior to his transfer from the unit recommendations were made to the transfer team for to consult on the pt medicine course the patient was transferred to the floor on during which time his mental status began to clear he had been intermittently oriented to and could discuss the plastics was consulted for the patient s stage iii sacral decub who noted that the decub is extending to the sacral fascia but not to the bone and recommended wound debridement packing and continuing linezolid he received multiple debridements of a sacral ulcer that had been present since his original surgery a wound culture from grew e coli and enterococcus and zosyn was added to his regimen on pt triggered for rr s s on l pt was afebrile at the time and hemodynamically stable and abg normal with it was thought it was likely mucous plugging cxr did show possible retrocardiac infiltrate but without cough and white count aspiration pna or hap is unlikely pt s respiratory rate came down after nebs and humidifying face mask on fio pt does have sleep apnea with bipap at home and maybe a possiblity we held off on bipap cpap since pt still at high risk for aspiration subsequent cxrs in the following days were negative and pt remained stable on ra and no futher episodes of triggers until day of transfer to micu on concerning the pt s anemia iron studies c w acd ferritin iron pt had prior transfusion with hct s pt s hct dropped to on and received u prbc on the pt remained guaic neg per ostomy pt also of italian descent g pd consideration which was negative prior to coming to the floor pt s factor v lieden and prothrombin mutation were also negative pt was continued on coumadin for his smv thrombosis and it was not clear to neuro what caused the smv thrombosis and the thalamic strokes in the first place on his prior admisison pt s coumadin did become subthereapeutic at one point and pt was started on heparin to be continued until he became therapeutic again concerning the patient s mental status his delirium initially when he came to the floor improved once there was some improvement and pt was able to communicate neuro was consulted who did not believe the pt has anoxic brain injury cardiac arrest instead pt s delerium infections and hospital setting likely bring out the cognitive defects associated with his thalamic stroke causing his decrescendo speech they also recommended to place his eye glasses and alternating eye patch for his diploplia stroke to help with delirium also pt s dm was well controlled with following and at no point did the pt become hypoglycemic and his lantus was up titrated his ventral hernia continued to slowly heal concerning his percutaneous drain general surgery s recommendation was to remove the drain after h of scant drainage to ensure that this was the case the pigtail was flushed with cc flushed well and continued to not have drainage surgery then was called who agreed and then pulled the drain tube was removed on after h of cc drainage pt was developing low grade fevers of axillary so pt s standing order of tylenol g q was d c on the patient developed fevers to standard infectious work up was negative with unchanged cxr negative blood cultures and u a with only yeast the foley was changed but continued to grow only yeast id was consulted and zosyn was changed to meropenem out of concern for drug fever on with urine eos however the patient continued to have fevers furthermore meropenem was kept on to treat the sacral decub infection presumptively for sacral osteomyelitis the linezolid was continuing to treat possible mrsa and vre the evening of the patient had an episode of tachypnea to the s without new hypoxia or acidosis on abg which resolved by morning on since the patient continued to have intermittent fevers the only remaining source was that the pt may have reaccumulated his intraabdominal abscess or developed a new abscess he was sent for a repeat ct torso this showed a large and worsened phlegmon at the site of the previous pigtail with a new fluid collection upon returning from ct he was tachycardic to the s s sinus and tachypnic with worsened abdominal pain surgery was called but felt his abdomen did not require surgical intervention he received l ns and mg po vitamin k for a potential ir drainage procedure in the am he denied chest pain worsened sob n v he was not hypotensive and an abg confirmed the lack of acidosis pt was then transferred to the micu for closer monitering and had replacement of intrabdominal drain by ir the next day micu course upon arrival to micu he was tachycardic hypotensive with drop in hct he was transfused prbc ct abdomen did not reveal any new bleeding and showed fluid collection jp placed by ir for drainage phlegmon he remained hemodynamically stable and he was transferred back to floor medicine course organized by problem sacral decubitus ulcer osteomyelitis while on the floor patient was continued on meropenem and linezolid for presumed osteomyelitis for a sacral decubitus ulcer that extends to bone he will complete a week course of these antibiotics on he had bleeding from this ulcer which resulted in a hematocrit drop and he was transfused plastic surgery also saw him at this time and sutured part of the wound that was bleeding they did not perform any more debridements due to risk of bleeding while on anticoagulation but recommended to tid wet to dry dressing changes they did not feel he was a candidate for vac dressing his heparin drip was held for days while we ensured his hematocrit remained stable and he no longer required transfusions two weeks prior to discharge it was noted that he had some surrounding area of skin breakdown with eshar formation plastics was reconsulted on and saw the wound but did not have any further recommendations other than continuing dressing changes they saw patient and examined wound on day of discharge and recommended wet to dry dressing changes with x approx week then follow up with plastic surgery in clinic plastic surgery follow up was arranged at earliest possible appointment smv thrombosis cva heparin was initially held x days when patient had bleed from sacral decubitus ulcer once hematocrit was stable and he did not have any further episodes of bleeding heparin drip was restarted since benefits of anticoagulation outweighed risks he was bridged to coumadin he did not have any further episodes of bleeding while on anticoagulation he will likely need lifelong anticoagulation given venous and arterial clots and should have inr followed closely on coumadin with goal inr regarding his double vision from cva neurology recommended alternating eye patches which the patient did not like wearing they felt his visual problems should improve with time intra abdominal abscess for his intra abdominal abscess e coli vre repeat ct was obtained which did not show any new collections his rlq jp drain was removed in early and he did not subsequently spike a fever show any signs of recurrent infection or have any abdominal pain dm for his type diabetes he was continued on lantus which was uptitrated for improved glycemic control and he was continued on humalog sliding scale with good glycemic control anemia patient had a chronic anemia which was consistent with anemia of chronic inflammation with elevated ferritin he did not have any further episodes of bleeding x weeks prior to discharge and hematocrit remained stable hematuria candiduria he had some hematuria in early which was felt to be secondary to foley trauma and resolved after foley was removed at time of discharge he was using urinal hematocrit remained stable patient completed day course of diflucan for fever and candiduria from to peripheral lesions on patient developed black lesion on tongue and right rd digit which was initially tender it was most likely secondary to trauma from fingersticks and possible tongue biting but there was concern for septic emboli he did not have any signs or symptoms of infection with no fever no elevated wbc and no new murmurs tte was obtained which did not show any vegetations lesion on tongue resolved and lesion on finger was no longer tender at time of discharge id was consulted and did not believe lesion was consistent with septic emboli blood and mycolytic cultures were obtained on and showed no growth at time of discharge also despite patient s multiple infections he never had bacteremia or positive blood cultures fen multiple multidisciplinary family meetings were held to discuss various issues including nutrition the patient s mental status had improved he was oriented x and was judged to be competent to make his own decisions peg tube placement was recommended for nutrition given risks of sinusitis and infection with ngt but pt declined and preferred to keep dobhoff ngt he was discharged on tube feeds via dobhoff he was regularly seen by speech and swallow therapy who helped him with swallowing exercises and therapy they recommended performing daily supervised trials of po puree intake with the speech and swallow therapist code status full medications on admission docusate sodium mg ml liquid sig one po bid times a day as needed senna mg tablet sig one tablet po bid times a day as needed heparin porcine unit ml solution sig one injection tid times a day simvastatin mg tablet sig one tablet po daily daily aspirin mg tablet sig one tablet po daily daily bisacodyl mg suppository sig one suppository rectal hs at bedtime as needed metformin mg tablet sig two tablet po bid times a day nystatin unit ml suspension sig five ml po qid times a day acetaminophen mg ml solution sig one po q h every hours as needed for fever metoprolol tartrate mg tablet sig one tablet po bid times a day insulin glargine unit ml cartridge sig one subcutaneous twice a day discharge medications atorvastatin mg tablet sig one tablet po daily daily aspirin mg tablet chewable sig one tablet chewable po daily daily acetaminophen mg ml solution sig six y mg po every hours as needed for pain ascorbic acid mg ml drops sig five hundred four mg po daily daily linezolid mg ml parenteral solution sig six hundred mg intravenous q h every hours for doses disp qs refills warfarin mg tablet sig three tablet po once daily at pm zinc sulfate mg capsule sig one capsule po daily daily insulin glargine unit ml cartridge sig forty two units subcutaneous twice a day please give qam and qhs humalog unit ml solution sig units subcutaneous four times a day humalog insulin sliding scale as directed see attached outpatient lab work please have cbc and lfts checked twice per week while you are on antibiotics imipenem cilastatin mg recon soln sig one intravenous four times a day for doses disp qs refills cholecalciferol vitamin d unit tablet sig two tablet po daily daily outpatient lab work inr should be checked daily until stabilized in therapeutic range of current warfarin dose of mg once daily may need to be readjusted outpatient occupational therapy discharge disposition extended care facility discharge diagnosis primary diagnosis perforated cecum abdominal abscess and wound infection mrsa vre s p jp drain superior mesenteric vein thrombus hospital acquired pna mrsa cardiac arrest in setting of respiratory failure pna urinary tract infection vre stage sacral pressure ulcer and infection e coli vre probable sacral osteomyelitis secondary diagnosis bilateral thalamic left peduncle strokes type diabetes mellitus osa discharge condition hemodynamically stable afebrile tolerating dobhoff tube feedings pain free discharge instructions you were admitted to the hospital with perforation of your colon you had surgery for this and had a hemicolectomy with ostomy placement you developed multiple infections which were treated with antibiotics you should continue on two antibiotics linezolid and ertapenem through this is to treat an infection in the bone where you have a sacral ulcer we are also treating you with a blood thinning medication called coumadin which you need to take every day this is to treat a clot you had in your blood vessels your dose of this medication may need to be adjusted based on blood levels which need to be followed very closely you should continue to take long and short acting insulin for you diabetes we made the following changes to your medications we added linezolid and ertapenem two antibiotics which you should take until we added coumadin a blood thinning medication we added vitamin c vitamin d and zinc we adjusted your insulin doses for your diabetes you are also on a baby aspirin and a statin medication for high cholesterol below are directions regarding management of your ostomy monitoring ostomy output prevention of dehydration keep well hydrated replace fluid loss from ostomy daily try to maintain ostomy output between ml to ml per day if ostomy output liter take mg of imodium repeat mg with each episode of loose stool do not exceed mg hours md with increased ostomy output please call your doctor or return to the er if you develop chest pain shortness of breath cough fever chills abdominal pain blood in the stool or dark stool nausea vomiting or any other concerning symptoms also please call your doctor if you have increased pain swelling redness or drainage from the incision site in your abdomen followup instructions please follow up in infectious disease clinic on urgent care id phone date time the address is please follow up with dr at medical unit phone date time follow up with dr in weeks please call for an appointment follow up with plastic surgery plastic surgery clinic phone date time please follow up with infectious disease provider md phone date time this was the soonest appointment we could arrange for you but you may be called with an earlier appointment if there is a cancellation md completed by,"{
""Diagnoses"": [""altered mental status"", ""morbid obesity"", ""type II diabetes"", ""osmotic syndrome""],
""Medications"": [""ceftriaxone"", ""insulin"", ""narcan""]
}"
62734,admission date discharge date date of birth sex m service cardiothoracic allergies tetanus toxoid adsorbed attending chief complaint asymptomatic major surgical or invasive procedure coronary artery bypass grafting x with left internal mammary artery to left anterior descending coronary artery reversed 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 endoscopic left greater saphenous vein harvesting history of present illness year old male with failed kidney allograft referred for cardiac catheterization as part of evaluation for kidney transplant his cardiac catheterization revealed severe three vessel disease past medical history hypertension polycystic kidney disease end stage renal disease with kidney allograft failure and hemodialysis mwf right subclavian tunneled catheter and a non matured left arm av fistula gout anemia incarcerated hernia as an infant surgically repaired skin cancer s p excision on back social history he is married to with adult children who live locally he works in a sales position in own company he denies any alcohol drug use or smoking family history mother and son with pkd physical exam pulse resp o sat ra b p right left no bp height weight lbs general wdwn in nad skin dry warm and intact right forearm is warm to palpation with mild erythema it is tender to touch right radial ecchymosis at puncture site from cath left wrist av fistula with minimal thrill heent ncat perrla eomi sclera anicteric op benign neck supple x full rom x no jvd chest lungs clear bilaterally x heart rrr nl s s no m r g abdomen obese soft x non distended x non tender x bowel sounds x rlq renal transplant incision well healed no hepatosplenomegaly extremities warm x well perfused x trace edema b varicosities none noted on standing some minor superficial varicosities noted which don t seem to be related to gsv system neuro grossly intact mae strength pulses femoral right left dp right left pt left radial right left thrill carotid bruit right bruit left question very faint bruit pertinent results am blood hct 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 inr pt am blood plt ct am blood plt ct am blood pt ptt inr pt am blood fibrino am blood urean creat k am blood glucose urean creat na k cl hco angap pm blood urean creat cl hco am blood calcium phos mg 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 aortic valve disease coronary artery disease left ventricular function mitral valve disease right ventricular function valvular heart disease icd codes test information date time at interpret md md test type tee complete d imaging 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 septal wall thickness cm cm left ventricle inferolateral thickness cm cm left ventricle diastolic dimension cm cm left ventricle ejection fraction to aorta annulus cm cm aorta sinus level cm cm aorta sinotubular ridge cm cm aorta ascending cm cm findings multiplanar reconstructions were generated and confirmed on an independent workstation 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 a catheter or pacing wire is seen in the ra no asd by d or color doppler left ventricle wall thickness and cavity dimensions were obtained from d images normal lv wall thickness normal lv cavity size low normal lvef right ventricle normal rv chamber size and free wall motion aorta normal descending aorta diameter simple atheroma in descending aorta aortic valve three aortic valve leaflets mildly thickened aortic valve leaflets no as mild ar eccentric ar jet mitral valve moderately thickened mitral valve leaflets mild thickening of mitral valve chordae no ms trivial mr tricuspid valve normal tricuspid valve leaflets with trivial tr pulmonic valve pulmonary artery normal pulmonic valve leaflet no ps physiologic pr pericardium no pericardial effusion general comments a tee was performed in the location listed above i certify i was present in compliance with hcfa regulations the tee probe was passed with assistance from the anesthesioology staff using a laryngoscope no tee related complications regional left ventricular wall motion conclusions pre bypass 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 atrial septal defect is seen by d or color doppler left ventricular wall thicknesses are normal the left ventricular cavity size is normal overall left ventricular systolic function is low normal lvef right ventricular chamber size and free wall motion are normal 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 mild aortic regurgitation is seen the aortic regurgitation jet is eccentric the mitral valve leaflets are moderately thickened trivial mitral regurgitation is seen there is no pericardial effusion post cpb preserved ventricular systolic function no change in vemvular structure or function electronically signed by md interpreting physician brief hospital course he was admitted same day surgery and underwent coronary artery bypass graft surgery please see operative report for further details he was transferred to the intensive care unit for post operative management in the first twenty four hours he was weaned from sedation awoke neurologically intact and was extubated without complications on post operative day one he was transferred to the floor for the remainder of his care renal was consulted for renal disease and dialysis physical therapy worked with him on strength and mobility he was ready for discharge home on post operative day five with plan for dialysis at outpatient dialysis medications on admission amlodipine mg po bid calcium acetate mg cap capsules po tid cincalcet mg po daily tx secondary hyperparathyroidism in ckd colchicine mg po daily furosemide mg po bid leflunomide mg po bid metoprolol tartrate mg po bid warfarin mg po daily stopped last week for cath this was to maintain patency of hd catheter phoslo mg tab tablets po tid 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 for months disp tablet s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills leflunomide mg tablet sig one tablet po twice a day disp tablet s refills acetaminophen mg tablet sig tablets po q h every hours as needed for pain amlodipine mg tablet sig one tablet po bid times a day disp tablet s refills cinacalcet mg tablet sig one tablet po daily daily disp tablet s refills calcium acetate mg capsule sig four capsule po tid w meals times a day with meals disp capsule s refills atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills colchicine mg tablet sig one tablet po twice a week monday and thrusday disp tablet s refills warfarin mg tablet sig one tablet po once a day dose changes based on inr please have checked at hd for further dosing disp tablet s refills metoprolol tartrate mg tablet sig one tablet po twice a day disp tablet s refills lasix mg tablet sig one tablet po twice a day disp tablet s refills discharge disposition home with service facility care discharge diagnosis coronary artery disease s p coronary artery bypass graft x hypertension polycystic kidney disease kidney allograft failure hemodialysis mwf right subclavian tunneled catheter and a non matured left arm av fistula on coumadin for tunnel line gout anemia incarcerated hernia as an infant surgically repaired skin cancer s p excision on back discharge condition alert and oriented x nonfocal ambulating gait steady sternal pain managed with tylenol prn discharge instructions please wash daily no shower due to tunnel line per renal 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 please call to schedule appointments surgeon dr tuesday at pm primary care dr in weeks cardiologist dr in weeks nephrology dr wound check appointment your nurse will schedule pt inr for coumadin dosing to be done with dialysis and further lab draws and dosing done at dialysis dr nephrologist completed by [NEW_RECORD] admission date discharge date date of birth sex m service surgery allergies tetanus toxoid adsorbed attending chief complaint left retroperitoneal bleed major surgical or invasive procedure embolization of distal branch of left renal artery feeding lower pole history of present illness m w hx of pkd s p failed kidney transplant on he is being evaluated for potential second kidney transplant he recently underwent cardiac cath which showed vessel disease now he is s p cabg x on patient presented to med center ed w l back flank pain ct scan shows blood around native l kidney in the retroperitoneum he is anticoagulated on coumadin for his hemodialysis port inr at osh he was hemodynamically stable on arrival the the osh hct he received u ffp and was transfered to the ed past medical history pmh hypertension polycystic kidney disease kidney allograft failure from bk nephropathy hemodialysis mwf right subclavian tunneled catheter and a non matured left arm av fistula gout anemia incarcerated hernia as an infant surgically repaired skin cancer s p excision on back psh kidney transplant cabg x left arm av fistula placement right chest subclavian port hemodialysis catheter x left knee reconstruction s p inguinal hernia repair as child social history married works in a sales denies alcohol tobacco or drug use family history mother and son with pkd physical exam on discharge afebrile vss no distress alert and oriented x perla eomi anicteric neck supple rrr lungs clear abdomen soft nontender nondistended groin soft no hematoma le no edema palpable pulses pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood hct 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 wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood hct am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood hct pm blood hct am blood glucose urean creat na k cl hco angap brief hospital course mr was transferred to with a left retroperitoneal bleed a repeat ct scan with iv contrast was performed here and this showed active extravasation from the left kidney he immediately went to interventional radiology for intervention they were able to coil a small branch of the left renal artery that was feeding the lower pole of his left kidney he was transferred to the sicu for close monitoring and serial hematocrits his serial hematocrits and inr were monitored and he received transfusions as needed he received a total of units of packed rbcs and units of ffp he did received dialysis on m w f as per his outpatient schedule on post procedure days his hematocrits remained stable and he was transferred out of the icu his diet was advanced which he tolerated without difficulty he was discharged home after his hematocrits remained stable for another hours on the surgical floor medications on admission wafarin mg qd aspirin mg qd ranitidine mg qd colace mg leflunomide mg amlodipine mg cinacalcet mg qd calcium acetate mg x tabs tid atorvastatin mg qd colchicine mg po twice a week mon thurs metoprolol mg lasix mg discharge medications metoprolol tartrate mg tablet sig three tablet po bid times a day ranitidine hcl mg tablet sig one tablet po daily daily amlodipine mg tablet sig one tablet po daily daily furosemide mg tablet sig two tablet po bid times a day leflunomide mg tablet sig two tablet po bid sevelamer carbonate mg tablet sig one tablet po tid w meals times a day with meals pravastatin mg tablet sig two tablet po daily daily cinacalcet mg tablet sig one tablet po daily daily calcium acetate mg capsule sig four capsule po tid w meals times a day with meals acetaminophen mg tablet sig one tablet po every six hours as needed for pain fever discharge disposition home discharge diagnosis ruptured left renal cyst with active extravasation acute blood loss anemia discharge condition good alert and oriented x ambulating without difficulty discharge instructions call your physician or return to the ed if you experience fever chills persistent nausea or vomiting lightheadedness palpitations or pain you may resume your home medications you may resume your coumadin but you need to follow up with your physician to have your dose adjusted because it was too high when you came to the hospital followup instructions follow up with dr in weeks call his office at to schedule your appointment continue your dialysis as you were prior to your hospitalization provider md phone date time,{}
19463,admission date discharge date service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint shaking chills major surgical or invasive procedure none history of present illness year old man with coronary artery disease s p cabg congestive heart failure with ventricular systolic dysfunction ef atrial fibrillation bph s p turp requiring x daily intermittent catheterization on chronic keflex with multiple uti s who presents with one day of acute onset shaking chill patient reports tripping over step while carrying groceries about a week ago fell and hit bridge of his nose and right ribs went to hospital negative ct and no rib fractures has had some continued nose bleeding since that time now minimal coumadin held for past few days then today reports developing shaking chills while lying next to his wife says otherwise only mild intermittent non productive cough with eating peanuts says has been catheterizing himself about three times a day no change recently and has not noted change in color or odor of urine also developed possible small volume hemoptysis x today says small amount in mucous today no other specific complaints generally feeling malaise since recent fall denies chest pain orthopnea pnd doe at baseline goes golfing help with care as his wife is demented and requires hour assistance but he can perform all his adl s no hematochezia melena other bleeding besides nose in the ed low grade fever to hypotensive to sbp s in the s and initially on room air to on liters and bp improved to s with liters ns initially tachy to s in er now in s wbc was with neutrophils he received ceftriaxone g iv azithromycin mg iv aspirin mg po and acetominophen g po past medical history coronary artery disease status post cabg in no cath since then atrial fibrillation on coumadin biventricular heart failure with an ef of mild as mr benign prostatic hypertrophy status post turp x now x daily catheterizations and keflex chronic suppression anemia for which he receives darbepoetin every weeks macular degeneration in left eye multiple utis last culture showed e coli and corynebacterium diphtheroid resistant to cipro levo bactrim amp but sensitive to ceftriaxone uti in grew bactrim ticarcillin and fq resistant bacteria uti in grew pan sensitive enterobacter cloacae parkinson s disease social history former smoker quit years ago he drank etoh regularly until years ago and now only drinks rarely lives at home with wife wife with dementia has hour caretaker active walks independently and independent of adls plays golf family very involved with his care hcp cell and daughter is second hcp used to be in the navy then worked in a creamery and then owned two restaurants and was in catering before he retired family history non contributory physical exam vs temp bp hr rr o sat rm airl i o liters cc general elderly male laying in bed nad pleasant heent right pupil round and reactive to light surgical left pupil eomi no scleral icterus op clear moist mucous dry dry blood over bridge of nose no active nasal oral bleeding no jvd neck supple no lad jvd cm lungs crackles way up bilaterally card irregular rhythm iii vi systolic murmur previously noted abd b s soft nt nd ext no edema weak dorsalis pedis pulses skin multiple ecchymoses neuro alert oriented x cn iii xii intact mild left facial droop which the patient says he s had for a long time speaks slowly but attentive jokes and tells stories pertinent results am wbc rbc hgb hct mcv mch mchc rdw am neuts bands lymphs monos eos basos am plt count pm vit b folate greater than am pt ptt inr pt am glucose urea n creat sodium potassium chloride total co anion gap alt ast alk phos t bili ldh alb cortisol am lactate pm digoxin am ck mb notdone am ctropnt pm ck mb ctropnt pm ck mb ctropnt spep wnl upep only albumin am urine color yellow appear clear sp am urine blood neg nitrite pos protein neg glucose neg ketone neg bilirubin neg urobilngn ph leuk neg am urine rbc wbc bacteria many yeast none epi blood cx no growth am urine site catheter final report urine culture final citrobacter freundii complex organisms ml trimethoprim sulfa sensitivity testing confirmed by this organism may develop resistance to third generation cephalosporins during prolonged therapy therefore isolates that are initially susceptible may become resistant within three to four days after initiation of therapy for serious infections repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used sensitivities mic expressed in mcg ml citrobacter freundii complex cefepime s ceftazidime r ceftriaxone r ciprofloxacin s gentamicin s imipenem s meropenem s nitrofurantoin i piperacillin r tobramycin s trimethoprim sulfa s urine cx no growth pm sputum source expectorated final report gram stain final pmns and epithelial cells x field per x field gram negative rod s per x field gram positive cocci in pairs and clusters per x field gram positive rod s per x field yeast s respiratory culture final moderate growth oropharyngeal flora gram negative rod s rare growth of three colonial morphologies ekg atrial fibrillation with rapid ventricular response leftward axis left bundle branch block since previous tracing of intraventricular conduction delay is new chest portable ap am findings compared with the moderate left ventricular cardiomegaly appears essentially unchanged status post cabg there is engorgement of the pulmonary vessels suggesting an element of chf additionally there is more confluent airspace opacity overlying the right mid lung field consistent with pneumonia echo the left atrium is markedly dilated the right atrium is moderately dilated no atrial septal defect is seen by d or color doppler the estimated right atrial pressure is mmhg left ventricular wall thicknesses are normal the left ventricular cavity is moderately dilated there is mild to moderate global left ventricular hypokinesis right ventricular chamber size and free wall motion are normal the aortic root is mildly dilated at the sinus level the ascending aorta is moderately dilated the aortic valve leaflets are mildly thickened there is mild aortic valve stenosis area cm no aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse mild mitral regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion compared with the prior study images reviewed of the ascending aorta is larger otherwise the findings are similar ct head w o contrast am findings the study is somewhat limited by motion artifact however there is no evidence of hemorrhage there is no mass effect the ventricles and sulci are mildly prominent there is a focal lacune in the right caudate head these findings have not changed since the prior study the right maxillary sinus appears small and there may be a surgical defect in its medial wall there is partial opacification of the ethmoid air cells and mucosal thickening in the maxillary air cells bilaterally and in the sphenoid sinus there are no fluid levels within the sinuses incidentally noted are hypodensities in the cerebellar hemispheres bilaterally that presumably represent lacunar infarctions conclusion no evidence of hemorrhage or other acute abnormality old lacunes in the right caudate head and in the cerebellar hemispheres bilaterally these findings are unchanged since video oropharyngeal swallow am findings the oral phase demonstrated difficulty bolus formation transition from oral to laryngeal phase was mildly delayed no epiglottic deflection was identified penetration aspiration were noted with thin liquid and nectar chin tuck improved aspiration with thin liquids with no effect on aspiration with nectar moderate retention within the valleculae was noted throughout the exam cough reflex was initiated induced by aspiration impression relatively unchanged aspiration with thin liquid and nectar that is partially responsive to chin tuck please refer to the speech pathologist note in ccc for further details brief hospital course urosepsis patient was initially admitted to the icu for care and started on meropenem and azithromycin imipenem vancomycin for broad antibiotic coverage blood pressure stabilized with ivf boluses stim was appropriate following hemodynamically stability and the results of his urine culture antibiotics were scaled back to levofloxacin for the uti with the addition of flagyl given concern for concurrent aspiration pneumonia blood cultures were negative patient will complete a total of days of antibiotics case discussed with dr who was comfortable with discontinuation of indwelling foley placed on admission and resumption of patient s regimen of regular straight catheterization emphasis with compliance with his tid regimen was made prior to discharge given his recent urinary tract infection troponin leak with new lbbb patient s cardiologist followed along while the patient was in the unit ckmb remained flat and echo was essentially unchanged the patient was thought to most likely have had demand ischemia in the setting of his hypotension he was continued on his asa and acei no beta blocker reportedly due to severe bradycardia ldl off any statin atrial fibrillation coumadin was initially held on admission but restarted prior to discharge he is on digoxin for rate control and had no rate issues aspiration pneumonia patient has a history of aspiration pneumonia he has been permitted thin liquids in the past but video eval concerning and given recurrent episodes speech recommends nectar thick liquids with soft solids to be continued at home as well patient is completing a day course of levo flagyl for his current aspiration pneumonia he is stable on room air at the time of discharge including with ambulation s p fall patient had a mechanical fall week prior to admission he complained of right rib pain but cxr without overt fracture no evidence of hematoma overlying bruising he did undergo a ct while in house given complaints of a mild headache this showed no evidence of intracranial bleeding orthostatic hypotension noted on pt evaluation spep upep folate b and lytes all normal patient given a fluid bolus to improve his volume status and will follow up with his primary for continued monitoring likely the digoxin is contributing to a blunted heart rate response patient warned to be slow and deliberate with positional changes to minimize his risk of falling ventricular heart failure ef patient was restarted on his home lasix and acei prior to discharge parkinson s stable on carbidopa levodopa fen nectar thick liquids and soft solids with aspiration precautions ensure pudding tid given low albumin code full communication hcp cell and daughter is second hcp dispo patient was discharged home with services for vitals check home pt and medication assistance medications on admission lisinopril mg daily omeprazole mg daily aspirin mg daily digoxin mcg daily carbidopa levodopa tid colace lasix mg daily warfarin being held mvi keflex mg daily discharge medications coumadin mg tablet sig tablets po once a day please resume your regular coumadin regimen lisinopril mg tablet sig one tablet po daily daily omeprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day aspirin mg tablet chewable sig one tablet chewable po daily daily digoxin mcg tablet sig one tablet po every day except friday carbidopa levodopa mg tablet sig one tablet po tid times a day docusate sodium mg capsule sig one capsule po bid times a day furosemide mg tablet sig one tablet po daily daily hexavitamin tablet sig one cap po daily daily levofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills metronidazole mg tablet sig one tablet po tid times a day for days disp tablet s refills discharge disposition home with service facility all care vna of greater discharge diagnosis primary urosepsis aspiration pneumonia s p mechanical fall orthostatic hypotension secondary atrial fibrillation cad s p cabg biventricular heart failure parkinson s disease discharge condition good ambulating with pt stable on room air blood pressure normal discharge instructions please call your doctor or go to the emergency room if you experience temperature chills chest pain worsening cough or other concerning symptoms because you have a diagnosis of heart failure you should weigh yourself every morning call your doctor if your weight increases by lbs or more limit yourself to gm of sodium per day adhere to a liter fluid restriction per day because right now there is evidence that you are aspirating thin liquids you must thicken all of your liquids until you have a repeat swallow test that shows you are no longer aspirating to maintain your nutrition please take ensure puddings per day given your current urinary tract infection you must straight cath at least times per day be sure to follow up with dr to discuss the results of tests sent to work up the decrease in your blood pressure when you stand and to discuss if further testing is needed to schedule a follow up swallow study in month to continue adjustment of your coumadin as needed please follow the speech swallow recommendations to decrease your risk of aspirating you must add thickener to all liquids to create nectar thickened consistency any solid food you eat should be of a soft consistency always do a chin tuck as you were instructed when you swallow to decrease your risk of aspirating crush all your pills and put them in puree followup instructions dr office will contact you with an appointment to see him within weeks please call tomorrow to confirm the time date of your appointment phone please call to schedule follow up with dr within weeks phone [NEW_RECORD] admission date discharge date service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint rigors major surgical or invasive procedure none history of present illness mr is an year old gentleman with history of cad s p cabg chf with biventricular systolic dysfunction ef atrial fibrillation on coumadin bph s p turp parkinson s disease and recurrent utis due to intermittent catheterizations who presents from home with day of rigors and cough he had been in his usual state of health until two days prior to admission he noted a sore throat and fatigue but no associated shortness of breath on the day of admission his voice was hoarse and he had a cough productive of yellow sputum he has a nursing assistant who lives in his home and was monitoring q h temperatures which had been normal until pm this evening when she got a temp of high for him and noted that his whole body was shaking he was brought to by ems reportedly no recent nausea vomiting diarrhea or urinary symptoms of note the patient reports frequent episodes of food going down the wrong tube and resultant coughing fits he has been on a dysphagia and nectar thickened diet during past admissions to in the ed vs were t rectal bp hr rr o sat on ra on l nc with g pr tylenol temperature improved to systolic bp remained stable in high s to low s labs notable for elevated white count with bandemia lactate blood and urine cultures sent chest xray was consistent with a new multifocal pneumonia lul head ct negative for bleed he was given cc ns boluses one dose of ceftazidime gm x and vancomycin gm x while in the ed per ed discussion with daughter dnr but intubation ok on arrival to the floor he denies any shortness of breath chest pain lightheadedness dizziness denies any dysuria urinary frequency no sick contacts at baseline mr is able to feed himself and go on short walks around his block can walk mile w o shortness of breath oriented x he and his wife have nursing assistance at their home in and have multiple family members who live near by past medical history coronary artery disease status post cabg in no cath since then atrial fibrillation on coumadin biventricular heart failure with an ef of mild as mr benign prostatic hypertrophy status post turp x now x daily catheterizations and keflex chronic suppression anemia for which he receives darbepoetin every weeks macular degeneration in left eye multiple utis last culture showed e coli and corynebacterium diphtheroid resistant to cipro levo bactrim amp but sensitive to ceftriaxone uti in grew bactrim ticarcillin and fq resistant bacteria uti in grew pan sensitive enterobacter cloacae parkinson s disease social history former smoker quit years ago he drank etoh regularly until years ago and now only drinks rarely lives at home with wife wife with dementia has hour caretaker active walks independently and independent of adls plays golf family very involved with his care hcp cell and daughter is second hcp used to be in the navy then worked in a creamery and then owned two restaurants and was in catering before he retired family history non contributory physical exam vs t bp hr rr o sat on humidified o gen thin elderly appearing male in nad heent dry mm eomi perrl neck no lad no thyromegaly no carotid bruits pulm scattered rhonchi no wheezes or rhonchi cor s irregularly irregular systolic murmur at apex radiating to axilla abdomen scaphoid nontender nondistended no organomegaly extremities no cyanosis or edema le cool to touch neuro aox year resting tremor bradykineasia cn ii xii intact 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 am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts bands lymphs monos eos baso atyps metas myelos nrbc pm blood pt ptt inr pt pm blood pt ptt inr pt am blood pt ptt inr pt 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 amylase totbili pm blood alt ast ld ldh alkphos amylase totbili am blood ck mb mb indx ctropnt pm blood calcium phos mg am blood caltibc vitb folate ferritn trf am blood cortsol pm blood cortsol am blood digoxin am blood type art fio po pco ph caltco base xs pm blood type art po pco ph caltco base xs intubat intubated pm blood type art rates peep fio po pco ph caltco base xs assist con intubat intubated pm blood type art temp rates tidal v fio po pco ph caltco base xs assist con intubat intubated am blood type art temp rates tidal v fio po pco ph caltco base xs assist con intubat intubated am blood type art po pco ph caltco base xs pm blood lactate am blood lactate studies cxr frontal chest radiograph new multifocal patchy bilateral airspace opacities are seen left greater than right cardiac and mediastinal contours appear stable again seen is evidence of prior cabg pulmonary vascularity remains within normal limits no definite pleural effusions identified impression findings consistent with multifocal pneumonia ct head findings there is no evidence of acute intracranial hemorrhage shift of normally midline structures or hydrocephalus again seen are focal lacunes involving the right caudate head and bilateral cerebral hemispheres these do not appear significantly changed compared to prior study white matter differentiation appears grossly preserved again noted is a hypoplastic right maxillary sinus no mucosal thickening is seen in the visualized paranasal sinuses impression no evidence of acute intracranial hemorrhage old lacunes in the right caudate head and bilateral cerebellar hemispheres again seen unchanged from prior tte no obvious vegetations seen on mitral aortic or tricuspid valves although due to valvular thickening the sensitivity of tte to detect endocarditis is decreased severe left ventricular systolic dysfunction mild right ventricular systolic dysfunction mild to moderate aortic stenosis moderate pulmonary hypertension moderate mitral regurgitation biatrial enlargement compared with the prior study images reviewed of left ventricular systolic function has declined estimated pulmonary artery pressures are higher right ventricular dysfunction is now present the heart rate is markedly faster the severity of mitral regurgitation has increased brief hospital course assessment and plan y o m with history of cad s p cabg chf ef af on coumadin who presents to the ed with day of rigors found to have new multifocal pneumonia with progressively worsening respiratory status ultimately intubated however continued to do poorly and decision made to change goals of care to comfort measures only pt expired respiratory distress pt with gradually worsening respiratory status specifically increased rr worsening ronchi on exam and cxr with worsening bilateral infiltrates concerning for ards decision made to proceed with intubation on elevated rr hypoxia however agreed to d trial as pt would not want tracheostomy per family he was continued on abx empirically for now awaiting sputum cx respiratory status continued to worsen despite intubation with rising pressures and poor oxygenation decision made to change goals of care to comfort measures only and pt expired on sepsis presented with rigors and cough temperature to bandemia and tachycardia hr s in ed with evidence of multifocal pna on cxr also some confusion upon arrival to ed pt treated with broad spectrum antibiotics for empiric coverage blood and urine cultures sent in ed attempted to get sputum culture pt given aggressive fluid resuscitation to maintain map received cc in ed with minimal uop and continued to receive ivf in micu however ultimately started levophed and then added neo given episodes of tachycardia culture data remained unremakrable throughout hospital course some yeast in sputum sample however pt treatd wtih ceftaz vanco and flagyl empirically sbps remained stable after fluid resuscitation and pt did tolerate gentle diuresis given pulmonary edema contributing to hypoxia however required pressors as above ultimately given hypotension and worsening respiratory status decision made to change goals of care to comfort measures only on and pt expired that day cardiac ischemia h o cad s p cabg no chest pain currently pt continued outpatient regimen of aspirin digoxin initially held amiodarone started dig level not toxic ce unremarkable check dig level with am labs rhythm pt with atrial fibrillation inr supratherapeutic thus held warfarin for supratherapeutic inr not on beta omr due to severe bradycardia on wide complex tachycardia given amio mg iv load and amiodarone gtt for svt with aberrancy vs vt with some improvement in rate given likely is abberancy d c d amdio in favor of diltiazem mg iv bolus then dilt gtt for afib also restarted dig as above pump last echo done which showed ef with mild as mild mr and lasix for now given borderline bps bph requires tid catheterizations and prophylaxis pt continued on home regimen of daily keflex and foley placed anemia baseline of on admission hematocrit likely hemoconcentrated from depleted intravascular volume however remained stable throughout admission disease pt continued on carbidopa levodopa as per home regimen fen npo as diet given tenuous respiratory status ppx supratherapeutic coumadin ppi bowel regimen code initially dnr only per family and patient ok to intubate discussed with daughter and son again plan will be for d trial of intubation with plan to reassess goals of care at that time specifically re trach however pt continued to do poorly with difficult to maintain oxygenation on and blood pressure on neo and levo and decision made to change goals of care to comfort measures only pt expired medications on admission medications from last d c summary carbidopa levodopa mg po tid digoxin mcg tablet daily aspirin mg tablet daily cephalexin mg capsule q h mg tablet daily docusate sodium mg daily lasix mg tablet every monday thursday saturday coumadin mg tablet daily on monday takes mg omeprazole mg capsule daily discharge medications pt expired discharge disposition expired discharge diagnosis pt expired discharge condition pt expired discharge instructions pt expired followup instructions pt expired,"{
""Diagnoses"": [""Coronary artery disease"", ""Congestive heart failure with ventricular systolic dysfunction"", ""Atrial fibrillation"", ""BPH"", ""TURP requiring"", ""Urinary tract infection""],
""Medications"": [""SP Cabg"", ""Efavirenz"", ""Amlodipine"", ""Lisinopril"", ""Losartan"", ""Furosemide"", ""Hydrocodone"", ""Atorvastatin"", ""Omeprazole"", ""Coumadin"", ""Keflex""]
}"
12835,admission date discharge date date of birth sex f service emergency allergies sulfa sulfonamides ampicillin codeine attending chief complaint cerebral hemorrhage major surgical or invasive procedure none history of present illness f with pmh notable for hypertension dm who was found by daughter with whom she lives at am pt was per report gurgling with vomit in her mouth and on her pillow she was unresponsive to her daughter s calls and was breathing heavily she had previously been seen at at pm the night before totally fine at her baseline mental status ems was called and pt was intubated in the field due to lack of gag reflex and poor mental status she was not sedated for the intubation in the ed the pt was noted to be unresponsive initial vitals were hr bp rr sat on the vent pt was not sedzated and had gcs of ct head revealed large hemorrhagic cva with midline shift and transtentorial and tonsillar herniation neurosurgery consult confirmed grim prognosis and likely irreversible neurologic injury extensive discussion between the patient s supportive family and the ed staff resulted in a decision to focus on pt comfort pt was made dnr dni although she would remain intubated she was transferred to the icu for further care past medical history hypertension diabetes mellitus dementia glaucoma legally blind subarachnoid hemorrhage status post fall in social history the patient lives with her daughter alcohol or tobacco use she has another daughter in the area and two grandsons who helps care for her family hx mother with daughter died of gastric ca family history nc physical exam gen elderly cachectic female intubated and unresponsive heent small right pupil opacified left dry mm intubated anicteric sclerae neck supple no lad heart rr no m g t lungs coarse bs b l abd soft scaffoid nabs ext warm thin nonpalpable pulses neuro unresponsive right pupil minimally reactive left eye opacified unable to assess cranial nerves muscles nl bulk but flaccid tone cannot assess sensation areflexic patellae and babinski b l pertinent results am wbc rbc hgb hct mcv mch mchc rdw am neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg am glucose lactate na k cl tco am urea n creat ct head there is a massive area of hemorrhage in the right frontal pariatrial region that that has caused shift of midline of cm this massive hemorrhage is associated with surrounding edema and also extends to the right lateral ventricle there is also enlargement of temporal horns of lateral ventricles suggesting non communicating hydrocephalus there is blood in the fourth ventricle and there is complete obliteration of the cisterns there is also nonvisualization of any csf space at foramen magnum suggesting inferior vermian herniation there is also no space around the mid brain suggesting transtentorial herniation the bone windows do not show any signs of fracture there are no extra axial hemorrhages impression massive right fronto parietal hemorrhage with associated shift of midline and severe mass effect and non communicating hydrocephalus and transtentorial and inferior tonsillar herniation brief hospital course patient is a yo female history notable for htn and sah p w massive intracranial hemorrage with likely irreversible neurologic injury family wishes pt be comfortable asking her to remain intubated since several family members are coming to see her subarrachnoid hemmorhage and herniation based on physical exam and respiratory status pt met criteria for brain death the et tube was removed and the patient subsequently expired at medications on admission metformin lipitor qd lisinopril mg discharge medications none discharge disposition expired discharge diagnosis expired discharge condition expired discharge instructions expired followup instructions expired,"{
""Diagnoses"": [""Cerebral hemorrhage""],
""Medications"": [""Sulfa"", ""Sulfonamides"", ""Ampicillin"", ""Codeine"", ""Attending chief complaint"", ""DNR"", ""DNI""]
}"
4427,admission date discharge date date of birth sex f service neurosurgery history of present illness the patient is a year old woman diagnosed with a nonruptured carotid ophthalmic aneurysm past medical history occipital neuralgia status post tens placement low back pain pernicious anemia status post appendectomy status post gastric stapling status post total abdominal hysterectomy status post multiple lumbosacral discectomies left breast lumpectomy and varicose vein stripping allergies steroids benadryl codeine and ibuprofen physical examination blood pressure was pulse in general she was a woman in no acute distress heent pupils were equal round and reactive to light extraocular movements full sclerae clear neck no lymphadenopathy no thyromegaly or nodules negative bruit chest clear to auscultation cardiac s and s had a regular rate and rhythm no murmurs abdomen soft positive bowel sounds no masses extremities negative ankle edema strength was reflexes were throughout cranial nerves were intact hospital course the patient was admitted status post a left pterional craniotomy for clipping of an ophthalmic artery aneurysm without intraoperative complications postoperatively the patient was monitored in the intensive care unit her vital signs were stable she was afebrile she was awake alert and oriented x pupils were equal round and reactive to light extraocular movements were full visual fields were full to confrontation bilaterally on postoperative day one she had a postoperative angiogram which showed good clipping of the aneurysm with no complications from the procedure she was in the intensive care unit until when she was transferred to the regular floor she was out of bed ambulating tolerating a regular diet neurologically intact she was discharged to home on discharge medications percocet tablets p o q hours p r n pain celexa mg p o q d premarin mg p o q day condition on discharge stable at the time of discharge follow up she will follow up for staple removal on before pm and with dr in two weeks m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex f service neurosurgery history of present illness the patient has a history of intracranial carotid stenosis and patient has had multiple intracranial aneurysms with prior coiling of the left ophthalmic unsuccessfully and a clipping in now with problems with intracranial carotid stenosis on the right side allergies codeine indomethacin benadryl ibuprofen and tape past medical history prior gastric bypass in pernicious anemia rheumatic arthritis versus fibromyalgia left l l surgery x lumpectomy in the past laminotomy with decompression of c ganglion in orif of the ankle hospital course patient was admitted status post a left ica stent placement without complication the patient had actual stent and coil embolization of this ica aneurysm her procedure went well she was monitored in the recovery room overnight her vital signs were stable she was afebrile she was awake alert and oriented times three pupils are equal round and reactive to light eoms full visual fields were intact bilateral groin sheaths were removed on post procedure day without evidence of hematoma her groin sites were clean dry and intact she had positive pedal pulses her strength was in all muscle groups post procedure day the groin sheaths were removed her groin sites were clean dry and intact she was transferred to the regular floor in stable condition her medications hydromorphone mg p o q h prn for headache pantoprazole mg p o q h colace mg p o b i d venlafaxine xr mg p o q d plavix mg p o q d aspirin p o q d condition on discharge patient s condition was stable at the time of discharge follow up instructions she will follow up with dr in weeks m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex f service nsu history of present illness the patient had a history of intractable headache and multiple intracranial aneurysms with prior coiling of the left ophthalmic and a clipping in she comes now for coil embolization with stent assistance for of the remaining right ica aneurysm allergies codeine indomethacin benadryl ibuprofen and tape past medical history prior gastric bypass surgery in pernicious anemia rheumatic arthritis versus fibromyalgia left l l surgery times six lumpectomy in the past laminotomy with decompression of c ganglion in open reduction internal fixation of the right ankle hospital course the patient was admitted with a right internal carotid artery aneurysm in the recovery room her vital signs were stable and she was afebrile awake alert and oriented times three her pupils are equal round and reactive to light and accommodation her extraocular movements were full visual fields were intact her strength was in all muscle groups the patient had embolization of right internal carotid aneurysm with stent assistance which was technically successful on postoperative day number one her temperature was her blood pressure was running her pulse rate in the s and her respiratory rate was she was percent on two liters her laboratories were within normal limits she was alert and oriented times three her vision was full to confrontation all fields grip was ips were and no drift left groin had a pressure dressing on it pedal pulses were palpable her assessment and plan at that time was that she was neurologically stable she was on aspirin and plavix advanced diet out of bed discontinued the arterial line and transferred to the floor check hematocrit at noon and temperature on postoperative day number two the patient was ambulating without difficulty dressing was clean and dry and intact and she was to be discharged home condition on discharge her condition was stable at the time of discharge follow up she will follow up with dr in one to two weeks p a dictated by medquist d t job,"{
""Diagnoses"": [""nonruptured carotid ophthalmic aneurysm"", ""occipital neuralgia"", ""low back pain"", ""pernicious anemia"", ""status post tens placement"", ""status post appendectomy"", ""status post gastric stapling"", ""status post total abdominal hysterectomy"", ""status post multiple lumbosacral discectomies"", ""left breast lumpectomy"", ""varicose vein stripping""],
""Medications"": [""steroids"", ""benadryl"", ""codeine"", ""ibuprofen""]
}"
91451,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint shortness of breath major surgical or invasive procedure none history of present illness yo male with multiple medical problems including copd type diabetes mellitus hypertension hyperlipidemia and prostate cancer was admitted from the emergency department with shortness of breath and chest pain patient is a poor historian and history was obtained via phone translator he was recently admitted to from with a copd exacerbation for which he was treated with oral steroids and nebulizers and discharged with a prednisone taper he was then seen in the ed on with urinary retention for which he had a foley placed and he was discharged with urology follow up since that time he reports elevated blood pressures at home and associated shortness of breath additional symptoms include increased yellow nonbloody sputum production and chest pain he cannot describe his chest pain any further he denies fevers shaking chills night sweats abdominal pain nausea vomiting or diarrhea upon arrival in the ed temp hr bp rr and pulse ox on nrb his exam was notable for diffuse wheezes his labs were generally unremarkable he recieved nitroglycerin sl x aspirin mg po x albuterol neb x methylprednisolone mg iv x morphine mg iv x ipratropium neb x ciprofloxacin mg po x and magnesium gm iv x he was started on a nitro gtt for persistently elevated blood pressure upon arrival to the floor he reports being very hungry and feeling somewhat short of breath but denies chest pain he also reports dysuria but denies any other symptoms past medical history copd fev fev fvc type diabetes mellitus hba c hypertension hyperlipidemia bronchiectasis obesity cataracts s p cataract surgery h o tobacco abuse h o prostate ca s p prostatectomy c b urinary inctontinence and more recently urinary retention h o rpr s p im penicillin in h o ppd cxr negative pt reports mo treatment with a pill social history patient has a former history of heavy tobacco use estimated at ppd for years having stopped years ago he denies alcohol or illicit drug use he worked as a carpenter family history non contributory physical exam vitals gen lying in bed audible wheezes speaking clearly in full sentences fatigued appearing no acute distress heent clear op mmm neck supple no lad no jvd cv regular rhythm tachycardic nl s s no murmurs rubs or gallops lungs diffuse wheezes and rhonchi throughout no crackles good air exchange abd soft nt nd nl bs no hsm ext no edema dp pulses bl skin no lesions neuro a ox appropriate cn grossly intact strength throughout normal coordination gait assessment deferred psych listens and responds to questions appropriately pleasant pertinent results cxr frontal view chest the lungs are clear without focal consolidation pleural effusion or pneumothorax there is no pulmonary edema mild cardiomegaly is stable tortuous aortic contour is noted impression no acute cardiopulmonary process mild cardiomegaly stable brief hospital course yo male with multiple medical problems including copd type diabetes mellitus and hypertension was admitted from the ed with shortness of breath shortness of breath he was treated for a copd exacerbation possibly exacerbated by bronchitis he was initially admitted to the icu and treated with iv steroids overnight and transitioned to po in icu next day he continued albuterol and tiotropium nebs standing he was treated with augmentin and improved to his baseline over his hours of admission he remains a high risk for readmission as his symptoms are exacerbated by his apartment which he describes as stuffy he was set up with visiting nurses for nursing and vital sign management as well as teaching atypical chest pain he ruled out for mi and chest pain resolved as his respiratory status improved hypertension blood pressure was elevated in the setting of respiratory distress but improved with clinical improvement and he was discharged on his home blood pressure medications he was treated in the ed with a nitroglycerin drip type diabetes mellitus initially treated with a sliding scale and then resumed metformin gerd stable continued ppi hyperlipidemia stable continued statin urinary retention with bacterial colonization mr had recently developed urinary retention and had a foley placed the foley was removed with no difficulty he had no further symptoms of a uti he had repeat urine culture which showed two different ecoli species and was discharged only to complete the augmentin course for his uri bronchitis of note he is colonized by esbl e coli comm hcp medications on admission albuterol mcg puffs q h prn doxazosin mg po qhs fluticasone salmeterol inh hctz mg po daily lisinopril mg po daily metformin mg po bid montelukast mg po daily simvastatin mg po qhs tiotropium inh daily prednisone taper omeprazole mg po bid ibuprofen mg po tid prn budesonide inh atropine eye drops drop per eye ipratropium puff times daily albuterol inh q h prn sob wheezing discharge medications albuterol sulfate mg ml solution for nebulization sig one nebulizer inhalation q h every hours as needed for shortness of breath or wheezing tiotropium bromide mcg capsule w inhalation device sig one cap inhalation daily daily hydrochlorothiazide mg capsule sig one capsule po daily daily lisinopril mg tablet sig one tablet po daily daily simvastatin mg tablet sig two tablet po daily daily metformin mg tablet sig one tablet po bid times a day omeprazole mg capsule delayed release e c sig one capsule delayed release e c po bid times a day doxazosin mg tablet sig one tablet po hs at bedtime prednisone mg tablet sig taper tablet po once a day tablets for days tablets for days tablets for days tablets for days tablets for days tablet for days over days disp qs tablet s refills augmentin mg tablet sig one tablet po three times a day for days acetaminophen mg tablet sig tablets po q h every hours as needed fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day montelukast mg tablet sig one tablet po once a day atropine care drops ophthalmic ibuprofen mg tablet sig one tablet po three times a day as needed for fever or pain atrovent hfa mcg actuation aerosol sig puff inhalation every six hours budesonide mcg inhalation aerosol powdr breath activated inhalation discharge disposition home with service facility vna discharge diagnosis copd exacerbation urinary retention hypertension diabetes mellitus ii hypertension discharge condition stable ambulating without difficulty not hypoxic foley catheter removed urinating freely discharge instructions you were admitted with an exacerbation of your lung disease you were treated with steroids and nebulizers and you improved return to the ed if your symptoms worsen recur with worsening shortness of breath high fevers chills chest pain palpitations followup instructions provider function lab phone date time provider interpret w lab no check in intepretation billing date time provider dr phone date time [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 dyspnea major surgical or invasive procedure none history of present illness yo male with multiple medical problems including copd type diabetes mellitus hypertension hyperlipidemia and prostate cancer was admitted from the emergency department with shortness of breath patient speaks creole and history was obtained via phone translator pt is also a very poor historian the patient has had multiple ed visits and admission for copd exacerbation he was recently admitted to from for copd exacerbation for which he was treated with oral steroids nebulizers and discharged with a prednisone taper and day course of levofloxacin the patient was seen by his pcp and reportly at his baseline he was started on mg prednisone daily the patient reports that he was at his baseline but became more sob this am he reports that he has been compliant with his medications although prior records reports that he has had difficulty due to his social situation with med compliance he denied any fevers or chills he has a baseline cough that is unchanged and no increase or change in his sputum he also reports no sick contacts and does not know what triggers his episodes he denied night sweats abdominal pain nausea vomiting or diarrhea upon arrival in the ed temp hr bp rr and on continuous albuterol neb the patient had increased wob sob and wheezes but improved with the nebs he did not require bipap he was given methylprednisolone mg iv x and azithromycin mg x upon arrival to the icu he reports being very hungry he states that his breathing is much improved he denied sob or cp he was ambulating around the unit asking for dinner past medical history copd fev fev fvc type diabetes mellitus hba c hypertension hyperlipidemia bronchiectasis obesity cataracts s p cataract surgery h o tobacco abuse h o prostate ca s p prostatectomy c b urinary inctontinence and more recently urinary retention h o rpr s p im penicillin in h o ppd cxr negative pt reports mo treatment with a pill social history home lives in an apartment building alone supportive family occupation previously employed as a carpenter etoh denies drugs denies tobacco former history of heavy tobacco use estimated at ppd for years having stopped years ago family history noncontributory physical exam t hr rr on cont neb gen sitting in a chair speaking clearly in full sentences mildly fatigued appearing no acute distress minimal accessory muscle use heent clear op dry mm neck supple no lad no jvd cv regular rhythm tachycardic nl s s no murmurs rubs or gallops lungs diffuse insp ext wheezes moderate air movement no crackles abd soft nt nd nl bs no hsm ext no edema dp pulses bl skin no lesions neuro a ox appropriate cn grossly intact strength throughout normal coordination gait assessment deferred psych listens and responds to questions appropriately pleasant pertinent results labs on admission wbc rbc hgb hct mcv mch mchc rdw plt ct neuts bands lymphs monos eos baso pt ptt inr pt glucose urean creat na k cl hco angap calcium phos mg abg temp o flow po pco ph caltco base xs glucose lactate k on discharge wbc rbc hgb hct mcv mch mchc rdw plt ct neuts lymphs monos eos baso glucose urean creat na k cl hco angap cardiac enzymes pm ck cpk ck mb ctropnt pm ck cpk ck mb ctropnt am ck cpk ck mb ctropnt cxr the lungs appear clear bilaterally with no areas of focal consolidation the cardiomediastinal silhouette is within normal limits unchanged no pleural effusion or pneumothorax is seen the aorta is somewhat tortuous stable impression no acute cardiothoracic process ecg sinus normal axis intervals no significant change from cxr impression persistent cardiomegaly no failure no pneumonia brief hospital course dyspnea patient with known history and multiple prior admissions with clinical exam consistent with copd exacerbation he improved with nebs and steroids his abg on the floor was was consistent with compensated respiratory acidosis given patient s normal ph and chronically elevated bicarb this is likely his baseline pt exacerbation likely in the setting of med non compliance no evidence of infection on cxr afebrile no wbc although pt with elevated lactate no evidence of volume overload or infiltrate low suspicion for pe discharged on steroid taper and albuterol sulfate mcg actuation hfa aerosol inhaler hypertension pt bp is sbp s continued his home bp meds chronic renal insuff pt with cr which is near his recent baseline continued home bp regimen of hctz and ace i and monitored closely anemia hematocrit on admission down to with baseline of previous iron studies showed iron deficiency email sent to pcp to suggest further workup of causes of his iron deficiency anemia bph continued home doxazosin type diabetes mellitus stable but may be elevated in the setting of steriods given statin for cardiac protection gerd stable continued ppi hyperlipidemia stable continued home statin medications on admission albuterol mcg puffs q h prn doxazosin mg po qhs fluticasone salmeterol inh hctz mg po daily lisinopril mg po daily metformin mg po bid montelukast mg po daily simvastatin mg po qhs tiotropium inh daily prednisone taper omeprazole mg po bid ibuprofen mg po tid prn budesonide inh atropine eye drops drop per eye ipratropium puff times daily albuterol inh q h prn sob wheezing clonazepam mg prn finasteride mg daily prednisone mg daily discharge medications albuterol sulfate mcg actuation hfa aerosol inhaler sig puffs inhalation every hours as needed for shortness of breath or wheezing disp inhaler refills doxazosin mg tablet sig one tablet po hs at bedtime fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day hydrochlorothiazide mg tablet sig one tablet po once a day lisinopril mg tablet sig one tablet po once a day metformin mg tablet sig one tablet po twice a day montelukast mg tablet sig one tablet po daily daily simvastatin mg tablet sig one tablet po daily daily spiriva with handihaler mcg capsule w inhalation device sig one inhalation once a day omeprazole mg capsule delayed release e c sig one capsule delayed release e c po bid times a day ibuprofen mg tablet sig one tablet po three times a day as needed for pain budesonide mg ml suspension for nebulization sig inhale inhalation twice a day atropine drops sig one drop ophthalmic times a day clonazepam mg tablet sig one tablet po twice a day finasteride mg tablet sig one tablet po once a day prednisone mg tablet sig as directed tablet po once a day prednisone mg daily through then mg daily then mg daily then mg qod until pcp disp tablet s refills discharge disposition home with service facility vna discharge diagnosis primary copd exacerbation secondary type diabetes mellitus hypertension hyperlipidemia chronic renal insufficiency discharge condition patient ambulating without o has inspiratory expiratory wheeze but good air movement stable bp tolerating po diet discharge instructions it was a pleasure taking care of you while you were in the hospital you were admitted to because of a copd exacerbation you were given steroids and nebulizers your breathing improved with these measures and you returned to baseline you were monitored in the icu but did not require additional respiratory support we also checked your labs and you did not have a heart attack please follow the medications prescribed below prednisone mg daily through prednisone mg daily prednisone mg daily prednisone mg every other day until pcp please follow up with the appointments below please call your pcp or go to the ed if you experience chest pain palpitations shortness of breath nausea vomiting fevers chills or other concerning symptoms followup instructions provider d phone date time provider md phone date time provider unit phone date time [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint dyspnea major surgical or invasive procedure none history of present illness year old male with dm hypertension copd and prostate cancer s p prostatectomy who presented with progressively worsening shortness of breath he had worsening shortness of breath at home not responding to nebulizer treatments so was brought in by ambulance to the ed denies any fever or cough at home no chest pain of note patient is frequently hospitalized with asthma copd exacerbations most recently on at and has been on a steroid taper since then because of his frequent hospitalizations he and his pcp have been considering a stay in pulmonary rehab in the near future however he has not gone yet in the ed initally rr and pt appeared to be in distress although maintaining o sat in the mid s on nonrebreather pt received methylprednisolone iv mg azithromycin gm iv albuterol and ipratroprium nebss and foley was placed he was placed on bipap abg on bipap showed ph improved from prior to bipap started although no full abg from that point appeared mroe comfortable on bipap as well and rr improved to s attempted to wean off bipap however rr increased to s again and pt became tachycardic so was placed on bipap again prior to transfer on arrival to the icu pt complains of pain in his l ankle which is chronic and stable otherwise has no complaints appears comfortable on bipap review of systems per hpi denies fever chills night sweats recent weight loss or gain denies headache sinus tenderness rhinorrhea or congestion denies cough shortness of breath or wheezing denies chest pain chest pressure palpitations or weakness denies nausea vomiting diarrhea constipation abdominal pain or changes in bowel habits denies dysuria frequency or urgency denies arthralgias or myalgias denies rashes or skin changes past medical history dm not on insulin hypertension hyperlipidemia asthma copd followed by dr bronchiectasis reactive airway disease ckd prostate cancer s p prostatectomy obesity cataracts s p cataract surgery tobacco abuse history positive rpr s p im penicillin in positive ppd cxr negative pt reports mo treatment osteopenia urinary incontinence possible l ankle gout treated with prednisone chronic diastolic chf social history lives at home with his wife mon sat he has four children he is from and come to the u s in has smoked for years ppd but has quit many years ago no drugs or alcohol family history not significant for asthma physical exam admission physical exam vitals bipap general alert oriented appears comfortable on bipap heent sclera anicteric mmm oropharynx clear neck supple jvp difficult to assess due to body habitus no lad lungs wheezes and rhonchi throughout cv regular rate and rhythm normal s s no murmurs rubs gallops however difficult to hear given respiratory wheezes abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly gu foley in place ext warmm well perfused pulses no clubbing cyanosis pitting edema in lle chronic per pt discharge exam vs tm afebrile tc hr s s bp s s s rr sao ra i o fsg s general x nad uncomfortable lying in bed eyes x anicteric perrl conjunctival injection and crusting around the eyes ent x mmm oropharynx clear hard of hearing neck no lad jvp cvs x rrr x nl s s x no mrg x no edema lungs no rales no wheeze x comfortable diffuse expiratory wheeze improved from yesterday abdomen x soft x nontender bowel sounds present no hepatosplenomegaly skin no rashes warm dry decubitus ulcers lymph no cervical lad no axillary lad no inguinal lad neuro x oriented x x fluent speech psych x alert x calm x mood affect appropriate pertinent results admission lab results 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 fibrino am blood glucose urean creat na k cl hco angap am blood type art rates tidal v peep po pco ph caltco base xs intubat not intuba vent spontaneou comment mask am blood glucose lactate na k cl calhco am blood hgb calchct o sat cohgb methgb am blood freeca micro blood culture ngtd imaging cxr findings the view is lordotic the heart is at the upper limits of normal size the aorta is moderately tortuous the mediastinal and hilar contours appear unremarkable there is a patchy opacity in the right costophrenic sulcus probably atelectasis although it is difficult to exclude a small pleural effusion no definite pleural effusion is seen however there is no pneumothorax impression no definite acute disease discharge notable labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap studies pending at discharge none brief hospital course year old male with type diabetes on metformin hypertension chronic lung disease copd vs asthma vs partially steroid responsive ild and prostate cancer s p prostatectomy admitted with shortness of breath due to an exacerbation of the patient s chronic lung disease copd asthma exacerbation exacerbation of chronic underlying lung disease the patient was initially admitted to the intensive care unit and treated with bipap in addition to steroids and azithromycin for respiratory acidosis cxr showed no obvious infiltrate and it was felt that the patient was experiencing a flare of his underlying lung disease he improved on bronchodilators steroids and azithromycin in discussion with the patient s dr it is unclear what the patient s underlying lung disease is as he does not have significant obstruction on his pfts and does have some restriction given his repeated admissions and improvement with steroids it is possible that the patient has another steroid responsive underlying lung disease such as chronic eosinophillic pneumonia or ild the patient was discharged on a week prednisone taper and will follow up with pcp and pulmonology shortly after completion of taper for further evaluation the patient was continued on ppi and started on calcium vitamin d as he is on steroid taper often pcp was deferred based on converation with the patient s dr he was continued on his home advair as well as anti allergic regimen including flonase nasal spray and fexofenadine chronic diastolic heart failure hypertension hyperlipidemia it was not felt that the patient s acute respiratory illness was due to decompensated heart disease and he was continued on his maintenance diuretics home antihypertensives and statin anemia baseline hct this was stable and there was no evidence of bleeding stage iii chronic kidney disease baseline cr remained stable through admission type diabetes mellitus patient was continued on metformin and sliding scale insulin was instituted prostate cancer s p prostatectomy c b incontinence tamsulosin was continued gastritis continued home omeprazole and carafate code full disposition patient was discharged home to complete week steroid taper and to fu with pcp and pulmonology in weeks medications on admission albuterol sulfate mg ml solution for nebulization use s inhaled every hours uses times a day a month in addition to the already given he has been using it incorrectly albuterol sulfate proair hfa mcg hfa aerosol inhaler puffs s inhaled q h as needed for shortness of breath or wheezing atropine drops drops s in the right eye twice a day azelastine mcg aerosol spray spray each nostril twice a day benzonatate mg capsule three times a day as needed for as needed for cough budesonide mg ml suspension for nebulization vial twice a day fluticasone mcg spray suspension puff s each nostril once a day for allergies running nose fluticasone salmeterol advair diskus mcg mcg dose disk with device puff po twice a day for asthma furosemide mg tablet one tablet s by mouth as directed please send pills in bottle hydrocodone acetaminophen mg mg tablet tablet s by mouth four times a day as needed for pain lactulose gram ml solution ml solution s by mouth once a day as needed for constipation lisinopril mg tablet tablet s by mouth once a day for blood pressure loratadine mg tablet tablet s by mouth once a day as needed for nasal congestion metformin mg tablet tablet s by mouth twice a day for diabetes also called glucophage montelukast singulair mg tablet tablet s by mouth once a day for breathing omeprazole mg capsule delayed release e c capsule s by mouth twice a day oxybutynin chloride mg tablet extended rel hr tablet s by mouth once a day as needed for urine frequency send in separate bottle not dose pack prednisolone acetate drops suspension drop r eye twice a day seated rolling walker use once a day simvastatin mg tablet tablet s by mouth qhs daily for cholesterol sucralfate gram tablet tablet s by mouth three times a day tamsulosin mg capsule ext release hr one capsule s by mouth once a day medications otc acetaminophen mg tablet tablet s by mouth three times a day with ibuprofen as needed for pain also called tylenol blood sugar diagnostic contour test strips strip use once a day blood glucose meter ascensia contour use twice a day calcium carbonate mg calcium mg tablet chewable tablet s by mouth daily daily calcium carbonate vit d min mg mg unit tablet chewable tablet s by mouth twice a day docusate sodium mg capsule capsule s by mouth twice a day lancets one touch ultrasoft lancets misc use twice a day discharge medications albuterol sulfate mg ml solution for nebulization sig one neb inhalation q h every hours as needed for shortness of breath or wheezing please use regularly every hours until starting use only as needed atropine drops sig one drop ophthalmic times a day azelastine mcg aerosol spray sig one spray to each nostril nasal twice a day cholecalciferol vitamin d unit tablet sig two tablet po daily daily calcium carbonate mg calcium mg tablet chewable sig one tablet chewable po bid times a day sucralfate gram tablet sig one tablet po tid times a day fluticasone mcg actuation spray suspension sig one spray nasal daily daily as needed for runny nose 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 lisinopril mg tablet sig two tablet po daily daily metformin mg tablet sig one tablet po bid times a day omeprazole mg capsule delayed release e c sig two capsule delayed release e c po bid times a day disp capsule delayed release e c s refills ipratropium bromide solution sig one neb inhalation q h every hours as needed for shortness of breath or wheezing use every hours until then starting use only as needed for shortness of breath loratadine mg tablet sig one tablet po once a day as needed for nasal congestion montelukast mg tablet sig one tablet po daily daily prednisolone acetate drops suspension sig one drop ophthalmic times a day simvastatin mg tablet sig two tablet po qhs once a day at bedtime acetaminophen mg tablet sig two tablet po q h every hours as needed for pain tamsulosin mg capsule ext release hr sig one capsule ext release hr po hs at bedtime colace mg capsule sig one capsule po twice a day lactulose gram ml ml solution sig fifteen ml po once a day as needed for constipation prednisone mg tablet sig as directed tablet po as directed please take as following tabs on tabs on tabs on tabs on tab on disp tablet s refills discharge disposition home discharge diagnosis copd exacerbation chronic diastolic heart failure hypertension hyperlipidemia type diabetes mellitus gastritis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted with shortness of breath and felt to have an exacerbation of your chronic lung disease you were started on steroids with improvement in your symptoms and are being discharged on a steroid taper please make sure to follow the instructions properly as written to taper your steroids please also use your nebulizers and inhalers regularly even if you feel well for the next days also please follow up with your pcp and as scheduled below followup instructions department st hlth ctr kcss when friday at am with md building ma campus off campus best parking free parking on site department pulmonary function lab when monday at am with pulmonary function lab building campus east best parking garage department medical specialties pulmonary when monday at am with rn dr building sc clinical ctr campus east best parking garage,"{
""Diagnoses"": [""shortness of breath"", ""chest pain"", ""copd exacerbation"", ""hypertension"", ""hyperlipidemia"", ""prostate cancer""],
""Medications"": [""oral steroids"", ""nebulizers"", ""prednisone"", ""foley""]
}"
5236,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint increasing fatigue major surgical or invasive procedure s p mvr mm mechanical cabgx lima lad svg pda maze history of present illness patient is a year old male with history of htn and dyslipidemia who was transferred from osh for cardiac cath prior to mitral valve surgery for severe mr reports that he was in his usual state of health until about months ago when he started noticing increasing fatigue upon exertion he did not experience any overt breathing difficulties but states that shortness of breath may have accompanied his fatigue occasionally patient had gone to his pcp on for a routine physical examination he was found to be in new onset atrial fibrillations with t wave inversions and he was sent to an osh for cardioversion patient was without complaints of chest pain shortness of breath palpitations leg swelling at that time patient received a tee at the osh which showed an lvef flail mitral valve with severe mr flow m s mildly dilated lv no evidence of thrombus moderate tr and moderate pulmonary htn patient received asa heparin gtt lopressor po q h protonix lipitor mg and lasix mg x at osh patient was then transferred to for cardiac cath patient has been asymptomatic except for an occasional dry cough worse when lying flat patient denies chest pain shortness of breath palpitations patient denies dyspnea on exertion but his routine exercise is limited and he works an office job past medical history htn dyslipidemia social history patient is a retired air force pilot who now works at an office patient lives with his wife denies etoh use patient smoked ppd for years and quit years ago denies drug use history family history sister has cad and had stents placed parents htn physical exam pe t bp hr gen patient in nad lying comfortably in hospital bed heent neck supple no carotid bruits jvd cm perrl cv s s irregularly irregular rhythm grade iii vi holosystolic crescendo decrescendo systolic ejection murmur best heard at apex pmi laterally displaced difficult to palpate abd soft nt nd no appreciable organomegaly bs ext dps no c c e pertinent results am blood hct pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt pm blood plt ct pm blood pt ptt inr pt am blood urean creat k brief hospital course mr was admitted on an echo from an outside hospital that showed a partially flail mitral leaflet and severe mr was taken on for cardiac catheterization which showed ef mr rca lesion lcx and lad lesions he was evaluated by dr for surgical intervention and it was decided that he would benefit from surgery he had an evaluation by the dental service and it was determined that tooth had a lesion on the distal root it was decided that the patient could be on perioperative antibiotics and have the tooth evaluated and extracted after surgery he was started on ampicillin and was taken to the operating room on by dr and underwent mvr with mechanical valve cabgx with lima lad and svg pda and a maze procedure for atrial fibrillation please see operative note for further details he was transferred to the intensive care unit in stable condition and was weaned and extubated from mechanical ventilation on pod without difficulty his chest tubes and pacing wires were removed without incident and he was stared on coumadin for his mechanical valve and atrial fibrillation he was started on amiodarone to help convert the patient to sinus rhythm on pod he was transferred from the icu to the regular floor and began ambulating with physical therapy he was able to walk feet and climb flight of stairs without difficulty and his inr was he was cleared for discharge to home on pod medications on admission maxzide mg po qd lipitor mg po qd discharge medications docusate sodium mg capsule sig one capsule po bid times a day for months disp capsule s refills furosemide mg tablet sig one tablet po twice a day 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 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 every hours as needed for pain disp tablet s refills atorvastatin calcium mg tablet sig one tablet po daily daily disp tablet s refills amiodarone mg tablet sig one tablet po bid times a day for months disp tablet s refills ampicillin mg capsule sig one capsule po q h every hours for weeks disp capsule s refills metoprolol tartrate mg tablet sig tablet po bid times a day disp tablet s refills coumadin mg tablet sig one tablet po once a day for days then per dr office disp tablet s refills discharge disposition home with service facility bayada nurses inc discharge diagnosis cad mr s p cabg mvr maze atrial fibrillation htn hypercholesterolemia discharge condition good discharge instructions you may take a shower and wash your incision with mild soap and water do not swim or take a bath for month do not apply lotions creams ointments or powders to your incisions do not lift anything heavier than pounds for month do not drive for month followup instructions follow up with dr office by phone on for your inr and coumadin dosing follow up with dr in the office in weeks follow up with dr in weeks follow up with dr in weeks follow up with your dentist for evaluation of tooth for possible extraction continue the antibiotics until cleared by your dentist completed by,"{
""Diagnoses"": [""cardiothoracic"", ""atrial fibrillations"", ""t wave inversions"", ""severe mitral valve regurgitation"", ""moderate tr""],
""Medications"": [""s p mvr"", ""lima lad"", ""pda maze"", ""mechanical cabgx""]
}"
54911,admission date discharge date date of birth sex m service medicine allergies zosyn attending chief complaint evaluation for liver transplant major surgical or invasive procedure multiple paracenteses cvvh multiple bone marrow biopsies multiple blood transfusions central line placement history of present illness yo m with h o alcoholic and hcv cirrhosis transferred from hospital for decompensated liver failure pt was admitted to osh for an elective tips procedure for refractory ascites pt underwent tips on complicated by liver laceration and massive hemorrhage requiring transfusion he subsequently underwent ir embolization of superior medial liver segment via the right superior subsegmental branch segment following embolization on the pt was transferred to the sicu and on pt underwent tips revision by ir using a covered endograft stent extending the tips shunt slightly further into the main portal vein excluding part of the left portal vein and right portal vein branches in an attempt to stop bleeding felt to be originating at either the extracapsular portion of the shunt or possibly a right posterior and inferior portal vein branch pt s mental status continued to be poor following tips revision and lactulose was started for hepatic encephalopathy he was finally intubated on for worsening mental status and hypoxia pt was treated for sepsis with broad spectrum abx and pna now only being treated with zosyn during the last week patient was been more stable weaning on his pressors currently on vasopress in only and is being transferred for urgent transplant evaluation according to pt had an episode of seizure activity on transfer for which he received mg of ativan and this resolved past medical history past medical history etoh hcv cirrhosis past surgical history tips procedure ir embolization of subsegmental branch of rha segm tips revision and l paracentesis social history social history h o etoh abuse last drink months ago family history family history unknown at this point physical exam physical examination on admission t hr bp rr so cmv x peep general intubated off sedation skin macerated ecchymotic lesions throughout the extremities and flanks neuro non responsive off sedation no voluntary movements does not respond to pain appropriate pupillary corneal and me reflexes lungs diminished breath sounds on both bases cardiac regular rate and rhythm s s abd soft mod to severe distension ascites nontender rectal normal tone no gross blood guaiac negative extrem warm well perfused edema bilaterally 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 fibrino pm blood glucose urean creat na k cl hco angap pm blood alt ast ld ldh alkphos amylase totbili pm blood lipase pm blood albumin calcium phos mg iron pm blood caltibc hapto ferritn trf please see attached paperwork with lab trends blood toxo toxoplasma igg antibody final toxoplasma igm antibody final report toxoplasma igg antibody final negative for toxoplasma igg antibody by eia iu ml reference range negative iu ml positive iu ml toxoplasma igm antibody final negative for toxoplasma igm antibody by eia interpretation no antibody detected blood ebv virus vca igg ab final virus ebna igg ab final virus vca igm ab final final report virus vca igg ab final positive by eia virus ebna igg ab final positive by eia virus vca igm ab final negative by ifa am immunology final report hcv viral load final hcv rna not detected blood cmv ab cmv igg antibody final cmv igm antibody cmv igg antibody final positive for cmv igg antibody by eia au ml reference range negative au ml positive au ml cmv igm antibody final negative for cmv igm antibody by eia interpretation infection at undetermined time serology blood varicella zoster igg serology varicella zoster igg serology final positive by eia serology blood rubella igg igm antibody rubella igg igm antibody final positive by latex agglutination serology blood rapid plasma reagin test final report rapid plasma reagin test final nonreactive reference range non reactive micro respiratory culture yeast stool clostridium difficile toxin a b test negative ascitic fluid culture ngtd stool clostridium difficile toxin a b test negative stool clostridium difficile toxin a b test negative pleural fluid gram stain final fluid culture no growth anaerobic culture no growth catheter tip iv wound culture no growth bronchoalveolar lavage gram stain final respiratory culture f yeast urine urine culture final peritoneal fluid gram stain final fluid culture no growth anaerobic culture no growth blood culture no growth blood culture no growth sputum gram stain final respiratory culture final yeast peritoneal fluid gram stain final fluid culture no growth anaerobic culture no growth fungal culture no growth acid fast smear no growth acid fast culture ngtd ascitic fluid cx no growth peritoneal fluid gram stain final fluid culture no growth anaerobic culture no growth acid fast culture ngtd acid fast smear final mini bal gram stain final respiratory culture no growth potassium hydroxide preparation final fungal culture yeast stool clostridium difficile toxin a b test negative peritoneal fluid gram stain final fluid culture no growth anaerobic culture no growth fungal culture no growth blood culture no growth sputum gram stain final respiratory culture no growth urine culture no growth blood culture no growth blood culture no growth imaging cxr some air is now present within the left lung though a large left hemothorax is still present with mediastinal shift impression some re expansion of left lung mediastinal shift persists ct torso ct of the chest there is a large left pleural effusion distributed in almost entire left hemithorax leading to right sided displacement of mediastinal structures the remnant left lung tissue seen predominantly in the anterior aspect of the left hemithorax demonstrates diffuse ground glass opacities the left pleural effusion demonstrates layering of the fluid with dependent area measures hounsfield units in attenuation consistent with hemorrhagic component there is moderate right pleural effusion measuring in attenuation with adjacent areas of compressive atelectasis essentially unchanged from exam the visualized portions of the right lung demonstrates diffuse opacities which are likely infectious in etiology the heart is of normal size without pericardial effusion the right and left internal jugular central venous catheters terminate within the svc the endotracheal tube terminates several centimeters above the carina ct of the abdomen there is massive ascites within the abdomen unchanged from exam there is hyperdense fluid material in the most dependent area within the left upper abdomen measuring hounsfield units in attenuation suggestive of the hemorrhagic component the liver is markedly diminished in size the surface morphology appears nodular consistent with cirrhosis a tips shunt is in unchanged position within limitations of a non contrast exam spleen adrenal glands and kidneys appear unremarkable an ivc filter within the infrarenal ivc is noted intra abdominal aorta is notable for calcified atherosclerotic disease without aneurysmal changes ct of the pelvis a foley catheter is in place large amount of fluid within the pelvis is noted there is no free air the rectum is displaced posteriorly and there is an adjacent area of hyperdense fluid measuring hounsfield units in attenuation consistent with hemorrhagic fluid osseous structures no suspicious lytic or sclerotic lesions are seen impression large left pleural effusion with hemorrhagic component with right sided displacement of the mediastinal structures moderate right pleural effusion unchanged from exam visualized portions of the lungs demonstrate diffuse opacities likely infectious in nature massive amount of ascites unchanged from exam however there are areas of hyperdense fluid within the left upper abdomen and pelvis with high attenuation consistent with hemorrhage the liver is markedly diminished in size and nodular in morphology consistent with cirrhosis a tips shunt is in unchanged position cta abd pelvis impression cirrhosis splenomegaly and varices changes of chemoembolization and tips resolving hemoperitoneum without evidence of active extravasation enlarging left and stable moderate right pleural effusions bibasilar consolidation consistent with pneumonia l compression fracture and l l posterior fixation post pyloric tube placement bone marrow biopsy diagnosis cellular bone marrow with trilineage maturing hematopoiesis increased histiocytes and morphologic features highly suggestive of marrow injury see note note the bone marrow evaluation is significant for evidence of cellular injury and macrophage infiltration with frequent hemophagocytic histiocytes in a background of left shifted myelopoiesis and reactive plasmacytosis the findings are similar to the patient s previous bone marrow biopsy and the differential diagnostic considerations for marrow injury include drugs medication toxins infections metabolic and immune causes the presence of hemophagocytic histiocytes is itself a non specific finding and must be interpreted in the appropriate clinical context importantly neutropenia developed after the tips procedure and in concert with metabolic decompensation microscopic description peripheral blood smear erythrocytes are decreased and exhibit marked anisocytosis with microcytic and macrocytic forms and marked poikilocytosis with numerous echinocytes acanthocytes and scattered red cell fragments and schistocytes few forms with coarse basophilic stippling and pappenheimer bodies are seen the white blood cell count appears markedly decreased neutrophils include some forms with toxic granulation rare hemophagocytic histiocytes are noted platelet count appears markedly decreased differential shows neutrophils bands lymphocytes monocytes eosinophils basophils aspirate smear the aspirate material is adequate for evaluation it consists of several cellular spicules any background histiocytes are present some containing ingested debris and several with ingested marrow precursor cells and erythrocytes hemophagocytosis the m e ratio is erythroid precursors are normal n number with normoblastic maturation myeloid precursors appear normal in number and show left shifted maturation megakaryocytes are present in decreased numbers based on a cell differential blasts promyelocytes myelocytes metamyelocytes bands neutrophils plasma cells lymphocytes erythroid clot section and biopsy slides the biopsy material is adequate for evaluation and consists of trabecular bone with an overall marrow cellularity of scattered collections of histiocytes containing ingested debris and cellular material are present plasma cells are abundant and present singly and in small clusters comprising approximately of overall cellularity focal marrow fibrosis is seen the m e ratio estimate is normal erythroid precursors are normal in number and have normoblastic maturation myeloid elements are normal in number and exhibit normal maturation megakaryocytes are present in decreased numbers marrow clot section adds no additional information the findings are very similar to those seen on a previous bone marrow biopsy s m ct head impression no evidence for an acute intracranial process abd us impression nodular cirrhotic liver tips stent in situ which is patent with normal flow the main portal vein is patent with normal flow the hepatic veins and hepatic artery patent with normal flow large amount of intra abdominal ascites tte the left atrium is normal in size left ventricular wall thickness cavity size and regional global systolic function are normal lvef the right ventricular cavity is markedly dilated with depressed free wall contractility there is abnormal septal motion position consistent with right ventricular pressure volume overload 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 no mitral valve prolapse mild mitral regurgitation is seen tricuspid regurgitation is present but cannot be quantified the estimated pulmonary artery systolic pressure is normal there is no pericardial effusion ct torso impression large amount of intra abdominal and intrapelvic free fluid with hounsfield units suggesting a combination of ascites and hemoperitoneum consistent with patient s known ascites and recent liver laceration bilateral patchy airspace consolidations are suggestive of multifocal pneumonia there is also bilateral moderate pleural effusions with adjacent relaxation atelectasis shrunken liver consistent with cirrhosis with hyperdense material in segment vii and viii consistent with recent embolization tips catheter is visualized in place from the main portal vein to the inferior vena cava l compression fracture with l through l posterior fixation and bilateral pedicular screws through l and l gastric tube and endotracheal tube tips remain in place brief hospital course sicu course mr was admitted to the sicu with fulminant liver failure following a tips procedure complicated by a bleed requiring embolization of segment and revision of his tips on initial admission his gcs was he was transferred from hospital intubated and on levophed for blood pressure support a full workup for transplant listing was initiated which included serologies liver duplex echo ct torso ct head and placement of a dobhoff tube postpyloric for feeding an initial ct scan of his head was negative for any significant pathology and it was felt that his current mental status was likely due to his liver failure neurology was consulted for evaluation of his mental status and during that time he had a tonic clonic seizure for which he was loaded and maintained on keppra an initial diagnostic paracentesis of his abdomen excluded spontaneous bacterial peritonitis and cvvh was initiated for his acute renal failure after his acute decompensation at hospital he was intially treated with zosyn at hospital during his decompensation and shortly after the start of zosyn he developed neutropenia his zosyn was discontinued here and cefepime was started emprically for his pneumonia a bal culture eventually grew yeast and he was started on fluconazole for coverage hematology was consulted regarding his neutropenia and a bone marrow biopsy was performed on which eventually showed agranulocytosis likely acute reaction to acute illness or medication he continued to remain neutropenic and coagulopathic from his liver disease with intermittent need for trasnfusions he also remained on cvvh for fluid removal with an inability to tolerate hd due to labile blood pressures his mental status improved and on he was arousable and able to follow commands on he continued to require ventilatory support but was awake and following commands he underwent a therapeutic paracentesis for liters of ascitic fluid the cefepime was discontinued with no positive culture data and levofloxacin was started for neutropenic prophylaxis he underwent a second paracentesis on for liters he continued to remain neutropenic with a wbc of with the continuation of his neupogen and he continued to require intermittent cvvh for fluid removal attempts to wean him from ventilatory support failed and he continued to remain coagulopathic from his liver disease a repeat bone marrow biopsy was performed on and during this time had a hypotensive episode requiring neosynephrine for blood pressure support he was eventually weaned from his requirement for neosynephrine the bone marrow biopsy did not demonstrate any signs of a malignant process and on his wbc started to increase he remained intubated with an inability to be weaned likely secondary to his deconditioned state his neutropenia continued to improve with a wbc of on and on although he had a normal wbc on he remained neutropenic and developed a neutropenic fever to that morning with hypotension requiring neosynephrine and empiric vancomycin meropenem and micafungin was started and later stopped without positive culture data multiple cultures were sent with only positive cultures growing yeast the last of which was from a bal he continued to remain coagulopathic with a need for intermittent blood product transfusions and on ventilatory support for his deconditioned respiratory failure he also remained on neosynephrine without a clear etiology on it was decided at liver allocation meeting that mr was not a liver transplant candidate dr had an extensive meeting with the family to notify them that he would not be listed for liver transplant and his care was transitioned to the micu service at this time micu course hypotension the patient was transferred with continued need for pressors neo initially was felt hypovolemia as patient was l net negative for los however hct began to trend down with an point hct drop over hours on cxr and ct chest revealed hemothorax on left where left hd line had been placed given his tenuous clinical status and his lack of synthetic function making clotting difficult it was decided not to evacuate this with a chest tube but instead to support him with blood products including platelets and cryo his hcts did stabilize however he still required pressor support anitbiotics were broadened to vanc day for a planned day course aztreonam day for a planned day course cipro day for a planned day course flagyl day for a planned day course micafungin day for a planned day course for yeast in the sputum in the hope of treating a septic etiology but he continued to be reliant on neo to keep maps at this point it was felt the hypotension may be secondary to vasodilation in setting of liver failure midodrine was added on and uptitrated to mg po tid on in hopes of weaning him off neo respiratory failure patient was transferred to the micu after having been intubated for days tracheostomy had been deferred in sicu neutropenia however on transfer to micu patient was no longer neutropenic unfortunately patient did develop the hemothorax see above and continued to require pressor support so tracheostomy was deferred additionally concerns regarding a trach in the setting of his coagulopathy prevented pursual of trach placement he failed daily sbts and required assist control ventilation likely due to deconditioning from his prolonged hospitalization acute renal failure thought hepato renal syndrome patient was transferred to the micu on cvvh in setting of hypotension cvvh was initially run even and then with hemothorax around hd line discontinued his creatinine contineud to trend up off cvvh is days off cvvh renal did not feel cvvh was indicated as he was not a transplant candidate and that he would be unable to tolerate intermittent hd in the setting of hypotension requiring neo cirrhosis liver failure patient was initially transferred to for workup for liver transplant however was deemed not a candidate deconditioned state family was interested in transfer to for possible transfer and he was accepted for transfer on during his stay in the micu he underwent a therapeutic paracentesis due to abd pain from increasing ascites on during which l of ascitic fluid was removed of note he will need cipro weekly for sbp ppx once off broad spectrum antibiotics goals of care multiple discussions have been held with the patient s wife his hcp regarding his poor prognosis however she wishes for further evaluation for liver transplant she contact a transplant surgeon at who agreed to accept him in transfer for further evaluation for liver transplantation code status full code medications on admission meds on transfer zosyn octreotide tid chlorhexidine oral rinse hydrocortisone tid iss lactulose reglan tid protronix daily rifaximin tid vasopressin gtt discharge medications chlorhexidine gluconate mouthwash sig five ml mucous membrane times a day glucagon human recombinant mg recon soln sig one recon soln injection q min as needed for hypoglycemia protocol rifaximin mg tablet sig one tablet po bid times a day nystatin unit g cream sig one appl topical times a day as needed for irritation levetiracetam mg ml solution sig five ml po daily daily phenylephrine hcl mg ml solution sig mcg kg min injection titrate to sbp nph insulin human recomb unit ml suspension sig ten units subcutaneous twice a day insulin regular human unit ml solution sig one sliding scale injection every six hours glucose insulin dose mg dl units mg dl units mg dl units mg dl units mg dl units mg dl units mg dl units mg dl units mg dl notify m d ipratropium bromide mcg actuation hfa aerosol inhaler sig six puff inhalation qid times a day albuterol sulfate mcg actuation hfa aerosol inhaler sig six puff inhalation q h every hours as needed for secretions lactulose gram ml syrup sig fifteen ml po bid times a day midodrine mg tablet sig one tablet po three times a day lanthanum mg tablet chewable sig two tablet chewable po tid w meals times a day with meals sodium chloride flush ml iv prn line flush temporary central access icu flush with ml normal saline daily and prn dextrose gm iv prn hypoglycemia protocol heparin flush units ml ml iv prn line flush dialysis catheter temporary lumen thin non dialysis vip lumen all nurses flush with ml normal saline followed by heparin as above daily and prn micafungin mg iv q h sodium chloride flush ml iv prn line flush temporary central access icu flush with ml normal saline daily and prn pantoprazole mg iv q h ascorbic acid mg iv q h ciprofloxacin mg iv q h aztreonam mg iv q h metronidazole flagyl mg iv q h fentanyl citrate mcg iv q h prn pain vancomycin mg recon soln sig five hundred mg intravenous dosed by level discharge disposition extended care discharge diagnosis primary liver failure hypercarbic respiratory failure acute kidney injury likely due to hepatorenal syndrome hemothorax persistent hypotension secondary alcoholic cirrhosis deconditioning discharge condition mental status confused always does not consistently follow commands is not oriented to place or time level of consciousness alert and interactive sometimes other times sleepy but arousable activity status bedbound discharge instructions you were transferred to from hospital on for evaluation for liver transplant you had a prolonged hospitalization with complications including kidney failure requiring continuous dialysis continued respiratory failure requiring mechanical ventilation persistent hypotension requiring medications to elevated your blood pressure as well as a bleed into your chest requiring multiple blood transfusions after a lengthy evaluation the liver transplant team did not feel you were a transplant candidate the liver transplant team at the agreed to accept you in transfer for further evaluation for liver transplant medication changes please see the attached medication list followup instructions you are being transferred to the hospital and will receive further care there completed by,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""m"", ""service"", ""medicine"", ""allergies"", ""Zosyn"", ""attending"", ""chief complaint"", ""evaluation for liver transplant"", ""major surgical or invasive procedure"", ""multiple paracenteses"", ""CVVH"", ""multiple bone marrow biopsies"", ""multiple blood transfusions"", ""central line placement"", ""history of present illness"", ""Yo"", ""M"", ""with H.O. alcoholic and HCV cirrhosis"", ""transferred from hospital for decompensated liver failure""],
""Medications"": [""alcoholic and HCV cirrhosis""]
}"
1085,admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint transferred from for streptococcus pneumoniae sepsis and mental status changes major surgical or invasive procedure intubation lumbar puncture thoracentesis tte history of present illness is a year old woman with a history of hodgkin s disease and splenectomy years ago who presented to with pneumococcal sepsis on and was transferred to the micu on she was in her usoh until when she developed chills diarrhea dry heaves and had several near syncopal episodes she was taken to the ed where she was febrile tachycardic and hypotensive blood cultures were drawn which eventually grew strep pneumoniae in bottles she was fluid resuscitated given xigris and treated with vancomycin and ceftriaxone follow up blood cultures were negative she developed hypoxemic respiratory failure due to fluid overload and required intubation two days after admission she was noted to be minimally responsive a head ct was negative and the family requested transfer to for further neurologic workup also of note during her admission the patient developed hyperbilirubinemia tbili direct elevated alk and thrombocytopenia nadir in addition a cxr on showed a consolidation at the right base the patient was transferred to the micu on her micu course was notable for id the patient was continued on vancomycin ceftriaxone with a planned day course an lp was negative she had a thoracentesis on of her right basilar consolidation analysis was consistent with a transudate and fluid sent for culture showed no growth she had a persistently elevated wbc in the s to s with intermittent low grade fevers repeat blood cultures and a urine culture showed no growth stool was negative for c diff pulmonary the patient responded well to diuresis and was extubated on thoracentesis as above gi the patient continued to have hyperbilirubinemia elevated alk and slightly elevated ast alt a ruq ultrasound was negative heme the patient had a persistently low hct to but her thrombocytopenia resolved she had a negative hemolysis and dic ttp hus workup hit antibody was negative at stool was guaiac negative neuro neurology consult felt that the patient s mental status changes were likely due to toxic metabolic abnormalities and sedating medication however given the finding of upgoing toes on physical exam they recommended a brain and c spine mri by the day of transfer to the floor the patient s mental status had returned to nutrition the patient was maintained on tpn and tube feeds while intubated she failed a swallow study after extubation and was on maintenance ivf on transfer to the floor past medical history hodgkin s disease s p xrt abvd and splenectomy premature ovarian failure splenectomy as above had pneumovax in hypothyroidism social history lives with her husband adopted week old baby boy and dog works at in no smoking etoh or drugs family history nc physical exam pe on admission to floor from micu vitals tc bp p r o sat on ra gen nad tired appearing heent bilateral subconjunctival hemorrhages no cervical lad cards rrr no m g r pulm coughs with deep inspiration ctab abd soft nt nd positive bowel sounds in all quadrants ext no le edema excoriated papules on l inner thigh biopsied neuro eomi perrl oriented x upgoing toes bilaterally pertinent results labs on transfer to floor from micu wbc hgb hct mcv rdw plt diff n b l m e b atyp metas pt ptt fibrinogen na k cl hc glucose alt ast alk tbili lipase ca phos mg micro csf gram stain and culture negative blood cultures from x no growth to date urine culture negative skin blister sent for herpes culture pending pleural fluid gram stain per x field polymorphonuclear leukocytes no microorganisms seen fluid culture preliminary no growth anaerobic culture preliminary no growth c diff negative cxr a right sided central venous catheter is seen with the tip positioned in the distal svc again seen are bilateral pleural effusions there has been interval removal of an et and ng tube scattered left retrocardiac atelectasis is noted the pulmonary vasculature is unchanged impression interval removal of an et and ng tube bilateral pleural effusions are again seen without any interval change ruq us normal decompressed gallbladder no evidence of intrahepatic bile duct dilatation brief hospital course pneumococcal sepsis the patient was maintained on ceftriaxone while in house vancomycin was discontinued after as cultures from showed sensitivity to ceftriaxone the patient will complete the last two days of a day course of antibiotics with po levofloxacin at home as cultures were sensitive to levofloxacin the source of her sepsis was felt to be pulmonary based on an infiltrate seen on cxr at while on the floor the patient s leukocytosis resolved and she remained afebrile the patient will follow up with dr at infectious disease clinic on for discussion of repeating the pneumovax vs prevnar mental status changes the patient s mental status changes had resolved by the time she was transferred to the floor brain and c spine mris were negative anemia while in house the patient had a stable anemia with hct about mcv and rdw were normal she was guaiac negative and had a negative hemolytic workup iron studies were negative for iron deficiency her anemia was felt to be secondary to bone marrow suppression due to infection a reticulocyte count was low consistent with bone marrow suppression thromocytopenia thrombocytosis the patient was initially thrombocytopenic with platelets on transfer from hit antibody sent at was negative dic and hemolysis labs were negative there were no schistocytes on peripheral smear after several days the patient s thrombocytopenia resolved and she developed thrombocytosis with platelets reaching a peak of on discharge a peripheral smear was negative for platelet clumping this thrombocytosis was felt to be reactive in the setting of infection and asplenia heme onc was curbsided and recommended against aspirin treatment the patient will get a follow up platelet count checked with her pcp hyperbilirubinemia transaminitis after reaching a peak tbili of the patient s hyperbilirubinemia had resolved by the time of discharge her ldh had normalized peak her alt ast and alk elevations had improved though all were still elevated at discharge alt from peak ast from peak alk from peak a ruq ultrasound was negative for liver lesions or intrahepatic bile duct dilatation these lab abnormalities were felt to have been caused by tpn chemical pancreatitis the patient had an elevated amylase peak but never had abdominal pain her amylase had decreased to by discharge heart murmur a i ii vi systolic murmur was heard on exam on the day of discharge a tte was done to rule out endocarditis it showed no vegetation dysphagia the patient received tpn and tube feeds while intubated after extubation she failed a swallowing study she refused ng tube placement and received only maintenance ivf until passing a repeat swallowing study three days later this study did however show trace aspiration and the patient will have a repeat swallowing study as an outpatient skin lesions in the micu the patient was noted to have several small erythematous papules on her left inner thigh cultures were sent for herpes which were still pending at discharge subconjunctival hemorrhages the patient had bilateral subconjunctival hemorrhages secondary to traumatic intubation an ophthalmology consult at ruled out endophthalmitis and intraocular hemorrhage hypothyroidism the patient was maintained on iv levothyroxine until she was taking po s when she was transitioned to po levothyroxine she will have her tsh checked as an outpatient ovarian failure the patient s estrogen progesterone replacement therapy was reinstituted as per her home regimen after she began taking po s disposition the patient will continue to work with physical therapy as an outpatient code status full code medications on admission home meds prior to admission levothyroxine mcg po q h medroxyprogesterone acetate mg po on days of cycle estradiol mg po q h discharge medications levothyroxine mcg po q h medroxyprogesterone acetate mg po on days of cycle estradiol mg po q h levofloxacin mg po qd x days first dose discharge disposition home with service facility discharge diagnosis pneumococcal sepsis hypoxic respiratory failure hyperbilirubinemia transaminitis thrombocytopenia reactive thrombocytosis anemia chemical pancreatitis pleural effusion discharge condition ambulating with pt urinating bming on own tolerating po diet discharge instructions if you have fevers chills shortness of breath or abdominal pain please call your doctor or come to the er please complete all your antibiotics please have your platelet count checked on friday followup instructions you have an appointment at the infectious disease clinic with dr date time a m the specific question to address with dr is whether the standard pneumovax or prevnar is more appropriate for you please call your pcp to make an appointment within the next two weeks you will need to get your tsh thyroid test rechecked and to follow up on the biopsy of your l thigh lesions md completed by,"{
""Diagnoses"": [""pneumococcal sepsis"", ""hypoxemic respiratory failure"", ""fluid overload""],
""Medications"": [""Xigris"", ""vancomycin"", ""ceftriaxone""]
}"
27846,unit no admission date discharge date date of birth sex f service nb post discharge name baby girl is a gram product of a di di and week twin gestation with an estimated date of confinement of she was born to a year old g p mother with prenatal screens of blood type o antibody negative rpr nonreactive rubella immune hepatitis b negative hiv negative gbs negative and a positive ppd in with a subsequent negative chest x ray and months of treatment ms was transferred from for management of her preterm twins the pregnancy was from donor eggs it was complicated by discordant growth between the twins that occurred late in gestation with being the smaller twin her labor was uncomplicated there was no maternal fever and rupture of membranes at the time of delivery this infant was born by induced vaginal delivery with apgar of at one minute and at five minutes significant family history ms suffered from premature ovarian failure at age all of her children have been from donor eggs and are from the same donor she is married to and she denies alcohol tobacco or drug use infants birth weight was kilos which was less than the th percentile her length was cm which was the th percentile head circumference was cm which was also at the th percentile summary of hospital course by systems respiratory the infant came to the nicu on room air and remained so never required any interventions has never had any spells has never been on caffeine cardiovascular the infant has had no cardiac workup she has always been on room air with heart rates in the s to the s she does not have a murmur her most recent blood pressure was with a map of she is pink and well perfused fluids electrolytes and nutrition the infant came to the nicu and started on ad lib feeds of either breast milk or premature enfamil calorie per ounce she was changed over to enfacare cals ounce and has continued to go to breast and p o well she will go home taking cal infacare as well as breast feeding her discharge weight is kilograms gi there are no issues she had a bilirubin drawn on that was over her repeat bilirubin on at the time of discharge was over hematology this baby s blood type was not drawn she has received no transfusions and did not have an initial cbc drawn infectious disease there were no prenatal risk factors for infection so the infant did not have a cbc diff or blood culture and did not receive antibiotics cmv in uriine sent because of the sga and remains negative to date neurology the infant acts appropriate and did not fit the criteria for a head ultrasound sensory and audiology passed her hearing screen on ophthalmology the infant was not examined she does not fit criteria for an ophthalmological exam immunizations hepatits b deferred until visit to pediatrician discharge physical examination the infant is alert and active swaddled in a bassinet tone is appropriate eyes are normally placed with a positive red reflex in both pupils are equal and reactive to light nose and ears are normally placed nares are patent as is the soft and hard palates tongue is appropriately placed clavicles are intact lungs are clear and equal to auscultation with no adventitious breath sounds and no retractions cardiovascular regular rate and rhythm noted s s audible no murmur appreciated pulses are and equal infant is pink warm and well perfused abdomen is soft no loops no masses no hsm appreciated cord stump is intact and dry gu near term infant female with normal female genitalia anus is patent extremities intact she moves them well and symmetrically her hips are intact without clicks or clunks spine is straight there are no or dimpling noted positive trunk and curvation assessed neuro anterior fontanel is open and flap posterior fontanel is open and flat positive positive suck positive moro positive palmar grasp elicited condition at discharge stable with the diagnoses of prematurity near term at and and iugr sga discharge disposition discharge home with parents primary pediatrician dr of appt on the care and recommendations for this infant she will go home breast feeding and being supplemented with enfacare calorie per ounce her calories can be adjusted as growth permits discharge medications none iron supplementation is recommended for pre term and low birth weight infants until months corrected age all infants fed predominantly breast milk should receive vitamin d supplementation at international units which may be provided as a multivitamin preparation daily until months corrected age car seat screening because of her small size this infant will go home in a car bed state newborn screening sent on those results are pending immunizations none the parents would prefer to hold off and have the baby receive her hepatitis b from her pediatrician immunizations recommended synagis rsv prophylaxis should be considered from through for infants who meet any of the following four criteria born at less than or equal to weeks born between and 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 hemodynamically significant congenital heart disease influenza immunizations 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 rotavirus vaccine the american academy of pediatrics recommends the 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 follow up appointments recommended would be a visit to her pediatrician in the next hours discharge diagnoses prematurity at and weeks she is considered a near term preemie iugr small for gestational age she does have urine for cmv pending and negative to date dictated by medquist d t job,"{
""Diagnoses"": [""preterm twins"", ""premature ovarian failure""],
""Medications"": [""inducing vaginal delivery"", ""apgar score"", ""rupture of membranes""]
}"
70378,admission date discharge date date of birth sex f service medicine allergies no drug allergy information on file attending chief complaint altered mental status major surgical or invasive procedure none history of present illness ms is a yof with history of opiate abuse and bipolar disorder on lamictal who was found altered on the subway a supervisor removed her from the train and ems was called upon ems arrival she was found to be unresponsive and an oral airway was placed when she arived to the ed she was apneic she was given mg intranasal narcan by ems then mg iv when access established became responsive in the ed the patient was restrained due to combative behavior thrashing vs were hr bp sat on ra she was placed on l nc and her sat came up to co monitor was o was decreased to l and the co went to fs was head ct and cxr were both normal tox screen was positive for benzodiazepines and methadone ekg showed qtc prolongation to with hr now in the s in the ed she also received l ns she was able to protect her airway but very sedated so she was transferred to the icu she reportedly denied ingestion but was able to state that she takes lamictal pt had blue card on person and ed resident talked with access nurse who confirmed history of recent admission at for opiate od also had klonipin overdose in with fetal demise on the floor the patient is nonresponsive to verbal stimulus but minimally arrousable to sternal rub her vs were rr l nc abg revealed hypercarbia and pt was given mg narcan with good effect review of systems unable to obtain as pt minimally responsive and not accompanied by family or friends past medical history bipolar disorder opiate abuse on methadone previous history benzodiazepine toxicity presumably with klonipin at complicated by fetal demise of wk intrauterine pregnancy pt denied si but claimed it was accidental ingestion in setting of multiple psychosocial stressors was enrolled in hospital for substance recovery prior to discharge heroin use hospitalized and given narcan hepatitis c asthma hx of pna head trauma x from abuse seizures states she had a w d seizure in jail weeks ago from benzos social history substance use tobacco ppd etoh drinks once a year now but had hx of binging in her teens no hx of treatment or etoh w d illicit initially addicted to oxycontin in teens then transitioned to heroin at age used iv heavily until age when she enrolled at habit co op states her last use was weeks ago after leaving jail because she could not get her methadone she used twice also has hx of cocaine use x month in the past but now uses rarely last weeks ago admits to taking more benzos than prescribed in the past denies other illicits sh origin b r in parents divorced at age lives with roommate in currently childhood parents has siblings abuse chaotic upbringing w physical and sexual abuse school completed through th grade employment unemployed on ssi relationships has bf off and on x years though recently had been in abusive relationship with another man from legal has court date upcoming for possession of class c substance with intent to distribute family history sister with substance abuse issues mother and grandmother have bipolar per her report physical exam vitals rr l nc general lethargic mildly arousable to vigorous rub and loud verbal stimuli heent pupils reactive to light mildly constricted sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs clear to auscultation bilaterally no wheezes rales ronchi cv bradycardic 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 pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood na k cl pm blood urean creat pm blood albumin calcium phos mg pm blood alt ast alkphos totbili pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg pm blood type art po pco ph caltco base xs intubat not intuba pm blood glucose lactate na k cl calhco pm blood lactate ua negative micro none images ct head no acute foci of hemorrhage cxr normal ekg nsr bpm nml axis no pr or qrs prolongation but qtc prolonged at ms no q waves twi or st changes brief hospital course yof with history of previous benzodiazepine and heroin overdose who presents with likely toxic overdose with altered mental status bradycardia decreased respiratory rate and tox screen positive for both methadone and benzodiazepines methadone benzodiazepine overdose the patient initially presented with polonged qtc bradycardia and decreased respiratory drive with a rate of abg revealed hypercapnea with pco initial labs did not reveal electrolyte abnormalities she responded to narcan in the ed and was administered another dose of mg on the floor one time with good effect her ventilation improved as the patient became more alert and after hours she was conversant her vital signs normalized she was placed on suicide precautions with a sitter although she denied intentional overdose she was evaluated by psychiatry who did not feel that she needed inpatient hospitalization and provided her with a referral to an outpatient substance abuse clinic at hospital the pateint was given one dose of mg of methadone and mg ativan for anxiety she was not provided with prescriptions for narcotics or benzodiazepines upon discharge follow up pt should follow up with hospital at am on pt should contact pcp for follow up appointment medications on admission methadone mg provided by habit discharge medications methadone mg provided by habit discharge disposition home discharge diagnosis primary diagnosis benzodiazepine overdose methadone overdose secondary diagnosis hepatitis c bipolar disorder 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 unconscious after accidentally overdosing on benzodiazepines and narcotics your breathing was dangerously low and you were given medication to treat the overdose you were admitted to the intensive care unit and monitored overnight you recovered overnight and were able to eat food without problems were evaluated by psychiatry who did not think this was an intentional overdose they recommend that you seek treatment in an outpatient substance abuse clinic it is important that you go to your appointment and seek help to prevent you from dying from your drug problem in the future followup instructions we have set up an appointment for you at the hospital located at the hospital is located in off the green st t stop on the line your appointment is set for tomorrow at am the phone number to the clinic is you should also follow up with your primary care doctor please call your primary care doctor dr to set up an appointment in the next week md,"{
""Diagnoses"": [""Ms is a YOF with history of opiate abuse and bipolar disorder""],
""Medications"": [""Lamictal"", ""Narcan""]
}"
3161,admission date discharge date date of birth sex f service csu ms is a direct admission to the operating room for aortic valve surgery she was seen in preadmission testing prior to her scheduled surgery at the time of visit in preadmission testing the patient s physical exam is as follows chief complaint asymptomatic patient history of present illness a year old woman with known as x years followed by serial echoes the last echo with worsening aortic stenosis and a diminishing aortic valve area referred for cath and followed by aortic valve replacement the patient had an echo done in that showed an ef of percent with an aortic valve area of and a peak gradient of and a mean gradient of with mild lvh plus ai and plus tr she had a cardiac cath done that showed an aortic valve gradient of with an aortic valve area of cm an ef of percent rca percent left main percent and an lad percent lesion past medical history hypertension aortic murmur hiatal hernia gerd diverticulosis hernia repair in cataract surgery in d and c in drainage of a thyroid cyst approximately years ago meds at admission cardizem cd once daily hydrochlorothiazide once daily lipitor once daily niferex once daily calcium glucosamine metamucil allergies the patient states environmental allergies as well as codeine although her reaction is simply confusion family history mother died of cad in her s father died of cad late in life social history she lives with her husband she denies tobacco use occasional alcohol use no other recreational drug use review of symptoms noncontributory physical exam vital signs heart rate blood pressure respiratory rate height feet inches weight pounds general sitting up in chair no acute distress skin warm dry and intact no lesions heent pupils equally round and reactive to light extraocular movements intact neck is supple with no jvd and no bruits but she does have a radiated murmur chest is clear to auscultation bilaterally heart regular rate and rhythm with a iv vi systolic ejection murmur abdomen is soft nontender nondistended with normoactive bowel sounds extremities are warm and well perfused with plus edema right greater than left varicosities none neurologically alert and oriented x nonfocal exam pulses femoral plus bilaterally dorsalis pedis plus bilaterally posterior tibial plus bilateral radial plus bilaterally carotid ultrasound showed less than percent stenosis bilaterally labs white count hematocrit platelets pt inr sodium potassium chloride co bun creatinine glucose alt ast alk phos amylase total bili albumin hemoglobin a c chest x ray showed no chf or pneumonia hospital course on the patient was directly admitted to the operating room where she underwent an aortic valve replacement with a number mm tissue valve her bypass time was minutes with a crossclamp time of minutes she tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit at the time of transfer the patient was in a normal sinus rhythm at beats per minute with a mean arterial pressure of and a cvp of she had propofol at mcg kg min and neo synephrine at mcg kg min the patient did well in the immediate postoperative period her anesthesia was reversed she was weaned from the ventilator and successfully extubated throughout that period she remained hemodynamically stable as she did throughout the operative day however she did require a nipride drip to maintain a blood pressure between and on postoperative day the patient continued to be hemodynamically stable she was begun on oral medications and weaned off of her nipride drip additionally her chest tubes were removed and she was transferred to the floor for continuing postoperative care and cardiac rehabilitation once on the floor the patient had an uneventful hospital course her activity level was increased with the assistance of the nursing staff as well as physical therapy on postoperative day her temporary pacing wires and her foley catheter were removed over the next days her activity level was further advanced with nursing and physical therapy assistance and on postoperative day it was decided that the patient was stable and ready to be discharged to home discharge vitals temperature heart rate sinus rhythm blood pressure respiratory rate o sat percent on room weight preoperatively kg at discharge kg lab data hematocrit sodium potassium chloride co bun creatinine glucose discharge physical exam neuro alert and oriented x moves all extremities follows commands nonfocal exam respiratory lungs clear to auscultation bilaterally cardiac regular rate and rhythm s s with no murmur sternum is stable incision with steri strips open to air clean and dry abdomen is soft nontender nondistended with normoactive bowel sounds extremities are warm and well perfused with no edema th is to be discharged to home with visiting nurses she is to have follow up with dr in weeks and follow up with dr in weeks additionally she is to have follow up with her primary care doctor once she returns to discharge diagnoses status post aortic valve replacement with a number tissue valve hypertension gastroesophageal reflux disease diverticulosis hernia repair cataracts discharged medications metoprolol mg colace mg aspirin once daily percocet tabs q hr prn atorvastatin mg once daily niferex mg once daily m d dictated by medquist d t job,"{
""Diagnoses"": [""Aortic valve surgery"", ""Aortic stenosis"", ""Aortic valve area"", ""Aortic valve gradient"", ""Mean gradient"", ""Mild LVH plus AI"", ""Mild LVH plus TR""],
""Medications"": [""Cardizem CD"", ""Hydrochlorothiazide"", ""Lipitor"", ""Niferex"", ""Calcium""]
}"
7045,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint failure to thrive major surgical or invasive procedure thoracentesis pleuroscopy chest tube placement history of present illness history of present illness mr is a yo male with pmh significant for cad dm htn cva dementia he presents with failure to thrive on this admission patient was recently discharged from osh after being admitted for fatigue and unable to stand course of hospital course is not known he was discharged to rehab on and since then has had minimal po intake and is unable to stand he presented to geriatrics clinic yesterday and was referred to the ed for further work up in the ed his initial vitals were t bp ar rr o sat ra he received asa mg po x past medical history cad s p cabg in type dm s p cva in and left basal ganglia affected patient has paresis of his right side hypertension frontal lobe dementia hypercholesterolemia gerd weight loss patient has had a greater than pound weight loss over the past three to four months social history patient has been at rehab facility since he was discharged from he lives with his wife on the bottom floor of a two family house he was independent with adls no current tobacco or alcohol use ambulates with cane family history nc physical exam vitals t bp ar rr o sat ra gen eyes closed responsive to voice difficult to understand speech heent mm dry heart nl s s no s s systolic murmur lungs decreased bs in rll posteriorly with dullness to percussion abdomen soft nt nd bs extremities no edema dp pt pulses neuro pt awake but unable to follow commands pertinent results ct chest on impression despite new small caliber right apical pleural drain large right hydropneumothorax persists with interval increase in air component and large layering fluid component containing clot asbestos related pleural plaques no pleural mass right middle and lower lobe collapse and upper lobe segmental atelectasis due to combination of retained secretions and compression by effusion bronchoscopy should be helpful to evaluate and clear the endobronchial components decreasing small left pleural effusion stable fusiform cm dilatation ascending thoracic aorta ct chest on impression large bilateral pleural effusions right greater than left with extensive continuous pleural plaque calcification due to asbestos exposure differentiation between mass mesotelioma lung ca and collapsed lung is difficult without iv we cannot exclude a mass in the right lower lobe depending on the results of pleural effusion cytology contrast enhanced ct is recommended dilatation of the ascending aorta extensive coronary calcifications extensive calcification of the aortic valve am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap pm blood ck mb pm blood ck mb mb indx ctropnt am blood ck mb mb indx ctropnt pm blood ck mb ctropnt pleural fluid chemistry protein glucose ld ldh tube pleural fluid wbc rbc poly lymph mono eos pleural fluid wbc rbc poly lymph mono eos brief hospital course mr is a yo male with pmh as listed above who presents with ftt and was found to have a large r sided pleural effusion on cxray r pleural effusion patient found to have large r sided pleural effusion on cxray in context of recent weight loss and lethargy concerned about underlying malignancy he has a past history of smoking cigars but currently has no tobacco use pt now s p thoracentesis afebrile and has no leukocytosis cytology from thoracentesis and pleural biopsies were negative although gross findings concerning for malignancy chest tube and pleurex catheters were placed chest tube has been pulled after drainage plateaued and pleural catheter still in place to drain fluid as needed fluid studies from show gram cocci in clusters cell count with diff is pending pleural fluid hematocrit is and also high counts concerning for empyema patient subsequently became hypotensive and was transferred to micu service for further management of empyema hypotension chest tube was placed patient eventually succumbed to complications from empyema and expired anemia baseline hct in low s hct on admission and dropped to and then received units prbc and bumped to had recurrent hemothorax that eventually led to patient becoming hypotensive and transferred to the icu weight loss per omr and fellow s note patient has had significant weight loss over the past several months per omr when he saw his geriatrician in he had lost lbs at that time likely underlying malignancy given new pleural effusion sister who is healthcare proxy has refused peg tube placement in the past started low dose megestrol for appetite stimulation as patient s sister has specifically requested this liver enzymes elevated particularly alkaline phos source unclear could be due to biliary stasis due to decreased po intake as ggt also elevated nutrition supplements with ensure nutrition consulted malignancy workup as above lethargy patient initially extremely tired and not responsive to commands likely related to large r sided pleural effusion has improved somewhat after thoracentesis he has also had significant weight loss with poor po intake over the past few weeks tsh wnl anemia work up as below frontal lobe dementia continue home regimen of memantine cad s p cabg patient denies chest pain on this admission patient had troponin leak after hypotensive episode continue asa beta blocker history of cva ct asa mg po daily hypertension patient does not appear to be on any medications at home although history of htn documented in omr he was started on beta blocker in ed continue metoprolol mg po bid with hold parameters type dm patient on metformin at home per omr bss s given poor po intake concerned that his bss may drop held oral regimen restarted at time of discharge communication sister medications on admission ecotrin mg daily ferrous sulfate mg daily metformin mg prilosec mg daily vitamin b compex tab daily namenda mg discharge medications n a discharge disposition expired discharge diagnosis empyema discharge condition expired discharge instructions n a followup instructions n a completed by,"{
""Diagnoses"": [""Failure to Thrive"", ""Major Surgical or Invasive Procedure"", ""Thoracentesis"", ""Pleuroscopy"", ""Chest Tube Placement""],
""Medications"": [""ASA"", ""PO"", ""CABG"", ""DM"", ""SP"", ""CVA"", ""Hypertension"", ""Frontal Lobe Dementia"", ""Hypercholesterolemia"", ""GERD"", ""Weight Loss""]
}"
93104,admission date discharge date date of birth sex f service medicine allergies codeine attending chief complaint difficulty breathing major surgical or invasive procedure placement of a midline iv history of present illness pt is a yo female with mmp incl asthma fibromyalgia and tobacco abuse here with complaint of difficulty breathing and wheezing for last days has been having similar problems for the last few months but more acute now pt states that she had fevers upto and chills at home generalized weakness and myalgias as well pt admits to a cough but hasn t been able to cough up anything denies any sick contacts denies nasal congestion or sore throat was recently treated for a uti with d course of cipro pt also complains of chest pain in the epigarstic area no radiation worse with deep inspiration and certain movements took her inhalers nebs and mg of prednisone yesterday with no improvement of symptoms of note pt went to see her pcp yesterday and had a ct chest that showed bilateral opacities she was told to come to the ed in the setting of increased sob pt was noted to have lymphadenopathy in the past and is being worked up for sarcoidosis in the ed initial vs were t p bp r o sat on ra patient s o sats went down to on ra she received nebs but was still hypoxic eventually requiring nrb pt also received l ns for ivf and solumedrol mg iv levofloxacin and ceftriaxone she was then transferred to the icu review of sytems per hpi admits to fever chills lb recent weight loss in the last wks admits to migraine headaches denies rhinorrhea or congestion admits to cough shortness of breath chest pain admits to some nausea and low po intake but denies vomiting diarrhea constipation or abdominal pain no recent change in bowel or bladder habits no dysuria admits to chronic arthritis and myalgias past medical history depression fibromyalgia asthma tobacco abuse obesity anemia internal hemorrhoids gasteoperesis gerd hiatal hernia vid d deficiency social history she is a cna worker in surgery here at but currently is on medical leave due to all of her chronic conditions she currently is smoking five cigarettes per day started at age of and smoked up to two packs per day in the past denies any alcohol use family history maternal aunt with breast cancer in her mid s maternal great aunt with breast cancer and rectal cancer of unknown age maternal grandfather diagnosed with pancreatic cancer and died at the age of mother with sarcoidosis physical exam vitals t bp p r o on nrb general alert oriented no acute distress heent mmm oropharynx clear dentures in place neck supple jvp not elevated no lad lungs diffuse wheezes no crackles cv regular rate and rhythm normal s s no murmurs rubs gallops abdomen obese soft non distended ttp in ruq bowel sounds present no rebound tenderness or guarding gu no suprapubic tenderness ext warm well perfused pulses no clubbing cyanosis or edema neuro strength in ble strength in bue decr sensation on r leg up to knee cnii xii intact gait deferred pertinent results pm urine color amber appear clear sp pm urine blood sm nitrite pos protein tr glucose neg ketone neg bilirubin sm urobilngn neg ph leuk neg pm urine rbc wbc bacteria mod yeast none epi pm urine hours random pm urine ucg negative pm urine uhold hold pm lactate pm glucose urea n creat sodium potassium chloride total co anion gap pm estgfr using this pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count wbc rbc hgb hct mcv plt ct glucose urean creat na k cl hco angap calcium phos mg imaging chest ct new widespread areas of ground glass opacities in both lungs involving all lobes with no central or peripheral predisposition as well as with no apical basal gradient with slightly more of the abnormality seen within the upper lungs the differential diagnosis might include infectious process such as viral pneumonia or mycoplasma less likely hypersensitivity pneumonitis eosinophilic pneumonia vasculitis or cop may be also suggested clinical correlation is recommended cxr the ct scan of one day prior demonstrates scattered areas of ground glass opacity throughout both lungs predominantly in the apices the current x ray study though limited as above demonstrates increased density in the left perihilar and lower lung regions it is unlikely that the process noted on the ct has resolved however some of the opacity in the left lung that is now visualized may be due to atelectasis if clinically feasible consider pa and lateral view for more sensitive evaluation however there is likely underlying evolving infection as detailed in the chest ct report cxr cardiomediastinal silhouette remains stable the patient is in mild volume overload there is still no focal consolidation demonstrated with the focal areas of ground glass opacities seen on prior chest ct from can be seen in the left upper lung and as previously mentioned might represent infectious process brief hospital course yo female with mmp incl asthma fibromyalgia and tobacco abuse admitted to icu for hypoxia respiratory distress respiratory distress hypoxia on admission to the patient was satting at on nrb patient reports this episode felt different from her usual asthma exacerbation as she felt much worse this time the differential diagnoses included cap pneumonia atypical pneumonia viral pneumonia influenza complicated by asthma exacerbation pe acs chf on differential but unlikely eosinophilic pna less likely as no peripheral eosinophila no other signs of vasculitis at this time esr and crp only mildly elevated per patient s pcp patient has long reported excessive mold in her building which could be significant given ddx includes hypersensitivity pneumonitis patient was put on levoquin for possible cap vs atypical pna cxr showed no consolidations or clear infiltrate together with her clinical exam of severe wheezing this was most consistent with viral pneumonia complicated by asthma exacerbation despite her negative viral cultures patient was put on advair flovent xopenex in addition solumedrol and singulair were started patient was initially put on high flow aerosol mask which was slowly weaned to nasal cannula on the day of transfer to floor patient walked laps on icu floor on room air with oxygen saturation of around while on the floor she remained stable with improvement in her tachycardia chest pain differential included pneumonia asthma exacerbation and chest tightness pe gerd anxiety or acs ekg showed no acute changes patient had very low risk for cad cardiac enzymes were negative x outpatient percocet was continued fibromyalgia patient complained of bilateral leg pain on admission home percocet q h prn was continued for pain home dose lyrica was continued as well depression stable home cymbalta and valium were continued gerd gasteoperesis home dose pantoprazole and ranitidine were continued vit d def home dose calcium and vitd supplementation were continued fen regular diet prophylaxis sc heparin bowel regimen code full code communication patient medications on admission albuterol sulfate mcg puffs q h as needed butalbital acetaminophen caff mg mg mg tablet qid prn ciprofloxacin mg tablet diazepam mg q h duloxetine cymbalta mg esomeprazole magnesium nexium mg fluticasone mcg sprays nasally daily advair diskus mcg mcg dose whiff s ondansetron mg q h prn for nausea oxycodone acetaminophen mg mg q hours prn for pain phenazopyridine mg tid prn pregabalin lyrica mg tretinoin retin a cream wig use as directed daily for alopecia vitamin d units m f units sasun ferrous gluconate mg daily loratadine mg tablet daily prn for allergies multivitamins minerals lutein daily ranitidine mg times daily discharge medications diazepam mg tablet sig one tablet po q h every hours as needed for anxiety duloxetine mg capsule delayed release e c sig one capsule delayed release e c po bid times a day fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills pregabalin mg capsule sig one capsule po bid times a day cholecalciferol vitamin d unit tablet sig two tablet po daily daily ferrous gluconate mg mg iron tablet sig one tablet po daily daily multivitamin tablet sig one tablet po daily daily ranitidine hcl mg tablet sig tablet po bid times a day ipratropium bromide solution sig one treatment inhalation every six hours as needed for shortness of breath or wheezing montelukast 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 bid times a day nystatin unit ml suspension sig five ml po qid times a day as needed for thrush prednisone mg tablet sig one tablet po daily daily disp tablet s refills discharge disposition home discharge diagnosis viral pneumonia asthma exacerbation discharge condition improved discharge instructions please return to the hospital if you develop fevers chills nausea vomiting chest pain or shortness of breath please follow up with dr to have a complete blood count checked and to plan a steroid taper followup instructions dr at dr phone at,"{
""Diagnoses"": [""asthma"", ""fibromyalgia"", ""tobacco abuse"", ""Sarcoidosis""],
""Medications"": [""codeine"", ""nebs"", ""prednisone""]
}"
21275,admission date discharge date service surgery purple team admission diagnosis colon cancer status post right colectomy history of present illness this is an year old man who was found to have a cecal lesion during colonoscopy for anemia given the lesion which was consistent with adenocarcinoma of the colon he was scheduled for a right colectomy by dr however this patient does have a significant coronary artery disease history so his main issue preoperatively was evaluation and cardiac clearance his cardiac history is significant for a myocardial infarction in for which he subsequently underwent bypass surgery he did undergo repeat catheterizations most recently in with stenting of a single artery echocardiograms in the past revealed an ejection fraction of with an inferior posterior wall motion abnormality the patient did have significant dyspnea on exertion preoperatively and is only able to walk up one flight of stairs sometimes not even able to achieve this he had a holter monitor examination which revealed ventricular ectopy nonsustained ventricular tachycardia episodes of av nodal wenckebach for which he underwent an exercise echocardiogram which demonstrated that the patient could only exercise for two minutes and again had premature ventricular contractions nonsustained ventricular tachycardia and sinus bradycardia with wenckebach given all of this it was felt that the patient had a sick sinus syndrome and av nodal disease with significant chronotropic incompetence for which he underwent electrophysiology evaluation for pacemaker placement however given the fact that he needed a colon resection in the near future electrophysiology did not want to place a pacemaker in him prior to the resection because of concerns related to infection with the pacemaker hence he was managed medically past medical history his past medical history is significant for the following coronary artery disease status post coronary artery bypass graft in saphenous vein graft to obtuse marginal status post percutaneous transluminal coronary angioplasty stent sick sinus syndrome valvular disease hypertension insulin dependent diabetes mellitus hyperlipidemia arthritis carotid artery stenosis of to bilaterally angina medications on discharge his medications on admission included lopressor mg p o b i d lisinopril mg p o q d imdur mg p o q d plavix mg p o q d mevacor prevacid aspirin glyburide probenecid and folate allergies no known drug allergies social history no smoking or alcohol family history his family history was noncontributory physical examination on presentation on physical examination prior to his procedure he was healthy appearing clear to auscultation his abdomen revealed no masses tenderness hernias or ascites hospital course he was given a fleets preparation kit the day prior to surgery and was admitted to the on for a colectomy on the patient underwent a right colectomy for right colon cancer by dr assisted by dr the findings were a right ascending colon mass there was cc of estimated blood loss liter of crystalloid was given intraoperatively the patient had a swan ganz catheter placed postoperatively in the postanesthesia care unit and was transferred to the intensive care unit for monitoring given concerns over his cardiac status as well as the fact that intraoperatively the patient had bradycardia to the s he was also hypertensive requiring a nitroglycerin drip for control of his blood pressure the patient had a day intensive care unit stay immediately postoperatively he was on a nitroglycerin drip for control of his blood pressure he was transfused while in the intensive care unit to maintain hematocrit in the range he was also ruled out for acute myocardial infarction he was maintained n p o until return of bowel function was noted with nasogastric tube decompression of his stomach he received a cardiology consultation while in the intensive care unit for assistance of evaluation of his cardiac status cardiology recommendations were for beta blockers and conversion to nitroglycerin paste from nitroglycerin as well as the addition of aspirin and accupril for control of his blood pressure recommendations were also to maintain hematocrit above and for implantable cardioverter defibrillator placement in the future by postoperative day four he was off of his nitroglycerin on postoperative day four his nasogastric tube was also removed and by postoperative day five he was transferred to the floor on the floor he did very well he was maintained n p o until return of bowel function he did begin having flatus by postoperative day seven and was begun on p o his diet was advanced which he tolerated very well his foley was removed and he was screened for rehabilitation however on the night between postoperative days seven and eight he did slip and fall out of bed while attempting to stand up to urinate he did not sustain and significant injuries from this by postoperative day eight given the fact that he was tolerating a regular diet hemodynamically stable with good urine output with an abdomen that was soft with an incision that was clean dry and intact without any erythema edema or induration it was felt that he was stable for discharge discharge diagnoses adenocarcinoma of the cecum status post right colectomy coronary artery disease status post coronary artery bypass graft and multiple stents sick sinus syndrome with tachy arrhythmias including nonsustained ventricular tachycardia carotid artery disease gastroesophageal reflux disease diabetes hypertension hyperlipidemia arthritis discharge diet he diet on discharge was cardiac diet medications on discharge hydralazine mg p o q i d colace mg p o b i d ambien mg p o q h s p r n probenecid mg p o b i d heparin units subcutaneous b i d imdur mg p o q d accupril mg p o q d aspirin mg p o q d sliding scale insulin metoprolol mg p o b i d protonix mg p o q d tylenol mg p o q h p r n discharge instructions his discharge instructions included the follow to follow up with his cardiologist and primary care to follow up with dr within one week for removal of his staples m d dictated by medquist d t job cclist [NEW_RECORD] admission date discharge date service history of present illness for details of mr hospital course up to please see the previously dictated discharge summary dated on the day prior to being transferred to rehabilitation last week mr developed chest pain which was associated with diaphoresis and nausea there was no vomiting no abdominal pain no jaw pain no lightheadedness no dizziness no palpitations no fluttering no radiation into the left arm the pain was described as a pressing band like pattern in the right and left upper chest ekg demonstrated pseudonormalization of the t waves with upright t s in leads v through v he was given an aspirin and started on heparin and beta blocker and morphine without any apparent relief of symptoms ck and troponin were negative for an acute mi he was sent to cath lab on where angiography showed two vessel disease in the native vessels with a patent svg to om graft and svg to diagonal and svg to pda graft occluded these occluded grafts were stable from previous catheterizations the patient was sent for a ct angiogram of the chest which demonstrated no evidence of acute pulmonary embolus or aortic dissection the patient continued to have chest pain which he described as atypical of his usual anginal pain kub was performed which demonstrated multiple air filled loops without any evidence of obvious obstruction or free air an ng tube was placed for suppression of gi tract he was observed in the ccu overnight post catheterization he had no overnight events in the ccu on the morning of he was transferred from the ccu to the medical service it was assumed that his chest pain was due to postoperative complications due to a possible postoperative ileus he had no evidence of any acute cardiopulmonary disease at the time of transfer to medicine after reaching the medicine floor the patient continued to advance his diet as tolerated he had several episodes of diarrhea on the initial day on the medial floor c diff toxin assay was negative at the time of discharge he was tolerating solid foods condition on discharge stable he will be discharged to rehabilitation discharge medications colace mg po bid ambien mg po q h s prn probenecid mg po bid heparin units subcu imdur mg po q d accupril mg po q d aspirin mg po q d metoprolol mg po bid protonix mg po q d tylenol mg po q hours prn mevacor mg po q d lasix mg po q d k dur meq po q d sliding scale insulin discharge diagnosis coronary artery disease sick sinus syndrome hypertension diabetes mellitus hypercholesterolemia osteoarthritis adenocarcinoma of the colon status post right hemicolectomy discharge status the patient will follow up with his cardiologist dr and his surgeon dr m d dictated by medquist d t job,"{
""Diagnoses"": [""colon cancer"", ""status post right colectomy""],
""Medications"": [""anemia"", ""stenting"", ""bypass surgery"", ""ventricular ectopy"", ""nonsustained ventricular tachycardia"", ""av nodal wenckebach""]
}"
59546,admission date discharge date date of birth sex m service medicine allergies penicillins attending chief complaint s p cardiac arrest major surgical or invasive procedure cardiac catheterization right internal jugular central venous catheterization intraaortic balloon pump placement arctic sun cooling protocol history of present illness yo m with cad s p cabg in ischemic cardiomyopathy ef afib on coumadin htn mr tr bifascicular block transferred from s p vtach vfib arrest the patient presented to for exercise stress testing with nuclear imaging ekgs from document a narrow complex rhythm with rate at a m between and a m there was a narrow complex tachycardia with rate depressions in v v at a m there was monomorphic vt at there was ventricular fibrillation the cardiopulmonary arrest record documents resusciation beginning at a m with the initial rhythm being vfib during the resuscitation the patient received shocks at joules plus amiodarone mg x atropine mg x epinephrine mg x and sodium bicarb x the patient was intubated after return of spontaneous circulation the patient was started on a norepinephrine infusion and transported to the cardiac catheterization lab at cardiac catheterization revealed a right dominant circulation with extensive disease of the native vessels svg lad patent svg pda occluded svg om occluded lima lad atretic on arrival the patient was intubated and sedated review of systems could not be obtained past medical history cardiac risk factors dyslipidemia hypertension cardiac history cabg percutaneous coronary interventions pacing icd other past medical history hypertension bifascicular block rbbb lafb persistent afib on coumadin pulmonary hypertension mild ar moderate mr moderate to severe tr with moderate to severe pulmonary hypertension ischemic cardiomyopathy with lvef glaucoma bph h o papilloma facial s p excision of bcc from r ear s p excision of pilonidal cyst in s p removal of wisdom teeth in social history never married lives alone retired does some work at the hockey rink tobacco history quit smoking in the etoh drinks week illicit drugs none family history unable to attain physical exam vs t bp hr rr o sat cmv general intubated sedated intraaortic balloon and arctic sun apparatus in place heent ncat sclera anicteric et tube ng tube and esophageal temperature probe in place neck right ij in place cardiac bradycardic irregular heart sounds otherwise obscured by sound of balloon pump lungs clear ventillated breath sounds anteriorly abdomen soft ntnd no hsm or tenderness abd aorta not enlarged by palpation no abdominial bruits gu foley in place extremities warm upper extremities cool lower extremities no edema neuro perrl sluggish does not respond to pain in any extremity pulses right radial dp doppler pt doppler left radial dp absent pt doppler pertinent results admission labs wbc rbc hgb hct mcv mch mchc rdw plt ct neuts lymphs monos eos baso pt ptt inr pt glucose urean creat na k cl hco angap alt ast ck cpk alkphos totbili ck mb mb indx ctropnt calcium phos mg abg fio po pco ph abg glucose lactate na k cl cardiac catheterization coronary angiography of this right dominant system demonstrated vessel native coronary artery disease the lad had a occlusion of the mid segment the distal lad filled from a svg the lcx had a occlusion of the mid segment the distal lcx filled from right to left collaterals the rca had a mid stenosis and occlusion in the distal segment arterial graft angiography showed a very atretic lima diagonal venous graft angiography showed a patent svg lad occluded svg om and patent svg rpda that had a mid graft stenosis resting hemodynamics revealed elevated right and left sided filling pressures with a rvedp of mmhg and a mean pcwp of mmhg there was moderate pulmonary arterial hypertension with a pa pressure of mmhg central aortic pressure was mmhg on norepinephrine the cardiac index was low at l min m a fiberoptix intra aortic balloon pump was inserted from the left common femoral artery final diagnosis three vessel coronary artery disease patent svg lad and svg rpda atretic lima diagonal occluded svg om cardiogenic shock moderate pulmonary hypertension elevated biventricular filling pressures cxr portable ap et tube tip is in standard position cm above the carina ng tube tip is in the stomach the side port is just at the level of the ge junction right ij catheter tip is in the lower svc swan ganz catheter tip is in the pulmonary outflow tract iabp tip cm below the top of the aortic arch there is moderate cardiomegaly there is no pneumothorax pleural effusion or pulmonary edema sternal wires are aligned patient is status post cabg ill defined opacity inferiorly to the right hilum could be atelectasis aspiration is another consideration echo transthoracic the left atrium is moderately dilated left ventricular wall thicknesses are normal the left ventricular cavity is mildly dilated there is mild regional left ventricular systolic dysfunction with thinning and akinesis of the basal inferior wall and inferolateral wall and hypokinesis of the basal to mid inferior septum and mid inferior and inferolateral segments the right ventricular cavity is dilated with depressed free wall contractility the aortic valve leaflets are moderately thickened there is no aortic valve stenosis mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse moderate mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened the estimated pulmonary artery systolic pressure is normal the pulmonic valve leaflets are thickened there is no pericardial effusion impression focal lv systolic dysfunction consistent with prior inferior mi moderate mitral and mild aortic regurgitation the right ventricle is not well seen but is probably dilated hypokinetic cxr pa and lateral in comparison with the study of there is no interval change icd implant remains in place with the tip in the region of the apex of the right ventricle no evidence of pneumothorax no vascular congestion pleural effusion or acute focal pneumonia brief hospital course yo m with cad s p cabg ischemic cardiomyopathy ef afib on coumadin htn mr tr bifascicular block transferred from s p vtach vfib arrest s p cardiac arrest the patient was transferred from after resuscitation from vtach vfib arrest on arrival to he was taken directly to the cardiac catheterization lab where an intraaortic balloon pump was placed the patient was then transferred to the ccu and the arctic sun cooling protolol was initiated after hours of cooling to degrees the patient was warmed after warming the patient s mental status gradually improved until he was alert fully oriented and able to converse appropriately continuous eeg revealed no evidence of epilepiform activity the etiology of the the patient s vt was thought to be scar mediated an icd was placed for secondary prevention the initial intent was to place a dual chamber icd but the lv lead failed to capture so single lead device to placed cardiogenic shock in the cardiac catheterization lab hemodynamics revealed an elevated pulmonary artery wedge pressure with a low cardiac index consistent with cardiogenic shock an intraaortic balloon pump was inserted the patient was treated with norepinephrine which was later changed to dopamine in the setting of bradycardia following rewarming the patient had been weaned off of pressors and the intraaortic balloon pump metoprolol was started but other home antihypertensives were held coronary artery disease the patient underwent cardiac catheterization on this revealed extensive vessel cad with patent svg lad and svg rpda grafts with an occluded svg om graft and an atretic limi diagonal graft no intervention was made the patient was treated with aspirin and lipitor beta blockade was held in the setting of cardiogenic shock cooling and bradycardia but was restarted as the patient s condition improved atrial fibrillation the patient was in slow atrial fibrillation during the cooling protocol dopamine was started for bradycardia to the upper s anticoagulation with warfarin was initially held due to supratherapeutic inr this was restarted prior to discharge at the time of discharge the patient s inr was mechanical ventillation the patient was intubated in the setting of his cardiac arrest he was successfully extubated on acute renal failure the patient s creatinine was elevated to on admission this was thought to be related to poor forward flow in the setting of cardiogenic shock along with the ischemic insult of cardiac arrest the patient s creatinine had improved to by the time of dischage elevated lfts the patient had mild lft elevations that were thought to be ischemic in etiology these trended down throughout the patient s admission medications on admission aldactone mg daily lasix mg qam avapro mg coumadin mg mg daily atenolol mg qpm kcl meq tablets wed and sat felodipine er mg daily lipitor mg qhs xalatan eyedrops alphagan one gtt right eye dorzolamide one gtt both eyes discharge medications atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills ciprofloxacin mg tablet sig two tablet po q h every hours for days disp tablet s refills latanoprost drops sig one drop ophthalmic hs at bedtime aspirin mg tablet sig one tablet po daily daily dorzolamide drops sig one drop ophthalmic twice a day warfarin mg tablet sig one tablet po once a day alphagan p drops sig one drop ophthalmic twice a day furosemide mg tablet sig tablet po once a day outpatient lab work please check inr on friday and call results to dr at metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po once a day disp tablet sustained release hr s refills discharge disposition home with service facility discharge diagnosis primary diagnosis vf vt arrest secondary diagnoses coronary artery disease ischemic cardiomopathy ef chronic systolic congestive heart failure 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 treatment after a cardiac arrest during your stress test you were treated with a cooling protocol and medicines to help support the heart in addition you had a balloon inserted into one of the major arteries to help support the heart we made the following changes to your medicines start ciprofloxacin mg twice daily to treat a urinary tract infection stop aldactone decrease lasix to mg daily stop avapro for now because of kidney dysfunction your cardiologist will restart this after you are home stop felodipine increase lipitor to mg daily stop atenolol start metoprolol xl to keep your heart rate low and prevent dangerous heart rhythms decrease your warfarin to mg daily please check your inr at dr office on friday weigh yourself every morning md if weight goes up more than lbs followup instructions cardiology clinic md phone date time an appointment has been scheduled for next tuesday in device clinic dr will call you tomorrow with appointment details behavioral clinic appointment scheduled for thursday at am office located in building on the primary care clinic d phone an appointment has been scheduled for wednesday at pm please talk to dr about seeing a dermatologist for the black mole on your chest completed by,"{
""Diagnoses"": [""ischemic cardiomyopathy"", ""cad"", ""s p cabg"", ""ef afib"", ""htn"", ""mr"", ""tr bifascicular block"", ""vtach"", ""vfib"", ""cardiac arrest""],
""Medications"": [""coumadin"", ""ekgs"", ""amiodarone"", ""atropine"", ""epinephrine"", ""sodium bicarb""]
}"
19251,admission date discharge date service gold chief complaint chest pain history of present illness this is an year old gentleman with a history of coronary artery disease status post coronary artery bypass graft times three in inferior myocardial infarction in status post percutaneous transluminal coronary angioplasty at clinic in who is transferred from an outside hospital for chest pain left arm numbness and nausea the patient noted the night before admission and the day of admission chest pain across his chest associated with left arm numbness and nausea he denied shortness of breath or diaphoresis his pain was noted by daughter who had taken him home from the nursing home for lunch and took him immediately back to the nursing home when he told her that he had chest pain the patient is unsure of how long the chest pain lasted the day before admission but lasted one to two hours on the day of admission the patient is an extremely poor historian secondary to his parkinsonian s dementia electrocardiogram on presentation showed elevations in avf and downsloping st depression in precordial leads v through v his initial cpk was and troponin was negative he was started on nitroglycerin gtt heparin gtt integrilin and lopressor and was transferred to for possible catheterization at an outside hospital on presentation to the emergency department at he was chest pain free and was maintained on the same gtt in the am while still in the emergency department the patient had more chest pains and associated shortness of breath and was given intravenous lasix he was given steroids zantac and benadryl for shellfish allergy and was taken to the catheterization laboratory complicated catheterization required cc of dye in order to visualize the graft pcw pa saturation v wave right atrial pressure right ventricular pressure left ventricular end diastolic pressure the patient had no significant left main disease but left anterior descending was occluded at the origin and severe proximal stenosis at the origin of obtuse marginal was noted also mid left circumflex occlusion and proximal occlusion of right coronary artery in terms of the patient s graft the saphenous vein graft to obtuse marginal was patent with complex severe distal stenosis the saphenous vein graft to left anterior descending was patent was distal stenosis with thrombus and the saphenous vein graft to right coronary artery has proximal stenosis with thrombus transthoracic echocardiography was performed demonstrating an ejection fraction of to with global reduction of left ventricular systolic function the inferior wall was noted to be akinetic and trace aortic regurgitation was mild mitral regurgitation was noted the patient was transferred out of the catheterization laboratory to the coronary care unit for observation and consideration of further options past medical history coronary artery disease status post coronary artery bypass graft at in status post inferior myocardial infarction and percutaneous transluminal coronary angioplasty at clinic in abdominal aortic aneurysm stable parkinson s disease times two years hypertension low back pain status post cholecystectomy hypercholesterolemia medications as outpatient atenolol mg b i d captopril mg t i d aspirin digoxin mg q day klonopin mg q hours prn nitroglycerin prn norvasc mg q day lipitor mg q day aricept mg q day celexa mg q day imdur mg q day requip mg t i d darvocet n mg q hours prn medications on transfer integrilin gtt nitroglycerin gtt heparin gtt lopressor mg t i d captopril mg t i d aspirin mg q day digoxin mg q day lipitor mg q day aricept mg q day celexa mg q day imdur mg q day requip mg t i d darvocet n tablet q hours prn pain maximum tablets per day klonopin mg p o q hours prn allergies shellfish social history lives in nursing home by patient report quit tobacco years ago no current alcohol or tobacco use physical examination physical examination on admission from the emergency room temperature pulse blood pressure respiratory rate on liters in general this is a thin elderly male in no acute distress oropharynx is benign pupils are equally round and reactive to light and accommodation pupils mm heart is regular rate and rhythm with s and s no murmurs rubs or gallops noted jugulovenous pressure at cm lungs are clear to auscultation bilaterally abdomen is soft nontender nondistended with good bowel sounds extremities with dorsalis pedis pulses laboratory data notable laboratory data on admission are bun creatinine white blood cells with neutrophils lymphocytes hematocrit platelets at an outside hospital ck is and troponin is negative bilirubin is slightly elevated at but alt ast alkaline phosphatase pt with inr of electrocardiogram demonstrates at outside hospital normal sinus rhythm axis and intervals within normal limits q in and avf elevations in and avf depressions in v v and downsloping st depressions in v through v which at was similar chest x ray demonstrated unusual tracheal course secondary to a possible thyroid mass and some emphysematous changes hospital course cardiovascular a ischemia the patient proceeded to rule in for myocardial infarction with cks of and then proceeded to taper down to on the patient underwent catheterization with results as above and was transferred to coronary care unit without intervention discussion ensued with family and patient who decided that high risk pci was not desirable at this time and the patient should be medically managed the patient was continued on beta blocker ace inhibitor and aspirin therapy as well as plavix q day lipitor and imdur were continued and the patient underwent hour course of integrilin lopressor and ace inhibitor were titrated up as an inpatient and will continue to be titrated up as an outpatient as the patient tolerates b pump the patient was noted to have an ejection fraction of on transthoracic echocardiography and will continue medical management lasix was begun and the patient will continue captopril and digoxin c rhythm the patient remained in normal sinus rhythm with occasional runs of premature ventricular contractions but no more than at a time were noted telemetry was continued during this hospitalization neurological the patient with a history of parkinson s with associated symptoms of dementia aricept and ropinirole were continued throughout this hospitalization with no issues code status the patient is do not resuscitate do not intubate this status was temporarily suspended during the patient s catheterization but was reinstated in the post procedure period fluids electrolytes and nutrition the patient was maintained on cardiac diet during this admission with no further issues disposition the patient will be discharged to rehabilitation once his medical management is optimized and a rehabilitation bed is available discharge diagnosis severe coronary artery disease abdominal aortic aneurysm hypertension parkinson s disease hypercholesterolemia medications on discharge plavix mg p o q day lopressor mg p o q day captopril mg p o q d this will be titrated up as tolerated to mg p o t i d digoxin mg p o q day aspirin mg p o q day imdur mg p o q day lipitor mg p o q h s nitroglycerin mg sublingually prn klonopin mg p o q hours prn aricept mg p o q day celexa mg p o q day requip ropinirole mg p o t i d darvocet n tablet q hours prn pain tylenol mg p o q hours prn pain or fever dulcolax mg p o p r q hours prn constipation trazodone mg p o q h s prn insomnia discharge condition fair dr dictated by medquist d t job [NEW_RECORD] name unit no admission date discharge date date of birth sex m service addendum the patient continued to have chest pain with maximized medical management catheterization films were reviewed and discussed with family it was felt that intervention would be too dangerous at this point so the patient will return to the nursing home with optimized medical management instructions were given to the nursing home that when the patient has chest pain to first given sublingual nitroglycerin as his blood pressure tolerates and then to try oral morphine discharge medications plavix mg p o q day lopressor mg p o twice a day captopril mg p o three times a day digoxin mg p o q day aspirin mg p o q day imdur mg p o q day lipitor mg p o q h s nitroglycerin mg sublingual p r n chest pain aricept mg p o q day celexa mg p o q day requip mg p o three times a day dulcolax mg p o p r q hours p r n constipation trazodone mg p o q h s p r n insomnia ms contin mg p o q hours p r n pain hold for sedation or mental status changes lasix mg p o q day mso to mg q four hours p r n of mg cc elixir ativan mg per cc to mg p o q six to eight hours p r n discharge instructions if patient has chest pain can receive sublingual nitroglycerin as blood pressure tolerates then try p o morphine elixir to cc q four hours p r n the patient also noted to be hyponatremic with sodium dropping to on day after admission and on day of discharge the patient is not taking significant amounts of liquids but will restrict free water would recommend restricting free water at nursing home and rechecking serum sodium in two to four days or is mental status changes occur condition at discharge fair code status do not resuscitate do not intubate m d dictated by medquist d t job,"{
""Diagnoses"": [""Chest pain"", ""History of present illness"", ""Inferior myocardial infarction"", ""Coronary artery disease"", ""Percutaneous transluminal coronary angioplasty""],
""Medications"": [""Nitroglycerin""]
}"
44416,admission date discharge date date of birth sex f service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint increasing dyspnea on exertion with her daily activities major surgical or invasive procedure aortic valve replacement mm st regent mechanical history of present illness year old female with known aortic stenosis back in she has not had any follow up for her as since that time she presented earlier this fall with complaints of dyspnea on exertion which has been progressively worse underwent echocardiogram which showed worsening cardiac function and referred for cardiac cath for evaluation for surgery past medical history aortic stenosis anemia social history lives with husband and her boys also has girls who live close by tobacco history quit years ago smoked for years cigarettes per day etoh very occ illicit drugs denies family history no family history of early mi arrhythmia cardiomyopathies or sudden cardiac death father had lung cancer died at age was a smoker mother is in good health currently age physical exam admission physical exam pulse resp o sat b p right left height weight lbs general no acute distress pleasant interactive skin dry x rash mid back non raised red with scabs from scratching 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 no palpable masses extremities warm x well perfused x edema none varicosities none x neuro grossly intact pulses femoral right left dp right left pt left radial right left carotid bruit right murmur left murmur pertinent results intraop tee pre cpb the left atrium is moderately dilated the left atrial appendage emptying velocity is depressed m s no thrombus is seen in the 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 is severely dilated overall left ventricular systolic function is severely depressed lvef after an epinephrine infusion was started the ef increased to the right ventricular cavity is moderately dilated with moderate global free wall hypokinesis 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 the aortic valve is bicuspid the aortic valve leaflets are severely thickened deformed there is critical aortic valve stenosis valve area cm mild to moderate aortic regurgitation is seen there is mild valvular mitral stenosis area cm mild mitral regurgitation is seen moderate tricuspid regurgitation is seen there is a small pericardial effusion there are small bilateral pleural effusions post cpb on infusions of phenylephrine epi av pacing well seated valve in the aortic position no ai preserved systolic function from pre cpb on inotropic support aortic contour is normal post decannulation wbc rbc hgb hct rdw plt ct wbc rbc hgb hct rdw plt ct pt inr pt pt inr pt pt ptt inr pt pt inr pt pt ptt inr pt glucose urean creat na k cl hco angap glucose urean creat na k cl hco angap glucose urean creat na k cl hco glucose urean creat na k cl hco alt ast ld ldh alkphos amylase totbili alt ast ld ldh alkphos amylase totbili alt ast ld ldh alkphos amylase totbili alt ast ld ldh alkphos amylase totbili brief hospital course ms was taken to the operating room and underwent aortic valve replacement regent mechanical valve replacement with dr please refer to operative report for further details she tolerated the procedure well and was transferred to the cvicu intubated and sedated requiring inotropic and pressor support she awoke neurologically intact and was extubated without difficulty she transferred to the floor on in stable condition on she was transferred back to the cvicu for hypotension hyperkalemia and cre pa line foley and low dose milrinone started echocardiogram revealed ef no tamponade avr well seated with moderate tr mr over the next few days she titrated off inotropes tolerated low dose ace and beta blockers she was transferred back to the floor on respiratory aggressive pulmonary toilet nebs incentive spirometer and ambulation she titrated off oxygen with saturations of ra cardiac beta blockers were titrated she remained in sinus rhythm ace was started on transfer to cvicu on on episode of atrial fibrillation s amiodarone bolus and beta blockers iv converted to sinus rhythm inotropes was titrated off carvediolol and ace were titrated gi h blockers and bowel regimen nutrition tolerated a regular diet renal atn briefly secondary to hypotension and hyperkalemia peak cre base resolved once hemodynamics improved she was gentley diuresed with good urine output electrolytes were repleted as needed heme heparin bridge to coumadin was started for mechanical aortic valve replacement with inr goal inr was followed daily iv access right brachial picc placed pain iv pain medications converted to po with good control disposition followed by pt who deemed her safe for home she was discharged on and will follow up with dr her cardiologist and pcp for further coumadin management medications on admission aspirin prescribed by other provider mg tablet one tablet s by mouth once a day mvi flaxseed oil garlic oil vitamin e calcium discharge medications docusate sodium mg capsule sig one capsule po bid times a day disp capsule 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 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 daily daily disp tablet s refills lisinopril mg tablet sig one tablet po daily daily disp tablet s refills carvedilol mg tablet sig one tablet po bid times a day disp tablet s refills lasix mg tablet sig one tablet po once a day disp tablet s refills warfarin mg tablet sig goal inr tablets po once a day dose to be adjusted for goal inr disp tablet s refills warfarin mg tablet sig goal inr tablets po once a day dose to be adjusted based on inr disp tablet s refills coumadin warfarin you have received prescriptions for two doses of coumadin so that the dose can be adjusted based on your lab results please take mg then inr will be checked and coumadin clinic at will call you with further instructions on what dose to take discharge disposition home with service facility rehab skilled nursing center discharge diagnosis aortic stenosis s p aortic valve replacement acute on chronic systolic heart failure anemia discharge condition alert and oriented x nonfocal ambulating with steady gait incisional pain managed with ultram incisions sternal healing well no erythema or drainage edema bilateral lower extremity 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 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 date time cardiologist dr am please call to schedule appointments with your pcp 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 avr goal inr first draw wednesday results to phone fax please check inr monday wednesday and friday for weeks then as directed by dr completed by,"{
""Diagnoses"": [""cardiothoracic"", ""aortic stenosis"", ""anemia""],
""Medications"": [""regent mechanical"", ""echocardiogram"", ""cardiac cath""]
}"
25515,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint hypercarbic respiratory failure major surgical or invasive procedure tracheostomy replacement history of present illness this is a m with lung cancer status post trach with vent dependence recent post obstructive pneumonia on broad spectrum antibiotics prior pulmonary embolus copd hypertension and diabetes he presented from a rehabilitation facility to the ed with increased respiratory distress and new opacities seen on chest x ray he had recently been discharged from the icu of an osh for dyspnea and lethargy there he had been diagnosed with the pneumonia and started on a day course of vancomcyin cefepime flagyl last day at am yesterday he was noted to be increasingly tachypneic a chest x ray reveal white out in the l lung field per facility report in the ed the pt was initially alert and interactive he was afebrile but tachypneic hypertensive and tachycardic wbc and lactate were normal chest x ray revealed l perihilar lung mass and opacities in the l lower lobe cta confirmed presence of these findings and in addition was negative for pulmonary embolus after the cta the patient s mental status began to decline and he became increasingly difficult to ventilate he became poorly responsive and a blood gas returned as it was believed that there were air leaks around his trach and there also was possibly some obstruction also of note he was given labetalol for control of his hypertension and tachycardia he was therefore transferred to the micu in the micu the patient was poorly responsive and exhibited agonal breathing a bronchoscopy was urgently performed and revealed an obstruction in the trach the patient was therefore intubated past medical history lung adenocarcinoma tracheostomy chronically ventilator dependent post obstructive pneumonia history of vre and mrsa infection s p g tube placement history of pulmonary embolism not on anticoagulation history of retroperitoneal bleed copd hypertension diabetes type ii urethral tear social history widowed has been in chronic vent facility daughter is health care proxy family history non contributory physical exam vs temp bp hr rr o sat vent ac tv rate fio peep gen alert follows commands heent perrl eomi anicteric mouth mm moist edentulous op without lesions neck trach in place intubated trach site c d i no jvd no carotid bruits no thyromegaly resp course breath sounds decreased on left no wheezes scattered rales no rhonchi cv rr s and s wnl no m r g abd mildly distended not tympanic non tender hypoactive bowel sounds ext no edema distal pulses normal skin no rashes no jaundice pertinent results pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count pm glucose urea n creat sodium potassium chloride total co anion gap am blood rates peep fio po pco ph caltco base xs aado req o assist con am blood type art po pco ph caltco base xs am blood type art rates tidal v peep fio po pco ph caltco base xs intubat intubated vent controlled pm blood type art rates tidal v peep fio po pco ph caltco base xs assist con intubat intubated pm blood type art temp rates peep fio po pco ph caltco base xs intubat intubated brief hospital course this is a year old gentleman with lung adenocarcinoma chronic vent dependence s p trach and peg placement recent pneumonia on broad spectrum antibiotics presents with respiratory failure that appeared secondary to blockage seen on bronchoscopy the patient was intubated and placed on assist control mechanical ventilation with respiratory and mental status returning to baseline as a result through the remainder of his admission the patient remained hemodynamically stable he underwent repeat bronchoscopy which revealed near complete occlusion of the trach tube the patient did complain of dyspnea intermittently and there was some concern that he had an air leak around his tracheostomy tube his respiratory status did remain stable with good oxygen saturation for the air leak the tracheostomy tube was replaced with a larger tube respiratory failure the patient arrived with tracheostomy tube misplaced the tracheostomy tube was changed and lumen changed to size speech and swallow was consulted for passy muir placement but were unable to see the patient due to his recent trach change because he has been intermittently unable to speak would recommend passy muir placement at rehab facility the patient was weaned off the ventilator once his new tube was in place and currently at patient should be aggressively weaned from ventilator as tolerated please encourage out of bed and continue physical therapy begun in hospital he should receive humidified o while on trach collar pneumonia likely lobar pneumonia rather than post obstructive as indicated in notes from osh given absence of obstruction noted on bronchoscopy a day course of broad spectrum antibiotics vancomycin cefepime metronidazole was completed osh had recommended this duration given patient s history of mrsa and vre blood and sputum cultures were negative at the time of discharge copd as above the patient was continued on bronchodilator therapy history of pulmonary embolus no evidence of pe on cta patient has ivc filter in place and history of retroperitoneal bleed and is therefore not anticoagulated hypertension grade i chf with diastolic dysfunction metoprolol mg was initiated after patient s respiratory status stabilized anemia patient s hematocrit ranged from during hospital stay iron studies were sent but pending on discharge guaiac negative although likely secondary to chronic disease please follow up iron studies diabetes no record of medications for glycemic control pt was maintained on a regular insulin sliding scale during his hospital stay history of ureteral tear mild hematuria on urinalysis the patient was maintain with a foley catheter he may need evaluation from urology in future non sclc stage iiib according prior records this has been deemed unresectable and patient is on no treatments at this time please consider reopening discussion of lung cancer treatment with his family access r ij was removed and a left picc line was inserted fen patient had episode of clogged g tube refractory to flushing efforts but an abdominal x ray with gastrografin contrast through g tube showed contrast in stomach subsequently tube feeds were successful please continue with tube feeds prophylaxis hep sq ppi bowel regimen code status full discussed with hcp contact hcp daughter cell home medications on admission cefepime flagyl vancomycin combivent calcium acetate colace senna protonix discharge medications senna mg tablet sig one tablet po hs at bedtime docusate sodium mg ml liquid sig fifteen ml po bid times a day acetaminophen mg tablet sig tablets po q h every to hours as needed lansoprazole mg susp delayed release for recon sig thirty mg po daily daily ipratropium bromide mcg actuation aerosol sig two puff inhalation qid times a day albuterol ipratropium mcg actuation aerosol sig puffs inhalation q h every hours as needed nystatin unit ml suspension sig five ml po qid times a day as needed chlorhexidine gluconate mouthwash sig fifteen ml mucous membrane qid times a day as needed metoprolol tartrate mg tablet sig one tablet po bid times a day hold for sbp or hr insulin use regular insulin sliding scale discharge disposition extended care facility hospital discharge diagnosis primary hypercarbic respiratory failure obstruction of tracheal tube secondary non small cell lung cancer pneumonia hypertension diabetes mellitus type ii discharge condition good respiratory status now returned to baseline mentating at baseline alert following commands and interactive otherwise afebrile and hemodynamically stable discharge instructions please return patient to emergency department for any sign of respiratory failure including hypoxemia unresponsive to adjustments in ventilation declining mental status also seek emergent medical intervention for any signs or symptoms of sepsis followup instructions patient to extended care facility please have patient follow up with his pulmonologist please have patient and family follow up with oncologist to discuss treatment options for lung cancer please have patient follow up with urology should hematuria recur [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 hypoxia major surgical or invasive procedure bronchoscopy picc history of present illness mr is a yo man with h o copd lll lung adenocarcinoma chronic respiratory failure pe s p ivc filter chf vap who presented to er from his long term rehab facility after his trach tube was foundto be loose and falling out today associated with high airway pressures of s s he was otherwise without complaint and was afebrile in the er he was seen by respiratory therapy who pushed his trach tube back into place with immediately resolution of airway pressures to the s shortly thereafter the patient became hypotensive to s systolic with hr he was given l ns to which he responded with return of his bp to the s in the er the patient received a total of l ns blood cultures and ua were sent he was given vancomycin he was admitted to the icu for monitoring and for bronch by interventional pulmonology tomorrow morning notably the patient was in the icu about two weeks ago at which time his trach tube had been changed from a to a bovina he was also diagnosed at that time with pseudomonal pneumonia and was treated with a course of vanco cefepime flagyl which he has completed per conversation with the pt s daughter and hcp she has seen her father pulling on his own trach tube many times and believes that he pulls it out per her description he appears to be at his baseline pleasant interactive but somewhat confused baseline ros pt unable to answer specific questions to this effect at this time past medical history lung adenocarcinoma tracheostomy chronically ventilator dependent post obstructive pneumonia history of vre and mrsa infection s p g tube placement history of pulmonary embolism not on anticoagulation history of retroperitoneal bleed copd hypertension diabetes type ii urethral tear recent pseudomonal pneumonia w ago hospitalized in icu recent change of trach tube from bovina to bovina weeks ago while hospitalized in icu social history unable to ask patient details widowed daughter is hcp lives in medical hospital with chronic ventilation family history noncontributory physical exam hr bp temp rr sat on ac x peep fio gen pt attempts to talk and answer questions seems confused but pleasant unable to write writes letters that do not make comprehensible words nad denies pain heent oral thrush on tongue perrl mm moist neck trach tube in place and secured no nvd cor rrr no r g m pulm diffuse coarse transmitted bronchial breath sounds abd soft nt nd decreased bs gtube in place and nonerythematous ext no edema bilateral skin changes of venous stasis barely palpable pt pulses bilaterally legs well perfused neuro unable to perform full neuro exam given ms skin no rashes venousstasis changes as above pertinent results pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts bands lymphs monos eos baso pm blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap pm blood calcium phos mg cxr tracheotomy tube tip just at the thoracic inlet approximately cm from the carina similar in position compared to prior study from similar sized left lung mass similar appearing left retrocardiac opacification consistent with atelectasis and or consolidation brief hospital course yo man with h o copd recent pseudomonal pneumonia longstanding trach on ventilation presents with dislodged trach tube high peak airway pressures which resolved with manipulation of tube and elevated white count as well as transient hypotension in the er respiratory failure likely secondary to dislodged trach tube pt s respiratory distress resolved upon physical resetting of the trach tube while he was in the emergency department bronchoscopy was done later and the trach tube was advance to a better position of note a small air leak from his trach cuff was discovered but it is not significant enough to comprimise his respiratory status intervention pulmonology did not feel this needed further workup his vent settings during this hospitalization was assisted control with fio of ml x peep his vent setting at rehab prior to admission was simv rr fio peep he recieved ipratropium and albuterol inhalers standing and prn for copd as he was getting prior to admission for his copd hypotension pt had a transient episode of hypotension to sbp of s in the emergency department after his trach tube was position it resolved quickly in about minutes with fluid rescucitation he received a total of minutes the hypotension was initially suspicious for sepsis but later thought likely to be secondary to auto peep from his vent urine cultures and blood cultures were sent and were still pending at time of discharge he was covered with antibiotics empirically for sepsis vancomycin for mrsa and zosyn for gram and pseudomonas please note patient was discharged on these two antibiotics please follow up on final results if negative should be able to discontinue vancomycin and zosyn after days last day uti pt with positive ua sent urine for culture and will follow on zosyn which should empirically cover last day of day course dmii his blood glucose was controlled with an insulin sliding scale and qid fingersticks oral thrush nystatin swish and spit qid htn will give pt s home dose of metoprolol mg po bid nutrition per nutrition consult he received probalance full strength with beneprotein gm day at goal of ml hr residual were checked q h and held for residual ml flushed w ml water q h ppx lansoprazole heparin sq given h o pe pneumoboots full code confirmed with pt s daughter hcp contact hcp daughter cell home medications on admission metoprolol mg per gtube colace per gtube senna tab per gtube qday ipratropium puffs qid combivent inhaler puffs q prn nystatin swish and spit qid regular insulin slide scale heparin subq tid lansoprazole mg per g tube qday discharge medications docusate sodium mg ml liquid sig one po bid times a day calcium acetate mg capsule sig two capsule po tid w meals times a day with meals senna mg ml syrup sig one tablet po hs at bedtime lansoprazole mg susp delayed release for recon sig thirty mg po daily daily insulin lispro human unit ml solution sig one as per sliding scale subcutaneous asdir as directed as per sliding scale ipratropium bromide mcg actuation aerosol sig two puff inhalation qid times a day albuterol mcg actuation aerosol sig puffs inhalation q h every hours as needed ipratropium bromide solution sig one neb inhalation q h every hours as needed nystatin unit ml suspension sig five ml po qid times a day metoprolol tartrate mg tablet sig one tablet po bid times a day heparin porcine unit ml solution sig units injection tid times a day sodium chloride flush ml iv daily prn peripheral iv inspect site every shift vancomycin hcl mg iv q h start in am piperacillin tazobactam na gm iv q h discharge disposition extended care facility hospital discharge diagnosis respiratory failure uti lung adenocarcinoma tracheostomy chronically ventilator dependent post obstructive pneumonia copd hypertension diabetes type ii discharge condition hemodynamically stable afebrile discharge instructions please take all medications as prescribed please keep all appointment with your doctors follow up with your primary care physician as soon as possible about your recent hospital stay if you have chest pain or shortness of breath please seek medical attention immediately please remember not to tamper with your tracheostomy and tubing in general please call your doctor or go to the emergency room if you have any medical concerns or questions followup instructions please follow up with your pcp as soon as possible completed by [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 trach dislodge major surgical or invasive procedure none history of present illness yo m hx copd lll lung adenocarcinoma chronic respiratory failure with trach pe s p ivc filter chf presented from long term rehab facility with dyspnea ms changes in the er he was seen by respiratory therapy who found trach to be displaced initial co of s improved to venous with replacement of the trach his mental status appear to resole with improvement in hypercarbia shortly after the manipulations bp dropped to s transiently responded to ivf to bp in s in addition his trach slipped out once more while waiting in ed he was admitted for observation of his bp and to reassess his trach no recent fevers chills no change in cough or sputum production no diarrhea or urinary symptoms he currently has a bovina trach past medical history lung adenocarcinoma tracheostomy chronically ventilator dependent post obstructive pneumonia history of vre and mrsa infection s p g tube placement history of pulmonary embolism not on anticoagulation history of retroperitoneal bleed copd hypertension diabetes type ii urethral tear recent pseudomonal pneumonia w ago hospitalized in icu recent change of trach tube from bovina to bovina weeks ago while hospitalized in icu social history unable to ask patient details as per omr widowed daughter is hcp lives in medical hospital with chronic ventilation family history noncontributory physical exam vitals temp hr bp rr o sat vent on cmv gen elderly male alert oriented nods appropriately to questions nad heent perrl eomi mm moist op clear neck trach tube in place and secured no nvd cor rrr no m r g pulm coarse breath sounds good air entry bilaterally abd soft nt nd bs gtube in place and nonerythematous ext no edema bilateral skin changes of venous stasis palpable pt pulses bilaterally neuro non verbal but appears fully oriented moves all extremities skin skin breakdown on sacrum no erythema or discharge no rashes 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 glucose urean creat na k cl hco angap am blood type po pco ph caltco base xs brief hospital course yo man with h o copd longstanding trach on ventilation p w dyspnea and ms changes found to have dislodged trach tube transient hypotension respiratory failure transient dyspnea likely mechanical disolodgement of trach repositioned in ed without difficulty new position confirmed by cxr discussed with ip given trach size no further changes can be made to make it more secure continue nebs for copd no evidence of pna on cxr or no evidence of worsened interstitial disease pt continued on rehab settings simv rr fio peep hypotension as like previous admission transient sbp s which resolved with ivf this may have been increased thoracic pressures at the time of desaturation no evidence of infection metoprolol held on hd and then restarted without difficulty ppx continued heparin sc and ppi pt discharged back to rehab medications on admission see below discharge medications lansoprazole mg susp delayed release for recon sig one po daily daily albuterol mcg actuation aerosol sig puffs inhalation q h every hours as needed ipratropium bromide mcg actuation aerosol sig two puff inhalation q h every to hours as needed docusate sodium mg ml liquid sig one po bid times a day as needed heparin porcine unit ml solution sig units injection tid times a day metoprolol tartrate mg tablet sig one tablet po twice a day discharge disposition extended care facility hospital discharge diagnosis chronic respiratory failure trach dislodge secondary htn tracheostomy sacral ulcer diabetes discharge condition stable discharge instructions please continue all medications as previously prescribed please return to ed if you have respiratory distress troubles with your trach fevers worsening sputum or any other concern please becareful and not dislodge your trach followup instructions please follow up with pcp as instructed,"{
""Diagnoses"": [""hypercarbic respiratory failure"", ""pneumonia"", ""status post trach with vent dependence"", ""COPD"", ""hypertension"", ""diabetes"", ""obstructive pneumonia""],
""Medications"": [""vancomcyin"", ""cefepime"", ""flagyl""]
}"
81328,admission date discharge date date of birth sex f service medicine allergies dilantin kapseal penicillins attending chief complaint dyspnea respiratory failure major surgical or invasive procedure thoracentesis intubation cardioversion history of present illness year old female with advanced cholangiocarcinoma hepatitis b c etoh cirrhosis and chronic alcohol abuse who presents from clinic with shortness of breath after a routine ct showed new right sided pleural effusion and pulmonary infiltrates she was diagnosed with cholangiocarcinoma in and has been evaluated by surgery but not deemed a surgical candidate the attempt at giving chemotherapy has been difficult due to ongoing substance abuse and poor medical compliance she was admitted for pain control due to abdominal pain she was on the medicine service and restarted on her home medications with improvement in her pain she also completed a course of keflex for cellulitis she reports the onset of dyspnea on exertion days ago that has progressively worsened also reports fever to yetserday as well as chills has had cough x week also reports nausea without vomiting and poor appetite has chronic abdominal pain but feels it is worse in the last few days has baseline peripheral edema but also feels this is worse in the last week has had regular bm no blood in stool also describes chest soreness with palpation and with coughing on the right side over the last week she was seen in clinic today and complained of shortness of breath she had a routine staging ct this am which showed pulmonary infiltrate and pleural effusion and is therefore being directly admitted from clinic review of systems per hpi has been losing weight cannot quantify denies headache denies palpitations denies nausea vomiting diarrhea constipation melena hematemesis hematochezia denies dysuria stool or urine incontinence denies arthralgias or myalgias denies rashes or skin breakdown no numbness tingling in extremities all other systems negative past medical history cholangiocarcinoma ms admitted on to when she presented to the emergency room with abdominal pain while in the hospital she underwent an abdominal ultrasound which showed increase in size of the common bile duct suspicious for an obstructive process ercp was performed on with brushings of the common bile duct which were positive for malignant cells consistent with adenocarcinoma she underwent abdominal mri on which showed a segment viii hepatic lesion which was compatible with cholangiocarcinoma the lesion is approximately x cm in size she was evaluated for surgical resection and was deemed a surgical candidate if she could remain abstinent from alcohol consumption given the high risk of complications with liver resection in patients who are actively abusing alcohol she has been unable to remain sober for any significant duration since that evaluation and continues to abuse etoh chronically she recieved her first cycle of gemcitabine and cisplatin past medical history etoh abuse with h o withdrawal seizures cirrhosis due to hcv genotype b hbv etoh cocaine abuse chronic abdominal pain gastritis alcoholic pancreatitis cholelithiasis diverticulosis seizure disorder c radiculopathy emg showed mild chronic reinnervation in the biceps and deltoid thoracic radiculopathy anterolisthesis of l on l grade hypertension asthma polyclonal gammopathy thrombocytopenia depression glaucoma social history lives with boyfriend in commonly stays in with her daughter not employed longstanding chronic etoh abuse history initially reports she hasn t consumed etoh since her cancer diagnosis but then admits to drinking an occasional wine thinks last drink about a month ago denies other current drug use although has had recent cocaine use per her primary oncologist family history mother had pancreatic cancer physical exam admission physical exam vitals ra general nad although does appear sob with minimal exertion including sitting up and speaking in long sentences heent at nc eomi perrla anicteric sclera patent nares mmm nontender supple neck cardiac rrr s s no mrg lung decreased breath sounds at the right base diffuse wheezing throughout crackles at left base abdomen mildly distended with some shifting dullness moderately tender to palpation in ruq and some in rlq no rebound or guarding positive bowel sounds m s moving all extremities well pitting edema bilaterally to the shins pulses dp pulses bilaterally pertinent results admission labs pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts lymphs monos eos baso am blood pt ptt inr pt pm blood urean creat na k cl hco angap pm blood alt ast alkphos totbili am blood calcium phos mg am blood albumin pm blood ethanol am blood lactate pertinent labs pm blood lipase am blood probnp am blood tsh am blood t t am blood anca negative b pm blood hiv ab negative pm blood carbamz pm blood ethanol glomerular basement membrane negative aspergillus antigen negative b d glucans pg ml highly positive ca negative discharge labs am 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 am blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos totbili am blood calcium phos mg microbiology blood culture routine final no growth blood culture routine final no growth urine culture final skin genital contamination legionella urinary antigen final negative sputum source expectorated gram stain final pmns and epithelial cells x field per x field gram positive cocci in pairs and singly respiratory culture final rare growth commensal respiratory flora legionella culture final no legionella isolated pleural fluid pleural fluid gram stain final per x field polymorphonuclear leukocytes no microorganisms seen this is a concentrated smear made by cytospin method please refer to hematology for a quantitative white blood cell count fluid culture final no growth anaerobic culture final no growth blood culture routine final no growth blood culture routine final no growth sputum source endotracheal gram stain final pmns and epithelial cells x field no microorganisms seen quality of specimen cannot be assessed respiratory culture final no growth blood culture routine final no growth urine culture final no growth bronchoalveolar lavage gram stain final no polymorphonuclear leukocytes seen no microorganisms seen respiratory culture final no growth cfu ml legionella culture final no legionella isolated potassium hydroxide preparation final test cancelled by laboratory patient credited this is a low yield procedure based on our in house studies if pulmonary histoplasmosis coccidioidomycosis blastomycosis aspergillosis or mucormycosis is strongly suspected contact the microbiology laboratory immunoflourescent test for pneumocystis jirovecii carinii final negative for pneumocystis jirovecii carinii fungal culture preliminary no fungus isolated acid fast smear final no acid fast bacilli seen on concentrated smear acid fast culture preliminary no mycobacteria isolated rapid respiratory viral screen culture respiratory viral culture final no respiratory viruses isolated culture screened for adenovirus influenza a b parainfluenza type and respiratory syncytial virus viral culture r o cytomegalovirus preliminary no cytomegalovirus cmv isolated cytomegalovirus early antigen test final negative for cytomegalovirus early antigen by immunofluorescence refer to culture results for further information blood culture routine final no growth blood culture routine final no growth urine culture final no growth source line r brachial picc purple port of blood culture routine final no growth c difficile dna amplification assay final negative sputum source endotracheal gram stain final pmns and epithelial cells x field no microorganisms seen quality of specimen cannot be assessed respiratory culture final commensal respiratory flora absent yeast rare growth serology blood cryptococcal antigen final cryptococcal antigen not detected csf spinal fluid source lp cryptococcal antigen final cryptococcal antigen not detected csf spinal fluid gram stain final no polymorphonuclear leukocytes seen no microorganisms seen this is a concentrated smear made by cytospin method please refer to hematology for a quantitative white blood cell count fluid culture final no growth fungal culture preliminary no fungus isolated viral culture preliminary no virus isolated csf spinal fluid hiv viral load ultrasensitive final hiv rna not detected hbv viral load final hbv dna not detected hiv viral load ultrasensitive final hiv rna not detected blood culture routine pending blood culture routine pending urine culture final yeast cfu ml blood culture routine pending blood fungal culture preliminary no fungus isolated blood afb culture preliminary no mycobacteria isolated imaging ct abd pelvis w w o contrast ct chest w contrast overall progression of disease with new diffuse tumor infiltration in the right hepatic lobe with metastatic foci in the left hepatic lobe new retroperitoneal lymph node enlargement new bony metastases mild intrahepatic bile duct dilation has increased moderate ascites new occlusion of the right anterior and right posterior portal veins the left portal vein and main portal vein are patent moderate to large right pleural effusion with adjacent compressive atelectasis multifocal left lung pneumonia ecg sinus tachycardia the q t interval may be slightly short particularly in the anterior precordial leads poor r wave progression consider prior anteroseptal myocardial infarction compared to the previous tracing of the rate has increased the q t interval has shortened lateral st segment depressions are not as prominent on the current tracing clinical correlation is suggested bilat lower ext veins port no evidence of deep vein thrombosis in either right or left lower extremity cta chest w w o c recons non coronary no evidence of pulmonary embolism alveolitis pulmonary edema or pulmonary hemorrhage significantly progressed since moderate posterior layeriing nonhemorrhagic right pleural effusion is smaller since ct head w o contrast no ct evidence for acute intracranial hemorrhage tee no spontaneous echo contrast or thrombus is seen in the body of the left atrium left atrial appendage or the body of the right atrium right atrial appendage left ventricular systolic function is hyperdynamic lvef 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 there is mild moderate tricuspid regurgitation impression no thrombus or spontaneous echo contrast in the la laa ra raa hyperdynamic biventricular systolic function mild aortic atheroma eeg this is an abnormal continuous icu monitoring study because of severe diffuse encephalopathy the pattern is one of a burst and burst suppression this may be medically induced although it can also occur as a result of an anoxic event there did appear to be epileptiform features in the left central region initially but then became bilateral and synchronous in both central regions as the tracing progressed the encephalopathic features appeared more prominently in that there was greater suppression of electrical activity and longer suppressive bursts the left central region remained fairly active to the end of this study liver or gallbladder us no evidence for biliary obstruction or main portal vein thrombosis heterogeneous liver and perihepatic nodal masses consistent with known cholangiocarcinoma cholelithiasis gallbladder wall edema may relate to underlying liver disease ascites perihepatic and right lower quadrant pockets of ascites eeg this is an abnormal continuous icu monitoring study which shows a generally attenuated background with frequent generalized periodic epileptiform discharges indicative of severe encephalopathy with generalized epileptogenic potential at times these generalized periodic discharges appeared to be higher amplitude and more frequent over the left central region they did not evolve to form electrographic seizures and did not appear to have an obvious clinical correlate on video compared to the prior day s recording there was no significant change chest portable ap indwelling support and monitoring devices remain in standard position worsening bilateral alveolar opacities likely reflect diffuse pulmonary edema differential diagnosis includes widespread pneumonia and pulmonary hemorrhage increasing large right and moderate left pleural effusions cytology pleural fluid negative for malignant cells mesothelial cells macrophages and lymphocytes bronchial washings atypical rare atypical cells are present alveolar macrophages and numerous neutrophils negative for malignant cells alveolar macrophages neutrophils and bronchial cells spinal fluid negative for malignant cells lymphocytes and histiocytes brief hospital course ms was a year old female with cholangiocarcinoma hep b c etoh cirrhosis and alcohol abuse who presented from clinic with shortness of breath after a routine ct showed new right sided pleural effusion and pulmonary infiltrates she was initially treated with ceftriaxone and azithromycin but she became more lethargic and so was switched to vancomycin cefepime flagyl she underwent a thoracentesis that removed transudative fluid but due to increasing respiratory distress she was sent to the micu during her micu course she initially tolerated and remained stable on bipap but then demonstrated progressive clinical deterioration in respiratory status hypoxemia and required intubation and mechanical ventilation ct scan showed multifocal pneumonia bal was performed without evidence for hemorrhage and negative for microbials pathogens she also developed afib with rvr and was cardioverted successfully but was continued on a heparin drip for anticoagulation slated to continue for month after cardioversion she developed altered mental status decreased level of consciousness despite lactulose and rifaximin for possible hepatic encephalopathy a min eeg was performed which showed epileptiform activity neurology was consulted and she was initiated on anti epileptic drugs though a continuous hr eeg did not show overt seizure activity ct head and lp were non revealing overall she demonstrated continued clinical decline with persistent respiratory failure progressive hypotension requiring vasopressor support oliguric renal failure and persistent coma despite discontinuation of sedatives for seveeral days several extensive family meetins updating medical status and poor prognosis ultimatley decision to move to focus care on comfort as primary goal was decided consistent with patients previously expressed wishes the patient quietly and peacefully expired shortly following extubation medications on admission albuterol nebs q h prn wheezing sob amlodipine mg po daily carbamazepine mg po bid citalopram mg po daily fluticasone mcg puffs ms contin mg po q h morphine mg po q h prn pain ondansetron mg po q h prn nausea cyclobenzaprine mg po tid prn back pain furosemide mg po daily prn le edema albuterol mcg inh q h prn sob wheeze folic acid mg po daily hydroxyzine mg po q h prn itching protonix mg po daily lactulose ml po tid discharge medications the pt expired discharge disposition expired discharge diagnosis the pt expired discharge condition the pt expired discharge instructions the pt expired followup instructions the pt expired md completed by,"{
""Diagnoses"": [""advanced cholangiocarcinoma"", ""hepatitis B"", "" cirrhosis"", ""chronic alcohol abuse""],
""Medications"": [""dilantin"", ""kapseal"", ""penicillins"", ""cephalexin""]
}"
10374,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint increasing chest pain major surgical or invasive procedure cabg x lima lad svg om pda history of present illness yo m with exertional angina x years now increasing cath with lm and vd mr now presents for elective surgical revascularization past medical history htn gerd hoh lle varicose veins s p hernia repair tonsilectomy hemorrhoidectomy social history retired facilities director lives with wife glass wine day quit tob years ago family history daughter with cabg at age physical exam nad hr bp rr skin unremarkable heent benign neck supple lungs ctab heart rrr no m r g abdomen soft nt nd extrem warm trace ble edema some varicosities left leg pertinent results am blood hct 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 creat k cxr stable postop chest with persistent bibasilar atelectasis which has improved on the left echo pre bypass the left atrium is mildly dilated and elongated left ventricular wall thicknesses are normal the left ventricular cavity size is normal overall left ventricular systolic function is low normal lvef right ventricular chamber size and free wall motion are normal the aortic arch and descending aorta are mildly dilated there are simple atheroma in the aortic arch and the descending thoracic aorta is mildly dilated no thoracic aortic dissection is seen the aortic valve leaflets appear structurally normal with good leaflet excursion there is no aortic valve stenosis trace aortic regurgitation is seen the mitral valve appears structurally normal with trivial to mild mitral regurgitation vena contracta measures less than mm pulmonary venous inflow pattern is normal mitral annulus averages cm in diameter cardiac output is calculated at l min post bypass preserved biventricular function lvef without wall motion abnormalities mitral regurgitation remains trace to mild there is now trace pulmonic insufficiency aortic contours are intact the remaining exam is unchanged all findings were discussed with the surgeons at the time of the exam ospital course mr was admitted to the on for elective surgical management of his coronary artery disease he was taken to the operating room where he underwent coronary artery bypass grafting to three vessels postoperatively he was transferred to the csru in stable condition on neosynephrine and propofol he was extubated the same day he was weaned from his neosynephrine and transferred to the step down unit on pod beta blockade aspirin and a statin were resumed he was gently diuresed towards his preoperative weight his drains and wires were removed per protocol mr continued to make steady progress and was discharged home on postoperative day four he will follow up with dr his cardiologist and his primary care physician as an outpatient medications on admission lisinopril omeprazole asa norvasc lipitor lecithin vitamin c toprol discharge medications docusate sodium mg capsule sig one capsule po bid times a day disp capsule 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 atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills hydromorphone mg tablet sig tablets po q h every to hours as needed for pain disp tablet s refills metoprolol tartrate mg tablet sig one tablet po bid times a day 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 lasix mg tablet sig one tablet po once a day for days take once daily with potassium for days then stop disp tablet s refills potassium chloride meq tab sust rel particle crystal sig one tab sust rel particle crystal po once a day for days take with lasix and stop in days disp tab sust rel particle crystal s refills discharge disposition home with service facility gentiva discharge diagnosis cad htn gerd hoh lle varicosities s p left hernia repair s p tonsillectomy as child s p hemorrhoidectomy s discharge condition good discharge instructions call with fever redness or drainage from incisions or weight gain more than pounds in one day or five pounds in one week no lifting more than pounds for weeks or driving for month you may shower no baths no lotions creams or powders to incisions until they have healed take lasix and potassium for five days as instructed and then stop call with any questions or concerns p instructions dr weeks dr weeks dr and or weeks please call all providers for appointments completed by,"{
""Diagnoses"": [""cardiothoracic"", ""angina"", ""CABG"", ""varicose veins"", ""hernia repair"", ""tonsilectomy"", ""hemorrhoidectomy""],
""Medications"": [""aspirin"", ""atorvastatin"", ""losartan"", ""metoprolol"", ""ramipril"", ""simvastatin"", ""theophylline""]
}"
6185,admission date discharge date service thoracic surgery discharged to rehabilitation facility history of present illness the patient is a patient of dr who has been referred to us she is a year old russian speaking only female who presented with a new myocardial infarction experiencing substernal chest pain and pressure for four days past medical history coronary artery disease hypertension hypercholesterolemia gastroesophageal reflux disease ptca to the right coronary artery three weeks prior to admission social history negative for ethanol abuse or tobacco abuse physical examination noncontributory cardiac catheterization her catheter results showed an ejection fraction of proximal left anterior descending artery occlusion of first diagonal right coronary artery middle right coronary artery was which was stented three weeks ago hospital course the patient was taken to the operating room for a coronary artery bypass graft x for the diagnosis of unstable angina on please see the op note for full details postoperatively she was transferred to the cardiothoracic intensive care unit on pressure support and she was extubated and transferred to the floor on on postoperative day jp drain was discontinued foley was discontinued and wires were discontinued she had some sternal drainage so she received a few doses of kefzol during her stay sternal drainage went down and the kefzol was stopped patient was seen by pt that day her hematocrit dropped again and she received several transfusions during the course of her stay to which she had no reaction and she did well patient was diuresed her chest tube continued to give off high output but was discontinued on passed a relatively low output a chest x ray done immediately post pull showed that the hydropneumothorax was stable and another chest x ray done on shows the same on postoperative day she is being discharged to a rehabilitation facility today on the following medications she will be going on captopril mg po tid she will have niferex mg caps po q day lopressor mg po bid protonix mg po q day lipitor mg po q day klonopin mg po bid xalatan one drop to each eye q hs plavix mg po once a day for a total of three months percocet tablets for pain q h prn aspirin mg po q day lasix mg po bid along with potassium chloride meq po bid for a total of one week colace mg po bid condition on discharge good condition with no acute problems m d dictated by medquist d t job [NEW_RECORD] name unit no admission date discharge date date of birth sex f service thoracic addendum the patient had a chest x ray p a and lateral downstairs in the radiology suite today after a portable x ray this morning showed poor quality the pneumothorax seen from prior studies is unchanged and stable per the attending radiologist s wet read with the radiology resident disposition the patient is discharged to rehabilitation m d dictated by medquist d t job,"{
""Diagnoses"": [""myocardial infarction"", ""unstable angina""],
""Medications"": [""aspirin"", ""clopidogrel"", ""heparin"", ""metoprolol"", ""atenolol""]
}"
20918,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint hypotension major surgical or invasive procedure cardiac catheterization s p cypher stents to left circumflex artery history of present illness y o male with chf htn presented to on with shortness of breath per patient he rarely received medical care prior to this admission and had no known heart disease he noted progressive worsening of doe over the past months over the past few weeks he noted a significant worsening of doe as well as orthopnea and pnd then a few days prior to presentation he noted le edema which prompted him seeking medical care he denied chest pain at any time he did have some n v over the past few weeks which he attributes to poorly fitting dentures he has had a dry cough for some time denies fever at he was treated with bronchodilators antibiotics for pna and nitro gtt ace bblocker and diuretics for chf he had an elevated bnp and tropi in the borderline zone he was started on asa plavix as well he diuresed at least liter with significant improvement in symptoms and le edema on he had a pharmacologic stress that showed mostly fixed inferior and lateral defects and an ef of on evening of he became symptomatically hypotensive sbp s he was given cc ivfs started on dopamine drip and transferred to on arrival to patient s bp was off dopamine and he denied chest pain shortness of breath lightheadedness past medical history hypertension hyperlipidemia tobacco use alcoholism social history retired financial services currently ciagarettes day smoker x years etoh glasses of wine night no ivda married and lives with wife family history non contributory physical exam discharge physical exam temp bp pulse s resp o sat ra gen awake alert no acute distress heent perrl extraocular motions intact anicteric mucous membranes moist neck no jvd noted no cervical lymphadenopathy no bruits chest clear to auscultation bilaterally no wheezing or crackles cv normal s s rrr ii vi sm at apex abd soft nontender nondistended with normoactive bowel sounds extr no edema dp pulses bilaterally blanching erythema of forearms b l 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 pt ptt inr pt am blood pt ptt inr pt am blood plt ct 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 ck cpk alkphos totbili am blood alt ast ld ldh alkphos totbili am blood ck mb notdone ctropnt am blood calcium phos mg am blood calcium phos mg am blood caltibc ferritn trf am blood hba c hgb done a c done am blood triglyc hdl chol hd ldlcalc am blood tsh cxr cardiomegaly without evidence of pulmonary edema the patient is rotated rightward which makes it difficult to evaluate right lung base and right hemidiaphragm there is a round lucency superimposed over the right side of the heart which may represent hiatus hernia cardiac catheterization coronary angiography revealed a left dominant system the lmca showed no angiographically apparent flow limiting stenosis the lad showed mild to moderate diffuse stenoses along its length to a maximum of stenoses the lcx gave rise to a small om and very large om with a long stenosis from the proximal to mid lcx and extending into the om vessel the distal lcx was a small caliber vessel giving rise to a small lpda the rca showed a proximal stenosis with right to right collaterals hemodynamic studies demonstrated severely elevated right sided filling pressures right atrial pressures mmhg with moderate to severe pulmonary hypertension pulmonary artery pressure mmhg as well as severely elevated pulmonary capillary wedge pressure mmhg and severely reduced cardiac index calculated by the fick method to be l min m there was no evidence of pressure gradient across the mitral valve or across the aortic valve upon pullback of the catheter from the left ventricle to the aorta successful predilation using x cross sail balloon and stenting using two x mm and one x cypher stents of the proximal mid cx and om branch with lesion reduction from to the final angiogram showed timi iii flow with no dissection or embolisation see ptca comments final diagnosis two vessel coronary artery disease severe diastolic dysfunction with severely elevated filling pressures suggestive of volume overload moderate to severe pulmonary hypertension successful stenting of the cx lesion ekg sinus rhythm rare ventricular premature beat non specific t wave inversions in leads i and v v broad q waves in lead iii small q waves in ii and avf non specific t wave abnormalities possible transmural inferior wall myocardial infarction old clinical correlation is required rare ventricular premature beat early transition no previous tracing available for comparison intervals axes rate pr qrs qt qtc p qrs t brief hospital course hypotension on admission his sbps were in the low s likelt secondary to diuresis and antihypertensives given at the outside hospital he was carefully monitored and all antihypertensives were held his blood pressure improved to the low s s cardiomyopathy chf patient was sent for cardiac catheterization which revealed stenosis of mid lcx stenosis rca and pcwp of he tolerated the procedure well with some persistent ooze at the groin site that resolved by the day after the procedure with pressure dressings he had only a small x cm hematoma it was felt that the degree if his coronary disease did not corrlate with the severe depression of his systolic function and that alcoholic cardiomyopthay was also playing a role ci he was diuresed with a lasix drip in order to avoid hypotension by discharge he was diursed approximately liters and his blood pressure remained stable he was started on lisinopril metoprolol and po lasix all of which he tolerated well on day prior to discharge he was started on po lasix but was net positive by cc by the end of the day hence on the day of discharge his lasix was upped to mg po daily the importance of avoiding alcohol and smoking were stressed and he was provided with information about maintaining a low salt diet and fluid restriction he will follow up with dr days after discharge and will have a follow up echocardiogram in month cad carduac catheterization revelaed chronic occlusion of rca and mlcx with ffr so lcx was stented with des he was started on asa plavix and metoprolol his lfts were elevated but began to trend down during his hospitalization he was started on lipitor mg po qd the day before discharge and will follow up with dr to monitor his lft and titrate his statin dose transaminitis this was felt to be secondary to liver congestion in the setting of chf as well as alcohol he was monitored for alcohol withdrawal but did not require any valium on ciwa scale his lfts continued to trend down and will be follow as an outpatient rash patient had a erythematous blanching rash on his bilateral forearms it was felt that this was a possible drug allergy to azithromycin or ceftriaxone given at these were discontinued and the rash resolved by the second hospital day medications on admission asa mg daily discharge medications clopidogrel mg tablet sig one tablet po daily daily disp tablet s refills aspirin mg tablet sig one tablet po daily daily acetaminophen mg tablet sig tablets po q h every to hours as needed 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 daily daily disp tablet sustained release hr s refills atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills lasix mg tablet sig two tablet po once a day please weigh yourself daily if you gain more than pounds please increase daily dosage to mg daily disp tablet s refills discharge disposition home discharge diagnosis congestive heart failure cad s p cypher stents x to left circumflex om branch hyperlipidemia hypertension discharge condition hemodynamically stable afebrile satting well on room air discharge instructions if you have any chest pain shortness of breath dizziness leg swelling or any other concerning symptoms call your doctor or come to the emergency room be sure to take all of your medications as directed you must take your plavix everyday you should check your weight daily if your weight increases by lbs or more or you notice increased swelling in you legs or shortness of breath you should call your doctor you should continue to eat a low salt diet and restrict your fluid intake to liters per day the following changes additions have been made to your medications lipitor mg once daily toprol xl mg once daily lisinopril mg once daily aspirin mg once daily plavix mg once daily lasix followup instructions you have a follow up appointment with dr on wednesday please call to find our the time of your appointment at that visit you should have your blood work checked including your electrolytes and liver enzymes you should also make an appointment with your primary p in weeks md completed by,"{
""Diagnoses"": [""hypotension"", ""cardiac catheterization"", ""s p cypher stents to left circumflex artery"", ""history of present illness"", ""CHF"", ""HTN"", ""pnd""],
""Medications"": [""bronchodilators"", ""antibiotics"", ""nitro gtt"", ""ace bblocker"", ""diuretics"", ""asaplavix"", ""liter""]
}"
68922,admission date discharge date service surgery allergies advil attending chief complaint abdominal pain major surgical or invasive procedure laparoscopic cholecystectomy laparoscopic lysis of adhesions approximately hours history of present illness yo f with one day of epigastric abdominal pain nausea vomiting and diarrhea non bloody non bilious vomitus non bloody brown watery diarrhea a ct scan of the abd pelvis shows a large distended gallbladder with a small amount of pericholecystic fluid us notes the presence of sludge within the gallbladder however the patient s pain is clearly centered over the epigastrium and not in the ruq her lfts were elevated as listed below raising concern for a common duct stone tbili baseline and transaminitis concerning for perhaps some other primary liver disease her lipase is elevated though which could account for the n v d and abdominal pain past medical history type ii dm diagnosed in s diet controlled htn left breast ca s p lumpectomy and rt gastric cancer stage iii s p gastrectomy gerd osteoporosis arthritis tinnitus fe deficient anemia cataract social history the patient lives in with her sister two daughters and a son she had children but many are deceased she moved to the us from in she denies alcohol smoking and recreational drug use family history her mother died at age from an unspecified cancer her father died at of natural causes no family history of cad but sister has type ii dm physical exam pe l nad lying comfortably in bed rrr cta b s nd tender in the epigastrium wwp pertinent results pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count pm alt sgpt ast sgot alk phos tot bili pm lipase pm glucose urea n creat sodium potassium chloride total co anion gap am alt sgpt ast sgot alk phos tot bili dir bili indir bil am lipase am glucose urea n creat sodium potassium chloride total co anion gap ct abd distended gallbladder with minimal pericholecystic fluid and likely gallbladder sludge correlation to physical examination clinical history and liver function tests is recommended if this correlation is equivocal these findings could be further evaluated via son atherosclerotic disease cardiomegaly periportal edema likely reflecting overhydration bilateral renal hypodensities some of which are cysts others of which are too small to characterize central uterine hypodensity likely endometrial and unchanged from previous studies if patient has vaginal bleeding consider outpatient ultrasound liver us large gallbladder with mobile sludge and stones as well as mild mural edema and trace pericholecystic fluid the common bile duct is normal measuring mm ercp evidence of a prior roux en y surgery was seen both limbs were evaluated the ampulla could not be reached due to the patient s surgical anatomy cardiac echo the left atrium is normal in size there is moderate symmetric left ventricular hypertrophy the left ventricular cavity is unusually small overall left ventricular systolic function is normal lvef tissue doppler imaging suggests an increased left ventricular filling pressure pcwp mmhg there is a mild resting left ventricular outflow tract obstruction there is no ventricular septal defect right ventricular chamber size and free wall motion are normal the right ventricular free wall is hypertrophied right ventricular chamber size is normal with normal free wall contractility 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 left ventricular inflow pattern suggests impaired relaxation the tricuspid valve leaflets are mildly thickened there is moderate pulmonary artery systolic hypertension there is no pericardial effusion pm blood culture final report blood culture routine final klebsiella pneumoniae final sensitivities bacteroides fragilis group beta lactamase positive fusobacterium species beta lactamase negative unable to further speciate sensitivities mic expressed in mcg ml klebsiella pneumoniae ampicillin sulbactam s cefazolin s cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s piperacillin tazo s tobramycin s trimethoprim sulfa s brief hospital course ms was evaluated by the acs service in the emergency room and admitted to the hospital with gallstone pancreatitis she was made npo hydrated with iv fluids and cultured she had one positive blood culture for klebsiella and was placed on unasyn she underwent ercp to clear the cbd but the procedure was aborted due to her prior roux en y and subsequent inability to reach the ampulla although she was a high risk operative candidate due to her age and heart disease she was also at a high risk for recurrent pancreatitis the cardiology service evaluated her and a cardiac echo revealed a normal ef with no new wall motion abnormalities her blood pressure and heart rate was controlled with beta blockers and although a high surgical risk she was cleared for surgery she was taken to the operating room on and underwent a laparoscopic cholecystectomy she tolerated the procedure well and returned to the pacu in stable condition she maintained stable hemodynamics and her pain was well controlled following transfer to the surgical floor she made very good progress her diet was gradually resumed on post op day after following a gradual decline in her lft s her surgical ports were healing well and her pain was controlled with tylenol alone the physical therapy service worked with her daily and she was up and ambulating independently with a rolling walker she had no chest pain or shortness of breath and her pre op medications were resumed with good blood pressure control after an uneventful recovery she was discharged to home on and will follow up with the clinic in weeks medications on admission vitamin b mg triamcinolone prn acetaminophen prn atenolol clonazepam qhs prn lisinopril omeprazole mylanta prn nitroglycerin sl q x prn colace sucralfate tid multivitamin tab tablet s by mouth once a day discharge medications omeprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day docusate sodium mg capsule sig one capsule po bid times a day atenolol mg tablet sig one tablet po bid times a day acetaminophen mg tablet sig two tablet po tid times a day senna mg tablet sig one tablet po bid times a day as needed for constipation sucralfate gram tablet sig one tablet po three times a day vitamin b mcg tablet sig two tablet po once a day multivitamin tablet sig one tablet po once a day discharge disposition home with service facility vna discharge diagnosis gallstone pancreatitis status post total gastrectomy gram negative bacteremia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions please call your doctor or return to the emergency room if you have 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 see blood or dark black material when you vomit or have a bowel movement 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 and take any new meds as ordered activity no heavy lifting of items pounds for weeks you may resume moderate exercise at your discretion no abdominal exercises wound care you may shower no tub baths or swimming if there is clear drainage from your incisions cover with clean dry gauze your steri strips will fall off on their own please remove any remaining strips days after surgery please call the doctor if you have increased pain swelling redness or drainage from the incision sites followup instructions call the clinic at for a follow up appointment in weeks provider md phone date time completed by,"{
""Diagnoses"": [""adhesions"", ""gallbladder"", ""laparoscopic cholecystectomy"", ""laparoscopic lysis of adhesions"", ""common duct stone"", ""sludge within gallbladder"", ""primary liver disease"", ""elevated lipase""],
""Medications"": [""Advil"", ""diarrhea"", ""nausea"", ""vomiting""]
}"
51519,admission date discharge date date of birth sex m service neurosurgery allergies dexamethasone attending chief complaint right temporal lesion major surgical or invasive procedure right sided craniotomy for mass resection history of present illness year old gentleman with a history of small cell lung cancer which was diagnosed in the patient underwent prophylatic wbrt but suffered a right temporal metastasis requiring radiosurgery performed via gks by dr at surveilllance mri post srs revealed persistent contrast enhancement in the region of the srs this has been closely monitored since that time and has remained unchanged until recently hoewever a surveillance mri on revealed interval increase in size and a pet scan on the same date revealed thallium uptake the patient presents today to discuss these findings and discuss possible intervention past medical history small cell lung ca chronic neck pain arthritis bph whole brain irradiation in gamma knife radiosurgery to a recurrent solitary right temporal brain metastasis by md medical center in social history lives alone and states that he is quite lonely he does have good friend support though he recently bought to keep him company and is thinking about getting back into painting he denies tobacco etoh drugs and says that he is trying to eat very healthy family history nc physical exam gen wd wn comfortable nad heent pupils perrl eoms intact neck supple lungs no adventicious sounds cardiac rrr abd soft nt extrem warm and well perfused neuro mental status awake and alert cooperative with exam depressed affect orientation oriented to person place and date language speech slow broken but with good comprehension post wbxrt encephalopathy cranial nerves i not tested ii pupils equally round and reactive to light to mm bilaterally visual fields left upper quadrant field cut 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 coordination slight dysmetria bilaterally handedness left exam on discharge patient is alert and orinted speech is a little slow but clear he was seen ambulating with physical therapy and needed assistance as he is slightly ataxic and falls to the left pertinent results mri since the prior study there is again minimal interval growth of the previously reported amorphous heterogeneously enhancing lesion within the right temporal lobe currently measuring x mm in an axial plane previous measurement x mm mass effect with distortion of the right temporal is stable there is no evidence of new metastatic foci and no acute intracranial abnormality on this non dedicated scan impression mild interval increase of right temporal heterogeneously enhancing lesion post op mri postoperative changes in the right temporal region with blood products in the surgical cavity with mild residual enhancement suspected at the posterior margin of the surgical cavity otherwise the examination is unchanged no acute infarcts or hydrocephalus seen brief hospital course patient presented electively for right craniotomy on operative course was uncomplicated post operatively he was transferred to the icu for observation he was quite agitated on post operative day one and unable to sit still for an mri a post op mri was again attempted on prior to discharge to evaluate wether there was complete resection of the tumor this was also unsuccessful on he was given a small amount of ativan which aided him in completing the post op mri scan also on he was evaluated by physical therapy and was found to be unsteady on his feet listing to the left and as such will require rehab placement he was screened later in the day on and he was offered a bed on he was deemed fit for discharge and given instructions for follow up medications on admission valium levothyroxine lorazepam oxycodone prednisone compazine ranitidine tamsulosin temodar coalce mvi discharge medications acetaminophen mg tablet sig tablets po q h every hours as needed for fever pain docusate sodium mg capsule sig one capsule po bid times a day heparin porcine unit ml solution sig units injection tid times a day oxycodone mg tablet sig tablets po q h every hours as needed for pain levothyroxine mcg tablet sig one tablet po daily daily multivitamin tablet sig one tablet po daily daily prednisone mg tablet sig one tablet po daily daily levetiracetam mg tablet sig two tablet po bid times a day senna mg tablet sig one tablet po bid times a day as needed for constipation bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for constipation ranitidine hcl mg tablet sig one tablet po bid times a day sodium chloride flush ml iv q h prn line flush peripheral line flush with ml normal saline every hours and prn ondansetron mg iv q h prn nausea hydralazine mg iv q h prn sbp sodium chloride flush ml iv q h prn line flush peripheral line flush with ml normal saline every hours and prn discharge disposition extended care facility discharge diagnosis left parietal brain tumor 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 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 on with a mild shampoo 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 if you are being sent home on steroid medication make sure you are taking a medication to protect your stomach prilosec protonix or pepcid as these medications can cause stomach irritation make sure to take your steroid medication with meals or a glass of milk clearance to drive and return to work will be addressed at your post operative office visit make sure to continue to use your incentive spirometer while at home call your surgeon immediately if you experience any of the following new onset of tremors or seizures any confusion 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 any signs of infection at the wound site increasing redness increased swelling increased tenderness or drainage fever greater than or equal to f followup instructions you will need to follow up in the brain clinic on at pm the brain clinic is located on the of in the building their phone number is please call if you need to change your appointment or confirm completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex m service neurosurgery allergies dexamethasone attending addendum the pathology of the lesion removed in this patient was consistent with radiation necrosis and was the final pathology diagnosis given also of note is that the patient had cerebral edema on imaging prior to removal of the lesion which was also present on the post operative mri scan and was clinically significant discharge disposition extended care facility md completed by,{}
18896,admission date discharge date date of birth sex m service cardiothoracic allergies norvasc attending chief complaint chest pain major surgical or invasive procedure coronary artery bypass graft x lima to lad svg to om svg to diag svg to pda on history of present illness y o male with substernal chest pain with radiation to both of his arms two days later he developed headaches lightheadedness and diaphoresis referred for a stress test which was abnormal then underwent a cardiac cath which revealed severe three vessel disease past medical history gastroesophageal reflux disease hypertension hyperlipidemia hypothyroidism diverticulitis s p gi bleed s p esophageal dilatation s p colon polyp resection h o shingles social history denies tobacco or etoh use family history non contributory physical exam vs skin unremarkable heent eomi perrl nc at neck supple from jvd carotid bruit chest ctab w r r heart rrr c r m g abd soft nt nd bs ext warm well perfused c c e varicosities neuro a o x mae non focal pertinent results cxr no sizable pneumothorax bilateral small pleural effusion improved linear atelectasis in both bases 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 pt inr pt pm blood urean creat cl hco am blood glucose urean creat na k cl hco angap am blood albumin phos mg brief hospital course mr was a same day admit after undergoing all pre operative work up as an outpatient on day of admission he was brought to the operating room where he underwent a coronary artery bypass graft x please see operative report for details following surgery he was transferred to the csru for invasive monitoring in stable condition within hours he was weaned from sedation awoke neurologically intact and extubated on post op day one he was started on beta blockers and diuretics and diuresed towards his pre op weight he appeared to be doing well on this day and was transferred to the telemetry floor on post op day two his chest tubes were removed also on post op day three he had episodes of atrial fibrillation which were treated with beta blockers and amiodarone on post op day four he continued to have episodes of atrial fibrillation and was started on coumadin also on this day his epicardial pacing wires were removed he slowly improved and worked with physical therapy for strength and mobility until his inr was therapeutic this was achieved on post op day six and he was discharged home with vna services and the appropriate follow up appointments medications on admission benicar hct mg qd toprol xl mg aspirin mg qd nexium mg qd discharge medications docusate sodium mg capsule sig one capsule po bid times a day disp capsule 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 benicar mg tablet sig one tablet po once a day disp tablet s refills ferrous sulfate mg tablet sig one tablet po daily daily disp tablet s refills tamsulosin mg capsule sust release hr sig one capsule sust release hr po hs at bedtime disp capsule sust release hr s refills hydromorphone mg tablet sig one tablet po every four hours as needed disp tablet s refills amiodarone mg tablet sig two tablet po bid times a day for days then mg tabs daily for week then tab mg daily until discontinued by dr disp tablet s refills metoprolol tartrate mg tablet sig two tablet po tid times a day disp tablet s refills furosemide mg tablet sig one tablet po twice a day for weeks disp tablet s refills potassium chloride meq capsule sustained release sig two capsule sustained release po q h every hours for weeks disp capsule sustained release s refills warfarin mg tablet sig three tablet po once a day for days inr to be checked on tuesday results to be called to dr office disp tablet s refills discharge disposition home with service facility partners discharge diagnosis coronary artery disease s p coronary artery bypass graft x post operative atrial fibrillation pmh gastroesophageal reflux disease hypertension hyperlipidemia hypothyroidism diverticulitis s p gi bleed s p esophageal dilatation s p colon polyp resection h o shingles discharge condition good discharge instructions shower daily no bathing or swimming for month no lifting for weeks no creams lotions or powders to any incisions call dr office for any fever wound drainage or redness followup instructions with dr in weeks with dr in weeks completed by,"{
""Diagnoses"": [""cardiothoracic"", ""allergies"", ""norvasc""],
""Medications"": [""attending"", ""chief complaint"", ""chest pain"", ""major surgical or invasive procedure"", ""coronary artery bypass graft"", ""lima to lad"", ""svg to diag"", ""svg to pda"", ""on history of present illness"", ""y"", ""male with substernal chest pain with radiation to both of his arms"", ""two days later he developed headaches"", ""lightheadedness"", ""diaphoresis"", ""referred for a stress test"", ""which was abnormal"", ""then underwent a cardiac cath"", ""which revealed severe three vessel disease""]
}"
17021,admission date discharge date date of birth sex f service ccu chief complaint the patient was admitted to the ccu status post ethanol septal ablation history of the present illness this is a year old female with a history of hocm sustained svt copd with recent admission in for shortness of breath chf exacerbation she underwent ethanol septal ablation on and noted to be in complete heart block recently she stated that she has not had any difficulty with her breathing chest pain has had mild lower extremity swelling denied any lightheadedness recent fever or chills she was admitted today for ethanol ablation she had some minimal dyspnea on exertion echocardiogram from showed hocm resting peak gradient of mmhg peak valsalva increased from in moderate mr and mitral annular calcification in ect echocardiogram showed normal augmentation of all myocardial segments lvot of pr plus no arrhythmia moderate mr mild to moderate ai review of systems no fevers chills mild lower extremity edema shortness of breath better recently no lightheadedness dizziness no cough and compliance with medications past medical history hocm hypertrophic obstructive cardiomyopathy in with echocardiogram as stated above history of chf copd emphysema restrictive lung disease gerd peptic ulcer disease status post appendectomy status post total abdominal hysterectomy with bilateral salpingo oophorectomy diverticulitis history of hypertension history of carotid artery disease bilateral stenosis on carotid ultrasound in history of vertebrobasilar disease by ultrasound history of renal insufficiency creatinine about history of spinal stenosis allergies motrin penicillin clindamycin which causes diarrhea social history the patient has a pack year tobacco history denied alcohol home medications atenolol q d ativan mg p o q h s verapamil q d b i d lasix q d flonase spray q d colace b i d b i d os cal b i d zantac b i d combivent mdi folex one q d enteric coated aspirin mg q d atrovent two b i d advair b i d physical examination on admission vital signs afebrile bp pulse respiratory rate saturating on room air general the patient was comfortable in no acute distress lethargic heent perrla extraocular motors intact neck supple cardiovascular regular rate and rhythm normal s and s respiratory clear bilaterally with mild crackles on the left side abdomen soft nontender nondistended positive bowel sounds no hepatosplenomegaly extremities there was lower extremity edema pulses with doppler bilaterally neurologic slightly lethargic with sensory and motor grossly intact laboratory radiologic data on admission white blood cell count h h and platelets sodium potassium chloride bicarbonate bun creatinine glucose calcium magnesium phosphorus ck inr ptt ekg had a rate of no st or t wave changes hospital course this was a year old female with a history of hocm history of chf mitral regurgitation copd who was presenting status post ethanol ablation which induced complete heart block and had a temporary pacemaker placed in the left arm when admitted to the ccu cardiac wise coronaries the patient was kept on aspirin without any difficulties no acute issues cad kept on aspirin pump she is now status post ethanol septal ablation for a history of hocm checking cardiac enzymes looking for peak she peaked at about ck and since then her ck has actually gone down her ck was on day number two of admission on the day before discharge the patient s ck has gone down to the range rhythm the patient depended on the temporary pacemaker initially at the setting set and then the settings were lowered and the patient s own rhythm was able to take over temporarily the following day the patient was unable to maintain her own rhythm and was dependent upon the pacemaker the pacemaker was put back on at a rate of and milliamps later on the patient was taken throughout the course of the hospitalization was taken to ep and a pacemaker was placed the patient has done well with the pacemaker and without any complications or difficulty chronic obstructive pulmonary disease emphysema the patient was continued on her mdis from her home regimen and has done well and was continued throughout the hospital course renal insufficiency the patient s creatinine was checked daily and the patient was kept at about her baseline creatinine at about the day before her discharge her creatinine level was which is lower than her baseline report of gastrointestinal she has a history of gerd and peptic ulcer disease she was kept on protonix for the term of her admission and her hematocrit was maintained stable at about the low s electrolytes nutrition her lytes were repleted as needed during this hospital stay and prophylactically she was getting subcutaneous heparin and protonix while on this admission the day before her discharge she was changed to pneumoboots she was then taken off the pneumoboots and encouraged to ambulate physical therapy had come on board and seen her and they recommended that she should not go home and she should actually be transferred to rehabilitation for further treatment before being sent home her glucose was maintained with regular insulin sliding scale discharge diagnosis complete heart block hypertrophic obstructive cardiomyopathy status post ethanol ablation status post pacemaker placement disposition the patient was discharged to a rehabilitation center discharge instructions the patient was to take it easy for the next several weeks and to follow up as described below with pcp and cardiologist follow up the patient is to follow up in the device clinic the appointment will be called in for her and she will get a call from the clinic for an appointment in one week which is going to be at the seventh floor at she is also to make an appointment with dr in the next week or two for follow up care and also dr her pcp the next week major surgical invasive procedures status post ethanol ablation status post pacemaker placement condition on discharge good stable discharge medications aspirin mg p o q d pantoprazole mg p o q d multivitamins one q d ipratropium micrograms two puffs inhaled q i d beclomethasone microgram spray nasal spray b i d albuterol ipratropium mix micrograms one to two puffs inhalation q six hours metoprolol mg tablet oral b i d captopril mg one half tablet t i d mg t i d sliding scale insulin maintain on sliding scale insulin for bowel regimen the patient is to be kept in rehabilitation center with docusate sodium mg p o b i d the patient is on some p r n medications such as the lorazepam mg p o h s p r n and morphine for pain mg iv q eight hours p r n to be held for sedation or respiratory rate depression senna two tablets p o b i d p r n m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex f service discharge diagnosis complete heart block status post ethanol ablation status post pacemaker chief complaint status post ethanol ablation septal ablation history of present illness the patient is a year old female with a history of hocm history of nssvt copd with recent admission in for shortness of breath chf exacerbation she underwent ethanol septal ablation on noted to be in complete heart block recently she stated she has not had any difficulty with breathing chest pain has had mild lower extremity swelling denies lightheadedness recent fever chills admitted today for ethanol ablation does have some minimal dyspnea on exertion echo on showed hocm resting peak gradient of mmhg peak valsalva increased from in she had moderate mitral regurg and also mitral annular calcification ett echo in normal augmentation of all myocardial segments lvot pr plus no ea or arrhythmia moderate mr mild to moderate ai review of systems no fever chills mild lower extremity edema shortness of breath better recently no lightheadedness or dizziness no cough compliant with meds past medical history hocm history of chf history of nssvt copd emphysema restrictive lung disease gerd pud status post appendectomy status post tah bso diverticulitis history of positive vre hypertension history of carotid artery disease with bilateral stenosis on carotid ultrasound in history of renal insufficiency creatinine about history of spinal stenosis allergies motrin penicillin and quinine gives her diarrhea social history the patient has a pack year tobacco history none currently outpatient medications atenolol q d ativan mg q h s verapamil q d kcl b i d lasix q d flonase two sprays q d colace b i d b i d zantac b i d combivent mdi folex q d enteric coated aspirin mg q d atrovent two b i d advair b i d physical examination on admission pulse blood pressure respiratory rate o sat percent in room air in general comfortable in no acute distress lethargic heent nc at perrla extraocular motions intact supple neck cardiovascular regular rate and rhythm normal s s no murmurs gallops or rubs appreciated respiratory some bilateral basilar crackles abdomen soft nondistended nontender bowel sounds present no hepatosplenomegaly extremities lower extremity edema bilaterally dorsalis pedis pulses bilaterally patient slightly lethargic but alert and oriented times three laboratory data on admission white blood cells hematocrit platelets sodium potassium chloride bicarb bun creatinine glucose calcium mag phos ck inr ptt hospital course the patient is a year old female with a history of hocm history of chf mitral regurg copd who is presenting now status post ethanol ablation and complete heart block cardiac coronary continued aspirin pump given her history of hocm she is now status post ethanol septal ablation checking cardiac enzymes to see peak also check chest x ray for pacemaker placement ep complete heart block will follow continue with telemetry patient with temporary pacemaker may require permanent one if not improved holding all calcium channel blockers and beta blockers for the time being while the patient was admitted while the patient was in the hospital she was continued on aspirin the patient had a permanent pacemaker placed on to follow up for the pacemaker for her coronary disease she was added back on beta blockers and for coronary disease also was on aspirin and ace inhibitor rhythm she is now status post pacemaker on the day of discharge without complications she was pacing at about the day before discharge on beta blockers chest x ray showed also good placement of the pacemaker pump she had mr ar chf resolving on chest x ray and also on exam and also decreased weight by kg post diuresis chf on exam improved dramatically with lasix for copd she was continued on mdi regimen and also with incentive spirometry which she was doing really well for chronic renal insufficiency the patient s baseline creatinine was she had good urine output creatinine the day before discharge was better than her regular baseline the patient did well status post ablation therapy and follow up as directed below the patient was discharged to an extended care facility final diagnosis complete heart block status post ethanol ablation status post pacemaker followup the patient will be called with an appointment for device clinic for appointment in one week after discharge this will be in seventh floor information given to the patient also to make an appointment with dr at for one week from now and dr her pcp early next week for post discharge followup care major surgical invasive procedure none the patient is status post ethanol ablation also status post pacemaker condition on discharge good stable discharge medications aspirin q d pantoprazole q d multivitamin q d ipratropium two puffs q i d beclomethasone mcg one spray b i d albuterol mcg one to two puffs q six hours metoprolol mg tablet mg b i d captopril t i d sliding scale insulin while in rehab furosemide mg tablet q d salmeterol mcg disk one disk inhalation q hours fluticasone mcg two puffs b i d m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies ibuprofen penicillins attending chief complaint abdominal pain fever major surgical or invasive procedure insertion of left subclavian line on s p electrical cardioversion on for rapid afib right knee arthrocentesis picc line placement intestinal feeding tube insertion endo tracheal intubation and mechanical ventilation history of present illness yo f with history of hypertrophic cardiomyopathy s pacemaker placement ef cri baseline cr copd on prednisone taper currently status post recent right total knee replacement with pre operative antibiotics s p tah bso appendectomy distant sbo presenting with rlq abdominal pain x several hours fever patient recently status post right tkr at with post operative course complicated by persistent oxygen requirement l s s on ra delirium described below was discharged from nebh on to rehab where remained until when was transferred back to for presumed chf at which time myocardial infarction was excluded by serial cardiac enzymes cta negative for pe she was diuresed for elevtaed bnp but persistently desaturated with minimal exertion to s patient was on coumadin post operatively for dvt prophyalxis and developed some hemoptysis while on bridge with iv ufh her hospital course was complicated by leukocytosis with cta evidence of ground glass opacities that were read as consistent with chf or pneumonia for which she was empirically treated with levofloxacin completed in house she was discharged back to rehab on prednisone taper pain control and lasix for chf on patient was doing well until the morning of when she awoke with achy non radiating rlq abdominal pain subjective fever anorexia her symptoms improved and appetite returned after a bm x unclear whether bloody pus or black and she remained stable until the morning of admission when pain returned in a similar location and with a similar quality in both instances the pain was constant and in the second case did not ease with oxycodone or bm on fever was noted to and patient was referred to for further evaluation no nausea vomiting hematemesis diarrhea brbpr melena hematuria dysuria back pain rash cough ha vision changes chest pain increased shortness of breath increased joint pain of note her family has noted some intermittent confusion since her r tkr consisting of right arm tremor weakness dysarthria speech difficulty and dysphagia for liquids solids she has had attacks of difficulty opening my mouth though she claims to comprehend speech and denies other focal weakness or numbness urinary incontinence these attacks have been ascribed to medications opiates but are not related temporally to medication administration past medical history chf cad hocm ef s p etoh septal ablation complicatedby complete heart block s p pacer knee arthritis s p r tkr htn carotic stenosis cri baseline copd emphysema restrictive lung disease gerd pvd s p appy diverticulitis vre s p tah bso social history lives alone one son locally one daughter in approx pack yr smoking history rare etoh family history non contributory no history of ibd physical exam vs cvp l i o in micu l uop ml since mn cc hr gen nad neck no jvd appreciated cor rrr s s ii vi sem at base variably increased with valsalva r g chest cta b with scattered wheeze abd soft distended hypoactive bs rlq llq tenderness with light palpation mild shake tenderness extr r knee tkr c d i without ooze non tender no c c e dp in both pulses neuro aaox appropriately interactive pertinent results echo tee echo tte the left atrium is mildly dilated left ventricular wall thickness cavity size and systolic function are normal lvef due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded the aortic valve leaflets are mildly thickened mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen there is mild pulmonary artery systolic hypertension no obvious evidence of endocarditis seen compared with the findings of the prior report tape unavailable for review of there has been no significant change echo ef 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 due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded overall left ventricular systolic function is 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 there is no aortic valve stenosis mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen the left ventricular inflow pattern suggests impaired relaxation there is mild pulmonary artery systolic hypertension there is no pericardial effusion cxr a permanent pacemaker remains in place there has been placement of a right picc line terminating in the superior vena cava and a feeding tube coursing below the diaphragm removal of a left subclavian vascular catheter is noted the heart is mildly enlarged there is vascular engorgement and worsening perihilar haziness as well as an increasing bilateral interstitial pattern small pleural effusions are noted bilaterally impression worsening congestive heart failure with increasing interstitial edema leni no dvt cxr mild interstitial pulmonary edema and greater caliber to the mediastinal veins suggest cardiac decompensation is progressed since moderate cardiomegaly is longstanding tip of the left subclavian central venous line projects over the lateral margin of the svc and should be withdrawn cm to avoid mural trauma transvenous right atrial and right ventricular pacer leads follow their expected courses from the right pectoral pacemaker no pneumothorax axr limited study secondary to body habitus no evidence of free air contrast is seen in the colon likely secondary to the patient s video oropharyngeal swallow study gas is seen in the stomach note is made of degenerative changes of the lumber spine impression no evidence of free air brief hospital course year old female who recently underwent a right total knee replacement at the who was admitted from rehab for fever abdominal pain and diarrhea with leukocytosis and ct scan evidence of colitis initial hospital course outlined by problem id c diff colitis she was initially treated broadly with levofloxacin and metronidazole since she had been on prednisone at the rehab for a copd exacerbation however once her c diff toxin assay returned positive her antibiotics were weaned to only metronidazole abdominal pain and diarrhea reduced dramatically after continued flagyl repeat c diff studies were negative x days her end date for flagyl will be days after stopping her levoquin ideally we would continue the flagyl for days until stopping all antibiotics however to avoid polypharmacy id favors the former plan coag negative staph line infection developed central line catheter infection with bottles postive and postive line culture the line was removed and she was started on vancomycin surveillance cultures were initially negative however a single bottle grew out coag neg staph days after starting treatement given the presence of her pacer and knee replacement it was decided in consultation with infectious disease to extend her vancomycin course to weeks tte was negative for obvious endocarditis and a right knee tap by her orthopedic surgeon grew no organisms all surveillance cultures were subsequently sterile a tee was not performed given the lack of further positive cultures and the great degree of anxiety that the procedure generated in this patient rash cellulitis the pt developed a weeping erythematous rash on her flanks bilaterally that was painful this was thought to be a mild cellulitis however worsened despite being on vanco for her line sepsis under the direction of id levoquin was added for gram negative coverage and her cellulitis appeared to improve toward the end of her hospital stay she continued to have persistent erythema with some tenderness on palpation however was afebrile with a normal wbc this was felt to be related to her anasarca and should improve with mobilization of her fluid she will have to have this area watched for skin breakdown related to the edema chf afib with rvr experienced episodes of atrial fibrillation with rapid ventricular rates symptomatic for chest pain and hypotension on each occasion she failed rate conrol with iv ccb s and bb s and needed resusitation with fluids and cardioversion first episode was treated with amio and cardioversion second episode was treated with cardioversion only third episode was attempted with ibutilide then cardioversion which was transiently successful she was then taken to the ep lab for an av nodal ablation she already had had a pacemaker placed in for her etoh septal ablation amiodarone was stopped anticoagulation was continued she continued to be in heart failure which was slow to diurese in the setting of her anasarca hypoalbuminemia and hocm she responded slowly with iv lasix without any worsening of her renal function she will need continued but careful diuresis given the low oncotic state of her plasma acei and bb held for low blood pressures surrounding afib with rapid vent rate with hypotension acei will need to be restarted fluids and nutrition unfortunately due to malnutrition hypoalbuminemia and deconditioning she was difficult to diurese iv lasix did result in an increase in urine output but it was a challenge to achieve net negative fluid balance in s included iv abx and tube feed volume she had a speech and swallow evaluation done on hod which revealed moderate remaining aspiration risk as such she has been tube fed with the goal of transitioning her back to po as tolerated this will likely need to be performed in consultation with nutrition ortho her right knee was also noted to be stiff and painful this was thought to be due to her recent surgery but with her recent bactermia a septic arthritis could not be ruled out so orthopedics was consulted to tap the knee the fluid revealed a hemarthrosis but no evidence for infection on the gram stain prior to discharge her orthopedic attending okay d her for full weight bearing status on her right knee heme maintained on coumadin for afib with goal inr held for intervention and restarted on pulm h o copd s p recent week prednisone taper for copd o via nc albuterol and atrovent nebs was increased at the end of her stay albuterol was stopped for worsening benign essential tremor micu update brief summary of prior hospital course f with hocm s p septal ablation with hospitalized for c diff colitis after total knee replacement in and rehab at rehab this hospitalization c b af rvr requiring ablation and pacer placement diastolic chf exacerbation pulmonary edema and anasarca poor nutrition coag neg staph line infection recurrent candiduria delerium and right abdominal wall cellulitis she was sent to ccu with hypotension and intubated for resp distress during a code for days previous to event she had episodes of hypothermia and hypoxia on floor presumably interpreted as worsening pulmonary edema requiring additional diuresis cta at that time with no pe but bilat ground glass with some pockets of consolidation and small bilat effusions diuresis continued with effect but on am of pt dropped sbp to s minimally responsive to l ns ivf dopamine gtt started at prior to ccu transfer with effect bp in the ccu hypotension presumed to be septic shock wbc up to creat up to from loose bowels noted bp was very responsive to low dose levophed and vasopressin cosyntropin stim performed after random cortisol without appropriate rise stress dose steroids were started ventilation complicated by poor compliance and high pips was placed on pcv then changed to ac for unclear reasons antibiotic treatment broadened to include caspofungin for candiduria not improving on fluconazole aztreonam for hospital acquired pneumonia in pt allergic to pcn and continued vancomycin for h o coag neg staph bacteremia weaned off levophed and vasopressin overnight with maps in ccu multiple attempts made at central line placement s b left subclavian hematoma despite ffp reversal of anticoagulation hct drop presumed due to volume shifts s p units prbcs micu course as of pt was transferred to the micu for further management of septic shock pseudomonas pneumonia responded to combination of aztreonam and gentamicin further fever work up showed no endocarditis no pacer abscess no other growth from cultures hypoxic respiratory failure initial resp failure was due to the combination of pneumonia and fluid overload and weaning was complicated by difficulty with diuresis and baseline interstitial restrictive lung disease of unclear etiology patient was transitioned to pressure support ventilation and continued a slow wean with plans for possible tracheostomy if the pt was unable to extubate by anemia hct has stabilized at adequate retics cri initially had elevated cr on transfer which improved with diuresis and hemodynamic stability diastolic chf h o hocm s p septal ablation pt was restarted on ace and bb for bp control and afterload reduction with iv lasix and chlorthalidone for diuresis cad pt was ruled out for mi and then continued on asa lipitor bb and ace i as bp tolerates af s p ablation and pacer pacer dependent will need rate turned down by ep currently at after either extubation or tracheostomy and stabilization of respiratory status code dnr dni no electricity of chest compressions communication daughter hcp and son addendum as per legnthy and frequent family meetings including a meeting between the family dr and dr on the decision was made to extubate the pt when she was thought to have the most promising picture for respiratory success with no further plans for future intubation despite the post extubation outcome therefore on the pt was felt to be doing well with a high risb decreased bicarb from diamox treatment and hob upright at this point the medical team felt that the pt is at a point where she has the best chance to succeed with an extubation the pt was subsequently extubated the pt was succeeding for a number of hours with moderate respiratory effort and family encouragement but then progressively became more tired with increased wob and slowly decreasing oxygen saturations as per the decided plan of action and as per the patients wishes to be dnr dni the pt was made as comfortable as possible through this time of increased air hunger without any further intubation attmepts the pt subsequently expired on and was not attempted to be resussitated due to her dnr order medications on admission acetaminophen mg tablet sig two tablet po q h every hours fexofenadine mg tablet sig one tablet po bid times a day docusate sodium mg capsule sig one capsule po bid times a day fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day gabapentin mg capsule sig one capsule po tid times a day metoprolol tartrate mg tablet sig three tablet po bid times a day multivitamin capsule sig one cap po daily daily ranitidine hcl mg tablet sig one tablet po bid times a day senna mg tablet sig one tablet po hs at bedtime ipratropium bromide solution sig one inhalation q h every hours albuterol sulfate solution sig one inhalation q h prn bisacodyl mg suppository sig one suppository rectal daily daily as needed lactulose g ml syrup sig thirty ml po bid times a day as needed lorazepam mg tablet sig one tablet po hs at bedtime as needed magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed oxycodone mg tablet sig one tablet po q h every hours as needed oxycodone mg tablet sustained release hr sig one tablet sustained release hr po q h every hours prednisone mg tablet sig two tablet po daily daily mg total on then taper to mg total each day for then taper to mg total each day for albuterol sulfate solution sig one inhalation q h every hours as needed furosemide mg tablet sig three tablet po daily daily discharge medications multivitamin capsule sig one cap po daily daily metoprolol tartrate mg tablet sig tablets po bid times a day gabapentin mg capsule sig one capsule po tid times a day fexofenadine mg tablet sig one tablet po bid times a day docusate sodium mg capsule sig one capsule po bid times a day ipratropium bromide solution sig one neb inhalation q h every hours albuterol sulfate solution sig one neb inhalation q h every hours albuterol sulfate solution sig one neb inhalation q h every hours as needed for wheezing sob ipratropium bromide solution sig one neb inhalation q h every hours as needed for wheezing sob pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours metronidazole mg tablet sig one tablet po tid times a day for days for c difficile colitis warfarin mg tablet sig one tablet po hs at bedtime dose may need to be adjusted goal inr aspirin mg tablet chewable sig one tablet chewable po daily daily atorvastatin mg tablet sig one tablet po daily daily heparin flush cvl units ml ml iv daily prn ml ns followed by ml of units ml heparin units heparin each lumen qd and prn inspect site every shift furosemide mg ml solution sig forty mg iv injection times a day for days adjust as needed for goal diuresis of approximately liters of fluid at a rate of cc daily lisinopril mg tablet sig one tablet po daily daily discharge disposition extended care discharge diagnosis respiratory failure psudomonas pneumonia c difficile colitis myocardial infarction due to demand related ischemia peak tropt hypertrophic obstructive cardiomyopathy atrial fibrillation with rapid ventricular response sepsis total knee replacement right leg chronic renal insufficiency chronic obstructive pulmonary disease congestive heart failure coronary artery disease central line infection coagulase negative staph bacteremia malnutrition discharge condition expired followup instructions provider clinic phone date time provider phone date time provider breathing tests phone date time please follow up with your pcp weeks,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""f"", ""service"", ""chief complaint"", ""ethanol septal ablation"", ""history of present illness"", ""copd"", ""shortness of breath"", ""chf exacerbation"", ""hocm"", ""sustained svt"", ""complete heart block"", ""mild lower extremity swelling"", ""lightheadedness"", ""recent fever or chills""],
""Medications"": [""ethanol ablation""]
}"
7569,admission date discharge date date of birth sex f service medicine allergies bactrim codeine penicillins benadryl iodine iodine containing demerol dicloxacillin morphine vioxx attending chief complaint dyspnea major surgical or invasive procedure intubation bronscopy a line history of present illness y o f w copd osa rsd gerd who presented to hospital tonight c o dyspnea per their notes she had four days of increasing shortness of breath raspy breathing and leg edema pt nods her head yes when asked if she has increasing swelling in her legs and difficulty breathing when lying flat says no when asked about cough en route to their hospital she developed chest pain on arrival she was tachycardic in the s hypertensive to the s s saturating on a nrb she was given nitro paste and lasix mg iv she continued to have chest and abd pain and was given morphine mg iv and pepcid mg iv she also received compazine mg levofloxacin mg iv and solumedrol mg iv she put out cc to the lasix her abg was and it was decided to transfer her to for further care in our ed her vitals were ranging s s s s rr initially with o sat on nrb she was emergently intubated for hypoxemic respiratory failure her abg here per ed resident was a preintubation abg but was after she had been intubated x minutes so was on either nrb vs intubated with fio she was given an additional mg levofloxacin as well as etomidate succinylcholine propofol versed fentanyl and tylenol she was admitted to the micu for respiratory failure past medical history cardiac arrest in while under anesthesia for surgery on hydradenitis hypertension chf ef here hydradenitis rsd gerd gastrointestinal bleed asthma bipolar d o ptsd hypercholesterolemia obesity dm diet controlled copd pfts here in with fev l pred fvc l pred fev fvc pred dlco pred s p cholecystectomy s p appy s p tah bso s p breast reduction surgery s p r knee surgery s p bladder surgery social history stopped smoking when she had the diagnosis of asthma made in no etoh x yrs family history father died of a cva and an mi presurgery mother had a cardiac cath and a dye shut down her kidneys and she died one brother had an mi another brother had a cva after an ear infection a sister had breast cancer two years ago at physical exam admission physical exam t bp p vent ac x fio spo peep gen awake answering questions by writing alert heent nc at anicteric mm dry neck obese unable to appreciate jvd lungs bronchial breath sounds at r base cv tachycardic regular no m r g abd soft nt nd bs morphine pump palpable in llq ext ble edema dp bilaterally pertinent results admission labs from blood wbc rbc hgb hct mcv mch mchc rdw plt ct blood neuts bands lymphs monos eos baso atyps metas myelos blood pt ptt inr pt blood glucose urean creat na k cl hco angap cardiac enzymes am blood ck cpk am blood ck cpk pm blood ck cpk am blood ctropnt pm blood ck mb mb indx ctropnt discharge labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap admission chest xray endotracheal tube terminating just above the carina cardiomegaly with mild volume overload versus mild chf widened superior mediastinum which can be positional opacities in both lower lobes representing combination of atelectasis and pneumonia dr was informed by telephone at a m on the day of the study enlarged cardiac contour raises the possibility of pericardial effusion admission ecg baseline artifact probable sinus tachycardia low voltage late r wave progression since the previous tracing of limb lead qrs voltage has diminished tte the left atrium is elongated there is mild symmetric left ventricular hypertrophy the left ventricular cavity size is normal due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded overall left ventricular systolic function is normal lvef right ventricular chamber size and free wall motion are normal the aortic root is mildly 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 mildly thickened no mitral regurgitation is seen there is borderline pulmonary artery systolic hypertension there is no pericardial effusion compared with the report of the prior study images unavailable for review of there is no definite change radiology report bilat lower ext veins p study date of pm impression no evidence of dvt brief hospital course in summary this is a year old f w obesity copd cad chf and diet controlled dm who presented with hypoxic respiratory failure requiring intubation hypoxic respiratory failure likely secondary to pneumonia given her fever bandemia infiltrates on chest xray has significant a a gradient based on her initial abg on fio also may have several other contributing factors including chronic hypercarbia likely from copd osa restriction due to habitus other obvious concern is that this is chf or complicated by chf given history of worsening le edema and orthopnea chest xray was consistent with both pneumonia and edema she was started on broad spectrum antibiotics bronchoscopy on demonstrated substantial secretions and likely mucous plug obstructing right middle lobe which was cleared with subsequent re expansion of rml tte was negative for tamponade or wall motion abnormality and unchanged from prior lenis were obtained and were negative for dvt multiple sputum cultures were sent and grew out staph aureus methacillin sensitive she was initially treated with broad spectrum antibiotics but coverage was eventually narrowed to levofloxacin she has a penicillin allergy she was extubated successfully on strongly recommend follow up with a pulmonologist and sleep study she was also diuresed with improvement in her respiratory status chf amlodipine and captopril were initially held gentle diuresis was performed tte showed mild symmetric lvh lvef no ar no mr borderline pulmonary artery systolic hypertension no pericardial effusion unchanged from echo dm placed on humalog sliding scale with good control of blood sugar hyperlipidemia atorvastatin was continued psychiatric cont depakote tiagabine restarted xanax once extubated and since off sedation but a dose lower than home regimen rsd has indwelling morphine pump will need pain consult on to refill pump fen while intubated received tube feeds for nutrition nursing was concerned that on thin liquids might have some aspiration no difficulty with thickened liquids transitioned to regular diet with thickened liquids recommend speech and swallow evaluation ordered but not performed at time of transfer ppx pneumoboots recieved sc heparin and pantoprazole mg per home regimen code status full discharged to on at patient request given improvement in respiratory status medications on admission medications per list from osh indwelling morphine pump norvasc mg daily depakote mg xanax mg po tid lipitor mg daily protonix mg percocet q h captopril mg tid compazine mg q h lasix mg daily lasix mg qpm carafate milk of magnesia qhs stool softener lactulose cc gabitril mg qam mg qhs theophylline mg qhs lidoderm patch discharge disposition extended care discharge diagnosis primary diagnoses respiratory failure pneumonia congestive heart failure secondary diagnoses asthma copd discharge condition improved extubated with stable respiratory status discharge instructions at your request you are being transferred to for further medical care including monitoring of your respiratory status continued antibiotic administration further diuresis as needed and adjustments in your pulmonary medications as needed we recommend that you follow up with a pulmonologist and sleep specialists followup instructions transfer to for further medical care per patient preference continued monitoring of respiratory status continued antibiotic administration follow up with pulmonologist and sleep specialists speech and swallow evaluation for aspiration risk completed by,"{
""Diagnoses"": [""Dyspnea"", ""Raspy breathing"", ""Leg edema"", ""COPD"", ""OSA"", ""Gerd""],
""Medications"": [""Bactrim"", ""Codeine"", ""Penicillins"", ""Benadryl"", ""Iodine"", ""Demerol"", ""Dicloxacillin"", ""Morphine"", ""Vioxx"", ""Attending"", ""Chief complaint"", ""Intubation"", ""Bronchoscopy"", ""History of present illness"", ""Y-O-F-W"", ""Copd"", ""Rsd"", ""Gerd""]
}"
25105,admission date discharge date date of birth sex f service medicine allergies demerol ampicillin niacin mevacor prilosec erythromycin base clindamycin attending chief complaint hypotension sepsis funguria acute kidney injury major surgical or invasive procedure picc line placement history of present illness the patient is an year old female who was recently admitted following a fall to hospital where she was treated for rll pneumonia requiring vanco ertapenem at hospital from at the time of discharge her creatinine was which reportedly was her baseline value at the rehab facility she was continued on vancomycin but her vancomycin was discontinued when her creatinine was found to be a vanco level was checked and found to be high reportedly in the s vancomycin was discontinued and ivfs given at rehab but despite these measures the cr worsened to on subsequent measurement she was also noted to be lethargic and with poor urine output cc hr she also had been having non bloody diarrhea that respected the night time that had been occuring for the last days she was taken to the ed initial vitals were l supine sitting triggered for hypotension into sbp s physical examinination notable for being fairly unremarkable laboratory data significant for na creatinine wbc bands hematocrit inr lactate ua with moderate leukocyte esterase large blood blood cultures urine cultures sent ct abdomen pelvis without contrast with bilateral effusion atrophic pancreas no hydronephrosis possible colitis cxr v reportedly without acute process received ciprofloxacin iv l ivf pressures subsequently sbp s on transfer to micu ra past medical history s p spinal fusion l s in s p laminectomy l s in gerd htn hypercholesterolemia chronic diarrhea diverticulosis gi bleed hiatal hernia anemia migraines hypothyroidism hemorrhoids chronic back spasms anxiety s p cholecystectomy s p appendectomy social history most recently at rehab facility after hospitalization at hospital prior to this she lived alone in in two estranged daughters in ca she did not want them to be contact hcp is a friend retired social worker denies tobacco alcohol or illicit drug use family history non contributory physical exam admission exam physical exam vs ra general chronically ill appearing elderly female in nad sleeping comfortably but easily arousable heent nc at perrla eomi sclerae anicteric mmm op clear neck supple no thyromegaly no jvd no carotid bruits lungs bibasilar crackles without significantly decreased breath sounds no wheezes or rhonchi good air movement resp unlabored heart rrr no mrg nl s s abdomen soft nt nd minimal tenderness to palpation no masses or hsm no rebound guarding well healing surgical scar extremities wwp no c c e peripheral pulses skin no rashes or lesions lymph no cervical lad neuro awake oriented to name month year cns ii xii grossly intact asymmetric pupils known prior surgery muscle strength throughout secondary to fatigue sensation grossly intact throughout steady gait gu foley in place no surrounding erythema discharge exam physical exam vs ra general chronically ill appearing elderly female in nad sleeping comfortably but easily arousable heent nc at perrla eomi sclerae anicteric mmm op clear neck supple no thyromegaly no jvd no carotid bruits lungs bibasilar crackles without significantly decreased breath sounds no wheezes or rhonchi good air movement resp unlabored heart rrr no mrg nl s s abdomen soft nt nd minimal tenderness to deep palpation of rlq extremities wwp no c c e peripheral pulses skin no rashes or lesions lymph no cervical lad neuro awake oriented to name month year cns ii xii grossly intact pertinent results admission labs pm urine hours random urea n creat sodium potassium chloride pm urine osmolal pm glucose urea n creat sodium potassium chloride total co anion gap pm calcium phosphate magnesium iron pm caltibc ferritin trf pm wbc rbc hgb hct mcv mch mchc rdw pm plt count pm ret aut pm glucose lactate na k cl tco pm glucose urea n creat sodium potassium chloride total co anion gap pm alt sgpt ast sgot tot bili pm wbc rbc hgb hct mcv mch mchc rdw pm neuts bands lymphs monos eos basos atyps metas myelos pm hypochrom anisocyt poikilocy macrocyt microcyt polychrom ovalocyt stippled pm plt smr normal plt count pm pt ptt inr pt pm urine color yellow appear cloudy sp pm urine blood lg nitrite neg protein glucose neg ketone neg bilirubin neg urobilngn neg ph leuk mod pm urine rbc wbc bacteria few yeast mod epi trans epi renal epi pm urine eos negative lytes 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 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 cbc diff pm 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 pm blood hct 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 pm blood neuts bands lymphs monos eos baso atyps metas myelos pm blood neuts bands lymphs monos eos baso atyps metas myelos am blood neuts bands lymphs monos eos baso atyps metas myelos uti pm urine color yellow appear cloudy sp pm urine rbc wbc bacteri few yeast mod epi transe renalep pm urine blood lg nitrite neg protein glucose neg ketone neg bilirub neg urobiln neg ph leuks mod am urine blood neg nitrite neg protein neg glucose neg am urine type random color straw appear clear sp ketone neg bilirub neg urobiln neg ph leuks tr microbiology urine culture positive yeast blood culture fungus mycobacteria negative c diff negative blood culture negative urine culture pending ngtd radiology cxr upright ap view of the chest right picc tip terminates in the svc the heart size is upper limits of normal unchanged mediastinal contours are stable pulmonary vascularity and hilar contours are within normal limits patchy opacities in both lung bases are present these likely reflect atelectatic changes no focal consolidation is noted no pleural effusion or pneumothorax is present no acute osseous findings are seen impression minimal patchy opacities in both lung bases likely reflect atelectasis ct abd pelvis study ct of the abdomen and pelvis without contrast coronal and sagittal reformatted images were also generated comparison ct of the abdomen and pelvis from findings abdomen in the visualized portion of the chest calcified atherosclerotic disease is seen involving the aortic valve and coronary arteries a small pericardial effusion is also seen bilateral simple pleural effusions are seen moderate on the right and small on the left with associated bilateral lower lobe atelectasis small hiatal hernia is present within the limits of a non contrast study the liver spleen and adrenal glands appear normal the gallbladder has been removed the pancreas is atrophic the kidneys show no evidence of hydronephrosis or calculi the small and large intestine show no signs of obstruction oral contrast has progressed just into the proximal right colon right colon is underdistended which likely makes the walls appear mildly thickened but no adjacent fat stranding is noted there is no lymphadenopathy or free air small amount of free fluid is seen around the liver diffuse anasarca is seen pelvis the bladder is decompressed around a foley balloon the patient is status post hysterectomy rectum appears unremarkable there is no pericolonic fat stranding but again trace free fluid is seen in the pelvis diffuse anasarca is present bones patient is status post posterior spinal fusion of l s with grade anterolisthesis of l on s additionally a compression deformity is seen in the l vertebral body which is unchanged compared to the mr from there is loss of intervertebral disc height at l l with vacuum phenomenon within the intervertebral disc there are no aggressive appearing lytic or sclerotic lesions impression diffuse anasarca with trace ascites and bilateral small to moderate sized pleural effusions right greater than left no definite evidence of colitis apparent wall thickening of the proximal right colon is likely due to underdistention and mixing with oral contrast no pericolonic stranding is present cxr history year old woman with new vomiting evaluate for aspiration impression ap chest compared to a m pulmonary and mediastinal vascular engorgement are new and although heart size is normal and pleural effusions are small if any the interstitial abnormality in the lungs is most likely mild edema dr paged cxr prelim no acute process improved from s chest x ray brief hospital course year old female with chronic anemia prior mrsa uti and recent admission for rll pneumonia admitted to micu with hypotension leukocytosis bandemia in context of recent nausea poor po intake diarrhea uti micu course in the micu she required fluid resuscitation and unit prbcs for hypotension she was treated for candidal uti with fluconazole initially cefepime linezolid until culture data returned initially also received vancomycin po given concern for colitis based on symptoms and finding of bowel wall thickening on ct abdomen pelvis on preliminary read symptoms resolved c difficile toxin was negative and final read changed to no evidence of colitis creatinine baseline improved from to with fluid resuscitation etiology suspected to be atn and component of prerenal azotemia patient on admission wished to be dnr dni due to issues with delirium her healthcare proxy was contact persistent agitation delirium psychiatry was consulted and recommend haloperidol mg po q hr prn agitation and mg po hs she was transferred from micu to medical service for further care hospitial floor course sepsis hypotension patient was afebrile off fluids and hemodynamically stable on transfer to the floor she remained afebrile without leukocytosis hemodynamically stable throughout her course with blood pressures in the s systolic the source of the sepsis was not fully ascertained although her admission urine culture grew out fungus and she clinically improved on fluconazole in the micu it seemed unlikely that fungal uti was responsible for her sepsis blood cultures showed no fungus growth patient was non toxic appearing her foley was discontinued and a repeat ua was obtained which was negative except for trace leukocytes and an additional urine culture was sent with all of these findings her fluconazole was discontinued at the time of discharge the patient remained afebrile hemodynamically stable and all of her culture data was with no growth to date we continued to hold all her anti hypertensive medications and her blood pressures were not elevated acute kidney injury the presented initially with a cr of very uop and urinary sediment that was consistent with atn the etiology of the atn was thought to be secondary to hypotension sepsis ongoing diarrhea decreased po intake as well as nephrotoxic tubular injury vancomycin level of in rehab per her micu course above she was fluid resusictated with some improvement of the cr to on the floor her urine output improved and her phosphorus came down to normal range however her cr rose slightly to nephrology recommended conservative management with no iv fluids renally dosed medications and expected her recovery from atn to be slow and perhaps incomplete given her age and the severity of the insult she should follow up with her pcp regarding this issue diarrhea the patient had been experiencing days of non bloody diarrhea during the initial onset of her symptoms in rehab a stool c diff was sent on admission and returned negative no stool cultures were obtained the diarrhea resolved on the floor without treatment and the patient reported that her stools were more formed at the time of discharge agitation psych as mentioned in above micu course patient was seen by psych for persistent agitation delirium etiology thought to represent mixture of personality style background of dementia with superimposed delirium in setting of hypotension and sepsis her citalopram was discontinued and she was started on mirtazapine mg qhs she was taken off of her prn valium which had been given at her rehab and started on both prn and standing pm haldol mg qhs qtc was obtained prior to each haldol administration and was consistently normal her behavior was more appropriate on this regimen per psychiatric consult s recommendation patient was discharged on mirtazapine and haldol as needed at bedtime her valium and citalopram remained discontinued she was counseled to follow up with her primary care physician regarding the management of these medications normocytic anemia her hematocrit was found to be at on admission and she was transfused u prbc in the micu but this hct value was reportedly around her baseline in the setting of myelodysplasia she was guiac negative on admission and was mantained on gi prophylaxis her hematocrit remained stable throughout her time on the floor until the time of discharge medications on admission milk of magnesia prn zantac mg po bid albuterol d c atenolol mg po daily hctz mg po daily d c lisinopril mg po qhs d c d ns at cc hour cc then cc compazine mg po q hours prn nausea ertapenem gram iv q hours vancomycin gram iv bid duonebs tid valium mg po q hours prn anxiety oxycodone mg po q hours prn pan citalopram mg po daily vitamin d units qweekly levothyroxine mcg po daily lipitor mg po daily asa mg po daily mirapex mg po daily colace mg po bid flovent mcg po bid discharge medications albuterol sulfate mg ml solution for nebulization sig one inhalation q h every hours as needed for shortness of breath wheezing levothyroxine mcg tablet sig one tablet po daily daily atorvastatin mg tablet sig one tablet po daily daily fluticasone mcg actuation aerosol sig two puff inhalation times a day pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours lidocaine mg patch adhesive patch medicated sig one adhesive patch medicated topical daily daily 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 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 as needed for constipation mirtazapine mg tablet sig tablet po hs at bedtime haloperidol mg tablet sig one tablet po hs at bedtime as needed for agitation discharge disposition extended care facility discharge diagnosis sepsis hypotension urinary tract infection yeast kidney damage acute tubular necrosis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms it was a pleasure taking care of you at you were admitted for blood pressure sepsis and kidney damage you were initially admitted to the intensive care unit where you received fluids and were started on iv antibiotics and you improved your urine culture grew out yeast and your iv antibiotics were changed to oral antifungals and you continued to improve your kidneys were damaged by the blood pressure and iv antibiotics you were taking prior to your admission once we stabilized your blood pressure your kidneys began to show signs of improvement althought we believe that recovery of function might take some time you should be sure to follow up with your primary care doctor about this issue closely you also had some of your psychiatric medications changed during your hospitalization see below and you should follow up with your primary care physician and be referred to a psychiatrist as needed regarding the use of these medications we made the following adjustments to your medications stopped valium mg po every hours as needed anxiety stopped citalopram mg by mouth at night started mirtazipine mg oral at night started haloperidol mg po at night as needed for agitation as a reminder the following medications were discontinued at your rehabilitation facility due to blood pressure we continued to hold your blood pressure because your blood pressure was not elevated you should follow up with your primary care physician about these medication stopped hctz mg by mouth daily stopped lisinopril mg by mouth at night stopped albuterol inhaler stopped mirapex mg po daily your follow up information is below followup instructions please schedule an appointment with your primary care physician week for this hospitalization sepsis hypotension urinary tract infection yeast acute tubular necrosis and psychiatric medication adjustment completed by,"{
""Diagnoses"": [""hypotension"", ""sepsis"", ""funguria"", ""acute kidney injury"", ""major surgical or invasive procedure""],
""Medications"": [""demerol"", ""ampicillin"", ""niarcin"", ""mevacor"", ""prilosec"", ""erythromycin"", ""clindamycin""]
}"
27212,admission date discharge date date of birth sex m service medicine allergies iodine attending chief complaint s p brady arrest major surgical or invasive procedure endotracheal intubation history of present illness mr was a year old male with h o cad s p cabg atatomy not known as well as pci with stent in in who was in his usoh until pm on when the patient collapsed after lifting heavy boxes by report cpr was initiated immediately and called with rapid ems response per report ems found pt in wct likely vt and pulseless pt received a total of shocks and lidocaine push during the transport to osh ed on arrival in the ed the patient was unreponsive and without a pulse s p two more shocks and intubated for airway protection ekg with wct and he was given amio bolus x and started on a drip the patient also was given epi and atropine during the code the patient remained hypotensive and was started on dopamine levophed for pressure support the patient was then transferred to for ongoing care echo at osh by report demonstrated an ef of with global hypokinesis no focal wall motion abnormalities but was a limited study ct of the head showed no acute changes meds on transfer included amio gtt and plavix past medical history cabg yrs ago anatomy lima to lad svg to high lateral pci w two des to mid and distal rca pci w des to svg cardiac risk factors dyslipidemia hypertension social history lives in was here in the in area family history not obtained physical exam per dr vs t bp hr rr o on ac gen intubated and sedated heent ncat sclera anicteric perrl eomi bleeding gums neck supple with jvp flat 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 intubated b l coarse crackles rib fracture abd soft ntnd no hsm or tenderness ext no c c e no femoral bruits pertinent results admission labs ck mb trop t ca mg p 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 fibrino pm 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 alt ast ld ldh alkphos totbili am blood alt ast ck cpk alkphos totbili am blood ck mb greater th ctropnt pm blood ck mb mb indx am blood ck mb mb indx am blood ck mb mb indx am blood ck mb am blood hapto am blood type art po pco ph caltco base xs pm blood type art po pco ph caltco base xs am blood type art temp tidal v peep po pco ph caltco base xs intubat intubated pm blood lactate stool clostridium difficile toxin assay neg stool clostridium difficile toxin assay neg stool clostridium difficile toxin assay neg urine urine culture ng urine urine culture ng sputum gram stain final pmns and epithelial cells x field no microorganisms seen respiratory culture final rare growth oropharyngeal flora klebsiella pneumoniae rare growth identification and sensitivities performed on culture f blood culture ng blood culture ng sputum gram stain final pmns and epithelial cells x field per x field gram negative rod s respiratory culture final oropharyngeal flora absent klebsiella pneumoniae sparse growth trimethoprim sulfa sensitivity testing available on request sensitivities mic expressed in mcg ml klebsiella pneumoniae ampicillin sulbactam s cefazolin s cefepime s ceftazidime s ceftriaxone s cefuroxime s ciprofloxacin s gentamicin s imipenem s meropenem s piperacillin tazo s tobramycin s catheter tip iv ng urine urine culture ng blood culture ng blood culture ng sputum gram stain final pmns and epithelial cells x field per x field gram positive cocci in pairs respiratory culture final sparse growth oropharyngeal flora klebsiella pneumoniae sparse growth trimethoprim sulfa sensitivity testing available on request sensitivities mic expressed in mcg ml klebsiella pneumoniae ampicillin sulbactam s cefazolin s cefepime s ceftazidime s ceftriaxone s cefuroxime s ciprofloxacin s gentamicin s imipenem s meropenem s piperacillin tazo s tobramycin s blood culture ng urine urine culture ng blood culture ng sputum gram stain final respiratory culture final klebsiella pneumoniae inpatient blood culture ng blood culture ng urine ng chest portable ap am two portable views comparison with the previous study done earlier the same day there is streaky density at the lung bases consistent with subsegmental atelectasis as before the patient is status post median sternotomy and cabg mediastinal structures are unchanged an endotracheal tube and nasogastric tube remain in place impression subsegmental atelectasis portable semi upright chest a m compared with at p m no obvious interval change in the pulmonary vascular engorgement centrally the patchy streaky opacities at the right lung base are slightly more prominent and confluent suggesting pneumonia cardiology report ecg study date of am sinus rhythm rate technical artifacts are seen an indeterminate axis is noted right bundle branch block pattern is seen ther is likely an anteroseptal myocardial infarction of undetermined age no previous tracing available for comparison echo measurements left atrium long axis dimension cm nl cm left atrium four chamber length cm nl cm right atrium four chamber length cm nl cm left ventricle septal wall thickness cm nl cm left ventricle inferolateral thickness cm nl cm left ventricle diastolic dimension cm nl cm left ventricle ejection fraction nl aorta valve level cm nl cm aorta ascending cm nl cm aortic valve peak velocity m sec nl m sec mitral valve e wave m sec mitral valve a wave m sec mitral valve e a ratio mitral valve e wave deceleration time msec pulmonic valve peak velocity m sec nl m s interpretation findings left atrium mild la enlargement right atrium interatrial septum mildly dilated ra normal interatrial septum no asd by d or color doppler dilated ivc cm with decrease during respiration estimated rap mmhg left ventricle normal lv wall thickness moderately dilated lv cavity no lv mass thrombus severely depressed lvef no resting lvot gradient no vsd right ventricle focal apical hypokinesis of rv free wall paradoxic septal motion consistent with conduction abnormality ventricular pacing aorta moderately dilated aortic sinus mildly dilated ascending aorta aortic valve mildly thickened aortic valve leaflets no as no ar mitral valve normal mitral valve leaflets no mvp trivial mr tricuspid valve tricuspid valve not well visualized indeterminate pa systolic pressure pulmonic valve pulmonary artery no ps pericardium no pericardial effusion general comments suboptimal image quality poor echo windows echocardiographic results were reviewed by telephone with the md caring for the patient conclusions the left atrium is mildly dilated there is an echodensity associated with the left atrial of the posterior mitral annulus vs artifact tissue no atrial septal defect is seen by d or color doppler the estimated right atrial pressure is mmhg left ventricular wall thicknesses are normal the left ventricular cavity is moderately dilated no masses or thrombi are seen in the left ventricle overall left ventricular systolic function is severely depressed with severe global hypokinesis and akinesis thinned of the basal inferior and lateral walls there is very apical dyskinesis there is no ventricular septal defect there is focal hypokinesis of the apical free wall of the right ventricle the aortic root is moderately dilated at the sinus level the ascending aorta 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 structurally normal there is no mitral valve prolapse trivial mitral regurgitation is seen the pulmonary artery systolic pressure could not be determined there is no pericardial effusion impression severely depressed lvef with regionality c w cad possible vs artifact if clinically indicated a tee may better characterize mr head w o contrast pm mr head w o contrast reason please assess for bleed please asses for thromboembolic cva medical condition year old man with brady arrest requiring shocks by dc cardioversion reason for this examination please assess for bleed please asses for thromboembolic cva please assess neck for cord compression and soft tissue injury indication cardiac arrest requiring shocks by cardiac conversion technique multiplanar t and t weighted sequences were obtained through the brain with diffusion weighted imaging findings evaluation of the adc map demonstrates diffuse cortical low signal this corresponds to increased signal on the diffusion weighted sequence within the cortex these findings represent diffuse cortical slow diffusion this would represent diffuse cortical injury from anoxia there is a tiny focus of abnormal magnetic susceptibility at the white matter junction in the posterior right frontal lobe consistent with petechial hemorrhage there is no midline shift mass effect or hydrocephalus the normal vascular flow voids are present there is paranasal sinus disease due to the patient s intubated status impression findings are consistent with diffuse anoxic brain injury mr cervical spine w o contrast pm mr cervical spine w o contrast reason now patient with c collar needs to be cleared medical condition year old man s p brady arrest and fall reason for this examination now patient with c collar needs to be cleared indication brady arrest and fall the patient with c collar needs to be cleared technique multiplanar t and t weighted sequences were obtained through the cervical spine with sagittal stir sequence findings the alignment of the cervical spine appears normal there is no abnormal bone marrow edema the intrinsic cord signal appears generally normal although it is poorly evaluated due to some motion at the level of there is a small focus of abnormal magnetic susceptibility within the left sided cord this is suspicious for an intramedullary hemorrhage there are multilevel posterior osteophytes causing mild spinal canal narrowing there are areas of moderate bilateral neural foraminal narrowing associated with these osteophytes given the patient s history and the presence of abnormal susceptibility within the cord the concern is for a cord injury impression small area of abnormal magnetic susceptibility within the cord at the level of c is concerning for a petechial hemorrhage this could be a secondary finding associated with cord injury the intrinsic cord signal is poorly evaluated due to patient motion artifact on the stir sequence there however is no bone marrow edema object bedside side eeg with viedo the heart was monitored because disorders of heart rhythms produce neurological complaints as described above or neurological disorders such as seizures when symptomatic produce cardiac arrhythmias referring doctor dr findings routine sampling a low voltage hz disorganized posterior background rhythm is seen with frequent electrode artifacts seen at the bilateral temporal leads with a very rhythmic alpha frequency quality that is limited to these leads however at other times it is also seen in the right central region there was also electrode artifact seen in the left central leads when these artifacts were at their lowest a very slow hz low voltage rhythm was noted with no clear regions of focal slowing and no clear epileptiform discharges noted sleep there were no normal sleep wake transitions seen cardiac monitor a generally regular rhythm was noted with an average rate of bpm however frequent premature ventricular contractions were seen automatic spike detection files there were these consisted primarily of electrode artifact particularly at the bilateral temporal leads there also seemed to be superimposed electrical artifact of low voltage and high frequency no true epileptiform features were noted automatic seizure detection files there were these consisted of the above noted electrode or electrical artifact seen in the bilateral temporal leads as well as multiple other leads no true electrographic seizures were recorded however pushbutton activations there were none impression this is an abnormal hour video eeg telemetry in the waking and sleeping states due to the low voltage suppressed slow and disorganized background rhythm with much superimposed electrical artifact nonetheless no true electrographic seizures or epileptiform features were noted there were no pushbutton activations this slow low voltage and disorganized background is suggestive of a severe encephalopathy which may be seen with medication effect toxic metabolic abnormalities or infections as well as global ischemic disease of note there were frequent premature ventricular contractions noted throughout the tracing neurophysiology report ep study date of object cardiac arrest assess neurologic function referring doctor dr findings brain stem auditory evoked potential after stimulation of the right ear there was no discernible evoked potential at any position this can often come from lesions in the viiith cranial nerve the patient was reported to have an earlier and severe hearing loss on the right after stimulation of the left ear there was a very poorly formed and faint peak at position i and another poorly formed peak at position v with a normal latency this suggests some conduction from the periphery to the mid brain and with a normal latency median nerve somatosensory evoked potential after stimulation of the right median nerve there was an evoked potential peak at erb s point with a normal latency subsequent peaks were not discernible this suggests a defect in the large fiber somatosensory conducting system after right median stimulation with the defect proximal to the brachialplexus this can be at the root level or centrally after left median nerve stimulation there were no discernible evoked potential peaks at any position there was no peak at erb s point this suggests a defect in the large fiber somatosensory conducting system peripherally this can be due to peripheral neuropathies body habitus and sometimes to technical factors brief hospital course m with h o cad s p cabg and pci who presented from osh s p cardiac arrest reportedly down for hrs pulseless s p multiple shocks intubated sedated on amiodarone and heparin gtt s hospital course by problem cad pt was s p cabg with unknown anatomy done in also with recent pci in ami per ekg due to an unkown etiology for his arrest thought seconsary to scar rather than acute mi in combination with his tenuous clinical status and questionable nuerologic recovery an acute cardiac catheterization was not performed rhythm his amiodarone drip was continued for several days he had only small runs of nsvt and a malignant arhythmia did not return his amiodarone drip was discontinued he remained in sinus rhythym while monitored on telemetry pump ef was reportedly at osh with global hk a repeat echo here showed an ef of resp he remained intubated up until the point he was made comfort measures only at which point he was taken off the ventilator neuro neurology was involved in this patient s care and an mri was obtained the mri showed diffuse cortical injury he did not recover meaningful cortical activity he developed epileptiform partialis continuium is his right arm and was initially started on a dilantin load this was discontinued after eeg showed no epileptiform activity a family meeting was held to discuss the neurologic prognosis and ultimately the family decided that given his poor prognosis they would change his care to comfort measures only febrile illness unclear source infectious vs central fever the patient appeared septic early in the course of his hospitalization and was broadly covered with vanc and zosyn this was changed to levoquin for days but high spiking fevers to returned and he was re started on vanc zosyn sputum cultures were not initially definitive for a source though eventually grew klebsiella cukture data above dispo the patient was made comfort measures only and expired on medications on admission diovan mg daily asa plavix lipitor folic acid discharge medications n a discharge disposition expired discharge diagnosis anoxic brain injury following cardiac arrest discharge condition expired discharge instructions not applicable followup instructions not applicable completed by,"{
""Diagnoses"": [""adult respiratory distress syndrome"", ""hypotension"", ""cardiac arrest"", ""pulseless ventricular tachycardia""],
""Medications"": [""amio"", ""lidocaine"", ""epi"", ""atropine"", ""dopamine"", ""levophed"", ""drip""]
}"
67442,admission date discharge date date of birth sex m service medicine allergies naproxen plavix rofecoxib fluoxetine attending chief complaint somnolence fluctuating mental status major surgical or invasive procedure none history of present illness the patient presented to hospital at am on due to sob and audible wheezes the patient has a h o copd and is on l nc at home during this episode of dyspnea the patient was on his baseline l the patient also c o slurred speech which he attributed to a swollen tongue according to the notes the patient recently started a new medication which he said was chantix three days prior the patient was also recently diagnosed with parkinsonism and is on sinemet at home the patient was also complaining of increased visual hallucinations at home prior to presentation at the patient had an abg that was on l nc he was given mg solumedrol duoneb levaquin mg his saturations remained in the high s on l nc during the ed stay at the patient took off all of his ekg leads and wanted to leave but was easily redirected by it was reported that the patient s tongue swelling had improved the patient was transfered to due to altered mental status and neurology consult during transport the patient continued to have visual hallucinations and was repsonding to internal stimuli which the patient says was baseline for him he was not distressed by these at initial vs were ra he triggered for episodes of unresponsiveness even to sternal rub on exam at first incredibly somnolent slurred speech tongue fasciculations otherwise cn ii xii intact strength throughout w e o l leg foot drop lungs exp wheezing bilat myoclonic jerks awoke spontaneously after minutes lactate normal abg normal head ct utox negative given narcan with no change in mental status on arrival to the micu the patient was initially difficult to arouse once awoken the patient was appropriate following commands and logical the patient says that he doesn t remember much of what happened today but notes that it started this am with some sob and then increasing visual hallucinations he says that he has had these hallucinations for weeks which he describes as seeing people whom he knows and he has conversations with these are nonthreatening hallucinations the patient also notes some orthostasis especially dizziness when he arises from bed in the am he complains of tremor both at rest and with movement which he says has gotten better since starting sinimet he denies rigidity or gait disturbance no urinary symptoms he notes dry mouth but little tongue swelling now review of systems per hpi otherwise unable to be elicited by patient past medical history past medical history left foot drop s p surgery in chronic back pain anxiety depression copd on l nc at home htn degenerative disk disease past surgical history cabg with aneurysm repair appendectomy subclavian stenting bl knee surgeries social history home lives in an apartment by himself independent in most adls drives has an appointed clerk who receives his benefits check and manages his finances has family support from his siblings he us also close with his ex wife his hcp is his sister tobacco ppd smoker since childhood after recent hiospitalization he has been trying to use nicotine patch and chantix alcohol prior h o heavy etoh abuse but none for years illicits occasional mj only family history mother disease with parkinsonism body features father killed by a drunk driver but previously was healthy w thyroid disease sister thyroid disease physical exam admission exam vitals t bp p r o ra general once arousable aox no hallucinations now able to carry on logical conversation heent sclera anicteric dry mm dry tongue non swollen no dysarthria perrla neck obese jvp not elevated no lad cv regular rate and rhythm normal s s no murmurs rubs gallops lungs distant breath sounds end expiratory wheezes abdomen soft non tender non distended bowel sounds present no organomegaly ext warm well perfused has brace on left foot due to foot drop neuro cnii xii intact strength upper lower extremities grossly normal sensation biceps reflex unable to elicit other reflexes gait deferred finger to nose intact some resting arm and chin tremor but normal cerebellar function discharge exam on discharge he is awake and alert oriented x denies hallucinations neuro exam intact 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 pm blood glucose urean creat na k cl hco angap pm blood alt ast alkphos totbili pm blood lipase pm blood calcium phos mg pm blood vitb pm blood tsh pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg pm blood type art po pco ph caltco base xs intubat not intuba pm blood lactate pm blood lactate am blood lactate 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 micro data rapid plasma reagin test negative blood culture no growth imaging ct head w o contrast no acute intracranial process chest single view mild bibasilar atelectasis low lung volumes blunting of the left costophrenic angle may be due to overlying soft tissue although a small left pleural effusion cannot be excluded no definite focal consolidation brief hospital course primary reason for hospitalization mr is a y o gentleman with copd cad s p distant cabg depression anxiety smoking and recent dx of parkinsonism who presented from for neurological evaluation given increasing somnolence and visual hallucinations active issues ams with hallucinations the etiology of his ams and hallucinations is not clear his fluctuating consciousness on admission with non threatening hallucinations could be c w a neurologic process such as body dementia although he did not have the characteristic motor findings the neurology service was consulted and felt his hallucinations were most likely polypharmacy vs hypoxia from his underlying lung disease his sinemet was discontinued as neurology felt he had no s sx parkinson s disease his alprazolam loratidine oxycodone amitriptyline and gabapentin were held his hallucinations resolved and mental status cleared on discharge it was recommended that he continue to hold these medications and follow up with his pcp and an outpatient neurologist for further evaluation chronic issues copd the patient has a long hx of copd and is a chronic smoker he remained at his baseline o requirement of l throughout hospitalization and abg was wnl he was continued on his home inhalers cad s p cabg he was continued on his home asa and statin htn he was continued on his home lisinopril and nifedipine transitional issues the following medications were discontinued sinimet chantix ropinirole alprazolam loratidine oxycodone amitriptyline and gabapentin he was scheduled to follow up with his pcp after discharge it was recommended that he ask his pcp about referral to a neurologist in his area medications on admission aspirin mg qday bisoprolol and hctz mg qday lisinopril mg qday nifedipine er mg qday zocor mg qhs sinemet tab qid gabapentin mg tid celexa mg qday amitriptyline mg qhs alprazolam mg oxycodone mg tid duoneb qid albuterol puffs q hr prn symbicort puffs singulair mg qhs loratidine mg qday fluticasone nasal spray sprays qday ropinirole mg tid pyridoxine mg vitamin b mcg prilosec mg qday nicotine patch chantix started days ago discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po once a day montelukast mg tablet sig one tablet po once a day claritin mg tablet sig one tablet po once a day proair hfa mcg actuation hfa aerosol inhaler sig two puffs inhalation every hours as needed for shortness of breath or wheezing flonase mcg actuation spray suspension sig two sprays nasal once a day sprays each nostril once daily vitamin b mg tablet sig one tablet po twice a day vitamin b mcg lozenge sig one lozenge po twice a day duoneb mg mg mg base ml solution for nebulization sig one neb inhalation once a day zocor mg tablet sig one tablet po at bedtime bisoprolol hydrochlorothiazide mg tablet sig one tablet po once a day prilosec mg capsule delayed release e c sig one capsule delayed release e c po once a day nifedical xl mg tablet extended rel hr sig one tablet extended rel hr po once a day symbicort inhalation neurontin mg capsule sig one capsule po three times a day lisinopril mg tablet sig one tablet po once a day nicoderm cq mg hr patch hr sig one patch transdermal once a day discharge disposition home with service facility home care services discharge diagnosis altered mental status due to medication side effect discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr you were admitted to because you were confused and having hallucinations we believe this happened as a side effect of multiple medications you were taking including sinimet chantix citalopram ropinirole and percocet we stopped these medications while you were in the hospital and your confusion improved you were also evaluated by our neurologists while you were in the hospital the neurologists do not feel that you have parkinson s disease and recommend that you stop taking sinimet as it could be contributing to your hallucinations we recommend that you follow up with a neurologist as an outpatient please talk to your primary care provider about setting up an appointment with a neurologist near you we recommend that you stop the following medications stop sinimet stop chantix we recommend you continue using your nicotine patch for smoking cessation stop ropinirole stop citalopram stop alprazolam stop percocet stop amitriptyline we made no other changes to your medications while you were in the hospital please continue taking the rest of your medications as prescribed by your outpatient providers we have scheduled an appointment for you to follow up with your primary care provider see below for your appointment time it has been a pleasure taking care of you at and we wish you a speedy recovery followup instructions name np location community health center of address phone appointment friday am it is recommended you follow up with a neurologist within weeks of discharge please discuss with your primary care provider at this appointment about getting setup with an appointment,"{
""Diagnoses"": [""COPD"", ""Parkinsonism"", ""Dyspnea"", ""Visual Hallucinations""],
""Medications"": [""Lasix"", ""Chantix"", ""Sinemet"", ""Solumedrol"", ""Levaquin"", ""Methylprednisolone""]
}"
21261,unit no admission date discharge date date of birth sex f service nb history baby girl is the gram product of a week gestation born to a year old gravida i para to i mother prenatal screens were notable for maternal blood type a positive antibody negative hepatitis b surface antigen negative rubella immune rpr nonreactive group b strep negative the pregnancy was notable for a prenatal diagnosis of tetralogy of fallot with pulmonary atresia with possible esophageal atresia chromosomes done by amniocentesis were normal his mother developed preterm labor with nonreassuring fetal heart tracing the infant was therefore delivered by stat cesarean section the infant emerged vigorous with good cry and was brought to the warmer and was dried stimulated and suctioned she was pink throughout with good heart rate with significantly bruised face from facial presentation of note on the initial physical examination the child had an imperforate anus apgar scores were at one minute and at five minutes she was admitted to the neonatal intensive care unit for further management physical examination the child was breathing in the s with a pulse in the s and a pulse oximetry of postductally on room air the anterior fontanelle was open and flat the face was discolored with significant bruising there were coarse breath sounds bilaterally with poor aeration and moderate tractions the infant had regular rate and rhythm with no audible murmur but good femoral pulses the abdomen was flat with no hepatosplenomegaly or masses there was normal female genitalia the child had an imperforate anus she was moving all extremities hospital course by system respiratory the child was noted to have poor aeration with increased work of breathing and so therefore was placed on cpap at cm with some improvement she was trialed off before transport throughout she good saturations in the mid s at target cardiovascular the child had reasonable perfusion the child was started on prostaglandin at mcg per kilo per minute and d gi a nasogastric tube was inserted but met with some resistance raising suspicion for esophageal atresia fluid electrolytes and nutrition an umbilical venous line was placed with good positioning by x ray confirmation total fluids were run with d at cc per kilo per day infectious disease the child obtained a cbc and blood culture antibiotics were not started pending the results given the minimal sepsis risk factors we consulted cardiology and arranged transport to the cardiac intensive care unit at consent was obtained and the transport team arrived to transport the child condition at discharge stable discharge disposition to level facility discharge diagnoses tetralogy of fallot with pulmonary atresia esophageal atresia imperforate anus m d dictated by medquist d t job,"{
""Diagnoses"": [""Tetralogy of Fallot with pulmonary atresia with possible esophageal atresia""],
""Medications"": []
}"
43083,admission date discharge date date of birth sex f service obstetrics gynecology allergies bactrim amoxicillin abacavir attending chief complaint symptommatic fibroid uterus history of abnormal pap smear left ovarian cyst major surgical or invasive procedure total abdominal hysterectomy left salpingoopherectomy history of present illness per preop assessment this is a year old woman with a history of an abnormal pap smear history of a known fibroid uterus and left adnexal mass on an ultrasound done on a bulky heterogeneous uterus measuring x x was seen previously it had measured x x cm there were multiple masses consistent with fibroids the largest is located on the left measures x x cm the endometrium was distorted by multiple fibroids however the visualized portion measures mm and appears unremarkable there is a cm thin walled cyst in the left adnexa impression mm left adnexal cyst interval increase in size of uterus the patient notes that her bleeding remains irregular embx for malignancy ecc pap smear ascus cannot r o cx sil hg ecc sil hg cin ii iii past medical history ob gyn history menarche at dysmenorrhea and menorrhagia for approximately six years she has been sexually active in the past with a male partner in she had a first trimester loss in she had a cesarean birth without complications past medical history significant for obesity diabetes mellitus g pd deficiency depression hypercholesterolemia hypertension lower back pain schizoaffective disorder hiv and history of pulmonary embolism in associated with bedrest surgical history diagnostic operative hysteroscopy and thermachoice balloon ablation in social history denies smoking alcohol or substance abuse family history mother with mental illness lives in and has been psychiatrically hospitalized father died of an mi at age both parents with type ii dm physical exam wd wn obese woman in nad heent n c a t eom full without thyroidmegaly lymphadenopathy cor without murmur gallop or rub abdomen obese soft nontender no hepatosplenomegaly or masses pelvic deferred to the or extremities without clubbing cyanosis or edema brief hospital course the patient underwent total abdominal hysterectomy her uterus was cm and estimated blood loss for the case was cc there were no complications please see full operative note for details the patient had somnolence requiring bipap in pacu after receiving analgesics and had hypertensive urgency and after treatment had persistent hypertesion of note sbp prior to surgery was elevated at she was transferred from the pacu to the icu she spent three days in the largely for blood pressure control her problems were managed as follows htn the patient was on lisinopril mg daily and hctz mg daily as an outpatient postsurgically the patient had hypertensive urgency which required a labetalol gtt to be started she continued to have labile bp and muptiple medications were added as the labetalol gtt was weaned off her medication regimen at transfer included lisinopril mg qd metoprolol increased to mg tid amlodipine was increased to mg daily also on hydralazine mg q h she responded well to hydralizine in the icu hctz was stopped due to hyponatremia goal sbp was set as during her icu stay renal was consulted and recommended hemolysis labs given a differential diagnosis which included microangiopathic disease and labs were not consistent with hemolysis of note she had an abominal ct in with no evidence of adrenal mass upon transfer to the floor the patient remained bp ranging from renal ultrasound was undertaken and showed no evidence of renal artery stenosis hyponatremia hypochloremia the patient was hyponatremic since admission and her na continued to decrease postoperatively she has a known history of hyponatremia in the past hyponatremia was thought to be secondary to diuretic use but did not improve after hctz discontinuation potassium is low so unlikely to be due to adrenal insufficency tte showed ef of in and no history of heart failure the patient appeared volume overloaded una ucl uosm una would support siadh as the kidneys are not holding onto na avidly patient is auto diuresising which may be contributing to her hyponatremia she was placed on a free water restriction of l day her sodium reached a nadir of and was prior to discharge chest pain in the icu the patient complained of pleuritic central chest pain which was constant denied sob or dizziness had been coughing and pain was worse with coughing also reproducible with palpation was resolved after a few hours ekg showed no change was likely musculoskeletal pain vs pleuritic pain from her lungs given no ekg changes and the description of the pain as well as its reproducibility on exam s p tah the patient had minimal pain which was well controlled with infreqent doses of dilaudid postoperatively upon tolerating po pain was controlled control with percocet prn she was encouraged to get out of bed and ambulated diabetes patient s nph was increased from qam pm to units as her sugars were elevated in the s to s sugars still in s the morning after increased she was continued on ssi her home metforin was held until the day of discharge asa was held and restarted the day of discharge hyperlipidemia the patient was continued on pravastatin hiv the patient was continued on her home atazanavir truvada and ritonavir as well as acyclovir ppx she was discharged pod in good condition and will follow up with her pcp medications on admission medications prescription acyclovir mg tablet tablet s by mouth increase to tid for days during an outbreak atazanavir mg capsule two capsule s by mouth once a day clotrimazole cream apply to affected areas cover with vaseline if area is open emtricitabine tenofovir truvada mg mg tablet one tablet s by mouth once daily folic acid mg tablet one tablet s by mouth twice a day glycopyrrolate mg tablet tablet s by mouth three times a day hydrochlorothiazide mg tablet tablet s by mouth qam insulin lispro humalog unit ml solution use pre meals and prn times a day lisinopril mg tablet tablet s by mouth once a day metformin mg tablet tablet s by mouth twice a day pravastatin mg tablet tablet s by mouth once a day in the evening ritonavir mg capsule one capsule s by mouth once a day along with two capsules of atazanavir medications otc aspirin aspirin ec mg tablet delayed release e c tablet s by mouth once a day blood sugar diagnostic one touch ultra test strip as directed up to times a day for glucose monitoring blood glucose meter blood glucose monitor kit kit use times a day ergocalciferol vitamin d vitamin d otc dosage uncertain ferrous gluconate mg tablet tablet s by mouth once a day insulin nph human recomb humulin n unit ml suspension use twice a day as directed insulin syringes syringe use four times a day and as needed lancets misc use four times a day and as needed multivitamins tablet chewable one tablet s by mouth once a day discharge medications atazanavir mg capsule sig two capsule po daily daily emtricitabine tenofovir mg tablet sig one tablet po daily daily acyclovir mg capsule sig two capsule po q h every hours glycopyrrolate mg tablet sig one tablet po tid times a day lisinopril mg tablet sig two tablet po daily daily pravastatin mg tablet sig one tablet po daily daily ritonavir mg capsule sig one capsule po daily daily phenobarb belladonna alkaloids mg ml elixir sig one tablet po tid times a day 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 as needed not to exceed pills in any hour period disp tablet s refills metoprolol tartrate mg tablet sig three tablet po bid times a day disp tablet s refills amlodipine mg tablet sig two tablet po daily daily disp tablet s refills folic acid mg tablet sig one tablet po bid times a day ferrous gluconate mg mg iron tablet sig one tablet po daily daily insulin lispro subcutaneous insulin nph human recomb subcutaneous metformin mg tablet sig one tablet po twice a day aspirin mg tablet sig one tablet po once a day discharge disposition home discharge diagnosis symptommatic fibroid uterus left ovarian cyst history of abnormal pap smear status post total abdominal hysterectomy left salpingoopherectomy hypertension discharge condition good discharge instructions please call your doctor if you experience fever chills nausea and vomiting worsening or severe abdominal pain heavy vaginal bleeding chest pain trouble breathing or if you have any other questions or concerns please call if you have redness and warmth around the incision if your incision is draining pus like or foul smelling discharge or if your incision reopens no driving while taking narcotic pain medication as it can make you drowsy no heavy lifting or strenuous exercise for weeks to allow your incision to heal adequately nothing per vagina no tampons intercourse douching for weeks please keep your follow up appointments as outlined below followup instructions provider d phone date time provider md phone date time provider md phone date time md completed by,"{
""Diagnoses"": [""fibroid uterus"", ""left adnexal mass"", ""obstetrics gynecology"", ""allergies - bactrim"", ""allergies - amoxicillin"", ""allergies - abacavir""],
""Medications"": [""total abdominal hysterectomy"", ""left salpingoopherectomy""]
}"
73155,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint left lower extremity swelling major surgical or invasive procedure ivc filter placement history of present illness mr is a year old male with a history of metastatic melanoma to brain lung and liver s p ten sessions of cranial radiation in who presented to outpatient oncology clinic for a scheduled appointment this morning and noted for the past three days that he has had left lower extremity swelling he does not have pain in his leg although this leg has felt heavy for the past months which prompted his initial ct scan which diagnosed his brain metastases he has not had any fevers chills chest pain difficulty breathing nausea vomiting abdominal pain dysuria hematuria leg pain he does have left sided leg weakness but this has been stable all other review of systems negative in detail he was referred to the emergency room directly from oncology clinic for evaluation of potential dvt in the ed initial vs were t p bp r o sat on ra he had a left lower extremity ultrasound which was positive for dvt he had a cta which was preliminarily negative for pulmonary embolism he had a non contrast ct of the head which showed three hemorrhagic metastases unclear how these compare in size post radiation given findings on ct head he was not started on anticogulation he was seen by vascular surgery for consideration of ivc filter he was also seen by neurosurgery official recommendations pending he was transferred to the icu for close monitoring on arrival to the icu he has no specific complaints left lower extremity weakness is unchanged he denies other numbness tingling weakness fatigue leg pain no blurry vision gait has been unstable since diagnosis of metastatic lesions he endorses lb weight loss over past two months all other review of systems negative past medical history metastatic melanoma to brain lung liver s p cycles xrt in hypertension hyperlipidemia steroid induced hyperglycemia social history pack year smoking history in his twenties no alcohol no ivdu lives with his wife in works in the window industry family history sister died of breast cancer brother died of asbestos related lung cancer physical exam vitals t bp p r o on ra 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 ext warm well perfused pulses erythema over left leg with non pitting edema no calf tednerness no clubbing or cyanosis neurologic cn ii xii tested and intact strength in the upper extremities strength in the left lower extremity in the right lower extremity sensation intact throughout reflexes in the upper extremities in left lower extremity right lower extremity decreased tone in left lower extremity gait not tested pertinent results labs on admission wbc rbc hgb hct mcv mch mchc rdw plt ct neuts bands lymphs monos eos baso atyps metas myelos hypochr normal anisocy occasional poiklo normal macrocy normal microcy normal polychr coags wnl albumin calcium phos mg labs on discharge wbc rbc hgb hct mcv mch mchc rdw plt ct pt ptt inr pt glucose urean creat na k cl hco angap calcium phos mg cta chest w w o c recons small right subsegmental pulmonary embolism in the right posterior lower lobe pulmonary artery no dissection or aortic aneurysm large left upper lobe soft tissue mass with pulmonary nodules in the right upper lobe and left lower lobe as described probable metastasis in the spleen head ct w o contrast multifocal high attenuation foci with the perilesional vasogenic edema in setting of known metastases suspicious for hemorrhagic intracranial metastases if further evaluation is desired please consider gadolinium enhanced mri no prior comparisons available to assess for change unilat lower ext veins left extensive dvt in the left lower extremity extending from common femoral vein to posterior tibial veins brief hospital course year old male with a history of metastatic melanoma to brain lung and liver who presents with a left lower extremity dvt lle dvt and small pe dvt found in lle with small subsegmental pe but patient also has hemorrhagic brain metastases shown on head ct preventing anticoagulation vascular was consulted recommended ivc filter placement if primary team decided against anticoagulation patient has an extensive clot burden in the lle but anticoagulation was held in light of the hemorrhagic potential of the brain metastasis ivc filter was placed by ir on pt tolerated procedure well without complications he was ambulatory the next day metastatic melanoma hemorrhagic brain metastasis with surrounding vasogenic edema demonstrated on ct head patient is s p sessions of xrt on admission to icu neurologic exam was notable for left lower extremity weakness and decreased reflexes neuro exams were performed every hours pt was continued on home dose decadron mg tid neurosurgery was consulted and left decision re anti coagulation to the primary team steroid induced hyperglycemia patient is usually on oral agents and long acting insulin at home but these were held while patient was npo riss was used for glycemic control with good results hypercalcemia likely related to malignancy pt s latest albumin of given l ivf calcium monitored with decrease to at time of discharge thrombocytopenia latest platelet count k baseline platelet count unknown also likely related to malignancy no evidence of bleeding platelets monitored with plt of at discharge hypertension patient was continued on home dose of lisinopril hyperlipidemia patient was continued on home dose of simvastatin code full discussed with patient communication patient wife home cell cell medications on admission multivitamin lisinopril mg daily simvastatin mg daily famotidine mg daily glyburide mg daily levemir u at pm dexamethasone mg tid discharge medications multivitamin tablet sig one tablet po daily daily lisinopril mg tablet sig one tablet po daily daily simvastatin mg tablet sig one tablet po daily daily dexamethasone mg tablet sig one tablet po q h every hours famotidine mg tablet sig one tablet po once a day glyburide mg tablet sig two tablet po once a day levemir unit ml solution sig ten units subcutaneous at pm discharge disposition home discharge diagnosis deep venous thrombosis and small pe with ivc filter placement metastatic melanoma to brain lung liver s p cycles xrt in hypertension hyperlipidemia steroid induced hyperglycemia discharge condition stable ambulatory afebrile discharge instructions you were admitted to the hospital for left leg swelling it was determined that you have a deep venous clot in your leg imaging also showed you have a very small clot in your lungs your oxygen saturation was good during your hospitalization due to the melanoma in your brain the risks of anti coagulation outweigh the benefits thus interventional radiology placed a filter in the vein between your legs and heart to prevent more clot from going to your lungs you tolerated the procedure well without any problems changes were made to your medications please call your pcp or return to the emergency room if you develop fevers chills shortness of breath pain with breathing palpitations worsening leg swelling or abdominal pain followup instructions please call the oncology office at assistant is to see dr within weeks next week if possible,{}
854,admission date discharge date date of birth sex m service neurology allergies patient recorded as having no known allergies to drugs attending chief complaint transient speech difficulty major surgical or invasive procedure none history of present illness mr is a year old male with a history of htn cad s p angioplasty x tia x in and high cholesterol paroxysmal afib and hx of pfo and atrial septal aneurysm with both right to left and left to right shunts on coumadin who was transfered from an outside hospital for evaluation of intracranial hemorrhage he was in his usoh until wednesday evening at when he had an acute onset of speech difficulty he was having a conversation with his wife when he noticed that he couldn t get his words out according to his wife he was making sounds some words and some nonsense but not saying complete phrases he was responding inappropriately to questions i e saying no when he meant to say yes but appeared to understand what was being said to him he was aware of his deficit and frustrated by his inability to communicate he denies associated numbness weakness dysarthria visual deficits or swallowing problems did not have cp palpitations or dizziness prior to this episode his wife called ems he was at the oh er in about minutes by which time his symptoms had resolved he had a head ct there which showed cm left temporal hemorrhage he was then transferred here for further management on arrival to the er his bp was and his speech was normal then around am he had another episode of language problems which lasted for a minute or so then spontaneously resolved he has been asymptomatic since he was started on nipride in the er for bp control he developed a headache and chest pain right sided radiating to neck this resolved with bp was better controlled he has had similar episodes of language problems in the past the first episode was in when he had an episode of slurred speech and mild right facial droop he had a second episode of inability to talk in he was found to have aphasia and mild right hemiparesis at that time he had a head ct which was negative and echo which showed pfo and atrial septal aneurysm he was started on coumadin at that time past medical history cad s p ptca in s p angioplasty x htn historically difficult to control hypercholesterolemia tia x paroxysmal afib pfo with asd on echo with right to left and left to right shunts social history lives with his wife his is a high school buisness and government teacher he has a year old son who is in college he denies smoking etoh or drugs family history uncle died of mi in s father leukemia mi at age uncle died of mi in s physical exam t bp decreased to sbp s initially with nipride hr rr o sat ra gen no acute distress appears comfortable heent mmm o p clear no scleral icterus or injection neck supple no lad or carotid bruits appreciated lungs cta bilaterally heart rrr nl s s sm abd soft nt nd nabs ext warm peripheral pulses throughout no edema neurologic ms alert and oriented x cooperative with exam able to say backwards registration intact to objects at seconds recall intact to objects at minutes repitition and naming intact speech fluent without paraphasic errors or hesitancy follows commands well able to relate coherent and detailed hpi cn perrl eoms intact without nystagmus fundi normal with sharp disc margins visual fields full to confrontation facial sensation and movement intact bilaterally hearing intact to finger rub tongue protrudes midline without fasiculations sternocleidomastoids intact bilaterally shoulder shrug intact bilaterally motor normal bulk and tone throughout no fasiculations no pronator drift b t d we wf ff fe ip hams quad at g r l reflexes symmetric throughout toes sensation intact bilaterally to light touch temperature pinprick and vibration in all extremities coordination and ffm intact bilaterally gait deferred 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 neuts lymphs monos eos baso pm blood pt ptt inr pt pm blood k am blood glucose urean creat na k cl hco angap pm blood ck mb ctropnt am blood ck mb ctropnt am blood ck mb ctropnt am blood ck cpk am blood calcium phos mg am blood type art ph brief hospital course he was admitted to the neuro icu for close observation and blood pressure control he was initially on a nipride drip which was changed to a labetalol drip for blood pressure control all antiplatelet agents were held and his inr was reversed he was started on dilantin for seizure prophylaxis he had an mri mra with gadolinium to evaluate the extent of the bleed and to assess for vascular malformation or underlying mass the mr showed mri of the brain demonstrates an acute left lateral temporal lobe hematoma with mild surrounding edema as seen on the ct scan of earlier in the day there is no enhancement in this location there are numerous small foci of susceptibility artefact within the brain likely representing hemorrhages from amyloid angiopathy or hypertension thus the new hemorrhage may be of the same etiology there is no abnormal vascularity detected on mr angiography and there is flow in the major branches of this circulation he had a repeat head ct on which showed no progression of the bleed he remained neurologically intact and did not have another episode of aphasia during his admission on hospital day his blood pressure medications were transitioned to oral meds and his blood pressure remained resonably well controlled although he required several doses of iv metoprolol to maintain sbp an cardiac ehco was performed on the echo showed the left atrium is moderately dilated the left ventricular cavity size is normal due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded overall left ventricular systolic function is difficult to assess but is probably normal lvef he was transfered to the neurology floor on where his neurologic exam remained unchanged his anti hypertensives were increased to improve bp control follow up plans he will be discharged with follow up with his pcp next week he will resume taking an aspirin mg next week he will have a repeat head ct in weeks on and should follow up with dr the following week at his follow up visit we will consider the option of re starting coumadin perhaps low dose to maintain inr between we will also consider whether he may be a candidate for a pfo closure procedure at that time discharge medications bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed disp tablet delayed release e c s refills docusate sodium mg capsule sig one capsule po bid times a day disp capsule s refills atorvastatin calcium mg tablet sig one tablet po daily daily disp tablet s refills digoxin mcg tablet sig one tablet po daily daily disp tablet s refills phenytoin sodium extended mg capsule sig one capsule po tid times a day disp capsule s refills lisinopril mg tablet sig two tablet po daily daily disp tablet s refills amlodipine besylate mg tablet sig two tablet po daily daily disp tablet s refills isosorbide mononitrate mg tablet sig one tablet po bid times a day disp tablet s refills hydrochlorothiazide mg tablet sig one tablet po daily daily disp tablet s refills labetalol hcl mg tablet sig two tablet po tid times a day disp tablet s refills clonidine hcl mg tablet sig one tablet po tid times a day disp tablet s refills discharge disposition home discharge diagnosis intracranial hemorrhage amyloid angiopathy hypertension discharge condition improved no neurologic deficit discharge instructions please continue to take your medications as directed in one week you should start to take a regular aspirin mg you should not take coumadin you may stop taking dilantin for seizure prevention in two weeks you should have a repeat ct scan of the head in six weeeks see appointments below if you experience difficulty with speech visual problems numbness weakness dizziness or increased headache please come to the emergency room for evaluation followup instructions follow up with your primary care doctor next week please have your blood pressure monitored your systolic blood pressure should be maintained under please have your dilantin level checked goal level ct scan radiology phone date time follow up with dr in at pm building clinic where ra complex nutrition phone date time md [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 melena hypotension major surgical or invasive procedure esophagogastroduodenoscopy egd history of present illness mr is a yo m with history of multiple myeloma paroxysmal atrial fibrillation and prior known duodenal ulcer who presented to an outside hospital with one day history of melena and hypotension to sbp in the s at home he had chemotherapy with valcade and dexamethasone at three days prior to admission at osh he was guaiac positive and his hct was found to be down from a baseline in the mid s per his wife was transfused two units of packed red cells and a cordis was placed patient also complained of chest pain on presentation and had dynamic st depressions in the lateral leads he was given nitro and blood with resolution of his symptoms patient was transferred to for further management in the ed initial vs were l nrb patient was given a iv bolus and started on a ppi drip he had a negative ng lavage but was again guaiac positive repeat labs here showed hematocrit of he did not bump his hematocrit after the two units given at the osh ekg here showed atrial fibrillation without any st changes gi was consulted and he was admitted to the icu for further management on transfer vitals were l nc in the micu the patient received a total of units which he tolerated well without complaints his chest pain completely went away when he received blood products patient had hours of diarrhea after taking his chemo on friday but did not notice any blood at that time he did have three hours of melena on saturday night but has had no further bms since no abdominal pain nausea vomiting constipation no change in po intake difficulty breathing or dyspnea on exertion past medical history multiple myeloma on chemo paroxysmal afib cad s p ptca in htn h o gastric ulcer tias hypercholesterolemia pfo with asd on echo with right to left left to right shunts presumed diagnosis of amyloid angiopathy h o ich while on warfarin no longer anticoagulated social history he is married and his wife is his hcp denies smoking etoh or drugs family history uncle died of mi in s father leukemia mi at age also aml uncle died of mi in s physical exam on transfer in the er temp hr bp resp o sat normal constitutional comfortable heent normocephalic atraumatic pale conjunctiva oropharynx within normal limits chest clear to auscultation cardiovascular tachy regular rate and rhythm normal first and second heart sounds abdominal soft nontender nondistended 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 hypochr normal anisocy poiklo macrocy microcy polychr spheroc ovalocy schisto occasional am blood pt ptt inr pt am blood glucose urean creat na k cl hco angap pm blood calcium phos mg pm blood alt ast ck cpk alkphos totbili am blood ctropnt pm blood ck mb ctropnt pm blood ck mb ctropnt pm blood ck mb ctropnt am blood ck mb ctropnt pm blood ck mb ctropnt ecg study date of am atrial fibrillation with rapid ventricular response diffuse non specific st t wave flattening compared to the previous tracing of the lateral ischemic appearing t wave abnormalities are no longer recorded however pseudonormalization cannot be excluded given the rapid rate atrial fibrillation has appeared followup and clinical correlation are suggested intervals axes rate pr qrs qt qtc p qrs t egd normal esophagus edematous erythematous antral fold noted consistent with inflammation and possibly underlying ulcer a single non bleeding mm ulcer was found in the stomach body otherwise normal egd to third part of the duodenum brief hospital course mr is a yo male with history of paroxysmal atrial fibrillation coronary artery disease hypertension and multiple myeloma s p recent chemo he has a known duodenal ulcer and presented with melena and hypotension sbp s to an outside hospital there he was found to have a hematocrit of down from his baseline in the mid s he also complained of chest pain with lateral st depressions noted on ekg that resolved when he received nitroglycerin and units prbcs icu course he was transferred to on initial evaluation in the emergency room he had a hematocrit of despite the units prbcs from the outside hospital and was noted to be in atrial fibrillation with a ventricular rate greater than he was started on a ppi drip and admitted to the icu for further management while in the icu his atrial fibrillation was controlled with metoprolol iv and reinstitution of his sotalol the patient had one further episode of chest tightness that resolved with nitrates as he received an additional units of prbc s with his hematocrit stabalizing in the low s he was ruled out for an mi and remained stable from a cardiac standpoint after that single episode he had no further melena or guaiac positive stools in the icu and underwent egd on with the results as noted above on transfer to the hospital floor on he had a transient episode of hypotension with a pressure of when he was transferring from the stretcher to the bed which was attributed to the patient having restarted his home dose of labetalol on the evening of transfer his labetalol was subsequently held until the day of discharge and his blood pressure stabalized gi bleed egd edematous erythematous antral fold noted c w inflammation and possibly underlying ulcer single non bleeding mm ulcer was found in the stomach body the patient was treated with a total of units of prbcs with stabalization of his hematocrit his intravenous pantoprozole was changed to po and the patient s diet was advanced on the th and th hospital days following transfer from the icu the patient had an episode of black tarry stool on each day in consultation with the gi service these episodes were felt to be due to old blood from his initital upper gi bleed his hematocrit and blood pressure remained stable over the course of these two days with no further evidence of new bleeding chest pain the patient s episode of chest tightness was felt to be demand ischemia related to gi bleed superimposed on atrial fibrillation and rapid ventricular response pain improved with sl nitroglycerin and blood transfusions his troponins remained flat and he ruled out for an mi he has been continued on his statin the hospital course was reviewed with the patient s primary cardiologist and the patient will follow up with him on atrial fibrillation the patient has paroxysmal atrial fibrillation treated with sotalol and labetalol his rapid ventricular response at the outside hospital appeared related to hypovolemia and ischemia from his gi bleed his rate has been controlled with single doses of metoprolol iv when in the icu and reinstitution of his sotalol he converted to nsr by hospital day on the last hospital day he has been restarted on a lower dose of his labetalol in addition to sotalol to prevent further rapid ventricular response but his dose is limited by his earlier hypotensive episodes the patient is anticoagulated with low dose aspirin and aggrenox but these were held during his gi bleed he received a single dose of each on the th hospital day just prior to having two further guaiac positive melenic stools although the stools are thought to be from old blood and the patient s hematocrit has remained stable his anticoagulation was discontinued this has been discussed with his primary cardiologist by phone and the patient will see him in follow up on to address restarting low dose aspirin and aggrenox multiple myeloma last chemo with velcade and decadron at the patient was continued on bactrim and acyclovir prophylaxis and he will follow up with dr at the on where he will be evaluated and the decision whether or not to proceed with chemotherapy will be made hypertension he takes numerous antihypertensives at home including amlodipine tekturna labetalol clondine and losartan these had been held in the setting of his hypotension and gi bleeding and only clonidine and labetalol have been reinstituted at the time of discharge he will follow up with his cardiologist on and his pcp on to reinstitute these medications as tolerated medications on admission aggrenox mg mg amlodipine atorvastatin mg mg daily aliskiren mg daily sotalol af mg daily labetalol mg clonidine mg furosemide mg daily aspirin low strength mg chewable daily takes losartan mg daily folic acid mg daily vitamin d unit qweek nitroglycerin mg sublingual prn multivitamin daily amlodipine besylate mg daily dexamethasone unknown strength revlimid unknown strength valcade unknown sig bactrim unknown strength qmonday wednesday friday acyclovir unknown daily discharge medications sotalol mg tablet sig tablets po daily daily simvastatin mg tablet sig one tablet po daily daily disp tablet s refills sulfamethoxazole trimethoprim mg tablet sig one tablet po qmowefr monday wednesday friday acyclovir mg tablet sig one tablet po daily daily clonidine mg tablet sig one tablet po twice a day omeprazole mg tablet sig one tablet po q h every hours disp tablet delayed release e c s refills labetalol mg tablet sig one tablet po bid times a day do not take if your pulse is less than beats per minute disp tablet s refills folic acid mg tablet sig one tablet po once a day vitamin d unit capsule oral multivitamin oral take your chemotherapy medicines as directed by your oncologist these include revlimid dexamethasone and velcade discharge disposition home discharge diagnosis upper gastrointestinal bleed from gastric ulcers atrial fibrillation coronary artery disease hypercholesterolemia multiple myeloma tias s p intracranial hemorrhage on warfarin for afib presumed amyloid angiopathy patent foranen ovale with asd on echo with righ to left and left to right shunts discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted with a bleeding ulcer that required intensive care because your blood pressure was low you were treated with blood transfusions and a new medicine to decrease your stomach acid production your anemia and low blood pressure caused you to have chest pain from your heart disease and caused your heart to beat fast from your atrial fibrillation afib the blood transfusions and heart medicine helped to stop the chest pain there are no signs that you had a heart attack in the setting of your bleeding your blood thinners for your afib and heart disease were stopped you will work with your cardiologist to decide the right time to restart your blood thinners because your blood pressure has been low we have stopped most of your high blood pressure medicines do not take your losarten amlodipine tekturna also called aliskiren or lasix until advised to restart these medications by your doctors do not take your aggrenox or low dose aspirin you should avoid taking any aspirin ibuprofen or drugs containing aspirin or nsaids motrin or aleve unless you have asked one of your doctors you were taking caduet a combination blood pressure and statin but you will take only atorvastatin now followup instructions hematology oncology name dr when monday at pm cardiology name dr when wednesday at pm department primary care name dr when thursday at pm address route phone department div of gastroenterology when wednesday at pm with md building ra complex campus east best parking main garage [NEW_RECORD] name unit no admission date discharge date date of birth sex m service neurology allergies patient recorded as having no known allergies to drugs attending chief complaint see previous major surgical or invasive procedure see previoius physical exam pt weighs lbs make sure he is losing weight at follow up visit brief hospital course see previous discharge disposition home discharge diagnosis see previous discharge condition see previous discharge instructions see previous followup instructions see previous md completed by,"{
""Diagnoses"": [""neurology"", ""intracranial hemorrhage"", ""speech difficulty"", ""high cholesterol"", ""paroxysmal afib"", ""atrial septal aneurysm"", ""PFO"", ""coumadin""],
""Medications"": [""coumadin""]
}"
18901,admission date discharge date service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint sepsis arf demand ischemia major surgical or invasive procedure none history of present illness pt is a y o f with dementia dm who resides at the for the aged who presented to ed with decreased mental status and hypoglycemia per notes from pt started complaining of a severe headache yesterday afternoon around pm on the night of admission pt noted to have altered mental status still complaining of a severe headache and left arm pain vitals at the time were o ra over the next few hours she continued to complain of severe headache at the back of her head and her mental status worsened ems was called and pt was found to have a blood sugar of for which she was given an amp of d at her nh she apparently takes glyburide but no insulin in the ed she was afebrile at and hemodynamically stable with bp in the s s but persistenly hypoglycemic so was given mcg of octreotide and eventually started on a d drip she got l of ns for hypovolemia a cxr showed a lll pna and a ua demonstrated a uti so she was given mg iv levaquin her cardiac enzymes were elevated with a tn of and she had a new lbbb since but flat ck s anion gap was with a lactate of according to the nurses at pt is normally ao x and interactive however she has been non ambulatory for the past several months despite intensive rehab past medical history dementia cataracts type ii dm hx of falls with pubic ramus fx in osteoporosis oa hearing impairment hx of abx associated diarrhea c diff neg in hx of left ankle fx s p repair of ruptured quadriceps tendon left s p cataracts extraction left social history pt lives at rehab family history n c physical exam temp with bear hugger bp hr r o nrb gen unresponsive to voice and sternal rub heent unequal pupils l r s p cataract surgery on the left both unresponsive to light neck c collar in place cv irreg irreg no g m r tachy chest scattered rhonchi in anterior fields no wheezes abd decreased bowel sounds nontender soft guaiac neg in ed ext pitting edema to thighs bilaterally nonpalp pulses erythema and warmth bilaterally on lower ext neuro unable to assess cranial nerves moving upper ext with occasional myoclonic jerks no movement in lower ext upgoing toe on right upgoing on left skin fungal rash in groin down onto bilateral thighs excoriations on right knee pertinent results am glucose urea n creat sodium potassium chloride total co anion gap am ck cpk am ck mb notdone ctropnt am wbc rbc hgb hct mcv mch mchc rdw am neuts bands lymphs monos eos basos atyps metas myelos am plt smr normal plt count am pt ptt inr pt am lactate am urine blood mod nitrite neg protein glucose neg ketone neg bilirubin neg urobilngn neg ph leuk mod am urine rbc wbc bacteria many yeast none epi am cortisol am albumin calcium phosphate magnesium cxr left basilar opacity which may represent collapse or consolidation small bilateral pleural effusions ct head no shift hemorrhage or mass effect ct c spine study limited by patient positioning and motion allowing for this no fracture or listhesis identified multilevel degenerative changes multinodular thyroid gland bilateral pleural effusions note added at attending review there is a possible odontoid fracture this is seen on the axial images but not visualized on the sagittal or coronal reformatted images this may be due to technical problems thick sections on the reformatted images repeat reformatted images again do not confirm a fracture however stability of the spine is not assured and spinal precautions should be maintained an mr is recommended to better evaluate these findings there is also a large soft tissue density posterior to the odontoid and body of c this may represent a large hematoma associated with an acute fracture alternatively if there is no fracture then this may be a hematoma in either case this is compressing the cervical cord and the cervico medullary junction this should be investigated with an mr examination plain film left humerus no fracture degenerative changes renal u s no evidence of hydronephrosis two simple right renal cysts echogenic kidneys consistent with medical renal disease brief hospital course y o female rehab resident with dementia and dm type ii was found to have gram positive sepsis pna uti new mass in cervical spinal cord arf and demand ischemia she had blood cx in ed growing gram positive cocci with pna as the likely source other possible sources were uti or cellulitis the patient was started on levoflox vanco and flagyl she was also started on stress dose steroids until her stim results returned she received iv fluids to keep map and pressors for a short period of time the patient presented with significant elevation in creatinine and marked uremia this was likely due to both hypovolemia and a distributive picture from her infected state an ultrasound in the ed showed no evidence of obstruction but does show evidence of chronic renal insufficiency she received fluid resuscitation her hyperkalemia was likely from her arf ecg was difficult to interpret for hyperkalemic related changes in the setting of a lbbb she received ca gluconate insulin d and an amp nahco the patient was found to have a cervical cord mass it was unclear of how acute this was although at she had been unable to walk the mass per radiology could be hemorrhage vs meningioma neuro exam was difficult neurosurgery was called to look at films though the patient was not a surgical candidate decadron was started to decrease brain swelling the patient s condition declined rapidly as the patient became hypotensive her hcp was consulted multiple times to discuss goals of care it was decided to maintain the patient s dnr dni status and refrain from aggressive measures such as central line placement later on in the evening the hcp decided to change goals to comfort only the patient was placed on a morphine drip titrated to comfort in the morning she expired after fatal arrhythmia medications on admission tylenol mg tid atenolol mg qd atropine one gtt to left eye calcitonin iu spray once daily tums tidac fibercon qd vit d u lasix mg qd glyburide mg qd lisinopril mg qd robitussin cc q hrs prn mom prn clotrimazole cream to inguinal area abd fold aloh to coccyx discharge medications none discharge disposition expired discharge diagnosis gram pos sepsis pneumonia uti new mass in cervical spinal cord arf demand ischemia dementia dm type ii discharge condition expired discharge instructions none followup instructions none,"{
""Diagnoses"": [""sepsis"", ""ARF"", ""ischemia"", ""major surgical or invasive procedure""],
""Medications"": [""glyburide"", ""d"", ""mcg of octreotide"", ""d drip"", ""levaquin"", ""cardiac enzymes""]
}"
85152,admission date discharge date date of birth sex m service cardiothoracic allergies patient recorded as having no known allergies to drugs attending chief complaint unstable angina major surgical or invasive procedure coronary artery bypass grafting times two lima lad svg om history of present illness mr is esrd on hd since who developed angina about years ago cardiac cath at that time showed cad and pci was not successful patient was not interested in surgery at that time since patient has become wheelchair bound had significant decrease in appetite and significant weight loss patient has had increasing frequency of angina sometimes taking up to sl ntg day he was given prescriptions for plavix but was unable to afford it he is now willing to consider surgery he underwent cardiac cath today which showed ef and severe vd past medical history esrd on hd since d t polycyctic kidney disease htn hyperlipidemia rbbb cad depression restless leg syndrome s p bilateral hip fractures s p surgical repair s p ankle fracture s p repair osteoporosis hyperparathyroidism secondary to renal disease unable to afford medication hyperkalemia remote h o af s p repair of bilat hipfracture s p repair of ankle fracture s p multiple l av fistulas and revisions social history lives with wife occupation disabled driver tobacco remote quit etoh denies family history unremarkable physical exam pulse resp o sat on ra b p right left unable d t fistula height weight kg general cachetic skin dry x intact x heent perrla x eomi x neck supple x full rom x chest lungs clear bilaterally x heart rrr x irregular murmur diastolic murmur abdomen soft x non distended x non tender x bowel sounds x extremities warm x well perfused x edema varicosities none x distal le w loss of hair and ruborous color neuro grossly intact pulses femoral right cath site without hemaotma left dp right left pt left radial right left carotid bruit right none left none pertinent results 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 a m radiology report chest port line placement study date of pm csru pm chest port line placement clip reason ptx medical condition year old man with s p cabg please with results if there is concern with findings reason for this examination ptx final report cxr portable film history status post cabg findings bilateral lower lobe opacities atelectases noted sternotomy small left apical pneumothorax et tube tip lies cm above the carina and is satisfactory swan ganz catheter tip lies in the main pulmonary artery outflow conclusion postop changes small left apical pneumothorax left chest tube is in place dr approved am echocardiography report complete done at pm final referring physician information department of cardiac s a status inpatient dob age years m hgt in bp mm hg wgt lb hr bpm bsa m indication 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 ventricle ejection fraction to findings left atrium no spontaneous echo contrast is seen in the laa right atrium interatrial septum normal interatrial septum left ventricle mildly depressed lvef right ventricle mild global rv free wall hypokinesis aorta normal ascending aorta diameter simple atheroma in descending aorta aortic valve normal aortic valve leaflets no as no ar mitral valve mildly thickened mitral valve leaflets no mr tricuspid valve physiologic tr pulmonic valve pulmonary artery physiologic normal pr pericardium no 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 tee probe was passed with assistance from the anesthesioology staff using a laryngoscope no tee related complications conclusions pre cpb no spontaneous echo contrast is seen in the left atrial appendage overall left ventricular systolic function is mildly depressed lvef with mild global free wall hypokinesis 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 mildly thickened no mitral regurgitation is seen there is no pericardial effusion post cpb there is preserved biventricular systolic fxn no ai no mr aorta intact i certify that i was present for this procedure in compliance with hcfa regulations electronically signed by md interpreting physician brief hospital course the patient was transferred from on he continued to have daily chest pain and was on iv ntg he had hd and on he underwent coronary artery bypass grafting times two with lima lad and svg om he tolerated the procedure well and was transferred to the cvicu on neo and propofol in stable condition the cross clamp time was minutes and the total bypass time was minutes he was extubated on the post op night and was transferred to the floor on pod he was dialyzed on pod his chest tubes were discontinued on pod his epicardial pacing wires were discontinued on pod he continued to progress and was discharged to rehab in stable condition on pod medications on admission toprol xl mg by mouth twice daily univasc mg by mouth twice daily asprin mg by mouth twice daily renvalia tabs w meals sl ntg discharge medications docusate sodium mg capsule sig one capsule po bid times a day ranitidine hcl 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 simvastatin mg tablet sig two tablet po daily daily oxycodone mg tablet sustained release hr sig one tablet sustained release hr po q h every hours as needed for pain acetaminophen mg tablet sig two tablet po q h every hours as needed for fever pain bisacodyl mg suppository sig one suppository rectal daily daily as needed for constipation sevelamer carbonate mg tablet sig one tablet po tid w meals times a day with meals b complex vitamin c folic acid mg capsule sig one cap po daily daily metoprolol tartrate mg tablet sig one tablet po tid times a day lorazepam mg ml syringe sig mg injection q h every hours as needed for anxiety univasc mg tablet sig one tablet po twice a day home dose mg titrate as discharge disposition extended care facility pines extended care facility spec discharge diagnosis esrd on hd polycystic kidney disease hypertension coronary artery disease hyperlipidemia depression restless leg syndrome s p bilateral hip fractures osteoporosis hyperparathyroidism atrial fibrillation in past s p multiple av fistula revisions discharge condition alert and oriented x nonfocal ambulating gait steady sternal pain managed with percocet prn 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 recommended follow up please call to schedule appointments surgeon dr in weeks primary care dr in weeks cardiologist dr in weeks wound check appointment your nurse will schedule completed by,{}
20848,admission date discharge date service ccu history of present illness the patient is a year old man with a history of hypertension catheterization ten years ago complicated by intracranial bleed and a pack year smoking history who developed the acute onset of substernal chest pain with shortness of breath nausea and diaphoresis on the day of admission he was taken to where he was found to have st elevations in electrocardiogram leads v v i ii and avf he was brought via flight to for primary angioplasty on catheterization he had elevated filling pressures with pulmonary artery systolic of diastolic of and mean of he was found to have right dominance his left main was normal proximal lad had a stenosis mid lad had stenosis left circumflex had no disease proximal right coronary artery had stenosis mid right coronary artery had stenosis the mid lad lesion was stented with mild impingement of d at the origin he received lasix mg in the lab integrilin was deferred secondary to history of hemorrhagic cerebrovascular accident he was then admitted to the ccu in stable condition for continued management physical examination vital signs on admission temperature was blood pressure pulse respirations oxygen saturation on l nasal cannula general he was alert and oriented times three he was in no acute distress he was pain free heent there was no jugular venous distention present no bruits there were carotid pulses bilaterally lungs clear to auscultation bilaterally heart regular rate and rhythm s and s there was a out of systolic ejection murmur abdomen soft nontender nondistended active bowel sounds extremities right pressure dressing intact no discomfort or hematoma in groin distal pulses bilaterally no edema present laboratory data on admission white count was hematocrit chem within normal limits coags with an inr of ptt ck initially peaked to the second cycle of cks with a mb fraction of troponin and the rest of the admission laboratories were not of noted electrocardiogram on admission revealed normal sinus rhythm at beats per minute normal axis and intervals marked st elevation in the anterior precordium v v lead i ii and avf after stenting there was partially normalizing of the st elevations new q waves and loss of r wave in v and v hospital course the patient was admitted and ruled in for myocardial infarction by enzymes and by electrocardiogram the enzymes peaked at on the th and continued to decrease on that day until the day of discharge the patient diuresed well on lasix captopril was added for afterload reduction and to decrease mortality plavix and aspirin were added status post myocardial infarction as well as because of the stent placement lopressor was added because of beta blocker favorable affects on mortality the patient was also given subcue heparin and zantac for prophylaxis the patient developed hemoptysis with brown sputum slightly blood tinged on day of admission this continued but decreased throughout the rest of his hospital stay the patient was covered with levaquin initially for community acquired pneumonia the patient s temperature spiked to on this regimen and was switched to ceftriaxone and azithromycin however the patient spiked a temperature to at that point the patient was switched to levaquin flagyl and received one dose of vancomycin at which point the patient defervesced an abdominal ct scan was also done which was negative for intra abdominal abscess however it did reveal right middle lobe pneumonia which had also been seen on earlier chest x rays also urinalysis revealed probably urinary tract infection which was felt to be treated on the levaquin and an electrocardiogram revealed possible v st elevation which would have been a new finding compared with previous electrocardiograms however because of a lack of increase in the ck or the ckmb fraction this was felt to be noncontributory the patient s remaining course was insignificant disposition stable for discharge discharge plan he is to be discharged to home with vna nursing possibly home physical therapy he will most likely have home oxygen he is to have cardiac rehabilitation in weeks discharge medications levaquin mg p o q d to finish off a day course flagyl mg p o t i d to finish a day course plavix mg p o q d to finish a day course aspirin mg p o q d lopressor will be switched to atenolol captopril will be switched to univasc phenobarbitol mg p o t i d lipitor mg p o q h s the patient will not receive any antibiotics as an outpatient follow up he will follow up with his primary care physician well as his cardiologist dr dictated by medquist d t job facility for home oxygen vna for home nursing care cclist,"{
""Diagnoses"": [""hypertension"", ""intracranial bleed"", ""acute onset of substernal chest pain"", ""shortness of breath"", ""nausea"", ""diaphoresis""],
""Medications"": [""lasix"", ""integrilin""]
}"
11506,admission date discharge date date of birth sex f service chief complaint this year old female presented with a chief complaint of acute renal failure digoxin toxicity anemia urosepsis and hypotension to the fenard intensive care unit history of present illness a year old female with a past medical history of congestive heart failure biventricular failure ejection fraction of mat status post left knee replacement in perforated duodenal ulcer in psoriasis eczema depression chronic lower extremity edema obesity recurrent lower extremity cellulitis rheumatoid arthritis interstitial lung disease on liters of home o hypothyroidism steroid induced hyperglycemia presents with being chronically ill and bedbound secondary to pain over the past month decreasing po intake and increasing fatigue and weakness she fell the night prior to admission on her left elbow and right foot with both with large hematomas she had no evidence of seizure no chest pain no shortness of breath no loss of consciousness and no head trauma her daughter was there and witnessed it she denied any fevers chills or sweats no nausea vomiting diarrhea no dysuria no headache no melena no bright red blood per rectum she continues to complain of severe buttock pain in the emergency room her vital signs were a temperature of pulse of blood pressure respiratory rate and sating on liters her systolic blood pressures dropped to the s and was given liter of iv fluid her sats also decreased and improved with liters of o she bradied down and was given mg of atropine and mg of dopamine to help her blood pressure she was started on levofloxacin and flagyl she received meq of potassium chloride and meq of potassium chloride in the emergency department she received a total of cc of normal saline allergies keflex ambien lorazepam diclox outside home medications fosamax once a week prevacid simethicone insulin lopressor lasix prednisone synthroid digoxin potassium chloride arava leucovorin methotrexate social history wheelchair bound family very involved physical examination on admission she was febrile at blood pressure of heart rate respiratory rate and sating on room air anxious and uncomfortable normocephalic atraumatic pupils are equal round and reactive to light equal ocular eye movements dry mucous membranes tachycardic s s irregularly irregular lungs are clear to auscultation bilaterally no wheezes abdomen is soft and nontender bowel sounds present guaiac negative extremities no clubbing or cyanosis bilateral pitting edema derm diffuse ecchymosis neurologic cranial nerves ii through xii are grossly intact oriented x initial presentation laboratories pertinent for a sodium of potassium creatinine of baseline of digoxin is and a complete blood count with a white count of with a differential of neutrophils bands for hematocrit and platelet count of leni was negative chest x ray showed chronic interstitial disease hip and knee films were negative for fracture patient was admitted for intensive care unit her hypertension did not really improve with continued iv fluids stress dosed steroids as she was on chronic steroids and continued on dopamine urosepsis was treated with levofloxacin acute renal failure improved somewhat digoxin toxicity resolved with holding her medications her hyponatremia and hypokalemia improved the patient remained in the intensive care unit until the nd and at that point on the evening prior to being called back to the floor the patient had a family meeting with the team and her family members and at that point the family and the patient decided they would like to switch her code status to comfort measures only patient was called out to the floor on at about in the afternoon and was pronounced at pm the patient s family was notified as was the attending cause of death urosepsis m d dictated by medquist d t job,"{
""Diagnoses"": [""acute renal failure"", ""digoxin toxicity"", ""anemia"", ""ureasepsis"", ""hypotension""],
""Medications"": [""digoxin"", ""iron supplements"", ""vasopressors"", ""hydration fluids"", ""antibiotics""]
}"
58540,admission date discharge date date of birth sex m service medicine allergies sulfa sulfonamide antibiotics hydrochlorothiazide attending chief complaint doe angina major surgical or invasive procedure cardiac cath cabg x lima to lad svg to om svg to pda history of present illness yo m with history of hypertension and hyperlipidemia who presented to pcp with complaints of exertional shortness of breath and chest discomfort he underwent stress test which was abnormal and was referred for elective cardiac catheterization cardiac catheterization today showed left main disease and cardiac surgery is asked to consult for surgical revascularization past medical history coronary artery disease s p cabgx hypertension hyperlipidemia gastroesophageal reflux disease social history lives with wife self employed in photo lab denies tobacco etoh occasional on wkds family history father with cabg at maternal paternal uncles with premature cad physical exam pulse resp o sat ra b p right left height weight lbs general nad lying in bed comfortably skin dry x intact x heent perrla x eomi x neck supple x full rom x chest lungs clear bilaterally x heart rrr x irregular murmur no m r g 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 mae nonfocal exam pulses femoral right cath site left dp right left pt left radial right left carotid bruit none right left pertinent results conclusions pre cpb the left atrium is mildly dilated no spontaneous echo contrast is seen in the left atrial appendage a patent foramen ovale is present left ventricular wall thicknesses are normal 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 there are simple atheroma in the descending thoracic aorta there are three aortic valve leaflets the aortic valve leaflets are mildly thickened but aortic stenosis is not present there is heavy calcification and leaflet restriction of the rcc mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen dr was notified in person of the results post cpb on infusion of phenylephrine sinus rhythm preserved biventricular systolic function with lvef mr is ai is aortic contour is normal post decannulation i certify that i was present for this procedure in compliance with hcfa regulations electronically signed by md interpreting physician am 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 am blood urean creat k brief hospital course admitted for cath which revealed severe left main and right coronary artery disease referred for cabg and w u completed underwent surgery with dr on and transferred to the cvicu in stable condition on titrated phenylephrine and propofol drips cefazolin was used for surgical antibiotic prophylaxis pod found the patient extubated alert and oriented and breathing comfortably the patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support beta blocker was initiated and the patient was gently diuresed toward the preoperative weight the patient was transferred to the telemetry floor for further recovery chest tubes and pacing wires were discontinued without complication 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 home in good condition with appropriate follow up instructions medications on admission asa mg daily simvastatin mg daily prilosec mg daily prn metoprolol succinate mg daily discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily omeprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily simvastatin mg tablet sig one tablet po daily daily disp tablet s refills metoprolol tartrate mg tablet sig one tablet po bid times a day 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 hydromorphone mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills discharge disposition home with service facility all care vna of greater discharge diagnosis coronary artery disease s p cabgx hypertension hyperlipidemia gastroesophageal reflux disease discharge condition alert and oriented x nonfocal ambulating gait steady sternal pain managed with oral analgesics 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 please call to schedule appointments surgeon dr pm primary care dr in weeks cardiologist dr in weeks completed by,{}
15667,admission date discharge date date of birth sex m service neurosurgery dictating for np history of present illness mr is a year old gentleman who was transferred to from an outside hospital he had presented to the emergency room with complaints of the sudden onset of weakness in the bilateral legs and arms the arm weakness worse than the leg weakness he reports that it sudden in onset and that he had fallen two to three times over the past two days he denies any loss of consciousness he also denies any headaches visual changes numbness tingling chest pain shortness of breath or palpitations he also states that he has had no recent illnesses he was seen at where he was noted to have bilateral subdural hematomas and was transferred to past medical history hypertension hypercholesterolemia chronic obstructive pulmonary disease bladder cancer status post urethral diversion gastritis ethanol chronic renal insufficiency with a creatinine of to taf colon cancer status post resection medications on admission verapamil mg by mouth three times per day lisinopril mg by mouth once per day lipitor mg by mouth once per day lasix mg by mouth once per day zinc mg by mouth once per day allergies no known drug allergies social history he lives with his wife and daughter has two to three glasses of wine per day he denies any intravenous drug use brief summary of hospital course the patient was transferred to and admitted to the intensive care unit where he was started on dilantin mg intravenously as a loading dose and then mg by mouth three times per day he was initially ruled out for a myocardial infarction he remained stable and was taken to the operating room on he underwent parietal and subdural bur hole openings with evacuation of bilateral hematomas he did well intraoperatively and was transferred to the postanesthesia care unit upon arrival he was extubated and arousable he was coughing on his own he was alert and oriented he was answering all questions appropriately he was following commands he left arm movement actually improved after his surgery he continued to do well in the postanesthesia care unit overnight and was transferred to the floor the next day he continued to do well on the floor he was moving all extremities well he was out of bed ambulating he was seen by physical therapy today who noted that he would benefit from a short term stay in rehabilitation assessment condition at discharge the patient is a year old male who had a complicated past medical history and was status post bilateral subdural hematoma with drainage on he was neurologically stable discharge disposition to be discharged to rehabilitation medications on discharge furosemide mg by mouth once per day acetaminophen mg tablets one to two tablets by mouth q h as needed famotidine mg by mouth twice per day thiamine hcl mg by mouth once per day folic acid mg by mouth once per day multivitamin verapamil mg by mouth q h phenytoin dilantin mg extended release tablets one tablet three times per day oxycodone mg tablets one to two tablets by mouth q h as needed for pain docusate sodium mg by mouth twice per day m d dictated by medquist d t job [NEW_RECORD] name unit no admission date discharge date date of birth sex m service neurosurgery this addendum covers the dates of to the time of his discharge patient continued to be afebrile with vital signs stable he did easily awaken to stimulation and did follow commands his dressing was clean dry and intact he did undergo repeat cat scan of the head which showed no interval change in the bilateral frontal small residual subdural collections and no new areas of hemorrhage he continued to be neurologically stable and was discharged to rehab in he will follow up in one month s time with dr and was to have staples removed on m d dictated by medquist d t job [NEW_RECORD] name unit no admission date discharge date date of birth sex m service neurosurgery this addendum covers the dates of to the time of his discharge patient continued to be afebrile with vital signs stable he did easily awaken to stimulation and did follow commands his dressing was clean dry and intact he did undergo repeat cat scan of the head which showed no interval change in the bilateral frontal small residual subdural collections and no new areas of hemorrhage he continued to be neurologically stable and was discharged to rehab in he will follow up in one month s time with dr and was to have staples removed on m d dictated by medquist d t job,"{
""Diagnoses"": [""bilateral subdural hematomas"", ""hypertension"", ""hypercholesterolemia"", ""chronic obstructive pulmonary disease"", ""bladder cancer"", ""status post urethral diversion"", ""gastritis"", ""ethanol"", ""chronic renal insufficiency"", ""colon cancer"", ""status post resection""],
""Medications"": [""verapamil"", ""lisinopril"", ""lipitor"", ""lasix"", ""zinc""]
}"
22443,admission date discharge date date of birth sex m service cardiothoracic allergies no drug allergy information on file attending chief complaint occasional chest pressure and palpitations major surgical or invasive procedure minimally invasive mv repair with mm band history of present illness yo male with chest discomfort for one year not related to exertion and assoc palpitations occasionally has known mitral valve prolapse mvp for at least years has had serial echos and cath done showed mr nl cors and ef referred to dr for surgical repair of mv had excellent exercise capacity on pre op testing and tee showed ef trace tr flail post mv leaflet and mr with trace ai past medical history htn depression anxiety bph mvp mild oa hands social history works as engineer lives with wife smoked remotely more than years ago glasses of wine per day family history non contrib for cardiac disease physical exam hr rr r l pounds mild rash on abdomen nad heent and neck exam unremarkable without bruits lungs cta bilat rrr sem at llsb no masses or organomegaly in abd extrems warm well perfused no edema without varicosities bilat fem dp pt pulses 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 calcium mg am blood freeca brief hospital course admitted underwent minimally invasive mv repair with mm annuloplasty band by dr transferred to csru in stable condition on a phenylephrine drip extubated early the following morning in sr on indulin and neo drips weaned off neo on pod and remained in unit for bed issues cts removed diuresis begun and transferred to to increase activity level beta blockade begun with lopressor patient did extremely well and was cleared for discharge late in the day right thoracot incis unremarkable lungs cta bilat rrr with no murmur abd soft with flatus extrems warm with edema discharged to home with vna services medications on admission lisinopril mg qd zoloft mg qd claritin prn mvi qd discharge medications docusate sodium mg capsule sig one capsule po bid times a day disp capsule 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 zoloft mg tablet sig tablets po once a day disp tablet s refills metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet s refills ibuprofen mg tablet sig one tablet po q h every hours take with food disp tablet s refills furosemide mg tablet sig one tablet po bid times a day for days disp tablet s refills potassium chloride meq tab sust rel particle crystal sig one tab sust rel particle crystal po twice a day for days disp tab sust rel particle crystal s refills discharge disposition home with service facility vna discharge diagnosis mitral regurgitation hypertension benign prostatic hypertrophy s p min inv mitral valve repair discharge condition good discharge instructions follow medications on discharge instructions you may not drive for weeks you may not lift more than lbs for weeks you should shower let water flow over wounds pat dry with a towel call our office for wound drainage temp do not use lotions powders or creams on wounds followup instructions make an appointment with dr for weeks make an appointment with dr for weeks completed by,"{
""Diagnoses"": [""cardiothoracic"", ""mitral valve prolapse"", ""high blood pressure"", ""depression"", ""anxiety"", ""benign prostatic hyperplasia""],
""Medications"": [""none""]
}"
29933,admission date discharge date date of birth sex m service nb admission diagnosis imperforate anus this infant was delivered at weeks gestation to a year old gravida para now woman with unremarkable past medical history and the following prenatal screens blood group a negative direct antibody test negative hepatitis b surface antigen negative rpr nonreactive rubella immune group b streptococcus negative the pregnancy was uncomplicated the infant was delivered by elective cesarean section without labor for breech presentation the intrapartum course was unremarkable the infant was vigorous at delivery with apgar scores of at one minute and at five minutes on initial examination imperforate anus was noted by delivery room staff the infant has been asymptomatic physical examination birth weight gm th percentile occipitofrontal circumference cm th percentile heart rate respiratory rate blood pressure with a mean of mmhg temperature degrees examination reveals a well appearing term infant in no distress the anterior fontanelle is soft and flat facies are non dysmorphic palate is intact neck and mouth are normal the infant is normocephalic and there is no nasal flaring there are no intercostal retractions and no grunting respirations he has good breath sounds bilaterally and no adventitious sounds the infant is well perfused with a regular cardiac rate and rhythm femoral pulses are normal st and nd heart sounds are normal and there is no murmur the abdomen is soft and nondistended with no organomegaly and no masses bowel sounds are active three vessel umbilical cord is noted the infant has an imperforate but normally placed anus with superficial dimpling of the skin there is no fistula noted the infant has a normal phallus and testes are descended bilaterally he is active alert and responsive to stimuli tone is normal and symmetrical he is moving all extremities symmetrically suck root and gag reflexes are intact and facies are symmetric the examination of the integument as well as spine limbs hips and clavicles is within normal limits impression this term infant presents with imperforate anus without other clinically evident anomalies plan the infant will be transferred to for definitive surgical management he has been placed npo with bowel decompression a peripheral intravenous dextrose solution will be started at a total fluid intake of ml per kg per day with the usual attention to fluid and metabolic issues a cbc and blood culture have been drawn however we will defer empirical antibiotic therapy in light of this clinically excellent appearance and absence of peripartum risk factors transfer has been accepted by dr at the parents have been updated regarding the infant s current status diagnostic considerations and our management plan dictated by medquist d t job,"{
""Diagnoses"": [""imperforate anus""],
""Medications"": []
}"
6942,admission date discharge date service vascular chief complaint peripheral vascular disease history of present illness this is an year old female with a complicated past medical history with peripheral vascular disease now presents for lower extremity bypass she was initially admitted to our institution on with mental status changes and hypotension at the same time she was worked up for right lower extremity cellulitis with arterial noninvasives showing arterial insufficiency and mri was done which was negative for osteomyelitis and arteriogram showed superficial femoral artery disease the patient was discharged home in stable condition the patient now returns for elective revascularization allergies sulfa intravenous contrast manifestations not documented medications aspirin mg q d atenolol q d lipitor q d diovan q d insulin b i d nitroglycerin sublingual prn protonix q day plavix mg q d last dose was ciprofloxacin mg q d flagyl mg q d nifedipine xl mg lasix mg imdur mg t i d potassium milliequivalents q d these have all been held in preparation for surgery past medical history coronary artery disease with angioplasty to the right coronary artery in history of rheumatic fever history of type diabetes insulin dependent history of dyslipidemia history of deep venous thrombosis history of breast carcinoma history of renal stones history of anemia of chronic disease history of osteoporosis history of diverticulosis cerebrovascular accident with a history transient ischemic attacks hospitalized in carotid stenosis to on the right internal carotid and less then in the left internal carotid artery past surgical history mastectomy in multiple vitreous hemorrhages repair partial hysterectomy in the physical examination vital signs sat on room air chest examination lungs are clear to auscultation bilaterally heart regular rate and rhythm abdominal examination is with bowel sounds otherwise unremarkable extremities are without edema pulse examination shows radial pulses femoral pulses popliteals are absent right dorsalis pedis pulse is dopplerable monophasic posterior tibial pulse is absent the left dorsalis pedis pulse and posterior tibial pulse are dopplerable monophasic signals admission laboratories white blood cell count hematocrit bun creatinine electrocardiogram normal sinus rhythm normal axis no acute changes chest x ray unremarkable hospital course the patient was admitted to the vascular service and started on intravenous antibiotics she underwent on a right common femoral to bk popliteal with in situ saphenous vein angioscopy valve lysis she required unit of packed red blood cells intraoperatively she was transferred to the pacu in stable condition postoperative hematocrit was the patient continued to do well and was transferred to the vicu for continued monitoring and care postoperative day one the patient was given ativan and of morphine resulting in increasing sedation analgesics and antilytics were held the patient was transfused a second unit of packed red blood cells physical examination was unremarkable a doppler examination showed a dopplerable peroneal dopplerable dorsalis pedis pulse and posterior tibial pulse mental status showed improvement with holding analgesics and ativan the patient remained in the vicu for hemodynamic monitoring the patient was agitated requiring restraint so she would not discontinue her swan or arterial line cardiac enzymes were flat electrocardiogram without changes urinalysis obtained which showed to white blood cells with occasional bacteria nitrite negative culture was sent which was finalized on as no growth the patient was delined on postoperative day number three and transferred to the regular nursing floor physical therapy was requested to see the patient in participation for evaluation for discharge planning the family will manage the patient at discharge even if rehab needs are required the remaining hospital course was unremarkable foley was discontinued on postoperative day three the patient was discharged in stable condition wounds were clean dry and intact she had a biphasic dorsalis pedis pulse artery pulse peroneal was a triphasic signal the patient is to follow up with dr in two weeks time discharge medications atorvastatin mg q d plavix mg q d aspirin mg q d atenolol mg q d hold for systolic blood pressure less then heart rate less then nifedipine cr mg q d hold for systolic blood pressure less then valsartan mg q d hold for systolic blood pressure less then protonix mg q d calcium carbonate mg discontinued acetaminophen to mg q to hours prn for pain discharge diagnoses peripheral vascular disease fem tibial disease status post right common femoral artery to bk popliteal bypass graft and nonreverse saphenous vein and vein angioplasty to the common femoral artery type diabetes insulin dependent controlled blood loss anemia corrected postoperative confusion secondary to sedation resolved m d dictated by medquist d t job [NEW_RECORD] admission date discharge date service surgery allergies sulfonamides iodine iodine containing ivp dye iodine containing attending chief complaint rle cellulitis ulcer major surgical or invasive procedure angioplasty of right peroneal vessel history of present illness y o woman with hx of cad who was admitted with rt foot ulcer and pain to dr service vascular surgery a plain film was consistent with rt st mt head osteomyelitis she was started on vanc cipro flagyl and underwent rt peroneal angioplasty on d after this she experienced rapid atrial fibrillation with sbp in the s a w troponin elevation this was rate controlled with lopressor she then experienced flash pulmonary edema on and was diuresed with lasix on the am of she was reportedly kg lighter and had sbp with hr s she was given two cc boluses with sbp up to s started on dopamine gtt and transfered to the ccu at dr request for further management patient improved and she was transfered back to vascular on medications adjusted physical therapy and nutrition following patient stable for discharge on see hospital course for full report past medical history s p ptca w rca iddm osteo diverticulitis cva and tias htn breast ca dvt anemia mastectomy r fem bpg w arm vein social history social history is significant for the absence of current tobacco use there is no history of alcohol abuse family history there is no family history of premature coronary artery disease or sudden death physical exam blood pressure was mm hg while seated pulse was beats min and irregular respiratory rate was breaths min generally the patient was well developed well nourished and well groomed the patient was oriented to person place and time the patient s mood and affect were not inappropriate there was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa the neck was supple with jvp of cm the carotid waveform was normal there was no thyromegaly the were no chest wall deformities scoliosis or kyphosis the respirations were not labored and there were no use of accessory muscles the lungs had basilar crackles bilaterally with normal breath sounds and no adventitial sounds or rubs palpation of the heart revealed the pmi to be located in the th intercostal space mid clavicular line there were no thrills lifts or palpable s or s the heart sounds revealed a normal s and the s was normal there were no rubs murmurs clicks or gallops the abdominal aorta was not enlarged by palpation there was no hepatosplenomegaly or tenderness the abdomen was soft nontender and nondistended the extremities had no pallor cyanosis clubbing or edema there were no abdominal femoral or carotid bruits inspection and or palpation of skin and subcutaneous tissue showed no stasis dermatitis ulcers scars or xanthomas rt foot w chronic ulceration medial aspect of r st mpj minimal surrounding redness no drainage b l dp pt pulses doppler pertinent results pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt ptt inr pt pm blood glucose urean creat na k cl hco angap pm blood calcium phos mg brief hospital course hypotension patient initially admitted to ccu for this but subsequently resolved could be multifactorial possible etiologies include hypoglycemia excessive diuresis infection cardiogenic symptomatic a fib required dopamine initially now weaned received unit prbcs but otherwise hematocrit was stable sepsis unlikely as patient has no increase in wbc and afebrile but still must be considered and was continued on vancomycin cardiogenic etiology unlikely given ck and trop flat ecg demonstrated global twi but essentially unchanged echocardiogram showed ejection fraction patient transferred from ccu to vicu continued to improve had nd event of bradycardia hypotension on lethargic confused ecg negative enzymes cycled patient improved after fluid bolus beta blocker discontinued amiodarone tapered and discontinued pump function diuresed during ccu admission atrial fibrillation continued amiodarone heparin gtt started initially for anticoagulation then transitioned to warfarin at time of discharge amiodarone discontinued discharged on coumadin mg daily with inr checks to be sent to dr and patient s primary dr osteomyelitis likely secondary to poor perfusion healing in the setting of diabetes continued vancomycin delirium likely sundowning as occured in the evening but otherwise stable and responded to haldol mg with monitoring of qtc since patient is also on amiodarone at time of discharge patient returned to her baseline oriented to self family coronary artery disease question of recent ischemia during ccu admission but as above enzymes flat at home on metoprolol and nifedipine but held in the setting of hypotension restarted beta blocker and uptitrated as blood pressure tolerated monitored ecg and cardiac enzymes continued aspirin atorvastatin and ezetimibe diabetes mellitus stable did have labile blood sugars initially continued sliding scale insulin but held home regimen until adequate po intake s p peroneal angioplasty vascular following appreciate recs will monitor neurovascular exam closely pain management as needed access right arm picc line was placed all lines discontinued at discharge ppx on coumadin ppi bowel regimen dnr but would want intubation for respiratory failure as needed for short period days health care proxy daughter vascular previous superficial femoral artery to above knee popliteal bypass graft on the right side who presented with right lower extremity ulcers underwent right lower extremity unilateral runoff with pta of the peroneal artery b l pt dp pulses dopplerable medications on admission allopurinol amiodarone asa atorvastatin cipro vanco flagyl dopamine gtt ezetemibe tramodol sc heparin insulin metoprolol nifedipine ppi tramodol prn discharge medications aspirin mg tablet chewable sig one tablet chewable po daily daily allopurinol mg tablet sig one tablet po every other day every other day atorvastatin mg tablet sig one tablet po daily daily ezetimibe mg tablet sig one tablet po daily daily tramadol mg tablet sig one tablet po q h every to hours as needed disp tablet s refills warfarin mg tablet sig tablet po hs at bedtime disp tablet s refills docusate sodium mg capsule sig one capsule po tid times a day as needed for constipation pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours other humalog sliding scale mg dl juice crackers mg dl units breakfast lunch dinner bedtime mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units mg dl units units units units insulin nph regular human rec unit ml cartridge sig units with breakast units with dinner subcutaneous twice a day acetaminophen mg tablet sig tablets po q h every to hours as needed for pain only outpatient lab work inr pt draw weekly and prn fax results to dr phone and fax and dr phone fax discharge disposition home with service facility vna discharge diagnosis peripheral vascular disease pta of r peroneal non st elevation myocardial infarct ulceration secondary to gout discharge condition stable bp ra b l pt dp pulses dopplerable discharge instructions division of vascular and endovascular surgery lower extremity angioplasty stent discharge instructions medications take aspirin mg once daily continue all other medications you were taking before surgery unless otherwise directed you make take tylenol or prescribed pain medications for any post procedure pain or discomfort what to expect when you go home it is normal to have slight swelling of the legs elevate your leg above the level of your heart use pillows or a recliner every hours throughout the day and at night avoid prolonged periods of standing or sitting without your legs elevated it is normal to feel tired and have a decreased appetite your appetite will return with time drink plenty of fluids and eat small frequent meals it is important to eat nutritious food options high fiber lean meats vegetables fruits low fat low cholesterol to maintain your strength and assist in wound healing to avoid constipation eat a high fiber diet and use stool softener while taking pain medication what activities you can and cannot do when you go home you may walk and go up and down stairs you may shower let the soapy water run over groin incision rinse and pat dry your incision may be left uncovered unless you have small amounts of drainage from the wound then place a dry dressing or band aid over the area that is draining as needed no heavy lifting pushing or pulling greater than lbs for week to allow groin puncture to heal after week gradually increase your activities and distance walked as you can tolerate no driving until you are no longer taking pain medications call and schedule an appointment to be seen in weeks for post procedure check and ultrasound what to report to office numbness coldness or pain in lower extremities temperature greater than f for hours new or increased drainage from incision or white yellow or green drainage from incisions bleeding from groin puncture site sudden severe bleeding or swelling groin puncture site lie down keep leg straight and have someone apply firm pressure to area for minutes if bleeding stops call vascular office if bleeding does not stop call for transfer to closest emergency room weigh yourself every morning md if weight lbs adhere to gm sodium diet followup instructions provider md phone date time you have a visit scheduled with dr on at pm you will have an ultrasound and then see dr call with any questions call dr office at to schedule follow up to be seen in weeks completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex f service addendum the hospital discharge was delayed secondary to requiring continued physical therapy and continued antibiotic therapy with levofloxacin and flagyl for right foot metatarsal joint two tenderness which improved after antibiotics condition at discharge the patient was discharged in stable condition discharge instructions followup the patient was to continue on antibiotics until seen in followup with dr m d dictated by medquist d t job,"{
""Diagnoses"": [""peripheral vascular disease"", ""lower extremity bypass"", ""hypotension"", ""mental status changes"", ""cellulitis"", ""arterial insufficiency"", ""superficial femoral artery disease""],
""Medications"": [""aspirin"", ""atenolol"", ""lipitor"", ""diovan"", ""insulin"", ""nitroglycerin"", ""protonix"", ""plavix"", ""ciprofloxacin"", ""flagyl"", ""nifedipine"", ""lasix"", ""imdur"", ""potassium""]
}"
24970,unit no admission date discharge date date of birth sex m service nb admission note baby is a gram product of a week gestation he was born to a year old gravida i para now i mother prenatal screens a positive antibody negative hepatitis b surface antigen negative rpr nonreactive rubella immune gbs negative hepatitis c negative and cystic fibrosis negative mother was followed at clinic and cardiology clinic for multiple fetal anomalies which include interrupted aortic arch large vsd asd and left club foot there were normal chromosomes by amniocentesis pregnancy was also notable for maternal substance abuse and she was on a methadone rehab program mother also has history of fetal thalassemia trait and she also admits positive tobacco use during the pregnancy the infant was delivered by planned cesarean section he emerged with nuchal cord x apgar score was at one minute and at five minutes he was electively intubated in the delivery room for grunting perioral cyanosis and narrow chest then he was brought to the neonatal intensive care unit for physical admission nicu physical examination temperature pulse s respiratory rate s s blood pressure with mean of oxygen saturation preductal postductal room air weight grams length cm head circumference four sequential blood pressures were noted and they were comparable anterior fontanelle open and flat with plagiocephaly dysmorphic features fused eyes low set ears orally intubated with et tube clear breath sounds bilaterally with pectus excavatum rate and rhythm regular with good femoral pulses bilaterally abdomen soft nondistended no hepatosplenomegaly pink and well perfused left club foot patent anus normal male genitalia with testes descended bilaterally moving all extremities slightly decreased tone assessment on admission newborn with prenatal diagnosis of coarctation of the aorta and ventricular septal defect also with dysmorphic features summary of hospital course by systems respiratory system he was intubated electively in the delivery room and was brought on a self inflated bag to the neonatal intensive care unit in the neonatal intensive care unit he was placed on very low ventilator settings and an x ray was done which showed the endotracheal tube to be high about cm above the carina the tube was advanced cm and he met target o saturation per cardiology in the mid s to low s he continued to remain stable on low ventilator settings and fio was at room air cardiovascular system his blood pressures were monitored as stated above and he was started on prostaglandin p at mcg per kilogram per minute as per cardiology cardiology fellow from was present at the bedside and he agreed with the cardiologic management fluid electrolytes and nutrition he was maintained n p o and started on iv fluids with d water at ml per kg per day and his dextrostix remained stable infectious disease a cbc and blood culture were drawn but they were no disease risk factors and the antibiotics were withheld pending cbc abnormality or culture results neurology he was to be scored for nas scores given the maternal substance abuse and history of genetics the plan was to obtain genetic consultation given the dysmorphic features at orthopedics ortho was following the baby preoperatively and the plan was to consult ortho for club feet social parents were updated in the delivery room and the plan was to transfer the patient to the cardiac intensive care unit sensory condition at time of discharge stable discharge disposition transfer to level hospital at cardiac intensive care unit name of primary care pediatrician care recommendations continue to be n p o continued on prostaglandin p at mcg per kg per minute continued on iv fluids at ml per kg per day discharge diagnoses coarctation of aorta interrupted aortic arch left club foot maternal substance abuse need for amnio rule out sepsis m d dictated by medquist d t job,"{
""Diagnoses"": [""gram product of a week gestation"", ""baby is a gram product of a week gestation"", ""fetal anomalies"", ""interrupted aortic arch"", ""large VSD"", ""ASD"", ""left club foot"", ""maternal substance abuse"", ""fetal thalassemia trait"", ""positive tobacco use during pregnancy""],
""Medications"": [""methadone rehab program""]
}"
10141,admission date discharge date date of birth sex m service nb id is a former wk premature infant with a history of rds and pneumothorax who is being discharged from the nicu at hx was born at weeks gestation to a year old gravida para now woman the mother s prenatal screens are blood type o positive antibody negative rubella immune rpr nonreactive hepatitis surface antigen negative and group b strep unknown the pregnancy was complicated for an infant noted on ultrasound to have large head with otherwise normal anatomy and mother had kidney stones the mother presented in labor on the day of delivery and was taken for c section secondary to breech presentation and decreased amniotic fluid index rupture of membranes occurred at the time of delivery the infant emerged vigorous apgar was at minute and at minutes the birth weight was g birth length was cm both in the th percentile for gestational age the birth head circumference was cm greater than the th percentile for gestational age newborn physical examination reveals a pink active nondysmorphic infant anterior fontanelle is soft and flat sagittal suture is split mm there is mild grunting flaring and retracting lungs are clear heart was regular rate and rhythm no murmur there was normal male genitalia and stable hip exam with legs held in breech positioning neurologic exam was nonfocal and age appropriate hospital course by systems respiratory status initially required nasopharyngeal continuous positive airway pressure on day of life he developed a right sided pneumothorax requiring a thoracotomy tube at that time he was also intubated and required high frequency oscillatory ventilation he received doses of surfactant and transitioned to simv on day of life the chest tube was removed on day of life and the infant extubated to nasal cannula oxygen on day of life and then to room air on day of life where he has remained for the rest of his nicu stay he has had rare episodes of apnea and bradycardia but none within days of discharge on examination his respirations are comfortable lung sounds are clear and equal cardiovascular status he has remained normotensive throughout the nicu stay his heart has regular rate and rhythm and no murmur heart rate is s s fluid electrolyte and nutrition status on the day of discharge his weight was g length cm and head circumference cm enteral feeds were begun on day of life and advanced without difficulty to full volume feeding by day of life he required supplemental gavage feedings for several days and eventually transitioned to full po feeds at the time of discharge he is taking breast milk calories per ounce and breastfeeding gastrointestinal status he never required phototherapy his peak bilirubin occurred on day of life and was total of direct gu he was circumcised on and the area has healed well hematology he never received any blood product transfusions during his nicu stay his last hematocrit on was infectious disease he was started on ampicillin and gentamicin at the time of admission for sepsis risk factors he completed days of antibiotics for presumed sepsis his blood cultures and cerebrospinal fluids remained negative from that time he has remained off antibiotics since that time neurologic head ultrasound was done on day of life secondary to mild macrocephaly and was within normal limits audiology hearing screen was performed with automated auditory brainstem responses and the infant passed in both ears psychosocial parents have been very involved in the infant s care throughout his nicu stay the infant is discharged in good condition he is discharged home with his parents primary pediatric care will be provided by dr of pediatrics telephone number recommendations after discharge feedings calorie per ounce breast milk made with enfamil powder of calories per ounce on an ad lib schedule the mother would also like to breast feed she has the telephone number of lactation consultant medications tri vi ml p o daily ferrous sulfate mg ml ml p o daily the infant passed the car seat position screening test the last state newborn screen was sent on he received his st hepatitis b vaccine on recommended immunizations synagis rsv prophylaxis should be considered from through for infants who meet any of the following criteria i born at less than weeks ii 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 or iii with chronic lung 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 follow up visits include lactation consultant as needed visiting nurse discharge diagnoses status post prematurity at weeks gestation status post respiratory distress syndrome status post right pneumothorax status post presumed sepsis status post hyperbilirubinemia of prematurity status post apnea of prematurity status post circumcision md dictated by medquist d t job,"{
""Diagnoses"": [""rds"", ""pneumothorax"", ""premature infant""],
""Medications"": [""none""]
}"
40614,admission date discharge date service medicine allergies codeine scopolamine hydrobromide attending chief complaint back jaw pain and nausea admitted s p cardiac cath major surgical or invasive procedure cardiac catheterization with placement of drug eluting stent to left main coronary artery history of present illness yo f hx htn cki hypothyroidism sjogren s syndrome presented s p cardiac cath with drug eluting stent to lmca extending to lad the pt presented to her pcp c o several month history of exertional back pain between the shoulder blades in the past few days it has been occurring at rest and associated with left arm pain as well as nausea the pain is difficult to categorize achy sharp and generally goes away after minutes she c o some palpitations occasionally associated with these episodes she takes baby aspirin and rests which help the pain this morning she had some pain at rest which radiated to her jaw she denies dyspnea on exertion pnd orthopnea and ankle swelling she ambulates well at home up and down stairs she was scheduled for stress thallium which showed normal myocardial perfusion at rest however the pt was sent to the cath lab as st changes were shown on ecg concerning for myocardial infarction cardiac cath showed proximal and distal lmca lesions she underwent cypher des to lmain extending to lad with slight jailing of lcx but persistent flow there was also a residual mid lesion which was left alone rca was large with mild disease in the cath lab she had a vagal response with sheath pull which responded to atropine mg of note her central sbps were mmhg than her noninvasive bps she was transferred to the ccu in stable condition on ros pt c o hearing problems with l worse than r dry mouth eyes secondary to sjogrens denies abdominal pain stool stress incontinence denies constipation or diarrhea denies increased urination or burning on urination no skin changes lumps or masses noticed denies weight changes fatigue fevers chills all other review of systems negative in detail past medical history cardiac risk factors hypertension cad cardiac history no history of cath echo stress test other past medical history endometrial ca stage b s p hysterectomy and s p pelvic radiation in hypothyroidism sjogren s syndrome sbo x with ex lap loa in social history lives alone in n adult children retired high school art teacher daughter is involved in care tobacco history none etoh none illicit drugs none family history non contributory physical exam vs t bp hr rr o on l nc general appearance no acute distress appears anxious hoarse trembling voice aaox eyes conjunctiva perrl eomi head ears nose throat normocephalic atraumatic oropharynx clear nasal cannula bilateral carotid bruits lymphatic cervical wnl supraclavicular wnl cardiovascular normal s s no s no s systolic ejection murmur heard best at lusb not heard at apex does not radiate to clavicles no rubs peripheral vascular right radial pulse present left radial pulse present right dp pulse diminished left dp pulse diminished respiratory chest clear to auscultation bilaterally limited to anterior exam only abdominal soft non tender bowel sounds present not distended not tender extremities right lower extremity edema absent left lower extremity edema absent right groin cath site cdi pertinent results on admission pm blood hct am 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 ret aut pm blood glucose urean creat na k cl hco angap am blood ck mb notdone ctropnt pm blood calcium phos mg am blood caltibc ferritn trf cardiac catheterization selective coronary angiography in this right dominant system demonstrated left main disease the lmca had a proximal stenosis a mid portion stenosis and a distal stenosis the lad had a mid stenosis the d had an stenosis at the origin the cx was small and had moderate plaque at the origin the rca was a large calibur vessel with mild disease severe systemic arterial hypertension with sbp of mm hg and dbp mm hg successful ptca and stenting of the lmca with a x mm cypher drug eluting stent which was postdilated to mm final angiography revealed no residual stenosis no angiographically apparent dissection and timi flow see ptca comments for details presumed bilateral subclavian stenosis left right with a mmhg resting gradient between central aortic and left brachial non invasive blood pressure final diagnosis left main coronary artery disease bilateral subclavian stenosis left right successful ptca and stenting of the lmca echocardiogram the left atrium is normal in size there is mild symmetric left ventricular hypertrophy the left ventricular cavity is unusually small regional left ventricular wall motion is normal overall left ventricular systolic function is normal lvef no masses or thrombi are seen in the left ventricle transmitral doppler and tissue velocity imaging are consistent with grade i mild lv diastolic dysfunction right ventricular chamber size and free wall motion 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 estimated pulmonary artery systolic pressure is normal there is no pericardial effusion impression small hypertrophied left ventricle with normal global and regional systolic function mild diastolic lv dysfunction no clinically significant valvular disease or pulmonary hypertension ct abdomen and pelvis large hyperdense structure in the right pelvis concerning for a large extraperitoneal hematoma tracking along the medial thigh unable to comment on active extravasation due to lack of iv contrast administration compression of the right distal ureter due to large pevic hematoma causing right kidney hydroureteronephrosis and calyceal rupture at the lower pole atrophic left kidney urology consult is recommended mag renal scan the differential function obtained by analysis of tracer concentration in the parenchyma from to minutes post tracer injection shows the left kidney to be performing of the total renal function and the right kidney performing impression right pelvic hematoma causes no significant right ureteral obstruction right renal function is mildly reduced persistent nephrogram in the left kidney is likely related to chronic renal disease or contrast nephropathy on discharge hbg hct k bun cr wbc plt brief hospital course year old female with a history of htn chronic kidney injury hypothyroidism sjogrens syndrome presented status post cardiac catheterization with drug eluting stent placed to the left main with extension to lad now with pelvic hematoma and renal caliceal rupture coronaries the patient s anginal equivalent is intrascapular back pain with nausea precath ecg showed mm st elevations in v and avr with depressions in avl left main disease seen on cath and stent placed to lmca extending to the lad post cath ecgs have been essentially unchaged post cath tnt ck no anginal equivalent during hospital stay the patient was started on aspirin po qd plavix po qd and atorvastatin po qd hematoma developed as the patient began sundowning and became very anxious restless hrs after cath ultrasound was negative for hematoma but induration and brusing along the inguinal ligament and suprapubic area developed afterwards ct abd pelvis showed x cm pelvic fluid collection it also showed the hematoma possibly compressing the right ureter causing hydronephrosis and possible calyceal rupture hematocrit dropped from two days prior to admission to the patient received units prbc and hematocrit has increased and stabilized vascular surgery was consulted and the recommended no intervention at this point urology was consulted and the recommended a mag renal scan to evaluate the function of non obstructed kidney the scan showed non obstructed r ureter and decreased function of bilateral kidneys likely due to chronic kidney injury vs contrast induced nephropathy follow up with dr in urology was recommended in weeks acute on chronic kidney injury the patient s baseline creatinine year ago was two days prior to admission the patient was advised to stop olmesartan over concerns of an increased creatinine to her creatinine was on admission fena was so a prerenal component was felt to be unlikely serum creatinine increased since admission likely due to obstruction of the right kidney as well as possible effects from the dye load during catheterization creatinine trended down in the days leading up to discharge follow up with the patient s primary care physician weeks was recommended as well as a repeat measurement of a labs including a bmp delirium the patient has a history of sundowning on previous hospital admissions she was given benzos on the day of admission and her mental status deteriorated she pulled out an iv as well as her foley catheter restraints were used temporarily we stayed away from benzos for the rest of the admission and the patient did not have any recurrences of delirium or notable sundowning pump the patient had no previous caths or echos no history or symptoms of previous hf echo showed mild diastolic dysfunction with ef she was placed on carvedilol po bid an acei or was held given the elevated creatinine we have recommended outpatient follow up and restarting of acei or upon resolution of serum creatinine hypertension the patient was on atenolol at home she was started on amlodipine po qd and carvedilol po bid and remained normotensive hypothyroidism the patient s tsh was normal two days prior to admission we continued levothyroxine mcg po qd anemia baseline outpatient h h mcv anemia of chronic disease on iron studies fen heart healthy low sodium diet access piv s code full comm patient daughter is involved in care dispo home with home pt medications on admission atenolol mg tablet one tablet s by mouth daily levothyroxine mcg tablet tablet s by mouth every day nitroglycerin mg tablet sublingual one tablet s sublingually prn chest pain aspirin buffered mg tablet one tablet s by mouth daily discharge medications outpatient lab work please check chem cbc on call results to dr at aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily levothyroxine mcg tablet sig one tablet po daily daily nitroglycerin mg tablet sublingual sig one sublingual prn as needed for chest pain clopidogrel mg tablet sig one tablet po daily daily disp tablet s refills amlodipine 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 carvedilol mg tablet sig one tablet po bid times a day disp tablet s refills discharge disposition home with service facility home health care discharge diagnosis primary diagnosis st elevation myocardial infarction secondary diagnoses hypertension cki hypothyroidism sjogren s syndrome endometrial ca stage b s p hysterectomy and s p pelvic radiation in discharge condition good hemodynamically stable and improved discharge instructions you were admitted to the hospital for back pain and found to be having a myocardial infarction commonly known as a heart attack you had a cardiac catheterization and a stent was placed in your left main coronary artery after your catheterization you developed a hematoma in your pelvis that compressed your right ureter causing a decline in your kidney function you were treated with several blood transfusions and close monitoring the bleeding resolved and your kidney function improved however it is important that you follow up with a urologist dr see below for appointment time and date to continue to monitor your overall kidney function please also follow up with your pcp and cardiologist appointments below we have made the following changes to your medications stop atenolol stop olmesartan start plavix this is a medication that helps to keep your blood thin and prevent further clots from forming in your coronary arteries do not stop this medication without speaking your cardiologist start carvedilol this is a medication to help control your blood pressure start atorvastatin this is a medication for cholesterol but is also important for stabilizing disease within your coronary arteries start amlodopine this is another medication to help control your blood pressure please continue to take your other medications as prescribed if you experience any further episodes of chest pain shortness of breath dizziness or other concerning symptoms please call or call your pcp followup instructions provider phone date time at am urology provider md division of urology clinical center phone date time tuesday at am cardiology phone date time at pm clinical center,"{
""Diagnoses"": [""back jaw pain"", ""nausea"", ""exertional back pain"", ""hypertension"", ""hypothyroidism"", ""Sjogren's syndrome"", ""history of present illness""],
""Medications"": [""codeine"", ""scopolamine hydrobromide"", ""baby aspirin""]
}"
97031,admission date discharge date date of birth sex m service medicine allergies hydrochlorothiazide attending chief complaint abdominal pain major surgical or invasive procedure ercp intubation extubation history of present illness yo m with a history of htn hl dmii obesity who presented with day of ruq pain found to have gallstone pancreatitis with concern for cholangitis patient was intubated on admission to per report of patient s wife patient ate chili at pm on the day prior to admission and developed epigastric pain directly after he had ongoing sharp pain which radiated to his back and not related to position he vomited throughout the night he was unable to have a bowel movement and took maalox he had several bowel movements on the morning of admission prior to coming to the er he did not have fever chills or night sweats he did have elevated blood sugars in the days prior to admission he has never had biliary colic cholecystitis or pancreatitis in the past in the ed inital vitals were t hr bp rr o sat labs were notable for wbc alt ast alk phos t bili lipase ruq ultrasound revealed multiple stones within distended gallbladder c w acute cholecystitis with common bile duct dilation to cm without identification of an intra ductal stone patient was evaluated by acs team who recommended ercp patient was given l ns zofran for nausea morphine for pain control and dose of unasyn then was sent for ercp during ercp patient desaturated while on sedation and required intubation following intubation patient was tachycardic and hypertensive he was difficult to ventilate and so was sedated and paralyzed and given albuterol with improved compliance and tidal volumes received l lr during procedure during ercp many gallstones were removed from the biliary tree which were partially obstructive pus was removed as well patient was hypertensive and tachycardic after transferred to intubated on arrival to the icu vital signs were t hr bp o sat patient was intubated and sedated at tv rr fio and peep wife was for further history as stated above and she completed icu consent the evening after arriving in the icu he self extubated and afterward needed to be on non invasive ventilation to maintain sats he was weaned to l nc prior to transfer to the floor past medical history dm htn morbid obesity premature ejaculation hl seasonal allergies tonsilectomy social history non smoker rare etoh no illicits works as supervisor for t married has five children family history no cad no thromboembolic disease physical exam admission exam vitals t bp p r o general morbidly obese male intubated and sedated heent sclera anicteric neck jvp difficult to assess due to body habitus lungs course crackles on right left clear to auscultation on left no wheezes appreciated cv tachycardic with normal rhythm normal s s no murmurs rubs gallops abdomen obese hypoactive bowel sounds no ttp gu no foley ext warm well perfused pulses no clubbing cyanosis or edema 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 glucose urean creat na k cl hco angap am blood alt ast alkphos totbili am blood alt ast alkphos totbili am blood lipase am blood albumin am blood calcium phos mg 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 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 alkphos totbili am blood alt ast alkphos totbili am blood calcium phos mg am blood calcium phos mg am blood calcium phos mg 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 alt ast alkphos totbili am blood lipase am blood calcium phos mg microbiology am urine site clean catch urine culture final organisms ml blood culture pending imaging cxr impression low lung volumes without radiographic evidence for acute process bibasilar atelectasis no evidence of free air beneath the diaphragms ruq u s impression findings consistent with acute cholecystitis dilatation of the common duct measuring up to mm suggests the presence of a distal cbd stone small hepatic lobe hypodensities are incompletely characterized and should be further evaluated with mr echogenic liver most consistent with fat deposition although more advanced disease such as cirrhosis and or fibrosis cannot be excluded ercp 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 bulging of the major papilla was noted cannulation cannulation of the biliary duct was successful and deep with a sphincterotome after a guidewire was placed contrast medium was injected resulting in complete opacification the procedure was mildly difficult biliary tree fluoroscopic interpretation the bile duct was opacified with contrast many round stones ranging in size from mm to mm that were causing partial obstruction were seen at the biliary tree impression mild post obstructive dilation was noted bulging of the major papilla successful cannulation of the bile duct cannulation many round stones ranging in size from mm to mm that were causing partial obstruction were seen at the biliary tree mild post obstructive dilation was noted a sphincterotomy was performed multiple stones and pus were extracted successfully using a balloon catheter otherwise normal ercp to third part of the duodenum left lower extremity findings grayscale and doppler son of the left common femoral superficial femoral deep femoral popliteal and proximal calf veins were performed there is normal compressibility flow and augmentation throughout impression no dvt in the left lower extremity brief hospital course y o m with a history of htn hl dmii obesity and asthma presenting with gallstone pancreatitis and possible cholangitis with ercp c b hypoxic respiratory distress requiring intubation acute cholecystitis complicated by gallstone pancreatitis and cholangitis patient presented with several days of ruq pain worse with food and was found to have acute cholecystitis complicated by pancreatitis tbili transaminases and lipase all elevated on presentation ercp performed with removal of stones successful sphincterotomy and removal of pus patient was given iv unasyn prior to procedure which was continued after the procedure and then transitioned to oral augmentin for a total day course following the procedure the patient was afebrile and hemodynamically stable without signs of sepsis the patient was advised that he would require a cholecystectomy in weeks as an outpatient hypoxic respiratory distress patient desaturated under sedation likely due to obesity and potential underlying obesity hypoventilation syndrome vs obstruction he was intubated successfully however he was difficult to ventilate he responded well to sedation paralysis and albuterol the patient had asthma so he likely had bronchoconstriction that also worsened oxygenation the patient self extubated shortly after arrival to and respiratory status improved once on the floor he was rapidly weaned off oxygen he may benefit from an outpatient sleep study for osa hypertension patient s blood pressure elevated on arrival to icu initially held home lisinopril amlodipine and metoprolol while intubated once his home meds were restarted the patient s sbp remained s this was thought secondary to saline loading from iv ns after a day of therapy with nitrates his sbp dropped to his normal range with home medication hyperlipidemia simvastatin held in the setting of gallstone pancreatitis plan to restart simvastatin once lfts return to baseline diabetes mellitus type ii patient followed at for diabetes last hgba c checked on and was up from patient on glipizide liraglutide and metformin covered with insulin sliding scale as inpatient recs on discharge restart home dose metformin and glipizide but discontinue liraglutide as it can contribute to pancreatitis code full emergency contact wife medications on admission amlodipine mg po daily lisinopril mg po daily metoprolol tartrate mg po bid aspirin mg po daily simvastatin mg po daily metformin mg po bid glipizide xr mg po bid liraglutide mg sc daily albuterol inh prn shortness of breath wheeze fluticasone mcg inh clomipramine mg po qhs mg po daily discharge medications amlodipine mg tablet sig one tablet po daily daily lisinopril mg tablet sig two tablet po daily daily metoprolol tartrate mg tablet sig one tablet po bid times a day metformin mg tablet sig one tablet po twice a day glipizide mg tablet extended rel hr sig one tablet extended rel hr po twice a day albuterol sulfate mcg actuation hfa aerosol inhaler sig two puff inhalation q h every hours as needed for wheeze clomipramine mg capsule sig three capsule po hs at bedtime fexofenadine mg tablet sig three tablet po once a day fluticasone mcg actuation aerosol sig two puff inhalation times a day amoxicillin pot clavulanate mg tablet sig one tablet po q h every hours for days disp tablet s refills discharge disposition home discharge diagnosis gallstone pancreatitis cholangitis 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 at you came to the hospital with abdominal pain nausea and vomiting an ultrasound found gallstones and lab work showed signs of pancreatitis you then underwent a procedure called ercp endoscopic retrograde cholangiopancreatography this procedure opened up the bile duct to allow the gallbladder to drain many gallstones were removed pus was seen in the biliary system a sign of infection following the ercp you had difficulty breathing on your own and were intubated you were transferred to the icu intensive care unit to assist your breathing you rapidly recovered and removed the breathing tube you were then transferred to the medicine floor where you continued to improve you were treated with nebulizers and supplemental oxygen after one day on the floor you no longer needed oxygen therapy and were breathing normally your pancreatitis which was caused by the blocked duct in your biliary tree was treated with iv fluids and pain relief as you improved you were able to eat normally without pain and your fever resolved the infection of your biliary system was treated with antibiotics you will need to continue antibiotics for a total of days to ensure that this infection is fully resolved we made the following changes to your medications stop liraglutide as this can worsen your pancreatitis stop simvastatin your primary care physician restart this when your liver function is back to normal start augmentin an antibiotic to treat the infection of the bile system you will take this for more days last day hold aspirin until then restart at your regular dose do not take any aspirin ibuprofen advil or naproxen aleve for days following your procedure you may start taking these medications on you will need to follow up with your outpatient physicians please follow up with your physician to adjust your diabetes management please make an appointment within the next two weeks as we have stopped one of your diabetes medications and do not want your sugar to get out of control you have an appointment with dr on please ask him to do a pre operative evaluation for your expected surgery you will also discuss when to restart your simvastatin you have an appointment with dr on at this time you will discuss the surgery to remove your gallbladder to avoid making your gallbladder more inflammed please follow a low fat diet fatty foods increase the probability of a gallstone attack and can worsen pancreatitis followup instructions department when monday at pm with md building ma campus off campus best parking on street parking department general surgery when wednesday at am with dr acute care clinic building lm bldg campus west best parking garage,"{
""Diagnoses"": [""pancreatitis"", ""cholangitis"", ""gallstone"", ""hydrocele""],
""Medications"": [""hydrochlorothiazide""]
}"
75618,admission date discharge date date of birth sex m service medicine allergies beta blockers beta adrenergic blocking agts gabapentin attending chief complaint need for peritoneal dialysis major surgical or invasive procedure none history of present illness mr is an yo m with af on warfarin cad s p cab esrd on peritoneal dialysis polyneuropathy and other medical issues transferred from hospital for peritoneal dialysis and recent intraventricular hemorrhage fall patient states frequent falls every other week since back surgery in he reports a fall about days ago and caused posterior scalp laceration s p stapling his inr was not checked and he had not had coumadin dose changed for the past several months he states taking warfarin mg daily except for friday when he takes mg about days prior to admission staples were removed but has been oozing he noticed that his pillow was stained with he went to hospital to get suture where his inr was found to be and point hct drop compared to about week prior per report he received ffp and vitamin k there however since does not do pd and his wife has not been able to help him with it due to recent hospitalization d c ed home yesterday he is transferred to in the ed initial vs were l nasal cannula guaiac negative he received unit of prbc mg iv vitamin k and about cc ns labs were drawn right after the prbc with hct and inr of ct head showed a small left intraventricular bleed in the posterior neurosurgery felt that patient did not require any surgical intervention per ed neurology thought patient was stable renal was contact and felt that he could get pd tomorrow has g x iv on the right arm vs upon transfer were ra on arrival to the micu currently feeling well he states that he falls at least once but no more than times a month he thinks it is a balance problem but would lose consciousness and find himself on the ground he denies prodrome or post ictal symptoms review of systems per hpi denies fever chills night sweats recent weight loss or gain denies headache sinus tenderness rhinorrhea or congestion denies cough shortness of breath or wheezing denies chest pain chest pressure palpitations or weakness denies nausea vomiting diarrhea constipation abdominal pain or changes in bowel habits denies dysuria frequency or urgency denies arthralgias or myalgias denies rashes or skin changes he denies tingling numbness diplopia past medical history cad s p cabg afib on coumadin htn hld esrd on peritoneal dialysis chronic lbp s p discectomy in chronic anemia h o strokes bph s p turp psoriasis carotid stenosis most recent carotid ultrasound in h o gib t dm anxiety social history lives at home with wife who is the hcp and next of retired engineer no smoking hx rare alcohol use family history no premature cad brother and sister with dm dm in aunt sisters and brother physical exam admission physical exam vitals t hr bp rr o sat ra general alert oriented no acute distress heent hematoma in the posterior occipital scalp s p suture sclera anicteric perrla mmm op clear neck supple jvp not elevated no lad carotid bruits l r cv irregularly irregular normal s and s no m r g lungs clear to auscultation bilaterally no wheezes rales ronchi abdomen soft non tender non distended bowel sounds present no organomegaly dialysis line in place area clean without erythema or drainage gu no foley ext warm well perfused pulses no edema neuro cnii xii intact strength upper lower extremities diminished sensation to light touch in the left foot gait deferred pertinent results admission labs pm wbc rbc hgb hct mcv mch mchc rdw plt ct pm neuts lymphs monos eos baso pm pt ptt inr pt pm glucose urean creat na k cl hco angap am calcium phos mg am type art po pco ph caltco base xs intubat not intuba imaging ct head findings a small amount of intraventricular hemorrhage layers posteriorly in the occipital of the left lateral ventricle no additional intra or extra axial hemorrhage is identified ventricular dilatation is unchanged since with prominence of the sulci likely due to atrophy focal hypodensities in the right thalamus and left lentiform nucleus are unchanged since and likely reflect lacunes confluent periventricular and subcortical white matter hypoattenuation is compatible with the sequela of chronic microvascular infarction a large posterior parietal subgaleal hematoma is present no fractures are seen visualized paranasal sinuses and mastoid air cells are well aerated calcification of the cavernous carotid arteries is present impression small amount of intraventricular hemorrhage in the occipital of left lateral ventricle large posterior parietal subgaleal hematoma cxr impression status post median sternotomy for cabg with stable cardiac enlargement and calcification of the aorta consistent with atherosclerosis relatively lower lung volumes with no focal airspace consolidation appreciated crowding of the pulmonary vasculature with possible minimal perihilar edema but no overt pulmonary edema no pleural effusions or pneumothoraces brief hospital course mr is an year old male with end stage renal disease esrd on peritoneal dialysis pd atrial fibrillation afib on warfarin coronary artery disease cad status post bypass surgery who presented with intraventricular bleed transferred to micu for neurological monitoring active issues by problem intraventricular bleed was secondary to recent fall in the setting of being on warfarin and with supratherapeutic inr based on ct head without contrast have some mild sensation deficit in the le l r could be chronic given underlying diabetes currently asymptomatic and stable from intraventicular bleed he did recieve one unit packed rbcs before transfer and his hematocrit was maintained above his warfarin was held and he was given vitamin k which brought his inr to therapeutic levels quickly neurosurgery was consulted and they recommended that he be closely monitored he was discharged with instructions to continue antiepileptic dilantin x days and to follow up with neurosurgery clinic in weeks with repeat head imaging given multiple falls would not recommend restarting anticoagulation anemia likely chronic in nature with acute intraventricular bleed as mentioned above recieved one unit packed rbcs and warfarin was held falls syncope based on history concerning for cardiogenic arrhythmia given no prodrome with drop attacks in the setting of underlying cad requiring cabg also could be due to gait instability from peripheral neuropathy from t dm also patient had history of cva and has carotid stenosis although symptoms unlikely from tia monitored on tele with no significant arrhythmias pt saw patient and felt that he could safely be discharged home with services esrd on pd creatinine at no significant electrolyte derangement at this time he did continue on pd while an inpatient continued renal cap and calcitriol he gets epo unit every other week followed by dr as an outpatient chronic af high risk for bleed given frequency of falls syncopes however with chads is also at high risk of stroke given ich warfarin was stopped and coagulopathy was aggressively reversed in the ed at time of discharge inr was decision whether to resume anticoagulation was deferred to cardiologist but is strongly not recommended given frequent falls at this time cad s p cabg htn hld hypertension and hyperlipidemia continued home diovan isosorbide furosemide amlodipine would recommend switching simvastatin to atorvastatin mg given higher risk of rhabdo with simvastatin on amlodipine diabetes mellitus type t dm on insulin continued home regimen anxiety continued citalopram mg as at home transitonal issues ich antiepileptic x days follow up with head imaging in neurosurgery clinic in weeks afib stopped coumadin given recent ich will need to discuss possible initiation of antiplatelts medications on admission diovan mg isosorbid mg daily furosemide mg simvastatin mg daily amlodipine mg daily calcitriol every other day renal cap daily folic acid daily b mg daily vitamin d iu daily mg citalopram iss with humalog units of lantus qhs tums tid epo unit every other week ferrex without food daily warfarin mg every day except friday mg on friday discharge medications b complex vitamin c folic acid mg capsule sig one cap po daily daily isosorbide mononitrate mg tablet extended release hr sig one tablet extended release hr po daily daily valsartan mg tablet sig one tablet po bid times a day furosemide mg tablet sig one tablet po bid times a day simvastatin mg tablet sig one tablet po once a day amlodipine mg tablet sig two tablet po daily daily calcitriol mcg capsule sig one capsule po every other day every other day folic acid mg tablet sig one tablet po daily daily cholecalciferol vitamin d unit tablet sig one tablet po daily daily pyridoxine mg tablet sig two tablet po daily daily citalopram mg tablet sig one tablet po daily daily insulin aspart unit ml solution sig per sliding scale subcutaneous per sliding scale phenytoin mg ml suspension sig one po q h every hours for days disp tablets refills lantus unit ml solution sig twelve units subcutaneous at bedtime calcium carbonate mg calcium mg tablet chewable sig one tablet chewable po tid times a day ferrous sulfate mg mg iron tablet sig one tablet po daily daily discharge disposition home with service facility vna discharge diagnosis primary diagnosis intraventricular hemorrhage supratherapeutic inr mechanical fall secondary diagnosis atrial fibrillation end stage renal disease on peritoneal dialysis 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 dear mr you were admitted to the hospital after a fall with in your brain you were seen by the neurosurgeons your coumadin was stopped and you were given products to reverse your thinning the bleeding in your head stopped but you will need to take medications to prevent seizure for the next days you will also need to follow up with the neurosurgery team with a repeat ct scan of your head in the next weeks please make the following changes to your medication regimen stop coumadin do not restart this medication talk to your cardiologist about other options like aspirin for your atrial fibrillation start dilantin mg three times daily for the next days end date please take all of your other medications as previously prescribed followup instructions follow up in clinic in weeks with a repeat head ct at that time and appointment with dr call to schedule follow up with cardiologist on monday as previously scheduled please follow up with your primary care physician in the next weeks call to schedule an appointment,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""m"", ""service"", ""medicine"", ""allergies"", ""beta blockers"", ""beta adrenergic blocking agents"", ""gabapentin""],
""Medications"": [""warfarin"", ""cad"", ""sp cab"", ""esrd"", ""peritoneal dialysis"", ""polyneuropathy"", ""other medical issues""]
}"
26947,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint altered menyal status major surgical or invasive procedure none history of present illness yo m h o hiv cd in vl undetectable hcv recent diagnosis of hcc w portal vein infiltration and rll pe admitted with alterred mental status patient was found earlier today in bed by his visitng nurse scratching his bed and bleeding from his bed also vna noted that patient s ms was worse than baseline with patient being oriented only to self and also patient being combative patient is non ambulatory at baseline so unlikely that he fell per vna bleeding probably from his scratching ems was called and brought patient to ed in the ed vs were t po warming blanket hr s o sat high s on l nc rr with bp in s s his bp responded to small ivf boluses cc with sbp in s serum tox negative including etoh tylenol level lactate inr crea baseline head ct and cxr essentially negative patient was given ffpx vitamin k and abx vanco levo flagyl as well as nac transferred to micu for further management patient was seen by liver service in ed of note patient was recently diagnosed with non transplantable hcc that had invaded the portal vein ros difficult to obtain but increasing edema unclear over what time period denies fevers chills cp sob abd pain past medical history hcv dx ed in vl in ifn and ribavirin in but stopped these due to hepatic encephalopathy requiring hospitalization at currently on lactulose hcc recently diagnosed during admission on non transplantable with portal vein thrombosis and rll pe should be followed up as outpatient h o recent rll pe diagnosed on cta to identify hepatic mass given asymptomatic and elevated inr no therapy was started hiv dx ed in cd and vl undetectable in on lopinavir ritonavir emtricitabine tenofovir two prior strokes in secondary to cocaine use with symptoms of left sided weakness left facial droop and blindness has residual of left leg weakness social history he is from with history of prior iv drug use as well as crack and cocaine quit in no alcohol lives with a caretaker and is well linked with social services and outreach programs family history no history of liver disease no history of seizures or other neurological diseases physical exam t bp hr rr l gen middle aged spanish speaking only man lying in bed in mild distress heent eomi perrl sclerae icteric jvd cv reg rate nl s s no m r g abd very obese soft nt distended bs present diffuse mild ttp ext bil edema anasarca neuro awake alert oriented x self and place rest of exam deferred lack of cooperation pertinent results am po pco ph total co base xs am k am glucose lactate k am lactate am hgb calchct am glucose urea n creat sodium potassium chloride total co anion gap am alt sgpt ast sgot ck cpk alk phos amylase tot bili am lipase am tot prot calcium phosphate magnesium am asa neg ethanol neg acetmnphn bnzodzpn neg barbitrt neg tricyclic neg am urine bnzodzpn neg barbitrt neg opiates neg cocaine neg amphetmn neg mthdone neg am wbc rbc hgb hct mcv mch mchc rdw am neuts bands lymphs monos eos basos atyps metas myelos am hypochrom normal anisocyt poikilocy normal macrocyt normal microcyt normal polychrom am plt smr normal plt count am pt ptt inr pt am urine color amber appear hazy sp am urine blood mod nitrite neg protein neg glucose neg ketone neg bilirubin lg urobilngn ph leuk neg am urine rbc wbc bacteria mod yeast none epi am urine granular hyaline am urine mucous occ brief hospital course a p yo m h o hiv cd in vl undetectable hcv recent diagnosis of hcc w portal vein infiltration and rll pe admitted with alterred mental status ams multifactorial etiology possible hepatic encephalopathy vs gi bleeding vs infection vs meds patient is in fulminant hepatic failure with coagulopathy and lactic acidosis was given abx ffp vit k in ed patients next of his sister was present during a family meeting the very poor prognosis was discussed advanced hcc ful hepatic failure renal failure the sister understood the implications and confirmed per telephone with patien s father who agreed that no aggressive measures should be pursued patient was made cmo he passed on at family and attending were notified family declined autopsy medications on admission emtricitabine tenofovir mg tablet sig one tablet po daily daily lopinavir ritonavir mg tablet sig two tablet po bid times a day levetiracetam mg tablet sig two tablet po bid times a day lactulose g ml syrup sig thirty ml po tid times a day discharge disposition expired discharge diagnosis hepatic failure cardiac arrest discharge condition expired followup instructions n a completed by,{}
59184,admission date discharge date service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint hematemesis major surgical or invasive procedure upper endoscopy history of present illness ms is an year old woman with a history of diabetes hypertension prior episode of ugib in distant past who presents with hematemesis she was in usoh until this evening when after having an uneventful dinner she awoke in the middle of the night and had one episode of approximately cc of hematemesis she denied abdominal pain diarrhea or blood in her stool but she did have a single brown nonbloody bowel movement per her daughter she was transported to the e d for further evaluation her recent history is negative for alcohol aspirin or other nsaid use in the ed vital signs were initially labs were notable for a hct of down from a baseline of and an ngl was positive for blood and coffee grounds and remained pink in color after lavage with l she was guaiac negative per rectum gi was consulted and felt that she was hemodynamically stable with a plan for egd in the a m she was started on pantoprazole and given l ivf and admitted to the for further management review of systems no fevers chills weight loss diaphoresis headache visual changes sore throat chest pain shortness of breath diarrhea melena pruritis easy bruising dysuria skin changes pruritis past medical history diabetes diet controlled choledocholithiasis status post sphincterotomy in distant history of hepatic abscess s p drainage ugib in in distant past no work up performed hypertension hypercholesterolemia social history no tobacco or alcohol she splits her time between this country living with her granddaughter and family history no history of bleeding disorders physical exam vs gen the patient is in no distress and appears comfortable skin no rashes or skin changes noted heent no jvd neck supple no lymphadenopathy in cervical posterior or supraclavicular chains noted chest lungs are clear without wheeze rales or rhonchi cardiac regular rhythm no murmurs rubs or gallops abdomen no apparent scars non distended and soft without tenderness extremities trace peripheral edema warm without cyanosis neurologic alert and appropriate cn ii xii grossly intact bue and ble both proximally and distally no pronator drift reflexes were symmetric downward going toes pertinent results studies upper endoscopy erythema in the antrum compatible with gastritis angioectasia in the fundus endoclip abnormal mucosa in the stomach otherwise normal egd to third part of the duodenum labs 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 hct pm blood hct 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 plt ct pm blood pt ptt inr pt 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 calcium phos mg micro time taken not noted log in date time am serology blood chem f helicobacter pylori antibody test negative brief hospital course ms is an year old woman with a history of diabetes hypertension prior episode of ugib in distant past who presents with hematemesis hematemesis hct from baseline of upper endoscopy showed angioectasia in the fundus which was clipped she was initially treated with iv pantoprazole she was transferred to the medical floor where her ppi was switched to an oral preparation her hct remained stable without additional transfusion her diet was advanced without difficulty an h pylori antibody was negative she was instructed to avoid nsaids or aspirin until seeing her primary care physician weeks she was instructed to arrange for a follow up appointment within weeks hypertension her home regimen was initially held due to acute bleeding but were restarted upon arrival to the medical floor without difficulty hctz lisinopril diabetes type diet controlled as an outpatient pt was covered with sliding scale insulin this was discontinued upon discharge disposition pt was evaluated by physical therapy due to deconditioning and weakness she walks with a walker at home at baseline but lives with her daughter only she was felt to benefit from hour supervision which her daughter was initially unable to provide additional family members ultimately arrived and she was discharged into their care with hour supervision medications on admission hydrochlorothiazide mg tablet tablet s by mouth daily lisinopril mg tablet tablet s by mouth daily omeprazole mg capsule capsule s by mouth daily discharge medications lisinopril mg tablet sig two tablet po daily daily disp tablet s refills hydrochlorothiazide mg capsule sig one capsule po daily daily disp capsule s refills pantoprazole 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 discharge disposition home discharge diagnosis primary hemetemesis gastric av malformation s p clipping discharge condition tolerating oral diet discharge instructions you were admitted to the hospital because you were vomiting blood you were found to have an artery vein malformation in you stomach which was the source of the bleeding and was clipped to stop the bleeding the following changes were made in your medication regimen you were started on a regimen of protonix mg by mouth twice daily followup instructions upon arriving home please arrange to be seen by your primary care physician within weeks j,"{
""Diagnoses"": [""Hematemesis"", ""Upper Endoscopy"", ""Hyperglycemia"", ""Hypertension"", ""Prior Episode of UGIB""],
""Medications"": [""Pantoprazole"", ""Liv 5"", ""IVF""]
}"
51664,admission date discharge date date of birth sex m service medicine allergies no known allergies adverse drug reactions attending chief complaint chest pain major surgical or invasive procedure cath lab ballon angioplasty in his right coronary artery history of present illness pcp m chief complaint chest pain history of presenting illness yo male with h o poorly controlled hypertension and tobacco abuse presented to his pcp s office today with chest pain seen in and now transferred to for stemi patient reports he felt like he had an attack on sunday days pta while taking a shower felt like his whole lungs hurt also had diaphoresis and dizziness at the time since then had been feeling short of breath and having chest pain finally presented to his pcp s office today for a medication refill and mentioned his pain pain at that time ecg reportedly concerning for mi he presented by car then to refused ambulance where troponin i was and ekg showed elevations in inferior limb leads with reciprocal changes in lateral chest leads started on heparin gtt loaded with mg given metoprolol and aspirin mg and transferred urgently to the cath in the cath lab he was found to have subtotal occlusion of rca lesion in mid prox lad and in lcx rca was a small lesion was poba d with good flow he was started on integrillin with plan to continue this for hours in the ccu on arrival to the ccu patient is chest pain free and comfortable review of systems 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 notable for presence of chest pain dyspnea diaphoresis no orthopnea ankle edema palpitations syncope or presyncope past medical history past medical history hypertension poorly controlled depression tobacco abuse iron overload pt reports needed therapeutic phlebotomy copd h o asbestos exposure medications ibuprofen mg allergies nkda social history works part time as a mechanic lives alone unmarried tobacco history ppd x years etoh beers per week beers in one sitting illicit drugs denies family history brother with cad s p stents physical exam vs t bp hr rr o sat ra general obese middle aged male 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 elevated jvp 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 bibasilar crackles no wheezes or rhonchi abdomen soft obese ntnd no hsm or tenderness extremities pitting edema of bilateral les tr band in place over radial site skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid dp pt left carotid dp pt pertinent results pm sodium potassium chloride pm ck mb pm plt count ekg nsr bpm na elevations in ii iii avf and v v twis in v v cardiac cath lmca patent lad diffusely diseased long mid lesion lcx large giving large om distal av groove has a lesion and om has diffuse luminal irregularities rca totally occluded proximally just past the conus origin lvedp successful poba of totally occluded rca moderate disease in the lad and lcx system brief hospital course yo m with history of poorly controlled hypertension and tobacco abuse who presented with chest pain found to have stemi now s p poba of rca acute issues stemi s p balloon angioplasty to the rca troponin i at osh however mb here is no mb at osh event likely occurred days prior to admission when he had severe pain and he arrived to the chest pain free echo showed likely preserved ef at with no obvious wall motion abnormalities however poor windows he was started on atorvastatin ace i beta blocker was also started at lower dose due to episodes of bradycardia see below we also encouraged smoking cessation and dietary changes bradycardia patient had several episodes of bradycardia with pauses lasting at longest seconds this was mainly at night and was asymptomatic episodes possibly a complication of his inferior mi with resultant ischemia to conduction system however more likely they are vagal in nature beta blocker dose was decreased and he had no further episodes on telemetry acute diastolic congestive heart failure lvedp elevated at in the cath lab volume overloaded on exam ef found to be preserved at likely had diastolic dysfunction in setting of acute mi volume status mproved with iv lasix diuresis chronic issues copd albuterol prn tobacco abuse he was given nicotine mcg patch we encouraged smoking cessation possible hemochromatosis report h o therapeutic phlebotomy hct and ferritin elevated however no sign of cardiac involvement transitional issues bradycardia will follow up with cardiologist will continue low dose metoprolol stemi will follow up with dr on discharged on metoprolol lisinopril aspirin and atorvastatin hemochromatosis follow up with heme onc medications on admission ibuprofen mg discharge medications aspirin mg po daily rx aspirin mg one tablet s by mouth daily disp tablet refills atorvastatin mg po daily rx atorvastatin mg one tablet s by mouth daily disp tablet refills clopidogrel mg po daily rx clopidogrel mg one tablet s by mouth daily disp tablet refills lisinopril mg po daily rx lisinopril mg one tablet s by mouth daily disp tablet refills metoprolol succinate xl mg po daily hold for sbp hr rx metoprolol succinate mg one tablet s by mouth daily disp tablet refills nicotine patch mg td daily rx nicotine mg one patch on arm daily disp transdermal patch refills tramadol ultram mg po bid back pain rx tramadol mg one tablet s by mouth twice a day disp tablet refills nitroglycerin sl mg sl prn chest pain take tab under tongue wait min then take up to more tab call if you still have chest pain after tabs rx nitroglycerin mg one tablet sublingually as directed disp tablet refills discharge disposition home discharge diagnosis coronary artery disease st elevation myocardial infarction hypertension acute systolic dysfunction hemochromatosis chronic obstructive pulmonary disease tobacco abuse discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were transferred from because you were having a heart attack the cardiac catheterization showed blockages in several arteries but the blockage that was causing the heart attack was opened with a balloon procedure you have been started on new medicines to help your heart recover from the heart attack and to prevent another heart attack you will see dr in about a month to discuss your heart disease further it is very important that you take all of your medicines and quit smoking this is crucial to prevent further health problems followup instructions name m location community physicians associates address phone appt at pm department cardiac services when thursday at am with md building sc clinical ctr campus east best parking garage,"{
""Diagnoses"": [""Chest pain"", ""Hypertension"", ""Tobacco abuse"", ""Poorly controlled hypertension"", ""STEMI""],
""Medications"": [""Metoprolol"", ""Aspirin"", ""Heparin""]
}"
19354,admission date discharge date date of birth sex f service blue surgery history of present illness patient is a year old african american female who underwent a sigmoid colectomy in for adenocarcinoma of the colon with one positive lymph node she also received chemotherapy adjunctive to the surgery of fu and leucovorin she has had a ct scan of the abdomen was performed on which demonstrated two lesions in the liver a cm lesion in segment for a x cm lesion in the inferior aspect of the right lobe near the liver edge she was then referred to dr for consideration of hepatic resection for this metastatic disease to the liver hypertension atrial fibrillation congestive heart failure ihss status post pacemaker placement ddd in colon adenocarcinoma with positive lymph node and status post surgery and adjuvant chemotherapy sleep apnea diabetes past surgical history is significant for status post sigmoid colectomy in and status post brain tumor resection in status post uvulectomy and sinus surgery medications on admission coumadin mg po taken as directed verapamil hcl mg po q day triazolam mg po q hs prn ranitidine mg po bid micro k meq q am lactulose two tablespoons hydrochlorothiazide mg po q day glyburide mg po q day glucophage mg po bid flonase one spray each nostril q day diovan mg po q day atenolol mg po q day mg po bid prn allergies she is allergic to sulfa and penicillin which cause rash social history she denies any alcohol or smoking history no history of iv drug use family history is significant for a mother who died of cerebrovascular accident her father died of a myocardial infarction and question of ihss at age sister died at age of a myocardial infarction and question of ihss physical examination patient is moderately obese female in no acute distress temperature is pulse blood pressure is respirations and weight is lb skin has keloids under both mandibles and several scars on the torso heent no scleral icterus oropharynx is clear no uvula neck is supple no lymphadenopathy and no thyromegaly lungs are clear to auscultation cardiac examination is normal s loud split s there is a systolic ejection murmur along the left sternal border regular rate and rhythm with pacemaker abdomen is soft nontender normal bowel sounds and no masses extremities have no peripheral edema neurologically she is intact laboratories hemoglobin hematocrit white count of platelets sodium potassium chloride bicarbonate glucose of bun of creatinine of ast of alt of alkaline phosphatase of total bilirubin of direct bilirubin of cea of she underwent a cardiac catheterization by dr which is only significant for an elevated pulmonary capillary wedge pressure of but her coronary arteries were open which is a moderate surgical risk electrocardiogram showed paced rhythm with a rate of cta showed one liver lesion in segment six of the right lobe measuring x cm second lesion in segment a measuring x cm there are two additional low attenuation foci they were too small to characterize hospital course on the date of admission the patient was taken to the operating room where she underwent a segment six and segment b resection cholecystectomy and intraoperative ultrasound she tolerated this procedure well and received crystalloid and estimated blood loss of and urine output of she was transferred to the pacu in stable condition she spent the first postoperative night in the intensive care unit for close monitoring where she remained hemodynamically stable and postoperative day she was transferred to the floor for remainder of recovery neurologically her pain was controlled with epidural for the first postoperative day the epidural was discontinued and patient was placed on iv morphine prn her pain has appropriately decreased and her use of pain medications has appropriately decreased she has remained alert and oriented and neurologically intact respiratory status has remained stable her o saturations have been in the high s to and has been weaned off oxygen successfully cardiovascular status has remained stable she is remaining hemodynamically stable she did have an episode on postoperative day where she described a her throat was closing due to the history of diabetes it is unknown if this was an atypical chest pain versus perhaps some laryngeal edema secondary to intubation she had an electrocardiogram which showed paced rhythm which was unchanged from a previous electrocardiogram she also had a set of cardiac enzymes sent which were negative with a troponin less than cpk of mb fraction of she had one other episode but has denied having any other episodes of her throat closing much of her symptoms have been focused only around her airway during this period also she did not have any periods of desaturation and remained hemodynamically stable her diet was advanced to a diabetic diet which she has been tolerating her wound has remained clean dry and intact her jp has continued to drain moderate amounts up to cc day of a darkly colored fluid she will be discharged with a jp in place with followup in clinic for evaluation and then possible removal her foley was discontinued she has been voiding without any problems endocrine wise the patient s blood glucose levels have remained in the s ranging anywhere from as low as to as high as josalin consult was obtained and patient was recommended to be started on insulin injections for better hyperglycemic control she was placed on nph insulin units in the morning and units before bedtime in an adjusted sliding scale she received diabetic teaching while in the hospital she will be going home with vna for injections of nph in the morning and in the evening will follow up with dr in the clinic on monday she was restarted on oral hypoglycemic medication once she was taken off the diabetic diet hematologically the patient s hematocrit has remained stable has gone from to her platelet count had dropped down to on postoperative day two from on postoperative day her zantac was stopped she is placed on protonix for gastrointestinal prophylaxis her heparin injections were continued and antibody was sent to the laboratory the patient has been ambulating stable and ready for discharge with followup with dr on in the clinic pathology has returned on the specimen with negative margins cm the section and resection were positive for metastatic adenocarcinoma of the colon discharge diagnoses status post liver resection of sections b and a cholecystectomy and intraoperative ultrasound metastatic colon adenocarcinoma to the liver hypertension diabetes mellitus ihss coronary artery disease atrial fibrillation discharge medications verapamil mg po q day zantac mg po bid hydrochlorothiazide mg po q day prn glyburide mg po q day glucophage mg po bid flonase one spray each nostril q day diovan mg po q day atenolol mg po q day mg po bid nph insulin units am units q pm lactulose two tablespoons po bid oxycodone mg po q hours prn and calor meq po q am condition on discharge stable discharge instructions the patient will go home with vna services for wound care jp care and insulin teaching nph administration patient has been taught appropriately to empty and record jp outputs the patient has had diabetic teaching for insulin shots patient will follow up with dr on and followup with dr on m d ph d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex f service cardiothoracic allergies penicillins bactrim ds sandostatin lar sulfa sulfonamides attending chief complaint hemoptysis major surgical or invasive procedure bronchoscopy mediastinoscopy thoracotomy for rul rml lobectomy history of present illness yo f w history of sigmoid colectomy in for colon cancer since s p resection of liver metastases in who presents w hemoptysis in ct scan reveals pulmonary nodules in r upper lobe and in r middle lobe biopsy demoanstrated adenocarcinoma consistent w past colon ca patient is administered chemotherapy with consequent tumor shrinkage and patient is admitted on for surgical excision of the pulmonary nodules past medical history colon cancer status post sigmoid colectomy in lymph nodes were positive and she received adjuvant fu and leukovorin she was found to have a liver metastases in and underwent resection of this her most recent colonoscopy and egd from were unremarkable however ct done for hemoptysis in revealed pulmonary nodules within the right upper lobe and right middle lobe the right upper lobe nodule appears to abut a subsegmental bronchus these were biopised and confirmed to be adenoca patient may begin chemo in near future hocm and resultant diastolic dysfunction hyperdynamic ef of mr hypertension ihss iddm paf osa not on cpap anxiety and depression chronic sinusitis pituitary tumor resection in sinus surgery in abnormal pap smear in pacemaker ddd obesity social history lives alone ssi since worked years in the polaroid plant smoking none oh none family history her father died at from an mi mother died at from a cva she has one sister who is a breast cancer survivor another sister who died at from an mi and two of her sisters are alive and well physical exam patient alert and oriented nad vs ra pulm vesicular bilat cardio rrr wound dry and clean no erythema no drainage no sign of infection pertinent results hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct am basic coagulation pt ptt plt inr pt ptt plt smr plt ct inr pt am chemistry renal glucose glucose urean creat na k cl hco angap am chemistry totprot albumin globuln calcium phos mg uricacd iron am radiology final report chest pa lat am chest pa lat reason ptx interval change medical condition year old woman s p rul rml lobectomy for metastatic colon ca ct now out reason for this examination ptx interval change two view chest of comparison indication pneumothorax examination is limited by underpenetration and low lung volumes a previously reported right lateral pneumothorax has nearly resolved in the interval with only a tiny residual lateral pneumothorax remaining cardiac and mediastinal contours are stable there is increasing hazy increased opacity within the lower portion of the right hemithorax there is also a probable small right pleural effusion allowing for technical factors the left lung is grossly clear and there is no evidence of significant left pleural effusion impression resolving right pneumothorax increasing hazy opacity in lower right hemithorax in the appropriate clinical setting evolving pneumonia should be considered dr approved mon pm brief hospital course patient is operated on under general anesthesia for felxible bronchoscopy mediastinoscopy r upper lobectomy and r middle wedge lobectomy immediate post op period is spent in pacu on cxr reveal r hemothorax patient is transfused with prbc and thoracotomy is performed on the same day to stop the bleeding an epidural cath is placed by anesthesia for pain control chest tubes are withdrawn on cardio on am patient went into atrial fibrillation a cardiology consult is requested and patient is treated with amiodarone mg x weeks then mg qd afib recurred at for hour therefore started on coumadin upon d c mg x days to be followed by clinic at dr and smentana emailed for re referral to clinic dose to be managed by appropriate clinic patient discharged to home in company of brother w services with f u appt by in weeks md cardiology in weeks clinic draw with dose f u by clinic medications on admission amiodorone mg diovan furosemide ranitidine atenolol kcl asa traizolam qhs lantus u qhs ss mom tab qhs flonase mcg plan home discharge medications amiodarone mg tablet sig two tablet po daily daily for weeks disp tablet s refills amiodarone mg tablet sig one tablet po once a day begin after you have completed the weeks of mg disp tablet s refills docusate sodium 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 senna mg tablet sig one tablet po bid times a day as needed acetaminophen mg tablet sig tablets po q h every to hours as needed furosemide mg tablet sig one tablet po bid times a day disp tablet s refills ranitidine hcl mg tablet sig one tablet po bid times a day disp tablet s refills aspirin mg tablet sig one tablet po daily daily triazolam mg tablet sig one tablet po qhs once a day at bedtime potassium chloride meq capsule sustained release sig one capsule sustained release po daily daily diovan mg capsule sig one capsule po twice a day insulin glargine unit ml solution sig twenty four units subcutaneous at bedtime insulin lispro human unit ml solution sig one unit subcutaneous four times a day as needed for for blood sugar insulin per blood sugar need times day atenolol mg tablet sig one tablet po twice a day disp tablet s refills coumadin mg tablet sig two tablet po once a day for days at bedtime take pill for then as per dr office directs disp tablet s refills albuterol mcg actuation aerosol sig puffs inhalation four times a day as needed for shortness of breath or wheezing disp refills discharge disposition home with service facility homecare discharge diagnosis pulmonary nodules metastatic colon cancer discharge condition good discharge instructions call dr office for fever shortness of breath chest pain drainage from incision site you may shower no tub baths or swimming for weeks you may change bandaids on chest tube sites as needed do not remove small strips on incision site let them fall off no lifting more than pound for weeks them as per lung surgery booklet restart regular medicine as previous take new medication as directed for pain no driving if taking narcotic medication can transition to tylenol when able followup instructions call for appointment w dr in days call for an appointment to see dr in weeks completed by,"{
""Diagnoses"": [""Adenocarcinoma of the colon"", ""Metastatic disease to the liver""],
""Medications"": [""Coumadin"", ""Verapamil"", ""Triazolam"", ""Ranitidine"", ""Hydrochlorothiazide""]
}"
28588,admission date discharge date service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint hypotension bradycardia major surgical or invasive procedure placement of pacemaker placement of right internal jugular catheter history of present illness yo woman with h o htn dm on insulin remote cva anticoagulated for h o pe and afib presents as transfer from with complete heart block pt was found to be lethargic at skilled nursing facility today bp could not be obtained pulse in s pt was brought to where she was noted to have decreased responsiveness and sob found to be in complete hb intubated for labored breathing with declining mental status and transferred to per transfer notes pt had gcs of was alert and oriented x and following commands upon arrival to the pt had hr and sbp she was given atropine mg without effect then placed on dopamine and levophed gtt also received mg glucagon in ed rij cordis with tv pacer placed hr in s sbp upon admission to ccu review of symptoms could not be completed secondary to intubation impaired mental status per chart review pt had denied chest pain past medical history epilepsy htn dm cad afib cva right side stroke hyperthyroidism asthma pe copd depression with anxiety dementia social history patient lives in long term care facility son is health care proxy family history not available on admission physical exam vs t bp hr rr o on fio ac peep fio gen elderly woman not currently receiving sedation responsive only to tactile stimuli intubated heent sclera anicteric pupils equally round reactive to light conjunctiva were pink no pallor or cyanosis of the oral mucosa neck supple cv pmi located in th intercostal space midclavicular line rr distant s s no s no s soft systolic murmur chest no chest wall deformities scoliosis or kyphosis on vent with good air entry b l coarse breath sounds throughout abd obese soft ntnd no hsm or tenderness no abdominial bruits neuro responding only to tactile stimuli with movement of limb pupils equal and reactive to light b l increased muscle tone in r arm with contractures clonus in ue and le b l spontaneous movement of le b l ext no c c e no femoral bruits skin no stasis dermatitis ulcers scars or xanthomas pulses right carotid without bruit femoral dp left carotid without bruit femoral dp pertinent results pm glucose urea n creat sodium potassium chloride total co anion gap pm estgfr using this pm alt sgpt ast sgot ck cpk alk phos amylase tot bili pm lipase pm ctropnt probnp pm albumin calcium phosphate magnesium pm digoxin pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count pm pt ptt inr pt ekg demonstrated normal sinus rhythm with no significant st t changes ekg from signficant for complete heart block prior ekg unavailable for examination telemetry demonstrated no legitimate alars d echocardiogram performed on demonstrated ef concentric lvh preserved lv systolic function calcification of mitral annulus with minimal mr aortic sclerotic changes and normal pulmonary artery pressures brief hospital course cardiac a rhythm bradycardia the patient presented with complete heart blcok with a rhythm that appeared to have been chb with junctional escape given the narrow complex and the fact that the qrs is similar to when the pt is in sr unclear what the primary process was causing the bradycardia hypoxemia vs sepsis vs primary cardiogenic medication effect of toprol and verapamil likely playing a large role as well after the day of admission the patinet remained in sinus rhythm with conduction throughout hospitalization the patinet had a transvenous pacer wire placed upon admission the patient remained without continued bradycardia and temporary pacer was removed given unknown etiology of block patient had a permanent pacemaker placed without complication set at vvi the patient was restarted on low dose metoprolol given history of atrial fibrilltion and hypertension while hospitalized and tolerated well b cad patient with unclear history of cad though known risk factors of cva dm the patient was continued on asa and bb c pump patient was hypotenison upon admission in the setting of bradycardia and was supported on dopa levophed after initial event patient was hypertensive during hospitalization and placed on hydralazine low dose metoprolol and hctz with adequate control respiratory failure the patient presented with respiratory failure and was intubated in the emergency room unclear etiology pna vs chf vs pe mental status may have precipitated intubation as well unclear from the records pe is a possibility as well though inr was on admission patient had an elevated wbc to and was started on vanc zosyn for suspected aspiration pneumonia was titrated to levo and completed the course cta was performed which had an equivical read of possible pe and patient was started on heparin upon discharge patient still not therapeutic on coumadin and will be sent on lovenox ppx dose given recent ppm placement and coumadin the patient was extubated on third day of admissison without difficulty and had remained comfortable neuro mental status changes at rehab likely hypotension and metabolic disturbances also with head ct revealing hypodensity in the left parietooccipital region in which acute stroke possibly watershed infarct cannot be ruled patient showed myoclonic movements at admission and neuro was consulted to evaluate non convulsive status vs anoxic brain injury eeg not c w ncse patient was extubated and showed deficit compared to baseline neuro started keppra for seizure ppx which should be titrated up mg each week until at goal of mg serial neuro exams consider neuro consult consider mri if more stable tomorrow arf patient presented with cr from baseline of cr improved with hydration and beleived to be secondary to dehydration coupled with hypoperfusion w bradycardia hypotension dm ssi nph medications on admission asa mg daily toprol xl mg daily verapamil mg lasix mg daily coumadin mg every other day coumadin mg every other day increased from mg on novolin units qam nph units qpm synthroid mcg daily potassium cl meq daily zoloft mg daily singulair mg daily trazadone mg qpm colace mg duonebs q h ssi discharge medications levothyroxine mcg tablet sig one tablet po daily daily sertraline mg tablet sig one tablet po once a day levetiracetam mg tablet sig tablets po bid times a day increase dose to mg on disp tablet s refills lisinopril mg tablet sig one tablet po once a day disp tablet s refills aspirin mg tablet chewable sig one tablet chewable po daily daily singulair mg tablet sig one tablet po once a day colace mg capsule sig capsules po twice a day as needed for constipation outpatient lab work please have inr checked on sunday and have the results faxed to dr ferrous sulfate mg ml liquid sig one po daily daily hydralazine mg tablet sig three tablet po q h every hours hydrochlorothiazide mg tablet sig tablet po daily daily metoprolol tartrate mg tablet sig tablet po bid times a day warfarin mg tablet sig two tablet po hs at bedtime lovenox mg ml syringe sig one subcutaneous once a day please d c when therapeutic on coumadin nph u qam u qpm iss discharge disposition extended care facility discharge diagnosis primary diagnosis complete heart block secondary diagnoses pneumonia pulmonary embolism discharge condition patient had no further episodes of bradycardia she was maintaining good blood pressures and had improved mental status to baseline she was able to eat and drink and her vital signs were stable without fevers discharge instructions you were admitted to the hospital with a dangerously slow heart rate a pacemaker was placed and this should protect you from further episodes in the future you developed a pneumonia which was treated with antibiotics you were also found to have a small clot to the lung for this and for your history of atrial fibrillation you will continue taking a blood thinner called coumadin please take all your medications as prescribed please attend all follow up appointments call your doctor or come to the hospital for shortness of breath palpitations chest pain fevers or any other concerning symptom followup instructions provider clinic phone date time,{}
6814,admission date discharge date date of birth sex f service neonatology history is a and week twin a girl who was delivered on via c section at grams she delivered to a year old gravida i para now ii mother with the following prenatal labs maternal blood type o positive antibody negative hepatitis b surface antigen negative rpr nonreactive rubella immune gbs status unknown medical history is notable for chiari malformation status post neurosurgical repair at age pregnancy was significant for preterm labor and premature rupture of membranes of twin b she received a complete course of betamethasone the twins delivered via c section given a concern for clinical chorioamnionitis after prolonged rupture of membranes for weeks emerged at the abdomen vigorous with spontaneous crying she was dried suctioned stimulated apgar and she was admitted to the nicu for respiratory distress and prematurity at weeks physical examination upon admission weight was grams th percentile length cm th to th percentile head circumference was cm hospital course respiratory was intubated for she received surfactant x she extubated to cpap and then advanced to room air she never required significant amounts of oxygen she remained on caffeine from of life to cardiovascular she has a pps murmur no echocardiograms were performed she received no medications for patent ductus arteriosus fen and gi she attained full enteral feeds by of life she received of total parenteral nutrition her maximum bilirubin was for which she received phototherapy heme her last hematocrit was drawn on was with a reticulocyte count of she has remained on iron she never received any blood transfusions id given the concern for maternal clinical chorioamnionitis she received of ampicillin and gentamicin blood cultures were no growth to date a lp was performed which showed glucose of protein of rbcs wbcs no polys lymphs monos csf culture was negative neurology her initial head ultrasound on of life was normal her subsequent of life head ultrasound was also normal she passed her hearing screen with automated auditory brainstem responses on eyes were examined most recently on revealing mature retinal vessels a follow up examination is recommended in months condition on discharge stable discharge disposition home primary pediatrician dr pedatrics at care recommendations feeds at discharge will include breast milk consisting of kilo cals per ounce made with enfamil powder medications include cc of iron and cc of gold mine multivitamins she passed her car seat position test on state newborn screening status initially had an elevated ohp on which normalized by a follow up screen sent on she received her hepatitis b vaccination on immunizations recommended 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 or school age siblings or with chronic lung 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 was recommended for household contacts and out of home caregivers month vaccinations are due at her first pediatrician appointment follow up appointments should include early intervention pediatrician ophthalmology discharge diagnoses prematurity at weeks respiratory distress syndrome resolved sepsis evaluation resolved hyperbilirubinemia resolved dictated by medquist d t job,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""service neonatology history"", ""history of preterm labor and premature rupture of membranes"", ""chiari malformation"", ""neurosurgical repair""],
""Medications"": [""betamethasone"", ""oxygen""]
}"
87646,admission date discharge date date of birth sex m service medicine allergies penicillins attending chief complaint v fib cardiac arrest major surgical or invasive procedure left heart catheterization drug eluting stent to left anterior descending artery history of present illness mr is a year old man with a history of coronary artery disease s p stenting lcx on asa and plavix presenting after collapsing during the marathon mr stopped smoking in as resolution and started running shortly thereafter he ate poorly but became good at running he started running with his son in in he had some exertional chest pain which led to nuclear stress test and catheterization with placement of a bare metal stent in left circumflex since that time he had been free of symptoms with his most recent stress test in this year not revealing any concerning ischemia per the patient he had received this care in where he lives with his wife most recently completed a marathon two months ago without chest pain mr was running the marathon today with his son without having taken his asa and plavix for the last two days his doctor had previously told him to hold these for two days prior to racing to reduce bruising he got to mile before witnessed callapse earlier increasing shortness of breath and fatigue followed by loss of consciousness bystander provided cpr until aed arrived no strips but aed determined shockable rhythm likely vf sinus rhythm was re established after two shocks and he was brought to and directly into the cath lab en route he received mg lidocaine in the ed he was noted to have st elevation in v with biphasic t waves st depression was also commented upon there code stemi was called he received integrillin ivfs l asa mg plavix loaded with mg vitals were hr rr nc cardiology was consulted and recommended direct transfer to the cath lab on coronary agiography lcx stent was appreciated and open lad disease was noted unlikely stemi infact unlikely acs but dr describes as likely angina ischemia with consequent vf and arrest possible that ischemic changes on ekg are secondary to demand and shocks a long stent drug eluting stent was placed in the lad he received mg iv lasix ekg had partly normalized after cath 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 pain all of the other review of systems were negative cardiac review of systems is notable for shortness of breath fatigue and notable for the absence of chest pain paroxysmal nocturnal dyspnea orthopnea ankle edema palpitations syncope or presyncope past medical history cardiac risk factors diabetes dyslipidemia hypertension cardiac history former cath and stent lcx cabg none percutaneous coronary interventions once pacing icd no social history tobacco history smoked for several years up to one pack per day until likely about pack years etoh beer after running commonly two drinks per night illicit drugs no migrated from fought in became citizen family history no family history of early mi but heart disease in many relatives typically noted in s physical exam vs t hr bp rr o sat ra general in nad tanned slim man heent ncat sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthalesma neck supple with jvp visible while lying flat s p cath cardiac rr normal s s no m r g no s or s lungs no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use some crackles upon initial deep breaths anteriorly only ausculatated anteriorly and laterally no wheezes or rhonchi given these limtis abdomen soft ntnd no hsm or tenderness no abdominial bruits extremities no c c e no femoral bruits skin no stasis dermatitis ulcers scars or xanthomas neuropsychiatric alert oriented to person place time not asked context mood affect appropriate jocular and more dissappointed about not finishing race that myocardial ischemia very pleasant and cooperative cn ii grossly intact eom wnls perl speech normal no errors dysphonia aphasia pulses right carotid dp pt left carotid dp pt pertinent results labs on admission cbc pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct coags pm blood pt ptt inr pt chem pm blood urean creat pm blood glucose urean creat na k cl hco angap cardiac biomarkers pm blood ck cpk pm blood ctropnt pm blood ck mb mb indx ctropnt am blood ck mb mb indx ctropnt pm blood ck mb mb indx ctropnt other labs pm blood calcium phos mg am blood hba c eag am blood triglyc hdl chol hd ldlcalc pm blood glucose lactate na k cl calhco pm blood lactate labs on discharge cbc am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood plt ct chem am blood glucose urean creat na k cl hco angap lfts pm blood alt ast ld ldh ck cpk alkphos totbili other chem am blood calcium phos mg cardiac cath comments coronary angiography in this right dominant system demonstrated two vessel disease the lmca was without angiographically apparent disease the lad had a long diffusely disease mid vessel stenosis the lcx had a widely patent stent the rca had an stenosis of a small pl branch resting hemodynamics revealed elevated right and left heart filling pressures with rvedp mmhg and pcwp mmhg there was mild pulmonary artery systolic hypertension with pasp mmhg the cardiac index was preserved at l min m the systemic and pulmonary vascular resistances were normal there was systemic arterial normotension successful ptca and stenting of the mid lad with a x mm cypher drug eluting stent which was postdilated to mm final angiography revealed no residual stenosis no angiographically apparent dissection and timi flow see ptca comments for details final diagnosis two vessel coronary artery disease status post vt vf cardiac arrest stemi elevated ventricular filling pressures mild pulmonary arterial hypertension successful ptca and stenting of the mid lad echo the left atrium is mildly dilated there is mild symmetric left ventricular hypertrophy with normal cavity size there is mild regional left ventricular systolic dysfunction with focal hypokinesis of the mid to distal anterior wall anterior septum and apex the remaining segments contract normally lvef right ventricular chamber size and free wall motion are normal the aortic arch is mildly dilated 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 no mitral valve prolapse the left ventricular inflow pattern suggests impaired relaxation the estimated pulmonary artery systolic pressure is normal there is a very small pericardial effusion impression mild regional left ventricular hypokinesis c w mid lad disease mild aortic regurgitation impaired left ventricular relaxation brief hospital course coronary artery disease v fib arrest the patient had previous diagnosis of coronary artery disease with a stent placed to the left circumflex in rhythm strips obtained from the aed in the field after his fall showed ventricular fibrillation prior to shocking the patient back into normal sinus rhythm he was brought to where he underwent cardiac catheterization this revealed two vessel disease with long diffuse disease in the mid lad with stenosis and stenosis of a small pl branch from the rca the lmca did not have disease and the left circumflex stent was widely patent the patient received a x mm cypher drug eluting stent to the lad without complications it was thought that the cause of his ventricular fibrilation was due to ischemia in the lad distribution from increased demand during the marathon he had an echo which showed mild regional left ventricular hypokinesis consistent with mid lad disease and impaired left ventricular relaxation his ef was previous records were obtained which showed in the patient had an lvef of on echo and no perfusion defects on nuclear ett indicating an interval insult to the lad which most likely was from an ischemic event during the marathon the patient had a cardiac mri to rule out any other areas of cardiac abnormalities that may have contributed to the arrhythmia the final report is pending but the preliminary report showed subendocardial gadolinium uptake in the lad territory which was likely from his recent ischemic event there were no other abnormalities therefore it was decided that an icd for secondary prevention was not indicated in this patient he was started on aspirin mg plavix mg and atorvastain mg as well as metoprolol mg tid he tolerated this well and was discharged on metoprolol succinate mg q day he was also started on lisinopril mg for the decreased ejection fraction and anterior mi he should continue on this medication and have his electrolytes checked in one week he was instructed to decrease his physical activity mainly his running over the next month and undergo an exercise stress test at that time before resuming more vigorous running he will see his cardiologist in in weeks when he returns home he should remain on his plavix for at least year and his aspirin indefinitely coping the patient exprtessed disappointment in not finishing the race and dealing with his diagnosis of myocardial infarction he was visited by social work to provide support hypercholesterolemia total cholesterol was previously noted to be per the patient but he was not taking a statin labs show presently his ldl is and t cholesterol is he was discharged on mg atorvastatin a day renal failure the patient initially presented with a creatinine of this was thought to be pre renal from his marathon his creatinine was trended and was the day of discharge leukocytosis the patient initially presented with a white count of this resolved over the next to days and was likley from the stress of the marathon and cardiac arest his white count was at discharge mental status the patient s family noted some subtle changes in his short term memory over time this seemed to have improved the patient denied any defecits in memory medications on admission asa stopped on advice of cardiologist plavix stopped on advice of cardiologist 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 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 metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po once a day disp tablet sustained release hr s refills lisinopril mg tablet sig one tablet po daily daily disp tablet s refills discharge disposition home discharge diagnosis cardiac arrest ventricular fibrillation ischemic cardiomyopathy coronary artery disease st elevation myocardial infarction discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions it was a pleasure to take care of you here at you were admitted for cardiac arrest or failure of your heart to beat you were rescued with cpr and shocked which restored your heart rhythm and saved your life you were then brought to the for further management where you went to the cardiac catheterization laboratory in the lab they found that the left anterior descending or lad artery was blocked a long drug eluting stent was placed to keep the artery open you underwent an echocardiogram which showed mild to moderate reduction of your heart function this may be temporary or permanent it will become clear once you repeat an echocardiogram or ultrasound in your heart in about a month we also obtained a cardiac mri to be sure that there was no other cause of the cardiac arrest other than the blocked lad artery which was confirmed to be correct according to the mri now that this blockage was corrected your chances of another cardiac arrest will be very low medication changes you will need to take a full dose aspirin and plavix every day for at least one year and possibly longer do not stop taking plavix or aspirin or miss unless dr says that it is ok you risk having heart attack if you stop these medicines start atorvastatin lipitor to lower your cholesterol and help your heart recover start metoprolol daily to lower your heart rate and help your heart recover start lisinopril daily to lower your blood pressure and help your heart recover followup instructions pcp and cardiologist dr la ph fax you should set up a follow up appointment with your cardiologist in weeks we have and will be in communication with him,"{
""Diagnoses"": [""coronary artery disease"", ""cardiac arrest"", ""major surgical or invasive procedure"", ""drug eluting stent""],
""Medications"": [""ASA"", ""Plavix""]
}"
4874,admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint sob cough le edema major surgical or invasive procedure right heart catheterization arterial line placement central line placement history of present illness yo f w a pmh of depression seasonal allergies presents with new cardiomyopathy with an ef of over the past months she has had progressive doe she noted that her excercise tolerance has steadily diminished over this time she was initially able to run on the treadmill for mi x week now she cannot do mi without sob approximately weeks ago she began to develop a cough and some wheezing which she attributed to seasonal allergies claritin provided some relief she traveled to were her cough worsened she developed fevers to and nausea vomiting she also noted trace le edema she presented to her pcp who treated her for bronchitis with azithromycin this did not relieve her symptoms her cough worsened she developed severe le edema at her cardiologist s office an echo revealed an ef of she was started on lasix po and coreg mg her edema improved markedly a few days prior to admission the pt presented to an osh with weakness dizziness diaphoresis she was noted to be hypotensive and received fluid resuscutation per osh records she had a and beat run of vt her cardiac enzymes were negative she was transferred to for further care review of systems orthopnea h o sob le edema poor appetite denies weight loss chest pain abdominal pain changes in bowel bladder fxn rashes joint pains denies recent fevers chills or rigors all of the other review of systems were negative cardiac review of systems is notable for absence of chest pain positive for dyspnea on exertion paroxysmal nocturnal dyspnea orthopnea ankle edema negative for palpitations syncope or presyncope past medical history depression seasonal allergies social history no tobacco use glasses of wine per week denies ivda she is married with children she is a self employed attorney family history father alcoholic expired mother healthy hx of endocarditis at yo sister rheumatoid arthritis diagnosed in her s physical exam vs t bp hr rr o ra weight kg gen well appearing overweight female in nad heent mmm ncat sclera anicteric perrl eomi neck supple with jvp of cm cv rr normal s s s present no m r g no thrills lifts chest no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use no wheezes notable for rales way up the back bilaterally abd soft ntnd no hsm or tenderness ext wwp no edema skin no stasis dermatitis ulcers scars pulses right carotid dp left carotid dp pertinent results ekg demonstrated not official read sinus tach left and right atrial enlargment twi in v v tw flattening in v freq pvcs low voltage in limb leads with no significant change compared with prior dated telemetry demonstrated tachycardia nsr freq pvcs d echocardiogram performed on demonstrated prelim read mild mr tr hypokinetic lv and rv la and ra enlargement small pericardial effusion cxr cardiac silhouette is enlarged pulmonary vascularity is within normal limits basilar atelectasis is present bilaterally and there are questionable small pleural effusions followup radiographs with improved inspiratory level may be helpful for more complete assessment of the bases when the patient s condition permits tte the left atrium is dilated the right atrium is dilated left ventricular wall thicknesses are normal the left ventricular cavity is moderately dilated there is severe global left ventricular hypokinesis ef the right ventricular cavity is moderately dilated with moderate global right ventricular free wall hypokinesis the number of aortic valve leaflets cannot be determined no aortic regurgitation is seen the mitral valve appears structurally normal with trivial mitral regurgitation the estimated pulmonary artery systolic pressure is normal there is a small pericardial effusion impression dilated left ventricle with severe global systolic dysfunction moderate right ventricular systolic dysfunction cath procedure right heart catheterization was performed by percutaneous entry of the right internal jugular vein using a french pulmonary wedge pressure catheter advanced to the pcw position through an french introducing sheath cardiac output was measured by the fick method conscious sedation was provided with appropriate monitoring performed by a member of the nursing staff hemodynamics results body surface area m hemoglobin gms fick pressures right atrium a v m right ventricle s ed pulmonary artery s d m pulmonary wedge a v m aorta s d m cardiac output heart rate beats min rhythm sinus o cons ind ml min m a v o difference ml ltr card op ind fick l mn m resistances systemic vasc resistance pulmonary vasc resistance saturation data nl svc low pa main ao technical factors total time lidocaine to test complete hour minutes arterial time hour minutes fluoro time minutes contrast injected non ionic low osmolar isovue optiray vol ml indications renal anesthesia lidocaine subq cardiac cath supplies used allegiance custom sterile pack comments resting hemodynamic monitoring demonstrates mildly elevated biventricular filling pressure moderate pulmonary hypertension and low cardiac output final diagnosis severe ventricular dysfunction abd ultrasound findings the liver is mildly increased in size with normal echotexture without evidence of focal lesion the gallbladder is normal there is no evidence of intra or extra hepatic biliary ductal dilatation the common duct measures mm the pancreas is not well visualized the aorta is normal in caliber throughout the right kidney measures cm and the left cm the renal parenchymal echogenicity and thickness are normal without evidence of calculi or hydronephrosis the spleen is normal in size and echogenicity the portal vein is patent with antegrade flow impression mild hepatomegaly otherwise unremarkable abdominal ultrasound carotid u s findings the bilateral common carotid artery internal carotid artery and external carotid artery are widely patent and demonstrate normal arterial waveforms the bilateral vertebral arteries are antegrade in direction peak systolic velocities of the right internal carotid artery is cm sec with a right ica cca ratio of no evidence of intraluminal plaque peak systolic velocity of the left internal carotid artery is cm sec corresponding to a left ica cca ratio of no evidence of intraluminal plaque impression normal carotid ultrasound no evidence of hemodynamically significant stenosis echo days later than previous conclusions the left atrium is normal in size left ventricular wall thicknesses and cavity size are normal there is severe global left ventricular hypokinesis apical contraction is relative preserved no intraventricular thrombus is seen but apical views are suboptimal the right ventricular cavity is mildly dilated with mild global free wall hypokinesis 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 mild pulmonary artery systolic hypertension there is a small circumferential pericardial effusion compared with the prior study images reviewed of biventricular systolic function is slightly improved but left ventricular function remains severely depressed pm potassium 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 notdone ctropnt pm albumin calcium phosphate magnesium iron pm caltibc ferritin trf pm tsh pm positive titer pm rheu fact 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 high plt count pm pt inr pt micro data final report clostridium difficile toxin assay final feces negative for c difficile toxin by eia reference range negative viral culture pending final report wound culture final no significant growth am serology blood final report lyme serology final no antibody to b burgdorferi detected by eia reference range no antibody detected negative results do not rule out b burgdorferi infection patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody patients with clinical history and or symptoms suggestive of lyme disease should be retested in weeks am sputum site expectorated final report gram stain final pmns and epithelial cells x field per x field gram positive cocci in pairs chains and clusters per x field gram positive cocci in chains per x field gram positive rod s per x field gram negative rod s respiratory culture final moderate growth oropharyngeal flora pm urine source catheter final report legionella urinary antigen final negative for legionella serogroup antigen reference range negative performed by immunochromogenic assay a negative result does not rule out infection due to other l pneumophila serogroups or other legionella species furthermore in infected patients the excretion of antigen in urine may vary am blood toxo source line arterial final report toxoplasma igg antibody final negative for toxoplasma igg antibody by eia iu ml reference range negative iu ml positive iu ml toxoplasma igm antibody final negative for toxoplasma igm antibody by eia interpretation no antibody detected the fda is advising that the result from any one toxoplasma igm commercial test kit should not be used as the sole determinant of recent toxoplasma infection when screening a pregnant patient am blood ebv source line arterial final report virus vca igg ab final positive by eia virus ebna igg ab final positive by eia virus vca igm ab final negative by ifa interpretation results indicative of past ebv infection in most populations of adults have been infected at sometime with ebv and will have measurable vca igg and ebna antibodies antibodies to ebna develop weeks after primary infection and remain present for life presence of vca igm antibodies indicates recent primary infection am blood cmv ab source line arterial final report cmv igg antibody final positive for cmv igg antibody by eia au ml reference range negative au ml positive au ml cmv igm antibody final negative for cmv igm antibody by eia interpretation infection at undetermined time a positive igg result generally indicates past exposure infection with cmv once contracted remains latent and may reactivate when immunity is compromised if current infection is suspected submit follow up serum in weeks greatly elevated serum protein with igg levels mg dl may cause interference with cmv igm results am serology blood source line arterial final report varicella zoster igg serology final positive by eia a positive igg result generally indicates past exposure and or immunity pm blood culture source line fem aline final report aerobic bottle final reported by phone to pm on corynebacterium species diphtheroids isolated from one set only anaerobic bottle final no growth brief hospital course hospital course the patient is a yo f with new onset cardiomyopathy with an ef of initially presented to an osh with hypotension responded well to ivf tranferred to for further w u and care initially req milrinone for inotropic support milrinone was stopped and pt was hemodynamically stable discharged on digoxin and captopril she also underwent initial evaluation for heart transplantation her hospital course was complicated by pneumonia cardiomyopathy newly diagnosed dilated cardiomyopathy initial echo on presentation showed an ef of a follow up echo on milrinone was she has had recent symptoms consistent with uri bronchitis therefore this is most probably viral cardiomyopathy other etiologies of her cardiomyopathy were explored fe studies hiv thyroid labs are all normal she had no significant alcohol or cad history also echo findings were not consistent with cad initially she was started on an ace inhibitor and diuresed with lasix however she became progressively hypotensive and her exam was consistent with cardiogenic shock a pa catheter was placed with initial findings showing a co of ci ra rv pcw pa she was started on milrinone in the cath lab and continued on milrinone on the floor her co ci improved to milrinone was weaned and captopril carvedilol and lasix was started over the following hrs her urine output decreased her ci worsened and her mv dropped to the s she was again restarted on milrinone gtt digoxin was started loading dose and milrinone was again weaned off with continuation of captopril she remained hemodynamically stable off of milrinone and did well on digoxin and captopril which was transitioned to lisinopril she was also started on a bb and aldactone prior to discharge because of that her digoxin level was checked and returned at this should be followed as her amiodarone achieves therapeutic levels also evaluation for potential heart transplant was initiated as an inpatient and she is scheduled to follow up with transplant center as well as clinic she was discharged on long acting ace inhibitor and toprol she will need follow up labs sent in a week or two to follow her renal function potassium and digoxin level in addition workup for cardiomyopathy revealed a positive anti and anti dsdna were sent and are pending at this time these will also need to be followed up fever the patient has had persisent fevers throughout her stay with temperatures up to she was started on ceftrioxone azithro for a rll pna she spiked to f despite ceftriaxone azithro and vancomycin for possible line infection blood cx grew gpr which is likely contamination cxr shows rll consolidation and a possible layering effusion her sputum gram stain was significant for gpcs after initiation of vancomycin her fever curve trended down however due to her peristent low grade fevers id was consulted multiple serologies and microbial studies were sent and were negative she was discharged on levofloxacin for total day course for community acquired pna id also recommended sending cdiff prior to discharge and it was negative other blood cultures and viral cultures are pending at this time and will need to be followed up by her pcp as well rhythm nsr tachycadia her tachycardia was likely due to compensatory mechanism for poor forward flow she was started on an ace i for afterload reduction beta blocker was initiated towards discharge and switched to long acting toprol xl ectopy the patient had several runs of nsvt throughout her stay she was asymptomatic during this episodes amiodarone was initiated ep was consulted for possible pacemaker placement or icd but she was too early in her dcm to be a candidate for icd placement cardiac transplant workup due to the severity of the patients cardiomyopathy and chf cardiac transplant workup was intiated was contact and the heart failure service was consulted hepatitis serologies were negative hiv was negative ppd was negative iron studies were normal abdominal us showed mild hepatomegaly aware heart failure service aware and she will follow up with these services cough dry received robitussin with codeine tes perles fen cardiac low salt diet fluid restriction ppx heparin sq bowel regimen code full code medications on admission cymbalta coreg mg lasix po qday discharge medications lorazepam mg tablet sig tablets po at bedtime as needed for insomnia disp tablet s refills digoxin mcg tablet sig one tablet po daily daily disp tablet s refills codeine guaifenesin mg ml syrup sig ten ml po q h every hours disp ml s refills metoprolol succinate mg tablet sustained release hr sig tablet sustained release hr po daily daily disp tablet sustained release hr s refills amiodarone mg tablet sig two tablet po daily daily for weeks take tabs daily for weeks then tab daily please confirm this dose schedule with your primary cardiologist disp tablet s refills lisinopril mg tablet sig one tablet po daily daily disp tablet s refills spironolactone mg tablet sig one tablet po daily daily disp tablet s refills levofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills discharge disposition home with service facility vna discharge diagnosis primary diagnosis cardiomyopathy congestive heart failure ef due to cardiomyopathy pneumonia ventricular ectopies secondary diagnosis depression discharge condition afebrile hemodynamically stable ambulating tolerating po discharge instructions you were admitted for cardiomyopathy with chf during your stay a work up was initiated for potential heart transplant you were also found to have a pneumonia for which you were treated with antibiotics you were started on several medications during this hospitalization see medication sheet please take these as written unless directed otherwise by your primary care physician or cardiologist please weigh yourself daily and check your blood pressure periodically report any significant weight gains lbs or blood pressure changes to your cardiologist please eat a low sodium diet g per day and avoid ibuprofen you have been diagnosed with a pneumonia you should continue the antibiotic levofloxacin for days please also continue to take all of your other medications as prescribed you should be on birth control due to your heart condition please discuss options with your primary care physician please attend your appointments as below if you experience shortness of breath chest pain leg swelling dizziness or other worrisome symptoms you should immediately seek medical attention followup instructions please follow up with your primary care physician dr within week after discharge from the hospital he she should also follow up on all the serologies and microbial studies that have been initiated in the hospital and were still pending upon discharge please follow up with dr primary cardiologist within week as well please follow up with from the clinic at on at pm phone please call ahead to confirm in addition please follow up with the advanced cardiomyopathy clinic at for further transplantation evaluation phone number they will call you tomorrow about an appointment in weeks please call them if you do not receive this phone call,"{
""Diagnoses"": [""cardiomyopathy"", ""depression"", ""seasonal allergies""],
""Medications"": [""claritin"", ""azithromycin"", ""lasix"", ""coreg""]
}"
9441,admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint copd flair hypercarbic respiratory failure major surgical or invasive procedure intubated x central line x arterial line x history of present illness year old woman with a history of copd fev fvc in on chronic home o at l nocturnal bipap at night for hypercarbia who was directly admitted to micu from the clinic by dr for management of copd with mental status changes and abg of ms has been in her usual state of health until several months ago when whe started to complain of has which were attributed to her hypercarbia her nocturnal bipap settings were changed from to however the patient did not do well on these new settings and developed abdominal distension that made her dyspnea worse in the last few weeks she completed two courses of levaquin and prednisone for copd exacerbation she did have cough productive of yellow sputum and increased shortness of breath she completed last course of prednisone taper last firday days prior to this admission prior to her current admission she has had increased confusion and was noted to be more lethargic and somnolent at home the patient was seen in the ed complaining of subacute progressive episodes of confusion and forgetrullness on where her abg was hco head ct was done and was negative for intracranial hemorrhage but did show suprasellar mass she then was discharged home over the weekend she reports that she did not feel well on the day of admission she saw her pulmonologist and an abg showed following these labs she was admitted to the micu she denies fevers chills nightsweats she does complain of nausea no vomiting and diminished appetite while on prednisone she denies urinary urgency frequency or incontinence no chest pain past medical history copd pfts on showed fev fvc on o chronically l when active l at rest one prior intubation at time of diagnosis in followed by dr hypertension hypercholesterolemia lung mass lingula enlarging on chest ct presumed neoplasm mm in sellar mass noted on head ct thought to be benign pituitary adenoma prolactin nl tsh slightly elevated at anxiety depression impaired glucose tolerance hr glucose of hgba c of no polyuria polydipsia visual changes bilateral cataract surgery social history pack years no etoh lives in with sons other children live nearby husband died a couple of decades ago not formerly employed family history father died at of lung cancer smoker mother at from diabetes four sisters in good health one died from alcohol five children one son with cancer at age physical exam vitals on l nc gen elderly woman lying in bed no apparent distress able to speak in full sentences heent ncat mucous membranes dry oropharynx clear eomi dentures surgical pupils neck supple no bruits no masses no lad jvd non elevated cv nl s s no murmurs rubs gallops pulm soft crackles bilaterally decreased air movement no wheezes back no cva tenderness no spinal tenderness abd nabs soft nt nd no organomegaly ext warm well perfused no clubbing cyanosis or edema dp bilaterally skin no exanthems neuro alert and oriented x confused at times but answers questions appropriately cnii xii intact motor good tone strength in upper and lower extremities sensation intact to light touch and vibration sense in upper and lower extremities bilaterally reflexes in ue and le bilaterally 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 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 pm blood neuts bands lymphs monos eos baso atyps metas myelos am blood neuts bands lymphs monos eos baso am blood neuts bands lymphs monos eos baso am blood neuts bands lymphs monos eos baso am blood neuts bands lymphs monos eos baso atyps metas myelos am blood neuts bands lymphs monos eos baso 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 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 glucose urean creat na k cl hco angap pm blood alt ast alkphos am blood ck mb notdone ctropnt pm blood albumin 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 am blood calcium phos mg am blood calcium phos mg am blood calcium phos mg pm blood tsh am blood free t pm blood cortsol pm blood cortsol pm blood type art po pco ph calhco base xs am blood type art temp po pco ph calhco base xs intubat not intuba comment bipap am blood type art temp po pco ph calhco base xs pm blood type art temp rates tidal v peep fio po pco ph calhco base xs am blood type art temp po pco ph calhco base xs am blood type art po pco ph calhco base xs pm blood type art temp rates tidal v peep fio po pco ph calhco base xs intubat intubated vent spontaneou pm blood type art temp rates tidal v peep fio po pco ph calhco base xs intubat intubated vent spontaneou am blood type art temp rates tidal v peep fio po pco ph calhco base xs intubat intubated pm blood type art po pco ph calhco base xs pm blood type art po pco ph calhco base xs intubat not intuba pm blood type art po pco ph calhco base xs am blood type art po pco ph calhco base xs assist con intubat intubated am blood type art temp rates tidal v peep fio po pco ph calhco base xs intubat intubated vent spontaneou am blood type art rates tidal v peep fio po pco ph calhco base xs assist con intubat intubated am blood type art po pco ph calhco base xs am blood type temp tidal v peep fio po pco ph calhco base xs intubat intubated vent spontaneou am blood type art temp rates peep fio po pco ph calhco base xs intubat intubated am blood type art temp rates peep fio po pco ph calhco base xs intubat intubated am blood lactate pm blood lactate ct head stable appearance of the brain parenchyma since the prior examination including unchanged appearance of large round sellar mass no intracranial hemorrhage noted ct chest an enlarging mass in the lingula suspicious for cancer multiple stable noncalcified pulmonary nodules new cm nodule at the left lung base attention to this on the followup ct is recommended severe diffuse emphysema diffuse esophageal wall thickening with air along the esophageal wall extending from the inlet to the carina likely esophagitis ct chest abd pelvis x cm region of inflammatory fat stranding in the midline abdomen just medial to the g tube insertion site most consistent with a phlegmon no focal fluid collections are identified this region of inflammation extends from the subcutaneous tissues into the peritoneum this is most likely related to the recent g tube manipulation unchanged left lingula mass unchanged mediastinal lymph nodes interval resolution of the left lung base nodule which likely was infectious in etiology on the prior scan the esophageal wall thickening unchanged emphysematous changes throughout the lungs unchanged cxr ap chest compared to and hyperinflation indicates copd aside from the left lung nodule lungs are clear of any focal abnormality heart is normal size there is no pneumothorax or pleural effusion thoracic aorta is tortuous and calcified but not focally dilated heart size normal cxr left mid lung zone nodular opacity which has grown compared to older chest radiographs and is highly concerning for primary lung malignancy emphysema minor bibasilar atelectatic changes ekg sinus tachycardia no ischemic changes occasional pvcs echo the left atrium is normal in size 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 and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present no aortic regurgitation is seen the mitral valve appears structurally normal with trivial mitral regurgitation there is mild pulmonary artery systolic hypertension there is an anterior space which most likely represents a fat pad cytology bal washings positive for squamous cell carcinoma micro blood cultures mrsa ngtd sputum cultures mrsa urine cultures ng stool cultures c diff neg tissue esophagus culture brief hospital course hospital course by problem respiratory failure mrs was admitted with hypercarbia and mental status changes at baseline she has severe copd with an fev of l and was on nocturnal bipap with settings of prior to admission without resolution of symptoms and with abg of on admission to the micu she was placed on bipap and started on a methylprednisolone taper and continued on albuterol and ipratropium at pm that evening abg was at approximately am that night she suffered respiratory arrest and was emergently intubated and placed on mechanical ventilation with fentanyl and versed sedation on her ventilatory requirements were weaned and that morning she was extubated however she quickly went into respiratory distress and was re intubated midday she self extubated and with increased work of breathing and respiratory distress she was again re intubated subsequently she was maintained on mechanical ventilation with continuous sedation via fentanyl and versed she was evaluated daily for possibility of extubation but the combination of her anxiety and agitation on lowering of sedation and low tidal volumes with low pressure support led to the conclusion that she was not a candidate for extubation on she went to the or and a tracheostomy left lingular bal egd and open g tube were performed notably she had concretized tube feeds in her esophagus and follow up formal egd and biopsy were recommended the procedure was otherwise uncomplicated post op her course was marked by tachycardia and hypertension with sputum cultures continuing to grow mrsa a day course of vancomycin was completed and the patient was placed on a day course of linezolid the patient successfully underwent multiple trach mask trials on the patient pulled out her tracheostomy tube after briefly being intubated the tracheostomy tube was re placed that morning and trach mask trials were re initiated blood pressure during the intubation on the night of arrival she became hypotensive with sbps in the s and was given ivf boluses and started on phenylephrine and norepinephrine drips cortisol stimulation test was normal this episode of hypotension was ascribed to hypovolemia lv preload dependence and sedation following placement of a central line she was given fluid boluses to maintain cvp she was again placed on pressors a neosynephrin drip on her re intubation this pressor requirement quickly resolved she then maintained her blood pressure systolic with hypertensive episodes when anxious agitated mrsa bacteremia on she spiked fevers to developed thickened and copious secretions and failed to wean from vent and was started on vancomycin and zosyn for presumed vent associated pneumonia central line and a line were replaced central line culture grew mrsa as did blood cultures and sputum cultures her wbc jumped to with a clear left shift on and then trended down to baseline high s low s over the next several days zosyn was d c d and a five day course of gentamicin was added for synergy with vancomycin tte was negative for vegetations or lesions by secretions were no longer thick and were minimal wbc was at baseline her last positive blood culture was from and surveillance cultures remained no growth pneumonia pt had been treated prior to admission with levaquin for two courses of management of copd flairs cxr on admission showed bilateral lower lobe interstitial infiltrate concerning for pneuomonia she was given a five day course of azithromycin for empiric treatment of cap rapid viral cultures were negative initial sputum sample was positive for gram positive cocci in pairs a second sample was negative and cultures only grew sparse oropharyngeal flora sputum cultures on grew mrsa and she was treated with vancomycin which she was on for mrsa bacteremia and then linezolid day course initiated mental status while intubated patient was kept on versed and fentanyl drips however she had periods of agitation concerning for thrashing movement and for her episodes of self extubation after attempting pharmacological intervention with ativan haldol ambien and zyprexa her regimens were simplified she was weaned entirely off fentanyl and versed and maintained only on prn ativan and zyprexa she continued to have waxing and mental status requiring restraints at night when in bed gi post intubation nutrition was provided by tube feeds of probalance at cc hr she had an open g tube placement at the time of tracheostomy and the g tube was subsequently used for feeding ct abd on done for complaint of abdominal tenderness as well as persistent low grade fevers revealed a phlegmon extending from the subcutaneous tissues to the peritoneum with no focal fluid collections this was deemed by surgery not concerning for abscess and the tube remained in use hyperglycemia as an outpatient she had been described as borderline diabetic with elevated hr glucose of and hgba c of in addition she was on steroids while admitted and consequently her elevated blood glucose levels were managed with insulin drip and then insulin sliding scale with standing nph hyperlipidemia maintained on home dose of lipitor lung mass cytology of bronchoalveolar lavage done at the time of tracheostomy was positive for squamous cell carcinoma family is aware medications on admission ativan mg po bid prn anxiety albuterol mcg ih puffs qid prn o l when active l at rest lipitor mg po qd lisinopril mg po qd servent diskus mcg dose puff asa discharge medications heparin porcine unit ml solution sig units injection tid times a day disp units refills atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills albuterol sulfate solution sig one neb inhalation q h every hours as needed disp neb refills lansoprazole mg susp delayed release for recon sig thirty mg po daily daily disp mg refills ipratropium bromide solution sig one neb inhalation q h every hours as needed disp neb refills nystatin unit ml suspension sig five ml po qid times a day for weeks disp ml s refills olanzapine mg tablet rapid dissolve sig one tablet rapid dissolve po qhs once a day at bedtime as needed for agitation disp tablet rapid dissolve s refills prednisone mg tablet sig one tablet po daily daily for days last dose disp tablet s refills insulin nph human recomb unit ml cartridge sig twenty four units subcutaneous qam disp cartridges refills insulin nph human recomb unit ml cartridge sig twenty two units subcutaneous qhs disp cartridges refills albuterol ipratropium mcg actuation aerosol sig puffs inhalation q h every hours for months disp qs mcg refills lorazepam mg iv q h prn agitation linezolid mg tablet sig one tablet po q h every hours for days day course started disp tablet s refills discharge disposition extended care facility hospital discharge diagnosis copd respiratory failure mrsa bacteremia mrsa pneumonia s p tracheostomy and open g tube discharge condition stable discharge instructions notify a physician or nurse if you have difficulty breathing chest pain abdominal pain dizziness or any other concerns followup instructions your physicians at the rehab center will arrange any necessary follow up for your lung mass or other conditions md,"{
""Diagnoses"": [""COPD"", ""Hypercarbia"", ""Mental status changes""],
""Medications"": [""Levaquin"", ""Prednisone""]
}"
64897,admission date discharge date date of birth sex m service cardiothoracic allergies no known allergies adverse drug reactions attending chief complaint mitral regurgitation major surgical or invasive procedure mitral valve replacement mm st mechanical history of present illness this year old man witha history of rheumatic heart disease has been followed by dr he immigrated to this country a few years ago and has been an active soccer player until about six months ago when he could no longer play a full game because of shortness of breath in his primary care physician auscultated murmur following complaints of worsening shortness of breath subsequent echocardiogram demonstrated severe polyvalvular rheumatic disease with dominant lesions of mixed mitral regurgitation and stenosis echocardiogram also notable for a dilated and slightly hypokinetic right ventricle with at least moderate if not severe pulmonary hypertension and right ventricular pressure overload given the above findings he was referred for possible mitral valve replacement surgery preoperative work up was previously completed and he was admitted now for same day surgery past medical history tobacco abuse reactive airway disease shoulder and back pain s p mva rhinitis rheumatic heart disease social history occupation cuts fish tobacco current smoker of cigerrettes day and histrory of pp week etoh denies family history non contributory physical exam pulse resp o sat ra b p right left height weight lbs general awake alert oriented skin dry x intact x heent perrla x eomi x neck supple x full rom x chest lungs clear bilaterally x heart rrr x irregular murmur soft diastolic murmur no radiation abdomen soft s non distended s non tender s bowel sounds extremities warm x well perfused x no edema no varicosities neuro grossly intact pulses femoral right left dp right left pt left radial right site of cath no hematoma left dressing intact pt has repair of laceration from recent injury carotid bruit right no left no pertinent results pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood 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 am blood pt ptt inr pt am blood pt ptt inr pt tee prebypass no atrial septal defect is seen by d or color doppler left ventricular wall thicknesses are normal the left ventricular cavity is moderately dilated regional left ventricular wall motion is normal overall left ventricular systolic function is low normal lvef intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation the right ventricular cavity is mildly dilated with mild global free wall hypokinesis the aortic valve leaflets appear structurally normal with good leaflet excursion trace aortic regurgitation is seen the mitral valve leaflets are severely thickened deformed the mitral valve shows characteristic rheumatic deformity there is moderate severe valvular mitral stenosis area cm moderate to severe mitral regurgitation is seen postbypass there is a well seated well functioning bileaflet mechanical prosthesis in the mitral position valvular mr is present which is normal in quantity and location for this type of prosthesis washing jets the lv now appears more depressed lvef rv systolic function appears normal the ai has increased but is still trace in quantity the study is otherwise unchanged from prebypass am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood pt inr pt pm blood pt inr pt am blood pt inr pt brief hospital course he was taken to the operating room on where he underwent a mitral valve replacement with a mm st mechanical valve see operative note for full details the patient tolerated the procedure well and was transferred to cvicu in stable condition with no pressor requirement he extubated on the post operative night without incident he was started on coumadin for his mechanical valve and anticoagulated with a goal inr on post operative day chest tubes were removed per cardiac surgery protocol he was started on low dose lopressor he was gently diuresed with lasix to his preoperative weight he was transferred to the step down unit in stable condition lopressor was discontinued as his blood pressure was intolerant of even mg twice daily he remained in sinus rhythm he continued to progress well and was seen for physical therapy for strength and mobility he was ambulating without difficulty tolerating a regular diet and his incisions were healing well and his inr was therapuetic on coumadin on when he was discharged home arrangements were made for follow up with his providers and the vna coumadin will be managed by his primary care physician medications on admission albuterol sulfate mcg hfa aerosol inhaler puff inhaled q h as needed for shortness of breath fluticasone prescribed by other provider mcg spray suspension puff s each nostril daily only using prn fluticasone flovent hfa not taking as prescribed pt reports using this prn mcg actuation aerosol puff inhaled twice a day ibuprofen mg tablet tablet s by mouth every six hours as needed for shoulder pain take with food penicillin v potassium mg tablet tablet s by mouth twice a day for rheumatic heart disease prophylaxis discharge medications aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily magnesium hydroxide mg ml suspension sig thirty ml po hs at bedtime as needed for constipation fluticasone mcg actuation aerosol sig two puff inhalation times a day disp qs refills albuterol sulfate mcg actuation hfa aerosol inhaler sig one puff inhalation every six hours as needed for shortness of breath or wheezing disp refills acetaminophen mg tablet sig two tablet po every hours as needed for fever or pain tramadol mg tablet sig one tablet po q h every hours as needed for pain for weeks disp tablet s refills warfarin mg tablet sig as directed tablet po once a day two tablets mg then daily as directed by dr disp tablet s refills outpatient lab work inr pt then prn phone results to dr or fax discharge disposition home with service facility homecare discharge diagnosis mitral reguritation s p mitral valve replacement h o rheumatic heart disease reactive airway disease discharge condition alert and oriented x nonfocal ambulating with steady gait incisional pain managed with oral analgesics incisions sternal healing well no erythema or drainage edema none 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 labs pt inr for coumadin indication mech mvr goal inr first draw results to phone fax dr followup instructions you are scheduled for the following appointments surgeon dr on at pm cards dr on at am please call to schedule appointments with 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 coumadin followup with dr indication mechanical mitral valve goal inr first inr on monday phone results to or fax completed by,"{
""Diagnoses"": [""mitral regurgitation"", ""polyvalvular rheumatic disease"", ""rheumatic heart disease""],
""Medications"": [""none""]
}"
13213,admission date discharge date date of birth sex m service urology history of present illness mr is a year old male with locally advanced distal esophageal cancer he has recently underwent a distal esophagectomy under the care of dr in addition he received localized external beam radial therapy and chemotherapy prior to his esophagectomy at which time he had received a port a cath in the esophagectomy was performed in during his work up for esophageal cancer an enhancing right upper pole real mass was identified mra showed this to be a x cm mass that enhances therefore had a high likelihood of renal cell carcinoma he denied any history of hematuria abdominal or flank pain past medical history esophageal cancer as stated above history of peptic ulcer disease past surgical history distal esophagectomy occurring with dr he has had port a cath placement and an exploratory laparotomy to rule out metastatic disease this was performed simultaneously in by dr additionally he has had a pilonidal cyst excision social history he quit smoking years ago he is an engineer he drinks one cup of coffee per day and occasional ethanol use family history his grandmother has diabetes but no other genitourinary cancer history allergies penicillin which causes hives admission medications zantac mg twice day admission physical exam vital signs pulse blood pressure respiratory rate with room air saturation he was afebrile with a temperature of orally chest port a cath in right upper chest incision site was well healed no erythema extremities his upper extremities were non edematous palpable pulses distally in the upper extremities head ears eyes nose and throat unremarkable he had no lymphadenopathy and septal neck his trachea was midline no jugular venous distention no carotid bruits cardiac regular rate and rhythm normal s and s no murmurs rubs or gallops lungs clear to auscultation bilaterally abdomen soft nontender no palpable masses no costovertebral angle tenderness no inguinal lymphadenopathy he does have a healed j tube removal site genitourinary he had a normal phallus meatus and testis no inguinal hernia rectal normal tone gm prostate no nodularity guaiac negative extremities and neurologic he moves all four extremities without difficulty normal gait neurologically and mentally intact significant preoperative labs hematocrit bun and creatinine of and x rays he had a ct and mri that showed a cm right upper pole mass stable over the last seven months he has an exophytic lesion involving the upper pole as well hospital course given the enhancement likely has a round carcinoma the patient was scheduled for an open right partial nephrectomy informed consent was obtained in the presurgical clinical visit on the patient went to the operating room and underwent a partial right nephrectomy the case was relatively uneventful he left the operating room with a jp drain chest tube and foley catheter at the postoperative check he was noted to be afebrile vitals were otherwise stable chest tube is draining to cc of serosanguinous effluent jp drains approximately cc postoperative hematocrit was white count platelet count chemistries significant for a bun creatinine of chest x ray postoperatively showed no evidence of pneumothorax chest tube in good position he did have basilar atelectasis on the right side and a small right effusion otherwise no acute cardiopulmonary disease his epidural would be utilized for pain control his oxygen was weaned appropriately he was encouraged to ambulate the following day and his hematocrit was followed serially on postoperative day he had an epidural in place blood pressure was stable at systolic he was started on a clear liquid diet he completed his perioperative ancef and was ultimately transferred to the floor by postoperative day the patient was tolerating clears he had had some flatus no nausea or vomiting he was out of bed ambulating at this time his epidural was capped and flagged and he was started on percocet chest tube was removed follow up chest x ray showed no evidence of pneumothorax he was stable hematocrit continued to be stable on postoperative day the patient had had the epidural completely removed although it had been previously capped and flagged again he was out of bed ambulating he did not pass flatus so he was kept on a clear liquid diet at this point he had developed a right upper extremity ij clot related to his port a cath this was discovered on the evening of postoperative day into postoperative day vascular and surgical consultation had been obtained they had recommended removal of the catheter and heparinization and coumadinization total treatment length for the coumadin therapy was to be six months given the fact that he had undergone recent partial nephrectomy dr declined to have the patient put on heparin he was just given arm elevation and his right subclavian port a cath was removed on postoperative day by dr service this was done uneventfully and done under local anesthesia after his conservative therapy his right upper extremity arm edema had decreased somewhat he was started on coumadin on postoperative day receiving an mg dose his ultimate doses for coumadin and management for his pt inr with a goal of to are to be managed by dr his primary care physician is a physician at the office pt inr values will be sent to his office and they will be evaluated accordingly his discharge inr was with a ptt of and a pt of discharge hematocrit was platelet count white count was bun and creatinine were and discharge medications percocet to tablets po q to prn colace mg po bid prn zantac mg po bid coumadin mg per day ultimate dosage to be titrated per patient s primary care provider follow up instructions see dr in approximately to days his staples were removed on the time of discharge with steri strips placed uneventfully at time of follow up he will be reassessed to see how the progression in his right upper extremity edema had gone this had markedly improved over hours of conservative management additionally the patient should follow up with his primary care physician in approximately to days and to have a pt inr drawn in approximately two days from time of discharge with results being sent to the primary care physician as previously stated discharge diagnoses status post open right partial nephrectomy for exophytic lower pole renal mass presumed to be renal carcinoma final pathology is pending please see final path report for further detail esophageal cancer status post chemotherapy xrt in status post esophagogastrectomy ivor procedure with dr in right ij central vein deep venous thrombosis under treatment status post right subclavian port a cath removal during same hospitalization discharge condition stable discharge status home follow up plans as stated above m d dictated by medquist d t job,"{
""Diagnoses"": [""locally advanced distal esophageal cancer"", ""x cm mass that enhances"", ""renal cell carcinoma""],
""Medications"": [""radial therapy"", ""chemotherapy"", ""port a cath""]
}"
69299,admission date discharge date date of birth sex m service medicine allergies vioxx dilaudid attending chief complaint abdominal pain major surgical or invasive procedure ercp attempted unable to cannulate major papilla history of present illness mr is a yo male with a history of cad s p cabg chf s p icd placement afib on coumadin chronic alcoholic pancreatitis and s p whipple procedure puestow procedure who presents with fevers chills nausea vomiting and abdominal pain reports that he had non radiating periumbilical abdominal pain that started days pta and was associated with nausea pain was dissimilar from prior pancreatitis or sbo pain or other pain he has had in past pain resolved by the following day on day pta pain recurred and was more severe and associated with n v d fevers and chills denies melena hematochezia lh dizziness chest pain sob cough emesis was dry heaves non bloody he initially presented to an osh where due to eleavted lfts and bilirubin ruq ultrasound was performed and was reportedly unremarkable he was given a dose of zosyn and transferred for possible ercp of note he reports etoh intake on tues and thursday of this week also c o pruritus which is stable from baseline in the ed initial vs were pain t hr bp rr o sat patient was repeatedly hypotensive with sbps s s and required multiple cc boluses of ivf which were given gently due to history of chf right ij cvl was placed labs were notable for wbc count k with bands k creatinine up from alt ast tbili inr lactate and a positive ua ct abdomen and pelvis with contrast showed no acute pathology he was evaluated by surgery and ercp team he received vancomycin g iv dilaudid mg iv and diphenhydramine mg iv vital signs on sign out were t hr bp rr o sat on ra with improvement in abdominal pain on arrival to the icu he reported abdominal pain was much improved compared with yesterday currently denies nausea but reports his usual back pain is more severe due to bed positioning on arrival to the floor he reported his abdominal pain to be resolved he also denied nausea and vomitting review of systems per hpi denies night sweats recent weight loss or gain denies headache sinus tenderness rhinorrhea or congestion denies cough change in usual shortness of breath or wheezing denies chest pain chest pressure palpitations or weakness denies nausea vomiting diarrhea constipation or changes in bowel habits denies dysuria frequency or urgency denies arthralgias or myalgias denies rashes or skin changes all other systems negative past medical history atrial fibrillation chronic alcoholic pancreatitis s p partial resection with whipple pancreatic pseudocyst diagnosed in coronary artery disease status post percutaneous transluminal angioplasty with stent x vessels in ef psoriasis with severe arthritis requiring hand surgery hyperlipidemia gout copd hyperlipidemia chronic abdominal pain on narcotics h o polysubstance absue etoh abuse mild chronic thrombocytopenia gerd s p icd placement l c b abscess and shange to r chronic af bph sbo past surgical history puestow procedure open cholecystectomy feeding jejunostomy tube appendectomy cervical fusion for c compression fx after assault on the job laminectomy cabg social history smokes packs daily for decades consumes etoh drinks per week drank drinks highballs scotch and water on thursday as well as monday denies recreational drug use no h o withdrawal gives up etoh every year for lent retired police officer lives alone son is hcp family history denies family history of gastrointestinal disorders and cancers including pancreatic disease father expired of bronchial cancer physical exam vs t hr bp rr o sat on ra general alert oriented no apparent distress heent sclera icteric mm slightly dry oropharynx clear neck supple jvp not elevated no lad lungs coarse breaths sounds bilaterally with exp wheezes cv irregular rate and rhythm normal s s no murmurs rubs gallops abdomen soft not tender to palpation no rebound or guarding bowel sounds present no organomegaly gu no foley ext warm well perfused pulses no clubbing cyanosis or edema skin diffuse erythematous silvery scaly patches with cream applied 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 warfarin held for procedure pm blood pt ptt inr pt warfarin held for procedure am blood pt ptt inr pt warfarin held for procedure am blood pt inr pt received warfarin mg am blood glucose urean creat na k cl hco angap am blood albumin calcium phos mg am blood calcium phos mg am blood alt ast ld ldh alkphos totbili dirbili indbili am blood alt ast ld ldh alkphos totbili am blood alt ast alkphos totbili am blood lipase am blood ctropnt pm blood ck mb ctropnt pm blood vitb folate am urine color amber appear hazy sp am urine blood sm nitrite neg protein glucose neg ketone tr bilirub mod urobiln ph leuks tr am urine rbc wbc bacteri mod yeast none epi urine culture final no growth mrsa screen mrsa screen final no mrsa isolated blood culture routine pending inpatient blood culture routine pending inpatient ct abd pelvis w contrast prior puestow procedure with minimal surrounding stranding nonspecific decrease in size of cystic lesions in the region of the proximal pancreas are likely residual pseudocysts lymphadenopathy as above progression of lower lumbar spine degenerative changes as above cxr impression broken sternal wires small bilateral pleural effusions and underyling collapse consolidation mild assymetric upper zone redistribution ercp impression cannulation of suspected minor papilla superficially with a sphincterotome using a free hand technique contrast medium was injected resulting in partial opacification of thin irregular pancreatic duct due to altered anatomy redundant folds and edema the major papilla was unable to be located for cannulation otherwise normal ercp to third part of the duodenum recommendations return to floor continue with current antibiotic therapy for day course consider pancreatic protocol ct scan to further delineate the pancreatic biliary anatomy as patient is unable to get mrcp due to defibrillator pending resolution of current inflammation would consider repeat ercp in weeks if clinically indicated brief hospital course year old male with a history of cad s p cabg af on coumadin copd chf chronic pancreatitis s p puestow procedure and cholecystectomy admitted with cholestatic lfts and abdominal pain with hypotension on admission c w biliary obstruction cholangitis with sepsis sepsis d t biliary obstruction cholangitis patient presented with hypotension fever leukocytosis and abdominal pain consistent with sepsis bp initially s s in ed but was fluid responsive now hemodynamically stable doing well on antibiotics see below biliary obstruction cholangitis pt was initially managed in the icu and was treated aggressively with vancomycin and pip tazo ercp and surgery were consulted he clinically stabilized with improvement in blood pressure after bolusing ivf and providing antibiotics he underwent ercp attempt but they were unable to cannulate the major papilla he was continued on antibiotics and his lft s were closely followed despite inability to complete the ercp his lft s continued to downtrend and the patient symptomatically improved with resolution of abdominal pain he remained hemodynamically stable and his blood pressure medications were able to be resumed prior to discharge he will complete a day course of cipro flagyl for his cholangitis days remain considering his clinical improvements the pt will pursue further and management as an outpt which will likely include ct pancreas and repeat ercp once the inflammation has decreased pt should have lft s cbc drawn at a follow up pcp urinary tract infection patient had a positive ua but ucx from had no growth thus it is unlikely that it was the source of his infection or reflective of bacteremia etoh abuse pt denies h o withdrawal although drinks on a fairly regular basis counseled at length the need for him to quit he was monitored on the ciwa scale but did not score there was no evidence of withdrawl cad he denies cp during this hospitalization although he reported cp in the ambulance and at the osh ed he stated that this was dissimilar from cardiac pain cardiac enzymes were checked and were negative he was provided aspirin mg po daily his blood pressure medications were initially held due to his sepsis but these were resumed prior to discharge and were tolerated well his crestor was held and will be held on discharge until pcp follow up considering his elevated lft s from his biliary obstruction please follow up and resume when appropriate atrial fibillation pt currently in afib rate controlled pt s metoprolol was resumed on which he tolerated without difficulty pt s warfarin was initially held for ercp but this was resumed prior to discharge please see results section for recent inr s and warfarin dosing his warfarin was resumed on please note the interaction with the antibiotics his inr will need close following discussed with patient the need for close inr monitoring especially while on antibiotics pt agrees to go to his coumadin clinic for inr check copd pt reports being on combivent at home although this was not on his medication list from the pcp he denied any respiratory symptoms he was discharged on his home regimen bph resumed flomax gout continued allopurinol gerd continued ppi psoriasis arthritis his methotrexate was held considering infection he was continued on folic acid he was provided clobetasol propionate cream appl tp for days and calcipotriene cream appl tp for days with reported benefit he was requested to f u with his pcp for management of his psoriasis medications after the hospitalization prophylaxis subcutaneous heparin code full discussed with patient medications on admission protonix mg daily folic acid mg daily aspirin mg daily methotrexate mg daily vs weekly allopurinol mg daily motrin mg tid for years coumadin mg po daily flomax mg po daily demerol mg po q prn imdur mg po daily metoprolol tartrae tabs po bid unsure of dose folic acid mg po daily combivent puffs q prn reglan mg po qhs prn discharge medications tamsulosin mg capsule sust release hr sig one capsule sust release hr po hs at bedtime allopurinol mg tablet sig one tablet po daily daily isosorbide mononitrate mg tablet sustained release hr sig one tablet sustained release hr po once a day furosemide mg tablet sig one tablet po once a day ambien mg tablet sig one tablet po at bedtime as needed for insomnia prescribed by other provider nitroglycerin mg tablet sublingual sig one tab sublingual as dir as needed for chest pain flovent hfa mcg actuation aerosol sig one puff inhalation twice a day warfarin mg tablet sig one tablet po q pm please follow closely with clinic and titrate dose as needed 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 twice a day aspirin mg tablet chewable sig one tablet chewable po daily daily ciprofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills metronidazole mg tablet sig one tablet po q h every hours for days disp tablet s refills combivent mcg actuation aerosol sig two puff inhalation twice a day folic acid mg tablet sig one tablet po daily daily discharge disposition home with service facility vna discharge diagnosis sepsis due to cholangitis biliary obstruction urinary tract infection coronary artery disease atrial fibrillation 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 with abdominal pain and low blood pressure and you were found to have a significant infection in your bile ducts due to an obstruction you were treated with antibiotics and we attempted to evaluate and treat this obstruction with a procedure called ercp but this was unsuccessful you will complete a week course of antibiotics and you will follow up with the ercp doctors for further please complete your antibiotics as prescribed it is extremely important that you follow closely with your clinic while you are on antibiotics as this will increase the effects of your coumadin and your dosing will need to be adjusted new medications ciprofloxacin flagyl metronidazole holding methotrexate crestor followup instructions please go to your clinic on thursday for an inr check name chakraborty aurobindo location suburban cardiology internal medicine address phone appointment monday at am please check cbc and lft s at this appointment department div of gastroenterology when thursday at pm with m d building ra complex campus east best parking main garage,{}
76876,admission date discharge date service medicine allergies no known allergies adverse drug reactions attending chief complaint fall major surgical or invasive procedure ng tube history of present illness patient is an year old female s p mechanical fall with head contusion taken to where she had a head ct which showed bilateral sdh pet reports she was confused and slow to follow commands as a result she was intubated for airway protection and transferred to on arrival patient had a blood pressure and intubated but moving purposeful she was motioning for the tube to come out past medical history htn hypercholesterolemia glaucoma vertigo syncope social history unknown family history nc physical exam o t af bp hr r o sats fio gen intubated seated heent traumatic with left occiput swelling eyes surgical clera ears no otorrhea nose patent tube at cm at teeth pupils perrl eoms full neck supple ett in place lungs cta bilaterally good chest rise b l cardiac rrr s s abd soft nt bs extrem warm and well perfused neuro gcs e v m t pupils are surgical no papilledema of fundoscopic exam patient is purposeful bilateraly moves for tube nods to question wants the tube out maes fully grimaces to pain no clonus toes downgoing bilaterally pertinent results ct head w o contrast impression diffuse extra axial hemorrhage including bilateral frontoparietal subdural hematomas and subarachnoid hemorrhage mild posterior layering intraventricular hemorrhage no signs of developing obstructive hydrocephalus large inferior frontal intraparenchymal hemorrhagic contusions no midline shift or evidence of impending herniation ct head w o contrast conclusion slight increase in the size of the right subdural hematoma with increased mass effect on the sulci and right lateral ventricle slight increase in leftward shift of normally midline structures stable appearance of left subdural hematoma bifrontal parenchymal hematomas bilateral subarachnoid hematomas and slight decrease in the intraventricular hematoma 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 neuts lymphs monos eos baso pm blood plt ct pm blood pt ptt inr pt am blood pt ptt inr pt am blood plt ct am blood fibrino pm blood glucose urean creat na k cl hco angap pm blood glucose urean creat na k cl hco angap am blood calcium phos mg pm blood calcium phos mg pm blood po pco ph caltco base xs comment green top pm blood type art rates tidal v peep fio po pco ph caltco base xs assist con intubat intubated pm blood lactate na k cl pm blood lactate 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 pm urine blood tr nitrite neg protein glucose neg ketone neg bilirub neg urobiln neg ph leuks sm pm urine color yellow appear clear sp am urine hours random urean creat na k cl am urine osmolal brief hospital course y o f s p fall presents with bilateral sdhs bifrontal contusions subarachnoid hemorrhage and intraventricular hemorrhage active issues mechanical fall c b intracranial hematomas she was admitted to the neurosurgery with bilateral sdhs bifrontal contusions subarachnoid hemorrhage and intraventricular bleed s p mechanical fall and placed in the icu for close monitoring she was started on dilantin on examination patient was slightly confused but alert to place and name she was moving all extremities with good strength on repeat head ct was performed which showed blossoming of bifrontal contusions and stable sdhs with sah and ivh she remained in the icu for close monitoring with a stable exam dilantin level was on the patient had a waxing and level of alertness only responsive to noxious stimuli at times she was sent for a repeat ct of the head which showed a minimally increased hematoma and no evidence of herniation when the patient was transferred to medicine on she was sleepy but roused to verbal commands and oriented only to self though she could repeat she did not know that this was a hospital her neurologic exam on changed to show a flattening of the left nasolabial fold a repeat study on the rd showed evidence of right subdural hematoma expansion with midline shift the brainstem was not compromised hyponatremia hyperkalemia the patient was held npo with minimal ivf her serum sodium slowly trended up and her potassium slowly trended down on the patient was transferred to the medicine service for management of a na of and a k of the patient s free water deficit was calculated at approximately liters and with the aid of a nephrology consult her sodium was corrected slowly so as to avoid any intracranial edema in the setting of six already known bleeds she was corrected at less than meq l hr her potassium was also repleted atrial fibrillation the patient was found to be in new atrial fibrillation on when she was transferred to the medicine service this was thought likely due to her low intravascular volume status with possible contribution from her severe electrolyte disturbances her medication regimen was changed and she responded very well to po metoprolol mostly remaining in sinus afterwards further episodes of atrial fibrillation responded very well to iv metoprolol tachypnea on approximately on the patient s respiratory rate abruptly increased to the mid s and her oxygen saturation dropped to the s this increased to the s with a non rebreather but her tachypnea did not respond she was seen immediately by the medical team her lungs were clear at the time and ng tube yielded only scant dark liquid a stat chest x ray showed clear lungs which corroborated the exam therefore acute cardiac decompensation was ruled out it was thought most likely that she had had a massive pulmonary embolism despite her heparin prophylaxis the possibility of an expansion of one of her six head bleeds was also entertained but considered less likely given her tachypnea her sodium had been corrected very slowly to avoid any cerebral edema and ct head confirmed this although the patient may have aspirated the sudden and dramatic desaturation with the most recent po intake having been a small amount of tea and broth several hours earlier that morning made this unlikely the primary team had extensive discussion with the family and the decision was made to transition the patient to comfort measures only her oxygen hunger was treated with morphine and benzodiazepines she died on the morning of medications on admission losartan mg hctz mg daily mirtazapine mg qhs timolol opthalmic solution daily discharge medications deceased discharge disposition expired discharge diagnosis bifrontal contusions bilateral sdh ivh sah discharge condition deceased discharge instructions deceased followup instructions deceased,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""service medicine"", ""allergies"", ""no known allergies"", ""adverse drug reactions"", ""attending chief complaint"", ""fall"", ""major surgical or invasive procedure"", ""ng tube history"", ""history of present illness"", ""patient is an year old female"", ""s p mechanical fall with head contusion"", ""taken to where she had a head CT which showed bilateral SDH"", ""patient was confused and slow to follow commands"", ""as a result she was intubated for airway protection"", ""transferred to on arrival""],
""Medications"": [""intubated for airway protection""]
}"
61587,admission date discharge date service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint fall bilateral humeral fractures major surgical or invasive procedure intramedullary rodding of right proximal humerus fracture open repair of right rotator cuff intramedullary rodding of left proximal humerus fracture central venous line placement history of present illness yo female with past medical history significant for cva afib dementia dchf temporal arteritis pmr presents s p unwitnessed fall at rehab with c o bilateral shoulder pain pt found to have bilateral proximal humeral fractures and nasal fracture in ed and admitted to trauma per nursing notes pt found on floor at am lying face down she was not noted to be in respiratory or cardiac distress pt recalls being hurt but cannot say what happened prior past medical history dementia amyloid angiopathy s p cva atrial fibrillation not anticoagulated due to amyloid angiopathy diastolic congestive heart failure echo ef chronic urinary retention periperal edema likely venous stasis osteoporosis temporal arteritis on prednisone polymyalgia rheumatica depression w catatonia and confusion assoc w dementia atrophic vaginitis vitamin d deficiency oh total ng ml fe deficiency anemia hx l pleural effusion hx utis inc esbl hx pna hx compression fractures hx central retinal vein thrombosis hx melenoma removed s p cataract surgery s p kyphoplasty l l social history lives at rehab non smoker no etoh family history nc physical exam vital signs t bp hr with bursts to s rr o lnc general pleasant with facial bruising and echymoccyes under eyes calls for daughter to c o pain heent normocephalic atraumatic no conjunctival pallor no scleral icterus mmm op clear neck supple no lad no thyromegaly cardiac irregular normal rate normal s s ii vi sem no rubs or jvp cm lungs anterior ctab good air movement biaterally abdomen nabs soft nt nd no hsm extremities no edema or calf pain dorsalis pedis skin no rashes lesions neuro a ox pertinent results admission labs am wbc rbc hgb hct mcv mch mchc rdw am neuts lymphs monos eos basos am plt count am glucose urea n creat sodium potassium chloride total co anion gap am pt ptt inr pt imaging ct head impression no acute intracranial hemorrhage chronic small vessel ischemic changes sinusitis changes displaced left nasal bone fracture periorbital swelling and hematoma anterior to the left zygoma orbital globes are intact ct cspine impression no evidence of acute fracture diffuse osteopenia and degenerative changes small left pleural effusion ct sinus impression displaced left nasal bone fracture opacification of the sinuses the left omu is occluded left periorbital swelling and hematoma echo the left atrium is normal in size there is mild symmetric left ventricular hypertrophy with normal cavity size 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 the estimated cardiac index is normal l min m right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened but aortic stenosis is not present moderate 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 moderate pulmonary artery systolic hypertension there is no pericardial effusion impression mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function moderate aortic regurgitation mild to moderate mitral regurgitation moderate pulmonary hypertension compared with the prior study images reviewed of the severity of aortic regurgitation has increased the severity of pulmonary hypertension has increased the rhythm now appears to be atrial fibrillation with beat to beat variation in left ventricular ejection fraction carotic us impression limited left sided study but less than carotid stenosis right side was not evaluated as described above cxr impression stable appearances with slight improvement in pulmonary edema which is mild persistent moderate to large left pleural effusion and smaller right pleural effusion kub there is less fecal material in the colon the bowel loops of the colon and gas filled small bowel loops in the abdomen are not distended maximum diameter of the colon is cm degenerative changes of bilateral hip joints vertebroplasty at several of the lumbar vertebral bodies are unchanged brief hospital course yo female with dementia who fell and sustained nasal fracture and bilateral humeral fractures s p intramedullary rodding of right proximal humerus fracture open repair of right rotator cuff and intramedullary rodding of left proximal humerus fracture she was transferred to the tsicu for afib with rvr and subsequently transferred to micu for volume overload bilateral ue humeral fractures she underwent intramedullary rodding of right proximal humerus fracture open repair of right rotator cuff and intramedullary rodding of left proximal humerus fracture as per orthopedics her activity level should be weight bearing in upper extremities as tolerated afib aflutter this was likely worsened by diuresis systemic infection and increased adrenergic tone she required a diltizem drip and was successfully transitioned to diltiazem extended release mg daily after her other acute issues had resolved her heart rate has been maintained in the s she was anticoagulated with asa alone given fall risk pulm edema chronic left pleural effusion patient was diuresed with iv lasix as needed her goal urine output should be l daily she is on lasix mg iv bid and she should receive prn iv lasix to achieve her goal urine output as her bp tolerates uti infectious diseases service felt that her urine cultures were consistent with contamination as she has had esbl uti s in the past she received a three day course of meropenem until it was stopped for this reason she is continued on premarin cream for prevention of uti c diff patient developed leukocytosis and abdominal pain as well as diarrhea she was found to have c difficile and was started on flagyl in the icu on because her white blood cell count continued to increase she was also started on po vancomycin on if the patient s abdominal exam shows evidence of rebound guarding or stool output stops quickly and in the setting of continued abdominal tenderness kub to assess for toxic megacolon should be performed kub on showed no evidence of toxic megacolon acute on chronic diastolic congestive heart failure patient with acute on chronic diastolic chf exacerbation upon transfer to the icu she was placed on lasix mg iv bid as well as prn lasix iv to achieve goal uop of l per day because of variable bp s with afib on rvr beta blocker was held if blood pressure will tolerate and hr remains stable in the s to s low dose coreg should be started patient also would require that acei started given chf kcl was held during hospitalization as daily labs were being drawn if labs are not obtained frequently at rehab she will require resumption of home dose meq kcl daily nasal fracture patient was seen by plastics who recommended dressing changes and surgical correction concurrent with humerus fix however risks benefits or reduction of nose was discussed with family who opted for non operative management due to risk of complications she was managed with xeroform and dsd to forehead daily x week then bacitracin osteoporosis calcium continued and vitamin d infusions as below temporal arteritis polymyalgia rheumatica continued prednisone home dose on discharge she was on stress dose steroids briefly while in the tsicu depression w catatonia and confusion assoc w dementia continued seroquel remeron and cymbalta vitamin d deficiency pt gets weekly infusion and will resume at rehab when discharged vitamin d infusion was held while inhouse chronic pain pt was on cymbalta at goal and continued on seroquel mg qhs pain service followed and recommended oxycodone q hours while she still has pain from b l humeral fractures anemia niferex was held during hospitalization given her acute infection with c difficile it should be resumed after course of antibiotics finished medications on admission cymbalta mg daily omeprazole mg daily seroquel mg remeron mg qhs asa mg enteric coated daily toprol xl mg daily lasix mg daily kcl meq premarin cream application moth prednisone mg daily niferex mg daily artificial tears drop ou tylenol mg qid vitamin d units po weekly anusol per rectum qhs amoxicillin gm prior to dental procedures skin creams aveeno bengay fleets enema daily prn hot pack to lower back qid prn discharge medications oxycodone mg ml solution sig mg po q h every hours as needed for pain please continue as long as having pain from upper extremity fractures furosemide mg ml solution sig twenty mg injection times a day hold for sbp diltiazem hcl mg tablet sustained release hr sig one tablet sustained release hr po once a day vancomycin mg capsule sig one capsule po q h every hours for days continue until metronidazole mg tablet sig one tablet po every eight hours for days please continue until mirtazapine mg tablet sig one tablet po hs at bedtime quetiapine mg tablet sig one tablet po hs at bedtime prednisone mg tablet sig one tablet po daily daily acetaminophen mg tablet sig two tablet po q h every hours aspirin mg tablet sig one tablet po daily daily omeprazole mg capsule delayed release e c sig one capsule delayed release e c po daily daily duloxetine mg capsule delayed release e c sig one capsule delayed release e c po daily daily heparin porcine unit ml solution sig one injection tid times a day calcium carbonate mg tablet chewable sig one tablet chewable po tid times a day 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 premarin mg g cream sig one application vaginal as dir please continue at dosing prior to arrival at hospital anusol ointment sig one application rectal once a day tears naturale forte drops sig one drop ophthalmic twice a day fleets enema please administer daily prn other please apply aveeno cream and bengay cream hot packs please apply to lower back qid prn bacitracin unit g ointment sig one application topical twice a day please apply until nasal fracture healed discharge disposition extended care facility for the aged macu discharge diagnosis primary diagnoses bilateral humeral fractures s p orif nasal fracture acute on chronic diastolic congestive heart failure atrial fibrillation and atrial flutter with rapid ventricular response clostridium difficile colitis discharge condition stable vital signs hr s oriented only to person discharge instructions you were admitted to on after falling you broke your nose and both of your arms you had surgery for your arm bone fractures you will need to continue physical therapy when you are in rehab and you can take oxycodone for pain you also had a fast and abnormal heart rate you will start taking a medication called diltiazem for this you also had some symptoms of heart failure and will require intravenous lasix to get some of the excess fluid off you should have daily weights and your doctor should be notified for any weight gain lbs in days follow a diet with less than grams sodium and restrict your fluid intake to l per day you also had a stool infection while you were hospitalized you will need to complete a week course of flagyl and vancomycin the following changes have been made to your medications stop taking toprol xl stop taking potassium supplements stop taking niferex start taking oxycodone every four hours start taking flagyl until start taking vancomycin until start bacitracin cream until nasal fracture healed stop taking lasix mg by mouth daily and start taking lasix mg iv twice a day increase cymbalta mg daily to mg daily increase aspirin mg daily to mg daily resume your vitamin d infusions as determined by your pcp please return to the hospital if you have chest pain shortness of breath fever worsening profuse diarrhea bloody black stool or any other symptoms concerning to you followup instructions please follow up with your pcp weeks after your discharge from rehab please follow up with dr on at pm on the phone number is,{}
22865,admission date discharge date service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint hypotension nausea vomitting major surgical or invasive procedure none history of present illness this is a yo male with htn chf cad advanced dementia who initially presented on with a day hx of diarrhea vomiting and cough while at rehab pt is non verbal thus history per records multiple others wsere sick at rehab pt was noted to be hypotensive at and transferred to in the pt was febrile to had bp of hr s and rr on arrival his bp improved after l ns he was found to have dirty ua possible infiltrate on cxr and was given vanc levo flagyl in the micu he was given fluids and continued on above antibiotics he did not require intubation or pressors he is dnr dni of note he was also found to have a creatinine of he had a hct drop from to but then on recheck was however does have guaiac brown stool past medical history anemia baseline hct in chf unkwnon ef cad h o mrsa uti h o dvt lle was on coumadin stopped advanced dementia per son pt opens eyes but mostly non verbal ra cri creat on psoriasis social history lives at rehab no smoking or etoh family very involved with care family history nc physical exam vitals t bp hr rr o sat l nc gen non verbal but responsive to painful stimuli mouth open heent perrl op dry neck no visible jvd cardio distant heart sounds rrr resp decreased bs throughout scattered rhonchi abd soft nt nd bs ext no edema severe contractures of bilateral upper ext neuro non verbal respons to painful stimuli does not open eyes to commands pertinent results am plt smr normal plt count am hypochrom normal anisocyt poikilocy normal macrocyt normal microcyt normal polychrom normal elliptocy am wbc rbc hgb hct mcv mch mchc rdw am albumin calcium phosphate magnesium am ck mb ctropnt am lipase am alt sgpt ast sgot ld ldh ck cpk alk phos amylase tot bili am estgfr using this am glucose urea n creat sodium potassium chloride total co anion gap am lactate am urine rbc wbc bacteria many yeast none epi am urine blood mod nitrite neg protein glucose neg ketone tr bilirubin neg urobilngn neg ph leuk mod am urine color yellow appear cloudy sp pm plt count pm wbc rbc hgb hct mcv mch mchc rdw pm ck mb ctropnt pm lipase pm alt sgpt ast sgot ck cpk alk phos amylase tot bili pm lactate pm fibrinoge pm plt smr normal plt count pm plt smr normal plt count pm hypochrom anisocyt normal poikilocy normal macrocyt normal microcyt normal polychrom normal ovalocyt elliptocy pm hypochrom anisocyt normal poikilocy normal macrocyt normal microcyt normal polychrom normal pm neuts bands lymphs monos eos basos atyps metas myelos pm wbc rbc hgb hct mcv mch mchc rdw pm wbc rbc hgb hct mcv mch mchc rdw pm urine osmolal pm alt sgpt ast sgot ld ldh ck cpk alk phos amylase tot bili pm glucose urea n creat sodium potassium chloride total co anion gap cxr possible early left lower lung zone infiltrate cardiomegaly am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood neuts bands lymphs monos eos baso atyps metas myelos am blood glucose urean creat na k cl hco angap am blood alt ast ld ldh alkphos amylase totbili am blood lipase am blood calcium phos mg pm blood caltibc hapto ferritn trf brief hospital course this is a yo m with htn chf cad p w n v d found to be septic sepsis the patient was admitted with leukoctyosis lactate elevation to and fever initially there was question of pna thought to be aspiration given his h o vomiting and the patient had a dirty urine with leukocytes the patient was found to be profoundly volume depleted and was resuscitated with ivf he was empirically started on vanc levo flagyl for broad coverage including mrsa given pt s history aspiration pneumonia and likely uti legionella antigen was negative blood sputum and urine cultures were sent after the aforementioned interventions the patient s bp normalized and the patient quicklyl defervesced after hrs blood and sputum cultures were negative but urine culture grew out coag positive staph aureus sensitivities are pending given the patient has not spiked in house and has no other clinical signs of pna coverage for asp pna was stopped we will continue the vancomycin for possible mrsa in his urine this should be continued for ten days or until sensitivities suggest otherwise c diff is also pending upon discharge this will also need to be followed up and flagyl restarted if positive conjunctivitis the patient was noted to have erythemetous conjunctiva l r and was started on erythromycin eye drops this should be continued for a seven day course anemia the patient has a normocytic anemia with a hct today of the patient was found to have guaiac stools however the family does not with to pursue any diagnostic procedures and would like to minimize any interventions therefore we did not work the anemia up any further cad chf after aggressive fluid resuscitation the patient briefly experienced pulmonary edema and was put on a nrb with sats in the mid s he was given lasix and was taken of the nrb mask and transitioned to l via nc with sao the patient s aspirin was discontinued as his stool was found to be guaiac positive and his hct was with a baseline crit in high s low s htn initially the pt s toprol and amlodapine were stopped given his hypotension however the patient was given mg toprol iv prn for hypertension as he was unable to take po medications and the family did not want an ngt placed the amlodapine was not continued the patient was discharged on no bp meds however metoprolol iv may be needed in the future for blood pressure control as the patient continues to recover from his infections elevated trop the patient s ck s and trops were elevated upon admission but mbs were negative ekg did not show evidence of ischemia therefore the elevated trops were likely secondary to increased demand in the setting of renal failure and severe hypotension acute on chronic renal failure the patient s most recent cr prior to admission was in he was initially thought to be pre renal in setting of sepsis with fena however his cr did not improve s p aggressive hydration renal usn neg for hydronephrosis therefore it was thought that the pt may be at a new baseline hypernatremia the patient came in with elevated na level which was attributed to a free water deficit in the setting of n v and diarrhea and decreased po intake he had a l water deficit on admission he was volume resuscitated with normal saline and then started on d w at cc hr for about hrs the family refused an ngt to deliver free water boluses therefore the patient was continued on d w with the rate increased to cc hr code dnr dni medications on admission acetaminophen mg po pr q h prn levofloxacin mg iv daily albuterol neb q h prn metronidazole flagyl mg iv q h or artificial tears prn protonix mg qday erythromycin ophth oint od qid heparin unit sc tid vanco gm iv q hrs ipratropium bromide neb q h discharge medications acetaminophen mg tablet sig tablets po q h every to hours as needed dulcolax mg tablet delayed release e c sig tablet delayed release e c s po once a day as needed for constipation calcium d mg unit tablet sig one tablet po three times a day topical creams please take the following creams as previously prescribed sebulex topical lac hydrin topical prn senna mg capsule sig capsules po at bedtime albuterol sulfate solution sig one neb inhalation every four hours as needed for shortness of breath or wheezing ipratropium bromide solution sig one neb inhalation q h every hours erythromycin mg g ointment sig two drops ophthalmic qid times a day for days vancomycin mg recon soln sig mg intravenous q hr for days dextrose in water sig ml hour continuous continue for goal sodium may adjust rate prn discharge disposition extended care facility center discharge diagnosis uti gastroenteritis conjunctivitis severe dehydration secondary to gastroenteritis discharge condition good discharge instructions please return to the er if you experience increasing fevers difficulty breathing or any symptoms that concern you please follow up on blood and stool cultures and sensitivities of urine culture results followup instructions please follow up with your pcp upon discharge please have him follow up on all culture data [NEW_RECORD] name unit no admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending addendum the pt was transferred from the icu to the floor for further treatment of hypernatremia and pna pt was treated with free water repletion his sodium improved somewhat with free water we continued vancomycin flagyl and levaquin his fever and wbc count improved speech and swallow eval deemed pt to be an aspiration risk however the family wanted the patient fed for comfort reasons they understood and accepted the risks of aspiration with feeding the pt did seem to aspirate and had copious secretions and cough on he again became febrile a subsequent cxr showed increased infiltrates in the lll probably to aspiration after discussions between the attending and family it was determined that goals of care for the patient would be made comfort measures the pt was transferred back to rehab for continued care the current levaquin treatment was to be continued per the families wishes discharge disposition extended care facility center md completed by,"{
""Diagnoses"": [""hypotension"", ""nausea"", ""vomiting"", ""advanced dementia"", ""hypertension"", ""heart failure"", ""chronic obstructive pulmonary disease"", ""anemia"", ""baseline creatinine level elevated"", ""creatinine drop"", ""guaiac brown stool"", ""microscopic hematuria""],
""Medications"": [""Vanc-Levo"", ""Flagyl"", ""Fluids"", ""Above antibiotics"", ""Coumadin"", ""Advanced dementia""]
}"
52046,admission date discharge date service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint right sided weakness major surgical or invasive procedure none history of present illness year old woman with history of afib for which she is on coumadin who this past monday realized that she felt her right arm was weak and that she was leaning toward the right she currently resides at a nursing home and today her nurse felt she should be evaluated so she was sent to an osh while there a head ct showed a cm x cm right cerebellar hemorrhage her inr was the day prior to admission and approximately at the osh per report she was reversed with ffp vitamin k and factor ix complex she was transferred to for further management her inr was for which she received ffp vitamin k and propylene ix in the emergency department she denies headache is blind in her right eye secondary to macular degeneration but has good vision with her left eye she is listing to her right when entering the room she is interactive past medical history atrial fibrillation flutter on warfarin hypertension type dm dyslipidemia right eye blindness secondary to macular degeneration glaucoma cataracts uterine prolapse with urinary incontinence prior hx of pesary spinal stenosis with radiculopathy osteoporosis depression social history smoked ppd x yrs quit in denies etoh and recreational drugs lives at nursing home living brother and sister and two nieces are very involved in her care widowed for years has a daughter in who is not involved she previously worked as an xray technician and helped physicians do house calls in the area family history brother with diabetes and eye problems denies cardiac or pulmonary disease physical exam o t bp hr r o sats gen wd wn comfortable nad heent ncat pupils r blind clouded over l mm mm eoms full without nystagmus neuro mental status awake and alert cooperative with exam normal affect orientation oriented to self and hospital language speech fluent with good comprehension and repetition naming intact no dysarthria or paraphasic errors cranial nerves i not tested ii pupils right blind clouded over secondary to cataracts and macular degeneration left mm to mm visual fields are full to confrontation with left eye 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 right pronator drift rue is not weak but is uncoordinated normal bulk and tone bilaterally no abnormal movements tremors strength full power throughout sensation intact to light touch and proprioception bilaterally toes downgoing bilaterally coordination finger to nose uncoordinated with right good with left normal heel to shin pertinent results ca mg p wbc hct plt ca mg p wbc hct plt hand x ray degenerative changes of osteoarthritis without evidence of fracture left upper extremity us occlusive thrombus seen within the left cephalic vein no deep vein thrombosis seen within the remainder of the veins of the left arm urine culture final escherichia coli organisms ml presumptive identification ampicillin s ampicillin sulbactam s cefazolin s cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s nitrofurantoin s piperacillin tazo s tobramycin s trimethoprim sulfa s a source catheter negative for urobil bili leuk protein mod bld sm nitr glu tr ket rbc wbc bact mod yeast mod epi a ca mg p wbc hct plt am glu urea n creat na k cl co calcium phosphate magnesium wbc hct mcv plt count pt ptt inr pt am glu urea n creat na k ch co ctropnt wbc hct mcv plt count neuts lymphs monos eos basos pt ptt inr pt cxr right sided hiatal hernia cardiomegaly no apparent pneumonia or chf ct head stable inferior right cerebellar hematoma with vasogenic edema no evidence of obstructive hydrocephalus and stable slight cerebellar tonsillar herniation ct head w o contrast right cerebellar intraparenchymal hemorrhage causing mass effect on the right lateral ventricle occipital no evidence of herniation in the absence of comparison direct interval change is not assessed mild perihemorrhagic edema and effacement of the fourth ventricle with mass effect on the medulla no evidence of tonsillar herniation ct head w o contrast overall stable appearance of the right sided inferior cerebellar hematoma and surrounding hypodensities due to edema and associated mass effect no new hemorrhage seen no hydrocephalus ekg aflutter with variable response bpm poor r wave progression prolonged qtc inferior q waves brief hospital course pt presented with right sided weakness secondary to right cerebellar hemorrhage she received vitamin k ffp and profiline to reverse the coumadin and decrease her inr in the icu her exam was stable so no interventions were performed on inr was and unit ffp was given she was transferred to medicine for step down care she had an asymptomatic episode of atrial flutter with higher degree of av block and bradycardia likely caused by over blockade it resolved with decreased doses of her beta and calcium blockers she was monitored on telemetry with no acute events her blood pressure was kept below systolic for her recent intracranial bleed she has been stable with no events on her current doses of long acting diltiazem and metoprolol her oxygen requirement resolved with incentive spirometry she was found to have a uti shown on culture to be pan sensitive e coli so she was started on d course of bactrim of note her wbc increased one day after treatment but patient remained asymptomatic so please repeat urine analysis after completion of antibiotics to confirm clearance during this hospitalization her hand became ecchymotic and edematous and she complained of severe pain work up was significant for occlusive cephalic venous thrombus which is likely causing her symptoms given her recent cerebellar hemorrhage neurosurgery advised that she not be therapeutically anticoagulated for this although sc heparin for dvt prophylaxis is acceptable and appropriate her hand is being managed with elevation physical therapy and pain control with tylenol she will need to follow up with neurosurgery this was scheduled the patient confirmed her full code status this admission medications on admission acetaminophen g lacri lube gtt qhs alphagan daily tums tabs daily diltiazem mg daily cosopt vitamin d units daily gabapentin mg qhs heparin flush xalatan eye drops qhs metoprolol succinate mg daily remeron mg tab qhs kcl meq daily senna tabs qhs tramadol mg trazodone mg qhs discharge medications acetaminophen mg tablet sig two tablet po q h every hours white petrolatum mineral oil ointment sig one appl ophthalmic hs at bedtime brimonidine drops sig one drop ophthalmic daily daily calcium carbonate mg mg tablet sig three tablet po once a day diltiazem hcl mg capsule sustained release sig one capsule sustained release po daily daily dorzolamide timolol drops sig one drop ophthalmic times a day ergocalciferol vitamin d unit capsule sig one capsule po once a day gabapentin mg capsule sig one capsule po hs at bedtime latanoprost drops sig one drop ophthalmic hs at bedtime mirtazapine mg tablet sig one tablet po hs at bedtime 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 once a day senna mg tablet sig two tablet po once a day tramadol mg tablet sig tablet po bid times a day as needed for pain metoprolol succinate mg tablet sustained release hr sig five tablet sustained release hr po daily daily sulfamethoxazole trimethoprim mg tablet sig one tablet po bid times a day for days miconazole nitrate powder sig one appl topical times a day as needed for groin rash discharge disposition extended care facility newbridge on th echarles rehab discharge diagnosis cerebellar hemorrhage bradycardia av block atrial flutter atrial fibrillation hypertension atelectasis cephalic vein thrombosis 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 were admitted for right sided weakness and found to have a brain bleed we stopped your coumadin you had an episode of slow heart rate which resolved with a change in your heart medication you were also found to have a urinary tract infection for which we began treatment with an antibiotic your left hand started hurting and was swollen which is likely caused by a blood clot in a superficial vein in your arm because of your brain bleed we cannot thin your blood anymore than the heparin shots you get three times a day it will resolve on its own do not re start your coumadin until cleared by the neurosurgeon 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 if you were on a medication such as coumadin warfarin prior to your injury you may safely resume taking this after you are cleared to do so in the clinic 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 provider scan phone date time provider md phone date time completed by,{}
25615,unit no admission date discharge date date of birth sex m service nb history twin number two is the gram product of a and week twin gestation born to a year old gravida ii para now white female prenatal screens reveal blood type a negative antibody negative hepatitis b surface antigen negative rpr nonreactive rubella immune group b strep negative she was betamethasone complete since pregnancy was otherwise uncomplicated the mother presented on the day of delivery with premature rupture of membranes the infant was delivered by cesarean section due to twin gestation he emerged vigorous and crying apgars were at one minute and at five minutes he was brought to the neonatal intensive care unit for admission physical examination physical examination reveals a premature male who is pink and comfortable in room air anterior fontanel open and flat clavicle and palate intact clear breath sounds with fair aeration no murmur regular rate and rhythm good femoral pulses abdomen soft nondistended no hepatosplenomegaly normal male genitalia testes descended into the scrotum patent anus moves all extremities initial impression premature small for gestational age twin male without respiratory distress he is at risk for sepsis secondary to prematurity only hospital course hospital course will be discussed by systems respiratory infant has been stable in room air he has not had significant apnea of prematurity he had one apneic and bradycardiac episode on day of life secondary to a spit cardiovascular he has remained hemodynamically stable there has never been a murmur fluids electrolytes and nutrition initially he was n p o on d w at ml per kg per day intravenously he was also started on parenteral nutrition feedings were started on day of life one and advanced to full feedings by day of life five he is currently on breast milk or similac special care with promod at ml per kg per day he requires a significant amount of gavage feedings and receives his feedings over one hour minutes his discharge weight is grams gastrointestinal he had mild hyperbilirubinemia requiring phototherapy his peak bilirubin was total direct his rebound bilirubin was total direct hematology his initial hematocrit was he has not required transfusions his blood type is a negative coombs negative infectious disease he had initial cbc which was benign with white blood cell count of polys bands blood culture was sent he was never started on antibiotics blood culture was negative at hours neurology he has a normal neurologic examination he has not required a head ultrasound sensory audiology hearing screen was not done it needs to be performed prior to discharge ophthalmology eye examination was not done as he is not at risk for retinopathy of prematurity psychosocial social work is involved with the family per routine the contact social worker can be reached at parents are involved in his care they desire transfer to for further care before discharge home condition on discharge good discharge disposition to special care nursery for level ii care name of pediatrician not yet chosen care recommendations the infant is on special care or breast milk with promod at ml kg day mainly by gavage over hour and minutes feedings p o are being encouraged as tolerated medications fer in ml p o daily vitamin e international units p o daily car seat position screening is recommended prior to discharge state laboratory screen has been sent times one results are pending no immunizations have been given immunizations recommended 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 two of the following daycare during rsv season a smoker in the household neuromuscular disease airway abnormalities or school age siblings or with chronic lung disease 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 house hold contacts and out of home caregivers follow up appointments scheduled recommended none on discharge from the infant should have follow up with his pediatrician discharge diagnoses prematurity twin number two small for gestational age mild apnea of prematurity hyperbilirubinemia treated sepsis ruled out without antibiotics dictated by medquist d t job cc,"{
""Diagnoses"": [""premature rupture of membranes"", ""twin gestation"", ""premature small for gestational age""],
""Medications"": [""betamethasone""]
}"
65723,admission date discharge date date of birth sex m service medicine allergies phenytoin tegretol attending chief complaint brbpr hypotension major surgical or invasive procedure colonoscopy history of present illness the patient is a year old male with a history of stroke residual partial aphasia cad hypertension diastolic chf with recent switch to torsemide and afib with recent initiation dabigatran who presents with brbpr he had a visit with his pcp at which he was feeling well with recent improvement in his le edema and breathing after switching to torsemide on immediately after the visit and over the next days he felt intermittently lightheaded but otherwise close to his baseline earlier today he noted brb after a bowel movement which was new for him given his recent initiation of dabigatran in he was concerned by the bleeding and contact his pcp recommended evaluation he denies any bruising or easy bleeding other than the above mentioned blood in his diaper over the past couple of hours that is daughter has been with him he has not had any stools and he reported that for the most part his stools have been brown in the ed initial vs were t hr bp rr and spo on ra physical exam showed irregular tachycardia clear lungs slight le edema and benign abdomen rectal exam was notable for bright red blood and streaks of brown stool notable labs included hct down from on creatinine up from baseline with creatine on most likely spurious cxr showed no acute process with clear lung fields and mild moderate cardiomegaly ecg showed atrial fibrillation at bpm with rbbb unchanged from prior on gi was consulted and recommended observation with consideration of cta if developing rapid bleeding access was obtained with three g pivs he was given normal saline ml with continued mild tachycardia and blood pressure s s which seems to be slightly below his baseline of around seen at recent clinic visits he was also given about ml of sodium bicarbonate meq in d w in anticipation of possible need for cta he was admitted to the micu for continued monitoring vs prior to transfer were t hr bp rr and spo on ra on arrival to the micu he reported feeling close to his baseline without any specific complaints past medical history htn bph history of cva post meningioma resection history of seizure disorder post meningioma resection history of l inguinal hernia repair depression history of cad s p vessel cabg hyperlipidemia social history denies tobacco alcohol or illicits retired from work at the post office his wife is currently in a and the patient lives alone family history non contributory physical exam admission exam vs bp hr rr spo on ra gen elderly male in nad oriented x mild aphasia pleasant and appropriate heent ncat sclera anicteric perrl eomi conjunctiva without pallor or injection mmm op clear neck supple jvp not elevated no cervical lymphadenopathy cv irregularly irregular with normal rate somewhat distant heart soudns normal s s no m r g appreciated chest respiration unlabored no accessory muscle use ctab with no crackles wheezes or rhonchi abd normal bowel sounds soft nt nd no organomegaly abdominal aorta not enlarged by palpation no abdominal bruits ext wwp le edema bilaterally distal pulses intact radial dp and pt skin chronic venous stasis changes on les no major ecchymoses hematomas or petechiae neuro cn ii xii grossly intact strength in all extremities discharge exam vs ra weight kg gen elderly male in nad oriented x mild aphasia gets aggitated when discussing prolonged hospitalization but redirectable heent ncat scleara anicteric dry mm neck supple jvp to mandible cv irregularly irregular and tachycardic no m r g appreciated chest respiration unlabored no accessory muscle use ctab with no crackles wheezes or rhonchi abd normal bowel sounds soft nt nd ext wwp improved no ankle ttp ttp left plantar facia neuro cn ii xii grossly intact strength in all extremities pertinent results admission labs 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 am blood calcium phos mg pm blood lactate pertinent labs am blood ck cpk pm blood alt ast ck cpk am blood ck cpk am blood alt ast ck cpk am blood ck cpk am blood ck cpk am blood ck mb mb indx ctropnt pm blood ck mb mb indx ctropnt am blood ck mb mb indx ctropnt dishcarge labs imaging cxr the patient is status post sternotomy the heart is mild to moderately enlarged the aortic arch is partly calcified the cardiac mediastinal and hilar contours appear unchanged the lungs appear clear there are no pleural effusions or pneumothorax mild to moderate osteophytes are noted along the visualized thoracolumbar spine final report indication swelling comparison none available le ultrasound findings waveforms in the common femoral veins are symmetric bilaterally with appropriate response to valsalva maneuvers in both lower extremities the common femoral proximal greater saphenous superficial femoral and popliteal veins are normal with appropriate compressibility wall to wall flow on color doppler analysis and response to waveform augmentation wall to wall flow is also present in the posterior tibial and peroneal veins on the left as well as in the posterior tibial veins on the right the peroneal vein in the right calf was not visualized just anterior to the right common femoral vasculature proximal to the insertion of the greater saphenous vein is a large ovoid hypoechoic collection measuring x cm without internal vascularity impression no deep venous thrombosis in either lower extremity the peroneal veins in the right calf were not visualized ovoid hypoechoic collection measuring cm in the right groin possibly a seroma chronic hematoma or lymphocele results discussed via telephone by dr with dr via telephone at on the study and the report were reviewed by the staff radiologist dr dr approved pm cxr final report single frontal view of the chest reason for exam fever right pneumonia comparison is made to the prior study mild to moderate cardiomegaly is stable vascular congestion has resolved the left lobe is clear there is no pneumothorax if any there is a small right pleural effusion multifocal right lung opacities have improved consistent with improving pneumonia dr approved pm video swallow final report history year old man with history of cva query for silent aspiration findings swallowing videofluoroscopy was performed in conjunction with the speech and swallow division multiple consistencies of barium were administered intermittent trace to mild laryngeal penetration was noted with thin liquid there was no gross aspiration impression trace to mild penetration with thin liquid no gross aspiration for full details please see detailed speech and swallow therapist s note in omr the study and the report were reviewed by the staff radiologist dr dr approved sat pm microbiology all negative stool clostridium difficile toxin a b test final inpatient urine urine culture final inpatient urine urine culture final inpatient blood culture blood culture routine final inpatient blood culture blood culture routine final inpatient stool clostridium difficile toxin a b test final inpatient urine urine culture final inpatient blood culture blood culture routine final inpatient blood culture blood culture routine final inpatient mrsa screen mrsa screen final inpatient 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 mg brief hospital course primary reason for admission the patient is a year old male with a history of stroke residual partial aphasia cad hypertension diastolic chf with recent switch to torsemide and afib with recent initiation dabigatran who initially presented with bright red blood per rectum in the setting of acute kidney injury brbpr hypotension he presented with one day of moderate brbpr in the setting of elevated coags and supratherapeutic dabigatran most likely related to his hct was on admission from baseline on and subsequently dropped to after iv fluids in the ed he never required transfusion his last colonoscopy was in showed only polyps and grade internal hemorrhoids he was seen by gi and admitted to the micu where his hcts were trended and were stable for h did not require transfusion asa pradaxa lisinopril terazosin and torsemide were all initially held and after discussion with outpatient pcp trifletti and cardiology dabigatran was restarted at mg to reduce risk of bleeding given fluctuating creatinine clearance colonoscopy inconclusive capsule endoscopy without any sites of recent acitve bleeding endoscopy with gastritis with recent bleeding and esophagitis the bleeding was thought most likely due to his hemorrhoids while patient frquent had blood pressures with systolics in the s on the floor he was always mentating at baseline and asymptomatic these blood pressures were thought not to be due from infection or bleeding but from increases in his required nodal agents for atrial fibrillation on ckd his creatinine was on admission from a baseline around on he was recently switched from furosemide to torsemide on with marked decrease in his le edema he saw his pcp where his creatinine was reported as but with bun most likely this creatinine value was spurious his ua on admission was completely bland he does have a history of bph but denied any recent change in urinary habits he was given gently ivf recussitation with improvement in his cr to baseline feurea was consistent with pre renal process creatinine had improved to baseline by time of discharge we recommend follow up of his electrolytes in week after discharge chronic diastolic chf his last tte was on with lvef he is followed by dr in cardiology and was recently switched from furosemide to torsemide with marked improvement in his le edema and overall volume status over the last few weeks given his current at admission he was thought to be over diuresed on this new regimen he received about ml iv fluids in the ed with continued respiratory stability and improvement in his cr he remained off his torsemide due to continued tachycardia and fevers with hcap and insensible losses approximately patient began developing increased le edema ankle pain and weight torsmide was restarted and then patient was aggresively diuresed with lasix cardiology was consulted and followed and he was discharged on home furosemide at a weight of kg his weight should be checked daily and if increase in more than pounds he should be given toresmide mg for two days and the cardiology doctor should be called atrial fibrillation he was recently started on dabigatran in for new persistent afib flutter and chads score with a prior cva he was on metoprolol succinate mg po daily for rate control at home his metoprolol was held in the micu in the setting of recent gib while on the medical floor patient developed afib with rvr with rates up to the s s without hemodynamic changes and without mental status changes this was thought likely due to volume overload status and left atrial dilation though did not develop signs of pulmonary edema on exam it was also thought that fever could suggest infectious etiology for rapid rates less likely pe as no calf tenderness no pulmonary cardiac sxs and lenis negative on he was uptitrated to maximum doses of metoprolol and diltiazem cardiology was consulted and planned for tee with cardioversion if rates did not improve with diuresis however tee was aborted due to trauma observed in the posterior oralpharynx dabigatran was restarted at mg after gi evaluation was completed plan is for outpatient cardiolgy evaluation in wees and consideration of cardioversion vs tee cardioversion in approximately month on dabigatran to reduce risk of blood clots embolizing patients heart rates at discharge were s thought adequate by cardiology diltiazem can be increased if needed to mg daily seizure history he has a seizure history s p meningioma resection and cva in he has not had any recent seizures besides his baseline aphasia and difficulty following instructions he did not have any changes in his neurologic exam his keppra was renally dosed to mg po bid home mg po bid hcap completed days of vanc zosyn on continues to saturate well on room air fever after treatment for hcap patient with high grade fever overnight to differential includes infectious stopped vanc zosyn days ago cxr with resolving pneumonia blood cultures pending and ua uctx shows hematuria with low number of wbcs to rbcs reviewed le u s with radiology and right groin cm fluid collection thought to be chronic and not an abscess possibly related to past cardiac catheterizations cdiff negative earlier during hospitalization on he had low grade temperatures approx during the remainder of his hospital course which were not thought to be indications of fever tracheal ulcer per gi on capsule tracheal ulcer seen while patient coughing though capsule never actually below glottis pictures obtained from gi today and were sent to ent and ip given patient has nonspecific sxs ip consulted they recommend outpatient management which they have arranged f u for rhabdomylysis during afib with rvr on patient noted to have new ek changes and a ck was checked which was this downtrended with ivf and stopping his statin to the normal range possibly due to viral illness later developed fever statin use statin restarted at lower dose of mg due to diltiazem on and cks remained stable they should be checked again with lipids in approximately weeks oralpharyngeal bleeding on in setting of possible tee trauma they did not pass probe past oral space no active bleeding or lacerations found by ent he should continue inhaled saline mist nebulizers and presedex at discharge will need outpatient ent f u at new ecg changes h o cad s p vessel cabg asymptomatic but new st segment depression in i avl earlier in admission ruled out for mi and asymptomatic hyperlipidemia decreased dose of simvastatin to mg given addition of diltiazem depression continued home sertraline bph given hypotension alpha blocker was held transitional issues check electrolytes in week monitoring of lipids cks given rhabdomylysis in weeks his weight should be checked daily and if increase in more than pounds he should be given toresmide mg for two days and the cardiology doctor should be called for atrial fibrillation plan is for outpatient cardiolgy evaluation in weeks and consideration of cardioversion vs tee cardioversion in approximately month on dabigatran to reduce risk of blood clots embolizing if blood pressure consistently above systolic would restart alpha blocker terazosin and then lisinopril medications on admission dabigatran mg po bid aspirin mg po daily atorvastatin mg po daily lisinopril mg po daily metoprolol succinate mg po daily torsemide mg po daily levetiracetam mg po bid terazosin mg po daily oxybutynin er mg po daily sertraline mg po daily discharge medications sertraline mg tablet sig two tablet po daily daily oxybutynin chloride mg tablet extended rel hr sig one tablet extended rel hr po once a day dabigatran etexilate mg capsule sig one capsule po bid times a day aspirin mg tablet chewable sig one tablet chewable po daily daily atorvastatin mg tablet sig one tablet po once a day metoprolol succinate mg tablet extended release hr sig two tablet extended release hr po q h every hours torsemide mg tablet sig one tablet po daily daily levetiracetam mg tablet sig one tablet po bid times a day omeprazole mg capsule delayed release e c sig one capsule delayed release e c po bid times a day acetaminophen mg tablet sig two tablet po q h every hours as needed for pain diltiazem hcl mg capsule extended release sig three capsule extended release po daily daily chlorhexidine gluconate mouthwash sig five ml mucous membrane times a day for weeks docusate sodium mg capsule sig one capsule po twice a day senna mg tablet sig one tablet po at bedtime as needed for constipation discharge disposition extended care facility livingcenter elmhurst discharge diagnosis primary gastritis esophagitis health care associated aspiration pneumonia atrial fibrillation with rvr acute on chronic diastolic chf discharge condition mental status confused always more than confused has aphasia with wrong word choice level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions you were admitted to because of bleeding from your gastrointestinal tract we think this was because of worsening kidney disease while you were on pradaxa a medication which is processed by the kidney while you were here your bleeding resolved and you did not require any blood transfusions you had an endoscopy colonoscopy and capsule endoscopy which found inflammation in the lining of your esophagus swallowing tube and stomach and hemorrhoides which may have been the cause of the bleeding while you were here you also had a pneumonia which resolved with one week of antibiotics you had uncontrolled heart rates from your atrial fibrillation and your chf worsened as your torsemide was initially stopped because of worsening kidney function you were given lasix to improve this cardiology followed you for the afib and chf your water pill torsemide was restarted once your kidneys improved you are now on new medications for your heart rate and the cardiology team wants to continue to see you as an outpatient for consideration of cardioversion to put your heart into a normal rhythm while you were here you also had trauma to the back of your mouth from one of the camera probes you were seen by an ear nose and throat doctor who did not find any ongoing bleeding or injury which needed intervention you were found to maybe have an ulcer in your trachea swallowing tube for these reasons you will see and ear nose and throat doctor and an interventional pulmonologist while you were here some of your medications were changed you should decrease pradaxa from mg twice a day and instead start mg twice a day decrease simvastatin from mg once a day and instead start mg once a day decrease keppra from mg twice a day and instead start mg twice a day increase toprol from mg daily to mg twice a day start diltiazem mg daily start omeprazole twice a day start chlorhexidine rinses for your mouth start docusate for constipation and senna if needed continue to take all other medications as prescribed by your doctors weigh yourself every morning md if weight goes up more than lbs followup instructions department hematology oncology for tracheal ulcer when thursday am with md building sc clinical ctr campus east best parking garage department cardiac services when wednesday at am with m d building sc clinical ctr campus east best parking garage department when wednesday at am with md building ma campus off campus best parking free parking on site department cardiac services when wednesday at am with md building sc clinical ctr campus east best parking garage department otolaryngology ent when wednesday at am with m d building lm campus west best parking garage,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""m"", ""service"", ""medicine"", ""allergies"", ""phenytoin"", ""tegretol""],
""Medications"": [""torsemide"", ""afib"", ""dabigatran""]
}"
96429,admission date discharge date date of birth sex f service medicine allergies penicillins phenobarbital sulfa sulfonamides latex attending chief complaint shortness of breath and palpitations major surgical or invasive procedure transesophageal echocardiogram history of present illness ms is a year old female with pmh of dm aortic stenosis dchf and new diagnosis of atrial fibrillation who was admitted from cardiology clinic for chf exacerbation and transferred to the ccu for atrial fibrillation with rvr she initially experienced dyspnea with associated palpitations in at that time she was noted to be tachycardic to the s but with regular rhythm she was later found to be in afib with rvr to the s and her dyspnea was attributed to her atrial fibrillation she was started on coumadin and metoprolol on she had a cxr showing pulmonary edema and was started on lasix her creatinine rose on this to from she was seen in cardiology clinic today and was volume overloaded on exam and tachycardic although in sinus rhythm so she was sent to on the floor she was initially feeling well she developed atrial fibrillation with associated symptomatic hypotension systolics in the s she was treated with metoprolol mg iv however this was limited by hypotension so she was cardioverted with a shock she was also given a loading dose of amidoarone iv and starting on an amiodarone drip on arrival to the ccu she was normotensive in sinus rhythm without complaint on review of systems she reports feelings of anxiety associated with her palpiations she reports significant doe and leg edema she admits to feeling exhausted while on metoprolol she also reports chronic pain in her hips she denies any prior history of stroke tia deep venous thrombosis pulmonary embolism bleeding at the time of surgery myalgias 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 on cardiac review of systems she admitted to doe dyspnea with her palpiations and leg edema she denied any pnd or orthopnea past medical history diabetes dyslipidemia hypertension aortic stenossis lbbb lvh diastolic chf hypothyroid traumatic brain injury social history tobacco history quit in smoked ppd x years etoh none illicit drugs none divorced lives alone sons writing a memoir of a life s p traumatic brain injury family history mother had multiple mis no other heart disease sudden death or dysrhythmia in other relatives physical exam vs t bp hr rr o sat on lnc general y o f in nad mood affect appropriate heent ncat sclera anicteric perrl pupils reactive l pupil larger than r pupil chronic change after pt s head injury conjunctiva were pink no pallor or cyanosis of the oral mucosa neck supple no significant jvd noted cardiac rrr systolic murmur loudest at the rusb lungs pt developed sob when trying to sit up no respiratory distress when lying flat lungs cta anteriorly abdomen soft ntnd no hsm or tenderness bowel sounds present extremities pitting edema in the bilateral lower extremities no calf pain noted dp pulses palpated bilaterally pertinent results admission labs 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 am blood calcium phos mg pm blood tsh pm blood alt ast ld ldh ck cpk alkphos totbili cardiac biomarkers pm blood ck cpk ck mb notdone ctropnt am blood ck cpk ck mb notdone ctropnt pm blood ck cpk ck mb notdone ctropnt pm blood probnp cxr there has been no appreciable interval change left infrahilar atelectasis and small bilateral pleural effusions persist heart size is top normal multiple right rib fractures are chronic no pneumothorax tee no spontaneous echo contrast or thrombus is seen in the body of the left atrium left atrial appendage or the body of the right atrium right atrial appendage right atrial appendage ejection velocity is good cm s no atrial septal defect is seen by d or color doppler there are simple atheroma in the ascending aorta there are simple atheroma in the aortic arch there are simple atheroma in the descending thoracic aorta there are three aortic valve leaflets the aortic valve leaflets are moderately thickened trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen there is a trivial physiologic pericardial effusion impression no intracardiac thrombus seen discharge labs 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 summary year old female with pmhx of dm aortic stenosis dchf and new diagnosis of atrial fibrillation who was admitted from cardiology clinic for chf exacerbation on the floor she went into afib with rvr became hypotensive and was emergently cardioverted she was transferred to the ccu where another cardioversion was required despite another cardioversion after an amiodarone load she was discharged in atrial fibrillation at bpm though tolerating this rate well by problem atrial fibrillation pt arrived on the floor and developed rvr with inability to sustain a normal blood pressure she underwent cardioversion on the floor and then was transferred to the ccu for furhter monitoring she was also started on amiodarone drip when she was on the floor which was converted to a po amiodarone load while she was in the ccu her tsh was checked on admission and was borderline low her thyroid medications were held she required and was failed by another cardioversion before transfer back to the floor for a third cardioversion before which she developed florid pulmonary edema thereafter she had an improving fluid status and stable blood pressure she was discharged on amiodarone for one month with mg digoxin she will then transition to once daily amiodarone acute on chronic systolic heart failure likely related to pt s atrial fibrillation on admission she was started on a lasix gtt for diuresis this was ultimately transitioned to a po lasix regimen her ef on tee was acute renal failure prior to admission the patient had a bump in her creatinine in the setting of starting lasix it was thought that this could be pre renal in the setting of diuresis versus to poor forward flow in the setting of her atrial fibrillation her creatinine was already improving at time time of her admission and it continued to improve during her hospital course diuresis was continued as above diabetes she is on metformin at home which was initially held acute renal failure she was placed on an iss metformin was restarted when creatinine improved hypothyroidism the patient was not entirely clear on her home dose as above tsh was borderline low on admission and thyroid meds were held during her ccu course she was counselled against taking any unregulated thyroid supplements her correct thyroid dose must be determined out patient dyslipidemia continue atorvastatin hypertension lisinopril was held on admission acute renal failure she was slightly hypotensive during her hospital course accordingly her ace was held on discharge medications on admission coumadin simvastatin mg a day metformin mg b i d lisinopril mg daily thyroid hormone mg multivitamin glucosamine chondroitin multiple other herbal remedies glucobalance primeve digest calcigard ultra potency cytozyme pan quercetin nature thyroid coenzyme q dhea adhs phosp medications on transfer metoprolol tartrate mg po ng metoprolol tartrate mg iv once mr multivitamins tab po ng daily glucagon mg im q min prn hypoglycemia protocol dextrose gm iv prn hypoglycemia protocol insulin sc per insulin flowsheet sliding scale lorazepam mg po ng q h prn anxiety insomnia simvastatin mg po ng daily warfarin mg po ng daily furosemide mg iv once furosemide mg hr iv drip infusion hatidylserine hydro zyme epa dha cognizin cal apatite with boron lipo discharge medications simvastatin mg tablet sig one tablet po daily daily multivitamin tablet sig one tablet po daily daily acetaminophen mg tablet sig two tablet po q h every hours as needed for pain or fever 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 amiodarone mg tablet sig two tablet po twice a day take this dose for one month your cardiologist will adjust it thereafter disp tablet s refills metformin mg tablet sig two tablet po bid times a day digoxin mcg tablet sig one tablet po daily daily disp tablet s refills warfarin mg tablet sig one tablet po once daily at pm disp tablet s refills levothyroxine mcg tablet sig tablet po once a day furosemide mg tablet sig one tablet po daily daily discharge disposition home with service facility vna discharge diagnosis atrial fibrillation acute systolic heart failure diabetes discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted from clinic with fluid overload this was found to be related to an abnormal heart rhythm termed atrial fibrillation in this rhythm your heart could not pump blood very well your blood pressure fell and fluid backed up in your lungs you required electrical cardioversions and a stay in the icu we started new medicines designed to control your rhythm that took a long time to take effect you were discharged to work on your continued rehabillitation new medicines amiodarone a heart rhythm medicine digoxin a heart rhythm medicine hold these medicines lisinopril your blood pressure has been lower this admission and your kidney function has been in flux have your blood pressure and kidney function checked by your pcp prior to restarting this medication thyroid supplements do not take thyroid supplements discuss the dose of your thyroid replacement with your pcp new doses coumadin take mg daily your dose is subject to change and will be guided by inr values weigh yourself every morning md if weight goes up more than lbs followup instructions follow up with coumadin clinic on wednesday md dr specialty internal medicine primary care date time pm location ma phone number appointment md dr specialty cardiology date time am location building ma phone number special instructions for patient you are also placed on a waitlist for an earlier appointment completed by [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies penicillins phenobarbital sulfa sulfonamides latex attending chief complaint sob hyponatremia major surgical or invasive procedure biv pacemaker placement history of present illness year old woman with recent onset atrial fibrillation on coumadin s p unsuccessful cardioversion hypertension lvh type diabetes hba c on moderate aortic stenosis left bundle branch block prior tobacco use diastolic and systolic chf s p multiple admissions hypothyroidism and prior traumatic brain injury p w worsening le edema increasing doe and found to have new hyponatremia to from on of note she was recently discharged on with chf exacerbation new afib renal failure tte that admission showed dilated lv with depressed ef and moderate severe mitral regurgitation and pap were mildly elevated mmhg this was presumed due to her tachyarrythmia the severity of aortic stenosis could not adequately be assessed she had a cardioversion and was discharged in nsr but appears to have gone back into afib shortly thereafter she is on amiodarone digoxin and coumadin her dry weight is pounds and patient reports gaining pounds over the past two weeks on she had been told to hold her home lasix mg po bid because her weight was decreasing and she was felt to be clinically dry with low bp s then because she was having increasing weight edema doe she called her cardiologist who advised her to restart lasix mg and hold home lisinopril patient was still complaining of sx and advised to increase lasix to mg daily she was also c o nausea told ok to hold digoxin and coumadin but to come in on monday am for lab testing found to have sodium of and referred to ed in the ed initial vitals were t p bp r on ra and then on l nc patient had two sets of labs to confirm her new hyponatremia to she also had a cxr that showed mild chf no medications were given in the ed cardiology and nephrology were consulted her hematocrit was noted to be slightly lower but guaiac was negative her inr is upon speaking with the patient and her son days ago patient had onset of fatigue weakness doe low uop which has been progressing to the point where she only has the energy to sit up and eat she denies cp denies angina she does endorse intermittent nausea vomiting on saturday constipated x days but passing flatus no abdominal pain no blood in stool no black stools son also notes she has been increasingly confused with memory difficulty she denies any new neurologic deficits on review of systems she denies any prior history of 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 diabetes afib s p multiple cardioversions dyslipidemia hypertension aortic stenossis lbbb lvh diastolic systolic chf last ef in hypothyroid traumatic brain injury social history tobacco history quit in smoked ppd x years etoh none illicit drugs none divorced lives alone sons writing a memoir of a life s p traumatic brain injury family history mother had multiple mis no other heart disease sudden death or dysrhythmia in other relatives physical exam general wdwn female in nad alert oriented x slow to speak memory difficulty defers many questions to son sclera anicteric perrl eomi conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthalesma neck supple with jvp to the angle of the jaw at degrees cardiac pmi located in th intercostal space midclavicular line tachycardic rate normal s s iii vi systolic murmur lungs rales to lung fields b l abdomen soft ntnd no hsm or tenderness extremities pitting edema b l wwp neuro pronator drift on left mild weakness in lue c w baseline cn ii xii intact ftn intact b l pertinent results labs on admission am glucose urea n creat sodium chloride total co am ctropnt am probnp am wbc rbc hgb hct mcv mch mchc rdw am pt ptt inr pt labs 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 mg am blood vitb folate greater th pm blood caltibc hapto ferritn trf pm blood free t pm blood tsh imaging cxr findings the heart size is enlarged mild prominence of the central pulmonary vasculature is noted as well as small bilateral pleural effusions consistent with mild chf unchanged left retrocardiac atelectasis there is no pneumothorax unchanged orthopedic intramedullary nail in the right humerus impression findings consistent with mild chf echo the left atrium is dilated left ventricular wall thicknesses are normal the left ventricular cavity is mildly dilated overall left ventricular systolic function is severely depressed lvef with inferior akinesis septal dyskinesis and apical akinesis dyskinesis with hypokinesis elsewhere lateral base moves best the right ventricular cavity is dilated with mild global free wall hypokinesis intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation the aortic valve leaflets are moderately thickened there is an echogenic structure associated with the right cusp see clip that is likely due to cusp thickening deformation or prominent lambl s excrescence generally an incidental finding cannot definitively exclude vegetation this echogenic structure was not seen in the prior study but the aortic valve was not as well visualized in the prior study there is moderate aortic valve stenosis valve area cm trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened moderate to severe mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened moderate tricuspid regurgitation is seen there is mild pulmonary artery systolic hypertension there is a trivial physiologic pericardial effusion compared with the prior study images reviewed of left ventricular systolic function appears more depressed the septum is now dyskinetic right ventricular systolic function appears slightly more depressed echogenic structure asosciated with aortic valve as noted above mri head c spine no definite evidence for acute intracranial pathology brief hospital course ms is a year old woman with recent onset atrial fibrillation on coumadin s p unsuccessful cardioversion hypertension lvh type diabetes hba c on moderate aortic stenosis left bundle branch block prior tobacco use diastolic and systolic chf s p multiple admissions hypothyroidism and prior traumatic brain injury p w chf exacerbation and severe hyponatremia hyponatremia patient with drop in sodium from in less than two weeks though likely in last week based on history likely hypervolemic in nature given history and exam sodium trended up to with iv lasix no acute mental status changes na aat discharge free water restriction in place acute on chronic systolic and diastolic chf last ef now depressed to thought to be secondary to tachyarrythmia in the past atrial fibrillation has contributed significantly to her exacerbations so she was evaluated by ep for ablation this was done see below and rates now paced could not tolerate acei and beta blocker given hypotension so these were held at discharge weight on day of discharge and furosemide mg cont qod lungs are clear and pt has diffuse peripheral edema please weigh daily and consider changing furosemide to mg daily if weight increases atrial fibrillation flutter rate in low s on admission has had multiple unsuccessful cardioversions for afib in the past ep was consulted and av node ablation with biv pacer was done on her pacer site is near left shoulder and has no ecchymosis or significant tenderness she will be on clindamycin po for total of days to prevent infection at the site a device clinic appt was made for one week after procedure in conjunction with an echo she will see her outpt cardiologist at the end of the month amiodarone and digoxin was discontinued after ablation inr in mid s on mg warfarin daily would check inr qod while pt on clindamycin coronaries no caths in past not thought to have ischemic cardiomyopathy as cause of heart failure troponins flat on admission despite several days of symptoms so likely not causing her symptoms not currently on asa consider baby asa due to anemia found to be fe deficient with drop from to in few days stool ob negative and no other obvious signs of bleeding thought that phlebotomy was a contributing factor but should consider repeat colonoscpoy if this continues to be an issue after discharge ferrous sulfate was started on hemolysis labs were negative on diabetes on metformin at home last hga c hiss inhouse given rising creatinine metformin was not started on d c but should be restarted when creatinine stable hypothyroidism continued synthroid dyslipidemia continued atorvastatin hypertension pt has been hypotensive for most of hospital stay lisinopril was held but should be restarted if systolic bp consistantly medications on admission acetaminophen mg q hrs prn digoxin mcg daily docusate sodium mg levothyroxine mcg daily metformin mg not taking nausea multivitamin tab daily simvastatin mg daily bisacodyl mg daily senna mg amiodarone mg daily warfarin mg daily furosemide mg daily discharge medications clindamycin hcl mg capsule sig one capsule po every six hours for days simvastatin mg tablet sig one tablet po daily daily levothyroxine mcg tablet sig tablets po daily daily multivitamin tablet sig one tablet po daily daily acetaminophen mg tablet sig tablets po every eight hours as needed for pain psyllium g wafer sig wafers po bid times a day take with full glass of water furosemide mg tablet sig tablet po every other day every other day ferrous sulfate mg mg iron tablet sig one tablet po daily daily docusate sodium mg capsule sig one capsule po bid times a day warfarin mg tablet sig three tablet po once daily at pm goal inr trazodone mg tablet sig tablet po hs at bedtime as needed for insomnia senna mg tablet sig tablets po bid times a day as needed for constipation bisacodyl mg tablet sig two tablet po once a day hold for diarrhea discharge disposition extended care facility for the aged discharge diagnosis supraventricular tachycardia acute on chronic systolic congestive heart failure hypertention diabetes mellitus type hypothyroidism hyponatremia 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 an exacerbation of your congetive heart failure and your low sodium level worsened you were diuresed to take of the fluid and it is thought that your high heart rate is contributing to the congestive heart failure we were unable to slow your heart rate with medicines and you did not tolerate the beta blocker you had an av node ablation and a biventricular pacemaker was placed on you tolerated this without complications you became quite anemic during your hospital stay possibly becuase of frequent lab tests but possibly because of some bleeding in your gi tract you will need to have your blood counts followed closely and should consider another colonoscopy if you continue to be anemic we have started you on iron tablets to help your body make more blood we made the following changes to your medicines discontinue the amiodarone and digoxin discontinue the lisinopril because your blood pressures are low started clindamycin for days total to prevent an infection at the pacer site start metamucil wafer and colace to prevent constipation start ferrous sulfate iron to help your body make blood decrease the lasix to mg every other day stop metformin for now with creatinine rising start trazadone to help you sleep at night weigh yourself every morning md if weight goes up more than lbs followup instructions primary care r phone date time please make an appt to see dr when you get home cardiology provider phone date time provider clinic phone date time pm clinical center provider md phone date time clinical center completed by [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies penicillins phenobarbital sulfa sulfonamide antibiotics latex gluten attending chief complaint hypotension major surgical or invasive procedure right total hip arthroplasty blood transfusion history of present illness ms is a year old woman now status post hip replacement being transferred to the cardiology service for continued evaluation of hypotension was initially admitted on for right hip replacement post operatively at her systolic blood pressures fell to the high s systolic by aline s by cuff she was asymptomatic at that time in response to the bp and a hct of she was transfused units of prbc also received two cc bolus of ivf she was evaluated by the cardiology team who found that her bp was improved with a pa pressure of and a wedge of mmhg currently she is feeling well and is without complaint she walked with pt and feels strong ros weight loss lbs a few years back since then stable fevers chills cp sob palps urinary frequency chronic no dysuria shoulder pain chronic calf pain right chronic all other ros negative past medical history hypertension diabetes hyperlipidemia aortic stenosis cm peak grad mmhg mean grad mmhg congestive heart failure ef biv pacemaker atrial fibrillation multiple dccv avj ablation lbbb hypothyroidism traumatic brain injury social history prior smoking history quit in smoked ppd x years no alcohol or drug use divorced lives alone and has sons writing a memoir of a life s p traumatic brain injury uses a walker at baseline family history mother had multiple mis no other heart disease sudden death or dysrhythmia in other relatives physical exam vitals bp hr rr on room air general lying in bed comfortable eyes anicteric no pallor right neck bandaged no carotid bruits noted cv sounds regular systolic murmur heart loudest at rusb but noted throughout including at apex s heard no radiation to carotids pulm clear no rales wheeze abdomen soft non tender ext warm right hip bandaged with edema noted trace bilateral lower extremity edema dp pulses palpable bilaterally integument no rashes neuro alert and oriented able to provide clear history strenght exam somewhat limited by pain left arm and leg appear to have full strength right arm is limited by pain especially at shoulder right leg also limited given post operative hip psych appropriate pertinent results admission labs wbc rbc hgb hct mcv mch mchc rdw plt ct neuts bands lymphs monos eos baso atyps metas myelos pt inr pt glucose urean creat na k cl hco angap tee intra operative no spontaneous echo contrast is seen in the left atrial appendage overall left ventricular systolic function is moderately depressed lvef basal segments contract well but all mid segments are hk and the apex is akinetic there is moderate global free wall hypokinesis there are simple atheroma in the descending thoracic aorta there are three aortic valve leaflets the aortic valve leaflets are moderately thickened there is critical aortic valve stenosis valve area cm no aortic regurgitation is seen the mitral valve leaflets are moderately thickened mild to moderate mitral regurgitation is seen there is no pericardial effusion pacing leads are seen in the right atrium and coronary sinus tte the left atrium is elongated no atrial septal defect is seen by d or color doppler left ventricular wall thicknesses are normal the left ventricular cavity size is top normal borderline dilated there is mild regional left ventricular systolic dysfunction with infero lateral hypokinesis rv with borderline normal free wall function the diameters of aorta at the sinus ascending and arch levels are normal the aortic valve leaflets are moderately thickened there is moderate to severe aortic valve stenosis valve area cm trace aortic regurgitation is seen the mitral valve leaflets are mildly thickened mild mitral regurgitation is seen the tricuspid valve leaflets are mildly thickened moderate tricuspid regurgitation is seen there is mild pulmonary artery systolic hypertension there is no pericardial effusion compared with the prior study images reviewed of lvef and rvef have increased ecg atrial rhythm is afib ventricular pacer with qs in lead i likely due to biv imaging pelvis impressions expected post operative changes after total right hip arthroplasty hip findings complete right hip replacement the prosthetic components are in correct position no evidence of fracture discharge labs 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 calcium phos mg brief hospital course year old woman with as cm schf ef s p biv pm and af who underwent total right hip replacement this hospitalization and whose course was complicated by fluid responsive post operative hypotension treated with units of prbcs active issues right total hip replacement at the time of this discharge summary an operative note is not in omr on discharge the patient is able to ambulate and there is no evidence of hematoma at the incision site post operative hypotension and anemia the patient had an episode of post operative hypotension in the pacu and received units of prbc in conjunction with ivf with an appropriate bump in her hct and resolution of her hypotension her hct is stable at about on discharge repeat tte was stable post operative thrombocytopenia patient s plt count was steadily trending in low s post operatively and the etiology remains unclear but it is likely related to intraoperative bleeding plts will need to be followed after discharge inactive issues atrial fibrillation remained hemodynamically stable in af and rate controlled on metoprolol unchanged from outpatient dosing anticoagulated with enoxaparin as an inpatient and bridged to unchanged warfarin dosing on discharge inr will need to be closely followed after discharge chronic schf lisinopril was held in the acute setting of hypotension but restarted unchanged from outpatient dosing tte as detailed above showed improved rvef and lvef hypothyroidism unchanged home dosing of levothyroxine remained full code for the duration of the hospitalization transitional issues as above in medications on admission furosemide mg when weight lbs levoxyl mg daily lisinopril mg daily prandin mg daily simvastatin mg daily klor con meq daily trazodone mg daily warfarin tylenol prn ascorbic acid probiotic calcium ferround gluconate glucosamine chondroitin guaifenesin magnesium mvi dhea psyllium discharge medications lisinopril mg tablet sig one tablet po daily daily simvastatin mg tablet sig one tablet po daily daily furosemide mg tablet sig one tablet po once a day as needed for when weight greater than lbs klor con meq tablet sustained release sig one tablet sustained release po once a day as needed for take with furosemide when weight greater than lbs weigh yourself daily weigh yourself daily take furosemide as prescribed if weight greater than lbs call your cardiologist if your weight does not decrease with this medication warfarin mg tablet sig one tablet po once a week take saturdays warfarin mg tablet sig one tablet po days per week not saturdays daily dose days per week is mg one mg tablet plus one mg tablet equals mg warfarin mg tablet sig one tablet po days per week not saturdays daily dose days per week is mg one mg tablet plus one mg tablet equals mg levothyroxine mcg tablet sig tablets po daily daily prandin mg tablet sig one tablet po once a day ferrous gluconate powder miscellaneous dhea oral ascorbic acid oral calcium d oral probiotic oral glucosamine sulf chondroitin oral guaifenesin oral magnesium oral multivitamin oral acetaminophen mg tablet sig two tablet po q h every hours oxycodone mg capsule sig one capsule po every hours as needed for pain disp capsule s refills 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 ondansetron mg film sig one film po every eight hours as needed for nausea enoxaparin mg ml syringe sig one syringe subcutaneous once a day for days until inr between disp syringes refills check inr check inr fax results to rehab physician check inr fax results to rehab physician check inr fax results to rehab physician continue to check inr until between at that time enoxaparin shots may be stopped as directed by rehab physician discharge disposition extended care facility discharge diagnosis primary right total hip arthroplasty post operative hypotension secondary chronic systolic heart failure atrial fibrillation 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 has been a privilege to take care of you at the you were hospitalized to undergo a total right hip replacement the surgery went well after the surgery you had an episode of low blood pressure in the recovery room you received a blood transfusion and iv fluids which raised your blood pressure into the normal range given your known heart conditions the cardiology service followed you very closely during your episode of low blood pressure and you were subsequently transferred to the cardiology floor from the recovery room on the cardiology floor no changes were made to your heart medicines they continue to be the following continue lisinopril mg daily continue simvastatin mg daily continue warfarin mg saturday mg days week continue to weigh yourself daily md if weight goes up more than lbs continue furosemide mg when weight lbs continue klor con meq daily when you take furosemide you will also need to continue on a blood thinning medication until your coumadin reaches therapeutic levels in your body start enoxaparin until inr between it is normal to experience pain after a major surgery like a hip replacement you are being discharged with the following pain regimen start tylenol mg every hours whether you are in pain or not start oxycodone mg every to hours as needed for pain stop tylenol with codeine start senna to prevent constipation that can result from oxycodone start colace to prevent constipation that can result from oxycodone please continue to take your other medications as previously prescribed they were not changed this hospitalization please attend all of your follow up appointments as detailed below followup instructions department orthopedics when friday at am with pa building sc clinical ctr campus east best parking garage department cardiac services when friday at pm with md building campus east best parking garage department cardiac services when tuesday at pm with device clinic building sc clinical ctr campus east best parking garage,"{
""Diagnoses"": [""Aortic stenosis"", ""Decompensated heart failure"", ""Atrial fibrillation"", ""Rapid ventricular response""],
""Medications"": [""Coumadin"", ""Metoprolol"", ""Lasix"", ""Methylprednisolone""]
}"
16333,admission date discharge date date of birth sex m service cardiothoracic surgery history of present illness briefly the patient is a year old male with a history of an untreated anterior wall mi in the patient presented to his primary care provider two months afterward and it was found that a subsequent stress echo was significant for st elevations in anterior precordial leads during exercise echo showed mild lv cavity dilatation akinetic anterior wall septum and apex the patient was sent to dr for a consult and sent to cardiac mri to evaluate for viability on it showed that he did have some viability and the patient was now being referred for an outpatient cardiac catheterization at the past medical history impotence past surgical history left shoulder surgery from an injury in a motor vehicle accident vertebral injury from a motor vehicle accident the patient has had a hemorrhoidectomy allergies no known drug allergies home medications include lipitor mg q hs lisinopril mg qd atenolol qd aspirin qd plavix qd for month prior to admission and nitroglycerin prn the patient is a nonsmoker hospital course cardiac catheterization showed three vessel coronary artery disease with impaired lv systolic and diastolic function with anterior viability by cardiac mr the patient underwent a cabg x lima to the lad svg to the diagonal svg to lpl svg to pda the patient tolerated the procedure without complication the patient was transferred to the floor on postoperative day and had an uncomplicated hospital course was able to tolerate a regular diet had good po pain control and was able to ambulate satisfactorily for physical therapy the patient was felt to be ready for discharge on postoperative day the patient will be following up with dr in four weeks dr in two weeks and dr his primary care provider one to two weeks discharge medications percocet tablets q h prn ibuprofen mg q h tylenol mg q h prn aspirin mg qd zantac mg until follow up with cardiac surgery colace mg lopressor mg lasix mg x days potassium chloride meq x days condition at discharge good discharge status to home with vna diagnosis status post coronary artery bypass graft x four m d dictated by medquist d t job cc,"{
""Diagnoses"": [""anterior wall MI"", ""coronary artery disease"", ""three vessel coronary artery disease""],
""Medications"": [""Lipitor"", ""Lisinopril"", ""Atenolol"", ""Aspirin"", ""Plavix"", ""Nitroglycerin""]
}"
2252,admission date discharge date date of birth sex m service nb history of present illness baby boy delivered at weeks gestation and was admitted to the newborn intensive care nursery from labor and delivery for management of respiratory distress his birth weight was grams mother is a year old gravida para now woman with the following prenatal screens blood type ab negative antibody negative hepatitis b surface antigen negative rpr nonreactive rubella immune and group b strep unknown pregnancy was uncomplicated by report delivery was by repeat scheduled cesarean section under epidural and spinal anesthesia rupture of membranes occurred at delivery for clear amniotic fluid there was no intrapartum fever or other clinical evidence of chorioamnionitis the infant was initially vigorous at birth with copious secretions he developed secondary apnea and cyanosis at seconds of age and received bag mask ventilation for breaths by anesthesiology upon arrival to the newborn intensive care nursery team the infant had well established spontaneous respirations but developed grunting in the first minutes and was transferred to the nicu for further evaluation apgars were at minute and at minutes physical examination birth weight grams to th percentile length cm th to th percentile head circumference cm th percentile nondysmorphic infant with palate intact mild nasal flaring moderate intercostal retractions decreased breath sounds bilaterally a few scattered coarse crackles well perfused with no murmurs femoral pulses normal abdomen soft nondistended no organomegaly no masses bowel sounds active patent anus three vessel cord normal penis testes descended bilaterally active alert and was responding to stimulation normal tone and reflexes hips stable summary of hospital course by systems respiratory the infant was placed on nasal cpap cm requiring room air at chest x ray consistent with transient tachypnea of the newborn weaned off cpap at hours to age to room air he has remained in room air since with respiratory rates in the to s oxygen saturations to cardiovascular he has had normal blood pressure and heart rate no murmurs recent blood pressure with a mean of fluids electrolytes and nutrition the infant was initially npo and maintained on intravenous fluid of dextrose maintaining normal blood glucoses of s to s he started feels on day of life is ad lib feeding well now voiding and stooling appropriately weight at discharge of g hematology hematocrit on admission bilirubin on dol infectious disease due to respiratory distress cbc and blood culture was drawn on admission and he received hours of ampicillin and gentamycin sepsis was ruled out neurology examination was age appropriate sensory hearing testing passed condition on discharge stable in room air feeling well discharge disposition discharge to home name of primary pediatrician dr care recommendations feeds ad lib breast or bottle feeding medications none state newborn screens drawn on with results pending immunizations received hepatitis b on discharge diagnoses appropriate for gestational age term male infant transient tachypnea of the newborn resolved sepsis ruled out dictated by medquist d t job,"{
""Diagnoses"": [""Respiratory distress"", ""Apnea"", ""Cyanosis""],
""Medications"": [""Bag mask ventilation"", ""Oxygen therapy""]
}"
815,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint food bolus impaction in esophagus major surgical or invasive procedure upper endoscopy x elective tracheal intubation history of present illness pt is a y w a pmh significant for htn who presents tonight w the acute onset of dysphagia and throat pain during a meal the patient was in his usoh until dinner tonight when he noted the above symptoms directly after swallowing he was unable to clear his throat at home and reports being unable to clear oral secretions he reports a past history of prior esophageal food boluses yrs ago that have required egd disimpaction but denies any cp sob fever abdominal pain n v or diarrhea today he denies any history of gerd symptoms and does not have any other significant gi history he has not had any recent dyspagia or odynophagia he denies any recent travel and has had no sick contacts has not had any caustic ingestions he denies a history of rheumatologic conditions or skin changes his past egds have not shown any evidence of stricture or ring and he claims to have had an esophageal motility study in the past that showed a sluggish though non pathologic esophagus in the ed the patient was given glucagon x for presumed esophageal impaction w out resolution of his symptoms and was admitted to the icu for egd managment of an impacted esophageal food bolus past medical history htn food bolus x social history single gay male works as a cpa drinks socially but denies tobacco or drug use lives in family history father w pancreatic cancer grandparents w cad physical exam l heent eomi mmm o p clear neck mild tenderness to palpation at site of bolus cv tachycardic no murmurs lungs cta bilaterally abd s nt nd bs ext no c c e neuro appropriate in conversation moving all extremities spontaneously skin no obvious rashes pertinent results am pt ptt inr pt am plt count am hypochrom normal anisocyt poikilocy macrocyt normal microcyt polychrom normal spherocyt ovalocyt am neuts bands lymphs monos eos basos am wbc rbc hgb hct mcv mch mchc rdw am calcium phosphate magnesium am glucose urea n creat sodium potassium chloride total co anion gap brief hospital course y w a pmh of htn and gerd who presented with an esophageal impacted foreign body esophageal impaction no relief with glucagon in the ed egd was done and showed a tight impaction with food pot roast was found in the middle third of the esophagus at cm from the incisors no ulceration were noted the scope was removed and an overtube was passed to protect the airway while meat impaction was removed the distal esophagus could not be seen despite multiple attempts to go around the bolus the large biopsy forceps and net and colonoscopy snare were used to remove the meat however after mins there was still a wedged piece of meat in the distal esophagus which could not be removed due to the patient becoming restless and concern about leaving the overtube in for a prolonged period of time the pt was electively intubated for airway protection and sedation for a second attempt to remove the foreign body during the second egd a food bolus was again seen in the middle third of the esophagus it was pushed into the stomach with the endoscope and the obstruction was completely removed there were some erosions seen on the site of the bolus in a patient with prior food impaction yrs back a motility disorder and or a schatzki s ring was suspected a mild schatzki s ring was found in the lower third of the esophagus probably not accounting for the impaction a small size hiatal hernia was seen the pt was extubated and his pt s diet was subsequently advanced slowly repeat egd in a few weeks to f u on the ring and biopsy to r o eosinophilic esophagitis was recommended the pt was empricially treated with ceftriaxone for presumed aspiration for days a repeat cxr showed no evidence of aspiration and the patient was asymptomatic there antibiotic coverage was stopped htn atenolol on hold pt normotensive ppx protonix code full medications on admission atenolol discharge medications omeprazole mg capsule delayed release e c sig one capsule delayed release e c po twice a day disp capsule delayed release e c s refills atenolol mg qd discharge disposition home discharge diagnosis food impaction in the esophagus discharge condition good discharge instructions please come back to the hospital immediately if you experience any chest pain fevers problems swallowing or if you have any other concerns continue to take omeprazole mg please continue to take a soft diet for two more days then advance to a regular diet followup instructions please follow up with your primary care doctor within the next week it is recommended that you have a repeat egd in four weeks to follow on the schatzki s ring and to have a biopsy to rule out eosinophilic esophagitis please call the gi department on monday to arrange for an appointment,"{
""Diagnoses"": [""dysphagia"", ""throat pain"", ""esophageal food bolus""],
""Medications"": [""none""]
}"
21576,admission date discharge date date of birth sex f service neurology allergies nevirapine attending chief complaint headache major surgical or invasive procedure lumbar puncture mri eeg history of present illness the pt is a year old woman with hiv no ois on haart last cd who presented to ed after days of headache pt describes prodromal illness with sore throat and stuffy nose the patient is followed by id and had been diagnosed with sinusitis earlier in the week and was started on levofloxacin the headaches continued and she presented to the ed on and was given compazine and some pain killers and discharged over the next two days the headache worsened and she developed nausea vomiting and malaise on returning to the ed she was found to have bilateral marked papilledema a head ct was consistent with significant global edema with marked sulcal effacement and ventricular narrowing as well as swelling adjacent to the basal cisterns id and neurosurgery were consulted the patient received decadron mg and was placed on ceftriaxone and acyclovir for empiric broad coverage for possible infection she was admitted to the icu for monitoring although she remained hemodynamically and neurologically stable intermittent blurry vision photophobia no diplopia difficulty with speech or swallowing weakness numbness dizziness vertigo denies f c s d chest pain palpitations constipation weight loss or gain blurry vision past medical history hiv diagnosed in on cd was viral load was copies migraines diagnosed winter social history has two children a daughter who is in college at wesleyan and a year old son with cp no pets only recent travel to x this summer physical exam pe gen wd wn nad heent at nc mmm no lesions neck supple no thyromegaly no no bruits chest cta b cvs rrr w o mgr abd soft ntnd bs ext no c c e no rashes or petechiae neuro ms aa ox appropriately interactive normal affect normal fund of knowledge normal insight attention world forward and backwards language fluent without paraphrasic errors memory at minutes l r confusion no l r confusion praxis able to mimic brushing teeth with either hand cn i not tested ii iii perrla vff by confrontation bilateral papilledema iii iv vi eomi w o nystagmus no ptosis v sensation intact to lt pp masseters strong symmetrically vii no facial asymmetry muscles of facial expression strong viii hears finger rub bilaterally ix x voice normal palate elevates symmetrically uvula midline gag intact scm trapezii xii tongue protrudes midline no atrophy or fasciculation motor normal bulk and tone mild left hand postural tremor high frequency rigidity or bradykinesia no pronator drift strength delt tri grip io psoas quad ham ta c c c c c l l l s l s s l r l coord rapid alternating and point to point fnf hts movements intact refl tri bra pat toe l dn r dn lt pp temperature position sense intact no evidence of extinction gait not tested pertinent results imaging head ct findings there is evidence of swelling or filling of the sulci with isodense material the sulci are thus invisible the lateral ventricles are slightly smaller than on the comparison mr and quadrigeminal plate cisterns are similarly effaced there is also effacement of the csf spaces at the level of the foramen magnum suspicious for tonsillar herniation no acute hemorrhage or evidence of midline shift is identified osseous windows reveal no acute fractures or bony abnormalities there is mucosal thickening within the ethmoid sinuses and a likely mucus retention cyst within the left maxillary sinus trace amount of opacification is seen within the right mastoid air cell impression effacement of the csf spaces diffusely this may reflect either swelling or filling of the subarchnoid space with isodense material thus the possibilities include brain swelling or meningitis recommend follow up mri with contrast to further characterize mri mra mrv of brain with contrast diffuse abnormal t signal within the white matter and some areas of matter associated with sulcal effacement imaging findings are most consistent with brain edema that may be related to an infectious or inflammatory condition although clinical correlation is necessary a form of reversible leukoencephalopathy is also possible findings are not typical for pml though it is possible meningitis also cannot be excluded downward displacement of cerebellar tonsils this is likely secondary to cerebellar edema and though the amount has progressed since the prior mr of the cervical spine from the supracerebellar cistern remains patent normal mra and mrv mri of the brain without and with gadolinium there appears to be a slight improvement in the extent of the abnormal t signal hyperintensity throughout the white matter of both cerebral hemispheres there are no new areas of abnormal enhancement or focal lesions visualized paranasal sinuses are clear with the exception of minor areas of high t signal within the posterior aspects of both mastoid processes which is unchanged since the prior study impression slight improvement in extent of abnormal t signal hyperintensity throughout both cerebral hemispheres several sulci not previously visualized are now visible suggesting reduction in edema no new abnormal enhancement labs am wbc rbc hgb hct mcv mch mchc rdw am plt count am neuts lymphs monos eos basos am pt ptt inr pt am asa neg ethanol neg acetmnphn bnzodzpn neg barbitrt neg tricyclic neg am hcg am lipase am alt sgpt ast sgot alk phos amylase tot bili am glucose urea n creat sodium potassium chloride total co anion gap pm urine blood lg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg brief hospital course neuro ct imaging showed limited sinus disease but marked diffuse cerebral edema the neurological exam was remarkably non focal the question of edema secondary to infection although she did not look toxic and had a negative brudzinski was addressed as well as venous sinus thrombosis secondary to a sinus infection and metastatic processes neurosurgery was consulted in case intervention became necessary and the patient was admitted to the icu with neurochecks q hr her haart therapy on admission was continued with the addition of ampicillin and urine sputum and blood cx s were sent the patient was started on decadron q and id was consulted on the patient continued to have frontal and parietal signs along with papilledema mri revealed diffuse t signal abnormality and mm downward displacement of cerebellar tonsils iv decadron continued at q patient s headache improved significantly on decadron and she was ultimately transferred to the general neurology floor on given the high level of concern for cns infection and after discussion with id and neurosurgery it was decided that an lp was necessary a repeat mri was performed first and showed no progression of edema and no change in the level of the cerebellar tonsils ms to the procedure and the lp on revealed op wbc lympho rbc protein glucose crypto negative hsv negative gram stain was negative for bacteria or poly s csf bacterial and fungal cultures were negative pending csf labs include eee wnv afb culture csf viral load was despite peripheral load of there was some concern that this represented hiv meningoencephalitis but was not thought to be a definite explanation for her cerebral edema the infectious disease team has been closely involved with her case as well as her pcp and dr during the course of the admission ms neurologic exam remained non focal with some mild difficulties with executive function her repeat mri on showed improvement in the edema and white matter changes her decadron was slowly weaned so that she was off the medication by see below for details of id tests that were performed ultimately no definitive etiology was found for her cerebral edema although it is suspected to have been infectious in nature hiv versus other infection id infectious disease consulted while patient in the emergency room following tests were sent on hcv ab cryptococcal ag negative vzv igg positive cmv igg positive and igm negative ebv igg positive and igm negative toxo ab negative lyme serology negative rpr negative mycoplasma ab negative for acute infection pending studies include wnv serology eee serology ophthalmology was consulted on and found no evidence of cmv toxoplasmosis pc choroidopathy or lymphoma due to concern for hiv mengingoencephalitis her haart therapy was adjusted to include medications with better cns penetration her new regimen included tenofovir mg daily abacavir mg po daily lamivudine mg daily and kaletra caps abacavir has a risk of rash but this did not occur during the admission she was diagnosed with oral thrush on and began a week course of diflucan ms had a wbc of on admission wbc of on the day of lp and peak wbc of on all with neutrophilia the pattern was that her wbc rose as expected after initiation of steroids but continued to rise after steroid taper she had multiple cultures of blood and urine sent all of which were negative and chest x rays were negative as well she was never febrile no clear source for the wbc could be identified ultimately but it has been coming down to a most recent level of on psych unfortunately although ms had been doing quite well neurologically after her steroid wean she became progressively more anxious and agitated during the weekend of and by the morning of was reporting hearing voices obsessing about the bible and wandering about agitatedly she said she had not slept at all the night before psychiatry was consulted and thought this could be related to a steroid psychosis although its coincidence with the wean of the steroids was a bit atypical the patient had no prior history of psychiatric illness except some mild depression her agitation improved during the course of the day on and she slept through the night after receiving seroquel mg on ms was much calmer although she was still a bit guarded and suspicious a repeat mri was obtained to ensure that her behavioral changes were not related to herniation with injury to basal forebrain structures but the mri was actually improved on the morning of ms again became acutely psychotic now reporting that she heard a voice commanding her to harm herself randomly calling relatives and telling them you re satan and repeatedly shouting for she attempted to leave the hospital and a code purple was called as the patient was in danger of harming herself she was moved to a private room near the nurses station with security posted outside her room over the course of the morning she calmed down but was refusing all medications her psychosis seemed to wax and wane over the course of the day an eeg was obtained due to concern for temporal lobe epilepsy and revealed no epileptiform activity she was placed on seroquel mg qhs which she refused the psychiatry team was consulted and were closely involved with her care during the day it was decided that she would be safest on an inpatient psychiatric med psych preferably given her complex history and arrangements for transfer were begun however there was significant difficulty in finding a bed for her either at or at or given her complicated prior medical issues we felt it most important that she remain here if possible she calmed down significantly and was much more lucid later in the day and hence she remained on the neurology floor for another day on she was quite calm and seemed to be doing well during the day but that night she awoke with nightmares and began walking outside her room and screaming due to concern about safety of other patients a code purple was called and she was briefly placed in restraints by the morning she was again more calm and lucid but understood that for her safety it would be necessary for her to move to the psychiatry service medications on admission atazanavir daily norvir daily tenofovir daily ddi daily excedrin migraine discharge medications seroquel mg qhs discharge disposition extended care facility discharge diagnosis cerebral edema psychosis likely steroid induced discharge condition psychotic but neurologically and medically stable discharge instructions please take your medications as directed and go to follow up appointments as directed please call your doctor headache visual changes nausea and vomiting weakness thoughts of harming yourself or others followup instructions provider md date time am phone location clinic optho f u on at pm in the eye clinic call with questions call to arrange for appointment sooner if visual changes or if cd less than also note that on discharge send home with epzicom tab po qday instead of abacavir and lamivudine provider date time am phone location east psych social workprovider licsw phone date time,"{
""Diagnoses"": [""neurology"", ""sinusitis"", ""bilateral marked papilledema"", ""global edema"", ""sulcal effacement"", ""ventricular narrowing"", ""swelling adjacent to the basal cisterns""],
""Medications"": [""levofloxacin"", ""compazine"", ""pain killers"", ""decadron"", ""ceftriaxone"", ""acyclovir""]
}"
87992,admission date discharge date date of birth sex f service medicine allergies plavix attending chief complaint pericardial effusion post pacemaker placement for symptomatic bradycardia major surgical or invasive procedure none history of present illness the patient is an yo woman with cad s p multiple prior mis and s p des to lcx stable aaa ckd bl cr atrial fibrillation and h o asymptomatic sinus node dysfunction who presented to the ed at with dizziness she first noted the dizziness approx days ago which was associated with nausea and vomiting and yesterday she also developed diarrhea and decreased appetite she notes a single episode of a small amount of hematemesis and that her diarrhea was soft and black but always is given that she takes iron supplements and stool softeners she also developed palpitations and chest tightness with radiation across the left side to the back for which she took two sublingual nitroglycerin with relief but she continued to have dizziness and unsteadiness she did not have any associated diaphoresis she denies any recent fevers chills or sweats she does not have any recent ill contacts or exposures she does also note persistent positional right flank and back pain on arrival to she was thought to have symptomatic sinus node dysfunction with a junctional escape rhythm in the s her nausea and vomiting were thought to be additional evidence of symptomatic bradycardia and the diarrhea was thought to be poor forward flow her first set of ces were negative ck trop her labs revealed an elevated creatinine to which was also thought to be dehydration and hypovolemia her cxr showed no evidence of chf a ct abdomen pelvis was done given the back pain and known aaa which showed a small right pleural effusion multiple renal cysts and bilateral non obstructive nephrolithiasis as well as a stable large fusiform abdominal aortic aneurysm and stable thick mural plaque along the aorta she was taken to the cardiac catheterization lab for dual chamber pacemaker implantation which was complicated by hypotension the patient had received mg of versed for agitation so she was treated with three separate doses of flumazenil with good effect and increase in her sbp to although she again became hypotensive at the end of the case she was transferred to the icu where an echocardiogram revealed a small to moderate sized circumferential effusion with possible mild diastolic collapse in the right ventricle she received an additional dose of flumazenil as well as a dose of narcan with improvement of her systolic blood pressure to she is being transferred to ccu for close observation post procedure hematocrit was also noted to be so she is received unit of prbcs in transit 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 or hemoptysis she notes black stools medications 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 the presence of chest pain that was relieved with sl ntg and dyspnea on exertion but the absence of paroxysmal nocturnal dyspnea orthopnea ankle edema palpitations or syncope past medical history cardiac risk factors diabetes dyslipidemia hypertension cardiac history cad s p multiple prior mis s p des of occluded proximal lcx cabg none percutaneous coronary interventions pacing icd atrial fibrillation and sinus node dysfunction previously minimally symptomatic so pacemaker implantation was on hold other past medical history chronic renal insufficiency baseline creatinine large fusiform abdominal aortic aneurysm stable on serial ct scans anemia cri on weekly procrit social history lives by self in apartment above garage in son s house very self sufficient tobacco history smokes packs per week on and off since college does not inhale etoh one drink of scotch times per week illicit drugs none family history father d age from mi no known family history of early mi arrhythmia cardiomyopathies or sudden cardiac death otherwise non contributory mother and siblings healthy d from old age physical exam general well appearing elderly woman in nad comfortable appropriate heent nc at perrl eomi sclera anicteric conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthalesma neck supple without jvd no lymphadenopathy trachea midline cardiac pmi located in th intercostal space midclavicular line rrr normal s s ii vi sem rusb no rub lungs no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use ctab no crackles wheezes or rhonchi abdomen nabs soft nd nt no hsm or tenderness abd aorta significantly enlarged by palpation and with bruit extremities wwp no c c e left femoral bruit left arm in sling pacemaker site c d i skin no stasis dermatitis ulcers scars or xanthomas neuro a ox cns ii xii grossly intact muscle strength throughout sensation grossly intact to light touch throughout pulses right radial dp pt left radial dp pt pertinent results admission labs 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 amylase totbili pm blood ck mb ctropnt imaging studies cxr no previous images there is enlargement of the cardiac silhouette with tortuosity of the aorta mild indistinctness of pulmonary vessels raises the possibility of elevated pulmonary venous pressure pacemaker device is in place with the leads in the area of the apex of the right ventricle and the right atrium no evidence of acute focal pneumonia there is however an area of vague opacification at the right base laterally that could represent a developing consolidation this area should be evaluated on subsequent images echo the left atrium is moderately dilated left ventricular wall thickness cavity size and regional global systolic function are normal lvef transmitral doppler and tissue velocity imaging are consistent with grade i mild lv diastolic dysfunction right ventricular chamber size and free wall motion are normal 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 a small pericardial effusion around the ra rv without echocardiographic signs of tamponade impression small loculated pericardial effusion normal global and regional biventricular systolic function compared with the prior study images reviewed of pericardial effusion is new the other findings are similar ct chest w o contrast impression small hemopericardium and indeterminate soft tissue in the mediastinum which may represent a small mediastinal hematoma versus a left atrial appendage if clinically indicated a ct with contrast is recommended to further evaluate these findings abdominal aortic aneurysm up to cm with dystrophic calcification within mural plaque or displaced intimal calcification which is likely chronic comparison with prior exams which apparently are available at an outside hospital is crucial to evaluate the stability of this aaa moderate bilateral pleural effusions which appear non hemorrhagic right lower lobe pneumonia multiple large renal cysts which are incompletely characterized however some of which are hemorrhagic or proteinaceous a renal ultrasound is recommended on a non emergent basis cxr findings in comparison with the study of there is no change in the appearance of the pacemaker leads which are in the general region of the right atrium and apex of the right ventricle there is increasing opacification at the right base where there was only a suggestion previously there is also obliteration of the costophrenic sulcus the findings are consistent with pleural fluid and possible pneumonia ecg atrial pacing and ventricular sensing compared to the previous tracing of precordial transition is now normal brief hospital course yo woman with cad s p multiple prior mis s p des to lcx stable aaa cri bl cr atrial fibrillation now p w dizziness thought to be dehydration and symptomatic sinus node dysfunction with junctional escape rhythm bpm s p pacemaker placement today c b hypotension thought to be sedation but found to have pericardial effusion w possible early tamponade physiology transferred to ccu for closer monitoring pericardial effusion echo on showed small loculated pericardial effusion without echocardiographic signs of tamponade patient remained hemodynamically stable and effusion did not require any drainage or any other intervention rhythm patient is status post pacemaker placement for sinus node dysfunction pacer was interrogated by ep who felt it was working properly cxr confirmed proper lead placement post pacemaker antibiotic regimen changed from keflex to levofloxacin since this was being used to treat a new pneumonia coronaries pt with known cad s p des to lcx no active issues on this admission she was continued on her outpatient regimen of asa mg daily and atorvastatin and was started on metoprolol for her cad and her hypertension pump echo on showed ef patient remained euvolemic during this admission anemia at osh hct noted to drop from to she was transfused one unit at the osh and hct was on admission her hct trended down to over hrs and she was transfused another unit here at after which her hct remained stable at a ct chest did not indicate any acute bleeding and a stable appearing abdominal aortic aneurysms was noted and compared to a recent ct scan at notably on physical exam the patient did develop a small hematoma in her pacer pocket which remained stable in size after application of a pressure dressing which may have contributed to the slight downward trend in her hct acute on chronic renal failure pt with reports of progressive chronic renal insufficiency with baseline creatinine creatinine at osh elevated to prior to transfer likely some element of acute renal failure dehydration and hypovolemia which improved during her course creatinine trended down to by discharge pneumonia pt developed a likely right lower lobe pneumonia for which she is being treated with a course of levofloxacin she is on day on discharge and will need to take one more dose of levofloxacin mg at home aaa patient with known large abdominal aortic aneurysm which has been followed by serial ct scans by her outpatient providers unclear whether there are plans for intervention she was continued on her outpatient regimen of hydralazine for bp control and starting on metoprolol hypertension hypertensive on admission to ccu continued on home regimen of hydralazine and started on metoprolol for improved control now that pacemaker in place dyslipidemia patient continued on outpatient statin renal cysts ct scan showed multiple large renal cysts which are incompletely characterized however some of which are hemorrhagic or proteinaceous a renal ultrasound is recommended on a non emergent basis as an outpatient medications on admission alendronate mg weekly on mondays hydralazine mg po tid procrit weekly which was due but pt missed appt aspirin mg po daily lipitor mg po daily multivitamin po daily iron supplement mg po daily otc stool softener discharge medications metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet s refills levofloxacin mg tablet sig one tablet po once for doses take dose on disp tablet s refills pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po once a day disp tablet delayed release e c s refills ferrous sulfate mg mg iron tablet sig one tablet po daily daily atorvastatin mg tablet sig one tablet po daily daily multivitamin tablet sig one tablet po daily daily hydralazine mg tablet sig one tablet po tid times a day alendronate mg tablet sig one tablet po qmon every monday acetaminophen mg tablet sig tablets po q h every hours as needed for pain aspirin mg tablet sig one tablet po once a day procrit unit ml solution sig one dose injection once a week please resume your procrit injections as regularly scheduled discharge disposition home with service facility discharge diagnosis primary pericardial effusion hypotension bradycardia secondary coronary artery disease atrial fibrillation chronic renal insufficiency abdominal aortic aneurysm discharge condition stable discharge instructions you were transferred to this hospital for further monitoring following pacement of your pacemaker at we determined that you have a small amount of fluid around your heart that is not interfering with its pumping function you had some bleeding after your procedure and required one unit of blood please follow the medications prescribed below take one dose of levofloxacin mg on start taking metoprolol mg twice each day start taking pantoprazole mg daily continue taking alendronate mg weekly on mondays continue taking hydralazine mg three times each day continue taking procrit weekly continue taking aspirin mg daily continue taking lipitor atorvastatin mg daily continue taking multivitamin pill daily continue taking iron supplement ferrous sulfate mg daily continue taking stool softener as needed please follow up with the appointments below please call your pcp or go to the ed if you experience chest pain palpitations shortness of breath nausea vomiting fevers chills or other concerning symptoms followup instructions please follow up with your cardiologist dr we have arranged a follow up appointment with dr on monday at pm please follow up with your pcp we have arranged an appointment with dr on at pm ct scan showed multiple large renal cysts which are incompletely characterized however some of which are hemorrhagic or proteinaceous a renal ultrasound is recommended on a non emergent basis completed by,"{
""Diagnoses"": [""pericardial effusion"", ""bradycardia"", ""asymptomatic sinus node dysfunction"", ""atrial fibrillation"", ""stable aaa ckd"", ""bl cr atrial fibrillation"", ""h o asymptomatic sinus node dysfunction""],
""Medications"": [""plavix"", ""none""]
}"
58456,admission date discharge date service medicine allergies no known allergies adverse drug reactions attending chief complaint s p pea arrest major surgical or invasive procedure intubation history of present illness this is a yo f w dementia and htn who presents s p pea arrest she recently had a hip replacement month ago and was in rehab for this per her family she had low blood pressures sbp s for days she had a witnessed collapse with no pulse cpr was started and ems found her to be in slow pea patient given epi and atropine and intubated she then developed a narrow pea upon arrival to osh ed she was given ivf bolus epi atropine and pulses returned w bp s she was started on dopamine but then pulses were lost again cpr and epi atropine were again initiated ecg at that time showed hr of s with rbbb there was question if she had vtach vs junctional rhythm with rbb patient has not had rbbb in the past patient was not started on amiodarone she was treated empirically for hyperkalemia with d insulin acalcium nahc she was started on levophed and dop and given more ivf bp had improved to s bedside echo showed no wall motion abnormality but did show dilated rv there was a question of pe which a cta at confirmed cardiac enzymes were negative at osh she was given g ceftriaxone and transferred to cr has been in the past but was on osh check patient was weaned of levo on route so just on dopa on admission vitals in the ed were hr bp on cmv fio x and peep in the ed patient was taken off dopa but put back on arrival to the floor as stated cta showed segmental pe s and large ascending aortic aneurysm which is old she was started on heparin and cooling protocol in ed patient s family still wants full code until they have more information ros negative since patient was intubated past medical history cardiac risk factors htn cardiac history cabg none percutaneous coronary interventions none pacing icd none other past medical history dementia social history lived with daughters prior to then was in hospital for mental health demential then broke her hip and went to rehab tobacco history none etoh none illicit drugs none family history no family history of early mi arrhythmia cardiomyopathies or sudden cardiac death otherwise non contributory physical exam general intubated cardiac rrr lungs ctab anteriorly abdomen soft ntnd extremities no edema cool pulses radial pulses bilaterally pertinent results pm pt ptt inr pt pm plt count pm neuts lymphs monos eos basos pm wbc rbc hgb hct mcv mch mchc rdw pm albumin pm ck mb mb indx pm ctropnt pm alt sgpt ast sgot ld ldh ck cpk alk phos tot bili pm estgfr using this pm glucose urea n creat sodium potassium chloride total co anion gap pm lactate pm type art rates tidal vol peep o po pco ph total co base xs aado req o assist con intubated intubated pm calcium phosphate magnesium pm ck mb mb indx ctropnt pm ck cpk pm glucose urea n creat sodium potassium chloride total co anion gap pm urine amorph occ pm urine granular hyaline waxy pm urine rbc wbc bacteria few yeast none epi pm urine color yellow appear clear sp pm urine osmolal pm urine hours random urea n creat sodium potassium chloride pm lactate pm type art po pco ph total co base xs pm ptt brief hospital course this was a yo f w h o htn hip fracture who presents s p pea cardiac arrest the most likely etiology was deemed to be from the pulmonary embolism the patient was cooled but upon rewarming the patient s neurologic status was not significantly improved given baseline cognitive impairment and deranged cardiac and hemodynamic parameters the overall impression of the primary team as well as neurology consultants was that the chances of meaningful neurologic recovery were low as such palliative care was instituted and the patient expired peacefully medications on admission geodon mg namenda mg hydrocodone acetaminophen tabs q prn pain ondansetron mg q prn nausea tylenol up to times daily prn dulcolax prn pain mvi daily metamucil tbsp daily and prn macrobid days completed rivastigmine mg hrs amlodipine mg daily citalopram mg daily folic acid mg daily lisinopril mg daily miralax daily discharge medications expired discharge disposition expired discharge diagnosis cardiac arrest pulmonary embolism discharge condition expired discharge instructions none followup instructions none md completed by,"{
""Diagnoses"": [""Dementia"", ""Hypertension"", ""Hip Replacement"", ""Intubation"", ""Collapse"", ""Blood Pressure"", ""Epinephrine"", ""Atropine"", ""Dopamine"", ""ECG"", ""HR"", ""RBBB"", ""VTach"", ""Junctional Rhythm"", ""Hyperkalemia"", ""Amiodarone""],
""Medications"": [""Epi"", ""Atropine"", ""Dopamine"", ""Levophed"", ""D Insulin"", ""Nahc"", ""Dop"", ""IVF"", ""BP"", ""Insulin"", ""Acalcium""]
}"