SUBJECT_ID,AGGREGATED_TEXT,EXTRACTION_JSON
27107,admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint chest pain major surgical or invasive procedure cardiac cath with stenting to rca intraluminal tpa history of present illness y o f with pmhx of htn hyperlipidemia who presented with cp that first began days pta and radiated to her back she reports first episode of cp began sunday at church with central chest pressure lightheadedness diaphoresis right arm pain the pain lasted approx hrs then resolved spontaneously pt was feeling better on monday with only mild intermittent cp and constipation then chest pain awoke her from sleep last night with assoc left arm pain diaphoresis dizziness pt presented to pcp this am still c o mild residual cp that resolved with sl nitro ekgs were noted to have some mild twis and pt was sent to ed on arrival to ed t bp hr rr sats on ra pt was denying cp sob noted to be guaic negative cardiac enzymes were positive and twi noted on ekg pt was started on heparin gtt and admitted for nstemi pt arrived to floor complaining of mild chest pain that resolved with nitro sl x ekgs essentially unchanged from ed tracings on cardiac ros pt has dyspnea on exertion with less than block of walking sleeps with pillows but they often end up on floor denies pnd ankle edema palpitations syncope or presyncope pt denies recent fevers chills recent uri denies brbpr melena dysuria pt has worsened constipaton over last month past medical history hyperlipidemia hypertension low back pain bilateral knee pain seborrheic keratoses s p l cataract surgery social history current tobacco use reports approx pack yr history of smoking there is no history of alcohol abuse family history there is no family history of premature coronary artery disease or sudden cardiac death physical exam vs t bp hr rr sats ra gen wdwn female in nad oriented x mood affect appropriate heent ncat sclera anicteric perrl eomi no lymphadenopathy no carotid bruits neck supple with jvp of cm no hepatojugular reflex cv rrr quiet heart sounds prominent s no m r g no thrills lifts no appreciable s or s chest resp were unlabored no accessory muscle use ctab no crackles wheezes or rhonchi abd soft ntnd no hsm or tenderness abd aorta not enlarged by palpation no abdominial bruits ext no c c e skin no stasis dermatitis ulcers scars or xanthomas pertinent results am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood glucose urean creat na k cl hco angap pm blood ck mb mb indx pm blood ck cpk pm blood ctropnt pm blood ck mb mb indx ctropnt pm blood ck cpk am blood ck mb mb indx ctropnt am blood ck cpk am blood calcium phos mg am blood triglyc hdl chol hd ldlcalc cardiac cath coronary angiography of this right dominant system demonstrated vessel coronary artery disease the lmca and lcx had no angiographically apparent flow limiting disease the lad had a mid vessel stenosis the rca had a proximal stenosis from a large thrombus limited resting hemodynamics revealed mild systemic arterial systolic hypertension with a central aortic pressure of mmhg successful stenting of the proximal rca with a x mm vision bms thrombectomy of the proximal rca with extraction of some white thrombus but persistent thrombus remained despite thrombectomy and ic administration of tpa final angiography revealed no residual stenosis in the stent residual clot in the vessel and timi ii flow see ptca comments final diagnosis two vessel coronary artery disease mild systemic arterial systolic hypertension thrombectomy of proximal rca stenting of the proximal rca echo the left atrium is moderately dilated there is mild symmetric left ventricular hypertrophy with normal cavity size there is mild regional left ventricular systolic dysfunction with hypokinesis of the inferior wall and basal inferior septum rca territory the remaining segments contract normally 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 regurgitation 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 there is an anterior space which most likely represents a fat pad impression mild regional left ventricular systolic dysfunction c w cad mild pulmonary hypertension mildly dilated thoracic aorta compared with the prior study images reviewed of it appears that the regional lv dysfunction is new although the prior study was technically suboptimal pulmonary pressures are higher on today s study junctional bradycardia prior inferoposterior myocardial infarction q t interval prolongation slight st segment elevation in leads ii iii avf these findings are new as compared with tracing of followup and clinical correlation are suggested cspine films degenerative changes at c c with narrowing of the intervertebral disc space subchondral sclerosis and anterior osteophyte formation if there is concern for nerve root compression mr may be performed brief hospital course y o f with pmhx of htn hyperlipidemia who presented with inferior nstemi nstemi pt presented with days of chest pain and was found to have an inferior nstemi pt was taken to the cath lab found to have an intracoronay thrombus in the rca she underwent pci to rca and received intracoronary tpa for thrombolysis she complete hrs of integrilin and was monitored in the ccu for hrs post cath pt did well and denied any recurrent cp or sob while in hospital pt was kept in house for heparin bridge to coumadin given the intracoronary thrombus with a plan for repeat cath in wks pt was discharged with vna to assist with home med teaching assistance with additional insurance coverage applications pt should continue on aspirin plavix atorvastatin metoprolol and lisinopril pt had a tte on that revealed hypokinesis of the inferior wall basal inferior septum and ef there was also evidence of mild pulmonary hypertension pt remained euvolemic in house and was given education about the importance of smoking cessation pt will be following up with pcp for inr monitoring junctional rhythm pt presented on high dose verapamil initial ecgs revealed an intermittent junctional rhythm with very prolonged pr msec verapamil was stopped repeat ekgs showed improved pr interval and return to nsr a few days after cath pt was started on metoprolol mg and ekgs remained stable with mildly prolonged pr in sinus bradycardia and q waves in leads ii iii and avf htn bp was well controlled on regimen of lisinopril mg metoprolol mg r shoulder pain pt was c o shoulder pain and radiating r arm in house and reported that it had been present for the last month rom was limited by pain plain films of shoulder showed no evidence of fracture or joint space narrowing cervical spine films show djd joint space narrowing in c c pt denied weakness numbness and both strength sensation were intact on exam it was thought likely that c spine djd and possible radiculopathy was contributing to her symptoms she was treated with tylenol mg q hrs and was encouraged to get outpatient physical therapy medications on admission diclofenac mg daily verapamil sr mg daily verapamil sr mg qhs lipitor mg daily glucosamine mg tid nasacort prn discharge medications outpatient lab work please draw pt inr and forward results to dr fax atorvastatin mg tablet sig one tablet po daily daily disp tablet s refills nitroglycerin mg tablet sublingual sig one tablet sublingual sublingual prn as needed you can take up to three tabs in min for chest pain please call pcp or come to ed if the chest pain does not improve disp tablet sublingual s refills 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 warfarin mg tablet sig one tablet po at bedtime disp tablet s refills lisinopril 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 nasacort aq mcg aerosol spray sig one nasal three times a day colace mg capsule sig one capsule po twice a day disp capsule s refills discharge disposition home with service facility vna discharge diagnosis primary chest pain nstemi cad s p stenting intracoronary tpa secondary hypertension hyperlipidemia tobacco dependance discharge condition stable discharge instructions you were admitted with chest pain and were found to have a myocardial infarction you had a cardiac catheterization and they placed a stent if your right coronary artery it is very important that you continue taking aspirin plavix every day we have also started you on a blood thinner called coumadin warfarin you will need to get labs drawn regularly while you taking this medication in order to keep the appropriate level in your blood dr office will help you with this we have stopped the verapamil you should not take that medication anymore we have started metoprolol mg twice daily and we have started lisinopril mg daily we have increased the lipitor to mg daily please discuss these changes with dr in follow up you will need to have labs monitored while on these medications we have given you a prescription for nitroglycerin to use only if you develop chest pain we have also give you prescription for colace mg twice daily and pantoprazole mg daily you were given information about quitting smoking please try to quit after you leave the hospital if you develop any chest pain shortness of breath weakness or any other general worsening of condition please go directly to the emergency followup instructions you have a follow up appointment with dr in cardiology on the of the building on at pm you have a follow up appointment with dr on thursday at am please call if you have any questions md,"{
""Diagnoses"": [""NSTEMI"", ""Hypertension"", ""Hyperlipidemia"", ""History of Present Illness""],
""Medications"": [""Heparin"", ""Nitroglycerin"", ""SL Nitro"", ""GTT""]
}"
929,admission date discharge date date of birth sex m service surgery purple team history of present illness the patient is a year old male with morbid obesity with a current body weight of pounds and a height of feet inches and a body mass index of he has been on numerous weight loss programs in the past without significant long term success and he has multiple obesity related comorbidities including type diabetes hypertension dyslipidemia sleep apnea and irritable bowel syndrome venous stasis syndrome and osteoarthritis and a history of depression past surgical history past surgical history is significant for excision of lipoma medications on admission current medications include avapro mg p o once per day hydrochlorothiazide mg p o once per day covera mg p o once per day glyburide mg p o three times per day glucophage mg p o three times per day vioxx mg p o once per day as needed various vitamin supplements hospital course the patient was taken by dr to the operating room on and underwent an open gastric bypass and cholecystectomy postoperatively the surgery went well on postoperative day one the patient became septic febrile and hypotensive and developed acute abdominal pain the drain that was left in the operating room began to drain out bilious material and the patient was transferred to the intensive care unit and resuscitated and the patient was emergently taken back to the operating room and underwent an exploratory laparotomy during this procedure the patient appeared to have a diffuse bile peritonitis with the gastric remnants appeared to be a leak coming from the gastric remnant and the leak was oversewn and repaired and the abdomen was irrigated a gastrojejunostomy tube was left in the gastric remnant it was felt that the patient probably had an anastomotic leak with a clot passing distally obstructing the common limb and led to the over distention of the gastric remnant postoperatively the patient was transferred to the intensive care unit and the patient was extubated on postoperative day one the patient was placed on broad spectrum antibiotics including flagyl for his peritonitis and the patient began to progress well since then on postoperative day two the patient underwent a swallow study which was normal and did not show any leak at the anastomotic site the patient s white blood cell count began to gradually come down and the patient was placed on a stage i diet and transferred to the floor the foley was subsequently discontinued and the left drain was discontinued on postoperative day four the patient was out of bed ambulating on the patient was deemed ready for discharge to home prior to discharge the patient was afebrile with stable vital signs his chest was clear the heart was regular in rate and rhythm the abdomen was soft nontender and nondistended the incision was clean dry and intact the left drain was also discontinued the right drain remained in because of high output the patient was taught to take care of the drain at home the patient had a gastrojejunostomy tube which will be capped when he goes home the patient was up walking around ambulating and tolerating a stage iii diet prior to discharge and had been passing flatus discharge status the patient was discharged to home discharge instructions followup the patient was to follow up with his primary care doctor in one week the patient was instructed to not take his antihypertensive medication and not to take his oral anti hyperglycemic agents the patient was instructed to do fingersticks at home and use an insulin sliding scale the patient was to follow up with his primary care physician in one week for adjustment of anti hyperglycemic agents and his insulin dose the patient was to follow up with the gastric clinic in two weeks the patient was also instructed to crush all pills medications on discharge zantac mg p o twice per day roxicet mg to mg p o q h as needed levaquin mg p o once per day for seven days flagyl mg p o three times per day for seven days hydrochlorothiazide mg p o once per day m d dictated by medquist d t job,"{
""Diagnoses"": [""admission date"", ""discharge date"", ""date of birth"", ""sex"", ""m"", ""service"", ""surgery"", ""purple team"", ""history of present illness""],
""Medications"": [""avapro"", ""hydrochlorothiazide"", ""covera"", ""glyburide"", ""glucophage"", ""vioxx"", ""various vitamin supplements""]
}"
9675,admission date discharge date date of birth sex m service neurology history of present illness the patient is a year old right handed man with a history of hypertension who presented to the emergency room with acute right sided weakness the patient was in his usual state of health when witnessed by his family at p m on when emergency room where his vital signs were stable he denied complaints on arrival he denied chest pain and palpitations according to his daughter he has some chronic shortness of breath past medical history well controlled hypertension benign prostatic hypertrophy osteoarthritis low b medications on admission coreg mg p o b i d diovan mg p o q d tylenol p r n b i m q month unclear if patient started this yet celebrex p r n social history the patient is a russian immigrant he is english speaking he is a retired artist he drinks alcohol rarely and does not smoke allergies the patient has no known drug allergies physical examination on physical examination on admission the patient had a blood pressure of respiratory rate pulse and oxygen saturation on three liters nasal cannula neck no carotid bruits cardiovascular distant heart sounds no murmur abdomen soft nontender lungs clear to auscultation bilaterally neurologic examination alert and oriented speech nonfluent with paraphrasic errors russian accent but speaking in english following commands repetition mildly impaired severe anomia perseverated with the word yes no neglect cranial nerves pupils mm and reactive to light optic disks sharp extraocular movements intact no nystagmus inconsistent but decreased response to finger movements in right hemivisual field right lower facial droop tongue midline palate symmetrically elevated motor dense right flaccid hemiparesis moderate flexion in arm and leg lifting self off the bed to painful stimuli reflexes and symmetric upgoing toe on right gait not assessed laboratory data a stat magnetic resonance imaging scan showed a left thalamic hemorrhage with encroachment into the ventricle no intraventricular hemorrhage there was a small enhancement with gadolinium which may just have been a penetrating vessel admission hematocrit was mcv potassium and ck hospital course the patient was admitted to the neurologic intensive care unit with an anterior aphasia right dense hemiparesis and questionable right visual field loss secondary to a left thalamic hemorrhage the etiology was assumed upon admission to be most likely secondary to hypertension he was admitted for frequent neurological checks to keep his systolic blood pressure between and in the intensive care unit the patient was observed for high blood pressure to keep his blood pressure between and he was kept on intravenous lopressor and his blood pressure was deemed to be in good control on the second day of admission the patient s neurological examination was deemed to be slightly worse with worsening aphasia and not following commands he had slightly fewer movements on the right than the previous day this was assumed to be due to more edema around the hemorrhage as this was likely we did not re scan him we also put him on mechanical venodynes for deep vein thrombosis prophylaxis on at p m a ct scan was done to evaluate decreased mental status to evaluate for re bleed the impression was a stable left thalamic hemorrhage with minimal surrounding edema there was no change compared with the magnetic resonance imaging scan from the previous day there was mild periventricular white matter hypodensity which may be chronic ischemic gliotic change a ct scan done on the third day of admission was done to evaluate questionable worsening of decreasing mental status as the patient s neurological on was showing a fluctuating response he was unable to follow commands he was opening his mouth when asked to and stuck out his tongue when he was asked in russian he was not fluent he was not repeating words he did not seem to be comprehending anything he had generalized right arm like weakness continuing from the previous examination good tone was on the left the ct scan on showed no change compared with the ct scan done on there was a small area of low attenuation surrounding the hemorrhage which represented edema with a minimal midline shift however this shift was stable in appearance and had not changed compared with the study of the previous day a swallowing study showed that the patient was not swallowing on and a nasogastric tube was placed also on the patient was spiking a fever to for which a chest x ray was obtained this chest x ray showed right lower lobe consolidation suggestive of pneumonia repeat films showed no evidence of pleural effusion and confirmed right lower lobe pneumonia with a view of the right hemithorax on the patient was started on intravenous metronidazole mg every eight hours and intravenous levofloxacin mg daily because of the fever and right lower lobe pneumonia seen on chest x ray the patient continued to spike fevers throughout the weekend although laboratory values of hi white blood cell count were seen to be low the initial white blood cell count on was on white blood cell count was on the white blood cell count was a repeat chest x ray on showed bibasilar alveolar opacities improved on the right and worsened on the left which likely represented a new aspiration pneumonia the patient was getting repeated nasogastric tubes because he continually removed them he was evaluated for a gastrostomy tube placement but because of his fevers he was not able to get the placement on on his white blood cell count was antibiotics of levaquin and flagyl were continued the patient s blood pressure was shown to be under good control blood cultures had been sent on and which did not grow out anything on the patient was no longer febrile and he received placement of a gastrojejunostomy tube under radiologic evaluation on the preceding day a portable chest x ray showed significant improvement of bibasilar pneumonia infectious disease had been consulted through the week of and they were following the patient s antibiotic treatment and his fever spikes they did not recommend any change in his levofloxacin and flagyl antibiotic regimen on tube feeds were started with neutra phos for a low phosphorous count the patient s intravenous blood pressure medications were changed to lopressor mg per gastrostomy tube twice a day his blood pressure had been well controlled the patient had been afebrile for over hours on the current intravenous levofloxacin and flagyl regimen on neurological examination the patient was still nonfluent in his language not able to repeat words he had a plegic right upper extremity and right lower extremity and he was able to freely move his left upper and lower extremities this examination is significantly changed from the admission examination however is consistent with the neurological examination of the patient is being changed to oral antibiotics and is to be discharged to rehabilitation today discharge medications lopressor mg per g tube b i d levofloxacin mg per g tube q d times six more doses for a total of days therapy flagyl mg per g tube q d times six more doses for a total of days therapy m d dictated by medquist d t job,"{
""Diagnoses"": [""acute right sided weakness""],
""Medications"": [""Coreg"", ""Diovan"", ""Tylenol"", ""Celebrex""]
}"
5709,admission date discharge date date of birth sex m service allergies the patient has no known drug allergies medications coumadin mg q d lasix mg q d b i d lasix meq to meq q d lopressor mg b i d glucophage mg q d serzone mg b i d buspar mg q three zantac mg b i d ambien mg q h s lipitor mg q d synacort one puff q d colace mg b i d flomax mg q d oxycodone p r n aspirin mg q d past medical history coronary artery disease chronic obstructive pulmonary disease diabetes mellitus type hypertension depression past surgical history status post cholecystectomy open aortic valve replacement mitral valve replacement permanent pacemaker placement history of the present illness the patient is a year old gentleman well known to cardiothoracic surgery status post avr and mvr both mechanical on by dr the patient did well for a few weeks but then developed shortness of breath the patient had bilateral pleural effusions he had talc pleurodesis six weeks to eight weeks prior to admission by dr prior to discharge the patient had increased shortness of breath echocardiogram on the date of admission showed pericardial effusion the patient presented to for treatment physical examination examination revealed the vital signs as follows temperature pulse and regular blood pressure respiratory rate saturation on two liters neck supple no bruits cardiovascular regular rate and rhythm respiratory coarse breath sounds decreased breath sounds at bilateral bases abdomen soft and nontender nondistended extremities bilateral edema laboratory data labs on admission revealed the following white blood cells hematocrit platelet count pt ptt sodium potassium chloride bicarbonate bun creatinine blood glucose hospital course the patient was admitted to the thoracic surgery department on admission the coumadin was held and the patient was started on heparin drip for anticoagulation on hospital day the patient s condition was unchanged some respiratory difficulties were as follows coarse sounds bilaterally on hospital day the patient was given vitamin k to reverse the anticoagulation status the patient still had some shortness of breath on hospital day the patient s condition remained unchanged the patient had heparin drip for anticoagulation on hospital day the patient was taken to the operating room where left vadc and cardiac window was performed by dr the operation went without complications cc of fluid was drained from the pericardium one pericardial and two chest tubes were placed in the operating room the patient was transported to the pacu in stable condition overnight in the pacu the patient initially did well however the patient started developing agitation the patient was taking swings at the nurse he had to be physical restrained and chemically restrained with midazolam to which he responded well also on postoperative day the patient was taken for bronchoscopy we found moderate amount of thick white secretions in both lungs and this was suctioned to clear airway the patient was in respiratory distress and required neo for his blood pressure the patient was transported to the sicu for further management and observation on postoperative day the patient remained agitated requiring chemical and physical restraints the patient was started on coumadin and extensive diuresis on postoperative day the patient was weaned off neo and started on coumadin on postoperative day the patient s postoperative delirium almost resolved he required minimal sedation and pain medication he was transferred to the floor in stable condition the patient s mental status was back to normal but he did complain of feeling tired weak and sleepy also on postoperative day the patient s pca was discontinued the patient s chest tube was also removed without complications he was started on percocet and ibuprofen for pain on postoperative day the patient remained stable increased to and the heparin drip was discontinued the patient continued ambulation exercise and physical therapy on postoperative day the patient remained stable while exercising with pt the was and he was discharged home with a visiting nurse in stable condition discharge medications lopressor mg b i d metformin mg q d nefazodone mg b i d buspar mg t i d mg q h s p r n atorvastatin mg q d flovent mcg two puffs b i d tamsulosin mg q h s aspirin mg q d milk of magnesia cc q p r n lasix mg po b i d percocet to tablets po q h to h p r n pain ibuprofen mg po q h p r n ranitidine mg po b i d docusate mg po b i d potassium chloride meq po b i d coumadin mg po q d hold on guaifenesin cough drops q h p r n condition on discharge good discharge status the patient is discharged home with for blood draws and wound check the patient should hold his coumadin on the date of discharge the patient s should be drawn daily for a week and results should be sent to the patient s primary care physician dr the patient s potassium should be checked on the patient should be dr in to days for and electrolyte check as well coumadin dose adjustment the patient will followup with dr in two weeks in his clinic discharge diagnoses coronary artery disease chronic obstructive pulmonary disease dm depression started on avr mvr pacemaker placement status post left pleural effusion pericardial window m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service allergies the patient has no known drug allergies medications coumadin mg q d lasix mg q d b i d lasix meq to meq q d lopressor mg b i d glucophage mg q d serzone mg b i d buspar mg q three zantac mg b i d ambien mg q h s lipitor mg q d synacort one puff q d colace mg b i d flomax mg q d oxycodone p r n aspirin mg q d past medical history coronary artery disease chronic obstructive pulmonary disease diabetes mellitus type hypertension depression past surgical history status post cholecystectomy open aortic valve replacement mitral valve replacement permanent pacemaker placement history of the present illness the patient is a year old gentleman well known to cardiothoracic surgery status post avr and mvr both mechanical on by dr the patient did well for a few weeks but then developed shortness of breath the patient had bilateral pleural effusions he had talc pleurodesis six weeks to eight weeks prior to admission by dr prior to discharge the patient had increased shortness of breath echocardiogram on the date of admission showed pericardial effusion the patient presented to for treatment physical examination examination revealed the vital signs as follows temperature pulse and regular blood pressure respiratory rate saturation on two liters neck supple no bruits cardiovascular regular rate and rhythm respiratory coarse breath sounds decreased breath sounds at bilateral bases abdomen soft and nontender nondistended extremities bilateral edema laboratory data labs on admission revealed the following white blood cells hematocrit platelet count pt ptt sodium potassium chloride bicarbonate bun creatinine blood glucose hospital course the patient was admitted to the thoracic surgery department on admission the coumadin was held and the patient was started on heparin drip for anticoagulation on hospital day the patient s condition was unchanged some respiratory difficulties were as follows coarse sounds bilaterally on hospital day the patient was given vitamin k to reverse the anticoagulation status the patient still had some shortness of breath on hospital day the patient s condition remained unchanged the patient had heparin drip for anticoagulation on hospital day the patient was taken to the operating room where left vadc and cardiac window was performed by dr the operation went without complications cc of fluid was drained from the pericardium one pericardial and two chest tubes were placed in the operating room the patient was transported to the pacu in stable condition overnight in the pacu the patient initially did well however the patient started developing agitation the patient was taking swings at the nurse he had to be physical restrained and chemically restrained with midazolam to which he responded well also on postoperative day the patient was taken for bronchoscopy we found moderate amount of thick white secretions in both lungs and this was suctioned to clear airway the patient was in respiratory distress and required neo for his blood pressure the patient was transported to the sicu for further management and observation on postoperative day the patient remained agitated requiring chemical and physical restraints the patient was started on coumadin and extensive diuresis on postoperative day the patient was weaned off neo and started on coumadin on postoperative day the patient s postoperative delirium almost resolved he required minimal sedation and pain medication he was transferred to the floor in stable condition the patient s mental status was back to normal but he did complain of feeling tired weak and sleepy also on postoperative day the patient s pca was discontinued the patient s chest tube was also removed without complications he was started on percocet and ibuprofen for pain on postoperative day the patient remained stable increased to and the heparin drip was discontinued the patient continued ambulation exercise and physical therapy on postoperative day the patient remained stable while exercising with pt the was and he was discharged home with a visiting nurse in stable condition discharge medications lopressor mg b i d metformin mg q d nefazodone mg b i d buspar mg t i d mg q h s p r n atorvastatin mg q d flovent mcg two puffs b i d tamsulosin mg q h s aspirin mg q d milk of magnesia cc q p r n lasix mg po b i d percocet to tablets po q h to h p r n pain ibuprofen mg po q h p r n ranitidine mg po b i d docusate mg po b i d potassium chloride meq po b i d coumadin mg po q d hold on guaifenesin cough drops q h p r n condition on discharge good discharge status the patient is discharged home with for blood draws and wound check the patient should hold his coumadin on the date of discharge the patient s should be drawn daily for a week and results should be sent to the patient s primary care physician dr the patient s potassium should be checked on the patient should be dr in to days for and electrolyte check as well coumadin dose adjustment the patient will followup with dr in two weeks in his clinic discharge diagnoses coronary artery disease chronic obstructive pulmonary disease dm depression started on avr mvr pacemaker placement status post left pleural effusion pericardial window m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service medical intensive care unit green team history of present illness this patient is a year old man with a history of congestive heart failure diabetes mellitus type rheumatic heart disease status post aortic valve replacement and mitral valve replacement with mechanical valves on transferred from hospital after he presented there on complaining of nausea vomiting and weakness for two days at the outside hospital the patient was found to be hypotensive with systolic blood pressure to the s hyperkalemic with potassium of digitoxin toxic level of and acute renal failure with bun and creatinine of and coagulopathic with an of patient had recently been admitted to on with a mild congestive heart failure exacerbation patient at that admission was diuresed with lasix with good result and discharged on with a bun and creatinine of following discharge the patient was taking lasix mg aldactone glucophage lisinopril which had just been started at discharge one day after discharge on the patient began experiencing lightheadedness nausea vomiting weakness for which he cut his ace inhibitor dose in half patient at this time denied other symptoms such as fever chills chest pain at the outside hospital patient underwent a renal ultrasound which was negative for hydronephrosis or other acute process patient was also given d units of insulin amp of sodium bicarb kayexalate amp of calcium gluconate all for his hyperkalemia patient was also bolused with normal saline and put on a dopamine drip as well as a dobutamine drip for his low systolic blood pressure to the s patient was also given amp of digibind for his digoxin level of patient s repeat potassium was at the outside hospital on arrival to the patient s systolic blood pressure decreased to the s while in the parking lot so his dopamine drip was increased to mcg kg minute patient at this time also complained of chest tightness and vomited once in the parking lot past medical history transient ischemic attacks anxiety rheumatic heart disease status post mitral valve repair and aortic valve repair in complicated by atrial fibrillation and asystole requiring ddd pacemaker placement also complicated by pericardial effusion and pleural effusions status post chest tube and pleurodesis as well as a pericardial window congestive heart failure ejection fraction greater than one year ago reportedly by the outside hospital benign prostatic hyperplasia esophageal dysmotility status post cholecystectomy diabetes mellitus type social history patient married retired manager former tobacco and alcohol use but quit in allergies no known drug allergies medications at admission aldactone once a day digoxin once a day lasix twice a day lisinopril once a day flomax once a day metformin twice a day aspirin once a day coumadin once a day protonix once a day serzone once a day ambien once a day lipitor once a day coreg x a day advair twice a day physical exam on admission vital signs heart rate of blood pressure map of oxygen saturation of on liters nasal cannula temperature respiratory rate general caucasian man lying in bed in no apparent distress breathing comfortably heent normocephalic atraumatic oropharynx clear moist mucous membranes extraocular muscles are intact pupils are equal round and reactive to light and accommodation no jugular venous distention no bruits heart regular rate and rhythm s s normal systolic murmur lungs are clear to auscultation bilaterally mild expiratory wheezes abdomen normoactive bowel sounds nontender and nondistended no hepatosplenomegaly extremities no clubbing cyanosis or edema pulses throughout neurologic alert and oriented times three no focal deficits genitourinary foley in place draining red urine laboratories on admission complete blood count white blood cell count hematocrit platelets of mcv coagulation pt ptt electrolytes sodium potassium chloride bicarb bun creatinine glucose calcium phosphate magnesium anion gap electrocardiogram a v paced at increased artifact but no peaked t waves concise summary of hospital course hypotension patient is hypotensive likely due to dehydration given patient s chest tightness in the parking lot cardiac enzymes were sent and the patient ruled out for myocardial infarction therapeutically the patient was switched from his dopamine and dobutamine drips to norepinephrine drip patient also given normal saline boluses of cc x on the day of admission the patient was monitored closely for signs of pulmonary edema as his ejection fraction was suspected to be low blood and urine cultures were also sent to rule out an infection although the patient did not have fever cough or other symptoms or signs of infection all cultures were negative at the time of discharge the patient s hypotension responded well to normal saline boluses and were in the range patient s norepinephrine drip was tapered and stopped and the patient s systolic blood pressure remained in the range acute renal failure likely combination of prerenal due to his hypovolemia as well as secondary to his high dose of lasix aldactone lisinopril and metformin at admission renal consult was brought in and believed that the acute renal failure was related to medication toxicity as well as hypotension leading to acute tubular necrosis the patient was initially considered for possible dialysis at admission however his potassium and other electrolytes on repeat had improved markedly after two days in the hospital the patient s electrolytes are all within normal limits starting on the second day after admission began diuresing briskly likely due to his iv fluid boluses as well as his post acute tubular necrosis diuresis patient s ace inhibitor glucophage lasix and digoxin were all held throughout his hospital stay nausea and vomiting patient s symptoms at presentation were likely related to digoxin toxicity and acute renal failure patient was given zofran iv once at admission and had no complaints of nausea or vomiting throughout his hospital stay congestive heart failure patient s beta blocker aspirin and ace inhibitor were all held an echocardiogram performed at the bedside in the medical intensive care unit revealed a left ventricular ejection fraction of greater than no aortic or mitral regurgitation no pericardial effusion after numerous iv fluid boluses the patient developed some crackles about half way up his lungs bilaterally patient at this point was kept fluid even to maintain perfusion to his kidneys while minimizing pulmonary edema hematuria likely due to post atn versus trauma upon foley placement the patient s hematuria decreased throughout his hospital stay and was monitored throughout diabetes mellitus type patient s fingerstick glucose remained in the range throughout his hospital stay and did not require regular insulin sliding scale fingersticks were checked every hours coagulation patient s coagulopathy at admission was reversed with units of fresh frozen plasma and vitamin k iv patient s came to within normal limits after these interventions the patient was maintained on a heparin drip throughout his hospital stay as he has mechanical valves patient was restarted on coumadin on at mg the patient s coagulopathy on admission was likely due to increased physiologic coumadin due to his acute renal failure fluids electrolytes and nutrition patient maintained on a renal cardiac diet which was tolerated well throughout his hospital stay as mentioned the patient was given normal saline boluses to keep his intake and out take even throughout his hospital stay patient s potassium decreased from his elevated levels to within normal limits with in one day of his hospital stay chronic obstructive pulmonary disease versus asthma patient continued on his home dose of advair throughout his hospital stay patient also placed on albuterol nebulizers prn as well as fluticasone mcg two puffs patient had intermittent periods of audible wheezing which responded well to nebulizers prophylaxis patient on heparin drip proton pump inhibitor throughout his hospital stay communication with patient and wife code status full access left femoral line was placed upon admission left groin hematoma developed but was stable and was continued on a pressure dressing condition on discharge stable discharge diagnoses hypotension acute renal failure congestive heart failure diabetes mellitus chronic obstructive pulmonary disease asthma coagulopathy anxiety discharge medications famotidine iv q odanzetron mg iv q h prn insulin sliding scale starting at unit of regular insulin for fingerstick glucose of and increasing by unit for every of glucose salmeterol diskus mcg one inhalation per q h fluticasone mcg two puffs inhaled twice a day lorazepam mg po or iv q prn heparin iv weight based albuterol nebulizer q h prn warfarin mg po q hs restarted on follow up plans patient is scheduled to be transferred to for further workup in the inpatient medicine floor patient s cardiologist dr will follow the patient at m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service history of present illness the patient is a year old male with history of congestive heart failure diabetes mellitus type ii status post aortic valve replacement and mitral valve replacement on coumadin he was transferred from an outside hospital where he presented with nausea vomiting and weakness and was found to be hypotensive with systolic blood pressure to the s hyperkalemic with potassium of digitoxin toxic at a level of and in acute renal failure with a bun and creatinine of over the patient was coagulopathic with an of the patient had recently been admitted on to the same outside hospital with a mild congestive heart failure exacerbation at that admission the patient was diuresed with lasix in house with good results and discharged on with a bun and creatinine of over the patient reports that after being discharged he took lasix mg p o twice a day aldactone glucophage and lisinopril which was newly started at discharge the day after discharge from the hospital the patient noted increasing light headedness nausea vomiting weakness at the outside hospital the patient underwent a renal ultrasound which was negative for hydronephrosis or other acute process the patient was given exalate one amp calcium gluconate mls of normal saline the patient was also started on a dopamine and dobutamine drips for decreased systolic blood pressure into the s the patient was also given one amp of digibind for his high digitoxin level the patient was then sent by ambulance from the outside hospital to where in the parking lot his blood pressure decreased to the s again the dopamine was increased to mcg per kg per minute the patient at this time also complained of chest tightness and vomited times one in the parking lot of past medical history transient ischemic attacks anxiety rheumatic heart disease status post mitral valve repair and aortic valve repair in complicated by atrial fibrillation and period of asystole requiring a ddd pacemaker placement also complicated by a peri cardial effusion and pleural effusions status post cardiac window and pleurodesis congestive heart failure ejection fraction of greater than on year ago reportedly ejection fraction of to by the outside hospital benign prostatic hypertrophy esophageal dysmotility status post cholecystectomy coronary artery disease status post clear coronaries one year ago found on catheterization diabetes mellitus type ii social history married living with wife retired manager former alcohol and tobacco use but quit in allergies no known drug allergies medications aldactone mg q day digoxin mg q day lasix twice a day lisinopril mg once a day max once a day metformin mg twice a day aspirin once a day coumadin mg q h s protonic mg once a day serazone mg once a day ambien mg once a day lipitor once a day coreg mg three times a day advair twice a day physical examination on admission vital signs revealed a heart rate of blood pressure oxygen saturation on two liters temperature respiratory rate general caucasian man found lying in bed in no apparent distress head eyes ears nose and throat extraocular movements intact pupils are equal round and reactive to light and accommodation moist mucous membranes normal cephalic atraumatic oropharynx clear neck jvp flat no bruits heart regular rate and rhythm s and s normal systolic murmur lungs clear to auscultation bilaterally slight expiratory wheezes abdomen normoactive bowel sounds nontender nondistended no hepatosplenomegaly extremities no clubbing cyanosis or edema pulses throughout neurologic alert and oriented times three no focal deficits genitourinary foley in place draining red urine incomplete report cut off m d dictated by [NEW_RECORD] admission date discharge date date of birth sex m service cardiothoracic history of present illness the patient is a year old man with a month period of episodic chest pain which has been progressively becoming worse these episodes occur up to three times per week developed at rest or with exertion they are associated with dizziness and left arm numbness which radiates down to his fingers he had noted using nitroglycerin in the past with some relief but he has not used any recently when these occur he performs some relaxation techniques which help in shortening the length of the episode sometimes they persist up to three hours he notes that he has had similar symptoms in the past and has had a cardiac catheterization twice in the early s all of which have been reported as negative though they reported valvular abnormalities a work up in the past has also included an echocardiogram which showed a dilated left atrium with normal left ventricular function positive mitral stenosis with a mean gradient of mmhg with a valvular area of cm sq mean aortic gradient of mmhg with a valvular area of cm sq due to the fact that his symptoms have progressively become worse over the last year the patient presents to for cardiac catheterization and then question avr mvr performed by the cardiothoracic team led by dr past medical history significant for hypercholesterolemia status post tia tia reports about times per week they present as loss of vision passing out dizziness or migraine symptoms and now patient was placed on coumadin also history of anxiety congestive heart failure decreased pfts and diabetes mellitus past surgical history significant for status post cholecystectomy medications on admission include coumadin mg on tuesday and thursday and mg on all other days coumadin was held on also glucophage mg po q hours p m lasix mg po q d lipitor mg po q d folate mg q h s toprol mg po q d serzone mg po bid buspar mg po tid ambien mg q h s prn social history the patient is married retired manager for a local company occasional etoh use occasional pipe use physical examination patient is a white male in no acute distress temperature heart rate blood pressure breathing at on room air his neck is supple with no lymphadenopathy his lungs are clear heart is regular rate and rhythm with systolic and diastolic murmurs abdomen is soft and nontender no peripheral edema distal pulses intact he is alert and oriented times three neurologically intact laboratory data on admission include white count of hematocrit platelet count sodium potassium chloride co bun creatinine chest x ray shows within normal limits no evidence of pneumothorax or infiltrate hospital course the patient was brought to where he underwent cardiac catheterization we felt this was significant for right dominant circulation with no flow limiting coronary artery disease also there was a significant aortic stenosis with of cm sq and a mean gradient of mmhg there is mitral stenosis with mean gradient of mmhg and mva of cm sq there was an ef of also significant for aortic regurgitation the patient procedure well and then on the patient went to the operating room where he underwent avr with a carbomedics and mvr with carbomedics the patient tolerated this procedure well was transferred to the sicu av paced on propofol drip postoperatively the patient s systolic blood pressure was labile initially he was placed on iv nitroglycerin on arriving to the unit he proceeded to have a high chest tube output of ml in minutes he received mg of protamine times two two units of fp and two units of packed red blood cells hematocrit then went from to the patient was weaned to extubate on postoperative day the patient was weaned off of drips was awake alert and oriented times three he continued to be paced with underlying nodal rhythm in the s postoperative day the patient was transfused with one unit of packed red blood cells for hematocrit of he was continued to be on vvi at a rate of he was otherwise stable when transferred to the floor on the floor the patient was reporting feeling jolts with the pacer in place the pacer was turned off and the underlying rhythm was junctional with a rate in the s his blood pressure was stable at he was left in this rhythm he was evaluated by the ep service who determined he would benefit from the placement of a pacemaker secondary to arrest of sinus node postoperative day the patient went into atrial fibrillation with the rate up to s blood pressure remained stable then on the morning of postoperative day the patient continued in an irregular rhythm with rates up into the s had an second pause on the monitor the patient stated he felt a hot burst through his body and a dull feeling in his heart the staff ran into the room and upon entering the monitor spontaneously showed the start of a junctional rhythm that day patient went to the ep lab where he underwent placement of a ddd pacer since that time patient has remained av paced blood pressures remained stable the patient has been coumadinized to the appropriate inr of greater than and for his valve and atrial fibrillation the patient has been ambulating tolerating a regular diet and is now ready for discharge to home discharge diagnosis valvular disease status post avr mvr with carbomedics and respectively status post pacemaker placement for the rest of sinus node atrial fibrillation hypercholesterolemia tia anxiety diabetes mellitus congestive heart failure discharge medications include lasix mg po bid times days colace mg po bid zantac mg po bid buspar mg po tid serzone mg po bid flomax mg po q d ambien mg po q h s prn lipitor mg po q d glucophage mg po q noon niferex mg q d asa mg po q d coumadin mg po q d which will be dosed m d lopressor mg po bid percocet po q hours prn the patient on discharge is stable discharge instructions follow up with dr in weeks follow up with pacemaker clinic on at a m in bldg follow up with dr in two weeks patient will receive vna home care for wound check and likely inr drawing to be adjusted by dr m d dictated by medquist d t job [NEW_RECORD] admission date discharge date date of birth sex m service cardiothoracic surgery chief complaint dyspnea on exertion history of present illness the patient is a year old gentleman status post aortic valve replacement mitral valve replacement with pacer secondary to asystolic period on he comes in with dyspnea on exertion for one week chest x ray revealed bilateral pleural effusions he was diuresed with lasix four days ago with good results and subsequently developed shortness of breath and dyspnea on exertion again he was seen at an outside hospital on the day of admission where a chest x ray showed bilateral pleural effusions and an echocardiogram subsequently revealed a pericardial effusion with query tamponade query vegetations the patient was transferred to for further treatment past medical history status post aortic valve replacement mitral valve replacement status post pacemaker atrial fibrillation hypercholesterolemia transient ischemic attack anxiety noninsulin dependent diabetes mellitus congestive heart failure status post cholecystectomy medications on admission lopressor mg b i d lasix mg b i d zantac mg b i d buspar mg t i d serzone mg b i d flomax mg q d ambien mg q h s lipitor mg q h s glucophage mg q d niferex mg q d aspirin mg q d coumadin mg tuesday and thursday and mg the other days hospital course the patient was admitted on the cardiac surgery service for question of pericardial tamponade he was admitted to the csr unit for close monitoring overnight he was stable overnight and required no intervention his inr on admission was so it was elected not to perform any procedures he underwent a transthoracic echocardiogram on hospital day two which was inconclusive he was transferred to the regular floor in stable condition while awaiting a reduction in his inr to a safe level meanwhile he was started on lasix b i d to diurese him he was started also on antibiotics a transesophageal echocardiogram was performed on which revealed a semisolid pericardial effusion with no evidence of tamponade and no evidence of vegetations he remained in the hospital while awaiting a safe inr for his thoracocentesis he remained mildly short of breath at this time on his inr had decreased to a safe level and he underwent a right thoracocentesis and drainage of ccs of fluid he had immediate relief of symptoms his chest x ray improved in appearance also he was restarted on his coumadin and discharged home on medications on discharge coumadin mg q d lopressor mg b i d tylenol mg q hours p r n buspar mg t i d serzone mg b i d ambien mg q d lipitor mg q h s glucophage mg q d niferex mg q d aspirin mg q d other treatment inr check on monday and then to be followed by his primary care physician care physician s office notified inr goal is to be to follow up dr in four weeks condition on discharge stable m d dictated by medquist d t job [NEW_RECORD] name unit no admission date discharge date date of birth sex m service addendum concise summary of hospital course by issue system continued hypotension issues the patient remained normotensive throughout the remainder of her hospital course acute renal failure issues the patient s renal function had resolved and remained normal congestive heart failure issues it was felt that the patient did not demonstrate systolic heart failure therefore his regimen was changed from carvedilol to an ace inhibitor the patient did well throughout the remainder of his course with mild diuresis with lasix hematuria issues the patient completed a day course for a urinary tract infection his hematuria resolved and was felt to be secondary to his heparin drip and likely foley catheter trauma urine cytology incidentally came back as atypical and could not exclude urothelial dysplasia neoplasia and will need to follow up on this with his primary care provider diabetes issues the patient s blood sugars remained well controlled on his regimen anticoagulation issues the patient stayed in the hospital for a coumadin bridge to a therapeutic level for his mechanical mitral valves and was discharged after his inr was to for hours the patient was to follow up with his primary care physician for an inr check hematoma issues the patient s groin hematoma remained stable throughout his hospital course condition at discharge condition on discharge was good discharge status discharge status was to home medications on discharge salmeterol diskus twice per day fluticasone puffs inhaled twice per day albuterol to puffs inhaled q h coumadin mg by mouth at hour of sleep times two days atenolol mg by mouth once per day lisinopril mg by mouth once per day nefazodone mg by mouth three times per day atorvastatin mg by mouth once per day tamsulosin mg by mouth at hour of sleep furosemide mg by mouth once per day metformin mg by mouth twice per day pantoprazole mg by mouth once per day aspirin mg by mouth once per day discharge instructions followup the patient was instructed to have his inr checked on the day after discharge the patient was instructed to follow up with his primary care provider dr on the patient was instructed to follow up with his cardiologist dr in two weeks the patient was instructed to follow up with his urologist dr in two weeks m d dictated by medquist d t job,"{
""Diagnoses"": [""coronary artery disease"", ""chronic obstructive pulmonary disease"", ""diabetes mellitus type"", ""hypertension"", ""depression""],
""Medications"": [""coumadin"", ""lasix"", ""lopressor"", ""glucophage"", ""serzone"", ""buspar"", ""zantac"", ""ambien"", ""lipitor"", ""synacort"", ""colace"", ""flomax"", ""oxycodone"", ""aspirin""]
}"
46243,admission date discharge date date of birth sex m service neurosurgery allergies no known allergies adverse drug reactions attending chief complaint s p fall major surgical or invasive procedure none history of present illness pt is an m who was transferred to from osh with frontal contusions and interventricular hemorrhage after an unwitnessed fall he was originally taken to osh after his downstairs neighbor heard the fall and called he has a long history of frequent falls and etoh abuse he currently denies any pain weakness in extremities speech difficulty or visual disturbances past medical history etoh abuse htn bph aortic valve replacement cabg protstate cancer social history lives alone etoh abuse family history nc physical exam bp hr r o sats gen wd wn comfortable nad heent pupils perrla mm eoms full neck c collar in place no tenderness to palpation neuro mental status awake and alert cooperative with exam normal affect orientation oriented to person only recall unable to recall objects at minutes language speech fluent 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 right pronator drift sensation intact to light touch bilaterally physical exam upon discharge awake alert to self only perrl eomi face symmetric tongue midline ecchymosis on right temple no pronator drift mae s with good strengths following commands pertinent results ct head slight interval increase in size of small hemorrhagic contusion in the left lateral inferior frontal lobe stable hemorrhagic foci in the subarachnoid right frontal lobe and subependymal right lateral ventricle interval increase in amount of dependently layering ventricular blood source unclear change in ventricle size correlate clinically and for coagulopathy and consider close followup hand x ray there are two osseous fragments adjacent to the volar and ulnar base of the first distal phalanx one may represent a sesamoid however the other likely represents an age indeterminate fracture there are moderate degenerative changes of the ip joint with osteophyte formation as well as moderate degenerative changes of the triscaphe joint degenerative changes at the first cmc are milder in extent vascular calcifications are diffuse soft tissue swelling about the thumb is moderate head ct and c spine ct preliminary read no acute changes interval resolution of sah brief hospital course patient presented to the er s p fall at home as a trasnfer from an osh upon arrival and assessment he was admitted to the icu for further observation and management repeat head ct showed some increase in the left lateral ventricle ivh however his clinical exam was improving he continued in a hard cervical collar into and it was decided that he would remain in the collar for two weeks and then return with imaging to assess stability on the afternoon of he was deemed stable for transfer to the floor for disposition planning pt and ot consults were ordered to determine the best disposition for him there was no bed available on the floor and the patient stayed another night in the trauma icu a hand x ray demonstrated right thumb osseous fx at ip volar aspect and according to trauma no splinting or f u is needed on transfer orders rewritten for transfer to the floor the patient keppra ws increased to the trauma icu team reviewed his right hand xray which was consistent with osseus frags at ip volar aspect and reccomenede there is no need for splinting of this fracture on the patient exam was stable the patient was oriented to self and hospital not date given choices he continues to wear a j cervical collar he was able to moves all extremities well with good strength he denied right thumb discomfort the patient inr was liver function tests were ordered which showed ap ldh were slightly elevated a social work consult was ordered as the patient lives alone and the daughter is worried that the patient suffers from self netglect the daughter does not feel that he is safe to go home as he is disoriented and does not eat the patient serum potassium was and repleated serum magnesium was both were repleated he was evaluated by speech who recommended soft reg thin liquids pt ot recommened acute rehab now dod patient is afebrile vss and currently neurologically stable he was given an aspen collar which he should remain wearing at all times until follow up he is tolerating a soft thin liquid diet he is set for discharge to rehab and will f o with dr in weeks medications on admission oxybutin lopressor discharge medications docusate sodium mg capsule sig one capsule po bid times a day multivitamin tablet sig one tablet po daily daily acetaminophen mg tablet sig two tablet po q h every hours as needed for pain fever oxybutynin chloride mg tablet sig one tablet po bid times a day thiamine hcl mg tablet sig one tablet po daily daily folic acid mg tablet sig one tablet po daily daily levetiracetam mg tablet sig tablets po bid times a day senna 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 heparin porcine unit ml solution sig one ml injection tid times a day discharge disposition extended care facility discharge diagnosis parafalcine sdh ivh neck pain 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 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 you have been discharged on keppra levetiracetam you will not require blood work monitoring continue to wear your cervical collar at all times you may remove it only to change the collar following a shower 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 flexion extension x rays 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"", ""no known allergies"", ""adverse drug reactions"", ""attending chief complaint"", ""s p fall"", ""major surgical or invasive procedure"", ""history of present illness""],
""Medications"": [""ETOH abuse"", ""HTN"", ""BPH"", ""aortic valve replacement"", ""CABG"", ""prostate cancer""]
}"
2980,admission date discharge date date of birth sex m service nb history of present illness erilus also known as baby boy is the former kg product of a and weeks gestation pregnancy born to a year old g now p woman prenatal screens blood type a positive antibody screen negative hepatitis b surface antigen positive rubella immune rpr nonreactive group beta strep status positive the pregnancy was notable for recurrent urinary tract infections treated with flagyl the mother also was in a motor vehicle accident days prior to delivery and was admitted to the and treated with magnesium sulfate at that time spontaneous premature rupture of membranes occurred at hours prior to delivery the mother was treated with interpartum antibiotics for greater than hours prior to delivery there was no maternal fever or other sepsis risk factors the infant was born by spontaneous vaginal delivery apgars were at minute and at minutes he was admitted to the neonatal intensive care unit for treatment of prematurity physical examination upon admission to the neonatal intensive care unit weight was kg th percentile length cm th percentile head circumference cm th percentile general well appearing vigorous active male infant in no acute distress heent anterior fontanel open and flat palate intact mild occipital molding chest breath sounds clear and equal comfortable in room air vigorous cry cardiovascular regular rate and rhythm no murmurs femoral pulses abdomen soft nontender nondistended bowel sounds present extremities warm pink well perfused genitourinary normal male external genitalia anus patent neurological appropriate tone and reflexes hospital course by systems including pertinent laboratory data respiratory showed lung and respiratory control maturity he was in room air with oxygen saturations greater than he did not have any episodes of desaturation or apnea and bradycardia cardiovascular this baby maintained normal heart rates and blood pressures no murmurs were noted fluids electrolytes and nutrition enteral feeds were started at the time birth he has been taking enfamil or breast feeding taking in a minimum of ml per kg plus breast feeding mother prefers him to be on formula weight on the day of discharge is kg infectious disease due to the positive group beta strep status and being less than weeks gestation this infant was evaluated for sepsis white blood cell count was with a differential of polymorphonuclear cells band neutrophils lymphocytes a blood culture was obtained and there was no growth at hours hematological hematocrit at birth at gastrointestinal serum bilirubin obtained at hours of life was total mg per dl over mg per dl direct the infant will return to the for a bilirubin check on neurological this baby has maintained a normal neurological examination during admission no concerns at the time of discharge sensory audiology hearing screening was performed with automated auditory brain stem responses and this baby passed in both ears psychosocial the baby s surname after discharge will be erilus condition on discharge good discharge disposition home with the parents name of primary pediatrician dr through pediatric health associates phone no care recommendations at the time of discharge feedings ad lib breast feeding or feeding calorie per ounce medications none car seat position screening was performed this baby was observed for minutes in his car seat without any episodes of oxygen desaturation or bradycardia state newborn screens were sent on with results pending immunizations received hepatitis b vaccine and hepatitis b immunoglobulin were administered on immunizations recommended synagis rsv prophylaxis should be considered from through for infants who meet any of the following three 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 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 with infant include nicu on for bilirubin check visit for saturday appointment with dr or primary pediatrician on discharge diagnoses prematurity at and weeks gestation suspicion for sepsis md dictated by medquist d t job,"{
""Diagnoses"": [""Recurrent urinary tract infections"", ""Spontaneous premature rupture of membranes"", ""Prematurity""],
""Medications"": [""Flagyl"", ""Magnesium sulfate"", ""Interpartum antibiotics""]
}"
2730,admission date discharge date date of birth sex m service ccu history of present illness the patient is a year old male with no significant past medical history other than hypertriglyceridemia low hdl and tobacco abuse who presents with st elevation myocardial infarction the morning of admission he woke up at a m and felt unwell with mild upper chest discomfort at rest he had no dyspnea on exertion nor shortness of breath he went to work had continued discomfort and at noon developed frank upper chest pain with radiation to both arms mild dyspnea though no nausea vomiting or diaphoresis he was brought to the where electrocardiogram showed inferior st segment elevation and he was transferred emergently to cardiac catheterization he was enrolled in the cool myocardial infarction study and randomized to the cooling arm left heart catheterization showed discrete lesion at the right coronary artery with timi one flow percutaneous transluminal coronary angioplasty was performed and by millimeter stent was employed following which repeat percutaneous transluminal coronary angioplasty was performed repeat angiography showed residual stenosis proximal to the stent therefore repeat percutaneous transluminal coronary angioplasty was done and repeat angiography done showed complete resolution of the lesion he also had a lesion at the second obtuse marginal that was not treated left ventriculogram showed inferior hypokinesis and ejection fraction of normal aortic and mitral valves the right heart catheterization showed mean right atrial pressure of pulmonary artery pressure of and a mean pulmonary capillary wedge pressure of the patient was transiently bradycardic and atropine was given with good results he was admitted to the ccu in order to continue the cool myocardial infarction protocol past medical history hypercholesterolemia in total cholesterol was triglycerides ldl and hdl primary care physician is medications on admission none allergies no known drug allergies social history the patient is a former emt he smokes one half pack per day approximately thirty pack year history no alcohol family history the patient s father and many in his father s family have coronary artery disease but no report of early death physical examination on admission temperature is cooling was in place heart rate blood pressure respiratory rate oxygen saturation in general he was alert in no acute distress head eyes ears nose and throat the pupils are equal round and reactive to light and accommodation extraocular movements are intact sclerae anicteric the neck is supple with no lymphadenopathy jugular venous pressure is not visible chest is clear to auscultation anteriorly cardiovascular is regular rate and rhythm no murmurs rubs or gallops normal s and s no s no s the abdomen is soft nontender nondistended positive bowel sounds groin sheaths in place no hematoma noted no bruit extremities no cyanosis clubbing or edema dorsalis pedis pulses skin no rashes laboratory data electrocardiogram showed normal sinus rhythm to elevation in leads ii iii and avf st depression in leads v and v and t wave inversion in leads v v and avl this was prior to cardiac catheterization white blood cell count was hematocrit platelet count differential of white count neutrophils lymphocytes monocytes chem revealed sodium potassium chloride bicarbonate blood urea nitrogen creatinine and glucose alt was ast ck alkaline phosphatase amylase calcium impression this is a year old male status post inferior st elevation myocardial infarction this morning who was brought immediately to cardiac catheterization where he received a stent to the right coronary artery he also had a stenosis at the om that was intervened upon he was enrolled in the cool myocardial infarction study and randomized to the cooling arm so was transferred to the ccu for the study protocol otherwise he was stable after catheterization hospital course cardiac the patient was continued on aspirin and plavix beta blocker therapy was initiated as was ace inhibitor therapy integrilin was continued for eighteen hours after cardiac catheterization cks peaked at with a mb of electrocardiographic changes resolved hypercholesterolemia was treated with lopid he will need a stress test in the future to address clinical significance of the lesion at the om with respect to the cool myocardial infarction protocol the patient did well and received demerol while cooling in order to treat rigors the patient had an echocardiogram on that showed an ejection fraction of to basal inferior and midinferior hypokinesis of the left ventricular wall and normal free wall motion of the right ventricular wall pulmonary there were no signs or symptoms of congestive heart failure renal the patient s blood urea nitrogen and creatinine were normal throughout the admission medications on discharge plavix mg p o once daily for thirty days aspirin mg p o once daily atenolol mg p o once daily lopid mg p o twice a day lisinopril mg p o once daily follow up follow up should be with dr in three to four weeks telephone and with his primary care physician telephone number above discharge status to home condition on discharge good discharge diagnoses myocardial infarction status post stent to the right coronary artery hyperlipidemia m d dictated by medquist d t job,"{
""Diagnoses"": [""St elevation myocardial infarction""],
""Medications"": [""Percutaneous transluminal coronary angioplasty"", ""Millimeter stent"", ""Repeat percutaneous transluminal coronary angioplasty"", ""Repeat angiography""]
}"
87320,admission date discharge date date of birth sex f service neurology allergies patient recorded as having no known allergies to drugs attending chief complaint aphasia right facial droop and right sided weakness major surgical or invasive procedure intra arterial tpa and merci procedure history of present illness ms is a year old right handed woman with a presumed past medical history including dm ii hyperlipidemia cardiac arrhythmia and prior right parietal and external capsule strokes who presents with the sudden of onset of aphasia right facial droop and right sided weakness her daughter and husband explain that ms was in her usual state of health when she went to bed at about pm on while initial interviews suggested that pm was the patient s last known well time it was ultimately discovered that ms was still well when she awakened at about am to go to the bathroom her husband recalls that at that time she ambulated independently and did not appear to have weakness or facial droop at about am he woke up next to her in bed because she was scratching her abdomen he apparently witnessed the subsequent development of right facial droop and hemiparesis between am and am concerned the family drove the patient to the for further care the family maintains that ms has not been herself since the stroke s eight months pta but deny specific illness and discomfort in the recent past review of potential contraindications to tpa absolute negative for stroke or head trauma within months of admission hx of intracranial hemorrhage major surgery within weeks of admission pregnancy persistent sbp or dbp platelets or inr relative negative for gu or gi procedure within weeks of admission lp within week of admission improvement in stroke sx seizure glucose nihss neurological review of systems difficult to assess general review of systems positive for as above shortness of breath negative for chest discomfort shortness of breath cough abdominal pain rash past medical history right parietal external capsule strokes months pta cardiac arrythmia dm ii hld per report labile htn in few weeks pta chronic abdominal pain back pain social history visiting from married has children family history positive for stroke father age physical exam physical examination vitals t p r bp sao ra general awake cooperative heent normocepahlic atruamatic no scleral icterus noted neck supple no carotid bruits appreciated cardiac tahcycardic rate irregularly irregular rhythm normal s and s pulmonary lungs clear to auscultation bilaterally abdomen round normoactive bowel sounds soft non tender non distended extremities warm well perfused skin no rashes or concerning lesions noted neurologic examination mental status degree of alertness alert language language is dysarthric and sparse comprehension appears intact pt able to correctly follow midline and appendicular commands cranial nerves i olfaction not evaluated ii perrl to mm and brisk visual fields full to confrontation iii iv vi limited upgaze eom otherwise intact without nystagmus v facial sensation intact to light touch in the v v v distributions per report of interpreter vii right facial droop viii hearing intact to finger rub bilaterally ix x palate not visible unable to assess xii tongue protrudes minimally but in midline motor bulk no evidence of atrophy tone increased in right lower extremity rue with spasticity drift right ue falls to bed strength left upper extremity throughout delt biceps triceps finger flex right upper extremity throughout delt biceps triceps finger flex left lower extremity throughout iliopsoas quad ham tib ant gastroc right lower extremity some voluntary adduction wiggles right toes reflexes left throughout biceps triceps bracheoradialis patellar right throughout biceps triceps bracheoradialis patellar babinski mute bilaterally sensation light touch intact bilaterally in lower extremities upper extremities trunk face per report pinprick intact bilaterally intact bilaterally in lower extremities upper extremities trunk face per report vibration intact bilaterally at level of medial malleolus per report coordination finger to nose intact on left gait not evaluated 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 fibrino am blood glucose urean creat na k cl hco angap am blood ctropnt am blood ck mb notdone ctropnt am blood hba c am blood triglyc hdl chol hd ldlcalc imaging cta abrupt cutoff of flow within the left m segment associated with hyperdense vessel and in this patient with acute onset of right sided symptom is concerning for an acute embolus no significant cortical edema is appreciated at this time normal variant origin of the vertebral arteries from the external carotid arteries chronic right hemispheric infarcts focal gas collection anterior to the esophagus likely represents an esophageal diverticulum though it is incompletely evaluated and should be correlated with patient s clinical course initial evaluation could take the form of barium swallow as indicated angio ct head there is no acute intracranial hemorrhage there is no definite low attenuation region in the left hemisphere hypodensities in the right frontal and parietal lobes with associated mild volume loss is unchanged there is preservation of the white matter ventricles and sulci are normal in size and appearance and the basilar cisterns are preserved no osseous abnormality is identified the paranasal sinuses and mastoid air cells are well aerated impression no evidence of significant cortical edema unchanged appearance of chronic right hemispheric infarcts echo the left atrium is mildly dilated 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 there are focal calcifications in the aortic arch 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 there is borderline pulmonary artery systolic hypertension there is no pericardial effusion brief hospital course ms is a year old right handed woman with a presumed past medical history including dm ii hyperlipidemia cardiac arrhythmia and prior right parietal and external capsule strokes who presented with sudden onset of aphasia right facial droop and right sided weakness clinical examination was notable for minimal dysarthric speech right facial droop right upper extremity plegia and spasticity right lower extremity paresis with increased tone and diffusely brisk reflexes the deficits localize to the left mca territory as she was out of the window for intra venous tpa the patient was taken to the angio suite the angio confirmed that the left distal mca stem was closed she was given a total of mg of ia tpa and started to open up the mca stem the superior division cleared nicely however the inferior division might be closed the merci device was also used to clear some thrombus from her mca stem it was decided not to go after the inferior mca division since the patient was getting out of a reasonable time window and because she had already mg of ia tpa on board the patient was then transferred to the icu she was extubated on that same day she was kept flat and her sbp dbp was kept below a repeat head ct did not show any hemorrhages she was restarted on asa and heparin the following day she was transferred out of the icu on to the floor for further care she was closely monitered for her neuro exam she was seen and evaluated by physical and occupational therapy for gait and stability assesment she was evlauted for swallow and speech tharpy as well she was started on tube feeds nasogastric however she was being follwoed by swallow tharpy on close basis and they felt that she was improving though gradually and may not need peg tube in long term planning however she should be further evaluated for swallow function and if she does not improve she should be considered for peg tube she was continued on iv heparin which was later bridged to lovenox and coumadin for a therapeutic inr of she was monitered continously on telemetry in setting of acute stroke and a fib she had an episode of rapid afib lasting for few seconds on night the rate was immediately controlled after administertion of metoprolol mg iv her ekg did not show significant st t changes and cardiac enzymes were negative neurologically she showed some improvement in her exam at the time of discharge she was still and was able to follow some commands her exam was significant for suggested plan of care aftre discharge physical occupational speech tharapy swallow and nutrition evaluation and continue tube feeds if she does not tolerate then she would need peg tube bridge on lovenopx till inr becomes therapeutic on coumadin management of a fib blood pressure aand other medical issues as felt appropritae by medical team prevention of bed sores and close watch over possible development of infections such as uti pna medications on admission amiodarone mg po bid simvastatin mg po glyburide mg po daily buscopam mg po daily dipridamol mg po daily discharge medications simvastatin mg tablet sig two tablet po daily daily amiodarone mg tablet sig one tablet po bid times a day docusate sodium mg ml liquid sig two po bid times a day insulin regular human unit ml solution sig one injection asdir as directed as per insulin sliding scale units units units more than md senna mg tablet sig one tablet po bid times a day as needed for constipation warfarin mg tablet sig one tablet po once daily at pm measure inr every day for dose adjustement hydralazine mg ml solution sig ten mg injection q h every hours as needed for sbp enoxaparin mg ml syringe sig eighty mg subcutaneous times a day continue till inr becomes stop after that omeprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day tylenol mg tablet sig tablets po q h prn as needed for pain discharge disposition extended care facility discharge diagnosis left mca stroke s p ia tpa and merci 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 admitted for evaluation of stroke you had ct scan of your brain which showed stroke on left mca distribution you recieved thrombolytic and endovascular therapy for acute stroke please take your medicines as prescribed please call or your doctor if you develop any concerning symptoms followup instructions please follow up with following providers scheduled appointments provider md ms phone date time provider md phone date time md [NEW_RECORD] name unit no admission date discharge date date of birth sex f service neurology allergies patient recorded as having no known allergies to drugs attending addendum please note the neurological exam at the time of disharge she was opening her eyes spontaneusly and tracking past midline on right side she is non verbal but is able to follow some commands she has facial droop on right side she is spastic on right side with clonus and is hemiplegic on right side her plantar is upgoing on right side chief complaint called by emergency department for code stroke major surgical or invasive procedure tpa and merci history of present illness ms is a year old right handed woman with a presumed past medical history including dm ii hyperlipidemia cardiac arrhythmia and prior right parietal and external capsule strokes who presents with the sudden of onset of aphasia right facial droop and right sided weakness her daughter and husband explain that ms was in her usual state of health when she went to bed at about pm on while initial interviews suggested that pm was the patient s last known well time it was ultimately discovered that ms was still well when she awakened at about am to go to the bathroom her husband recalls that at that time she ambulated independently and did not appear to have weakness or facial droop at about am he woke up next to her in bed because she was scratching her abdomen he apparently witnessed the subsequent development of right facial droop and hemiparesis between am and am concerned the family drove the patient to the for further care the family maintains that ms has not been herself since the stroke s eight months pta but deny specific illness and discomfort in the recent past review of potential contraindications to tpa absolute negative for stroke or head trauma within months of admission hx of intracranial hemorrhage major surgery within weeks of admission pregnancy persistent sbp or dbp platelets or inr relative negative for gu or gi procedure within weeks of admission lp within week of admission improvement in stroke sx seizure glucose nihss neurological review of systems difficult to assess general review of systems positive for as above shortness of breath negative for chest discomfort shortness of breath cough abdominal pain rash past medical history right parietal external capsule strokes months pta cardiac arrythmia dm ii hld per report labile htn in few weeks pta chronic abdominal pain back pain social history visiting from married has children family history positive for stroke father age physical exam physical examination vitals t p r bp sao ra general awake cooperative heent normocepahlic atruamatic no scleral icterus noted neck supple no carotid bruits appreciated cardiac tahcycardic rate irregularly irregular rhythm normal s and s pulmonary lungs clear to auscultation bilaterally abdomen round normoactive bowel sounds soft non tender non distended extremities warm well perfused skin no rashes or concerning lesions noted neurologic examination mental status degree of alertness alert language language is dysarthric and sparse comprehension appears intact pt able to correctly follow midline and appendicular commands cranial nerves i olfaction not evaluated ii perrl to mm and brisk visual fields full to confrontation iii iv vi limited upgaze eom otherwise intact without nystagmus v facial sensation intact to light touch in the v v v distributions per report of interpreter vii right facial droop viii hearing intact to finger rub bilaterally ix x palate not visible unable to assess xii tongue protrudes minimally but in midline motor bulk no evidence of atrophy tone increased in right lower extremity rue with spasticity drift right ue falls to bed strength left upper extremity throughout delt biceps triceps finger flex right upper extremity throughout delt biceps triceps finger flex left lower extremity throughout iliopsoas quad ham tib ant gastroc right lower extremity some voluntary adduction wiggles right toes reflexes left throughout biceps triceps bracheoradialis patellar right throughout biceps triceps bracheoradialis patellar babinski mute bilaterally sensation light touch intact bilaterally in lower extremities upper extremities trunk face per report pinprick intact bilaterally intact bilaterally in lower extremities upper extremities trunk face per report vibration intact bilaterally at level of medial malleolus per report coordination finger to nose intact on left gait not evaluated 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 fibrino am blood glucose urean creat na k cl hco angap am blood ctropnt am blood ck mb notdone ctropnt am blood hba c am blood triglyc hdl chol hd ldlcalc imaging cta abrupt cutoff of flow within the left m segment associated with hyperdense vessel and in this patient with acute onset of right sided symptom is concerning for an acute embolus no significant cortical edema is appreciated at this time normal variant origin of the vertebral arteries from the external carotid arteries chronic right hemispheric infarcts focal gas collection anterior to the esophagus likely represents an esophageal diverticulum though it is incompletely evaluated and should be correlated with patient s clinical course initial evaluation could take the form of barium swallow as indicated angio ct head there is no acute intracranial hemorrhage there is no definite low attenuation region in the left hemisphere hypodensities in the right frontal and parietal lobes with associated mild volume loss is unchanged there is preservation of the white matter ventricles and sulci are normal in size and appearance and the basilar cisterns are preserved no osseous abnormality is identified the paranasal sinuses and mastoid air cells are well aerated impression no evidence of significant cortical edema unchanged appearance of chronic right hemispheric infarcts echo the left atrium is mildly dilated 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 there are focal calcifications in the aortic arch 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 there is borderline pulmonary artery systolic hypertension there is no pericardial effusion brief hospital course ms is a year old right handed woman with a presumed past medical history including dm ii hyperlipidemia cardiac arrhythmia and prior right parietal and external capsule strokes who presented with sudden onset of aphasia right facial droop and right sided weakness clinical examination was notable for minimal dysarthric speech right facial droop right upper extremity plegia and spasticity right lower extremity paresis with increased tone and diffusely brisk reflexes the deficits localize to the left mca territory as she was out of the window for intra venous tpa the patient was taken to the angio suite the angio confirmed that the left distal mca stem was closed she was given a total of mg of ia tpa and started to open up the mca stem the superior division cleared nicely however the inferior division might be closed the merci device was also used to clear some thrombus from her mca stem it was decided not to go after the inferior mca division since the patient was getting out of a reasonable time window and because she had already mg of ia tpa on board the patient was then transferred to the icu she was extubated on that same day she was kept flat and her sbp dbp was kept below a repeat head ct did not show any hemorrhages she was restarted on asa and heparin the following day she was transferred out of the icu on to the floor for further care she was closely monitered for her neuro exam she was seen and evaluated by physical and occupational therapy for gait and stability assesment she was evlauted for swallow and speech tharpy as well she was started on tube feeds nasogastric however she was being follwoed by swallow tharpy on close basis and they felt that she was improving though gradually and may not need peg tube in long term planning however she should be further evaluated for swallow function and if she does not improve she should be considered for peg tube she was continued on iv heparin which was later bridged to lovenox and coumadin for a therapeutic inr of she was monitered continously on telemetry in setting of acute stroke and a fib she had an episode of rapid afib lasting for few seconds on night the rate was immediately controlled after administertion of metoprolol mg iv her ekg did not show significant st t changes and cardiac enzymes were negative suggested plan of care after discharge physical occupational speech tharapy swallow and nutrition evaluation and continue tube feeds if she does not tolerate then she would need peg tube bridge on lovenopx till inr becomes therapeutic on coumadin management of a fib blood pressure aand other medical issues as felt appropritae by medical team prevention of bed sores and close watch over possible development of infections such as uti pna please note the neurological exam at the time of disharge she was opening her eyes spontaneusly and tracking past midline on right side she is non verbal but is able to follow some commands she has facial droop on right side she is spastic on right side with clonus and is hemiplegic on right side her plantar is upgoing on right side medications on admission amiodarone mg po bid simvastatin mg po glyburide mg po daily buscopam mg po daily dipridamol mg po daily discharge medications simvastatin mg tablet sig two tablet po daily daily amiodarone mg tablet sig one tablet po bid times a day docusate sodium mg ml liquid sig two po bid times a day insulin regular human unit ml solution sig one injection asdir as directed as per insulin sliding scale units units units more than md senna mg tablet sig one tablet po bid times a day as needed for constipation warfarin mg tablet sig one tablet po once daily at pm measure inr every day for dose adjustement hydralazine mg ml solution sig ten mg injection q h every hours as needed for sbp enoxaparin mg ml syringe sig eighty mg subcutaneous times a day continue till inr becomes stop after that omeprazole mg capsule delayed release e c sig one capsule delayed release e c po once a day tylenol mg tablet sig tablets po q h prn as needed for pain discharge disposition extended care facility discharge diagnosis left mca stroke s p ia tpa and merci discharge condition mental status confused always level of consciousness lethargic but arousable activity status bedbound discharge instructions you were admitted for evaluation of stroke you had ct scan of your brain which showed stroke on left mca distribution you recieved thrombolytic and endovascular therapy for acute stroke please take your medicines as prescribed please call or your doctor if you develop any concerning symptoms followup instructions please follow up with following providers scheduled appointments provider md ms phone date time provider md phone date time md completed by,"{
""Diagnoses"": [""Aphasia"", ""Right facial droop"", ""Right sided weakness"", ""Major surgical or invasive procedure (intra-arterial TPA and Merci procedure)"", ""History of present illness (MS)"", ""Hyperlipidemia"", ""Cardiac arrhythmia"", ""Prior right parietal and external capsule strokes""],
""Medications"": [""""]
}"
99865,admission date discharge date date of birth sex f service surgery allergies codeine sulfa sulfonamides penicillins attending chief complaint hepatocellular ca major surgical or invasive procedure right hepatecomy history of present illness year old female who was recently diagnosed with a right lobe hepatocellular carcinoma this was initially diagnosed during routine imaging follow up for renal cell carcinoma of her right kidney which is now status post rfa she has had prior imaging from dating back to that showed a liver lesion of cm most recently a ct scan and pet scan both demonstrated enlargement of the liver lesion to greater than cm a biopsy demonstrated hepatocellular carcinoma the kidney lesion has been noted to be stable a ct scan of the chest demonstrated no evidence of pulmonary metastases a triphasic ct scan demonstrated a large arterial and hyper enhancing mass involving segments and of the liver consistent with a biopsy proven hcc with no further concerning lesions being identified preoperative liver function tests included ast alkaline phosphatase total bilirubin albumin cea ca ca she has undergone thorough preoperative evaluation of her cardiac and cerebrovascular vasculature and has been cleared for surgery she has provided informed consent and is brought to the operating room for right hepatic lobectomy past medical history the patient has a history of coronary artery disease and had a heart attack in peripheral vascular disease s p r external iliac stent and angioplasty hypertension hyperlipidemia depression osteoarthritis anemia cataracts cm abdominal aortic aneurysm vulvar cancer r renal cell cancer s p radiofrequency ablation psurghx r le angioplasty bilateral cataract surgery vulvar cancer resection and bilateral inguinal lymph node biopsy hip replacement x right knee replacement and appendectomy as a child social history she smokes one pack of cigarettes a day and has done so for years she denies alcohol or drug use family history mother died of sbo father died of cerebral hemorrhage sister died of leukemia sister with bladder cancer brother with prostate cancer physical exam post op exam t hr bp rr spo gen sedated difficult to arouse opens eyes to painful stimuli but not voice intubated cardiac rrr chest ctab upper airway sounds abd decreased breath sounds mildly distended clean dressings sanguinous drainage in jp gu foley urine concentrated ext warm and well perfused decreased pedal 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 am blood pt inr pt am blood glucose urean creat na k cl hco angap intraoperative liver u s large right lobe liver mass which is lobulated in contour but appears to be solitary pathology pt n mx g greatest dimension cm additional dimensions cm x cm liver u s no large fluid collections are seen normal color flow and doppler waveforms were noted in the main hepatic artery hepatic vein and portal vein the common duct measures mm mrcp status post right hepatectomy the liver demonstrates moderate dropout of signal intensity on out of phase imaging consistent with fatty infiltration there is no evidence of other worrisome lesions there is no evidence of intrahepatic or extrahepatic biliary dilatation small amount of perihepatic fluid is noted without evidence of organized fluid collection the portal vein is patent the hepatic artery is patent ct abdomen pelvis extensive perihepatic hematoma with mass effect upon the liver portal vein and stomach small bilateral pleural effusions right greater than left liver u s stable appearance of the resection bed hematoma heterogeneous collection measuring x x cm as compared to the ct from normal flow in the main portal vein left hepatic vein and hepatic artery liver bx severe hepatocellular and canalicular cholestasis primarily involving zone with prominent hepatocellular swelling mild lobular and focal portal neutrophilic infiltration with neutrophilic aggregates and infiltration of bile ducts no bile duct proliferation is seen mild to focally moderate steatosis not seen on previous resection cxr interval increase in bilateral right greater than left small pleural effusions with associated atelectasis without evidence of pneumonia cxr as compared to the previous radiograph from there is improvement with decrease in extent of the right sided pleural effusion the clips the drains projecting over the liver and the monitoring and support devices are in unchanged position no newly appeared focal parenchymal opacity suggesting pneumonia no evidence of pneumothorax liver u s resolving collection in the right hepatic surgical bed no biliary dilatation and appropriate vascular waveforms seen in the left lobe of the liver right pleural effusion le u s no lower extremity deep venous thrombosis brief hospital course on she underwent right hepatic lobectomy and cholecystectomy with intraoperative ultrasound surgeon was dr please refer to operative note for complete details postop patient was transferred intubated to the pacu due to episodes of apnea on cpap accompanied by respiratory acidosis likely related to the earlier administration of intrathecal morphine consequently further opiate medication was limited patient was successfully extubated and transferred to the floor on was tolerating a regular diet and started on lasix for weight gain and edema total bilirubin and alkaline phosphatase increased post op alk phos peaked at on and t bili at on before starting to decline for this reason an mrcp was obtained on that demonstrated no biliary obstruction on wbc rose to from the day before patient was afebrile cultures were obtained and were negative drain output had wbcs but fluid culture was negative she was empirically started on vancomycin levofloxacin and flagyl for the leukocytosis sanguinous output was noted from jp patient received u prbc on after a decline in hct to as well as u ffp for an inr of a dobhoff was placed and tube feeds were started for poor oral intake on l blood was noted from jp drain with a decline in hct to from prior and was taken to or for hematoma evacuation hematoma was observed but no active bleeding was identified please refer to dr operative note from for further detail two jp drains were placed patient was kept in sicu following surgery for monitoring she required albumin and a fluid bolus for hypotension low uo prbcs for hct and u plts for platelets of she had an episode of delerium treated with seroquel liver biopsy obtained intra operatively demonstrated severe cholestasis cultures obtained from the hematoma intra op grew sparse coag neg staph aureus on she was hemodynamically stable and was transferred to the floor but still had confused mental status despite withholding of sedating medications on ffp plt and vitamin k were given for an inr of but there was no evidence of bleeding from the jp drains which had decreased output on dermatology was consulted for a worsening rash over her flanks and lower abdomen and suggested a drug reaction versus contact dermatitis that afternoon she was noted to have worsening mental status and complaint of shortness of breath for which albuterol nebs were given chest xray demonstrated right greater than left pleural effusion but mild vascular congestion she was maintaining her saturations at on l nc and appeared more awake and responsive by the late afternoon the morning of patient was transferred to the sicu for increased confusion and tachypnea with concern over airway protection ammonia level was patient was closely monitored in the icu and was maintaining her airway until when she was found to be in respiratory arrest and was subsequently intubated at this time patient went into cardiac arrest and acls was initiated with pressor drip bleeding was noted from drains accompanied by abdominal distension with drop in hct from to rise in inr from to and platelets of massive transfusion protocol was initiated and patient underwent exploratory laparotomy at bedside by dr but bleeding was unable to be controlled and patient required cpr and external pacing patient expired at after discussion with daughter to withdraw care for details see death pronouncement note of medications on admission atenolol mg daily omeprazole mg isosorbide mononitrate mg lovastatin mg daily amitriptyline qhs ferrous sulfate mg discharge medications n a discharge disposition expired discharge diagnosis hepatocellular ca s p resection intra abdominal hematoma s p evacuation delirium respiratory depression cardiac arrest hemorrhage coagulopathy discharge condition expired discharge instructions n a followup instructions n a md,"{
""Diagnoses"": [""right lobe hepatocellular carcinoma"", ""renal cell carcinoma"", ""hepatocellular carcinoma""],
""Medications"": [""codeine"", ""sulfonamides"", ""penicillins""]
}"
87035,admission date discharge date date of birth sex f service cardiothoracic allergies codeine vicodin demerol attending chief complaint worsening dyspnea on exertion chest pain major surgical or invasive procedure cardiac catheterization avr mm ce pericardial mv repair mm cg future ring cabg x lima to lad svg to om aortic endarterectomy hypertension moderate aortic stenosis valve area of cm in last echo in our system mild lvh gout gerd l l laminectomy in post nasal drips s p hysterectomy s p tonsillectomy pneumonia history of present illness ms is a year old female with a h o moderate aortic stenosis valve area cm on echo in htn lvh who presents with a few weeks of worsening dyspnea on exertion she reports shortness of breath and feeling as though her throat is closing with any amount of activity about steps which resolves with rest she has also had a wet nonproductive cough that is worse with deep breathing she denies any orthopnea le edema recent illnesses she reports the throat tightness being present for past few years always with exertion and relieved by rest and drinking ice water she also has been having intermittent jaw pain usually associated with the throat tightness never occurs at rest she denies any associated chest pain but has been very bothered by her wet nonproductive cough which only occurs when she takes a deep breath which she says is a change from prior in the ed initial vitals were on ra labs and imaging significant for a troponin of bnp of d dimer of ekg was sinus tachycardia with a lbbb with no priors for comparison cardiology was consulted who felt that she was in heart failure likely due to worsening of her as but could also be ischemic her symptoms of throat tightening were concerning for angina given that it resolves with rest the cardiology fellow felt that her lbbb was likely related to a structural problem so no need for anti coagulation at this time patient was given aspirin mg vitals on transfer were on ra on arrival to the floor her initial vs were on ra patient currently feels well says that she only has trouble breathing when she moves around or is coughing for a long period of time also she is concerned about what she thinks is a fungal infection in her groin area which she has had in the past and is currently somewhat painful past medical history cardiac risk factors diabetes dyslipidemia hypertension cardiac history cabg none percutaneous coronary interventions none pacing icd none other past medical history moderate aortic stenosis valve area of cm in last echo in our system mild lvh gout gerd l l laminectomy in social history used to work as an occupational therapist widowed tobacco history denies etoh very rare illicit drugs denies family history significant for mother who died of heart disease father who died of ca of the prostate and also heart disease she has a son with cad an aunt on her mother s side who died of breast cancer she has three siblings all of whom are alive two of them have heart issues physical exam on admission vs t bp hr rr o sat on ra general wdwn female in nad oriented x mood affect appropriate heent ncat sclera anicteric conjunctiva were pink no pallor or cyanosis of the oral mucosa no xanthalesma neck supple hjr jvp cardiac rr normal s s systolic murmur best heard at lusb no s or s lungs resp were unlabored no accessory muscle use decreased breath sounds at the bases crackles about the way up abdomen soft ntnd no hsm or tenderness extremities no c c e no femoral bruits pulses right carotid dp left carotid dp 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 ck cpk am blood ck cpk am blood ck cpk am blood alt ast alkphos amylase totbili dirbili indbili pm blood ck mb probnp pm blood ctropnt am blood ck mb ctropnt am blood ck mb ctropnt am blood calcium phos mg cholest am blood hba c eag am blood triglyc hdl chol hd ldlcalc ldlmeas carotid u s bilateral calcified plaque slightly greater on the right but no hemodynamically significant stenosis identified cxr bilateral small pleural effusions with bibasilar atelectasis unchanged background emphysema cath selective coronary angiography revealed moderate lmca and multivessel coronary artery disease the lmca is heavily calcified with stenosis the lad is heavily calcified with mid vessel stenosis relative to calcium shell there is a distal short myocardial bridge with systolic compression there is mild moderate diffuse disease apically a modest d and larger d the lcx is heavily calcified there is a tiny om and om there is proximal mid tubular ulcerated eccentric stenosis before om om has a large lower pole with hazy stenosis there is a modest om and om om lpl has proximal stenosis there is a small lpl patent lpda and distal av groove cx the rca is heavily calcified it is a small nondominant vessel which is mildly moderately diffusely diseased it supplies conus and atrial branches resting hemodynamics revealed elevated left and right sided filling pressures with rvedp mmhg and lvedp mmhg there is mild pulmonary arterial hypertension with pasp mmhg the pcwp is moderately elevated at entry at mmhg the cardiac output is minimally depressed with ci l min m using an assumed oxygen consumption there was severe aortic stenosis with a mean gradient of mmhg and a calculated valve area of cm final diagnosis moderate lmca and multivessel coronary artery disease in a left dominant system severe aortic stenosis moderate left ventricular diastolic heart failure in setting of newly diagnosed systolic heart failure mild pulmonary arterial hypertension vagal reaction to attempts at right antecubital venous access ct chest thoracic aortic calcifications as described severe coronary calcifications severe aortic valvular calcifications mm left lower lobe pulmonary nodule in the absence of risk factors a month followup chest ct is warranted however if risk factors are present then a six month followup is warranted left thyroid nodule for which an ultrasound could be performed incompletely evaluated left adrenal lesion and incompletely evaluated right liver lesion these could be further evaluated with ct or mri bilateral pleural effusions and atelectasis biapical mild centrilobular emphysema conclusions prebypass no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage left ventricular wall thicknesses are normal the left ventricular cavity is moderately dilated there is severe regional left ventricular systolic dysfunction with borderline normal function of the inferior and anterior walls severe hypokinesis of the inferior and anterior septal and septal walls dyskinesis of the anterior apical septum and apical akinesis overall left ventricular systolic function is severely depressed lvef right ventricular chamber size and free wall motion are normal there are simple atheroma in the aortic arch there are complex mm 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 mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened moderate to severe mitral regurgitation is seen due to bileaflet tethering there is no pericardial effusion postbypass the patient is on infusions of milrinone and norepinephrine and is a paced there is a new mitral annuloplasty ring which appears well seated immediately postbypass there was a jet of mitral regurgitation moderate in severity originating from the base of the anterior leaflet just inside the annuloplasty ring likely around the a scallop consistent with a perforation in the base of the leaflet after discussion with the surgeon the patient was returned to bypass for repair after coming off cardiopulmonary bypass for a second time this regurgitant lesion was now mild in intensity there was also mild regurgitation from the coaptation point there is no evidence of systolic anterior motion of the anterior mitral leaflet and there is no stenosis mean gradient mmhg at a co of l min there is also a new bioprosthetic valve in the aortic position which is well seated without evidence of regurgitation or paravalvular leak gradient through this valve is peak mean mmhg at a co of l min left ventricular function is slightly improved lvef now with some improved contractility of the lateral inferior and anterior walls the anteroseptal wall continues to be dyskinetic with severe hypokinesis akinesis of the septum and apex the thoracic aorta is intact dr was notified in person of the results at the time of the study i certify that i was present for this procedure in compliance with hcfa regulations electronically signed by md interpreting physician brief hospital course y o female with a h o moderate aortic stenosis with most recent echo in htn who presented with progressive dyspnea among other symptoms vd on cath and worsening aortic stenosis aortic stenosis last echo in with valve area cm now with severe aortic stenosis area cm ar symptoms of progressive doe may be related to worsening aortic stenosis she was slightly volume overloaded on admission and diuresed with daily iv lasix she was evaluated by cardiac surgery and found to be a good candidate for avr had cath done on this admission which showed vessel disease see below and good candidate for concomitant cabg with avr chf exam cxr and symptoms consistent with progressive chf last echo in showed ef and echo on this admission shows markedly decreased lvef likely in setting of cad vd on cath she was cautiously diuresed pre operatively stable angina she was ruled out for acs on admission with negative enzymes catheterization was performed and showed moderate lmca and multivessel coronary artery disease in a left dominant system see cath report for details she was on asa mg daily statin mg daily emphysematous changes on cxr pt is non smoker no occupational exposure no history of asthma ct chest shows mild changes which are unlikely to be clinically significant pre op w u completed and underwent surgery with dr on see operative note for details post operatively she was admitted to the cvicu in stable condition on propofol levophed and milrinone drips all drips were weaed off with stable henodynamics she was started on carvedilol lasix and lisinopril and maintained on statin therapy she was extubated on pod and transferred to the floor on pod to begin increasing her activity level went into rapid a fib and was treated with amiodarone and ultimately dccv coumadin was started of note she developed sacral ulcer treated with mepilex medications on admission diovan mg daily dyazide tablet daily tylenol mg q h prn pain omeprazole mg daily naproxen mg sl nitro prn coenzyme q glucosamine 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 simvastatin mg tablet sig one tablet po daily daily allopurinol 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 multivitamin tablet sig one tablet po daily daily quetiapine mg tablet sig one tablet po hs at bedtime carvedilol mg tablet sig two tablet po bid times a day lisinopril mg tablet sig one tablet po daily daily magnesium hydroxide mg ml suspension sig thirty ml po hs at bedtime as needed for constipation tramadol mg tablet sig one tablet po q h every hours as needed for pain potassium chloride meq tablet extended release sig two tablet extended release po q h every hours warfarin mg tablet sig as directed for afib tablet po once a day dose based on daily inr until at goal of amiodarone mg tablet sig two tablet po twice a day mg x days then mg daily x days then mg ongoing bisacodyl mg suppository sig one suppository rectal daily daily as needed for constipation acetaminophen mg tablet sig two tablet po q h every hours as needed for fever pain lasix mg tablet sig one tablet po twice a day until lower extremity resloves may need to increase to tid discharge disposition extended care facility for the aged macu discharge diagnosis postop a fib on coumadin coronary artery disease mitral regurgitation hypertension moderate aortic stenosis valve area of cm in last echo in our system mild lvh gout gerd groin fungal rash sacral ulcer l l laminectomy in post nasal drips s p hysterectomy s p tonsillectomy pneumonia discharge condition alert and oriented x nonfocal requires assist with mobility incisional pain managed with oral analgesics incisions sternal healing well no erythema or drainage leg left healing well no erythema or drainage edema lower extremity 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 monday pm a cardiologist dr 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 labs pt inr for coumadin indication afib goal inr first draw md completed by,{}
63834,admission date discharge date date of birth sex m service surgery allergies no known allergies adverse drug reactions attending chief complaint pedestrian struck major surgical or invasive procedure none history of present illness m pedestrian struck found unresponsive under car at scene w gcs intubated for airway protection on scene apparently had been struck by a car traveling approx mph while he was trying to cross the street hypotensive transiently to s systolic at osh pcxr confirmed tube placement otherwise no imaging performed foley placed at ohs with bloody urine no blood reported at the meatus transferred to for definitive care etoh of otherwise tox negative past medical history none physical exam physical exam on admission constitutional intubated sedated heent boggy hematoma to occiput c collar in place chest clear to auscultation cardiovascular tachycardic abdominal past negative moderately distended gu flank foley with gross hematuria extr back scattered abrasions skin no rash neuro moves all extremities to painful stimuli physical exam on discharge avss aox cv rrr no m r g resp ctab gi ntnd ext no c c e lle with strength pertinent results imaging cxr non displaced right sixth rib fracture no pneumothorax ct head minimal sub arachnoid hemorrhage over both cerebral hemispheres extra axial hemorrhage overlying the right frontoparietal region is minimal small quantity of sub dural hemorrahge overlying both leaflets of the tentorium cerebelli no midline shift left parietal subgaleal hematoma and laceration ct neck no acute fracture or malalignment ct torso hypodense region in the inferior aspect of hepatic segment vi isconcerning for a liver laceration no active extravasation likely subcapsular splenic hematoma no definite splenic laceration is identified linear hypodensities throughout both kidneys are likely related to prior infection or reflux although in the setting of trauma these could represent small lacerations thought to be unlikely bilateral lower lobe consolidations are concerning for aspiration in the setting of intubation non displaced right sixth rib fracture and minimally displaced left l transverse process fracture ct cysto no evidence of bladder rupture no evidence of ureteral injury retro urethrogram successful peri catheter urethrogram without evidence of extraluminal contrast eeg final read pending mri head the abnormality in the splenial region is nonspecific and could be seen in patients with seizures or antiseizure medications right frontal and parietal cortical subcortical junction abnormalitieslikely due to diffuse axonal injury small areas of blood products in the subarachnoid space from the known subarachnoid hemorrhage lenis impression no dvt brief hospital course m pedestrian struck intubated at scene and transferred from osh for further care he sustained the following injuries injuries minimal sah over both cerebral hemispheres minimal extra axial hemorrhage overlying the right frontoparietal region small sdh sub dural overlying both leaflets of the tentorium cerebelli no midline shift left parietal subgaleal hematoma and laceration grade liver laceration subcapsular splenic hematoma non displaced right th rib fracture minimally displaced left l transverse process fracture brief hospital course icu course the patient was admitted to the trauma icu on and extubated on on extubation he was moving all extremeties following commands inconsistently and was consfused he became increasingly tachycardic and hypertensive thought to be most likely secondary to alcohol withdrawal an ngt was placed to prevent aspiration and he was managed with avitan and valium per ciwa scale lopressor was used to manage his hypertension and tachycardia he pulled out his ngt which was subsequently replaced with a dobhoff with the initiation of tube feeds on he was transferred to the floor on in stable condition sdh sah the patient was evaluated by the neurosurgery service given his subdural hematoma and subarachnoid hemorrhage he completed a course of dilantin for seizure prophylaxis he was also noted to have an l transverse process fracture for which no intervention was required he was to follow up with the neurosurgery service in weeks after discharge for a repeat non contrast ct of his head mental status left lower extremity weakness the patient was begun on zyprexa in an attempt to help clear his mental status which appeared to help he was noted to have left lower extremity weakness when walking with physical therapy a ct of his left lower extremity was negative neurology was consulted who recommended mri of the brain which showed evidence of diffuse axonal injury he was begun on nimodipine to help prevent vascular spasm an eeg was completed with final read pending on discharge he was to follow up with dr in the traumatic brain clinic on discharge he worked with physical therapy throughout his hospitalization on discharge he was ambulatory independently with minimal assistance pulmonary he was extubated in the trauma icu with post extubation cxr showing no obvious consolidations his non displaced r th rib fracture was managed with pain control and is he continued to saturate well on ra throughout his hospitalization fen gi he sustained a grade liver laceration and splenic laceration serial hematocrits were stable and he did not require any blood transfusions given his altered mental status on presentation thought to be secondary to alcohol withdrawal a dobhoff tube was placed and he was initially mainted on tube feeds as his mental status improved he was transitioned to a regular oral diet which he was tolerating well on discharge hematuria the patient was noted to have hematuria at the outside hospital with concern for urethral injury the urology service was consulted and recommended his foley catheter be left in at least week a subsequent per cathether retrourethrogram showed no extravasation of contrast and therefore his foley catheter was removed after days he did not have any subsequent hematuria and voided without difficulty infectious disease the patient was febrile to upon arrival to the icu urinalysis was significant for nitrite and he completed a day course of iv ciprofloxacin he continued to be intermittently febrile throughout his hospitalizsation without a clear source lenis were negative for dvt ultimately his intermittent fevers were thought to be secondary to the blood accumulated in brain secondary to his subarachnoid hemorrhage sub dural hematoma and not to any clearly identified infectious source on discharge he was ambulating with hand held assistance to his left hand tolerating a regular diet and with pain well controlled on oral pain medications he will follow up with neurology as an outpatient given his new onsent left lower extremity weakness he will also follow up with neurosurgery on discharge he was discharge on new medications olanzapine to assist with his mental status and nimodipine to prevent vascular spasm per neurology recommendations he was discharged with hour supervision his father stays with him at home medications on admission none discharge medications olanzapine mg tablet sig one tablet po bid times a day disp tablet s refills nimodipine mg capsule sig two capsule po q h every hours disp capsule s refills oxycodone mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills colace mg capsule sig one capsule po twice a day disp capsule s refills discharge disposition home discharge diagnosis grade liver laceration grade splenic laceration right th rib fracture subarachnoid hemorrhage and subdural hematoma diffuse axonal injury discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance hand held assistance to left hand discharge instructions you were admitted to the hospital after you were struck by a car and suffered a small ammount of bleeding in your brain you should call the neurosurgery department as below for a follow up appointment in weeks for repeat imaging of your brain your left leg was noted to be weak during this hospitalization for which you were started on a new medication nimodipine which you should continue to take you should follow up with the neurology doctors below please continue to perform your physical therapy exercise as followup instructions please call the neurosurgery department at to schedule a follow up appointment in weeks with a non contrast cat scan of the head the office is located in the medical building please call the acute care surgery clinic at for a follow up appointment within the next weeks please call dr of neurology for a follow up appointment in weeks in traumatic brain clinic completed by,"{
""Diagnoses"": [""adult respiratory distress syndrome"", ""hypotensive shock"", ""transient ischemic attack""],
""Medications"": [""oxygen"", ""vasopressors"", ""Foley catheter""]
}"
17052,admission date discharge date date of birth sex f service surgery allergies sulfa sulfonamides attending chief complaint fever body aches major surgical or invasive procedure bronchoscopy history of present illness year old female with a history of end stage renal disease secondary to dm severe gastroparesis and autonomic neuropathy status post living unrelated renal transplant in and status post pancreas transplant on with reoperation for intraabdominal hemorrhage she was doing well at home until when she experienced increased fatigue with chills and fever to on she denied any increased nausea vomit patient usually vomits on a daily basis secondary to gastroparesis or any changes in her appetite past medical history status post pancreas transplant status post living unrelated renal transplant end stage renal disease secondary to type diabetes mellitus gastroparesis autonomic neuropathy diabetic retinopathy and peripheral neuropathy osteopenia depression social history married no children denies alcohol ivdu and tobacco family history non contributory physical exam vs card tachy lungs cta bilaterally abd soft nt mildly distended incision clean staples in place no drainage extr warm pertinent results pm glucose urea n creat sodium potassium chloride total co anion gap alt sgpt ast sgot alk phos amylase tot bili lipase albumin wbc rbc hgb hct mcv mch mchc rdw neuts bands lymphs monos eos basos hypochrom normal anisocyt poikilocy normal macrocyt normal microcyt normal polychrom normal plt smr normal plt count pt ptt inr pt urine color yellow appear clear sp blood lg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg rbc wbc bacteria rare yeast none epi on discharge am blood wbc rbc hgb hct mcv mch mchc rdw plt ct glucose urean creat na k cl hco angap alt ast alkphos amylase repeat lipase repeat totbili brief hospital course y o female s p pak on doing well at home but now presents with fever to on day of admission had chills the previous day and decreased energy patient was started on broad spectrum antibiotics chest xray on shaowed no acute cardiopulmonary process cta on shows transplant pancreas in right iliac fossa with mild surrounding edema there is external compression of donor splenic portal vein which remains patent and thrombus in the distal smv patent arterial y graft with some thrombus in the distal donor sma that appears beyond branches that supply the pancreas though this is uncertain transplant kidney in left iliac fossa with mild calyectasis on patient had fever to and was having a worsening respiratory status with hypoxemia patient was transferred to the icu where she underwent a bronchoscopy and elective intubation chest xray on that day post intubation showed worsened diffuse confluent opacities consistent with worsened pulmonary edema most likely with an infectious component but could be pulmonary hemorrhage or infection bronchoalveolar lavage cultures were negative for legionella p carinii fungal elements negative by koh and acid fast bacilli by smear culture remains pending blood cultures taken throughout the hospitalization remained negative patient also tested for cryptococcal antibodies toxoplasmosis cmv which were all negative she did have diarrhea intermittently throughout the course c diff negative x as well as stool culture which was negative for pathogens urine cultures were performed throughout the hospitalization which were all negative patient did have some urinary retention but did not wish to have foley catheter encouraged to urinate on a scheduled basis patients temperature ranged from with some element of fever up until days prior to discharge when it was tmax of patient was switched from iv antibiotics vanco days and meropenem days to po fluconazole and augmentin on which will be continued for one week post hospitalization patient had a mild bump in amylase lipase on however repeat labwork later in the day was much improved blood sugars throughout the entire hospitalization u s of pancreas on showed that the pancreas was well seen on ultrasound and shows no evidence of edema no fluid or collections around the pancreas are seen there is normal arterial and venous blood flow identified in all areas patient to discharge home with labwork on and followup visit with dr next monday medications on admission mmf fk lopressor domperidone prozac desipramine kcl nystatin s s neurontin asa lasix discharge medications normal saline normal saline cc bag please infuse up to bags daily via portacath as needed for fluid management disp refills heparin lock flush porcine unit ml syringe sig one ml intravenous daily daily as needed for portacath disp syringes refills aspirin mg tablet chewable sig one tablet chewable po daily daily valganciclovir mg tablet sig one tablet po daily daily disp tablet s refills metoprolol tartrate mg tablet sig tablet po bid times a day zolpidem mg tablet sig one tablet po hs at bedtime disp tablet s refills nystatin unit ml suspension sig five ml po qid times a day fluoxetine mg capsule sig three capsule po daily daily pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours gabapentin mg capsule sig one capsule po bid times a day fluconazole mg tablet sig one tablet po q h every hours for weeks disp tablet s refills amoxicillin pot clavulanate mg tablet sig one tablet po tid times a day for weeks disp tablet s refills mycophenolate mofetil mg tablet sig two tablet po bid times a day tacrolimus mg capsule sig two capsule po bid times a day outpatient lab work labs every week for cbc chem calcium phos ast t bili albumin amylase lipase and trough prograf level fax to attn rn discharge disposition home with service facility healthcare discharge diagnosis fever of unknown origin s p pancreas transplant pneumonia discharge condition good discharge instructions please take your medications as directed please call return to if you experience persistent fevers temp chills nausea vomiting inability to keep medications down abdominal pain glucoses or greater or dizziness labs every monday thursday for cbc chem calcium phos ast t bili albumin amylase lipase and trough prograf level fax to attn rn continue one more week of augmentin and fluconazole followup instructions provider md phone date time completed by [NEW_RECORD] admission date discharge date date of birth sex f service surgery allergies heparin agents sulfa sulfonamides attending chief complaint pneumonia major surgical or invasive procedure nasointestinal tube placement now removed intubation central line placement now removed history of present illness yf with longstanding dm i c b severe gastroparesis autonomic neuropathy and esrd who is s p lurt and pak she subsequently underwent re exploration for intraabdominal hemorrhage she presented to osh and was found to have a bibasilar pneumonia and was placed on nrb and received dose of levaquin upon arrival to the ed she was sat ing in the mid s to s on nrb and on bipap she received g of vancomycin and l of crystalloid before admission to sicu past medical history s p hitt from admission hit ab positive but sra negative status post pancreas transplant status post living unrelated renal transplant end stage renal disease secondary to type diabetes mellitus gastroparesis autonomic neuropathy diabetic retinopathy and peripheral neuropathy osteopenia depression r vitrectomy left antecubital arteriovenous fistula on social history social history married no children denies alcohol ivdu and tobacco her husband was the donor for her kidney transplant in family history there is no history of dm in her family her father died of lymphoma and her mother has htn physical exam vitals cpap general labored breathing awake alert and oriented x heent mucous membranes dry no lad neck supple cvs tachycardic no arrhythmias no m r g chest bibasilar crackles labored breathing abdomen soft nontender tympany to percussion no hsm nabs extremities no c c e rectal no masses guaiac negative pertinent results cxr moderately severe pulmonary edema not appreciably changed since earlier in the day the lung volumes have improved bibasilar consolidation presumably represents coalescent edema and atelectasis small bilateral pleural effusions are present heart size normal et tube and nasogastric tube and right pic catheter in standard placements respectively no pneumothorax cxr previous severe pulmonary edema has improved substantially consolidation is largely restricted to the lower lungs which may be a combination of edema and atelectasis not necessarily pneumonia heart size is normal pleural effusions if any are small and there is no pneumothorax tip of the endotracheal tube is partially obscured but appears to be more than a centimeter above the upper margin of the clavicles and cm from the carina and should be advanced cm nasogastric tube ends in the lower stomach and an esophageal manometer in the upper right jugular line ends in the upper right atrium nasointestinal tube placement successful placement of post pyloric feeding tube with tip in the distal duodenum 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 alkphos amylase totbili lipase albumin calcium phos mg 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 phos mg brief hospital course the patient was admitted to transplant surgery as a transfer from an outside hospital for management of her bilateral pneumonias upon arrival to the ed she was transfered immediately to the icu neuro the patient was sedated with propofol and versed throughout initial period of intubation pain was adequately controlled during hospitalization pulmonary upon arrival to the sicu she was intubated and bronchoscopied pulmonary was consulted on hd the patient was successfully extubated without complications cardiovascular upon arrival to the sicu she was started on pressors for hemodynamic instability and transfused u prbc by hd she was weaned off of pressors but eventually required another units of prbc renal the patient required aggressive diuresis with furosemide after she was hemodynamically stable creatinine on admission and on discharge with mild variations during hospitalization followed by renal no biopsy at this time infectious diseases upon arrival she was started on iv vanco zosyn cipro infectious diseases service was consulted bal revealed no organisms on gram stain or culture pcp stains were all negative but the patient was switched from inhaled pentamidine to bactrim for prophylaxis vanco was d c d on hd cmv viral load was found to be positive with initial result of copies she was started on iv gancyclovir she on iv prophylaxis as an outpatient for weeks post discharge due to concerns that po dosing will not be appropriately absorbed endocrine the patient s glucose was initially labile and required an insulin drip followed by while hospitalized she will resume lantus and humalog upon discharge fen gi nasointestinal tube was placed via fluoroscopy on to start tube feeds which were d c d by immunosuppression she was maintained on her cyclosporin but required several modifications to her dosages she also was placed on iv solumedrol until she was able to take adequate po and was switched to prednisone mg this was subsequently tapered and she will be discharged home on mg daily upon discharge the patient was afebrile with all vitals stable tolerating po feeds ambulating but requiring assistive devices which were provided for home use through and with pain controlled on po pain medication medications on admission albuterol mcg pf in prn with pentamidine treatments ativan mg tablet s by mouth as needed alendronate mg tablet s by mouth qweek aranesp polysorbate mcg ml once per week weekly benadryl mg capsule s by mouth as needed calcitriol mcg capsule s by mouth once a day cellcept mg capsule s by mouth three times a day cellcept mg tablet s by mouth three times a day domperidone bulk mg prn mg tid with meals ergocalciferol vitamin d unit capsule s by mouth qmonth x months fluoxetine mg capsule s by mouth once a day florinef mg tablet s by mouth as needed for low bp gengraf mg capsule s by mouth twice a day metoprolol succinate mg tablet s by mouth twice a day prednisone mg tablet s by mouth once a day pentamidine mg mg ih once per month may give albuterol pre and post treatment discharge medications ganciclovir sodium mg recon soln sig sixty mg intravenous once a day for weeks disp refills picc line care avoid heparin products flush with cc ns following use flush daily and prn normal saline normal saline ml bag infuse liters daily as needed for hydration dispense forty boxes of bags refills two picc line care picc line dressing kit change dressing q days and as needed per agency protocol dispense ten refills two home oxygen therapy oxygen via nasal cannula at l maintain sats diagnosis pulmonary cmv infection with o sats documented less than disp qs for maintenance of l o outpatient physical therapy please provide wheelchair for patient use at home diagnosis pulmonary cmv infection weakness commode please provide bedside commode diagnosis pulmonary cmv infection weakness glucose test strips accucheck aviva glucose test strips dispense three refills six insulin glargine unit ml solution sig ten units subcutaneous once a day disp bottles refills insulin lispro unit ml solution sig as directed per sliding scale subcutaneous four times a day disp bottles refills insulin syringe microfine ml x syringe sig one syringe miscellaneous times daily disp box refills outpatient lab work biweekly cbc with diff chem ast alt alk phos t bili and trough cyclosporine level fax to transplant office and infectious disease outpatient lab work weekly cmv viral load fax to attn dr infectious disease calcitriol mcg capsule sig one capsule po every other day every other day aspirin mg tablet chewable sig one tablet chewable po daily daily fluoxetine mg capsule sig three capsule po daily daily metoprolol tartrate mg tablet sig one tablet po twice a day aranesp polysorbate mcg ml syringe sig one injection once a week trimethoprim sulfamethoxazole mg tablet sig one tablet po daily daily disp tablet s refills ipratropium bromide mcg actuation aerosol sig two puff inhalation qid times a day disp inhaler refills amlodipine mg tablet sig one tablet po daily daily disp tablet s refills prednisone mg tablet sig one tablet po once a day disp tablet s refills cyclosporine mg capsule sig one capsule po twice a day cyclosporine mg capsule sig one capsule po twice a day disp capsule s refills mycophenolate mofetil mg tablet sig one tablet po bid times a day guaifenesin mg ml syrup sig ten ml po q h every hours disp ml s refills discharge disposition home with service facility hospice discharge diagnosis pulmonary cmv infection s p kidney transplant with elevated creatinine discharge condition fair stable discharge instructions please call the transplant clinic at if you experience fever chills increased difficulty with breathing increased cough or sputum production monitor for nausea vomiting diarrhea wear o goal is to maintain sats on l nasal cannula picc line inplace maintain hydration at l ns daily as needed use commode and wheelchair as needed you will be receiving home pt have labwork drawn per transplant clinic guidelines followup instructions md phone date time pft interpret w lab no check in pft intepretation billing date time pulmonary function lab phone date time follow up with dr pulmonologist at please schedule follow up with dr and dr md phone date time completed by,{}
10421,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint enterocutaneous fistulae major surgical or invasive procedure exploratory lapartomy lysis of adhesions takedown of enterocutaneous fistulae g tube exchange small bowel resection with anastomosis history of present illness m with h o sigmoid colectomy in for diverticulitis he underwent an exploratory laparotomy x in for sbo complicated by multiple enterotomies that were combined and converted to a proximal end jejunostomy further complicated by an enterocutaneous fistula presents for enterocutaneous fistula repair and takedown of ostomy past medical history pmh copd prostate cancer meningitis as child diverticulitis psh appendectomy left inguinal hernia repair radical prostatectomy sigmoid colectomy ex lap loa end ileostomy with gj tube placement sbo social history married with children etoh years ago ppy tobacco years ago retired federal government family history non contributory physical exam admission physical exam ra nad ncat perrl eomi cnii xii grossly intact neck supple no cervical lymphadenopathy lungs clear heart rrr abd soft nt nd bs end ileostomy gj tube present ext ankle edema no cyanosis or clubbing 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 alkphos amylase totbili dirbili indbili pm blood albumin calcium phos mg iron pm blood caltibc ferritn trf pm blood type art temp po pco ph caltco base xs intubat not intuba comment room air discharge labs operative report preoperative diagnosis enterocutaneous fistula postoperative diagnosis difficult abdomen enterocutaneous fistula multiple adhesions and multiple enterocutaneous fistulas indications for surgery i heard from a hospital in in which he had undergone surgery for intestinal obstruction apparently the procedure was extraordinarily difficult and after a number of hours there were multiple enterotomies which could not be dealt with at least loops of bowel according to my findings today were brought out through an incision and the incision was closed thus giving him loss of domain and incisional hernia at that point the operation was terminated and he was later referred to me with a wide open central abdominal wound with multiple loops of bowel on the surface and an abdominal fistula the nutritionalist assisted the patient including days preparation in which he had a quick burst of around the clock enteral nutrition to increase his transferrin to from the situation in which he previously had a transferrin down around he had lost about of pounds 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 before draping the incision the old gastrostomy tube was removed and a new fresh sterile gastrostomy tube was calibrated at the appropriate level and sewn in with some fiberwire we began the operation by extending the incision cephalad and inferiorly and it was a relatively small incision through which it would have been difficult to do the operation as it turned out we used the entire length of the midline incision in the abdomen we began the incision superiorly entering the abdomen above the liver without making any enterotomies and without making any holes in the liver the bowel as one would expect was intimately associated with the abdomen we isolated the small bowel loops after very strenuous dissection and very difficult with the bowels the bowel really matted to each other we were able to get him back to having one afferent limb and one efferent limb which we then placed kochers and then resected the bowel the mesentery which was a single mesentery across these loops had approximately inches to inches of bowel attached to it but he had ample bowel remaining so that nutrition with and silk mostly until we had gotten the loops of small bowel proximal and distal immediately adjacent to each other there was a slight difference in caliber because the top part of the anastomosis had had some food passed through it in the past and the distal had not had any food for approximately about months and so there was complete diversion as a matter of fact in the colon there was some stool balls in the right colon and they had probably been there for months we had tried to enematize them prior to the operation without success after this we carried out a two layer silk silk anastomosis in end to end and had ligated the mesentery and sutured the mesentery before we had put these loops of bowel together the blood supply was excellent and we were very happy with the anastomosis the fistula which has a lot of skin attached had also been resected prior to doing this and this was satisfactory as well it then became time to mobilize the abdominal wall widely to repair his incisional hernia which was brought about by the previous operation carried out elsewhere this was done with immobilization of the entire area and was extensive enough to require drains in the subcutaneous area gloves gowns and drapes were then changed the wound was closed in layers with prolene in running fashion on the fascia vicryl as the subcutaneous closure this was difficult in the area below the umbilicus but this was successfully carried out with interrupted vertical mattress of nylon the superior portion was closed with monocryl and vicryl estimated blood loss was cc the patient tolerated the procedure well two sponge counts needle counts and instrument counts were reported as correct by the nurse in charge dictated by brief hospital course was admitted to on under the care of dr tpn was continued preoperative labs showed trf albumin baseline pco preoperatively hibiclens washes were provided and he was given a prep of neomycin erythromycin he was taken to the operating room on where he underwent an exploratory laparotomy lysis of adhesions gastrostomy tube change enterocutaneous fistula resection primary anastomosis w repair of incisional hernia he tolerated the procedure well and was taken to the icu postoperatively for closer monitoring pain was controlled via epidural and pca at pod he was afebrile and with good urine output hct was he was transferred to the floor at pod he received unit prbcs for a hct of the narcotic component of the epidural as discontinued we continued to await bowel function at pod reglan was started he was afebrile and ambulating at pod he was febrile to the epidural was removed cxr showed lll pna he was flatus he was tolerating clear liquids the incision site particularly around the g tube had a moderate amount of erythema purulent drainage vancomycin cefepime flagyl were started for empiric coverage blood urine cultures were negative for growth incisional drainage was for yeast enterococcus mrsa fluconazole was added at pod he continued to have an elevated wbc count at incisional cellulitis and drainage was resolving repeat cxr showed continued lll pna and right middle lobe opacities at pod he was tolerating a regular diet wbc count was chest ct was completed which showed small bilateral effusions and severe emphysema at pod he was somnolent abg was obtained which showed pco of ph po albuterol atrovent were provided with good response narcotics were discontinued tpn was discontinued at pod he was afebrile and with good bowel function wbc count was repeat abg showed pco at megace and zinc were started for poor appetite calorie counts showed g protein kcal at pod pt discharged to home with services at this point pt is tolerating a regular diet and po intakes have significantly improved since he was first discontinued from tpn he will continue to take iv vancomycin and po cipro flagyl and fluconazole at home for additional wk medications on admission diltiazem mg qd atrovent puffs qid albuterol puffs q h prn temazepam mg qhs prn ativan mg prn paroxetine mg qd protonix oxycodone mg q h darvocet q h prn discharge disposition home with service facility critical care systems discharge diagnosis enterocutaneous fistulae emphysema post op pneumonia post op anemia post op wound infection discharge condition good discharge instructions please return or contact for fever f or chills abdominal pain nausea or vomiting increased shortness of breath or chest pain redness or drainage from incision site increased swelling or redness of extremities inability to pass gas or stool any other concerns followup instructions please follow up with dr in weeks please call for an appointment completed by,{}
18833,admission date discharge date date of birth sex m service nb disposition transferred to for an evaluation in the operating room history was born on to a year old gravida iv para to mother at and weeks he was born vaginally after spontaneous rupture of membranes on day of delivery with preterm labor mother s prenatal screens include blood type a positive antibody negative hepatitis b surface antigen negative rubella immune rpr nonreactive group b strep unknown past medical history polycystic ovarian disease depression attention deficit disorder hsv with last outbreak past obstetric history includes week twins with one fetal demise the other twin spent weeks in the nicu maternal medications welbutrin zoloft terazodone several herbal supplements delivery course the infant emerged with poor tone and respiratory effort he was given positive pressure ventilation intubation was attempted for persistent poor respiratory effort and was discontinued with improvement of work of breathing he was given blow by oxygen and transferred to the newborn intensive care unit for further evaluation physical examination weight was kg greater than the th percentile length cm head cm also th percentile heent anterior fontanel open and flat soft cleft palate small cleft at the upper gums small chin low set ears posteriorly rotated neck with linear red mark appears to be an abrasion heart regular rhythm no murmur pulse is equal lungs mild retractions air exchange is fair to good bilaterally abdomen is soft no masses palpable liver cm below the costal margin active bowel sounds three vessel cord clamped normal external male genitalia testes palpable neurology poor tone almost inverted u with ventral suspension deep tendon reflexes lower extremities is normal difficult to elicit upper extremities no clonus hospital course respiratory initially was placed in nasal cannula liter flow and was then placed on nasal prong c pap for poor respiratory effort he required up to oxygen to maintain sats greater than he had an arterial hyperoxia gas which showed a ph of for a pa for bicarbonate and for base deficit he weaned from prong c pap of cm on day of life and then was placed in room air subsequent to that he continues in room air he has been noted to have occasional drift in his oxygen saturations and had a mild pectus noted on examination as well he breathes comfortably to in room air he continues to have desaturations mostly with sucking and feeding he develops stridor with feeds at about and weeks of age and continues with stridor due to stridor he was evaluated by the otolaryngology service at on they performed a flexible scope at the bedside this revealed moderate laryngomalacia and floppy arytenoid tissue he started on zantac at that time which was and has continued on zantac mg kg twice a day with some improvement noted but continues to have stridor mostly noted with feedings addendum by infant had bronchoscopy at today dr orl attending reported that airway from subglottic area to carina appeared normal epiglottis and aryepiglottic folds were not redundant and that tongue appeared to be the reason for infant s intermittent upper airway obstruction dr and were contact by dr to consider tongue lip adhesion procedure dr and ms this evening of we will try positioning infant prone with head slightly down and modify nipple with nasal trumpet extending beyond tip of nipple to see if each of these procedures will help reduce desaturation and airway obstructive episodes addendum by infant remains in room air still has stridor especially with feeds prone positioning during and appears to have helped cardiovascular was hemodynamically stable with blood pressure means s to s means s to s his ap ranged from s to s he had no murmur due to concern for dysmorphic features an echocardiogram was performed and cardiology service he had an electrocardiogram which was normal for age he had an echocardiogram which revealed normal anatomy fluids electrolytes and nutrition was maintained n p o until respiratory stability was developed he had intravenous fluids of d w he had maintenance electrolytes added and his serum electrolytes were followed and noted to be in the normal range he started enteral feeds on day of life and advanced ml kg twice a day as tolerated he reached full enteral feeds by day of life with breast milk or premature enfamil calorie per ounce he was offered p o feedings at about week of age which he had difficulty with coordinating his suck swallow breathing due to feeding difficulties and the soft cleft palate he had a consult with the craniofacial team at dr and rn they were concerned with his cleft palate his dysmorphic features with the small chin the broad nasal bridge with the bifid nose and low set ears and question of thymic tissue neck the facial and neck tissue were consistent with branchio oral facial syndrome or bofs skull films were normal genetics was as well several studies were obtained that will be described in further detail a feeding team evaluation was also obtained after several attempts at different types of nipples have not worked well for his mother has had some success with breast feeding and he seems to be comfortable breathing at the breast he has been fed with the pigeon nipple per the craniofacial teams recommendation and later switched to the feeder per the feeding team recommendation with good success currently is taking cc kg day breast milk cal oz concentrated with cal of enfamil powder due to persistent poor tolerance and ability to po feed infant will have gastrostomy tube placed at on gastrointestinal has been noted to pass normal meconium transitional and infant stools they have been guaiac negative he was treated for physiologic jaundice with a peak bilirubin of over on day of life he continued on phototherapy until day of life and a rebound bilirubin was over on day of life this issue has been resolved hematologic initially had a cbc and blood culture obtained upon admission with a white count of polys and band a hematocrit of and a platelet count of he received hours of ampicillin and gentamycin and had negative blood cultures he has remained clinically well off of antibiotics he was started on tri vi on day of life and continues on that at this time l eye drainage for staph species conjunctivitis rx d with polymcin ophthalmic oint improved marked decreased drainage neurologic due to concern for hypotonic neurologic examination some posturing and tremors noted a neurology consult was obtained upon admission in addition to the genetics consult aforementioned metabolic investigations included liver function tests serum amino acids lactate pyruvate a karyotype urine for amino or organic acids liver function tests his liver function tests were normal serum amino acids lactate and pyruvate were normal his organic acids were normal save for increased hydroxy phenylacetate and hydroxy phenylpyruvic chromosomes were sent which were normal a signature chip is pending at this time a darker banding was noted on the chromosomes a urine cmv was negative mri was obtained on and was normal per neuroradiology at skull films were also obtained and those were interpreted as normal as well neurologic examination continues to alternate between times of hypoactivity and hypertonicity some of his clinical symptoms have been attributed to maternal medication administration including welbutrin zoloft and terazodone which have demonstrated abnormal neurologic examinations in the initial newborn period sensory referred on his right ear on the initial newborn hearing screen on he will need a follow up diagnostic brain stem auditory evoked response test in the near future ophthalmology on an ophthalmology examination was obtained and this was interpreted as normal psychosocial a social worker was involved with this family parents have been involved and concerned over diagnosis and ability to feed well condition on discharge good discharge disposition transfer to pediatric surgery service dr for gastrostomy tube placment on infant will be admitted to nicu north following his surgery and then transferred to name of primary pediatrician dr medications tri vi sold car seat position screening has not yet been done we recommend car bed seat for infant not regular car seat at this time due to concern re risk of upper airway problems in car seat state newborn screens have been done per protocol immunizations received included hepatitis b vaccine discharge diagnoses prematurity at and weeks rule out sepsis branchio oro facial syndrome laryngomalacia resolved physiologic jaundice feeding intolerance need g tube for long term nutritional maintenance md dictated by medquist d t updated job [NEW_RECORD] admission date discharge date date of birth sex m service nb history of present illness is a former kilogram product of a and week gestation pregnancy born to a year old g p now woman prenatal screens blood type a positive antibody negative hepatitis b surface antigen negative rubella immune rpr nonreactive group beta strep status unknown the obstetrical history was significant for a prior delivery of week twins there was a fetal demise of one of the twins this pregnancy occurred in this pregnancy was uncomplicated until spontaneous rupture of membranes and onset of preterm labor on the day of delivery was born by spontaneous vaginal delivery he emerged with poor tone and apnea in the delivery room he required positive pressure ventilation intubation was attempted for persistent poor respiratory effort but was discontinued with improvement in respiratory effort he was given blow by oxygen and transferred to the newborn intensive care unit other past significant maternal history includes polycystic ovarian disease chronic depression attention deficit disorder and chronic herpes simplex virus infection with the last outbreak in physical examination upon admission to the neonatal intensive care unit weight kilograms th percentile length cm th percentile head circumference cm also th percentile head eyes ears nose and throat anterior fontanel open and flat very small chin low set and posteriorly rotated ears soft cleft palate small cleft at the upper gum line lip has the appearance of an interrupted cleft as well neck with a mass in the upper brachio cephalic area chest mild retractions fair air exchange heart regular rate and rhythm no murmur peripheral pulses equal abdomen soft no masses palpable liver cm below the costal margin active bowel sounds three vessel cord gu normal external male genitalia testes palpable spine straight normal sacrum hips stable neurological poor tone inverted u with ventral suspension deep tendon reflexes in the lower extremities normal no clonus elicited hospital course respiratory was initially on nasal cannula o with worsening respiratory effort he was placed on continuous positive airway pressure his work of breathing and respiratory effort improved and he was transitioned to room air on day of life number he has remained in baseline room air for the rest of his neonatal intensive care unit admission he had episodes of oxygen desaturation and developed stridor at weeks of life he was evaluated by the otorhinolaryngology service attending dr a bedside flexible laryngoscopic exam raised concern for laryngeomalacia he underwent a rigid bronchoscopy under general anesthesia at which was normal it was felt at this time that his large tongue and small airway were the etiology for his stridor and episodes of oxygen desaturation with the other facial findings a consultation with dr plastic surgeon from was obtained it was dr opinion that had all the clinical features of branchio oculo facial syndrome a very rare genetic disorder characterized by the incomplete cleft of the lip and palate and the other craniofacial abnormalities was successfully managed in the prone position without further episodes of serious desaturation at the time of discharge he is able to be in any position either prone or supine without episodes of desaturation he passed a car seat test on his baseline respiratory rate is to breaths per minute he does develop stridor with feeds which persist for a short time after the feeding in between feedings his breath sounds are clear and equal and he does not have any evidence of respiratory distress is slated to have surgical repair of his facial anomalies with dr in or he is being discharged home with an oximeter for use while sleeping to ensure that he has no significant desaturations cardiovascular due to the other abnormal clinical findings had a screening electrocardiogram and echocardiogram all results were within normal limits and the echocardiogram did not show any structural heart disease baseline heart rate is to beats per minute with a recent blood pressure of with a mean of fluids electrolytes and nutrition was initially npo and maintained on intravenous fluids enteral feedings were started on day of life number and gradually advanced he had inconsistent success with po feedings even when different nipples and feeding devices were tried his most consistent success was with a habermann feeder due to the concern of inconsistent feeding ability the decision was made to place a gastrostomy feeding tube a surgically placed gastrostomy tube was placed at on by dr the gastrostomy tube began leaking approximately days postoperatively he was diagnosed with a cellulitis at the site he was made npo and treated with a week of intravenous kefzol the enteral feeds were started again on and has been predominantly po feeding with some additional intake through the gastrostomy tube without any problem since that time he is being discharged home on mother s breast milk fortified to calories per ounce calories oz by enfamil powder weight on the day of discharge is kilograms with a corresponding head circumference of cm and a length of cm serum electrolytes were checked at numerous junctures and all were within normal limits infectious disease had a complete blood count and blood culture drawn on admission to the neonatal intensive care unit the blood count was within normal limits the blood culture was no growth at hours received hours of ampicillin and gentamicin during the pending blood culture as previously noted had a cellulitis at the gastrostomy tube insertion site and was treated with a week of kefzol blood culture obtained at that time was also no growth has had intermittent problems with eye drainage as part of his syndrome he has a blocked tear duct on the right in the past with development of conjunctivitis he has been treated with erythromycin garamicin and polymixin currently the blocked duct is being treated with lacrimal massage and his mother has ciprofloxacin by ointment to treat on an as needed basis if he develops evidence of conjunctivitis hematological blood type a positive coombs negative hematocrit at birth was he did not receive any transfusions of blood products his most recent hematocrit was on at he is being discharged home on supplemental iron gastrointestinal required treatment for unconjugated hyperbilirubinemia with phototherapy peak serum bilirubin occurred on day of life number total mg per deciliter direct as noted he has a gastrostomy tube placed genetics as part of his workup for the abnormal physical findings was evaluated by the genetic consult service at he will be followed by dr at months of age chromosomes were normal showing a normal karyotype he also had a signature chip chromosome study sent with results that remain pending there were extensive metabolic studies drawn with all results within normal limits neurological was also evaluated by the neurology service at as time progressed his tone improved he will be followed in the neonatal neurology program at after discharge head ultrasound on was normal an mri performed on was also normal skull films were obtained as part of the workup and also were normal sensory audiology hearing screening was performed with automated auditory responses passed in the left ear and referred in the right ear he was retested on and again referred in the right ear he is being referred to for further audiological evaluation ophthalmology as part of his work up for the abnormal physical findings had an ophthalmological exam on his eyes are structurally normal he has intermittent problems with the blocked tear ducts and will be treated on an as needed basis with antibiotic opthalmic ointment psycho social social work has been involved with this family the contact person is and she can be reached at condition on discharge good discharge disposition home with the parents primary pediatrician dr pediatric associates phone number fax number care and recommendations at discharge feeding ad lib po with a minimum of cc per kilo per day of breast milk fortified to calories with enfamil powder if unable to take oral feedings gastrostomy feedings to supplement to a minimum of cc per kilo per day medications ferrous sulfate mg per ml dilution ml po once daily tri vi or other vitamin e d c supplement ml po once daily car seat position screening was performed was observed in his car seat for minutes without any episodes of oxygen desaturation or bradycardia state newborn screens were sent on results within normal limits immunizations received hepatitis b vaccine was administered on pediarix was administered on injectable polio vaccine on prevnar on synagis was administered on and immunizations recommended synagis rsv prophylaxis should be considered from through for infants who meet any of the following criteria first born at less than weeks second 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 thirdly 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 care givers follow up appointment scheduled dr within days of discharge dr plastic surgery phone number one month after discharge clinical genetics dr at at age months feeding team at weeks after discharge or as needed neonatal neurology at dr phone number for neonatal neurology clinic discharge diagnoses branchio oculo facial syndrome prematurity at and weeks gestation suspicion for sepsis ruled out cleft lip and palate rule out hearing loss in the right ear blocked tear ducts status post unstable airway status post gastrostomy status post circumcision status post rigid bronchoscopy conjunctivitis treated hyperbilirubinemia treated dictated by medquist d t job,"{
""Diagnoses"": [""admission for an evaluation in the operating room"", ""preterm labor""],
""Medications"": [""Welbutrin"", ""Zoloft"", ""Terazodone"", ""Herbal supplements""]
}"
52343,admission date discharge date date of birth sex m service cardiothoracic allergies aspirin attending chief complaint chest pain nstemi major surgical or invasive procedure aortic valve replacement mm mechanical regent history of present illness this is a yom with a history of hepatitis c and polysubstance abuse who was transferred from for further management of a nstemi thought to be secondary to aortic valve vegetation embolism he first presented on with fevers and lightheadedness he was found to have strep viridans endocartiditis with large vegetation on his noncoronary cusp as well as posterior root seen on tee he was treated with penicillin and gentamicin and transferred to state on at which point he was transitioned to high dose ceftriaxone he completed four weeks of antibiotics on and has been without fevers chills malaise weakness sensory deficits vision abnormalities since that time he presented to days ago with anterior chest pain radiating to the left side which started on troponin was found to be elevated at and though there were no acute ekg changes per report he was treated for nstemi with lovenox and plavix asa allergy a tte demonstrated persistentce of a large aortic valve vegetation along with moderate severe aortic regurgitation an embolic vegetation is suspected as the source of the nstemi past medical history viridans strep aortic valve endocarditis nstemi depression iv drug use heroin hepatitis c marijuana use migraines social history lives w his wife in has four kids ppd for years quit hx of polysubstance abuse particularly heroin but claims to be clean since d c from state hospital utox was for mj at admission to lgh had tried cocaine times in the months prior to initial admission but none since not currently working applying for ssi family history mom had cva with hemiparesis dad with dm four living siblings are healthy one murdered physical exam admission physical exam vs t bp hr rr o sat ra general 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 flat positive carotid thrill cardiac rrr iii vi pan diastolic murmur loudest at rusb lungs no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use ctab no crackles wheezes or rhonchi abdomen soft ntnd no hsm or tenderness abd aorta not enlarged by palpation no abdominial bruits extremities no c c e no femoral bruits no lesions or splinter hemorrhages skin no stasis dermatitis ulcers scars or xanthomas multiple tatoos pulses right carotid dp pt left carotid dp pt neuro walking w o difficulty normal gait cnii xii intact strength throughout 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 ld ldh alkphos totbili am blood ck mb ctropnt am blood calcium phos mg am blood caltibc ferritn trf am blood hba c eag am blood hbsag negative hbsab positive hbcab negative hav ab positive am blood hcv ab positive blood cultures no growth ct head findings there is no intracranial hemorrhage the white matterdifferentiation is preserved there is no edema mass or mass effect the ventricles and sulci are normal in size and configuration the mastoid air cells and paranasal sinuses are clear there is no fracture impression no acute intracranial process coronary ct impression suboptimal cardiac gating due to high heart rate and inability to proceed with large dose of iv beta blockers due to patient s low blood pressure no central obstructing filling defect demonstrated in right coronary artery left main left circumflex artery normal anatomic origin of the coronary arteries large vegetation of a known bicuspid valve accompanied by calcifications thickening of the aortic valve apparatus versus less likely papillary muscle hypertrophy tee 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 is moderately dilated overall left ventricular systolic function is moderately depressed lvef xx right ventricular chamber size is normal with borderline normal free wall function the ascending transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque the aortic valve leaflets are severely thickened deformed there is a large vegetation on the aortic valve no aortic valve abscess is seen there is no aortic valve stenosis moderate aortic regurgitation is seen the mitral valve appears structurally normal with trivial mitral regurgitation there is no pericardial effusion post mechanical valve in aortic position well seated and good leaflet excursion with expected washing jets peak gradient mm hg rv and lv have unchanged systolic function radiology report chest portable ap study date of am medical condition year old man with s p avr final report the patient is status post median sternotomy and aortic valvular surgery with stable post operative appearance of the cardiomediastinal contours minimal area of atelectasis is again demonstrated in the right lower lobe with otherwise clear lungs extreme left lung base has been excluded from the radiograph precluding assessment for small left effusion or peripheral basilar left lung abnormality brief hospital course patient was transferred to after ruling in for nstemi at has had been treated prior to that admission for aortic valve endocarditis an echo prior to transferred revealed severe aortic regurgitation following admission he remained stable cardiac catheterization was not performed due to risk of embolization of the vegetation cardiac surgical consultation was requested on he went to the operating room after the usual preoperative workup please see operative report for details in summary he had aortic valve replacement with a mm st mechanical valve reference number his bypass time was minutes with a crossclamp time of minutes he tolerated the operation well and post operatively was transferred to the cardiac surgery icu in stable condition he remained hemodynamically stable awoke intact was weaned from the ventilator and extubated all tubes lines and drains were removed per cardiac surgery protocols he was started on bblockers diuretics and anticoagulation the day following surgery he transferred to the stepdown floor on pod physical therapy saw him for strength and mobility his methadone was resumed he received opiates and toradol for surgical pain the remainder of his hospital course was uneventful he continued to make good progress and was cleared for discharge to home on pod eight his inr is to be followed by coumadin clinic starting on his first inr check is the day after discharge with results to cardiac surgery oncall staff at before or coumadin clinic if after all follow up appointments were advised medications on admission methadone mg daily lorazepam mg daily prn tylenol colace omeprazole mg daily senna simethicone bisacodyl discharge medications ranitidine hcl mg tablet sig one tablet po bid times a day for weeks disp tablet s refills docusate sodium mg capsule sig one capsule po bid times a day for months disp capsule s refills metoprolol tartrate mg tablet sig tablets po tid times a day disp tablet s refills hydromorphone mg tablet sig tablets po q hrs 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 methadone mg ml solution sig seventy five mg po daily daily warfarin mg tablet sig as directed tablet po once a day take mg daily until otherwise directed by the clinic target inr disp tablet s refills nicotine mg hr patch hr sig one transdermal once a day disp refills clopidogrel mg tablet sig one tablet po daily daily disp tablet s refills outpatient lab work inr to be drawn on with results sent called to the answering service inr should then be drawn again on with results on that day and thereafter sent to the clinic at fax discharge disposition home discharge diagnosis aortic insufficiency s p mechanical avr h o aortic valve endocarditis hepatitis c h o intravenous drug abuse polysubstance abuse depression discharge condition alert and oriented x nonfocal ambulating with steady gait incisional pain managed with dilaudid and motrin 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 at pm cardiologist dr at pm pcp 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 day after discharge and results to coumadin clinic t they will follow starting phone fax confirmed with completed by,"{
""Diagnoses"": [""cardiothoracic"", ""allergies"", ""aspirin"", ""NSTEMI"", ""aortic valve replacement"", ""Hepatitis C"", ""polysubstance abuse""],
""Medications"": [""penicillin"", ""gentamicin"", ""ceftriaxone"", ""Lovenox"", ""Plavix""]
}"
46403,admission date discharge date date of birth sex f service medicine allergies levofloxacin morphine zosyn attending chief complaint pulmonary edema intubation major surgical or invasive procedure endotracheal intubation history of present illness y o with hx of cva in the past and baseline left sided weakness who initially presented to with abdominal pain ct scan at bin revealed uncomplicated diverticulitis and was started on zosyn she received cc of fluid in setting of iv contrast pt w cr of at bin and developed respiratory distress with bp of per report this was thought to be flash pulmonary edema and was treated with mg iv lasix and nitro paste also received asa pt was sedated with propofol as well as receiving several doses of ativan and was intubated no abg obtained at that time pt then apparently developed hypotension possibly in setting of lasix nitro and propofol and was started on levophed at r ij and s were placed and transferred to on arrival to propofol ggt was stopped and started on fent versed on admission vitals were bp hr rr lactate vent settings were ac tv peep fio abg was on these settings pt also had ekg at bin which showed lateral st depressions and upright t waves repeat at showed twi in avl v v troponin noted at on admission vitals on transfer to icu t hr bp rr on vent on of levophed past medical history right caudate cva presumptively embolic gerd hypertension gait ataxia low back pain with history of laminectomy history of pneumonia trigeminal neuralgia social history patient has daughter who is nicu rn involved in care and son who is a rabbi patient is divorced recently moved from to nursing facility she does not smoke or drink alcohol no history of illicit drug use prior to hospitalization she was ambulating well with a walker family history notable for congestive heart failure mother died at father died at from pulmonary embolism sister at with myasthenia brother with heart disease there is a family history of diabetes physical exam admission physical exam vitals t hr bp rr general intubated sedated non responsive to verbal or tactile stimulation heent sclera anicteric perrla neck supple no jvd lungs bilateral coarse breath sounds cv regular rate and rhythm normal s s no murmurs rubs gallops abdomen soft mildly distended no tenderness illicited bowel sounds present gu foley ext bilaterally inverted feet cool feet pulses trace edema discharge physical exam tm on ra exam general chronically ill appearing awake oriented x nad conversant this am heent sclera anicteric oropharynx with dry mucous membranes no thrush perrl eomi neck supple no lad jvp is difficult to assess lungs improved scattered crackles at bases bilaterally no wheezing cv regular rate and rhythm normal s soft s murmur heard best at lusb radiates to carotids pulsus tardus present no rubs or gallops abdomen soft mildly tender in ruq non distended normoactive bowel sounds present no rebound tenderness or guarding no organomegaly bruises from subq heparin ext muscle wasting in all limbs warm well perfused pulses no clubbing cyanosis or pitting edema neuro perrl eomi l arm and leg significantly weaker than on r but able to perform hand grip and lift leg off bed babinski s downgoing sensation intact reflexes brisk on l access pivs pertinent results labs studies 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 probnp am blood ck mb ctropnt am blood calcium phos mg am blood caltibc vitb folate hapto ferritn trf am blood triglyc pm blood tsh c diff negative blood cultures x ngtd cxr pulmonary edema has resolved there are low lung volumes with bibasilar atelectasis there is no pneumothorax or pulmonary effusions cardiomegaly is stable there are no new lung abnormalities tte 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 arch is mildly dilated the aortic valve leaflets are moderately thickened there is moderate aortic valve stenosis valve area cm mild aortic regurgitation is seen the mitral valve leaflets are mildly thickened there is no mitral valve prolapse moderate mitral regurgitation is seen there is a very small pericardial effusion peak velocity m s peak gradient valve area cm ekg possible ectopic atrial rhythm left axis deviation may be due to left anterior fascicular block although is non diagnostic anterolateral lead st t wave changes are non specific since the previous tracing of ectopic atrial rhythm and further st t wave changes are both now present swallow impression penetration and aspiration with thin barium swallow much improved but still some degree of aspiration of thin liquids brief hospital course f yo f p w diverticulitis c b shock and respiratory failure after receiving ivf she was intubated for presumed pulmonary edema c b post intubation lasix hypotension and elevated cardiac biomarkers in the setting of critical as shock likely both cardiogenic and septic secondary to ivf followed by lasix nitro paste in the setting of critical as and patient being volume depleted from diverticulitis and having a uti pt was weaned off pressors pt was then started on lasix ggt with good output and stable bps patient likely pre load dependent given critical as she completed a day course of cefepime flagyl and vancomycin which provided coverage for uti pneumonia and diverticulitis critical as improved to moderate as valve area cm on tte consistent with moderate as once she was no longer septic likely cause of pulmonary edema and subsequent hypotension in setting of fluid shifts pt had hypertensive episode and had acute pulmonary edema secondary to aortic stenosis cardiology was consulted and patient was not considered for replacement valve or valvuloplasty at that time because of her critical condition at the time she was scheduled for follow up with cardiology dr respiratory failure flash pulmonary edema with xray showing bilateral pleural effusions and edema likely secondary to critical as the patient was diuresed with lasix ggt to optimize volume status before extubation goal diuresis of negative liters was met on multiple days and pt respiratory status improved her rsbi score gradually decreased and she was able to tolerate psv settings while being weaned off of sedation pt was eventually extubated but shortly after extubation she began to have stridor we administered racemic epi and heliox but ultimately pt was reintubated she was given hours and then another trial of extubation occured this time with steroids given hours prior to extubation and then q hrsx after extubation pt was successfully extubated she subsequently had episodes of subjective respiratory distress but all the while was satting in the high s and without stridor these symptoms were best controlled with seroquel to calm her down pt continued to diurese and she was eventually transitioned to po lasix he respiratory status stabilized and was ready to be called out of the on the floor the patient was diuresed with mg po lasix per day with good response her pulmonary edema improved by clinical exam and xray and the patient was thought to be nearly euvolemic on the day of discharge the patient was not discharged on diuretics because of her dependent on preload given moderate severe aortic stenosis hypertension the patient was very hypertensive in the icu and upon transfer to the floor her bp regimen was changed to captopril mg tid and her pressures normalized she was also on metoprolol mg tid for atrial fibrillation with rapid ventricular response anemia required units prbcs throughout admission with last being on with goal to keep hct likely related to elevated coags anemia work up showed iron tibc ferritin trf b folate hapto are wnl these indicate likely iron deficiency anemia with component of anemia of chronic dz her hct was stable on the days leading up to discharge diverticulitis pt presenting to osh with abdominal pain found to have diverticulitis of the left colon likely explained her leukocytosis as high as trended down to as well as her hypotension abdomen was soft on the day of discharge she was tolerating prethickened liquids and soft foods on the days leading up to discharge renal failure per family baseline is and on admission to is but has trended up to thought to be to contrast nephropathy creatinine was at her baseline on the day of discharge elevated troponin though to be demand ischemia given sepsis blood loss and fluid shifts in the setting of critical as trops peaked at on but now trended downward she was discharged on aspirin mg qday and metoprolol history of afib per discussion with family patient does not really have history of afib coumadin was started for hx of cva the patient had episodes of afib w rvr that required an esmolol or dilt drip after transfer to the floor the patient remained in sinus rhythm with infrequent spontaneously remitting episodes of tachycardia possibly afib w rvr though appeared regular and could have represented avnrt she was discharged on metoprolol mg tid and coumadin she became supratherapeutic on coumadin and her dose was held on and on the day of discharge inr was she is to restart coumadin on sunday at mg qday she should have her inr checked on tuesday trigeminal neuralgia not taking tegretol at home per records we have available nutrition the patient was eating soft solids on the day of discharge she had swallow studies which showed aspiration of thin liquids and she was received nectar pre thickened liquids her second swallow showed much improvement and she will need repeat eval at rehab the patient received subq heparin before she was therapeutic on coumadin on the day of discharge inr was the patient remained full code after her transfer from the icu long family discussions were held and they are still in the process of finalizing their thoughts at this time the patient is full code communication was primarily with the patient s daughter at medications on admission per clinic note on doses unknown atenolol mg daily pantoprazole mg daily benicar mg daily multivitamin daily acetaminophen g qid warfarin mg qmtwrf mg q sat and sun senna tabs daily vitamin d units tegretol mg po bid unable to find this med listed discharge medications bisacodyl mg tablet delayed release e c two tablet delayed release e c po daily daily as needed for constipation senna mg tablet one tablet po bid times a day as needed for constipation aspirin mg tablet chewable one tablet chewable po daily daily trazodone mg tablet one tablet po hs at bedtime as needed for insomnia acetaminophen mg tablet two tablet po tid times a day as needed for pain fever metoprolol tartrate mg tablet tablets po tid times a day captopril mg tablet one tablet po tid times a day lansoprazole mg tablet rapid dissolve dr one tablet rapid dissolve dr daily daily docusate sodium mg ml liquid ten ml po bid times a day as needed for constipation benzonatate mg capsule one capsule po tid times a day as needed for cough multivitamin oral coumadin mg tablet one tablet po once a day please hold dose on restart on sunday with inr check on tuesday vitamin d unit tablet chewable one tablet chewable po once a day outpatient lab work please check inr on tuesday discharge disposition extended care facility newbridge on the discharge diagnosis primary aortic stenosis moderate hypoxic respiratory failure s p intubation hospital acquired pneumonia diverticulitis atrial fibrillation with rapid ventricular response acute pulmonary edema non st elevation myocardial infarction secondary hypertension cerebrovascular accident chronic kidney disease stage iii discharge condition mental status clear and coherent hard of hearing confused sometimes about details of history but oriented 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 initially admitted for diverticulitis however you became hypertensive and with iv fluids had fluid accumulate in your lungs you were intubated for this condition and you were on a ventilator for several days your hospital course was complicated by pneumonia and atrial fibrillation with rapid ventricular response an abnormal fast heart rhythm you improved with antibiotics and we worked to get the fluid out of your lungs with a medication called furosemide lasix you will need close follow up for a condition we discovered which is known as aortic stenosis this is a narrowed heart valve we have made a follow up appointment with an excellent cardiologist dr this appointment information is listed below we also performed swallow studies which showed that you did have a problem swallowing thin liquids the second study showed improvement however you will be followed up for this condition at the rehab facility we made the following changes to your medications we stopped atenolol and started metoprolol mg three times per day for heart rate we stopped benicar and started captopril mg three times per day for blood pressure we started aspirin mg once per day we changed pantoprazole to lansoprazole once per day for heartburn we stopped tegretol carbamazepine because it was not clear you were taking this for trigeminal neuralgia we changed your coumadin dosing you will restart coumadin on sunday at mg per day you will need your inr checked on tuesday and may need your coumadin adjusted to mg if your inr is too low your follow up information is listed below followup instructions department med grp when thursday at am with md building ma campus off campus best parking on street parking md,"{
""Diagnoses"": [""uncomplicated diverticulitis"", ""flash pulmonary edema""],
""Medications"": [""Zosyn"", ""Lasix"", ""Nitro"", ""Levophed"", ""Fentanyl"", ""Propofol""]
}"
83547,admission date discharge date date of birth sex f service cardiothoracic allergies motrin naproxen vicodin tylenol codeine no attending chief complaint mitral regurgitation major surgical or invasive procedure mitral valve replacement mm st history of present illness this year old spanish speaking female presented with complaints of dyspnea on exertion for a few months she states that she has noticed some ankle edema and pillow orthopnea but no paroxysmal dyspnea she was admitted to with acute heart failure and was diuresed with improvement echocardiogram showed deformed mitral valve leaflets and mr she was referred for surgical correction past medical history hypertension noninsulin dependent diabetes mellitus obstructive sleep apnea uses cpap mitral regurgitation anxiety gastroesophageal reflux bipolar disorder h o coma at for months after mva s p hysterectomy s p right femoral rodding s p pelvic fracture h o fractured skull s p cyst excision right breast social history patient lives with boyfriend she smokes cig per day for years no etoh illicits family history brother passed away in his s from mi father passed away from mi physical exam admission pulse resp o sat on l b p right height weight lbs general skin dry x intact x heent perrla x eomi x congested l conjunctiva hemorrhage 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 neuro grossly intact 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 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 echocardiography report complete done at am final referring physician information department of cardiac s a status inpatient dob age years f hgt in bp mm hg wgt lb hr bpm bsa m indication left ventricular function mitral valve disease preoperative assessment 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 atrium long axis dimension cm cm left atrium four chamber length cm cm left ventricle diastolic dimension 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 descending thoracic cm cm mitral valve peak velocity m sec mitral valve mean gradient mm hg mitral valve pressure half time ms mitral valve mva p t cm findings left atrium elongated la right atrium interatrial septum no asd by d or color doppler left ventricle normal lv wall thickness normal lv cavity size overall normal lvef intrinsic lv systolic function likely depressed given the severity of valvular regurgitation right ventricle normal rv chamber size and free wall motion aorta normal ascending transverse and descending thoracic aorta with no atherosclerotic plaque aortic valve mildly thickened aortic valve leaflets mild ar eccentric ar jet mitral valve moderately thickened mitral valve leaflets mild thickening of mitral valve chordae mild valvular ms mva cm moderate to severe mr vena contracta is cm tricuspid valve normal tricuspid valve leaflets mild tr pulmonic valve pulmonary artery normal pulmonic valve leaflets physiologic normal pr general comments a tee was performed in the location listed above i certify i was present in compliance with hcfa regulations the patient was under general anesthesia throughout the procedure no tee related complications regional left ventricular wall motion n normal h hypokinetic a akinetic d dyskinetic conclusions prebypass 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 overall left ventricular systolic function is normal lvef intrinsic left ventricular systolic function is possibly more depressed given the severity of valvular regurgitation 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 are mildly thickened mild aortic regurgitation is seen the aortic regurgitation jet is eccentric the mitral valve leaflets are moderately thickened there is mild valvular mitral stenosis area cm moderate to severe mitral regurgitation is seen the mitral regurgitation vena contracta is cm post bypass biventricular systolic function is preserved there is a well seated well function bileaflet mechanical prosthesis in the mitral position valvular mr which is normal in quantity and location for this type of prosthesis is visualized washing jets the study is otherwise unchanged from the prebypass study 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 she underwent mechanical mitral replacement on please see operative report for further details she weaned from bypass on neo synephrine and propofol weaned and extubated easily all lines and drains were discontinued in a timely fashion pressor weaned off and she was transferred to the floor as per dr atrial pacing wires were discontinued and the ventricular pacing wires were cut without difficulty physical therapy was consulted to evaluate her strength and mobility on pod her hematocrit was found to be repeated a cxr was unremarkable and she was stable two units of red blood cells were given along with lasix between units anti coagulation was initiated with coumadin and a heparin bridge for goal inr the remainder of her postoperative course was essentially uncomplicated on pod she was cleared for discharge to rehab in for further increase in strength and mobility inr on day of discharge was geodone and klonopin were resumed for history of polar disorder all follow up appointments were advised medications on admission actos mg po daily asa mg po daily cyclobenzoprine mg po daily lisinopril mg po daily zolpidem mg po daily albuterol prn flovent prn erythromycin ointment clonazepam mg po prn trazadone mg po daily geodone mg not taking singulair omeprazole mg po daily discharge medications omeprazole mg capsule delayed release e c sig one capsule 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 bisacodyl mg suppository sig one suppository rectal daily daily as needed for constipation montelukast mg tablet sig one tablet po daily daily fluticasone mcg actuation aerosol sig two puff inhalation times a day albuterol sulfate mg ml solution for nebulization sig one inhalation q h every hours as needed for dyspnea ipratropium bromide solution sig one inhalation q h every hours erythromycin mg gram ointment sig one ophthalmic qid times a day pioglitazone mg tablet sig two tablet po daily daily 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 oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain trazodone mg tablet sig two tablet po hs at bedtime as needed for sleep camphor menthol lotion sig one appl topical q h every hours as needed for itching insulin glargine unit ml solution sig one subcutaneous once a day units of glargine at breakfast insulin regular human unit ml ml insulin pen sig one subcutaneous four times a day dose per sliding scale qid clonazepam mg tablet sig two tablet po daily daily as needed for anxiety ziprasidone hcl mg capsule sig one capsule po bid times a day hydromorphone mg tablet sig tablets po q h every hours as needed for pain furosemide mg tablet sig one tablet po once a day for weeks potassium chloride meq tab sust rel particle crystal sig one tab sust rel particle crystal po once a day for weeks warfarin mg tablet sig one tablet po daily daily dose daily for goal inr discharge disposition extended care facility care rehab wood mill discharge diagnosis mitral regurgitation s p mvr mm st anxiety gastroesophageal reflux obstructive sleep apnea hypertension noninsulin dependent diabetes mellitus s p femoral rodding bipolar disorder s p hysterectomy 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 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 females please wear bra to reduce pulling on incision avoid rubbing on lower edge of sternal wound 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 please call to schedule appointments with 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 labs pt inr for coumadin mm st mechanical mitral valve goal inr to be managed by rehab during stay following discharge dr will manage first draw upon discharge from rehab results to dr cardiologist phone completed by,{}
11612,admission date discharge date service neurology history of present illness this is an year old woman with dementia coronary disease hypothyroidism and hypercholesterolemia who lives in a nursing home and was found to have a generalized tonoclonic seizure upon arrival to emergency department she was unresponsive except to pain and had a left gaze preference her blood pressure was and she was started on a nipride drip she was also loaded on dilantin a ct scan showed a large left parietal intraparenchymal bleed with ventricular extension we are told that she lives in a nursing home and is not very functional her code status is dnr dni and her family reinforces this code status past medical history dementia frequent urinary tract infections coronary disease hypercholesterolemia irritable bowel syndrome depression hypothyroidism allergies penicillin bactrim aricept medications actonel mg q week levoxyl mcg po q day risperdal mg po q day zoloft mg po q day zyprexa mg po bid exten mg po bid social history she is a widow who lives in nursing home her cousin is the healthcare proxy family history significant for coronary disease examination upon admission temperature blood pressure heart rate of generally this is an elderly woman who is not quite responsive heent mucous membranes moist no carotid bruits are noted neck is supple cardiovascular regular rate and rhythm pulmonary clear to auscultation bilaterally abdomen is soft nontender nondistended with normoactive bowel sounds on the neurological exam she is stuporous but opens eyes to sternal rub on cranial nerve exam the fundoscopic exam was limited but did reveal left disc that seemed blurred the pupils are reactive to light mm bilaterally extraocular eye movements are full to doll s movement facial movements symmetric on motor examination her bulk is normal tone is increased she withdraws her left had and localizes pain but extends her right arm to pain she withdraws the left leg but the right leg appears weak on reflexes she has brisk reflexes right greater than left she has extensor plantar reflexes on sensory exam she withdraws to pain as above laboratories white count of hematocrit of platelets sodium potassium chloride bicarbonate bun creatinine inr a head ct revealed a x large intraparenchymal bleed in the left frontal and parietal lobes with interventricular extension and mild hydrocephalus the basal cisterns are open hospital course the patient was immediately admitted to the neurology intensive care unit where her blood pressure was controlled under the systolic of she was continued on her dilantin treatment she was found to have a urinary tract infection which was initially treated with levaquin but the antibiotics were discontinued as she was made comfort measures only chest x ray showed no evidence of infection it is believed that she likely bled secondary to amyloid in speaking with her cousin mrs it was felt that the patient would want to be placed on comfort measures only therefore no nasogastric tube nor antibiotics was administered she instead was kept comfortable with ativan morphine and scopolamine patches she will return to her nursing home with hospice care a family meeting was done on with the understanding that the prognosis for this patient is less than ideal therefore there was an agreement among both the healthcare proxy member and family member that ms would have wishes to be comfort measures only in this setting discharge diagnosis left frontoparietal hemorrhage discharge medications scopolamine patch q h lorazepam mg po q h with the lorazepam q h prn anxiety morphine sublingual solution mg q h with q h prn pain discharge condition serious discharge status to nursing home with hospice care m d dictated by medquist d t job,"{
""Diagnoses"": [""dementia"", ""coronary disease"", ""hypothyroidism"", ""hypercholesterolemia"", ""tonoclonic seizure""],
""Medications"": [""nipride"", ""dilantin"", ""levoxyl"", ""actonel"", ""zoloft"", ""zyprexa"", ""exten"", ""risperdal""]
}"
63139,admission date discharge date date of birth sex m service medicine allergies no drug allergy information on file attending chief complaint ams major surgical or invasive procedure none history of present illness yo m with an unknown past medical history presents to the ed with presumed drug overdose per report patient was found in a parking lot with altered mental status by ems and saying that he took a handful of pills that were mostly dilantin but unknown if anything else was mixed in he was exhibiting altered gait at that time around am he was only oriented x at this time additional history is not available at this time patient did report that he was intentionally trying to hurt himself on arrival to the ed triage vs were ra and patient was lethargic but arousable an answering questions at arrival he was about minutes post ingestion he did confirm a past medical history of seizures but no other known medical history was obtained he was given activated charcoal and then started to refuse this intervention and became progressively more somnolent he received narcan with no improvement he was intbated for poor mental status but was not reportedly hypoxic or in respiratory distress intubation was uncomplicated but was noted to have aspiration of charcoal et tube was noted to be high and was advanced cm qrs was narrom on ekg dilantin level was and tox screen was positive for tcas ag was mildly elevated at on transfer vs were hr ac x peep and sat a toxicology consult was requested and advised serial dilantin levels q h with administration of extra charcoal dose if greater than ekg q h and ct head without contrast in the icu patient is unarousable he appears comfortable past medical history depression epilepsy past mva w left shoulder injury social history lives in with wife yo daughter and not working on disability reports drinking up to bottle of whisky plus beer per day in the past but has not drunk anything for a month denies smoking or doing illicit drugs family history non contributory physical exam vitals t bp p r o ac cc x fio general intubated somnolent does not arouse to sternal rub 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 neuro negative babinski bilaterally patellar and biceps reflex tone mildly increased no asterxis and no clonus discharge exam vitals t bp p r o on ra general sitting comfortably nervous and very fixated on past automobile accident very anxious to approval of doctors medical team 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 no rebound tenderness or guarding no organomegaly gu no foley ext warm well perfused pulses no clubbing cyanosis or edema neuro cnii xii intact otherwise non focal 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 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 pm blood alt ast alkphos totbili pm blood calcium phos mg pm blood phenyto pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl pos pm blood type art po pco ph caltco base xs assist con pm blood type art temp fio po pco ph caltco base xs assist con intubat intubated admission ekg bassline artifact sinus rhythm inferior t waves cannot be interpreted clinical correlation is suggested no previous tracing available for comparison chest ap x ray low lung volumes are noted with mild crowding of bronchovascular markings the lungs are clear without consolidation or edema there are no pleural effusions or pneumothorax an endotracheal tube is seen with tip below the thoracic inlet cm from the carina a nasogastric tube is present in the stomach chest ap findings in the interval the patient has been extubated and the nasogastric tube has been removed today s image represents a normal chest radiograph without evidence of pulmonary edema pulmonary infection or pleural effusions the size of the cardiac silhouette and the appearance of the mediastinum is unremarkable n c head ct impression no acute intracranial abnormality brief hospital course yo m with unknown past medical history presents with apparent intentional drug overdose with likely phenytoin and tcas now s p intubation for airwary protection altered mental status appears to be related to drug overdose dilantin level peaked at and then trended down tca positive on serum tox but no ekg changes so less likely to be toxic from tca no clear toxic prodrome fits this clinical picture as patient without tachycardia hypertension and diaphoresis sympathomimetics agitation tachycardia flushing anticholinergics miosis lack of response to narcan opiods or autonomic instability clonus tremors serotonin syndrome no dramatic anion gap so less likely ethylene glycol or methanol toxicity ct head without acute ich the patient was intubated in the ed for somnolence and maintained with mechanical ventilation he received activated charcoal toxicology followed the patient and recommended serial ekgs which remained unchanged and serial dilantin levels which were never toxic the day after admission the patient s mental status improved and he was extubated without any complications his neurologic exam was normal and he had no other symptoms he had one low grade temperature to without any accompanying symptoms cxr and ua were negative suicideal ideation per report patient was attempted to hurt himself by taking a handful of pills he describes the decision as impulsive and contact his psychotherapist afterwards he was seen by psychiatry who felt that he was suicide risk and required inpatient psychiatric evaluation he was kept with a section but made no attempts to leave ama his home anti depressants were held per psychiatry recommendation epilepsy most recent seizure weeks ago per patient report dilantin level went down to so he was given a mg one time loading dose and restarting on his home regimen of mg sinus tachycardia stably tachycardic benzo and alcohol tox screen negative on admission not recently using per patient not responsive to fluid boluses patient unsure of baseline heart rate medications on admission amitriptyline mg qhs effexor sr mg prozac mg qam dilantin mg lorazepam mg remeron mg qhs viagra vit d discharge medications phenytoin sodium extended mg capsule sig one capsule po bid times a day discharge disposition extended care discharge diagnosis final diagnosis overdose secondary diagnoses depression epilepsy discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted after taking a handfull of your medicines you were confused and sleepy so you were intubated and went to the intensive care unit you are doing better now but we are worried about your depression and think that you should go to our inpatient psychiatric floor we stopped all of your medications except your dilantin phenytoin your psychiatrists will decide if your other medications should be restarted followup instructions when you are ready to leave the hospital please call your primary care doctor and make an appointment within the next weeks he should check your dilantin level to make sure you are protected from having a seizure completed by,"{
""Diagnoses"": [""Drug Overdose"", ""Intentional Self-Harm""],
""Medications"": [""Dilantin"", ""Narcan""]
}"
16819,admission date discharge date service history of present illness the patient is a year old female with a history of aortic stenosis and hypertension who presents with a two to three day history of fatigue and malaise she denies chest pain shortness of breath syncope or near syncope the patient was in her usual state of health until four days prior to this initial presentation when she was noticing increased fatigue and orthostatic symptoms the patient was recently seen by her primary care physician one week ago and was told that she was find the patient was evaluated by an electrocardiogram in the emergency room and was found to be in complete heart block with a ventricular rate of to beats per minute the patient s blood pressure at this time was and stable she denied chest pain shortness of breath orthopnea paroxysmal nocturnal dyspnea lower extremity edema fever or chills she also denied any medication changes or overdoses or any new medications the patient denies any history of syncope or heart block in the past the patient also denies any cough or dysuria physical examination on physical examination the patient had a blood pressure of respiratory rate to oxygen saturation in room air and she was afebrile neck decreased carotid upstroke bilaterally chest clear to auscultation bilaterally cardiovascular bradycardia with normal s and s grade iv vi systolic murmur abdomen soft nontender nondistended extremities without cyanosis clubbing or edema past medical history hypertension history of lung cancer in status post left pneumonectomy history of aortic stenosis with last echocardiogram showing a valvular surface area of cm history of breast cancer blood pressure bilateral mastectomies social history the patient has no history of tobacco or alcohol allergies morphine sulfate medications on admission atenolol mg p o q d candesartan mg p o q d prevacid calcium gm p o q d laboratory data admission white blood cell count was hemoglobin platelet count sodium potassium slightly hemolyzed chloride bicarbonate bun creatinine up from ck and troponin negative prothrombin time inr and partial thromboplastin time electrocardiogram revealed complete heart block with ventricular rate of to right bundle branch block with elevated t wave hospital course the patient had a temporary wire placed per the electrophysiology team upon presentation on the patient had a ddd pacemaker implanted without incident the patient s post procedure course was uncomplicated and she remained stable without any evidence of arrhythmia chest discomfort or shortness of breath disposition the patient was discharged on in stable condition discharge medications same as admission medications discharge instructions the patient is to follow up in the pacemaker clinic one week after discharge the patient is to follow up with dr in one to two weeks after discharge the patient was discharged to a rehabilitation facility discharge diagnoses complete heart block status post pacemaker placement severe aortic stenosis m d dictated by medquist d t job [NEW_RECORD] admission date discharge date service cardiothoracic chief complaint fatigue history of present illness a year old woman with known as recently admitted for congestive heart failure underwent a balloon valvuloplasty on post valvuloplasty aortic valve area is with a gradient of discharged to home on cardiac catheterization data aortic valve area gradient with three vessel disease echocardiogram from ejection fraction of to mitral regurgitation tricuspid regurgitation and moderate to severe as past medical history neurogenic bladder diverticulosis hypertension restrictive lung disease on home o tonsillectomy and appendectomy both in the multiple cervical and lumbar spine procedures kidney repair in the gastroesophageal reflux disease complete heart block status post pacemaker bilateral mastectomies in the hysterectomy in left pneumonectomy due to lung cancer multiple hand surgeries for arthritis left humeral fracture in positive ppd medications prior to admission atenolol mg po qd cozaar mg qd ditropan mg prevacid mg qd mg aspirin mg qd atrovent metered dose inhalers amoxicillin for urinary tract infection which was completed on allergies morphine from which she develops rash cipro and levaquin from which she develops flu like symptoms including nausea and diarrhea fentanyl from which she develops agitation physical examination prior to admission vital signs heart rate and regular respiratory rate blood pressure height is inches weight is pounds general frail appearing woman in no acute distress skin intact head ears eyes nose and throat unremarkable neck limited range of motion chest clear to auscultation in the right lung field heart regular rate and rhythm grade ejection murmur abdomen softly distended nontender positive bowel sounds extremities warm with no peripheral edema limited mobility of the left arm secondary to a humeral fracture no varicosities neurologic grossly intact labs all labs are pending electrocardiogram is a v paced rhythm chest x ray is also pending hospital course the patient is to be admitted as a postoperative admission for coronary artery bypass graft avr on as stated previously the patient was postoperative admit on she was admitted to the operating room at which time she underwent coronary artery bypass graft x with a saphenous vein graft to the lad and saphenous vein graft to distal rca as well as an aortic valve replacement with a pericardial valve please see the operating room report for full details the patient was transferred from the operating room to the cardiothoracic intensive care unit with an open chest at that time she had epinephrine at mcg per kg per minute levophed at mcg per kg per minute propofol and the patient also had an anterior aortic balloon pump in place at to upon arrival in the csru the patient was noted to have bright red blood per nasogastric tube the gastrointestinal service was consulted and an esophagogastroduodenoscopy was done unfortunately the patient was unstable during the esophagogastroduodenoscopy and the procedure had to be aborted before completion no source of gastrointestinal bleeding was noted in the stomach blood was pooled in the cardia there was no blood in the antrum or the duodenum during her cardiac procedure and subsequent upper gastrointestinal bleed the patient received a total of units of packed red blood cells units of platelets and units of fresh frozen plasma on the day of her surgery over the next several days the patient remained in the cardiothoracic intensive care unit sedated and paralyzed hemodynamically she continued to slowly improve and was weaned from some of her cardioactive drugs on postoperative day she returned to the operating room at that time her balloon pump remained in place however she was able to have her chest closed she returned from the operating room to the cardiothoracic intensive care unit again with propofol neo synephrine and intra aortic balloon pump at to this patient was hemodynamically stable upon arrival to cardiothoracic intensive care unit for the course of the evening and night following closure the patient was weaned from all cardioactive drugs on the morning of postoperative day and she was weaned from the intra aortic balloon pump which was ultimately discontinued without any hemodynamic compromise following the removal of the intra aortic balloon pump all sedation was discontinued the patient was weaned from full support mechanical ventilation to pressure support ventilation neurologically the patient was slow to awaken for her sedation she as initially unresponsive and over the next several days regained the ability to follow commands two days following chest closure the patient s chest tubes were removed on postoperative day and the patient s swan ganz catheter was removed on postoperative and the patient was transferred from the cardiothoracic intensive care unit to the surgical intensive care unit for continuing postoperative care in an intensive care unit environment over the next several days the patient was slowly weaned from pressure support ventilation and ultimately on she was successfully extubated following extubation the patient remained in the intensive care unit where we closely monitored her respiratory status several days following extubation a swallow study was performed which the patient felt initial plans were made to have a peg placed however decision was made not to place peg her nasogastric feeding tube was changed to a dobbhoff tube the patient remained in the intensive care unit throughout the rest of her hospital course due to weakness and her high risk of aspiration on it was decided that as stable and ready for transfer to rehabilitation center of continuing postoperative care and cardiac rehabilitation at the time of transfer the patient s physical exam is as follows vital signs temperature heart rate av placed blood pressure respiratory rate os on liters nasal oxygen weight preoperatively is pounds at discharge it s pounds lab data on white count hematocrit platelets od potassium chloride co bun creatinine glucose chloride co bun creatinine physical exam general alert and responsive follows some commands respiratory breath sounds clear to auscultation on the right no breath sounds on the left cor regular rate and rhythm s s sternum stable incision with steri strips open to air clean and dry abdomen soft nontender nondistended with positive bowel sounds extremities warm and well perfused with edema and dopplerable pulses bilaterally discharge medications lopressor mg heparin units subcutaneous mg q hs colace mg enteric coated aspirin qd lansoprazole mg qd regular insulin sliding scale dulcolax suppository pr qd prn discharge diagnoses as status post avl with pericardial valve coronary artery disease status post coronary artery bypass graft x with a saphenous vein graft to the lad and the saphenous vein graft to the distal rca hypertension diverticulosis restrictive lung disease kidney repair neurogenic bladder complete heart block status post permanent pacemaker gastroesophageal reflux disease bilateral mastectomies status post left pneumonectomy status post hysterectomy status post appendectomy allergies cipro and levofloxacin from which she gets flu like symptoms morphine from which she gets a rash and fentanyl from which she develops agitation also listed in ace inhibitor for which no reaction is listed follow up the patient is to have follow up with dr in one month and follow up with her primary care provider in three to four weeks following discharge from rehabilitation m d dictated by medquist d t job,"{
""Diagnoses"": [""aortic stenosis"", ""hypertension""],
""Medications"": [""""]
}"
3491,admission date discharge date date of birth sex f service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint hypoxia hypotension fevers major surgical or invasive procedure central line intubation history of present illness y o f with pmh sle polymyositis hyperlipidemia htn s p recent admission for evaluation of chest pain dyspnea with extensive w u which was neg who presented to hospital with respiratory distress fevers to hypotension and acute renal failure according to her brother in law she was d c d days ago from with baseline dyspnea symptoms ambulatory sats good on ra with the only reported complaint by her being decreased blood sugars for the last days pta in s weakness lethargy headache on which resolved on its own and neck stiffness unclear if this was musculoskeletal however on the morning of admission she was found by her yr old son on the couch not feeling herself reportedly lethargic and in resp distress per osh notes she was found by ems to be cyanotic and was given mg iv lasix by ems prior to arrival to ed at ed rr in s with bilateral rhonchi on exam and cxr c w bilateral infiltrates t rectally sbp s tachycardic with hr s labs notable for elev bun creat trop elev to with ck mb mbi ldh ast alt wbc nl at but with bandemia u a neg pt initially given alb atrovent nebs but given incr respiratory distress tachypnea was intubated simv rate fio with abg subsequently pt also had femoral tlc catheter placed had l ns given and was also started on dopamine gtt for persistent sbp s she was given dose zosyn gm solumedrol mg iv versed boluses total mg iv asa mg tylenol urine tox screen also neg for etoh cocaine opiates and benzos after intubation was then transferred to for further management past medical history lupus dxed in currently in remission when first dxed manifested as hand swelling joint aches dry eyes unclear if treated with steroids in past on last admission at low titer with neg anti double stranded dna neg anti neg c c polymyositis dxed months prior to last admission had muscle bx at due to inability to walk and persistent myalgias was apparently treated with high dose cyclosporine and prednisone for months prior to presentation at on last hospitalization had right thigh bx which was c w polymyositis avascular necrosis of r femoral head and both distal femurs and prox tibias htn hypercholesterolemia previous record of narcotic dependence od cocaine use in the past hyperlipidemia dm atypical chest pain w u extensive on last admission including neg pain mibi neg pmibi neg cardiac mri neg cta chest and abdomen neg cxr echo mildly depressed lvef per dr but not formally read on echo mild lvhk social history she lives in with her two children a son and daughter aged and she used to work licensing footage for channel and now works on a contract basis she reports no etoh or illicit drug use she notes that she has used ms contin for pain she has smoked cigarettes ppd x yrs she notes that her husband died of aml years ago and she is still very sad about this she even notes that at times she still looks or calls for him family history mother died of mi at age father died of aaa at age has one sister in good health physical exam t oral bp p decr to sat ac tv gen sedated intubated heent pupils small equal and reactive to light op with dry mm neck jvd diff to assess chest coarse rhonchi throughout cv reg rhythm tachy no audible m r g abd soft obese nt bs ext cool to touch could not palpate dp pulses but were dopplerable r arm warmer than l arm with more palpable pulse on r l skin good skin turgor on right thigh at area of bx large area of induration and erythema with palpable hematoma warm to touch 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 normal macrocy normal microcy polychr normal pm blood plt smr normal 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 lipase pm blood ck mb mb indx ctropnt pm blood albumin calcium phos mg pm blood osmolal pm blood cortsol pm blood vanco pm blood asa neg ethanol neg acetmnp neg bnzodzp pos barbitr neg tricycl neg pm blood type art temp rates peep fio po pco ph calhco base xs aado req o assist con intubat intubated pm blood type art temp rates tidal v peep fio po pco ph calhco base xs aado req o intubat intubated vent controlled pm blood type pm blood lactate pm blood hgb calchct o sat am blood acylcarnitines quantative plasma pnd am blood anti jo antibody pnd r leg u s subcentimeter anechoic lesion within the right thigh as above deep to the biopsy site differential is broad and was outlined above there is no drainable fluid collection brief hospital course respiratory distress pt was extubated on and was sat ing well on shovel mask she had a rml infiltrate on cxr as well as diffuse alveolar infiltrates with a possible component of ards possible pneumonia sources include cap atypical organsisms and pcp fungal given h o immunosuppression on cyclosporine and high dose prednisone a bronch on was neg for pcp had been initially placed on zosyn vanc then switched to ceftriaxone gm vanc levofloxacin for initial coverage of cns infection mrsa atypical as well as broad gp and gn coverage and is currently on levo flagyl for treatment for possible aspiration pna she is continued on ss bactrim for pcp whilst taking steroids upon transfer to the floor the patient continued to have coupious secretions which she was unable to clear due to dysphagia see below she was given a yankower for suctioning as well as an inexeffalator she was treated with a day course of antibiotics flagyl and levo which was changed to azithro ctx on the last days due to prolonged qtc for aspiration pna on discharge the patient s secretions had noticably decreased shock the etiology was felt to be most likely septic as temp and lactate elevated on admission to possible sources of infection included pneumonia urine blood csf right thigh biopsy site she was given ivfs and gradually weaned off of pressors she was also on stress dose steroids which was changed from solu medrol to prednisone today as treatment for polymyositis an u s of her right thigh was negative for fluid collection or abscess and an echo was negative for cardiogenic etiology of hypotension as well as any pericardial effusion on the floor her blood pressure was stable repeat u s of ther r thigh showed a small possible hematoma vs seroma which was not drainable she was afebrile and with negative blood cultures elevated troponin mild elevation was felt to be likely demand ischemia in setting of infection and tachycardia ekg with old rbbb but otherwise unchanged her troponins were trending down and she was restarted on metoprolol and continued on asa anemia her baseline hct was noted to be she was transfused units prbcs and her hct has since been stable acute renal failure the patient had an elevated creatinine initially which improved after fluid hydration indicating that the etiology was likely prerenal polymyositis the diagnosis was confirmed by biopsy at last hospitalization and thought that this could explain the positive ck elevated lft s were also felt to be likely from muscle destruction she was consulted by rheum and was treated with steroids stress dose changed to soludmedrol mg daily given bronchospasm there was a question of whether polymyositis could contribute to chest wall dysfunction and weakened diaphragm resp muscles leading to decreased oyxgenation and anti antibodies were checked for to see if it could be related to ild pulmonary process which returned negative she was changed to prednisone mg daily given through ngt re evaluation of the tissue biopsy by rheum as well as neuromuscular consult teams led to a question of the diagnosis of polymyositis as the clinical course did not seem consistent with polymyositis hepatology was also consulted about the possibilty of cryoglobinemia and empiric treatment with ifn and determined that there was no evidence on cryoglobinemia complement levels normal no evidence on biopsy she also had a ct torso to check for possible lymphoma atypical cells on biopsy which was also normal carnitine and other mitochondrial lipid metabolism labs were sent to evaluate for mitochondrial disease but there was no evidence of lipid abnormality on tissue biopsy which made these labs of low probability levels were normal ultimately the course of the patients episodes of myopathy was felt to be most consistent with toxin induced perhaps from drug abuse although the patient was not forthcoming with this information in an individual who may have had an underlying predisposition to myopathy she was started on a slow steroid taper prednisone decrease mg every days until off her dysphagia which on the floor was really her only objective evidence of continued myopathy gradually resolved in a manner that was perhaps consistent with post intubation dysphagia her only other notable abnormality was the global hypokinesis on echo which was of uncertain significance given her history of drug abuse and our inability to establish its acuity given no previous normal echos on file attempts were made to obtain records from where the patient had received most of her previous care but these records were not available at the time of discharge elevated transaminases the admission ast was markedly elevated when compared to alt although the patient had a negative etoh level at osh she has h o hep c but nl transaminases in the past there was a question of whether these enzymes could have been elevated due to shock liver in setting of hypotension the lfts were trending down upon transfer fen the patient failed speech and swallow evaluation on several attempts on initial admission to the floor she had an ngt placed which was removed by the patient then replaced and then self d c d by the patient while the ngt was in place the patient was given tube feeds she was again seen by speech and swallow who observed no aspiration with bedside eval but recommended a video swallow study to evaluate for silent aspiration which was refused by the patient pain control the patient continued to require large amounts of narcotics for pain control while on the floor she attributed the pain to the site of her biopsy which was stable above through several ultrasounds the nature of her pain complaints was tough to pin down and upon discharge she said that it was well controlled we ultimately felt that a large component of the pain was due to dependence and although we could not pursue this route given her other medical problems it should be addressed as an outpatient of note she was also followed by psychiatry in house and may benefit continued follow up with social work and or psychiatry as an outpatient dispo the patient repeatedly threatened to sign out ama during the hospitalization despite the obvious evidence of her inability to clear her own secretions much less take in anything po and the risk for aspiration that it posed she was talked down multiple times although she was certainly difficult and typically needed the involvement of her brother in law to convince her to stay she was seen several times by psychiatry who determined that she has an adjustment disorder with depressed mood this as well as her likely narcotic dependence should be followed upon discharge medications on admission calcium vitamin d bactrim mwf for pcp started on last hospital admission protonix qd senna lasix qd plaquenil celebrex toprol xl qd lisinopril prednisone qd ms contin mg neurontin tid colace glyburide qd discharge medications albuterol sulfate solution sig puffs inhalation once a day disp inhaler refills cholecalciferol vitamin d unit tablet sig one tablet po daily daily calcium carbonate mg tablet chewable sig one tablet chewable po tid w meals times a day with meals aspirin mg tablet chewable sig one tablet chewable po daily daily trimethoprim sulfamethoxazole mg tablet sig one tablet po qmwf disp tablet s refills pantoprazole sodium mg tablet delayed release e c sig one tablet delayed release e c po q h every hours prednisone mg tablet sig as directed tablet po daily daily for days tab tab tab tab disp tablet s refills msir mg tablet sig one tablet po every hours prn as needed for pain disp tablet s refills discharge disposition home with service facility vna discharge diagnosis septic shock aspiration pneumonia acute renal failure hepatitis c myopathy unspecified history of avascular necrosis of the r femoral head distal femurs proximal tibias diabetes mellitus hypercholesterolemia cardiomyopathy discharge condition stable although pt refused video swallow to document absence of silent aspiration discharge instructions take all of your medications as directed several of your medications have changed during this admission please see the discharge list in particular you should discontinue taking your glyburide and blood pressure medications lisinopril and metoprolol until you are seen by your primary care physician on complete your prednisone taper and your antibiotic course you will take mg prednisone tabs mg prednisone tabs mg prednisone tab mg prednisone tab we are concerned that you will aspirate at home therefore to minimize the chances of this take your medications in applesauce and as we discussed you should drink thickened liquids you should be sitting upright when you eat and do not lie down for minutes after you eat if you are coughing after you eat this is a sign that you are continuing to aspirate and should return to the hospital phone your physician or return to the hospital if you experience any fevers night sweats cough chest pain shortness of breath rash or any other symptoms concerning to you in addition as you are leaving the hospital against medical advice we recommend that you return to the er at any time you are willing so that you can be readmitted to the hospital followup instructions m d where neurology phone date time provider m d where lm 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 bilateral calf pain major surgical or invasive procedure none history of present illness f with possible lupus diagnosis unclear prior hx rhabdomyolysis who p w b l leg pain diffusely pt followed by rheum re w c w polymyositis but more c w narcotic induced rhabdo or rare enzyme abnormality on chronic narcotics for fibromyalgia and chronic b l leg pain using up to mg ms contin pt noticed increased calf pain b l for days gradual in onset pt feels like this is a lupus flare she gradually stopped walking due to pain she denies any fevers no leg ulcers or skin breakdown can t walk because of pain she s been bed bound x days per pt report she denies taking any motrin or ibuprophen or more ms contin than her usual dose of mg she denies any recent abx use pt also has diminished po intake due to nausea further ros denies constitutional sx no fevers weight changes no cp palpitations sob occasional atypical cp but not now n no emesis no abdominal pain diarrhea or constipation normal bms daily no brbpr no melena no dysuria no ha confusion lh dizziness ed course pt s intial ck received l ivns received mg iv morphine mg iv dilaudid and mg anzemet x renal consult in ed started aggressive fluid hydration rec to start nahco for bicarb w aggressive lyte repletion tox screen for benzos and optioates past medical history atypical cp myocarditis chf ef no wall motion abnormalities htn hyperlipidemia hypothyroidism avascular necrosis on knees b l steroid induced dm chronic recurrent rhabdomyolysis cpk trend from s current since w normal cpk thereafter persisitently elevated s until current presentation asthma anemia cholycystectomy hcv chronic hepatitis c with grade inflammation and stage fibrosis lupus no definative dx no clinical evidence for this lack of titer and compliment levels significant narcotic abuse h o heroin use pt denies h o ivda narcotics contract and violation of narcotics contract termination of care at for several narcotic violations fybromyalgia social history lives in with two children yo yo not currently working used to work licensing tv footage remote h o cocaine and heroin abuse reported in omr denies current use ppd x years denies alcohol husband died of leukemia y ago family history her mother died of an mi at the age of her father died of an abdominal aortic aneurysm at the age of she has one sister in good health her husband died in of aml physical exam vitals po bp hr rr ra general nad speaking in short sentences blunted affect teary eyed heent dry mm perrl minimally icteric sclera no thyromegaly or cervical lad resp ctabl ant ly cv reg nml s s no m r g abd soft obese nd nt w distraction no rebound no guarding extrem no c c e warm dp pulses b l pt uncooperative due to pain asking for pain medication to be able to move legs no femoral bruits neuro a ox no focal neuro deficits pertinent results pm plt count pm hypochrom occasional anisocyt poikilocy macrocyt normal microcyt normal polychrom ovalocyt pm neuts bands lymphs monos eos basos pm wbc rbc hgb hct mcv mch mchc rdw pm ck cpk pm glucose urea n creat sodium potassium chloride total co anion gap pm urine amorph few pm urine rbc wbc bacteria rare yeast none epi pm urine blood lg nitrite neg protein glucose neg ketone tr bilirubin neg urobilngn ph leuk neg pm urine color amber appear clear sp pm calcium phosphate magnesium pm glucose urea n creat sodium potassium chloride total co anion gap pm asa neg ethanol neg acetmnphn neg bnzodzpn pos barbitrt neg tricyclic neg pm tsh pm calcium phosphate cxr single view of the chest cardiac and mediastinal contours appear stable with persistent enlarged cardiac silhouette pulmonary vascularity appears within normal limits no focal consolidations are seen within the lungs no evidence of pleural effusion impression no evidence of acute cardiopulmonary process or significant change from prior cxr findings there is no significant interval change in the frontal view when compared to prior the lateral projection shows some pleural thickening which could be some loculated fluid posteriorly and some discoid atelectasis as well impression no change from prior no new consolidation le u s neg for dvt cxr pa and lateral views of the chest are obtained on and compared with the prior radiograph of there is cardiomegaly with tortuosity of the aorta the right lung appears clear there is some patchy increase in density in the left lower lung field probably in the lingula which is unchanged from prior examination and likely represents subsegmental atelectasis no frank consolidation is seen impression no significant change in the appearances since the study of with atelectasis airspace disease in the left lower lung zone 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 am blood caltibc ferritn trf am blood hba c hgb done a c done brief hospital course year old female with a history of fibromyalgia possible lupus significant marcotic abuse history and hypothyroidism presents with recurrent rhabdomyolysis rhabdomyolysis the patient s ck peaked at and with aggressive hydration trended down to on discharge orthopedics followed her throughout her hospital stay given concern that she might develop compartment syndrome serial exams were without evidence of this the patient has a history of recurrent rhabdomyolysis with extensive prior work up in the past rheumatology has suspected narcotic related myotoxicity prolonged treatment with high dose opioids for chronic pain although adult onset metabolic myopathy was an another unlikely possibility prior muscle biopsies were not consistent with polymyositis per patient she was only taking ms contin discussion with her pharmacy revealed she was also filling scripts for percocet and oxycodone she has been reluctant to taper off mscontin but now agrees to do so over the course of her hospital stay she was tapered from mscontin mg po bid to mg po bid this should continued to be tapered as an outpatient when she follows up with her new pcp acute renal failure creatinine peaked at from a baseline cr likely secondary to rhabdomyolysis urine electrolytes were consistent with a renal etiology fena and the renal service followed her throughout her hospital course at time of discharge her creatinine was stable at this will need to continue to be monitored as an outpatient she will follow up with dr at as an outpatient next creatinine to be checked and faxed to dr urinary tract infection she will complete a day course of ampicillin for an enterococcal urinary tract infection pneumonia given a persistent cough a chest x ray was obtained which showed a left lower lung opacity atelectasis versus infiltrate she will complete a day course of levofloxacin for presumed pneumonia chronic pain the patient has a history of naroctic abuse and has multiple violations of her pcp narcotic contract the pain management service was consulted and followed her closely throughout her hospital stay her pain was managed with tylenol hydromorphone mg po q prn ms contin was decreased from to over her hospital course she was started on amitriptyline which was titrated up to mg daily htn she was maintained on beta blocker and clonidine possible lupus this diagnosis has been questioned by rheumatology in the past given absence of clear clinical signs despite a positive in her cellcept was discontinued and her prednisone tapered to mg daily she will need to re institute rheumatology follow up as an outpatient type ii diabetes this was steroid induced and she was diet controleld at home her hemoglobin a c was and her fingersticks remained well controlled throughout her hospital stay hypothyroid continue levothyroxine mcg tsh on admission anemia hematocrit trended down from on admission although at time of discharge it was stable at her iron studies were consistent with iron deficiency anemia she was started on iron and will need a colonoscopy as an outpatient dispo the patient was discharged home with home physical therapy she has a a follow up appointment with dr from nephrology but will need to establish care with a new pcp have given her the numbers for and medications on admission confirmed with pharmacy ativan mg last filled ambien mg cellcept gm last filled levothyroxine mcg prednisone mg taper clonidine mg daily potassium meq atenolol mg daily lisinopril mg qd suboxone mg tabs dr suboxone mg dr suboxone mg dr percocet mg dr oxycodone mg dr ms mg oxycodone mg oxycodone mg ms contin mg dilaudid discharge medications atenolol mg tablet sig one tablet po once a day hydromorphone mg tablet sig one tablet po q h every to hours as needed for pain disp tablet s refills clonidine mg tablet sig one tablet po once a day prednisone mg tablet sig one tablet po daily daily levothyroxine mcg tablet sig one tablet po daily daily amitriptyline mg tablet sig two tablet po hs at bedtime disp tablet s refills ferrous sulfate mg tablet sig one tablet po daily daily lorazepam mg tablet sig tablet po q hrs prn as needed for anxiety disp tablet s refills ambien mg tablet sig one tablet po at bedtime as needed for insomnia levofloxacin mg tablet sig one tablet po q h every hours for days disp tablet s refills zolpidem mg tablet sig one tablet po hs at bedtime as needed morphine mg tablet sustained release sig three tablet sustained release po q h every hours disp tablet sustained release s refills outpatient lab work chem please fax results to dr discharge disposition home with service discharge diagnosis primary rhabdomyolysis secondary acute renal failure hypertension hypothyroidism urinary tract infection pneumonia asthma steroid induced type ii diabetes iron deficiency anemia fibromyalgia discharge condition hemodynamically stable ambulatory discharge instructions please take all medications as instructed there were several changes made to your current medications regimen if you experience any fever increased leg pain nausea vomiting lightheadedness chest pain shortness of breath or any other concerning symptoms please seek medical attention immediately followup instructions please have your creatinine and other electrolytes drawn on and faxed to dr at please make a follow up appointment with a primary care doctor within the next week the following appointments have already been made for you dr nephrology pm tel provider md phone date time md,"{
""Diagnoses"": [""hypoxia"", ""hypotension"", ""fevers"", ""acute renal failure"", ""dyspnea"", ""polymyositis"", ""hyperlipidemia"", ""HTN"", ""SP"", ""recent admission for evaluation of chest pain""],
""Medications"": [""lasix""]
}"
5538,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 aortic valve replacement history of present illness this is a yo female who was admitted for workup of syncope cardiac cath revealed severe aortic stenosis without coronary artery disease and with an ef of she was thus referred for avr past medical history diabetes type hypertension aortic stanosis bipolar hyperlipidemia osteoarthritis fibromyalgia transient ischemia attacks with right sided neglect sleep apnea appendectomy ccy hernia repair vein stripping left sinus surgery x left lumpectomy benign social history patient lives alone in senior citizen housing reports remote tobacco use quit years ago denies etoh use reports frequent exercise walking days per day family history brother with valve surgery deceased with cad in s mother deceased with cad in s 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 pm blood alt ast alkphos totbili brief hospital course ms was admitted to the hospital on following a syncopal episode at home on presentation she also reports intermittent doe and chest discomfort with exertion workup included cardiac cath revealing severe aortic stenosis and she was referred for avr pre op workup ensued with neuro consult in light of prior tias and reports of dizziness and lightheadedness she was cleared by the neurology service on she proceeded to the or for aortic valve replacement with dr please see op note for full details she was successfully weened and extubated on her operative evening on pod one she was transferred to the inpatient telemetry floor for ongoing recovery pod two was significant for only repletion of electrolytes and initiation of iron and vit c for anemia pods three and four were uneventful with ongoing hemodynamic monitoring and physical therapy on pod fiev it was decided that she was medically stable for discharge with need for ongoing physical therapy at a rehabilitation medications on admission lisinopril daily metofrmin adderall lipitor daily aspirin daily zyprexa daily clonazapam lexapro daily neurontin discharge medications metoprolol tartrate mg tablet sig one tablet po bid times a day potassium chloride meq capsule sustained release sig two capsule sustained release po q h every hours for days lasix mg tablet sig one tablet po twice a day for days aspirin mg tablet delayed release e c sig one tablet delayed release e c po daily daily atorvastatin calcium mg tablet sig one tablet po daily daily metformin hcl mg tablet sig one tablet po bid times a day olanzapine mg tablet sig one tablet po daily daily clonazepam mg tablet sig one tablet po bid times a day amphetamine dextroamphetamine mg tablet sig two tablet po bid escitalopram oxalate mg tablet sig one tablet po daily daily gabapentin mg capsule sig one capsule po bid times a day ascorbic acid mg tablet sig one tablet po bid times a day polysaccharide iron complex mg capsule sig one capsule po daily daily docusate sodium mg capsule sig one capsule po bid times a day discharge disposition extended care facility of discharge diagnosis aortic stenosis hypertension diabetes type bipolar disorder discharge condition stable discharge instructions wash incisions daily with soap and water rinse well do not apply any creams lotions powders or ointments no lifting greater than pounds followup instructions call to schedule appointment with dr call to schedule appointment with dr call to schedule appointment with cardiologist completed by,{}
67619,admission date discharge date date of birth sex f service surgery allergies no known allergies adverse drug reactions attending chief complaint abdominal pain nausea vomiting major surgical or invasive procedure ercp x intubation cvl placement history of present illness yo vietnamese speaking patient who comes in with three days of worsening abdominal pain patient states through step son who is a surgical interpreter at that she had acute onset of pain a few hours after eating dinner two night ago pain progressed to the point that she thought it necessary to come to ed she denies fever chills normal urination normal bowel movements no chest pain sob dyspnea palpitations pain is localized to the ruq and radiates to her r scapula vomitus was described as yellowish with foodstuffs in it past medical history pmh iddifuclt to ascertain but through interpreter and through prior notes she seems to have the following htn gouty arthritis hypothyroidism osteoporosis psgh right hip arthroplasty within past year supposedly done here but no record of such social history vietnamese speaking family history nc physical exam aao x via interpreter rrr no mrg cta b l no rrw soft tender in ruq sign nd no scars rectal exam deferred by patient no cce pertinent results chem agap ca mg p lft s alt ap tbili alb ast ldh dbili pnd tprot lip cbc n band l m e bas u a bacteria wbc leuk nitr us per report gallstones moderately distended gallbladder neck not well visualized which a lodged stone equivocal gallbladder wall edema cbd not well visualized these findings may represent early cholecyctitis ercp cannulation of the biliary duct was performed with a sphincterotome using a free hand technique there was a filling defect that appeared like sludge in the distal cbd the cystic duct was filled but the gallbladder did not opacify the biliary tree was otherwise normal with cbd measuring approximately mm in diameter a sphincterotomy was performed in the o clock position using a sphincterotome over an existing guidewire some sludge was extracted using a balloon catheter final cholangiogram did not reveal any further filling defects excellent drainage of bile and contrast was noted ercp active arterial bright red bleeding was noted at the sphincterotomy site using a combination of bipolar gold probe cautery and submucosal epinephrine injections approximately ml of a solution at o clock and o clock positions of the sphincterotomy complete hemostasis was accomplished brief hospital course mrs presented with a physical exam and u s concerning for possible acute cholecystitis due to worsening lfts an ercp was obtained on which showed sludge in the cbd this procedure was complicated by post procedure bleeding and melanotic stools with an associated hct drop which required transfer to the icu intubation for hypotenstion sedation as well as units of prbc on mrs a repeat ercp which did show active arterial bleeding from the prior ercp site the bleeding was successfully stopped mrs a few episodes of svt while in the icu she was started on metoprolol while in the hospital and did not have any further recurrence pt was discharged on this medication and her pcp was notified pt was transferred to the floor on and hct continued to be stable as were vs pt tolerated a regular diet on and was discharged home with follow up care in one week in the clinic nsaids were held the plan is for interval ccy once patient recovers from this hospitalization medications on admission allopurinol hctz fosamax naproxen prn levothyroxine ultram prn senna colace prn discharge medications hydrochlorothiazide mg capsule sig one capsule po daily daily levothyroxine oral allopurinol mg tablet sig one tablet po once a day fosamax mg tablet sig one tablet po once a day senna oral colace oral 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 cholelithiasis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to the surgery service for stones in your gall bladder and common bile duct you a procedure called ercp and had bleeding after this procedure for which you received blood and were transferred to the icu you recovered very well and you were transferred back to the regular floor we started you on a new medication called metoprolol for a very fast heart rate you were found to have you should should take this medication once a day until you see your primary care doctor do not take any nsaids motrin ibuprofen for an additional days as this may increase your risk of bleeding tylenol is ok for your pain you will eventually need to return to have your gall bladder removed this will be discussed with you further during your follow up appointment 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 wheeze 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 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 concerning symptoms general discharge instructions 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 followup instructions please follow up with the acs surgery clinic in week please call for an appointment md completed by,"{
""Diagnoses"": [""abdominal pain"", ""nausea"", ""vomiting"", ""hypothyroidism"", ""gouty arthritis"", ""osteoporosis"", ""right hip arthroplasty""],
""Medications"": [""ercp"", ""intubation"", ""cvl placement""]
}"
27840,admission date discharge date date of birth sex m service neurosurgery allergies codeine attending chief complaint fall major surgical or invasive procedure none history of present illness hpi yo m under the influence of etoh fell down flight of stairs in his home onto tile flooring not witnessed but wife heard fall and came to find him unarousable ems found him to have gcs of so he was intubated in the field it is recorded that he had a seizure no further description of semiology or duration which resolved with mg ativan and he was loaded with dilantin around midnight when transferred to a hospital in noted to have cc brb from ng tube but apaprently no intraabdominal injuries detected ecg nsr cxr done due to concern re aspiration post seizure and showed rul infiltrate he arrived at by past medical history pmhx asthma etoh dependence hernias social history social hx lives with wife etoh abuse family history nc physical exam physical exam t tymp bp hr r o sats ra gen wd wn intubated nad heent bilat periorbital ecchymoses no hemotympanum bilat neck c spine collar lungs cta bilaterally no flail chest crepitus to palpation cardiac rrr s s abd soft nt bs extrem cool and well perfused neuro repeated after propofol off for mins mse gcs intubated for verbal response opens eyes weakly to voice and localizes to pain does not follow commands cn perrl to bilat r somewhat more sluggishly positive corneal reflex bilat unable to do oculocephalics due to c spine precautions oculocalorimetry testing deferred facies symmetric motor sensation nml bulk and tone bilat moves all extremities symmetrically to noxious stim reflexes dtrs and symmetric plantars mute bilat pertinent results ct head w o contrast findings there are numerous small areas of parenchymal contusion and subarachnoid hemorrhage involving both frontal lobes and left temporal lobe hyperdensity along the left tentorial leaf is consistent with subdural hematoma there is no shift of normally midline structures mass effect hydrocephalus or evidence of acute major vascular territorial infarction included in the field of view are acute nondisplaced fractures of the lateral and medial walls of the right orbit right temporal bone left sphenoid and left zygoma which extends into the lateral wall of the left orbit there is a small amount of fluid in the left frontal sinus air cell and the nasopharynx and several ethmoid air cells are opacified possibly due to blood the mastoid air cells are clear there is mild underlying maxillary sinus mucosal thickening which is probably chronic there are a few small locules of gas within the right orbit but no evidence of retroorbital hematoma impression multifocal areas of parenchymal contusion and subarachnoid hemorrhage involving the frontal lobes and left temporal lobe small subdural hematoma layering along the left tentorial leaf multiple nondisplaced fractures are better seen on the companion ct sinus facial bone study and reference to this report is suggested c spine ct from osh non displaced fracture through l pedicle and facets of c etoh midnight mg dl h am was ast alt amylase lact na tox screen positive for bzd only coags and other routine bloodwork nml brief hospital course pt was admitted to the icu and monitored closely he was extubated on hd his neurologic exam improved and he became less lethargic he was following all commands ct of c spine showed c facet fracture and he was kept in the hard collar his diet and activity were advanced he was transferred to the floor he was seen by pt and ot who worked with him a couple visits and ultimately cleared him for discharge to home medications on admission none discharge medications oxycodone acetaminophen mg tablet sig tablets po every hours as needed disp tablet s refills phenytoin sodium extended mg capsule sig two capsule po bid times a day for days disp capsule s refills discharge disposition home discharge diagnosis traumatic brain injury multiple facial fractures c facet fracture discharge condition stable discharge instructions discharge instructions for head injury wear collar at all times 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 you have been prescribed an anti seizure medicine take it as prescribed until finished you may shower with collar on 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 please call to schedule an appointment with dr to be seen in weeks you will need a cat scan of the brain without contrast and c spine xray ap lat completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex m service neurosurgery allergies codeine attending addendum meds at discharge dilantin percocet colace discharge medications oxycodone acetaminophen mg tablet sig tablets po every hours as needed disp tablet s refills phenytoin sodium extended mg capsule sig two capsule po bid times a day for days disp capsule s refills colace mg capsule sig one capsule po twice a day take while on pain med disp capsule s refills discharge disposition home md completed by,"{
""Diagnoses"": [""Neurosurgery"", ""Seizure"", ""Asthma"", ""ETOH dependence"", ""Hernia"", ""Social history of ETOH abuse""],
""Medications"": [""Codeine"", ""Ativan"", ""Dilantin"", ""Methylprednisolone""]
}"
95632,admission date discharge date date of birth sex m service neurosurgery allergies no known allergies adverse drug reactions attending chief complaint headache major surgical or invasive procedure left occipital craniotomy for biopsy and debulking of brain mass history of present illness this is a year old gentleman without significant pmh with complaint of weeks of headache he was evaluated by his pcp was given ativan for headache and anxiety without relief ct done revealed a left parietal mass he was instructed to go to the ed hitchcock was evaluated there and given dilaudid for pain his mental status was declining so patient given decadron x and medflighted to neurosurgery consult requested for evaluation past medical history hl s p appy s p vasectomy social history he is married he lives with wife in he works in a chemical comapny he does not smoke cigarettes or use illicit drugs he drinks alcohol occasionally family history his parents are alive and well his mother has memory problems while his father has a history of coronary artery disease and underwent bypass surgery his sister died in her s with a glioblastoma he has other siblings and they are healthy he has children one was born premature and has cerebral palsy while the other two are healthy physical exam admission examination physical exam o t bp hr r o sats ra gen laying on stretcher asleep heent pupils mm neck supple extrem warm and well perfused neuro mental status lethargic arouses to voice light stimuli orientation oriented to self only cranial nerves i not tested ii pupils equally round and reactive to light to mm bilaterally 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 physical exam upon discharge awake alert to self hospital perrl eomi face symmetric tongue midline full strengths x incision staples intact well healing 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 calcium phos mg pm blood asa neg ethanol neg acetmnp neg bnzodzp neg barbitr neg tricycl neg radiology ct head w o contrast study date of pm impression large ill defined left occipitoparietal mass with associated vasogenic edema and hemorrhage exerting mass effect including subfalcine and uncal herniation early signs of hydrocephalus mr head w w o contrast study date of pm impression left occipital irregularly enhancing mass with chronic blood products and several low signal areas indicative of areas of necrosis the findings are suggestive of an infiltrative primary neoplasm such as glioma there is extensive surrounding edema seen with left sided uncal herniation and distortion of the midbrain resulting in moderate obstructive hydrocephalus no restricted diffusion is seen cta head w w o c recons study date of am impression left occipital mass demonstrates no evidence of acute hemorrhage increased vascularity is seen predominantly from the left posterior cerebral artery with no large draining veins identified or arteriovenous malformation is seen vascular displacement is seen but no aneurysm is identified ct head w o contrast study date of pm findings there has been interval left parieto occipital craniotomy with overlying skin staples and mild pneumocephalus changes of tumor debulking are noted in the left parietal region with adjacent hyperdense material representing hemorrhage and or post surgical changes just inferior to this region there is evidence of residual hyperdense tumor involving the left occipital lobe temporal lobe and splenium persistent surrounding vasogenic edema extends superiorly into the left parietal and posterior frontal lobes and inferiorly into the left temporal lobe left cerebral sulci are diffusely effaced and the left lateral ventricle is compressed there is continued mm rightward subfalcine herniation and mm rightward shift at the level of the third ventricle continued slight widening of the left ambient cistern relative to the right is suggestive of impending uncal herniation coarse calcifications are noted in the bilateral cavernous carotid arteries middle ear cavities and mastoid air cells are clear paranasal sinuses are well aerated the orbits and intraconal structures are intact impression tumor debulking with stable rightward mass effect and subfalcine herniation mr head w w o contrast study date of am impression status post left occipital craniotomy and tumor resection with expected postoperative changes areas of enhancement within the left occipital and left temporal lobes are consistent with residual tumor rightward shift of midline structures and left uncal herniation is unchanged brief hospital course this is a year old left handed man with no significant past medical history with progressive forgetfulness confusion right parietal headache and nausea and voomiting who eventualy developed right sided weakness and initiallty presented to the hitchcock ed on ct head scan there revealed a large left parietal mass with signifcant mass effect given a decrease in conscious level following narcotics for headache he was medflighted to the he was assessed by neurosurgery loaded with phenytoin and admitted to the neurosurgery icu on his cognitive symptoms improved somewhat and mri revealed a left occipital irregularly enhancing mass with chronic blood products and areas suggestive of necrosis in addition to extensive edema with left uncal herniation and distortion of the midbrain resulting in moderate obstructive hydrocephalus he was administered mannitol and dexamethasone and a cta head showed increased vascularity is mainly from the left pca neuro oncology were consulted and he proceeded to a left parietal craniotomy with subtotal tumor debulking and decompression postoperatively the patient was extubated and transferred to the icu for q hour neurochecks and sbp control less than post op ct was stable without evidence of hemorrhage and postop mri demostrated subtotal resection of tumor he did well post operatively and was transferred to the floor on decadron was weaned to mg tid which he will continue on until follow up he was seen on pt ot on it was recommended that he be discharged to inpatient rehab on he was cleared for discharge medications on admission lipitor ativan discharge medications acetaminophen mg tablet sig tablets po q h every hours as needed for pain t bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily senna mg tablet sig one tablet po daily daily docusate sodium mg capsule sig one capsule po bid times a day phenytoin sodium extended mg capsule sig one capsule po tid times a day heparin porcine unit ml solution sig one ml injection tid times a day pantoprazole mg tablet delayed release e c sig one tablet delayed release e c po q h every hours dexamethasone mg tablet sig one tablet po q hrs oxycodone mg tablet sig tablets po q h every hours as needed for pain atorvastatin mg tablet sig one tablet po daily daily magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed for no bm lactulose gram ml syrup sig thirty ml po q h every hours as needed for no bm discharge disposition home with service facility vna discharge diagnosis left occipital brain tumor discharge condition level of consciousness alert and interactive activity status ambulatory independent mental status confused sometimes 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 dressing may be removed on day after surgery your wound was closed with staples you must wait until after they are removed to wash your hair 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 senna 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 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 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 followup instructions follow up appointment instructions you have an appointment in the brain clinic on at am 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 completed by,{}
30603,admission date discharge date date of birth sex f service neurosurgery allergies patient recorded as having no known allergies to drugs attending chief complaint sudden onset worst headache of life major surgical or invasive procedure angiogram and coiling of p comm aneurysm stereotactic placement of evd placement of picc line history of present illness patient is a f who presented to osh this afternoon after experiencing worst ha of life while at home and subsequent fall to floor she was taken to the local ed by ems she was ct scanned at the osh revealing a large left sided sah with ivh and associated shift there is also a sdh noted on transfer likely caused by patient s fall to floor past medical history htn obesity social history married residing at home with children family history non contributory physical exam on admission physical exam o t afebrile bp hr rr intubated rate per ventilator cmv o sats gen wd obese female intubated upon arrival to ed heent normocephalic atraumatic pupils perrl sluggish neuro mental status intubated spontaneously moving all extremities left side greater than right no spontaneous eye opening does not follow commands cranial nerves i not tested ii pupils equally round and reactive to light mm to mm bilaterally but sluggish iii xii unable to assess motor unable to asses no posturing noted toes upgoing bilaterally on discharge pertinent results head ct impression diffuse left sided subarachnoid hemorrhage with extension into the basilar cisterns and ventricles bilaterally with no evidence for hydrocephalus the appearance may be slightly exaggerated due to residual contrast material from prior angiogram small left subdural hematoma no significant midline shift with mild mass effect on the adjacent cortex head ct post evd impression interval placement of ventricular catheter from a right frontal approach with tip terminating in the inferior frontal of the right lateral ventricle unchanged diffuse left sided subarachnoid hemorrhage and bilateral intraventricular hemorrhage without evidence of hydrocephalus unchanged left subdural hematoma without significant mass effect or shift of normally midline structures cta p impression status post coiling of posterior communicating artery aneurysm compared to the study of one day prior there is diffuse mild narrowing of bilateral aca and mca which may represent mild diffuse vasospasm in addition although the left pca demonstrates better flow compared to yesterday a segment of narrowing remains consistent with persistent vasospasm cta and ct perfusion demonstrate regions of increased blood flow in the left operculum which may be due to reperfusion phenomenon no ischemic changes are seen continued slight decrease in left frontoparietal subarachnoid hemorrhage small left subdural hemorrhage and mild rightward shift unchanged right intraventricular catheter unchanged in position hypodensities in the left centrum semiovale and extending down to the level of the left lentiform nucleus unchanged and likely due to prior intraventricular catheter placement left inferomedial temporal lobe hypodensity consistent with infarction unchanged radiology final report cta head w w o c recons am cta head w w o c recons reason please evaluate for vasospasm perfusion please perform ct a medical condition year old woman s p pcomm coiling with significant vasospasm reason for this examination please evaluate for vasospasm perfusion please perform ct angiogram with perfusion study to be performed with neurosurgery contraindications for iv contrast none history year old female status post posterior communicating artery aneurysm coiling with significance vasospasm comparison cta head and neck of technique contiguous axial imaging was performed through the brain without administration of iv contrast subsequent imaging was performed during rapid infusion of ml of iv optiray images were then processed on a separate workstation with display of maximal intensity projection images apparently no ct perfusion study was performed circle of volume rendered images are pending ct head there is no evidence of new intracranial hemorrhage the left subdural collection is unchanged measuring up to mm in thickness associated sulcal effacement remains although rightward shift is slightly less from mm to mm left frontoparietal subarachnoid hemorrhage is no longer apparent the patient is status post removal of a right intraventricular catheter from a right frontal approach small amount of air remains within the right lateral ventricle again streak artifact from coils within the left posterior communicating artery aneurysm limits evaluation of the middle cranial fossa however hypodensity in the inferomedial portion of the left temporal lobe and in the left basal ganglia are unchanged consistent with evolving infarcts hypodense tract along the left centrum semiovale from prior catheter placement is unchanged vascular calcifications are again noted in the cavernous carotid arteries there is complete opacification of the right sphenoid sinus as well as mucosal thickening in the left sphenoid sinus which may relate to the right sided ng tube the mastoid air cells remain well aerated cta head circle of volume rendered images are pending again noted is diffuse narrowing of the intracranial arteries however based on axial source images and mip images alone there appears to be slight increased blood flow within the m and m segments of the left mca compared to the prior cta study of otherwise diffuse narrowing of the right mca bilateral aca and the posterior circulation appears relatively unchanged impression ct head is little changed with left subdural collection and related sulcal effacement slight decrease in rightward shift after removal of right intraventricular catheter small amount of air remains in the right lateral ventricle evolving infarct in the left medial temporal lobe and left basal ganglia unchanged volume rendered images are pending based on source axial images and mip images there appears to be slight increase in blood flow in the m and m segments of the left mca otherwise diffuse vasospasm appears largely unchanged report to be finalized after review of volume rendered circle of images the study and the report were reviewed by the staff radiologist dr dr approved tue pm radiology final report ct head w o contrast pm ct head w o contrast reason evaluate for hydrocephalus following evd removal medical condition year old woman with subarachnoid hemorrhage reason for this examination evaluate for hydrocephalus following evd removal contraindications for iv contrast none indication year old female for followup of subarachnoid hemorrhage please evaluate for hydrocephalus following evd removal comparison technique non contrast head ct findings evd has been removed and ventricular size is slightly increased with expected pneumocephalus seen within the frontal of the right lateral ventricle basal cisterns are normal mm rightward subfalcine herniation is unchanged presumably secondary to small left subdural hematoma unchanged evolving areas of hypodensity in the left basal ganglia and cerebral hemisphere are again seen consistent with evolving infarction left internal carotid aneurysm coils are again noted limiting evaluation of structures in this region impression slight ventricular enlargement and small pneumocephalus following evd removal the study and the report were reviewed by the staff radiologist dr dr approved sat pm radiology final report chest portable ap am chest portable ap reason ngt placement medical condition year old woman with reason for this examination ngt placement indication year old woman with ng tube placement comparison single ap semi upright bedside radiograph of the chest ng tube is extending into the pyloric end of the stomach and out of the field of view the left subclavian catheter is terminating at the brachiocephalic confluence distal relative to the lung volumes remained low however there are no focal consolidations there is no pulmonary edema cardiomediastinal silhouette is unchanged there is no pneumothorax impression ng tube extending into the pyloric end of the stomach and out of the field of view the left subclavian catheter appears to be in the brachiocephalic confluence further out relative to the prior study the study and the report were reviewed by the staff radiologist dr dr approved pm test name value units reference range am report comment source line r subclavian complete blood count white blood cells k ul performed at west stat lab red blood cells m ul performed at west stat lab hemoglobin g dl performed at west stat lab hematocrit performed at west stat lab mcv fl performed at west stat lab mch pg performed at west stat lab mchc performed at west stat lab rdw basic coagulation pt ptt plt inr platelet count k ul performed at west stat lab test name value units reference range am report comment source line r subclavian renal glucose glucose mg dl performed at west stat lab urea nitrogen mg dl performed at west stat lab creatinine mg dl performed at west stat lab sodium meq l performed at west stat lab potassium meq l performed at west stat lab chloride meq l performed at west stat lab bicarbonate meq l performed at west stat lab anion gap meq l chemistry calcium total mg dl performed at west stat lab phosphate mg dl performed at west stat lab magnesium mg dl performed at west stat lab chemistry calcium total mg dl performed at west stat lab phosphate mg dl performed at west stat lab magnesium mg dl performed at west stat lab pituitary thyroid stimulating hormone uiu ml brief hospital course pt was admitted to the sicu after er eval for sah ivh and sdh after fall by report of ems the pt experienced the worst ha of life while at home and had a subsequent fall to floor she was taken to the local ed by ems she was ct scanned at the osh revealing a large right sided sah ivh and sdh she required evd external ventricular drain placement in the ed the placement of the drain was difficult and required stereotactic placement in the operating suite she underwent a cerebral angiogram based on the appearance of her ct scan a p comm aneurysm ct was identified and coiled during that same angiogram she was transferred back to sicu she was started on nimodpine as well as aed it was noted that her left hand was cool and discolored blue a vascular consult was obtained there was no formal treatment ie embolization or thrombectomy she underwent multiple cta ctp s to assess for vasospasm if noted on imaging it was followed up with a cerebral angiogram with verapamil followed by hhh therapy during these imaging series it was noted that she had infarcts to left medial temporal lobe as well as the left basal ganglia clamping trials of the evd were done she did not tolerate clamping early on during the hospitalization a csf sample was sent off after pt had reported fever the results showed klebsiella an id consult was obtained and their recommendations were followed ultimately her evd was removed on and she has tolerated this very well she has no active signs or symptoms of meningitis she did have some right sided weakness as well as aphasia the weakness is improving greatly as well as the aphasia her hhh therapy was backed off on on as this was day post bleed and the likelihood of continued vasospasm is very low she was transferred to the stepdown icu on for continued care her tube feedings were held as she passed a speech swallow exam on the ngt will be removed as she assures us she can take in enough po she is seen by pt ot as well they reccomend acute rehabilatation on discharge her central line was removed and midline catheter was placed neurologically she was awake alert and orientated x though she has difficulty speech she answered y n questions appropriately followed step commands expressively she is communicating via short phrases and sentences while there is no groping appreciated sentences are often labored and slow with several second pauses between words pt has frequent word finding issues of which she is aware and often frustrated speech and voice are wnl her motor strength was full throughout she was tolerating a regular diet and voiding without difficulty she was discharged to rehab on medications on admission unknown discharge medications methimazole mg tablet sig one tablet po tid times a day acetaminophen mg tablet sig tablets po q h every hours as needed for pain tablet s docusate sodium mg capsule sig one capsule po bid times a day famotidine mg tablet sig one tablet po bid times a day methimazole mg tablet sig one tablet po tid times a day heparin porcine unit ml solution sig one injection tid times a day levetiracetam mg tablet sig two tablet po bid times a day miconazole nitrate powder sig one appl topical qid times a day as needed oxycodone acetaminophen mg ml solution sig mls po q h every hours as needed for pain insulin regular human unit ml solution sig one injection four times a day as directed during inpatient stay ceftazidime gram recon soln sig one recon soln injection q h every hours discharge disposition extended care facility discharge diagnosis large left sided subarrachnoid hemorrhage bilateral intraventricular hemorrhage small left subdural hemorrhage posterior communicating artery aneurysm coiled vascular compromise left hand resolved cerebral vasospasm cns infectin klebsiella new diagnosis diabetes insulin dependent in hospital cerebral infarct left medial temporal lobe verebral infarct left basal ganglia discharge condition neurologically greatly improved stable discharge instructions general 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 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 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 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 need to follow up with your primary care physician to update him or her of your medical conditions hospitalization and for new diagnosis of diabetes completed by [NEW_RECORD] name unit no admission date discharge date date of birth sex f service neurosurgery allergies patient recorded as having no known allergies to drugs attending addendum additional d c instructions important information regarding midline placement an unsuccessful midline placement was attempted at it was agreed that medical personnel at rehab would place a midline on monday current antibiotic regimen ceftazidime g iv q h start date end date per id specialists at additional pertinent results csf culture wbc rbc polys lymphs monos macroph discharge disposition extended care facility md completed by,"{
""Diagnoses"": [""sudden onset worst headache of life"", ""major surgical or invasive procedure"", ""angiogram and coiling of p comm aneurysm"", ""stereotactic placement of evd"", ""placement of picc line""],
""Medications"": [""none known""]
}"
5529,admission date discharge date date of birth sex f service gyn oncology history of present illness the patient is a year old g p diagnosed with grade endometrioid type endometrial cancer by ultrasound guided dilatation and curettage on during an evaluation for post menopausal bleeding the patient has been having postmenopausal bleeding since approximately the patient was originally scheduled to see dr for evaluation on but was admitted to the gyn oncology service on for increased vaginal bleeding the patient had a decrease in hematocrit from to the patient s vaginal bleeding decreased substantially while in house the patient did not require blood transfusion and remained hemodynamically stable the patient was discharged to home on hospital day two and scheduled for staging procedure on anesthesia preoperative patient was admitted during hospital stay the patient denies lightheadedness fainting abdominal pain or urinary symptoms past obstetrical history full term normal spontaneous vaginal delivery times five gyn history no abnormal pap smears or sexually transmitted diseases the patient is unsure of last mammogram allergies penicillin family history no gyn or colon cancer past medical history asthma type diabetes hyperlipidemia obesity hypertension degenerative joint disease anxiety gout glaucoma medications glucophage mg po b i d valium mg prn procardia xl mg q d flovent serevent nitro prn quinine mg q h s alphagan ou t i d betaxolol ou b i d lasix q d proventil prn lipitor mg po q d allopurinol mg po q d xalatan ou t i d social history no alcohol or drugs chews tobacco lives alone physical examination the patient was afebrile vital signs are stable upon presentation no acute distress obese no cervical lymphadenopathy cardiovascular regular rate and rhythm no murmurs rubs or gallops lungs clear to auscultation no rales wheezes or rhonchi abdomen obese nontender nondistended positive bowel sounds sterile speculum examination normal external female genitalia normal vaginal mucosa no cervical masses sterile vaginal examination difficult secondary to habitus no adnexal masses slightly enlarged uterus rectovaginal no palpable masses extremities no clubbing cyanosis or edema assessment plan this is a year old p with endometrial cancer dr discussed with the patient while she was admitted the nature of the tumor and recommendations of a staging procedure with a total abdominal hysterectomy and bilateral salpingo oophorectomy the patient was explained that the surgery could involve lymph node dissection depending on intraoperative findings the patient was told that the need for postoperative adjuvant therapy radiation therapy and chemotherapy both would be determined by the surgical and pathologic findings details and risks of the surgery were discussed with the patient including bleeding infection potential damage to bowel or urinary system requiring more surgery consent was signed hospital course for details of surgery done on please see operative note postoperatively the patient required a hour admission to the intensive care unit secondary to anemia decreased urine output decreased mental status for her mental status changes the patient had received pain medications and became increasingly somnolent and difficult to arouse the patient was given narcan in the intensive care unit and instantaneously became arousable and alert and oriented times three from a renal standpoint the patient s renal output had dropped to approximately cc per hour on postoperative day zero of note she had been npo all day and had cc estimated blood loss the patient also had a bowel prep the night before the patient received unit of packed red blood cells with no significant increase from her preoperative hematocrit the patient remained hemodynamically stable the patient was transfused an additional units of packed red blood cells for a total of on postoperative day the patient s hematocrit improved the patient s urine output improved overnight with hydration and transfusion the patient s creatinine stayed within normal limits the patient was discharged from the intensive care unit and transferred to the floor on postoperative day one neurological the patient was changed to pain medications on postoperative day two without difficulty the patient s pain remained controlled during entirety of hospital stay the patient was discharged to home with percocet and motrin renal the patient s hematocrit stayed within normal limits during hospital stay the patient had adequate urine output during hospital stay the patient s foley catheter was discontinued on postoperative day two without difficulty gastrointestinal the patient was advanced to a regular diet on postoperative day three with passage of flatus the patient had several episodes of emesis on postoperative day three and just was made npo for hours on postoperative day four the patient was tolerating a regular diet without nausea and vomiting and was discharged to home tolerating a regular diet endocrine type diabetes the patient was on finger sticks q i d being covered with a regular insulin sliding scale and the patient was tolerating po the patient is to start glucophage upon discharge to home pulmonary asthma the patient was on asthma medications during hospital stay without difficulty fluids electrolytes and nutrition the patient was transitioned from intravenous fluids to po diet on postoperative day two without difficulty the patient s electrolytes were repleted as needed the patient was tolerating a regular diet by postoperative day four without difficulty physical therapy consult was obtained to evaluate home needs regarding activities of daily living and ambulation the patient will require a walker initially at home the patient was given a walker upon discharge to home discharge diagnoses endometrial cancer status post total abdominal hysterectomy bilaterally salpingo oophorectomy omental biopsy hypertension type diabetes hyperlipidemia glaucoma discharge status good discharge condition the patient is discharged to home with vna for home safety evaluation and the patient is to follow up with dr and is to call the office to confirm appointment the patient is to resume all home medications and the patient was given a prescription for percocet and motrin dr dictated by medquist d t job,"{
""Diagnoses"": [""grade endometrioid type endometrial cancer""],
""Medications"": [""""]
}"
4969,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 sob major surgical or invasive procedure coronary artery bypass grafting x left internal mammary artery grafting left anterior descending reversed saphenous vein graft to the marginal branch ramus intermedius branch diagonal branch and posterior descending coronary artery re exploration history of present illness y o male with increasing frequency of angina ett referred for cath which revealed vcad past medical history cad htn hypercholesterolemia dm gout pmr prostate cancer s p xrt hormones social history retired firefighter lives with wife etoh never smoked physical exam unremarkable upon admission 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 patient test information indication introp cabg evaluate aortic atheroma ventricular function valvular function height in weight lb bsa m m bp mm hg hr bpm 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 r measurements left ventricle septal wall thickness cm nl cm left ventricle diastolic dimension cm nl cm left ventricle systolic dimension cm left ventricle fractional shortening nl left ventricle ejection fraction to nl aorta valve level cm nl cm aorta ascending cm nl cm aorta arch cm nl cm aorta descending thoracic cm nl cm aortic valve peak velocity m sec nl m sec aortic valve peak gradient mm hg aortic valve mean gradient mm hg aortic valve lvot peak vel m sec aortic valve lvot vti aortic valve lvot diam cm aortic valve valve area cm nl cm interpretation findings right atrium interatrial septum lipomatous hypertrophy of the interatrial septum no asd by d or color doppler left ventricle mild symmetric lvh overall normal lvef right ventricle normal rv chamber size and free wall motion aorta mildly dilated aortic sinus focal calcifications in aortic root normal ascending aorta diameter focal calcifications in ascending aorta normal aortic arch diameter simple atheroma in aortic arch mildly dilated descending aorta simple atheroma in descending aorta aortic valve three aortic valve leaflets moderately thickened aortic valve leaflets mild as aova cm mitral valve mildly thickened mitral valve leaflets no ms trivial mr tricuspid valve physiologic tr pulmonic valve pulmonary artery physiologic normal pr conclusions pre bypass there is mild symmetric left ventricular hypertrophy overall left ventricular systolic function is normal lvef cannot exclude focal thinning of the basal inferior wall 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 aortic arch 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 moderately thickened the non coronary cusp is heavily calcified and poorly mobile there is mild aortic valve stenosis area cm the mitral valve leaflets are mildly thickened trivial mitral regurgitation is seen post bypass patient is in sinus rhythm on phenylepherine gtt preserved biventricular function with lvef no change in valves aortic contours intact remaining exam is unchanged all findings disucssed with surgeons at the time of the exam electronically signed by md on physician brief hospital course admitted from with unstable angina on he had a carotid ultrasound as well as other pre operative testing he remained stable and was taken tot he or on with dr he underwent cabg x lima lad svg om svg diag om svg pda post op he was taken to the csru he had a significant amount of post operative bleeding despite correcting coagulation parameters and he was therefore taken back to the or on the night of surgery a bleeding site was found and repaired he returned to the csru where he remained hemodynanically stable with no further bleeding problems was extubated and weaned from vasoactive drips over the next hours he was transferred to the telemetry floor on pod where he progressed with pulmonary toilet and ambulation a hit screen was sent due to thrombocytopenia and it was negative he remained stable and was discharged home on medications on admission allopurinol asa hctz avapro metoprolol lipitor prandin toprol xl discharge medications furosemide mg tablet sig one tablet po once a day for days docusate sodium mg capsule sig one capsule po bid times a day disp capsule 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 atorvastatin 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 irbesartan mg tablet sig one tablet po daily disp tablet s refills repaglinide mg tablet sig two tablet po tidac times a day before meals disp tablet s refills metoprolol tartrate mg tablet sig tablet po bid times a day disp tablet s refills albuterol ipratropium mcg actuation aerosol sig two puff inhalation q h every hours disp refills tramadol mg tablet sig one tablet po q h every to hours as needed disp tablet s refills discharge disposition home with service facility discharge diagnosis coronary artery disease worsening angina unstable angina operation coronary artery bypass grafting x left internal mammary artery grafting left anterior descending reversed saphenous vein graft to the marginal branch ramus intermedius branch diagonal branch and posterior descending coronary artery discharge condition good discharge instructions patient may shower no baths no creams lotions or ointments to incisions no driving for at least one month no lifting more than lbs for at least weeks from the date of surgery monitor wounds for signs of infection please call with any concerns or questions followup instructions cardiac surgeon dr in weeks local pcp in weeks local cardiologist dr in weeks completed by,"{
""Diagnoses"": [""cardiothoracic"", ""allergies"", ""coronary artery bypass grafting"", ""left internal mammary artery grafting"", ""left anterior descending reversed saphenous vein graft to the marginal branch ramus intermedius branch diagonal branch and posterior descending coronary artery re exploration""],
""Medications"": [""cad"", ""htn"", ""hypercholesterolemia"", ""dm"", ""gout"", ""pmr"", ""prostate cancer"", ""s p xrt"", ""hormones""]
}"
43917,admission date discharge date date of birth sex f service medicine allergies penicillins shrimp mayonnaise attending chief complaint abdominal pain major surgical or invasive procedure none history of present illness the patient in a yo woman with a h o recurrent pancreatitis with last episode in presenting as an osh transfer for pancreatitis with a lipase of through an interpretter the patient states that burning epigastric pain awoke her from sleep at a m and progrssively began to spread around her flanks to her back and into her l shoulder the pain was similar in quality to her prior episodes of pancreatitis but was much more intense symptoms were accompanied by nausea and more than episodes of emesis with a green tinge about half of time the emesis was tinged with red blood she also reports ha blurry vision and dizziness assoicated with the emesis and limited inspiration due to pain she denies any alcohol use changes to her medications including those for hld otc or herbal remedies no changes in bowel habits and a normal brown bm yesterday labs at the osh were notable for lab samples that could not initially be processed to due grossly lipemic collections and lipase of she was given pain medications and anti emetics and was transfered to for possibly plasmapheresis in the ed she was avss w ongiong pain labs were notable for wbc of alt ast lipase lactate cr ca mg and phos of ruqus showed an edematous pancrease without a definitive organized fluid collection no focal lesion in the liver with patent portal veins and a mm cbd and a surgically absent gall bladder the patient received mg of iv hydromoprhone and mg of iv ondansetron with minimal symptom relief vs prior to admission were t bp hr rr on ra of note she reports that this is her fourth episode of intense pain due to pancreatitis she also reports that in in she underwent a pancreatic biopsy that found cancer cells and she underwent a course of radiation therapy but not chemotherapy past medical history ccy recurrent pancreatitis x hypercholesterolemia anxiety gastritis migraines hypoglycemia patient follows a nutritionist and says she eats x a day denies hyperglycemia or metabolic syndrome and says she gets low blood sugar no loc or seizures from this tubal ligation social history patient lives in a shelter with other families in ma curently smokes reporting history of pack every days infrequent etoh use and no history of ivdu family history no history of pancreatitis gallstones liver disease or pancreatic disease no history of cystic fibrosis physical exam admission exam vitals bp hr rr satting on ra general uncomfortable tearful moaning in pain heent perrl eomi sclera anicteric injected conjunctiva no oral lesions or ulcers with moist mucous membranes neck no carotid bruits jvd about cm above clavicle at degrees thyroid is full without any nodules appreciated or masses lungs ctab heart rrr normal s s no mrg abdomen soft nbs intense ttp in epigastric ruq region no change in symptoms with rebound manuver could not appreciate organomegaly extremities no c c e no rashes neurologic a ox cnii xii focally in tact moving all extremities discharge exam vitals t hr rr bp sao on ra general obese woman speaking spanish heent mucous membranes moist lungs ctab heart rrr normal s s no mrg abdomen obese moderately distended mildly ttp in epigastrum and left side improved extremities wwp no edema neurologic a ox cns intact moving all four follows commands 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 pm blood alt ast alkphos totbili pm triglycer pm urine ucg negative pm urine hours random pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk neg pm lactate pm lipase pm albumin calcium phosphate magnesium pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count sinus rhythm normal ecg no previous tracing available for comparison tracing intervals axes rate pr qrs qt qtc p qrs t us findings pancreas has no definitive organized fluid collections the liver is unremarkable with no focal lesions main portal vein is patent with appropriate directional flow limited views of the kidneys are unremarkable the common bile duct is not dilated measuring mm the patient is status post cholecystectomy no stones are seen within the common bile duct the spleen is unremarkable measuring cm limited views of bilateral kidneys show no evidence of hydronephrosis stones or masses impression patient is status post cholecystectomy no evidence of cbd dilation or stones cxr findings the lung volumes are low normal appearance of the lung parenchyma no pulmonary edema no pneumonia no pleural effusions normal size and shape of the cardiac silhouette normal hilar and mediastinal contours kub findings there is a non obstructive bowel gas pattern with air seen in the colon there is a paucity of bowel gas within small bowel loops clips are seen in the right upper quadrant there is no evidence of free air osseous structures are unremarkable 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 pm blood alt ast ld ldh alkphos totbili dirbili indbili am blood triglyc brief hospital course f female with history of recurrent pancreatitis presenting with intense epigastric pain and elevated lipase c w pancreatitis pancreatitis this is the th time the patient has been hospitalized with pancreatitis and she reports intermittent epigastric pain at baseline she reports only minimal alcohol use and most recently about a month ago given her hypertriglyceridemia and grossly lipemic blood samples it seems most likely that her recurrent bouts of pancreatitis are caused by elevated triglycerides she was adopted so no family history of hypertriglyceridemia or pancreatitis could be obtained she also has an unclear history of pancreatic radiation therapy in in after a biopsy showed cancer cells but her first episodes of pancreatitis predate that procedure she was made npo and given ivf boluses and a basal rate of cc hr but had only minimal urine output and began to have progressively more abdominal distension suggesting extravascular fluid accumulation her o sats remained in the s on room air and her lung exam was clear for pain she was started on a morphine pca but despite escalating doses her pain was very difficult to control she required dilaudid pca followed by dilaudid iv she was then transitioned to dilaudid po with good results she eventually tolerated po without significant pain hypertriglyceridemia patient with tg close to on admission responded well to fluids once tolerating po gemfibrozil was started tg on discharge were appointment was made for lipid clinic however unable to be seen until hypotension in the afternoon on the day of admission she developed sbps in the s s and appeared progressively more drowsy although her rr remained in the high teens and she continued to moan in pain distributional shock due to the pancreatitis with accumulation of extravascular fluid despite aggressive resuscitation was considered to be likely given her ongoing need for aggressive fluid resuscitation and concern for acute pulmonary edema she was transferred to the icu for hemodynamic instability and a possible imminent need for pressors and airway protection upon arrival to floor patient was normotensive and did not require any management of hypotension anxiety agitation patient had numerous episodes of anxiety agitation she stated she was unhappy with the care here and that she wanted to report the hospital news agencies she also complained of anxiety and responded well to mg ativan she eventually had less complaints as her panreatitis improved depression patient takes celexa mg po at home it was re started once she was able to tolerate po medication hematuria likely to traumatic straight cath versus contamination from menses considering patient had no si sx of uti decision was made to hold off on empiric treatment or urine cx hx of gastritis patient was treated empirically with ppi while in house no acute exacerbation medications on admission preadmission medications listed are correct and complete information was obtained from greater family health center fluticasone propionate nasal spry nu loratadine nf mg oral qd citalopram mg po daily ranitidine mg po daily propranolol mg po bid discharge medications citalopram mg po daily gemfibrozil mg po bid rx gemfibrozil mg tablet s by mouth twice a day disp tablet refills ranitidine mg po daily propranolol mg po bid loratadine nf mg oral qd fluticasone propionate nasal spry nu hydromorphone dilaudid mg po q h prn pain discharge disposition home discharge diagnosis primary acute pancreatitis hypertriglyceridemia 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 treat you at for your pancreatitis your pancreatitis occurred as a result of your high trigylceride levels you were treated with bowel rest fluids and pain medication when you were able to tolerate eating and drinking we started you on a medication to decrease your triglycerides called gemfibrozil please take the medications we have prescribed you and keep the appointments we have made followup instructions name dr location greater family health center address phone appointment monday am department div of gastroenterology when wednesday at pm with md building ra complex campus east best parking main garage department west clinic when thursday at am with m d building de building complex campus west best parking garage completed by,"{
""Diagnoses"": [""pancreatitis""],
""Medications"": [""penicillins"", ""shrimp"", ""mayonnaise""]
}"
14384,admission date discharge date date of birth sex f service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint expanding right groin hematoma status post cardiac catheterization major surgical or invasive procedure evacuation of hematoma with repair of profunda history of present illness yo f with no past cardiac hx was found with a new lbbb during a routine checkup with her pcp only complaint was exertional dyspnea a subsequent p mibi showed anterior and anterolateral defects and an ef of a subsequent echo at did not show a depressed ef she precented for ardiac catherization past medical history pmh depression anxiety cardiomyopathy ef clean coronaries per cath sp lle bpg sec trauma mvc yrs ago sp open ccy morbid obesity social history 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 ysical examination vs t bp hr rr o gen wdwn 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 with jvp of cm cv pmi located in th intercostal space midclavicular line rr normal s s no m r g no thrills lifts no s or s chest no chest wall deformities scoliosis or kyphosis resp were unlabored no accessory muscle use ctab no crackles wheezes or rhonchi abd soft ntnd no hsm or tenderness abd aorta not enlarged by palpation no abdominial bruits r groin inc c d i ext no c c e no femoral bruits skin no stasis dermatitis ulcers scars or xanthomas pertinent results am blood hct brief hospital course yo f with no past cardiac hx was found with a new lbbb during a routine checkup with her pcp only complaint was exertional dyspnea a subsequent p mibi showed anterior and anterolateral defects and an ef of a subsequent echo at did not show a depressed ef here for cardiac catheter cardiac cath showed no angiographically apparaent coronary disease there was no gradient acress the aortic valve there is moderate diastolic dysfunction with an lvedp of mmhg an lv gram shows an ef of by report there was some difficulty obtaining access was due to body habitus and approximately min after the sheath removal a large hematoma began to form and the patient became hypotensive to requiring pressor support with dopamine her pressure improved however she continued to ooze from her groin operative site a clamp was placed for hemostasis transfered to the ccu the patient was tachycardic and her hematoma continued to expand she received unit of blood and a urgent vascular consult was obtained she was taken to the or for clot removal and repair of the arterial bleed she tolerated the procedure well transfered to the floor in stable condition pt pt stable for home with services medications on admission meds buspar ambien prn topamax vicodin klonopin prn paxil recently started on asa carvedilol lisinopril for mi discharge medications hydromorphone mg tablet sig tablets po q h every to hours as needed for breakthrough only disp tablet s refills hydrocodone acetaminophen mg tablet sig tablets po q h every to hours as needed disp tablet s refills clonazepam mg tablet sig one tablet po q h every hours as needed famotidine mg tablet sig one tablet po q h every hours buspirone mg tablet sig tablets po q h every hours topamax mg tablet sig one tablet po twice a day aspirin mg tablet chewable sig one tablet chewable po daily daily lisinopril mg tablet sig one tablet po daily daily disp tablet s refills carvedilol mg tablet sig one tablet po twice a day disp tablet s refills discharge disposition home with service facility vna discharge diagnosis r groin hematoma s p cardiac catheter discharge condition stable discharge instructions post surgery wound care overview your doctor has placed sutures stitches to keep the incision closed for proper wound healing sometimes sutures need to be removed in a few weeks sometimes the sutures are all under the skin and will eventual dissolve on their own and do not need to be removed in either case please follow these routine wound care instructions leave the original bandage that was applied at the time of your surgery in place for hours if the bandage should become loose reinforce the dressing with surgical tape after approximately hours you can gently remove the bandage if you have steri strips on your incision little white paper tapes keep them in place until they begin to fall off on their own do not pull the steri strips off as this could put stress on the incision line when the steri strips start to peel off they can be gently washed off please try to keep the incision line clean and dry you can shower and gently wash the incision line with soap and water dry the incision area and keep the incision line open to air it is not necessary to apply antibiotic ointment alcohol hydrogen peroxide or a new bandage to the incision line if your sutures get caught on your clothing or there is a small amount of drainage from the incision you may want to cover it with small gauze for your own comfort if so please use as little tape as possible to hold the gauze in place as tape can irritate the skin a small amount of drainage from the incision in the first few days after surgery is not unusual and it will probably resolve on its own however if you should notice bleeding from the surgical site apply firm direct pressure for ten minutes if the bleeding persists reapply firm direct pressure for an additional ten minutes if the bleeding does not stop after minutes call our contact phone numbers or go to the nearest emergency room for assistance what to avoid please avoid the following do not submerge the incision line under water for a prolonged period of time with activities like taking a bath swimming or sitting in a hot tub do not participate in any vigorous activities or exercises that may put stress on the incision do not take aspirin ibuprofen or any other nonsteroidal anti inflammatory medication that may cause problems with bleeding unless instructed by your doctor do not apply perfumes or scented lotions to the sutures as this may cause irritation when to call the doctor please contact us immediately if you develop fevers chills or night sweats increasing redness pain or pus at the incision bleeding that does not stop with firm pressure followup care if your sutures need to be removed this is usually done weeks after surgery even if your sutures will dissolve the doctor usually likes to examine the incision while it is healing therefore you should have been scheduled for a follow up appointment in clinic at the time of your discharge from surgery as this appointment is very important please contact the clinic if you do not have one scheduled or you need to change the date and or time followup instructions call dr office at schedule an appointment for weeks after you get discharged completed by,{}
57554,admission date discharge date date of birth sex m service surgery allergies patient recorded as having no known allergies to drugs attending chief complaint sob major surgical or invasive procedure history of present illness m h o non traumatic splenic rupture c b large peri splenic hematoma requiring percutaneous drainage and recurrent left pleural effusion requiring intermittent drainage pt now returns with increasing sob over the past hours until today he was feeling well afebrile eating well and ambulating this am he felt sluggish and sob his vna noted decreased breath sounds on the left and recommended he come to he reports having a fever today as well ros per hpi denies pain chills fatigue malaise lethargy changes in appetite nausea vomiting hematemesis bloating cramping melena brbpr dysphagia chest pain cough edema urinary frequency urgency past medical history pmh atraumatic splenic rupture htn dm psh none social history sh works as director of facilities at a private school married former smoker pack year history quit months ago occational etoh no other drug use family history fh mother with hypertension father with dm renal failure copd physical exam on admission physical exam f ra gen a o nad heent no scleral icterus mucus membranes moist cv rrr no m g r pulm clear to auscultation on the right decreased breath sounds at the left base no w r r abd obese soft nondistended nontender no rebound or guarding normoactive bowel sounds no palbable masses ext mild le edema le warm and well perfused brief hospital course patient evaluated in emergency department by surgical team and admitted to acs service cta chest done revealed recurrent left pleural effusion now loculated after splenic rupture he also had an increased temp and wbc he was admitted to surgery for splenectomy and thoracic surgery was consulted for chest tube placement on he underwent left sided chest tube placement exploratory laparotomy splenectomy abscess washout he tolerated the procedure well and remained intubated overnight his vent was weaned and he was extubated on without event he was transferred to the floor he had significant pain control issues requiring high dose of intravenous narcotics once his chest tube was removed his pain seemed to diminish an abdominal binder was also used which seemed to contribute significantly to his comfort he is being discharged on oral pain regimen and bowel medications he was closely followed by physical therapy and initially recommended for rehab but given that he progressed rapidly once his pain was better controlled he was recommended for home with services by the time of discharge he was tolerating a regular diet and ambulating with a cane he will follow up in acs and thoracic clinic as an outpatient he will also require follow up with his primary providers medications on admission motrin prn lisinopril statin glyburide metformin discharge medications hydromorphone 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 magnesium hydroxide mg ml suspension sig thirty ml po q h every hours as needed for constipation senna mg tablet sig two tablet po hs at bedtime metoprolol tartrate 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 metformin mg tablet sig tablet po twice a day glyburide mg tablet sig one tablet po twice a day atorvastatin mg tablet sig one tablet po once a day discharge disposition home with service facility all care vna of greater discharge diagnosis splenic rupture infected perisplenic hematoma left sided pleural effusion 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 for a splenectomy removal of our spleen and placment of a chest tube in oreder to drain fluid from your chest performed in the operating room on resume your home medications as prescribed by your providers general discharge instructions you have had an abdominal operation this sheet goes over some questions and concerns you or your family may have if you have additional questions or t understand something about your operation please call your surgeon activity do not drive until you have stopped taking pain medicine and feel you could respond in an emergency you may climb stairs you may go outside but avoid traveling long distances until you see your surgeon at your next visit t lift more than pounds for next weeks this is about the weight of a briefcase or a small bag of groceries this applies to lifting children but they may sit on your lap you should start some light exercise such as walking times daily sor short periods astolerated you may shower but will need to stay out of bathtubs or swimming pools for a time while your incision is healing ask your doctor when you can resume tub baths or swimming heavy exercise may be started after weeks but use common sense and go slowly at first you may resume sexual activity unless your doctor has told you otherwise how you feel you may feel weak or washed out for weeks you might want to nap often simple tasks may exhaust you you may have a sore throat because of a tube that was in your throat during surgery you might have trouble concentrating or difficulty sleeping you might feel somewhat depressed you could have a poor appetite for a while food may seem unappealing all these feelings and reactions are normal and should go away in a short time if they do not tell your surgeon your incision your incision may be slightly red around the stitches or staples this is normal you may gently wash away dried material around your incision do not remove steri strips for weeks these are the thin paper strips that might be on your incision but if they fall off before that it s ok it is normal to feel a firm ridge along the incision this will go away avoid direct sun exposure to the incision area do not use any ointments on the incision unless you were told otherwise you may see a small amount of clear or light red fluid staining your dressing or clothes if the staining is severe please call your surgeon you may shower as noted above ask your doctor when you may resume tub baths or swimming over the next months your incision will fade and become less prominent followup instructions follow up with clinic next week to have your staples removed please call to make an appointment follow up with dr surgery in weeks call for an appointment follow up with your primary care providers in the next weeks for ongoing managment of your medical conditions you will need to call for an appointment completed by,"{
""Diagnoses"": [""non-traumatic splenic rupture"", ""large peri-splenic hematoma"", ""recurrent left pleural effusion""],
""Medications"": [""percutaneous drainage"", ""intermittent drainage"", ""pain medication"", ""anti-nausea medication"", ""anti-vomiting medication"", ""blood thinner""]
}"
85767,admission date discharge date date of birth sex m service medicine allergies phenergan attending chief complaint abd pain major surgical or invasive procedure none history of present illness yom with hx of chronic pancreatitis and ethanol intoxications with multiple admissions for abd pain presents with abdominal pain found to have hct drop of pts and grossly red blood on digital rectal exam pt reports pain is diffuse abdominally without resolution with pain meds at home not associated with bms no associated fevers or chills but with some blood per stool over past few days pain is baseline w oxycodone apap but reports today in ed bp hr exam notable for diffuse abdominal pain pt noted to be acutely intoxicated digital rectal exam showed no external hemorrhoids but with evidence of red blood on exam glove heme positive lipase not elevated hct upon arrival bps then dropped to after l ivf and dilaudid hct rechecked after blood on dre found to have dropped to two g pivs and piv g t s units iv ppi gi reportedly called by ed staff admitted to for hemodynamic monitoring and gib work up past medical history recurrent pancreatitis etoh abuse gastritis alcohol abuse complicated by dts blackouts chronic hepatitis c anemia nos prosthetic left eye secondary to glass injury hiv negative in per patient report social history the patient moved to the area from a few months ago he is homeless and has been living with various friends family and shelters he is unemployed and receives ssi secondary to anxiety problems with depth perception and gait disturbance tobacco ppd x years etoh patient is actively drinking drinks up to beers daily drinks vodka as well illicits patient reports prior use of marijuana and inhaled cocaine years ago denies any history of ivdu family history non contributory physical exam vitals on ra general pleasant well appearing male in nad heent normocephalic atraumatic no conjunctival pallor no scleral icterus perrla eomi mmm op clear neck supple no lad no thyromegaly cardiac regular rhythm normal rate normal s s no murmurs rubs or jvp not visualized lungs ctab good air movement biaterally abdomen abdomen ttp in epigastrum soft nt nd no hepatosplenomegaly or other organomegaly extremities no edema or calf pain dorsalis pedis posterior tibial pulses skin no rashes lesions ecchymoses neuro a ox appropriate mild resting tremor normal coordination gait assessment deferred psych listens and responds to questions appropriately pleasant pertinent results am hct am pt ptt inr pt am wbc rbc hgb hct mcv mch mchc rdw pm wbc rbc hgb hct mcv mch mchc rdw brief hospital course assessment yom hx alcoholism with presumed chronic pancreatitis presenting with abdominal pain with blood identified on dre with hct drop from to in ed after l ivf without hemodynamic decompensation admitted to for work up of gib gastrointestinal bleed patient presented to the ed with abdominal pain and was found to have bright red blood per rectum in the setting of a hematocrit drop from to he was transfused one unit of blood and admitted to the the source of his bleeding was thought to be lower gi and the gastrointestinal service was consulted a kub was negative for free air he initially refused to undergo gastric lavage but the procedure was performed and was negative for blood of note however he has a history of a positive h pylori antigen in and does not recall receiving treatment for peptic ulcer disease before the patient could undergo colonoscopy he signed out ama because he was unhappy about the amount of pain medication he was receiving of note he was given mg iv dilaudid for complaints of abdominal pain while on the floor chronic pancreatitis multiple past admits muliple couseling attempting at ethanol cessation concern for secondary gain has been offered detox programs seen by addictions nurse has followed on past admissions for pain medication use last discharge plan was for short term percocet use with ssri start up by pcp narcotic contract but walked out of pcp appointment after being told he would not receive narcotics etoh abuse positive for history of delirium tremens states that he is currently trying to reduce his alcohol intake he was given mvi thiamine and folate and put on a q hr ciwa scale he demonstrated no evidence of withdrawal while inpatient medications on admission multivitamin qd thiamine hcl qd omeprazole mg qd ativan mg po q prn oxycodone acetaminophen mg q hrs prn folic acid mg qd discharge medications multivitamin qd thiamine hcl qd omeprazole mg qd ativan mg po q prn oxycodone acetaminophen mg q hrs prn folic acid mg qd discharge disposition home facility left ama discharge diagnosis left ama discharge condition left ama discharge instructions left ama followup instructions left ama completed by [NEW_RECORD] admission date discharge date date of birth sex m service medicine allergies phenergan plain reglan vancomycin prochlorperazine maleate attending chief complaint not feeling right major surgical or invasive procedure none history of present illness yo m with a hx of alcohol abuse with multiple ed visits for alcohol intoxication and pancreatitis who presented two days ago intoxicated and complaining of pain related to recent right sided rib fractures he also complained of chronic abdominal pain in the center of his abdomen he was noted to be incoherent tremulous and uncooperative and was found to have an etoh level of with a sodium of his admission cxr demonstrated no acute cardiopulmonary process but had evidence of old rib and clavicle fractures he required iv diazepam over seven hours while in the ed and was transferred to the micu for his severe withdrawal symptoms while in the micu he required diazepam mg q h and was chronically asking for pain medication for his abdominal and msk pain however he described a history of narcotic dependence having recently received narcotic pain medication from a family member of note he refused an hiv test prior to transfer he reports continued non radiating central abdominal pain that is associated with nausea nbnb emesis and poor appetite he states that this abdominal pain is unlike his prior episodes of pancreatitis he denied any jaundice recent episodes of hemoptysis or melena he also reports right sided chest wall pain that is constant at the site of his prior rib fractures he also acknowledged his alcoholism and stated he wanted help past medical history pancreatitis lipase has ranged from normal level to ct abd pelvis x has shown no evidence of acute or chronic pancreatitis but has shown diffuse fatty infiltration of the liver chronic pain secondary to pancreatitis narcotics use alcohol abuse starting at age multiple attempts at detox w h o dt s no h o withdrawal seizures gastritis hepatitis c not documented in this system iron deficiency anemia prosthetic left eye positive h pylori serology panic disorder social history tobacco ppd since the age of now ppd etoh drinks l of vodka per day etoh abuse for nearly yrs last drink sometime on illicits none now but in past stated that he flirts with illicit drugs of all types but not a regular user always uses clean needles admited to past heroin use but denies recent use also admits to occasional marijuana use and use of percocet and oxycodone denies cocaine use in past living at house recently also living occassionally with friends family history father and mother w history of alcoholism physical exam admission physical exam vitals ra general alert oriented no acute distress psych flat affect heent sclera anicteric mmm oropharynx dry dilated and responsive right pupil neck supple jvp not elevated lungs clear to auscultation bilaterally no wheezes rales ronchi cv regular rate and rhythm normal s s no murmurs rubs gallops abdomen soft diffusely tender mostly epigastric non distended bowel sounds present no rebound tenderness or guarding ext warm well perfused pulses no clubbing cyanosis or edema discharge physical exam vitals ra general diaphoretic otherwise lying in bed comfortably heent mmm op clear evidence of prosthetic left eye neuro alert and oriented resting tremors appreciated in hands bilaterally no evidence of asterixis lungs poor inspiratory effort limited by pain otherwise clear to auscultation bilaterally cv rrr nml s s no m r g abdomen tenderness to palpation in the epigastrium with mild guarding otherwise soft non distended bs ext wwp no evidence of le edema 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 alt ast alkphos totbili pm blood asa neg ethanol acetmnp neg bnzodzp neg barbitr neg tricycl neg discharge labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct am blood glucose urean creat na k cl hco angap am blood calcium phos mg studies cxr findings the lungs are clear without pleural effusion or pneumothorax fracture deformities are seen in the right lateral fourth through seventh ribs but appear subacute to chronic the heart is normal in size with normal cardiomediastinal silhouette an old left clavicular fracture is again seen impression no acute intrathoracic process brief hospital course mr is a yo m with history of etoh abuse and pancreatitis who presented with both alcohol and opioid withdrawal symptoms and abdominal pain that has required large doses of benzodiazepines and narcotic medications active issues alcohol withdrawal upon admission the patient was noted to be tremulous restless and uncooperative he received a banana bag and was placed on a ciwa protocol for alcohol withdrawal and transfered to the micu where he required diazepam mg iv q h he was transferred to the floor and his diazepam requirement slowly decreased he did not exhibit dts or seizures throughout admission he received a banana bag and declined po mvi thiamine and folate while the patient was amenable to joining a rehab he left ama given that he felt his pain was not being appropriately managed opioid withdrawal during the course of the hospitalization the patient s pain management was transitioned from narcotics to non opoids however the patient described a history of narcotic dependence and demonstrated signs of opioid withdrawal while on the floor therefore he was restarted on oxycodone for his pain with a plan to taper his dosing however he left ama because he felt his pain was not being managed appropriately abdominal pain over the course of the hospitalization the patient described chronic abdominal pain that was likely due to either chronic pancreatitis or gastritis in the setting of alcohol abuse given the lack of fevers or elevated wbc count there was less concern for an infectious process his pain was controlled with low dose narcotics however he left ama because he felt that his pain wasn t adequately managed inactive issues anemia on admission the patient was noted to be anemic with a hct of likely secondary to his chronic alcoholism his hct steadily improved over the course of the hospitalization and returned to its baseline by discharge thrombocytopenia the patient s platelet count was noted to be low throughout his admission however there was no evidence of bleeding as his hct normalized by discharge the etiology is likely secondary to hypersplenism or bone marrow suppression in the setting of alcoholism of note his last plt count was but a workup couldn t be initiated as he left ama hypernatremia upon admission the patient was noted to have a sodium of in the setting of poor po intake his hypernatremia resolved following ivfs and remained normal throughout admission medications on admission prilosec mg capsule delayed release e c sig one capsule delayed release e c po twice a day but ran out a few days ago trazodone mg tablet qhs usually passes out at night before needs to take it oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for severe pain klonipin mg daily lorazepam mg daily discharge medications trazodone mg tablet sig one tablet po at bedtime prilosec mg capsule delayed release e c sig one capsule delayed release e c po twice a day thiamine hcl 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 discharge disposition home discharge diagnosis primary alcohol withdrawal opioid withdrawal secondary abdominal pain secondary to gastritis chronic pancreatitis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions mr thank you for allowing us to participate in your care you were admitted to the hospital for alcohol withdrawal we gave you benzodiazepines to treat your withdrawal symptoms while hospitalized you were also noted to be withdrawing from opioids given your history of alcoholism and narcotic addiction we recommend you go to a substance abuse rehabilitation center establish care with a new primary care provider consider treatment at a clinic information regarding follow up with these services is listed below please note the following in your medications stop percocet stop klonopin stop ativan start thiamine and folate followup instructions below is a list of local suboxone providers you will need to contact one of them to set up treatment new clinic pc suite c miles miles miles miles miles f dr optimind health park plaza fourth floor miles g dr miles miles to establish a new primary care physician please contact once you have established primary care at your pcp can refer you to their mental health providers for psychiatry and counseling for addictions out patient treatment please contact,"{
""Diagnoses"": [""chronic pancreatitis"", ""ethanol intoxication"", ""gastrointestinal bleeding"", ""hemodynamic instability""],
""Medications"": [""oxycodone"", ""apap"", ""dilaudid"", ""piv g t s units iv ppi gi"", ""gib work up""]
}"
1648,admission date discharge date date of birth sex m service csu history of present illness this is a year old gentleman who presented to emergency room the beginning of with complaints of dizziness shortness of breath and chest discomfort at that time the patient ruled out for myocardial ischemia the patient underwent stress test subsequently which was positive and was referred to for cardiac catheterization past medical history hypertension arthritis status post hernia repair allergies penicillin medications folic acid indocin aspirin mg a day social history the patient is married and works as an emergency medical technician laboratory data preoperative laboratory evaluation included a creatinine of hospital course on the patient underwent cardiac catheterization which showed a left ventricular end diastolic pressure of ejection fraction was percent totally occluded left anterior descending after first diagonal severe diffuse disease of the right coronary artery with percent stenosis the patient was referred to dr for operative management of his coronary disease on the patient was taken to the operating room by dr and underwent a coronary artery bypass graft times two with left internal mammary artery to left anterior descending and saphenous vein graft to posterior descending artery total cardiopulmonary bypass time was minutes cross clamp time was minutes the patient was transferred to the intensive care unit in stable condition on neo synephrine and propofol infusion the patient was weaned and extubated from mechanical ventilation on his first postoperative evening he remained hemodynamically stable on postoperative day number one he was transferred from the intensive care unit to the regular part of the hospital his chest tubes were removed without incident the patient began ambulating with physical therapy the patient was started on lasix and beta blockers on postoperative day number two his foley catheter and pacing wires were removed the patient s hematocrit on postoperative day number two was found to be and the patient was complaining of some light headedness with exertion the patient was transfused one unit of packed red blood cells which he tolerated well his post transfusion hematocrit was by postoperative day number four the patient was working with physical therapy and he was able to ambulate feet and climb one flight of stairs on postoperative day number five the patient was cleared for discharge to home condition on discharge temperature maximum of pulse and sinus rhythm blood pressure respiratory rate of room air oxygen saturations were percent neurologically the patient was awake alert and oriented times three examination was nonfocal heart was regular rate and rhythm without rub or murmur respiratory breath sounds were clear bilaterally gastrointestinal positive bowel sounds abdomen was soft nontender nondistended chest x ray on showed small bilateral effusions and bilateral atelectasis extremities were warm and well perfused with trace pitting edema sternal incision was clean dry and intact without erythema or drainage the right lower extremity vein harvest port sites at knee and upper thigh were clean dry and intact without erythema or drainage the right thigh had a moderate amount of ecchymosis discharge medications colace mg p o twice a day zantac mg p o twice a day aspirin mg p o once daily plavix mg p o once daily dilaudid mg tablets one p o every four to six hours prn iron sulfate mg p o once daily vitamin c mg p o twice a day lasix mg p o once daily times five days potassium chloride meq p o once daily times five days lopressor mg p o twice a day lipitor mg p o once daily the patient is to be discharged to home in stable condition he is to follow up with dr in one to two weeks he is to follow up with dr in one to two weeks and he is to follow up with dr in five to six weeks discharge diagnoses coronary artery disease status post coronary artery bypass graft hypertension dictated by medquist d t job,"{
""Diagnoses"": [""dizziness"", ""shortness of breath"", ""chest discomfort"", ""myocardial ischemia"", ""hypertension"", ""arthritis"", ""status post hernia repair""],
""Medications"": [""penicillin"", ""folic acid"", ""indocin"", ""aspirin""]
}"
16271,admission date discharge date date of birth sex f service cardiothoracic allergies penicillins attending chief complaint transfer from outside hospital for concern of tracheomalacia major surgical or invasive procedure flexible bronchoscopy placement of interpulmonary stent history of present illness pt is a f transferred from with tracheomalacia she was admitted on for copd exacerbation after outpatient taper of prednisone from to mg and was intubated there ms was extubated over the weekend prior to admission but night of had increased bp tachycardia she was re intubated s p bronch which demonstrated occlusion w expiration patient experienced hypotension to systolic s during bronch thought to be medication related mg versed pt rec d cc of ns and levophed at mcg min weaned to off on the ride over from osh of note lovenox was d c d this a m due to hematuria but with stable hct past medical history copd gerd depression pack year smoker social history lives at home with husband pack year hx quit in occ etoh family history mother died at from mi father died from etoh related physical exam v s tm hr bp s on fio ps peep gen awakes to name follows commands suchs as hand squeeze and toe movement heent intubated perrla cv s s no m r g lungs occais wheezes anteriorly abd soft nt nd bs bruising on lower abd extending to upper labia ext no c c e bruising on upper arm 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 alt ast ld ldh alkphos amylase totbili pm blood albumin calcium phos mg pm blood lactate pm blood freeca labs on discharge microbiological data c diff negative am sputum source endotracheal 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 respiratory culture final sparse growth oropharyngeal flora bcx pending bcx pending ucx no growth gram stain final pmns and epithelial cells x field per x field gram positive cocci in pairs and clusters respiratory culture final sparse growth oropharyngeal flora bcx x no growth ucx no growth radiology cxr ap lungs are clear heart size is normal and there is no evidence of appreciable pleural effusion et tube and right subclavian line are in standard placements respectively and a nasogastric tube passes below the diaphragm and out of view no pneumothorax cxr ap the et tube tip is cm above the carina the ng tube tip terminates in the stomach the right subclavian line tip is in the mid svc heart size is normal lungs are unremarkable no sizeable pleural effusion is identified cxr ap interval development of mild lower lobe interstitial pulmonary edema findings were discussed with dr on date of exam at approximately p m cxr ap impression no chf or pneumonia satisfactory endotracheal tube tip placement impression no pneumomediastinum support tubes and lines stable lungs clear brief hospital course impression plan yo female with copd flare s p intubation transferred secondary to concern for tracheomalacia s p stent by interventional pulmonary on copd initially admitted for exacerbation at osh and was intubated she was successfully extubated but reintubated due to tracheomalacia pt was transferred here vented and is s p ip stent placement with good resolution of tracheomalacia on she was continued on a steroid taper and nebulizer treatments in terms of weaning she was changed from ac to pressure support but had a lot of tachypnea likely secondary to a large anxiety component ativan was too sedating for her on hd she was able to be changed to pressure support and was weaned down she was successfully extubated on she required bipap for a short period of time on for increased wob but has been stable since then on l nc and comfortable she had pfts and a minute walk test with ip prior to discharge she remained stable on l nc baseline pt had several fever spikes during her first few days of hospitalization patient was pancultured without any obvious source cxr did not reveal evidence of pna sputum cultures here were mixed oropharyngeal flora the central line was d cd on hd when a picc was placed tip was sent to culture it is possible that the central line placed at osh was a potential source pt was on vancomycin and levaquin started on hd for a day course end she had no futher fever after transfer to the floor tachycardia and htn ekg showed sinus tachycardia which was attributed to severe anxiety she was started on iv metoprolol q hours which was required hd and then d cd her tachycardia is also likely albuterol nebs and dehydration ivf were given which helped her tachycardia to some degree patient was not symptomatic her tachycardia has improved since transfer to the floor she is baseline in the low s sinus tach with occasional bumps to the s with anxiety anxiety as above ativan was attempted but lead to severe somnolence lexapro was continued gerd continued protonix anemia baseline hct is there was evidence of extensive ecchymosis from lovenox sc on pt s lower abdomen labial area she was guaiac positive though hct remained stable ppi was increased to and this will need to be addressed as an outpt hypokalemia pt had mild hypokalemia noted on the day of discharge she was repleted with po kcl and lab rechecked it should be monitored intermittently while in rehab fen was on tubefeeds while intubated ppx pneumoboots insulin sliding scale as on iv steroids heparin sc not given ecchymosis was above pneumoboots were employed access rij placed d cd when picc was placed we d ced a line on code full medications on admission duonebs combivent ativan spiriva colace lovenox sc lexapro from celexa qday lasix iv prn last given insulin ss solumedrol mg pantoprazole iv propofol drip senakot tylenol prn ativan mg iv prn maalox prn zofran discharge medications docusate sodium mg capsule one capsule po bid times a day as needed fexofenadine mg tablet one tablet po bid times a day prednisone mg tablet as instructed tablet po once a day take tablets daily x days mg tablets daily x days mg tablets daily x days mg tablet daily x days mg and then tablet daily x days mg then stop disp tablet s refills escitalopram mg tablet two tablet po daily daily lansoprazole mg tablet rapid dissolve dr one tablet rapid dissolve dr po bid times a day guaifenesin mg ml syrup mls po q h every hours as needed albuterol sulfate mg ml solution one neb inhalation q h every hours as needed fluticasone salmeterol mcg dose disk with device one disk with device inhalation times a day guaifenesin mg tablet sustained release two tablet sustained release po bid tiotropium bromide mcg capsule w inhalation device one cap inhalation daily daily lorazepam mg tablet one tablet po q h every hours as needed for anxiety disp tablet s refills discharge disposition extended care facility discharge diagnosis tracheomalacia s p stenting copd pneumonia discharge condition stable discharge instructions you were hospitalized for tracheomalacia following intubation for copd you had a stent placed in your trachea by interventional pulmonology and will need to be carefully followed by them after your discharge you were also treated for pneumonia and will need to continue antibiotics as an outpatient until call your doctor or return to the emergency department if you experience any of the following worsening shortness of breath new cough chest pain or difficulty breathing fever any new or concerning symptoms followup instructions please follow up with the interventional pulmonology clinic one week following your discharge you will need to call for an appointment the number to call is please make an appointment to see you primary care provider after your discharge from rehab md [NEW_RECORD] admission date discharge date date of birth sex f service cardiothoracic allergies penicillins ceclor morphine oxycontin attending chief complaint tbm major surgical or invasive procedure tracheoplasty flexible bronchoscopy midline history of present illness ms is a year old woman who had had a copd flare requiring intubation in of this year she was unable to wean from the vent until a tracheal y stent was placed this was secondary to the observation of severe tracheobronchomalacia the patient noted that her overall level of functionality which had been reduced secondary to severe dyspnea on exertion was markedly better following placement of the y stent specifically in comparison to her preintubation level of performance despite her severe copd after multidisciplinary consideration of her case the recommendation to proceed with surgical tracheoplasty and bronchoplasty was made as her response to stenting was so profoundly good past medical history copd gerd depression pack year smoker social history lives at home with husband pack year hx quit in occ etoh family history mother died at from mi father died from etoh related physical exam general well appearing female in nad except ongoing dry cough heent unremarkable except for small amt residual sq air cor rrr s s abd large round soft nt nd bs extrem no c c e neuro intact w occas anxiety attack which reponds to ativan pertinent results am bronchial washings gram stain final per x field polymorphonuclear leukocytes per x field gram negative rod s per x field gram positive cocci in pairs and clusters respiratory culture final unable to r o other pathogens due to overgrowth of swarming proteus spp organisms ml oropharyngeal flora proteus mirabilis organisms ml trimethoprim sulfa sensitivity testing available on request aztreonam sensitive at mcg ml cxr pa and lateral chest radiographs the patient is status post removal of the right apical pleural drain after accounting for slight differences in patient positioning there is likely no change to small right apical pneumothorax again seen is a lateral component with an air fluid level the appearance of the right lateral hydropneumothorax is unchanged and probably partially loculated severe subcutaneous emphysema in the right thoracoabdominal wall and both sides of the neck may be slightly improved compared to the heart size is normal and no pneumomediastinum is evident on the current study the left lung is again hyperinflated but clear brief hospital course pt was admitted to the hospital on for bronchoscopy to eval for tbm and subsequent tracheoplasty pt underwent the following procedures flexible bronchoscopy tracheoplasty with mesh right mainstem bronchus and bronchus intermedius bronchoplasty with mesh left mainstem bronchoplasty with mesh right upper lobe apical wedge resection tracheoplasty or course wasuneventful post operatively pt had an epidural for pain control a right chest tube for pleural drainage and was admitted to the sicu for ongoing pulmonary assessment and care pt was d c d from the icu on pod she progressed quickly post operatively her chest tube and epidural were removed on pod subsequently she developed large amounts of sq air over the right chest back neck and face the sq air remained stable and slowly decreased over pod s on pod she had a bronch to eval her plasty prior to d c home and had a severe resp decompensation requiring icu admission a right anterior dart was placed for decompression of ptx it was presumed she had reactive airway rxn to the bronch and was treated w iv steriods and high flow oxygen she refused non invasive ventialtion d t severe anxiety she did well and transferred out of the icu on pod the dart was placed to water seal on pod w stable cxr she was on empiric levo vanco until bal from grew out proteus and she was started on meropenum at the time of discharge after consultation w id she was switiched to ertapenum to complete a day course of antibiotics total a midline was placed for home iv therapy the dart was d c d on pod w stable cxr medications on admission advair puff albuterol inh mg combivent puff spiriva mcg puff klonipin qhs lexapro mg discharge medications fluticasone salmeterol mcg dose disk with device one disk with device inhalation times a day albuterol ipratropium mcg actuation aerosol puffs inhalation q h every hours as needed tiotropium bromide mcg capsule w inhalation device one cap inhalation daily daily metoprolol tartrate mg tablet tablet po bid times a day dr will stop this medicine at your follow up appointment disp tablet s refills fexofenadine mg tablet one tablet po daily daily escitalopram mg tablet one tablet po daily daily senna mg tablet tablets po bid times a day as needed docusate sodium mg capsule one capsule po bid times a day clonazepam mg tablet one tablet po qhs once a day at bedtime as needed guaifenesin mg ml syrup mls po q h every hours as needed disp ml s refills albuterol sulfate mg ml solution one inhalation q h every hours as needed for shortness of breath wheezing lidocaine pf mg ml solution mls injection tidpc times a day after meals disp doses refills ertapenum one gm intravenous once a day for days disp days refills ranitidine hcl mg tablet one tablet po hs at bedtime disp tablet s refills albuterol sulfate mg ml solution one neb inhalation q h every hours as needed for shortness of breath wheezing disp doses refills hydromorphone mg tablet tablets po q h every hours as needed disp tablet s refills heparin flush heparin flush midline 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 discharge disposition home with service facility vna assoc of discharge diagnosis tbm stent placed removed copd pna gerd depression chronic inactive duodenitis s p appy tbm tracheoplasty discharge condition good discharge instructions call dr office if you develop chest pain shortness of breath fever chills productive cough difficulty breathing return of subcutaneous air or difficulty swallowing you may shower on wednesday after showering remove the chest tube site dressing and cover the area with a clean bandaid until healed complete your iv antibiotics as ordered followup instructions you have a follow up appointment with dr on at am in the chest disease center please arrive minutes prior to your appointment and report to the clinical cebter radiology for a chest xray completed by,{}
30983,admission date discharge date date of birth sex f service cardiothoracic allergies iodine latex attending chief complaint asymptomatic major surgical or invasive procedure redo thoracoabdominal aortic aneurysm repair history of present illness y o female who underwent thoracoabdominal aneurysm repair in for aneurysm and chronic type b dissection since that time she has been followed by serial chest ct scans for aneurysmal component of visceral patch she currently remains asymptomatic but last ct showed residual distal descending throracic aortic anuerysm which extends into visceral segment of abdominal aorta and aorto iliac bypass past medical history thoracoabdominal aortic aneurysm w type b dissection s p thoracoabdominal aortic aneurysm repair and aorto iliac bypass graft in hypercholesterolemia hypertension obstructive sleep apnea obesity s p partial hysterectomy s p tonsillectomy s p tubal ligation social history quit smoking yrs ago after pack year history occ etoh family history non contributory physical exam vs reg gen wdwn pleasant female in nad skin w d intact well healed thoraco abdominal incision heent eomi perrl ncat neck supple from jvd carotid bruit chest ctab heart rrr faint sem abd soft nt nd bs ext warm well perfused well healed left femoral incision neuro a o x mae non focal discharge exam vss t bp p r a general a o x nad heent at nc perrl wnl cvs rrr lungs cta abd bs soft nt nd ext warm neg c c trace edema right groin wound open with purulent drainage packed with dsd left thoracoabdominal incision with steri strips c d i pertinent results pm blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood glucose urean creat na k cl hco angap echo pre bypass 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 right ventricular chamber size and free wall motion are normal the descending thoracic aorta is markedly dilated there is evidence of intramural hematoma graft in the distal 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 post r heart bypass pt removed from partial r heart bypass on phenylephrine infusion and was in normal sinus rhythm valves as noted pre bypass no evidence of dissection in the ascending or distal aortic arch post decannulation or post graft placement radiology final report chest pa lat pm chest pa lat reason assess for effusions infiltrates medical condition year old woman s p thoracoabdm aaa repair reason for this examination assess for effusions infiltrates history postoperative aaa repair findings in comparison with study of there is little change increased opacification at the left base extending along the lateral chest wall is again seen the atelectatic streaks at the right base have cleared and the right lung shows no evidence of pneumonia picc line remains in place dr radiology final report cta chest w w o c recons non coronary pm cta chest w w o c recons non cta abd w w o c recons reason s p redo throcoabdominal abdominal aortic aneurysm medical condition throcoabdominal abdominal aortic aneursym reason for this examination s p redo throcoabdominal abdominal aortic aneurysm contraindications for iv contrast none history year old female with multiple thoracoabdominal aortic surgeries for reassessment technique ct of the chest abdomen and pelvis was performed without intravenous contrast followed by ct of the chest abdomen and pelvis post administration of intravenous contrast reconstructions were performed in the axial sagittal and coronal planes reconstructions were also performed in the d imaging lab comparison there is no prior examination at this institution comparison was made with the available outside study findings ct chest with and without intravenous contrast there is a left basal effusion with atelectasis most likely related to recent surgery there are scattered subcentimeter mediastinal lymph nodes there is no pericardial effusion ct abdomen with and without intravenous contrast there are bilateral renal hypodensities likely cysts there is hypoperfusion at the lower pole and the interpolar cortex of the left kidney suggestive of ischemia infarction the liver spleen adrenal glands and pancreas appear unremarkable the gallbladder is unremarkable there are scattered subcentimeter upper abdominal lymph nodes there is inflammatory change and fluid in the left upper quadrant abutting the spleen and the aortic graft most likely postoperative ct pelvis pre and post administration of intravenous contrast there is free fluid in the pelvis which may represent sequela of the recent abdominal surgery there are tubal clips seen in situ there is no pelvic lymphadenopathy there is colonic diverticulosis without evidence of diverticulitis musculoskeletal there is extensive subcutaneous edema along the left lower thoracic and abdominal wall most likely sequelae of recent surgery there are no worrisome bone lesions ct angiogram there is a bovine arch the patient has had multiple abdominal aortic operations the ascending aorta at the level of the right main pulmonary artery measures x mm and the descending thoracic aorta at the level of the left inferior pulmonary vein measures x mm there is no central or segmental pulmonary embolism or aortic dissection there has been a reanastomosis of the abdominal aortic branches the celiac trunk shows short segment focal stenosis with post stenotic dilatation the luminal diameter at the stenosis is x mm and the post stenotic luminal diameter is x mm the superior mesenteric artery is patent the inferior mesenteric artery fills in retrogradely the right and left renal arteries are patent the iliac vessels are diminutive in caliber although these are patent conclusion patent aortoiliac graft and abdominal vasculature with minimally short segment stenosis of the celiac artery with post stenotic dilatation as described above left basal effusion with atelectasis should be followed up with a chest ct to ensure resolution in two months areas of hypoperfusion in the left kidney are most likely ischemic there are multiple bilateral renal hypodensities likely cysts anasarca along the left chest and upper abdominal wall and fluid in the upper abdomen and the pelvis are most likely sequelae of the recent surgical intervention the study and the report were reviewed by the staff radiologist dr dr brief hospital course mrs was a same day admit after undergoing all pre operative work up as an outpatient on day of admission she was brought directly to the operating room where she underwent a redo thoracoabdominal aortic aneurysm repair please see operative report for surgical details following surgery she was transferred to the cvicu for invasive monitoring in stable condition infectious disease was consulted on post op day one following gpc found at anastomosis site of graft from prior aneurysm repair and she remained on vanocmycin patient remained intubated for several days as she was a difficult intubation and required significant fluid rescusitation but was eventually weaned from sedation and diuresed and awoke neurologically intact and was extubated on post op day three she received racemic epi and heliox for stridor which improved lumbar drain was removed on chest tubes were removed on post op day four and she was later transferred to the telemetry floor for further care it was decided that she receive week course of iv antibiotics due to findings from culture during surgery therefore on post op day five a picc line was placed over the next several days the patient remained in the hospital on iv antibiotics during this time she continued to have low grade fevers with no obvious source she was given a day course of cipro for proteus uti on pod her groin wound was noted to have purulent drainage it was opened debrided and packed with wet dry packing covered with dsd she was tranfused for hct ct scan showed no source of bleeding she continued to have daily low grade temperatures infectious work up was negative however eosinophils increased and she was switched from vancomycin to daptomycin fevers stopped on pod she was discharged home with vna medications on admission labetolol mg hctz mg qd prinivil mg qd zocor 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 oxycodone acetaminophen mg tablet sig tablets po q h every hours as needed for pain disp tablet s refills simvastatin mg tablet sig two tablet po daily daily disp tablet s refills vancomycin mg recon soln sig mg intravenous q h every hours for weeks wks from surgery continue thru disp qs weeks course mg refills metoprolol tartrate mg tablet sig one tablet po tid times 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 two tab sust rel particle crystal po once a day for weeks disp tab sust rel particle crystal s refills heparin lock flush unit ml solution sig qd and prn intravenous once a day 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 disp qs refills discharge disposition home with service facility home care vna in virginea discharge diagnosis thoracoabdominal aortic aneurysm s p thoracoabdominal aortic aneurysm repair in with visceral button aneurysm now s p redo thoracoabdominal aortic aneurysm repair pmh hypercholesterolemia hypertension obstructive sleep apnea obesity s p aorto iliac bypass graft s p partial hysterectomy s p tonsillectomy s p tubal ligation discharge condition good discharge instructions call with fever redness or drainage from incision or weight gain more than pounds in one day or five in one week shower no baths no lotions creams or powders to incisions no lifting more than pounds for weeks no driving until follow up with surgeon followup instructions dr in weeks md phone date time dr medical in va cardiologist dr pcp in va in weeks dr infectious diseases in va weeks completed by,{}
93823,admission date discharge date date of birth sex m service medicine allergies lisinopril hydrochlorothiazide attending chief complaint gi bleed major surgical or invasive procedure capsule endoscopy single balloon enteroscopy history of present illness this is a year old male with pmh of cad s p mi years ago pvd s p bilateral lower extremity bypass surgery with y graft in claudication and chronic kidney injury presenting in transfer from the icu at for further evaluation of gi bleeding he first presented to his primary care physician for further evaluation of claudication on routine lab work at that time revealed a hct of and he was referred for an outpatient egd colonoscopy at he received unit prbcs as an outpatient on and again on on the egd revealed an irregular z line suspicious for short segment barrett s esophagus he also had a non obstructing mild schatzki s ring with erythematous gastric mucosa and a normal duodenal bulb the colonoscopy showed old tarry blood in his colon and terminal ileum with non bleeding initernal hemorrhoids following this outpatient procedure he was referred for admission to for observation and received another unit of prbcs he received a total of units that week and remained hemodynamically stable throughout his hospital course given his chronic kidney insufficiency there was concern about administering contrast for a cta abdomen he was therefore referred to for further management and potential enteroscopy on arrival to the micu the patient had no acute complaints he has not had any bowel movements since his bowel prep for the colonoscopy on he reports that he noticed dark stools at home over the last couple of weeks but did not see any frank blood he thought that the change in his stool color was secondary to eating more black olives and chocolate cake recently past medical history cad s p mi in pvd s p bilateral lower extremity bypass with y graft in on coumadin claudication chronic kidney injury cva social history lives with his wife of years in a senior living housing complex in he is independent in his adls iadls he is retired since and used to manage a warehouse for a living his oldest son just passed away at age otherwise he has a daughter who is a nurse and a son who is he smoked ppd for years but quit years ago after his mi he does not have a history of alcohol or ivdu family history positive for cad mother passed away at age physical exam vitals t bp p r o ra general alert oriented no acute distress heent sclera anicteric mmm oropharynx clear eomi perrl neck supple cv regular rate and rhythm systolic ejection murmur noted 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 discharge exam vss gen patient lying comfortably in bed nad a ox heent mmm oropharynx clear neck supple no thyromegaly cv rrr no m r g resp ctab no w r r abd soft nt nd bs extr no le edema good pedal pulses bilaterally derm no rashes ulcers or petechiae neuro cn grossly intact non focal psych normal affect and mood pertinent results admission labs 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 calcium phosphate magnesium iron pm caltibc ferritin trf pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count pm pt ptt inr pt pm ret aut ekg normal sinus rhythm at with pvcs q waves in inferior leads suggestive of prior infarct egd irregular z line suspicious for short segment barrett s esophagus non obstructing mild schatzki s ring erythematous gastric mucosa normal duodenal bulb colonoscopy old tarry blood in colon and terminal ileum tortuous colon non bleeding internal hemorrhoids capsule endoscopy fresh blood is seen in a segment of the small bowel likely in the proximal to mid jejunum debris are seen in the lumen but an underlying mass lesion cannot be excluded a single lymphangiectasia is seen in the duodenum multiple venous structures are seen throughout the small bowel limited visualization of the stomach due to excessive debris single ballon enteroscopy normal esophagus normal stomach normal duodenum the distal jejunum was reached it was tattooed with indian ink there was a sharp angulation that prevented further advance of the scope otherwise the exam of the jejunum was normal no evidence of bleeding or mass was seen otherwise normal single balloon enteroscopy to distal jejunum under fluoroscopic guidance and with direct endoscopic view mr enterography preliminary reportimpression no mass lesion identified on this limited study cta is more sensitive for identifying occult gi bleeds and should be considered in this patient cholelithiasis without evidence of cholecystitis prior aortobifemoral bypass with some irregularity of the left common iliac graft this could also be further evaluated at the time of cta if required discharge labs am blood wbc rbc hgb hct mcv mch mchc rdw plt ct pm blood hct brief hospital course year old male with pmh of cad s p mi years ago pvd s p bilateral lower extremity bypass surgery with y graft in claudication and chronic kidney injury presenting in transfer from the icu at for further evaluation of gi bleeding on arrival to the micu the evening of the patient had no acute complaints he has not had any bowel movements since his bowel prep for the colonoscopy on he reports that he noticed dark stools at home over the last couple of weeks but did not see any frank blood he thought that the change in his stool color was secondary to eating more black olives and chocolate cake recently he remained hemodynamically stable throughout the micu course with hct at and was transferred to the general medicine service on just before transfer he received vitamin k mg po x on arrival he states that he feels well gi bleed source is likely small bowel patient reports weeks of dark stools prior to presentation but no brbpr egd shows gastritis likely short segment barrett s esophagus and mild schatzki s ring colonoscopy showed old tarry blood in colon and terminal ileum with a tortuous colon and non bleeding internal hemorrhoids hct stable on admission at after units of prbc transfusion since admission on at outside hospital initial hct was possibility of syndrome given that he has a murmur suggestive of aortic stenosis was transferred to the for capsule endoscopy which on revealed a lesion in the jejumum he received an additional units prbcs on for hct of he underwent single balloon enteroscopy which did not reveal a bleeding source since the enteroscopy his hematocrit has remained stable although he continues to have guaic stools he underwent an mre to evaluate for small bowel pathology which showed no masses although it could not be done with iv contrast his hct was slight downtrending on day of discharge but he was asymptommatic and he will have a close pcp follow up and call dr for double balloon enteroscopy he was discussed with gi who thought he was stable for discharge the patient will have a copy of his capsule endoscopy and balloon enteroscopy when he is discharged pcp f u on and then with dr hx of stroke year ago placed on coumadin with goal inr coumadin and asa were initially held prior to enteroscopy capsule endoscopy after discussion with the gi team primary team and family the patient was restarted on his asa mg and coumadin was held patient will f u with pcp coumadin should be held until bleeding source can be found ckd iii patient s admission creatinine is which has decreased slightly to after mr enterography a suggestion to have cta to evaluate for occult bleed was made by radiology but with pt already having enteroscopy and capsule endoscopy planned for a double balloon enteroscopy and concern for worsening his renal disease contrast induced nephropathy the ct scan was deferred he will follow up with gi for his bleed and pcp will u with ckd cad initially asa was held in setting of bleeding after enteroscopy asa was restarted statin was continued throughout his hospitalization medications on admission gemfibrozil mg po qhs furosemide mg po daily amlodipine mg po daily zetia mg po daily clonidine mg po bid asa mg coumadin mg tu th mg m w f sat pravachol mg per patient recently started pletal but has only taken one dose timolol drops each eye daily discharge medications gemfibrozil mg tablet sig one tablet po daily daily ezetimibe 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 colchicine mg tablet sig one tablet po daily daily as needed for gout flare pravastatin mg tablet sig four tablet po daily daily clonidine mg tablet sig two tablet po bid times a day timolol maleate drops sig one drop ophthalmic daily daily amlodipine mg tablet sig two tablet po daily daily aspirin mg tablet chewable sig one tablet chewable po daily daily discharge disposition home discharge diagnosis gi bleed 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 low blood counts from a gi bleed a single ballon enteroscopy was performed but could not find a source of the bleeding a capsule endoscopy and mr enterography were also performed but no clear source of bleeding was found you were transfused units of blood on and your blood counts increased appropriately on the day of discharge your blood counts had been stable for days and were slightly downtrending but you did not have any symptoms you will have a follow up with your primary care physician days and will also follow up with dr for a procedure to look for a bleeding source double balloon enteroscopy please stop taking coumadin because it could make your bleeding worse medication change stop taking coumadin hold your lasix until you are seen by pcp followup instructions name np location medical group address ste a phone appointment thursday am this is a follow up appointment for your hospitalization you will be reconnected with your primary care physician after this visit please contact dr office to set up your followup procedure double balloon enteroscopy,"{
""Diagnoses"": [""gi bleed"", ""barrett's esophagus"", ""schatzki's ring"", ""erythematous gastric mucosa"", ""non-obstructing mild schatzki's ring""],
""Medications"": [""lisinopril"", ""hydrochlorothiazide""]
}"
54794,admission date discharge date date of birth sex f service medicine allergies demerol attending chief complaint hemoptysis major surgical or invasive procedure none history of present illness yo previously healthy female beyond h o aspergillosis in treated with antimicrobials for at least one year by an infectious disease doctor nh dr she reports she has been feeling very well since then however developed cough approx days ago she reports daily episodes of a small amt of bloody sputum upon waking up in the morning but denies associated sx of fevers chills no brown yellow sputum no sob no chest pain she further denies other uri sx and she denies sick contactss she has been able to do a cardio workout at the gym without difficulty she called her id doctor who treated for aspergillus upon onset of her hemoptysis he recommended going to the er for further evaluation however she was concerned about inability to afford the copay for ed visit instead she provided sputum samples that apparently couldn t be processed because she did not refrigerate them last night she reports a coughing fit w more substantial episode of hemoptysis at home perhaps half cup of bright red blood she presented to hospital and coughed up cc of hemoptysis per report otherwise she nauseated all day due to anxiety no vomiting review of systems otherwise negative of note she reports multiple respiratory infections as child and through adulthood requiring antibiotics at least once yearly sometimes extended courses d t unsuccessful st course of rx she does not have asthma she denies any weight loss fevers night sweats she denies rashes uop has been normal nonbloody not foamy she has had multiple industrial exposures and reports she previously worked in factory making test tubes of fiberglass ovens used there contained asbestos but she reports she always wore appropriate protective mask respirator whenever required at work for the last years she has worked in a factory making computer chips with the chemical thixotropic she denies tb risk factors including no travel incarceration homelessness contacts ppd was placed years ago in the setting of hemoptysis and reportedly was negative she reports that years ago she developed hemoptysis in the setting of lung congestion she underwent bronchoscopy at that time and reports mds were initially concerned for tb tests however came back negative for this ppd and hiv reportedly negative at that time it was at that time that she was diagnosed instead with pulmonary aspergillosis she says that she was followed by id in and reports having taken pills daily for a year but she is unsure of the medication names as above she reports she has been doing well since then in the ed her vs were t bp hr rr o sat a pulmonology c s was requensted in the ed ppd placed in r forearm ct chest showed a cavitating lesion measuring cm with thick walls consistent with possible fungal infection labs revealed a normal hct and normal renal function she was in no respiratory distress ros the patient denies any fevers chills weight change nausea and poor appetite in setting of anxiety with hemoptysis no vomiting abdominal pain diarrhea constipation melena hematochezia steatorrhea chest pain shortness of breath orthopnea pnd lower extremity edema cough urinary frequency urgency dysuria lightheadedness gait unsteadiness focal weakness vision changes headache rash or skin changes past medical history pulmonary aspergillosis mycobacterium scofulacem treated in g p migraines gerd h o multiple ear surgeries tmj surgery episiotomy repair social history lives in with her daughter and boyfriend quit smoking several years ago and endorse approx packyear history prior to that very infrequent etoh only at special occasions no illicits works in factory as outlined above family history father had dm and died of mi brother had mi sisters all with dm sister had neck lung and ln cancer physical exam gen well appearing well nourished intermittently tearful due to anxiety 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 mild crackles lul however lungs o w clear without rhonchi wheezing 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 cn ii xii grossly intact strength and sensation to soft touch grossly intact skin no jaundice cyanosis or gross dermatitis no ecchymoses pertinent results admission labs am neuts lymphs monos eos basos am plt count am pt ptt inr pt am wbc rbc hgb hct mcv mch mchc rdw am albumin am alt sgpt ast sgot ld ldh alk phos tot bili am glucose urea n creat sodium potassium chloride total co anion gap am hct pm hct pm potassium 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 am sputum source expectorated gram stain final pmns and epithelial cells x field per x field multiple organisms consistent with oropharyngeal flora quality of specimen cannot be assessed respiratory culture final sparse growth oropharyngeal flora aspergillus fumigatus id performed on corresponding fungal culture fungal culture preliminary aspergillus fumigatus acid fast smear final no acid fast bacilli seen on direct smear this is only a preliminary result if ruling out tuberculosis you must wait for confirmation by concentrated smear due to duplicate specimen concentrated smear not available acid fast culture final test cancelled patient credited duplicate specimen specimen combined with sample v multiple specimens collected on different days are recommended for optimal recovery of mycobacterium species cta chest impression no evidence of pulmonary embolism within a segmental or large subsegmental branch scattered centrilobular nodules with bronchiectasis in the left lower lobe and lingula these findings can be consistent with aspergillus infection although there is no convincing evidence for invasive aspergillosis the presence of nodules suggest an active endobronchial process and developing mycetomas within bronchiectatic segments cannot be excluded particularly in the left base brief hospital course ms is a yo female with hx of treated aspergillosis who presents now with hemoptysis hemoptysis upon admission to the the source was almost certainly pulmonary based on ct findings pt w hx of aspergillosis mycobacterium scofulaceum with unknown risk factors cavitary lesion on ct scan may be consistent with recurrence of aspergillosis m scofulaceum also w bronchiectasis the differential of the cavitary lung lesion included tb other fungal infxn malignancy autoimmune wegener s or bacterial infection initially she was started on azithromycin and ceftriaxone for empiric pna coverage her prior work up was all at outside hospitals hiv was repeated here and was negative cultures from were obtained from and which showed mssa growth thus the pt was sent home with a day prescription of levofloxacin a beta glucan was sent and came back positive after the pt s discharge aspergillus galactomannan antigen was negative however after her discharge when aspergillus studies came back positive results were faxed to her pcp at at time of discharge pt was ambulating well without desaturation or hemoptysis hct was stable at ppd was placed and read here and was negative coagulopathy very mildly elevated inr to no history of easy bleeding bruising no known h o liver dz and no lfts in our system nutritional seems unlikely to be contributing significantly to above bleeding pt s lfts and coags were monitored in house and she recieved vit k prior to discharge gerd continued ppi pantoprazole while in house prevacid as outpatient medications on admission prevacid fioricet benadryl discharge medications levofloxacin mg tablet sig three tablet po daily daily for days disp tablet s refills guaifenesin mg ml syrup sig mls po q h every hours as needed disp bottle refills prevacid mg capsule delayed release e c sig one capsule delayed release e c po once a day discharge disposition home discharge diagnosis primary diagnosis pneumonia secondary diagnosis allergic rhinitis discharge condition good stable o sat while walking hemoptysis resolved discharge instructions you were admitted because you were coughing up blood while you were here we determined that you have a lung infection most likely not from tb but from a common bacteria called mssa a type of staph to treat this we put you on days of levofloxacin please continue this medication until it runs out also please continue the guaifenesin as needed for cough please follow up with your primary care doctor dr in the next week also please see your infectious disease doctor in the next wks either your pcp or your id doctor should refer you to a pulmonary doctor to follow up if you have worstening cough fever cough productive of blood shortness of breath chest pain or any other concerning symptoms please return to the hospital or call your doctor followup instructions please follow up with your primary care doctor dr in the next week also please see your infectious disease doctor in the next wks either your pcp or your id doctor should refer you to a pulmonary doctor to follow up we also recommend you talk to your id physician or pulmonologist about getting repeat ct scan in months you should also talk to your pulmonologist about getting pulmonary function tests during the change in seasons when your symptoms are at their worst completed by,"{
""Diagnoses"": [""Aspergillosis""],
""Medications"": [""Demerol""]
}"
15926,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 coronary artery bypass grafting x with a left internal mammary artery graft to the left anterior descending and reverse saphenous vein graft to the ramus intermedius branch first diagonal branch and left ventricular branch history of present illness this is a year old male with a week history of intermittent chest pain his anginal episodes would last approximately minutes and resolve spontaneously on the day of admission he experienced rest pain associated with left arm numbness he denied sob syncope presyncope nausea vomiting and diaphoresis he sought medical attention at the while in the ew his chest pain was relieved with sublingual nitro and morphine his first set of cardiac enzymes were negative he was subsequently admitted for further evaluation and treatment past medical history active smoker ppd for years hypercholesterolemia history of spontaneous bilateral pneumothoraces s p pleurodesis hemorrhoids polypectomy social history active smoker pack year history admits to several alcoholic drinks per day he works as a consultant he lives with a male partner family history unknown patient adopted physical exam vitals bp hr rr sat ra general well developed male in no acute distress heent oropharynx benign neck supple no jvd heart regular rate normal s s no murmur lungs clear bilaterally abd soft nontender ext warm no edema pulses distally no carotid femoral bruits neuro nonfocal pertinent results 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 mg brief hospital course mr was admitted and ruled out for a myocardial infarction the following day he underwent stress testing which was notable for ischemic ecg changes with angina nuclear imaging revealed severe and reversible anterior wall defects extending from the apex to the mid chamber and a moderate reversible defect in the inferior wall most notable in the mid chamber there was global hypokinesis with apical akinesis there was ischemic dilatation with an end diastolic volume of ml the left ventricular ejection fraction was subsequent cardiac catheterization showed a right dominant system with severe three vessel disease left venriculography showed a preserved ejection fraction of with mild anterolateral hypokinesis angiography showed that the lad had a long stenosis after the first septal extending to the origin of d the ramus had an ulcerated plaque in its proximal segment the circumflex had an ulcerated stenosis and was totally occluded after a large collateral to the rca the oms were small and occluded and the rca was occluded proximally and filled with l r collaterals based on the above results cardiac surgery was consulted and further evaluation was peroformed workup was essentially unremarkable and he was cleared for surgery on dr performed four vessel coronary artery bypass grafting within hours he awoke neurologically intact and was extubated without incident he weaned from inotropic support without difficulty he was transfused with prbc to maintain hematocrit near he maintained stable hemodynamics and transferred to the sdu on postoperative day two over several days medical therapy was optimized he responded well to lasix and by discharge was near his preoperative weight with oxygen saturations over on room air he remained in a normal sinus rhythm the rest of his postoperative course was routine and he was discharged to home on postopertive day four medications on admission none discharge medications 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 atorvastatin mg tablet sig one tablet po daily daily disp tablet 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 discharge diagnosis hypercholesterolemia hemorrhoids h o spontaneous bilateral pneumothorax s p pleurodiesis coronary artery disease s p cabg discharge condition stable discharge instructions shower wash incision with soap and water and pat dry no lotions creams powders or baths call with fever redness or drainage from incisions or wieght gain more than pounds in one day ro five in one week no lifting more than pounds or driving until follow up with surgeon followup instructions dr in weeks dr in weeks completed by,"{
""Diagnoses"": [""cardiothoracic"", ""coronary artery bypass grafting"", ""allergies"", ""no known allergies to drugs""],
""Medications"": [""sublingual nitro"", ""morphine""]
}"
10440,admission date discharge date date of birth sex f service neurology allergies sulfonamides attending chief complaint code stroke speech disturbance major surgical or invasive procedure none history of present illness yo woman with vascular rf s including cad htn dm high chol former smoker early family hx who presents five days after a lap ccy and ercp for abd pain and nausea with post operative confusion for several days per notes with acute onset dysarthria and aphasia at am according to note by neurologist at hosp where she had presented she had apparently c o headaches for several days prior to admission neuro exam revealed decreased level of consciousness inability to follow complex commands r visual field cut decr blink to threat r decreased sensation to pain and speech with frequent paraphasic errors that was intermittently fluent per notes the gi md about risks of tpa and benefits would outweigh risks despite recent surgery thus iv tpa given at pm for possible l mca infarct head ct at the time was neg and bp at osh initially was hr inr gluc iv tpa was given but soon into infusion pt c o severe bifrontal ha tpa was stopped and head ct was repeated neg for bleed apparently tpa was restarted and soon after pt c o abd pain tpa was again stopped and pt transferred to for further w u unfortunately we do not have records of how much tpa was given before onset of abd pain but we have bottle of remaining tpa which is full pt is quite inattentive and unable to provide further hx regarding nocturnal confusional states these were thought to be related to nightmares on osh record from patient reported to have nightmare and prior to admission falling out of bed after a similar episode at that point all narcotics including morphine percocet also ambien were discontinued unclear if an eeg was performed per osh neurologist rec d mg bolus then infused of bottle totaling approximately mg iv tpa past medical history chf high chol cad s p lad stent last stress now off plavix htn dm cri hypothyroid s p ccy and ercp d ago had p w incr lft s and abd pain migraines with confusion and temporary aphasia memory loss s p pet neg for ad melanoma s p resection l arm with lymph node dissection tah for bleeding gerd with schatzi ring bilat stapedectomy removal benign breast tumors s p mva social history lives with husband no and no etoh now but formerly smoked for yrs quit yrs ago former kitchen bath designer family history no strokes father had mi at age physical exam t bp hr rr o sat ra gen lying in bed left hand to forehead in mod distress heent nc at moist oral mucosa neck supple no carotid or vertebral bruit back no point tenderness or erythema cv rrr nl s and s sem lsb murmurs no gallops rubs lung clear to auscultation bilaterally abd bs soft diffuse tenderness no exudate or pus from incisions which are c d i ext no edema neurologic examination mental status drowsy cooperative but inconsistent with effort during exam and slight distress from headache oriented to person place and not to date attentive speech is fluent with normal comprehension and repetition naming intact no dysarthria partially intact registers recalls in minutes no right left confusion no evidence of apraxia or neglect cranial nerves pupils equally round and reactive to light to mm bilaterally visual fields are full to confrontation extraocular movements intact bilaterally no nystagmus sensation intact v v facial movement symmetric hearing intact to finger rub bilaterally palate elevation symmetrical sternocleidomastoid and trapezius normal bilaterally tongue midline movements intact motor normal bulk bilaterally tone normal no observed myoclonus or tremor no pronator drift tri wf we fe ff ip h q df pf te tf r l sensation intact to light touch intact throughout reflexes and symmetric throughout toes downgoing bilaterally coordination finger nose finger normal gait deferred discharge exam unchanged pertinent results admission labs na cl bun glc agap k co cr ck mb notdone trop t ca mg p alt ap ast urine benzos barbs opiates cocaine amphet mthdne negative wbc d hgb plt hct n l m e bas ua color yellow appear clear specgr ph urobil bili neg leuk neg bld neg nitr neg prot neg glu neg ket tr imaging cxr no evidence for acute cardiopulmonary abnormality including infiltrate or congestive heart failure abd ct impression status post cholecystectomy with stranding in the gallbladder fossa and right paracolic gutter but no fluid collection this appearance is likely consistent with postoperative change no hematoma vascular calcifications hypoattenuating foci in the liver and spleen which are not fully characterized here following acute illness when clinically feasible these findings should be evaluated with multiphasic post contrast imaging namely mr to characterize them further hct no hemorrhage carotid u s no stenosis of the right or left ica eeg abnormality brief multisecond bursts of moderate voltage polymorphic delta was seen from the left mid to posterior temporal region in waking some admixed slow wave theta of similar voltage amplitude was seen abnormality independent polymorphic slow wave theta was seen in brief bursts from the right mid to posterior temporal region rare associated delta was seen in conjunction abnormality brief several second bursts of moderate to moderately at times high voltage polymorphic delta and theta were seen with at times a bifrontal voltage predominance abnormality a slowed posterior background was seen with maximal hz activity seen bioccipitally background the anterior posterior voltage gradient was poorly preserved no frank epileptiform discharges were seen hyperventilation not performed intermittent photic stimulation no activation of the record sleep not obtained cardiac monitor no arrhythmias noted impression abnormal eeg due to bursts of slowing occurring independently from the l r mid to posterior temporal regions along with bursts of slowing occurring in a generalized fashion with at times a bifrontal voltage predominance and a slowed posterior background the record overall suggests a mild encephalopathy with superimposed increased irritability involving left and right posterior quadrants independently with some involvement as well as subcortical and deeper midline structures no frank epileptiform discharges were however seen tte the left atrium is normal in size left ventricular wall thickness cavity size and systolic function are normal lvef regional left ventricular wall motion is normal 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 without prolapse there is trivial mitral regurgitation there is an anterior space which most likely represents a fat pad though a loculated anterior pericardial effusion cannot be excluded abd u s small amount of echogenic material in the gallbladder fossa reflecting either a small hematoma comparable to findings on the prior ct as limited by differences in technique no intra or extrahepatic biliary ductal dilatation please note that this study cannot exclude cholangitis no ascites in the right upper quadrant cta head unremarkable cta of the head brief hospital course yo womam with multiple vascular risk factors and recent lap ccy ercp presented with acute dysarthria and aphasia per osh and s p iv tpa within hr window given her persistent headache and exacerbation of head and abdominal pain head and abdominal ct were performed which were negative for bleed head ct was also negative for signs of acute ischemia patient s exam improved from reports from outside hospital she was following commands and no longer had dysarthria or aphasia she apparently received mg of tpa a fraction of the wgt based dose she was supposed to receive due to worsening headache it is possible that she may have been experiencing a migraine which is associated with transient aphasia she had several episodes of confusion mostly at night accompanied by visual hallucinations which spontaneously resolved she was evaluated with carotid u s no stenosis cta normal tte good lvef and eeg see report as above she was monitored with hcts which were repeatedly normal she was initially observed in the icu where her course was complicated only by the confusion mentioned above and by brief episodes of chest pain resolving spontaneously without changes in ekg or cardiac enzymes otherwise she was also followed by the ercp team and had a ruq u s which was unremarkable per their recs she was treated with levofloxacin and flagyl for empiric gi coverage for her neuro status she was started on asa and lipitor she and her husband refused for her to be discharged to rehab so she was sent home with services medications on admission diovan mg tricor mg atenolol mg asa mg levothyroxine mcg dyrenium mg nexium insulin sliding scale 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 folic acid mg tablet sig one tablet po daily daily thiamine hcl mg tablet sig one tablet po daily daily cyanocobalamin mcg tablet sig tablet po daily daily aspirin mg tablet sig one tablet po daily daily disp tablet s refills atenolol mg tablet sig one tablet po daily daily disp tablet s refills oxycodone acetaminophen mg tablet sig one tablet po q h every to hours as needed lactulose g ml syrup sig thirty ml po tid times a day metronidazole mg tablet sig one tablet po tid 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 levothyroxine mcg tablet sig tablet 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 once a day disp tablet s refills discharge disposition home with service facility vna discharge diagnosis transient ischemic attack diabetes high cholesterol discharge condition stable walking steadily discharge instructions please take all medications as prescribed please keep all follow up appoiments please return to the nearest ed if symptoms worsen followup instructions provider m d phone date time md,"{
""Diagnoses"": [""stroke"", ""dysarthria"", ""aphasia"", ""headache"", ""cerebral infarction"", ""bleeding""],
""Medications"": [""tpa"", ""iv tpa"", ""bipolar"", ""gluc"", ""inr"", ""hr""]
}"
12008,admission date discharge date date of birth sex f service medicine allergies penicillins attending chief complaint stemi chest pain major surgical or invasive procedure cardiac catherization swan ganz catheter arterial line history of present illness f htn tobacco abuse h o pulmonary embolism neurofibromatosis alcohol abuse transferred to for cath from osh following diagnosis of stemi usual state of health until the morning prior to admission had substernal chest pain with nausea and diaphoresis patient waited hours however pain persisted and so she called ems who brought her to and was found to have st elevations in i ii v patient was transferred to for catheterization upon arrival to cath lab pressures were low s sbp total occlusion lad in om rca lad was stented w heparin coated stents x and reopro such that plavix could be dc d if needed in the setting of acute gi bleed following intervention patient dropped sbp to s and was started on dopamine drip w hr in s s and bolused w cc ns heparin was stopped and no additional iib iiia inhibitor given due to history of brbpr x few days and decreased hematocrit of note patient had brbpr by rectal exam in cath lab as well as at home on tissue no blood in toilet bowl at home no melena or hematemesis does have nausea and vomiting but able to tolerate liquids has lost pounds over last months patient has had claudication after walking feet sleeps on pillows for breathing past medical history neurofibromatosis hypertension pulmonary embolism malignant nerve sheath tumor s p removal from left anterior chest wall and radiation depression hypothyroidism pneumonia in hypercalcemia alcoholism schizoaffective disorder social history tobacco ppd alcohol quit years ago but history of abuse family history neurofibromatosis in multiple family members with history of early death physical exam ra general no acute distress lying in bed comfortable diffuse neurofibromas from head to toe cafe spots in axillae cv s s regular no murmurs rubs or gallops jvd not appreciable lungs ctab no wheezes rales or rhonchi abdomen active bowel sounds soft nt nd no rebound or guarding scar on left anterior chest wall extremities warm no clubbing cyanosis or edema dp and pt pulses bilaterally neuro alert and oriented x strength and sensation grossly intact walks with walker as per baseline pertinent results pm urine hours random pm urine bnzodzpn neg barbitrt neg opiates pos cocaine neg amphetmn neg mthdone neg pm type art po pco ph total co base xs pm o sat pm type mix pm o sat pm sodium potassium chloride pm asa neg ethanol neg acetmnphn neg bnzodzpn neg barbitrt neg tricyclic neg pm hct pm type art rates po pco ph total co base xs intubated not intuba pm k pm hgb calchct o sat pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm anisocyt microcyt pm plt count pm pt ptt inr pt pm type art po pco ph total co base xs intubated not intuba pm k pm o sat pm glucose urea n creat sodium potassium chloride total co anion gap pm ck cpk pm ck mb mb indx ctropnt ecg study date of pm baseline artifact sinus rhythm ventricular ectopy with ventricular couplets left axis deviation anterior q waves with a late transition consistent with prior anterior myocardial infarction diffuse non specific st t wave changes no previous tracing available for comparison c cath study date of selective coronary angiography of this right dominant system revealed multi vessel disease the lmca contained mild diffuse disease the lad was totally occluded after the first diagonal branch the lcx was without flow limiting disease but gave off an om branch with lesion the rca contained a proximal lesion resting hemodynamics revealed an elevated mean pcpw of mmhg with a low cardiac index of l min m left ventriculography was not performed successful ptca stenting of the proximal mid lad with x mm and x mm overlapping hepacoat stents final angiography revealed no residual stenosis no dissection and timi flow see ptca comments distal aortography revealed severe bilateral iliac and common femoral disease procluding the potential placement of iabp at completion of the case the patient s hct was noted to be down from at case start a rectal exam revealed gross blood the patient s blood pressure transiently dropped to sbp in the s but responded to fluid boluses blood transfusion and dopamine the patient left the lab hemodyamically stable on low dose dopamine echo study date of ef there is moderate to severe regional left ventricular systolic dysfunction with akinesis of the antero septum and entire distal lv including the apex the remaining segments are hyperdynamic no masses or thrombi are seen in the left ventricle 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 there is no aortic valve stenosis the mitral valve appears structurally normal with trivial mitral regurgitation the left ventricular inflow pattern suggests impaired relaxation the estimated pulmonary artery systolic pressure is normal there is an anterior space which most likely represents a fat pad with a superimposed trivial pericardial effusion there are no echocardiographic signs of tamponade brief hospital course f neurofibromatosis htn hypothyroidism recent pna transferred here w stemi revasc lad hypotension post intervention hypotension initially hypotensive in cath lab following procedure required initiation of dopamine then addition of levophed on hospital day of note ci was never low and svr was intermittently s s during episodes of hypotension svr increased appropriately with uptitration of pressors although this was physiology consistent with sepsis or adrenal insufficiency patient was never febrile cxr and pan cultures were negative and cosyntropin stimulation yielded appropriate secretion of cortisol rec d one unit of blood on hod for hct spontaneously weaned off of dopamine on hospital day without complications indeed patient became hypertensive to sbp s and was started easily on carvedilol and lisinopril at that point intermittently however patient continued to have episodes of asymptomatic hypotension while sleeping at night given this clinical picture patient s initial hypotension post stemi was thought to be secondary to cardiogenic shock despite swan ganz values and as patient s cardiac function recovered blood pressure improved appropriately acid base disturbance when patient arrived had ag of potassium of and abg suggesting a respiratory alkalosis w mixed gap and non gap metabolic acidemia this may have been due in combination to cardiogenic shock and volume repletion with saline rta type ii was felt to be a possibility and bicarb load was considered however this was not attempted given patient s cardiac issues and need for euvolemic status as patient s clinical status improved gap continued to close and bicarb normalized and other than hypotension early during course patient never had any signs or symptoms localizing metabolic disturbance of note patient s laboratory values often fluctuated within hours suggesting large fluid shifts intra extravascular of unclear etiology further cosyntropin stim revealed no adrenal insufficiency that would explain patient s condition given resolution without clear clinical etiology further workup of this issue was deferred to outpatient ischemia occluded lad reopened with hepacoat stents om and rca significant unrevascularized disease patient was started on asa plavix lipitor and carvedilol and lisinopril as hypotension resolved although further intervention could be pursued given high grade malignant peripheral nerve sheath tumor and multiple nodules noted on mri and ct at and it was felt that patient would be best served with workup and thorough staging and prognostic evaluation of malignancy to further determine utility of revascularization followup was arranged with dr in within one month of discharge pump ef bedside echo w anterior hypokinesis post cath hypotensive but weaning dopamine continue iv fluids for now wedge in lab as noted above as hypotension improved patient was started on carvedilol and lisinopril to improve cardiac remodeling rhythm while on dopamine patient was in continuous sinus tachycardia s s however patient did have one isolated episode nsvt x beat run with weaning of dopamine and uptitration of carvedilol patient s heart rate improved to s s at the time of discharge further consideration for prophylactic icd placement would pend revascularization of remaining vessel disease pvd severe iliac disease seen on cath as correlates with patient s baseline claudication can walk ft this was not intervened upon at the time of catheterization given patient s hemodynamic instability again further intervention of these lesions would depend upon patient s malignancy and prognosis brbpr following catheterization patient was noted to have brbpr and required one unit of packed red cells however following this acute episode patient had guaiac negative stools and no longer required any further transfusions it was recommended to the patient that she undergo outpatient colonscopy for further evaluation hypothyroidism tsh and free t patient was empirically started on mcg levothyroxine given history of noncompliance and unclear dose to reach euthyroid level patient intermittenly on mcg levothyroxine records on this patient was clinically euthyroid but would require followup thyroid function test evaluation following discharge communication extensive communication with son at the time of discharge patient was hemodynamically stable with no further episodes of chest pain or gi bleeding patient was to followup with oncologist for pet ct evaluation of malignant peripheral nerve sheath ca medications on admission toprol xl levoxyl albuterol discharge medications clopidogrel bisulfate 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 atorvastatin calcium 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 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 quetiapine fumarate mg tablet sig four tablet po hs at bedtime 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 albuterol mcg actuation aerosol sig puffs inhalation every hours as needed for shortness of breath or wheezing discharge disposition home with service facility health vna discharge diagnosis st elevation myocardial infarction malignant peripheral nerve sheath tumor hypothyroidism neurofibromatosis cardiogenic shock anorectal bleeding discharge condition good no further episodes of chest pain shortness of breath continued to have episodes of asymptomatic hypotension at night while sleeping discharge instructions please take all medications as directed followup instructions colonoscopy recommend followup colonoscopy given anorectal bright red blood to rule out malignancy as outpatient hypothyroidism recommend repeat thyroid function tests to monitor thyroid replacement oncology please follow up with dr at as scheduled on please go for your pet scan and ct of the chest and abdomen at as scheduled by dr office cardiology please follow up with dr at as scheduled on tuesday at am on the of hospital [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies penicillins colchicine bactrim attending chief complaint hypotension sob chest pressure major surgical or invasive procedure place of central venous catheter right ij history of present illness yo female with pmh significant for cad copd on home o l systolic hf with ef of pe and nf adrenal insufficiency due to chronic steroid use and hypothyroidism who presented to the ed with cp and sob in the ed initial vs were t p bp r o sat on l attempts at peripheral ivs failed she became hypotensive to rij placed for access cultures were drawn from the line she was given l ns without increase in bp levophed was started at and titrated up to and back to on transfer patient was given an additional l ns vancomycin g x and zosyn g x were given followed by levofloxacin mg iv x and flagyl mg iv x as well as solumedrol mg iv x her cvp was monitored initially increased to on levo she had low urine output with cc draining after placement of foley no voiding overnight her creatinine was up from vitals on transfer ra total uop of in the ed on the floor the patient reports chest pain which she states is not new for her she called an ambulance for chest pressure in the center of her chest she took all her morning meds but no sl nitro she reports this pain does not feel nearly as severe as the pain she had in the past with her mis she also reports while in the ambulance she felt like she could not take a complete breath in she reports she has a chronic non productive cough for the past days she s had loose stools but not she has pillow orthopnea and pnd she denies urinary sx jaw pain arm pain back pain sweatiness review of systems per hpi chronic cough denies fever chills headache sinus tenderness rhinorrhea or congestion denies shortness of breath or wheezing denies palpitations denies nausea vomiting constipation abdominal pain denies dysuria frequency or urgency denies rashes or skin changes past medical history coronary artery disease s p revascularization with stemi bms x in in and rca congestive heart failure with lvef moderate copd on home oxygen pulmonary embolism neurofibromatosis type malignant nerve sheath tumor s p removal from left anterior chest wall and radiation depression hypothyroidism adrenal insuficiency chronic steroid use for copd exacerbation hypercalcemia alcoholism per omr patient denies current etoh abuse schizoaffective disorder gout social history ms lives with her boyfriend in a trailer in boyfriend has mr to seizures she is on disability used to work as a nursing aide she is no longer taking stray cats no other pets tobacco quit smoking in past few months smoked for years etoh drink a week drugs none at last admission the patient was screened for inpatient rehab but could not afford co pay and was not accepted at state facilities the patient was discharged with home nursing home physical therapy and follow up family history mother sister nephew son with neurofibromatosis father w copd sister w copd mother w asthma mother died of mi at age father died of mi at age physical exam vitals t bp p r o ra general alert oriented no acute distress heent mmm oropharynx clear neck supple jvp difficult to assess given large neck lungs expiratory wheeze in right lower lung and mild crackles in right lung base cv distant heart sounds no appreciated murmur abdomen soft obese non tender non distended bowel sounds present no rebound tenderness or guarding ext warm hand mildly cold feet dp pulses no edema skin diffuse neurofibromas pertinent results admission labs pm wbc rbc hgb hct mcv mch mchc rdw plt ct pm pt ptt inr pt pm glucose urean creat na k cl hco angap pm calcium phos mg pm k pm lactate transfer labs am wbc rbc hgb hct mcv mch mchc rdw plt ct am glucose urean creat na k cl hco angap pm calcium mg cardiac biomarkers pm ctropnt pm ck mb ctropnt am ck mb ctropnt probnp urine pm urine hours random urean creat na k cl pm urine neg nitrite neg protein tr glucose neg ketone neg bilirub neg urobiln neg ph leuks neg pm urine color yellow appear hazy sp pm urine rbc wbc bacteri few yeast none epi imaging portable tte focused views done at pm conclusions porr image quality the left atrium is mildly dilated left ventricular wall thicknesses are normal the left ventricular cavity size is normal overall left ventricular systolic function is probably mildly depressed lvef distal lv apical akinesis to dyskinesis is suggested a left ventricular mass thrombus cannot be excluded there is no ventricular septal defect the aortic root is mildly dilated at the sinus level there is no aortic valve stenosis no aortic regurgitation is seen no mitral 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 the lvef appears improved if indicated a repeat tte with echo contrast definity or cardiac mri may better assess regional global lv systolic function and exclude apical thrombus chest x ray study date of am right internal jugular line tip is at the level of mid low svc cardiomediastinal silhouette is stable but there is new consolidation in the left lower lung worrisome for interval progression of infectious process loculated pleural effusion along the left pleural surface is unchanged right basal consolidation has slightly improved in the interim bilat lower ext veins study date of am impression limited assessment of the calf veins without evidence of dvt microbiology pm urine site clean catch urine culture final gram positive bacteria organisms ml alpha hemolytic colonies consistent with alpha streptococcus or lactobacillus sp clostridium difficile toxin a b test final feces negative for c difficile toxin a b by eia reference range negative brief hospital course sirs sepsis septic shock most likely etiology of her shock was sepsis secondary to pneumonia she had a low grade fever with hypotension and an elevated white count she initialy required low doses of levophed and placed on stress dose steroids after initial broad coverage her antibiotics were switched to levofloxacin with course completed before discharge congestive heart failure systolic acute on chronic likely produced in the setting of acute illness with ivf administration improved with furosemide diuresis coronary artery disease and chest pain had intermittant chest pains which were somewhat different from her chronic chest pain troponins were checked and ecg was unchanged from her prior she was continued on her home regimen including aspirin clopidogrel metoprolol initially held and lisinopril initially held acute on chronic renal failure creatinine on and was on admission this was all likely pre renal in the setting of hypotension she was volume resuscitated with l and her creatinine normalized to prior to transfer to the floor also of note she recently had ain thought due to bactrim her ace i was held and then resumed on the floor her cr normalized to while on the floor neurofibromatosis type history of malignant nerve sheath tumor s p removal from left anterior chest wall and radiation stable no new manifestations innumerable fibromas on exam hypothyroidism tsh of free t normal continued mcg po daily medications on admission aspirin mg po daily clopidogrel mg po daily rosuvastatin mg po daily fluticasone salmeterol mcg dose po bid metoprolol succinate mg po daily docusate sodium mg po bid senna mg po bid as needed for constipation bisacodyl mg tabs po daily prn constipation levothyroxine mcg po daily tiotropium bromide mcg daily albuterol sulfate mg ml solution every hrs as needed for sob wheeze zyrtec mg po daily omeprazole mg po daily percocet mg tab po every hours nitroglycerin mg tablet sublingual sig one sublingual once a day as needed for chest pain repeat x if need more than once call your physician prednisone mg po daily vitamin d unit daily multivitamin po daily nicotine mg hr patch daily atovaquone mg ml suspension sig ten ml po once a day new med lasix mg tablet po once a day lisinopril mg po daily ranitidine po bid rx bottles brought in by boyfriend discharge medications aspirin mg tablet sig one tablet po daily daily clopidogrel mg tablet sig one tablet po daily daily rosuvastatin mg tablet sig one tablet po daily daily fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation 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 bisacodyl mg tablet delayed release e c sig two tablet delayed release e c po daily daily as needed for constipation levothyroxine mcg tablet sig two tablet po daily daily ipratropium bromide mcg actuation hfa aerosol inhaler sig two puff inhalation qid times a day albuterol sulfate mg ml solution for nebulization sig one inhalation q h every hours as needed for sob wheeze omeprazole mg capsule delayed release e c sig two capsule delayed release e c po daily daily oxycodone acetaminophen mg tablet sig one tablet po q h every hours as needed for pain cholecalciferol vitamin d unit tablet sig tablets po daily daily multivitamin tablet sig one tablet po daily daily prednisone mg tablet sig one tablet po daily daily atovaquone mg ml suspension sig two ml po daily daily bismuth subsalicylate mg tablet chewable sig two tablet po tid times a day as needed for diarrhea lisinopril mg tablet sig one tablet po daily daily ferrous sulfate mg mg iron tablet sig one tablet po bid times a day metoprolol tartrate mg tablet sig two tablet po bid times a day ipratropium bromide solution sig one inhalation q h every hours as needed for shortness of breath or wheezing insulin lispro unit ml solution sig as directed subcutaneous asdir as directed furosemide mg tablet sig one tablet po bid times a day percocet mg tablet sig one tablet po every six hours as needed for pain discharge disposition extended care facility nursing and rehabilitation discharge diagnosis bacterial pneumonia sirs sepsis septic shock acute on chronic systolic congestive heart failure acute renal failure copd 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 with low pressure high white cell count hypoxia low oxygen levels and acute renal failure you were admitted to the intensive care unit and treated for a presumed pneumonia you were also treated on the medical floor for congestive heart failure your kidney function recovered it will be important for you to record your weight frequently to get a sense of how much fluid you have in your body followup instructions rehabilitation will coordinate follow up with your primary care doctor [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies penicillins colchicine bactrim attending chief complaint dyspnea major surgical or invasive procedure none history of present illness ms is a year old female with a history of neurofibromatosis copd on l home o systolic hf pe adrenal insufficiency due to chronic steroids who was transferred to the micu from the ed for management of dyspnea and evaluation of high lactate of note she has been admitted times just in the past year this am she reports chest heaviness pressure no radiation also with sob and difficulty expiring air she took some nebs this morning with only a teeny amount of response and notes she usually takes nebs at a noon p p p she thinks the exacerbating factor was a hot shower this morning initial vitals in the ed were t hr bp rr sat l nasal cannula she had a leukocytosis to with neutrophils her lactate trended from to while in the ed but was down to by tranfer antibiotics received in the ed includes azithromycin mg po once and levofloxacin mg iv once narcotics administered in the ed included oxycodone mg po once and morphine mg iv twice she also recieved aspirin mg several nebulizer treatments and solumedrol mg iv of note she is in the middle of a steroid taper was down to mg daily ekg twi in avl unchanged from previous the morphine was administered for chest pain that occurred at some point in the ed first set of troponins were negative and ekg was unremarkable due to difficult stick and elevated lactate a rij cvl was placed her lactate was then noted to go from to just before admission to micu she had a recent admission to from to for evaluation of chest pain and presyncope which were thought to be non cardiac in origin copd vs musculoskeletal she was treated for a copd exacerbation with a steroid taper she had been taking prednisone mg daily currently she was also treated for c diff which was confirmed by pcr in a prior admission and she completed a course of po vancomycin past medical history coronary artery disease s p revascularization with stemi bms x in in and rca congestive heart failure with lvef moderate copd on home oxygen pulmonary embolism neurofibromatosis type malignant nerve sheath tumor s p removal from left anterior chest wall and radiation depression hypothyroidism adrenal insuficiency chronic steroid use for copd exacerbation hypercalcemia alcoholism per omr patient denies current etoh abuse schizoaffective disorder gout c diff colitis recurred social history ms lives with her boyfriend in a trailer in ma boyfriend has mr secondary to seizures she is on disability used to work as a nursing aide is visited x week by vna tobacco quit smoking in past weeks smoked for years etoh reports drink a week drugs denies ivdu family history mother sister nephew son with neurofibromatosis type i father w copd sister w copd mother w asthma mother died of mi at age father died of mi at age physical exam admission physical exam vs p l nc short obese woman in no distress conversant and speaking full sentences without difficulty has obvious fleshy colored papules covering her entire body consistent with known nf eomi sclera clear eyes are squinting can t guage jvd poor air movement but no obvious crackles wheezes or rhonchi almost inaudible s s likely due to habitus no m g abd obese nt nd benign no ble edema noted extrems are warm well perfused cn no focal neuro deficits noted discharge physical exam vs l nx general obese woman sitting in bed conversant and speaking in full sentences neck no jvd appreciated neck is supple and without lad resp good air movement faint inspiratory bibasilar crackles no wheezes or rhonchi cardio nml s s no murmurs rubs or gallops appreciated abdomen obese non tender non distended normoactive bowel sounds present extremities mild non pitting upper and lower extremity edema skin flesh colored cm nodules over entire body consistent with known nf ecchymoses over sites of trauma and injections on all limbs neuro pertinent results admission labs pm glucose urean creat na k cl hco angap am calcium phos mg pm wbc rbc hgb hct mcv mch mchc rdw plt ct pm alt ast alkphos totbili pm lipase pm ctropnt am ctropnt am ck mb ctropnt pm po pco ph caltco base xs pm lactate pm lactate pm lactate am lactate am lactate pm lactate am lactate discharge labs am glucose urean creat na k cl hco angap am calcium phos mg am wbc rbc hgb hct mcv mch mchc rdw plt ct cxr suspect underlying emphysema no acute pulmonary process identified within limitations cxr in comparison with study of there has been placement of a right ij catheter that extends to the mid to lower portion of the svc no evidence of pneumothorax bibasilar areas of opacification could reflect merely atelectasis and small effusions in the appropriate clinical setting however the possibility of supervening pneumonia would have to be considered cxr in comparison with the study of earlier in this date the questioned opacification at the right base is less prominent and may merely represented fortuitous overlap of normal pulmonary vessels leni no evidence of deep venous thrombosis involving the left lower extremity slightly dampened respiratory variation within the left venous system however this is likely due to compression from the patient s pannus which was asymmetrically positioned overlying the left groin brief hospital course year old female with a history of copd on l home o with multiple recent admissions for copd exacerbation neurofibromatosis systolic hf with ef pe history of adrenal insufficiency due to chronic steroids initially transferred to the micu for management of dyspnea and elevated serum lactate transferred to floor without intubation and o sat prior to discharge with normalized lactate copd exacerbation patient presented from home with dyspnea with o sat on l and tight non radiating chest pain her last outpatient pfts on with fev fvc of and fev of predicted with dlco indicating moderate to severe disease she was continued on oxygen via nasal canula with stable o saturation on l she was treated with standing albuterol nebulizer treatments high dose prednisone and antibiotics on hd per the request of her outpatient pulmonologists she underwent supine and upright spirometry to evaluate for diagphragmatic weakness given previous reduced mips meps but the session was terminated prematurely due to chest pain later felt to be musculoskeletal she was discharged with the plan to continue prednisone mg qday along with albuterol fluticasone salmeterol and tiotropium inhalers and nitrofurantoin for a day course until prednisone dosing will be re evaluated at outpatient clinic and at pcp will reschedule testing as an outpatient uti patient treated for uti with symptoms of polyuria and dysuria started on day course of levofloxacin for complicated uti given history of immune suppression uti treatment with levofloxacin was concurrent with treatment for copd final urine cultures returned as e coli resistant to levofloxacin so patient was started on day course of nitrofurantoin until elevated lactate serum lactate with high of on which normalized with ivf initial elevation was likely secondary to dehydration upon presentation abg was not acidotic with ph and pco low pressures patient with sbp in low s and remained in range with holding home lisinopril and metoprolol on discharge sbp not orthostatic by vitals nor symptomatic and hct stable has h o adrenal insufficiency but already on higher dose prednisone we continued to hold metoprolol and lisinopril on discharge they should be restarted on an outpatient basis as tolerated recurrent chest pain the patient endorsed chronic chest tightness myocardial infarction was ruled out with no ekg changes and negative cardiac enzymes x repeat ekgs at time of pain showed no change from baseline given reproducible tenderness to palpation this was felt to be musculoskeletal v tightness from copd exacerbation she was pain free on discharge history adrenal insufficiency chronic steroid use for copd exacerbation patient was begun on steroid taper with mg x and mg x then dose increased to mg qday given worsening of symptoms with plan for prednisone taper she was continued on atovaquone ppx and vitamin d calcium supplementation coronary artery disease s p revascularization with stemi bms x in in and rca patient was continued on home anticoagulants mg qday rosuvastatin mg qday and clopidogrel mg qday home beta blocker and ace i held on discharge but should be restarted as bp tolerates congestive heart failure with lvef creatinine upon admission was elevated to but at time of discharge was lasix was continued at home dosage of mg qday and spironolactone was continued at mg qday home metoprolol and lisinopril were held in the setting of relative hypotension sbp hypothyroidism patient was currently asymptomatic and well controlled throughout admission was continued on home dose of levothyroxine recent c diff infection patient has history of two recent c diff infections completing po vancomycin course she was started on po vancomycin for prophylaxis secondary to receiving levofloxacin as risk factor for recurrent infection discharged with plan to continue po vancomycin until end of day course of levofloxacin ambulation patient is ambulatory at home was evaluated by pt during admission and was found to be weak and at times have right knee pain that limited ambulation she states that she fell from bed approximately month ago and has had knee pain that has not limited ambulation since she fell physical exam was notable for positive right knee medial joint line tenderness without swelling erythema or effusion the patient consented to home pt evaluation issues for outpatient management determination of prednisone taper and maintenance dose pressure monitoring and restarting metoprolol and lisinopril as tolerated medications on admission calcium carbonate mg calcium mg tablet chewable two tablet chewable po bid times a day atovaquone mg ml suspension sig ten ml po daily lisinopril mg po daily daily furosemide mg po bid oxycodone mg tablet po every four hours as needed for pain albuterol sulfate neb q h prn sob wheezing ferrous sulfate mg mg iron po daily daily loperamide mg capsule po tid prn diarrhea vancomycin mg po q h to be completed gabapentin mg capsule po q hr prednisone mg tablet pills mg total pills mg total pill mg total pill mg total metoprolol tartrate mg po bid discharge medications fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day oxycodone mg tablet sig one tablet po q h every hours as needed for pain clopidogrel mg tablet sig one tablet po daily daily aspirin mg tablet sig one tablet po daily daily omeprazole mg capsule delayed release e c sig two capsule delayed release e c po daily daily levothyroxine mcg tablet sig one tablet po daily daily rosuvastatin mg tablet sig one tablet po daily daily multivitamin tablet sig one tablet po daily daily tiotropium bromide mcg capsule w inhalation device sig one cap inhalation daily daily calcium carbonate mg calcium mg tablet chewable sig one tablet chewable po bid times a day atovaquone mg ml suspension sig one po daily daily vancomycin mg capsule sig one capsule po q h every hours for days capsule s refills gabapentin mg capsule sig one capsule po q h every hours spironolactone mg tablet sig tablet po daily daily furosemide mg tablet sig tablet po daily daily prednisone mg tablet sig two tablet po daily daily for days tablet s refills nitrofurantoin monohyd m cryst mg capsule sig one capsule po bid times a day for days capsule s refills loperamide mg capsule sig one capsule po tid prn ferrous sulfate mg mg iron tablet sig one tablet po once a day cholecalciferol vitamin d unit tablet sig one tablet po once a day albuterol sulfate mg ml solution for nebulization sig one nebulizer inhalation am am pm pm pm qday as needed for shortness of breath discharge disposition home with service facility health systems discharge diagnosis primary diagnosis copd exacerbation secondary diagnoses urinary tract infection systolic heart failure exacerbation discharge condition mental status clear and coherent level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair o saturation on l at rest with ambulation discharge instructions you were admitted to for shortness of breath you were taken to the intensive care unit for close monitoring and then you were brought to the medicine service during your time here you were treated with antibiotics an increased dose of steroids prednisone and nebulizer medications for your breathing you will discuss your steroid taper at your clinic appointment you were also diagnosed with a urinary tract infection and treated with antibiotics for this you had several episodes of chest tightness with shortness of breath which we evaluated with imaging of your chest chest x ray and heart ekg and telemetry which were negative for heart attack you also had imaging of your legs to look for clots leni which was negative as well you had diarrhea so we sent your stool to look for c difficile an type of infection that you had before that test is still pending at the time of your discharge from the hospital but your diarrhea has resolved on the last two days of your hospital stay your pressure was lower running so we held your pressure medications metoprolol and lisinopril when you left the hospital because you have a history of heart failure we recommend that you follow up closely with your primary care physician to discuss these changes as well as your increased dose of prednisone to monitor your heart condition please weigh yourself every morning md if weight goes up more than lbs the following changes were made to your medications we stopped metoprolol we stopped lisinopril we increased prednisone we started nitrofurantoin ends for urinary tract infection we started vancomycin while on nitrofurantoin ends followup instructions you have an appointment in the clinic please discuss your prednisone dose department medical specialties when thursday at pm with m d building campus east best parking garage you will need a breathing test before this appointment please call the office for the time of your breathing test it is important for you to follow up with your primary care physician to review the changes made to your medications you have an appointment scheduled for your upcoming appointment with dr on department when wednesday at pm with md building sc clinical ctr campus east best parking garage md [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies penicillins colchicine bactrim attending chief complaint altered mental status major surgical or invasive procedure none history of present illness y o f with pmh of nf copd on l home o adrenal insufficiency chronic steroid use presents from hospital with altered mental status fevers and increased oxygen requirement patient was recently discharged from hospital hrs ago to rehab facility today at rehab found to be desatting to on l and possibly more confused temperature in am she was sent to ed for further evaluation ua there grossly positive althoguh and cxr concerning for pneumonia she also had head ct and lp with wbc she was given vancomycin and ertapenem at pm given l ns and transported to for further management in the ed at initial vs were l exam notable for labs notable for wbc of no bands hct baseline low thirties sodium of anion gap of lactate creatinine baseline calcium alk phos low s previously ast ua showed wbc w moderate bacteria urine and cultures obtained cxr showed left lower lobe consolidation mild alveolar edema possible small left pleural effusion patient was given hydrocortisone mg iv given recently completed steroid taper given l ivf vitals on transfer l and g for access on arrival to the icu patient was somnolent but rousable responded to voice but non cooperative for examination history taking vitals were l review of systems unable to obtain from patient given somnolence she denied any pain past medical history coronary artery disease s p revascularization with stemi bms x in in and rca congestive heart failure with lvef moderate copd on home oxygen pulmonary embolism neurofibromatosis type malignant nerve sheath tumor s p removal from left anterior chest wall and radiation depression hypothyroidism adrenal insuficiency chronic steroid use for copd exacerbation hypercalcemia alcoholism per omr patient denies current etoh abuse schizoaffective disorder gout c diff colitis recurred social history ms lives with her boyfriend in a trailer in ma boyfriend has mr secondary to seizures she is on disability used to work as a nursing aide is visited x week by vna tobacco quit smoking in past weeks smoked for years etoh reports drink a week drugs denies ivdu family history mother sister nephew son with neurofibromatosis type i father w copd sister w copd mother w asthma mother died of mi at age father died of mi at age physical exam admission pex vitals l general obese multiple neurofibromatoses all over face body somnolent but rousable unable to cooperate with examination heent small oral orifice dry appearing mouth neck supple jvp not elevated no lad lungs bilateral basal crackles no wheeze appreciated but patietn unable to take deep breaths 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 foley with dark urine in bag ext warm well perfused pulses no clubbing cyanosis or edema discharge pex pertinent results labs on admission 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 pm alt ast ld ldh alkphos totbili pm lipase pm albumin calcium phos mg pm tsh pm t t am type po pco ph caltco base xs am type art po pco ph caltco base xs pm glucose lactate na k cl calhco am freeca pm urine color yellow appear cloudy sp pm urine lg nitrite pos protein glucose neg ketone neg bilirub neg urobiln neg ph leuks lg pm urine rbc wbc bacteri mod yeast none epi pm urine casthy castwbc pm urine mucous many am urine eos positive am urine bnzodzp neg barbitr neg opiates pos cocaine neg amphetm neg mthdone neg am urine u pep pnd osmolal am urine hours random urean creat na k cl totprot hco less than prot cr brief hospital course y o f with pmh of neurofibromatosis copd on l home o adrenal insufficiency chronic steroid use presented from hospital with altered mental status fevers and increased oxygen requirement urinary tract infection patient completed a course of meropenem days ending for a citrobacter ecoli uti her foley catheter was removed pneumonia cxr findings suggestive of left lower lobe consolidation with mild alveolar edema and small left pleural effusion however these findings appear only marginally changed from prior received iv vancomycin levaquin and meropenem empirically patient is allergic to penecillins iv vancomycin and levaquin were discontinued when cxr findings resolved with diuresis metabolic encephalopathy likely related to infection uremia hypercalcemia osh ct head was negative lp showed wbcs only so not likely cns source tox screen was negative electrolyte abnormalities were corrected infection was treated with antibiotics her mental status improved during the course of the admission on discharge the pt was alert oriented to name and date acute kidney injury likely related to sepsis and decompensated heart failure her renal function improved with ivf initially when septic and later diuresis acute on chronic systolic heart failure on she decompensated with ivf given for but responded to lasix most of her cardiac meds had been held in the icu and were restarted on since then her heart failure symptoms have improved she returned to her baseline home oxygen requirements tte demonstrated a globally depressed lvef consistent with cardiomyopathy of sepsis discussed with interpreting cardiologist multivessel cad also a possibility but felt to be less likely given clinical scenario copd adrenal insufficiency her last outpatient pfts on indicate moderate to severe copd given copd recent steroid taper patient received hydrocortisone mg iv in the ed she was changed to po prednisone mg on then slowly weaned to mg on with no decompensation in her respiratory status albuterol and ipratropium nebs were continued at baseline she is on home o for copd l via nc g pd was checked and when deficiency was ruled out she was switched from atovaquone to dapsone for pcp acute pancreatitis on she developed significant tenderness to palpation in ruq of the abdomen abdominal ultrasound showed cholelithiasis a single cm gallstone without evidence of acute cholecystitis cbd was not dilated portal vein patent it was a technically limited study lfts were normal with the exception of a slightly elevated alk phos which was unchanged however lipase was elevated to was three days earlier an abdominal ct was ordered iv contrast could not be given due to limitations of her picc line it showed stranding consistent with acute pancreatitis symptomatically this improved on and on discharge the pt was tolerating a normal diet leukocytosis diarrhea after most of her abdominal pain had begun to resolve she developed a rapid rise in her wbc to accompanied by voluminous diarrhea as she had been treated for cdiff at within the last month and at osh within the last two weeks she was empirically started on po vancomycin and iv flagyl cdiff toxin was negative x and pcr finally returned negative as well id was consulted and recommended treating with po vanco and iv flagyl for a full day course furthermore she should receive po flagyl whenever receiving broad spectrum abx in the future that said they felt that the resolving pancreatitis was more likely the cause of her leukocytosis leukocytosis the pt had persistent leukocytosis ranging from wbc of during the last week of the hospitalization without any localizing signs or symptoms heme onc reviewed her smear and it was consistent with the effect of steroids many mature polys and lymphs her wbc should be checked one and two weeks after discharge and if it is peristently high she should be referred to heme onc as an outpatient adrenal insufficiency on prednisone mg for almost month tapered to on on then to on long term basal dose is mg daily she will be due to taper down to on hypothyroidism continued on levothyroxine iv access please d c left picc on after the pt s final dose of metronidazole medications on admission rosuvastatin mg qd furosemide mg qd prednisone mg qd spironolactone mg tiotropium mcg capsule inh daily aspirin mg ec qday allopurinol mg qd clopidogrel mg po qd ferrous sulphate mg po qd advair diskus puff po bid metoprolol albuterol mg nebuliser qid calcium carbonate mg po bid gabapentin mg po bid lantus u subcut at night regular insulin sliding scale levothyroxine mcg qd oxycodone mg q h prn ranitidine mg po qd florastor probiotic supplement milk of magnesia po qd prn bisacodyl mg pr qd fleet s enema qd prn prune juice po qd prn discharge medications rosuvastatin mg tablet sig one tablet po daily daily furosemide mg tablet sig tablet po daily daily prednisone mg tablet sig one tablet po daily daily please taper down to mg daily on spironolactone mg tablet sig one tablet po daily daily tiotropium bromide mcg capsule w inhalation device sig one cap inhalation daily daily aspirin mg tablet delayed release e c sig one tablet po daily daily allopurinol mg tablet sig two tablet po once a day clopidogrel mg tablet sig one tablet po daily daily ferrous sulfate mg mg iron tablet sig one tablet po once a day advair diskus mcg dose disk with device sig one puff inhalation twice a day metoprolol tartrate mg tablet sig one tablet po tid times a day albuterol sulfate mg ml solution for nebulization sig one neb inhalation q h every hours as needed for wheezing calcium carbonate mg calcium mg tablet sig one tablet po twice a day gabapentin mg capsule sig one capsule po bid times a day dapsone mg tablet sig one tablet po daily daily oxycodone mg tablet sig tablet po q h every hours as needed for pain levothyroxine mcg tablet sig one tablet po daily daily vancomycin mg capsule sig one capsule po q h every hours stop on metronidazole flagyl mg iv q h fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day heparin porcine unit ml cartridge sig one inj injection three times a day please continue until patient is ambulatory participating with pt tid ranitidine hcl mg capsule sig one capsule po once a day miconazole nitrate powder sig one appl topical qid times a day as needed for groin rash lisinopril mg tablet sig one tablet po once a day discharge disposition extended care facility nursing rehab center discharge diagnosis toxic metabolic encephalopathy urinary tract infection acute pancreatitis acute of chronic systolic heart failure hypercalcemia symptomatic clostridium difficile colitis 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 ms you were admitted to for the treatment of multiple infections while you were here you were also treated for heart failure and acute pancreatitis several changes have been made to your medications and a full list of what you should be taking will be provided to the rehabilitation facility to which we are transferring you here are the changes that were made prednisone was increased vancomycin po and metronidazole iv were started and will continue until a picc line was placed and should be removed on after your final dose of metronidazole followup instructions department when friday at pm with md building sc clinical ctr campus east best parking garage department pulmonary function lab when wednesday at am with pulmonary function lab building campus east best parking garage [NEW_RECORD] admission date discharge date date of birth sex f service medicine allergies penicillins colchicine bactrim attending chief complaint altered mental status gi bleed major surgical or invasive procedure right internal jugular central venous catheter left subclavian central venous catheter history of present illness yo female with history of neurofibromatosis htn hyperlipidemia and recent hospitalization for complicated pna pancreatitis c diff colitis and adrenal insufficiency who presents with gi bleed hypotension and hypoxia the patient was in her usual state of health when she was found to have decreased responsiveness at her nursing home she had a similar presentation about month ago and was found to be septic given this concern she was brought to the ed for further evaluation on arrival to the ed the patient was thought to be hypoxic however she had clear lung sounds and was breathing comfortably she was initially placed on nrb but was quickly weaned to nc and sats remained stable her mental status however did not improve patient was also found to be hypotensive in the ed and was briefly started on levophed with improvement in her bp she received vancomycin and ceftriaxone given concern for sepsis and got l iv fluids she had melanotic stool in the ed so she was started on protonix gtt and received u prbcs in the ed gi aware of the patient labs pertinent for elevated potassium elevated lactate and troponin ua positive for uti wbc of the patients mental status improved so she was not intubated triple lumen and arterial lines were placed she denied any localizing symptoms ekg showed deep anterior t wave inversions she remained afebrile in the ed on arrival to the micu t bp p r o on nc patient was oriented and had no acute complaints past medical history coronary artery disease s p revascularization with stemi bms x in in and rca congestive heart failure with lvef moderate copd on home oxygen pulmonary embolism neurofibromatosis type malignant nerve sheath tumor s p removal from left anterior chest wall and radiation depression hypothyroidism adrenal insuficiency chronic steroid use for copd exacerbation hypercalcemia alcoholism per omr patient denies current etoh abuse schizoaffective disorder gout c diff colitis recurred social history ms lives with her boyfriend in a trailer in ma boyfriend has mr secondary to seizures she is on disability used to work as a nursing aide is visited x week by vna tobacco quit smoking in past weeks smoked for years etoh reports drink a week drugs denies ivdu family history mother sister nephew son with neurofibromatosis type i father w copd sister w copd mother w asthma mother died of mi at age father died of mi at age physical exam vitals t bp p r o on nc general alert oriented sleeping heent sclera anicteric mmm eomi neck supple jvp not elevated no lad cv regular rate and rhythm normal s s no murmurs rubs gallops lungs clear to auscultation anterolaterally good respiratory effort 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 grossly intact normal sensation gait deferred pertinent results pm wbc rbc hgb hct mcv mch mchc rdw plt ct pm neuts bands lymphs monos eos baso atyps metas myelos pm pt ptt inr pt pm glucose urean creat na k cl hco angap pm alt ast alkphos totbili pm lipase pm ctropnt pm calcium phos mg brief hospital course yo female with history of htn hyperlipidemia and recent hospitalization for complicated pna pancreatitis c diff colitis and adrenal insufficiency who presents with gi bleed hypotension and hypoxia anemia gi bleed patient presented to the emergency department with symptoms of a gi bleed the patient required multiple transfusions of packed red cells her hematocrit stabilized there is no source of bleeding visualized on the ct of the abdomen and pelvis upon admission laboratory evaluation was not significant for hemolysis gi consultation felt that she was mostly suffering from a gi bleed however did not feel that an egd or colonoscopy was indicated due too severe to clinical status the patient had a second episode of melena with a drop in her hematocrit days prior to death patient was transfused with more units of packed red cells platelet transfusions one fresh frozen plasma sepsis patient presented with leukocytosis as well as elevated lactate and hypotension patient does have a history of known c difficile infection her cultures that were initially drawn in the emergency were positive patient was treated with linezolid iv vancomycin meropenem eventually the iv vancomycin was discontinued as well as her meropenem this course was complicated by continued elevations of her lactate as well as white cell count after initial improvement repeat culture showed gram negative rods the patient was restarted on meropenem the patient s pressure support requirements increased prior to that as for source of her sepsis it was not initially clear patient has possibly an intra abdominal infection although there was no source of infection found on ct of the abdomen patient was treated for questionable ventilator associated pneumonia altered mental status the patient s mental status was altered throughout her stay although the patient was on sedatives for her intubation status we eventually were able to discontinue sodas it without return of patient s normal baseline mental status she does have underlying dementia however per her family her mental status is worse and neurologic consultation was obtained and they were unable to give a clear etiology as she has multiple medical problems currently eeg was performed showing diffuse lower legs but no specific evidence of nonconvulsive status epilepticus direct hyperbilirubinemia throughout her stay her bilirubin as well as lfts alkaline phosphatase became elevated was suggestive of obstructive or cholestatic process right upper quadrant ultrasound was obtained and did not show any intrahepatic obstruction but the cbd was not visualized possibly secondary to the mass effect of her pseudocyst surgery evaluated the patient and stated that a hida scan would most likely not be useful due to her severe clinical condition that would prevent any surgical intervention he discontinued all about toxic medications to help improve her liver function coagulopathy the patient will coagulopathy as her liver function deteriorated her inr was increased to above after her second episode of gi bleed the patient was given fresh frozen plasma to improve her coagulation status her inr did improve to c difficile colitis patient has a known history of c difficile colitis she had a negative toxin by pcr was positive the patient was treated with p o vancomycin as well as iv flagyl a kub was obtained and did not show evidence of toxic megacolon pancreatic pseudocyst on initial ct of the abdomen the patient was found to have a large pancreatic pseudocyst with questionable hemorrhage versus infection surgical consultation was obtained and they believe that the pseudocyst had hemorrhage they did not perform any intervention secondary to her severe clinical status hypoxic respiratory failure the patient required intubation due to persistent hypoxia there were multiple times to wean the patient from ventilation however it was not successful the patient s ventilation status was monitored with consistent arterial gases respiratory failure is most likely secondary to pulmonary edema there was some evidence later in her hospital course a ventilator associated pneumonia and she was treated for such hypothyroidism patient has a known history of hypothyroidism a tsh was drawn and was elevated a free t was pending at the time of the death during her admission we continue her home dose of levothyroxine there is little evidence that this was a myxedema coma adrenal insufficiency patient has a known history of adrenal insufficiency she received stress dose of steroids on her initial admission we continued her home dosing of prednisone gout known history of gout we discontinued her allopurinol and colchicine in the setting of acute kidney injury acute kidney injury patient was admitted with acute kidney injury her renal function improved after fluid resuscitation copd patient is on home oxygen to significant copd she was intubated coronary artery disease patient has no history of coronary artery disease we discontinued her secondary to gi bleed a holter beta blocker and ace inhibitor in the setting of hypotension we continued her aspirin regimen after continued deterioration in the setting of the icu a family meeting was held for goals care discussion after lengthy discussion the family decided to make the patient comfort measures only we discontinued pressor and ventilation support the patient expired approximately hours after the patient was made comfort measures only time of death was on her primary care physician was notified the family did not request autopsy medications on admission rosuvastatin mg tablet sig one tablet po daily furosemide mg tablet sig tablet po daily prednisone mg tablet sig one tablet po daily spironolactone mg tablet sig one tablet po daily tiotropium bromide mcg capsule w inhalation device sig one cap inhalation daily daily aspirin mg tablet delayed release e c sig one tablet po daily daily allopurinol mg tablet sig two tablet po once a day clopidogrel mg tablet sig one tablet po daily daily ferrous sulfate mg mg iron tablet sig one tablet po once a day advair diskus mcg dose disk with device sig one puff inhalation twice a day metoprolol tartrate mg tablet sig one tablet po tid times a day albuterol sulfate mg ml solution for nebulization sig one neb inhalation q h every hours as needed for wheezing calcium carbonate mg calcium mg tablet sig one tablet po twice a day gabapentin mg capsule sig one capsule po bid times a day dapsone mg tablet sig one tablet po daily daily oxycodone mg tablet sig tablet po q h every hours as needed for pain levothyroxine mcg tablet sig one tablet po daily metronidazole flagyl mg iv q h fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day ranitidine hcl mg capsule sig one capsule po once a day miconazole nitrate powder sig one appl topical qid times a day as needed for groin rash lisinopril mg tablet sig one tablet po once a day discharge medications n a discharge disposition expired discharge diagnosis sepsis bacteremia gi bleed with anemia hemorrhagic pancreatitis discharge condition expired discharge instructions n a followup instructions n a md,"{
""Diagnoses"": [""STEMI"", ""Neurofibromatosis"", ""Alcohol Abuse"", ""Pulmonary Embolism"", ""Hypertension"", ""Tobacco Abuse""],
""Medications"": [""Heparin"", ""Reopro"", ""Plavix"", ""Dopamine"", ""Hr in s s"", ""Bolused with CC NS Heparin"", ""No additional IIB IIA inhibitor given""]
}"
25753,admission date discharge date service history of present illness this admission of this year old woman was occasioned by the complaint of nausea and abdominal pain for hours at a nursing home she had not been vomiting her last bowel movement was unknown no records were available and she was unable to contribute to the history because of dementia past medical history past medical history was remarkable for duodenal ulcer and dementia and aortic stenosis medications on admission medications included ultram aricept aspirin zocor and zoloft physical examination on presentation on examination she had a fever of blood pressure was she was elderly in wrist restraints and agitated and moaning pupils were equal and reactive she had a regular rate and rhythm her chest was clear to auscultation bilaterally she had distended and diffusely tender abdomen with percussion tenderness rectal was guaiac negative radiology imaging she had a kub that showed free air under the diaphragm hospital course she was taken to the operating room where she underwent exploration for a perforated viscus and was found to have a perforated sigmoid colon procedure was done and a colonoscopy she was sent to the surgical intensive care unit in guarded condition postoperatively she did not do well and on it was noted that she had difficulty maintaining her blood pressure and was tachycardic on at she was pronounced deceased discharge status deceased discharge diagnoses perforated sigmoid colon m d dictated by medquist d t job,"{
""Diagnoses"": [""nausea"", ""abdominal pain"", ""perforated sigmoid colon""],
""Medications"": [""Ultram"", ""Aricept"", ""Aspirin"", ""Zocor"", ""Zoloft""]
}"
6704,admission date discharge date date of birth sex m service neurosurge history of present illness the patient is a year old gentleman with a history of left nephrectomy in for renal cell carcinoma reportedly diagnosed during workup for polycythemia he now presents with a three day history of nausea vomiting dizziness a mild frontal headache and mild lightheadedness progressing with increased vomiting times three days three times today he denies sense of spinning or vertigo he notes progressive unsteadiness of gait and mild photophobia he denies chest pain shortness of breath cough dysuria abdominal pain or diarrhea the patient reports a positive history of lung metastases diagnosed in treated with two treatments of interleukin with no change in pulmonary metastases on follow up medications on admission multivitamins ibuprofen cyclobenzaprine allergies benadryl past medical history renal cell carcinoma with lung metastases polycythemia glaucoma rash past surgical history left nephrectomy in physical examination on physical examination the patient had a temperature of heart rate blood pressure respiratory rate and oxygen saturation in room air the patient was a gentleman in no acute distress awake alert and oriented times three conversant but with towel over eyes secondary to mild photophobia and headache pupils equal round and reactive to light and accommodation extraocular movements intact no nystagmus tongue midline palate rises in midline facial sensation intact bilaterally v through v smile symmetric neck supple lungs clear to auscultation cardiovascular regular rate and rhythm no murmur rub or gallop abdomen soft nontender nondistended positive bowel sounds sensation intact to light touch strength in all groups increased tone throughout no clonus gait deferred deep tendon reflexes inconsistent due to increased tone laboratory data ct low density round to cm midline cerebellar lesion with question of early compression of the fourth ventricle but no obvious hydrocephalus on lateral ventricles white blood cell count was hematocrit platelet count sodium potassium chloride bicarbonate bun creatinine glucose prothrombin time inr and partial thromboplastin time chest x ray showed no infiltrates or congestive heart failure hospital course on the patient underwent a suboccipital craniotomy for resection of tumor there were no intraoperative complications postoperatively the patient was monitored in the surgical intensive care unit he was afebrile with stable vital signs his blood pressure was under control with nipride he was started on oral lopressor and nipride was weaned off the patient was transferred to the regular floor on postoperative day number two the patient was seen by physical therapy and occupational therapy and found to require rehabilitation prior to discharge to home his vital signs have remained stable he has been afebrile and neurologically he is awake alert and oriented times three moving all extremities with no drift discharge medications colace mg p o b i d lopressor mg p o b i d hold for systolic blood pressure less than heart rate less than vasotec mg p o b i d hold for systolic blood pressure less than zantac mg p o b i d decadron mg p o q h to wean to mg b i d condition at discharge stable follow up the patient will follow up in the brain tumor clinic to see dr and is also to see dr in a week to ten days for staple removal m d dictated by medquist d t job,"{
""Diagnoses"": [""nephrectomy"", ""renal cell carcinoma"", ""polycythemia"", ""glaucoma"", ""rash""],
""Medications"": [""multivitamins"", ""ibuprofen"", ""cyclobenzaprine"", ""Benadryl""]
}"
21960,admission date discharge date date of birth sex f service cardiac surgery chief complaint chest pain history of present illness this year old woman was transferred from hospital after rule in myocardial infarction and cardiac catheterization which showed three vessel disease the patient was admitted to hospital after awaking during the night with chest pressure and she went to the bathroom she felt dizzy fell down and lost consciousness she did have a myocardial infarction years ago catheterization at that time showed no blockages stress test this past summer was okay a recent cardiac catheterization showed a left main coronary artery stenosis left anterior descending and anomalous septal branch stenosis left circumflex stenosis and a right circumflex greater than stenosis past medical history hypertension hypercholesterolemia coronary artery disease myocardial infarction ten years ago peripheral vascular disease carotid disease and disc surgery allergies she is allergic to amoxicillin which gives her hives medications medications at home include atacard mg p o q d norvasc mg p o q d aspirin medications on transfer included heparin drip nitroglycerin drip aspirin protonix social history she lives with her husband she does have a positive smoking history but she quit five years ago ethanol she takes one drink a day family history no family history of coronary artery disease laboratory data her outside hospital laboratory data were significant for an elevated creatinine kinase of and an elevated troponin of creatinine kinase at the outside laboratory showed a sinus rhythm at st elevations in and avf and depression in lateral leads v to v echocardiogram showed good ejection fraction of mild mitral regurgitation and moderate tricuspid regurgitation physical examination on physical examination she was afebrile sinus rate and on liters thin woman in no acute distress she is alert and oriented times three and follows commands no focal deficits on neurological examination head and neck examination she is pupils equal round and reactive to light and accommodation extraocular movements intact anicteric mucous membranes are moist neck is supple no lymphadenopathy positive bruits bilaterally chest examination heart is regular rate and rhythm s and s no murmurs lungs are clear to auscultation bilaterally abdomen is soft nontender nondistended her extremities warm and well perfused no cyanosis clubbing or edema with and equal pulses in the carotids femorals radials and dorsalis pedis hospital course this is a patient who has three vessel disease who is admitted to the cardiac surgery service for a coronary artery bypass graft evaluation and treatment she was admitted and over the next couple of days she was observed with telemetry and preopped for a coronary artery bypass graft procedure on after being appropriately consented the patient was taken to the operating room for a coronary artery bypass graft please refer to the previously dictated operative note by dr from in brief a left internal mammary artery was connected to the left anterior descending artery however further grafts could not be performed as the aorta was extremely calcified and the right coronary artery was bifurcated in an awkward angle therefore she was sent to the catheterization laboratory basically the operation was stopped after a single bypass graft and then the patient was sent to the catheterization laboratory where she underwent a right coronary artery stent placement the patient tolerated both of these surgical interventions well and was transferred to the cardiac surgery recovery unit in good condition that evening the patient was extubated and weaned off of all of her intravenous drips and did well in the cardiac surgery recovery unit on postoperative day the patient did well enough that she was transferred to the floor the rest of her admission can be described in the organ based fashion central nervous system the patient did not have any central nervous system symptoms during her admission however her pain was controlled well with percocet and at the time of discharge she was taking one percocet every four hours for break through pain cardiovascularly the patient underwent a coronary artery bypass graft on she also underwent two percutaneous transluminal coronary angioplasty stent placements on and with good result she has done very well with respective to her cardiovascular status since her surgeries pulmonary immediately after surgery the patient suffered from increased secretion and a chronic sort of nonproductive cough she was followed with serial and chest x rays which at first did not show anything but some nonspecific postoperative atelectasis with some small effusions however by postoperative day on these were read as having a right middle lobe collapse pulmonary consult was obtained a computerized axial tomography scan showed a right lower lobe collapse and focal consolidation on the patient was bronchoscoped revealing tracheobronchial malacia and right middle lobe and right lower lobe collapse secondary to increased secretions these were sent off for culture and subsequently grew out methicillin sensitive resistant staphylococcus aureus follow up chest x ray on and both showed decreased consolidations and collapse renal the patient was adequately diuresed and was kg at the time of discharge which was very close to her preoperative weight hematologically the patient had several episodes of anemia which responded well to red blood cell transfusion fluids electrolytes and nutrition the patient s nutritional status revealed she was tolerating a regular diet soon after surgery but had decreased appetite and calorie counts were followed prior to her discharge it was noted that she was taking of her recommended caloric intake prior to discharge otorhinolaryngology throughout her floor admission the patient complained of clogged ears and cerumen impaction which she suffers from chronically an otorhinolaryngology consult was obtained which recommended otic drops and a follow up appointment in the clinic with dr before discharge on infectious disease the patient had one contaminated sputum culture which reveal gram positive cocci a bit of a red but bronchoalveolar lavage from did grow out staphylococcus aureus which were resistant to oxacillin she was immediately started on vancomycin and soon her white count came down and she began feeling better she had a more productive cough and began to breath much better on vancomycin on the patient was switched over to linezolid for p o coverage and as discussed with infectious disease she was recommended to go home with two weeks of linezolid coverage for her methicillin sensitive resistant staphylococcus aureus pneumonia so ms was being discharged on postoperative day discharge diagnosis hypertension hypercholesterolemia coronary artery disease acute myocardial infarction peripheral vascular disease methicillin sensitive resistant staphylococcus aureus pneumonia tracheobronchial malacia right lower lobe right middle lobe collapse due to accumulated secretions chronic blood loss anemia requiring transfusion cerumen impaction follow up she has follow up appointments with dr in clinic dr her primary care physician cardiologist her her cardiothoracic surgeon and dr her interventional cardiologist discharge medications linezolid p o q aspirin mg p o q d plavix mg p o q d percocet one tablet p o q hours prn for pain norvasc mg p o q d around the clock colace mg p o b i d as needed for constipation albuterol inhaler neomycin polymyxin otic drips m d dictated by medquist d t job,"{
""Diagnoses"": [""myocardial infarction"", ""cardiac surgery"", ""three vessel disease"", ""coronary artery disease"", ""peripheral vascular disease"", ""carotid disease""],
""Medications"": [""atacard"", ""norvasc"", ""aspirin"", ""heparin"", ""nitroglycerin"", ""protonix""]
}"
14286,admission date discharge date service i note date of discharge is expected to be chief complaint fevers and increased white blood cell count history of present illness this is an year old female with multiple medical problems who was sent in to the emergency room from her nursing home for fevers and an increased white blood cell count the patient was recently admitted to from until initially for shortness of breath and then had a prolonged hospital course which included respiratory distress thought secondary to a chronic obstructive pulmonary disease flare from pseudomonal pneumonia other etiologies were entertained including allergic bronchopulmonary aspergillosis versus turk during the patient s last admission she had intermittent shortness of breath episodes that were treated with lasix for pulmonary edema she had also ruled out for an myocardial infarction at that time her hospital course at that time was also complicated by a steroid induced myopathy incidental thyroid nodule with biochemically sick euthyroid acute t compression fracture ataxia attributed to steroid myopathy pancytopenia attributed to medication and a peg placement upon evaluation for the current admission the patient s daughter stated that since her discharge the patient s mental status has been at baseline until the day prior to admission when she became slightly more depressed she had been calling out for her deceased mother the patient also appeared confused and agitated at the nursing home her temperature was f heart rate was and respiratory rate was she was saturating on two liters and had been placed on a nonrebreather by the ems at the nursing home she had been given ciprofloxacin azithromycin and ceftazidime for one day per the patient s daughter the patient had not had any headache chest pain change in her vision diarrhea she complained of mild abdominal diffuse pain past medical history status post pseudomonal pneumonia chronic obstructive pulmonary disease diverticulitis pancreatitis complicated by pseudocyst asthma gastroesophageal reflux disease history of eosinophilia hypercholesterolemia atrial fibrillation rate controlled alzheimer s dementia degenerative joint disease coronary artery disease with a history of anterior myocardial infarction and an ejection fraction of greater than t compression fracture bronchiectasis pancytopenia sick euthyroid steroid myopathy status post peg placement medications albuterol nebulizers q six hours calcitriol micrograms q day salmeterol micrograms q hours guaifenesin q six hours p r n multivitamin tylenol p r n dulcolax suppositories p r n colace mg p o twice a day flovent micrograms six puffs twice a day alendronate mg p o q day lidocaine patch p r n calcium carbonate mg twice a day prednisone mg p o q day atrovent nebulizers q six hours nystatin swish and swallow paxil mg p o q day risperdal mg p o twice a day p r n zithromax mg q day ciprofloxacin mg q day ceftazidine one gram intravenously q eight hours lasix mg p o q day diltiazem social history the patient has a significant history of tobacco use she resides at the home for the past week since her discharge from the hospital physical examination on evaluation in the emergency room the patient was febrile with a temperature of f blood pressure heart rate respiratory rate on a non rebreather on room air at rest the patient appeared sedated and was becoming agitated and combative at times her pupils equally round and reactive to light her neck was supple without any lymphadenopathy or bruits her oropharynx was dry and her mucous membranes were moist without exudates she had fine crackles half way up bilaterally on her lung examination and had occasional expiratory wheezes she had no accessory muscle use her heart was regular rate and rhythm with s s her abdomen was soft nontender to deep palpation she had normoactive bowel sounds and no guarding her peg site was clean dry and intact without erythema or drainage her legs were in lambs wool boots she had trace edema to the ankles there were no cords or erythema present on neurologic examination she responded to commands by opening her eyes but appeared sedated she had no point tenderness over her spine she had no sacral decubitus ulcers and no skin ulcers laboratory her labs were as follows on admission white blood cell count hematocrit platelets she had neutrophils and bands her electrolytes were as follows sodium potassium chloride bicarbonate bun creatinine glucose her lactate was her first set of cardiac enzymes revealed the following a ck of mb of troponin of her second troponin was her inr was two sets of blood cultures and a urine culture were drawn her alt was alkaline phosphatase total bilirubin lipase amylase on urinalysis she had moderate leukocytes and moderate blood she had a white blood cell count of greater than in her urine and many bacteria there were three to five epithelial cells chest x ray showed increasing rounded but ill defined opacity in the left upper lobe same as in there was a question of cavitary worsening left upper lobe opacity an ekg was done which showed sinus tachycardia at with normal intervals and left axis deviation hospital course by problem fevers initially the patient s fevers were thought to be due to a urinary tract infection as seen on her urinalysis upon admission she had been placed on levaquin to treat for the urinary tract infection however when the cultures came back showing methicillin resistant staphylococcus aureus the patient was switched to vancomycin also blood cultures had been drawn upon admission the first set of blood cultures ended up growth enterococcus which was resistant to vancomycin thus the patient s vancomycin was discontinued and the levaquin was discontinued as well she was then started on linezolid an infectious disease consultation was obtained they recommended that the patient undergo possible transesophageal echocardiogram however given the patient s agitated state this test was not done she was kept on the linezolid and she was also started on clindamycin per infectious disease recommendations the patient was to be kept on the linezolid for a total of three or four weeks the patient continued to have occasional spikes in her temperature surveillance blood cultures were drawn daily the patient daily did not complain of any sort of symptoms however it was difficult to obtain a history daily given that the patient has a baseline dementia pulmonary nodule given the presence of this pulmonary nodule on chest x ray upon admission a ct scan was recommended by a pulmonary consultation that had been obtained in the early part of the hospital course ct scan showed that the nodule had been present on a prior ct scan but had slightly grown in size they were unable to rule out whether this was tb versus aspergillosis thus the patient was placed in isolation in order to have her ruled out for tuberculosis sputum was induced on multiple occasions the first two sets of sputum cultures had no acid fast bacilli on smear cultures were pending the third set at the time of this dictation has not been induced yet the patient had initially been placed on ceftazidime and ciprofloxacin in case this had been a recurrence of her pseudomonal pneumonia however after an infectious disease consultation had been obtained they thought that this was low suspicion and decided to place the patient on clindamycin the pulmonary team followed the patient throughout her hospital course elevated troponin given that the patient s ck and mbs were within normal limits it was thought that the patient s slightly elevated troponins were likely from demand ischemia she had no new ekg changes and the patient continued to be asymptomatic she denied any chest pain or shortness of breath throughout her hospital course she was placed on telemetry throughout her hospital course there were no events up to the time of this dictation decreased hematocrit the patient had a slightly decreased hematocrit upon admission on hospital day two she was transfused one unit of blood her hematocrit remained stable throughout the remainder of her hospital course mental status the patient has baseline alzheimer s disease dementia initially she appeared improved since her last admission although at times she had periods of agitation and depression she was placed on risperdal twice a day p r n for agitation nutrition the patient was continued on her tube feeds for her peg that had been placed at her prior admission a swallow consultation was obtained to see if the patient was at high risk for aspiration the patient refused to have this test done and given that she clearly had some risk of aspiration she was made npo as her diet throughout her hospital course code status the patient was a full code during her hospital stay up until the point of this discharge summary prophylaxis the patient was placed on colace dulcolax heparin subcutaneously for deep venous thrombosis prophylaxis fall precautions aspiration precautions diabetes mellitus the patient had her fingersticks checked four times a day she was placed on a regular insulin sliding scale due to the diabetes mellitus that had developed from her long chronic use of prednisone her blood sugars remained well controlled during her hospital stay the plan is for the patient to be discharged to a rehabilitation facility after she is ruled out for tuberculosis at the rehabilitation facility she will receive the antibiotics linezolid and clindamycin up to a total of three weeks discharge status discharged to a rehabilitation facility condition at discharge stable discharge diagnoses vre bacteremia methicillin resistant staphylococcus aureus urinary tract infection severe chronic obstructive pulmonary disease pulmonary nodule rule out tuberculosis asthma gastroesophageal reflux disease alzheimer s disease dementia t compression fracture bronchiectasis pancytopenia steroid myopathy discharge instructions the patient was instructed to call her doctor or return to the emergency room if she experienced any further chest pain increased shortness of breath abdominal pain fevers change in mental status or other worrisome symptoms she was also told to follow up with the infectious disease clinic she is to follow up with her primary care physician in addition the patient had been scheduled for certain appointments during her prior hospital stay which were still pending such as her appointment with neurology and pulmonary if there are any further events in the hospital course they will be dictated at a later time md dictated by medquist d t job cc [NEW_RECORD] name v unit no admission date discharge date date of birth sex f service med allergies compazine tetracyclines aspirin sulfa sulfonamides darvocet n ultram flagyl clindamycin attending chief complaint dyspnea respiratory failure major surgical or invasive procedure non invasive ventilation brief hospital course the patient was transferred to the with increasing o requirements and worsening respiratory status over the course of the next several days neither the patient s mental status nor respiratory status improved despite continued antibiotics agressive pulmonary toilet she continued to appear uncomfortable and received prn pain medications after discussion with the family the patient was made dnr dni but continued to require non invasive ventilation after several more days without any improvement another family meeting was held the patient s son and daughter communicated that the patient would have opted for comfort measures at this point the patient was made cmo and started on a morphine drip titrated to the patient s comfort within hours the patient had expired the patient s son was present at the time of her death family members requested a partial autopsy to investigate the patient s dementia the patient s primary care physician continued to be in contact with the family and to follow the patient in the icu discharge disposition extended care discharge diagnosis vre bacteremia mrsa uti severe copd pulmonary nodule r o tb delirium discharge condition deceased md completed by,"{
""Diagnoses"": [""fevers"", ""increased white blood cell count"", ""shortness of breath"", ""chronic obstructive pulmonary disease"", ""pseudomonal pneumonia"", ""allergic bronchopulmonary aspergillosis"", ""myocardial infarction"", ""steroid-induced myopathy"", ""acute t-compression fracture"", ""ataxia"", ""pancytopenia""],
""Medications"": [""Lasix"", ""steroids"", ""thyroid medication"", ""peg placement""]
}"
5503,admission date discharge date date of birth sex m service cardiothoracic surgery history of present illness mr is a pleasant year old male with a known history of coronary artery disease with a catheterization in of this year which showed vessel coronary artery disease however the patient was ultimately referred to outpatient medical therapy because he denied permission for a coronary artery bypass graft his symptoms persisted with angina on exertion and had a positive stress test approximately one month ago ultimately he agreed to a coronary artery bypass graft and was transferred from the where he was recently admitted for substernal chest pressure and a rule out myocardial infarction protocol past medical history the patient s past medical history is significant for cardiac risk factors of hypercholesterolemia positive family history as well as hypertension he did have a non q wave myocardial infarction in he has had low back pain chronically requiring narcotics to treat he did fracture his right foot years ago past surgical history his past surgical history included tonsillectomy he has had a lymph node removed from his neck years ago and a hair implant years ago review of systems review of systems was notable just for exertional substernal chest pain relived with nitroglycerin he had no respiratory complaints medications on admission his medications on admission were atenolol mg p o q d aspirin lipitor nitroglycerin allergies he has no known drug allergies physical examination on presentation his examination was notable for a blood pressure of heart rate of in no acute distress his head ears nose eyes and throat examination revealed pupils were equal round and reactive to light and accommodation mucous membranes were moist his trachea was midline no bruit heart had a regular rate and rhythm with no murmurs lungs were clear to auscultation bilaterally his abdomen was soft nontender and nondistended with no bruit his extremities were normal there were normal palpable posterior tibialis and dorsalis pedis pulses bilaterally laboratory data on presentation his admission laboratories were notable for white blood cell count hematocrit platelets chemistries were sodium of potassium chloride bicarbonate blood urea nitrogen creatinine glucose pt and inr were within normal limits hospital course he was therefore admitted on to the cardiothoracic surgery service to have his coronary artery bypass graft to be completed on additional information about the admission workup included a chest x ray that was negative a urinalysis that was also negative the patient went to the operating theater on with dr where he underwent a vessel coronary artery bypass graft he received grafts including left internal mammary artery to the left anterior descending artery left radial graft to the pl as well as saphenous vein graft to the first obtuse marginal sequential to the diagonal postoperatively he was transferred to the intensive care unit where he was on nitroglycerin propofol and neo synephrine on postoperative day one the patient was taken off of pressonex his neo synephrine was weaned to off he was placed on a cardiac diet he was started on lopressor lasix and aspirin his postoperative hematocrit was white count of platelets were blood urea nitrogen and creatinine of and ultimately he was transferred to the floor on postoperative day one his postoperative course was complicated only by high pain requirement the patient ultimately had an acute pain consultation and was placed on oxycodone mg to mg p o q h p r n as well as tylenol mg p o q h p r n on postoperative day three his temperature was noted to be he was cultured times two additionally he got a chest x ray that showed a new left retrocardiac density since surgery which was suspicious for a possible pneumonia urinalysis was negative blood cultures did not grow out anything during his hospital course he was empirically started on levaquin and flagyl to treat presumed pneumonia his temperature curve quickly defervesced once he was started on the empiric therapy his pain was well controlled he was ambulating and voiding spontaneously portable chest x ray showed no evidence of pneumothorax just small bilateral effusions right greater than left additionally the aforementioned retrocardiac densities were present on the left side by postoperative day four the patient was ambulating a level v and had completed stairs his discharge laboratories were notable for a hematocrit of a white blood cell count of as well as blood urea nitrogen of and creatinine of his discharge examination was notable for a temperature of pulse blood pressure respiratory rate on liters in no acute distress his sternum was stable there was no drainage no was no erythema the staples were intact his heart was regular with no murmur his lungs were clear to auscultation except for decreased breath sounds left greater than right no crackles were present however his abdomen was benign his lower extremities were warm and well perfused with palpable dorsalis pedis and posterior tibialis pulses bilaterally medications on discharge the patient s discharged medications included the following lopressor mg p o b i d lasix mg p o q d times seven days k dur meq p o q d times seven days colace mg p o b i d while he is taking oxycodone oxycodone mg to mg p o q h p r n zantac mg p o b i d aspirin mg p o q d tylenol mg p o q h p r n levaquin mg p o q d for a total course of seven days to be completed by flagyl mg p o t i d to be completed by discharge followup the patient s follow up will include being seen by dr in one month from the time of discharge he will require no home services with he was to be seen in the wound care clinic one week from the time of this discharge discharge status the patient s disposition was to home condition at discharge condition on discharge was stable afebrile discharge diagnoses status post vessel coronary artery bypass graft for unstable angina m d dictated by medquist d t job,"{
""Diagnoses"": [""cardiothoracic surgery"", ""coronary artery disease"", ""angina"", ""myocardial infarction"", ""substernal chest pressure""],
""Medications"": [""hypercholesterolemia"", ""hypertension"", ""narcotics""]
}"
13977,admission date discharge date date of birth sex m service cardiothor history of the present illness this is a year old male referred for an outpatient cardiac catheterization which was performed on for the past months the patient has experienced exertional anginal symptoms he has had chest pain after climbing a few stairs or walking too fast he denies shortness of breath or any chest pain at rest in the past week the pain had progressed to a point where it was not relieved at rest the patient denies claudication orthopnea edema paroxysmal nocturnal dyspnea lightheadedness past medical history glaucoma benign prostatic hypertrophy hypertension hypercholesterolemia prior smoking past surgical history history revealed hemorrhoid surgery medications monopril q d klor con meq q d flomax mg q d ecotrin aspirin mg q d prevacid mg q d sublingual nitroglycerin p r n xalatan eye drops alphagan eye drops allergies the patient has no known drug allergies physical examination examination revealed the patient to be afebrile vital signs stable heent no masses no lymphadenopathy lungs lungs were clear to auscultation bilaterally heart regular rate and rhythm normal s and s systolic ejection murmur extremities no edema cardiac catheterization was performed on please see the report for full details of the summary summary left circumflex stenosis lad mid stenosis rca mild disease the aortic valve could not be crossed after several attempts the echocardiogram however revealed severe aortic stenosis with moderately thickened leaflets ejection fraction was hospital course the patient was brought to the operating room on he had an avr with mm pericardial ce valve and a cabg times two with lima to the lad and saphenous vein graft to the om postoperatively the patient had two ventricular and two atrial pacing wires along with two mediastinal and one pleural tube bypass time was minutes with cross clamp time being minutes the patient was transferred to the intensive care unit the patient was postoperatively on neo synephrine and propofol both drips were appropriately weaned and he was rapidly extubated the patient was a paced in the intensive care unit on postoperative day by postoperative day the patient s heart rate was with no pacing the patient was transferred to the floor on postoperative day due to minimal output of the tubes chest tubes were removed post pull chest x ray revealed no pneumothorax and no effusions on postoperative day the patient went into rapid atrial fibrillation he was po amiodarone loaded on postoperative day the patient was transfused two units of packed red blood cells for a hematocrit of on postoperative day pacing wires were removed a small amount of drainage from the sternal incision was seen at the inferior aspect he was started on vancomycin on postoperative day the patient had two more episodes of atrial fibrillation it was decided at that point that coumadin should be started by postoperative day the patient was in sinus rhythm and drainage from the sternum had stopped the patient was tolerating a regular diet well and ambulating at a level condition on discharge stable discharge medications lopressor mg b i d lasix mg q d times days potassium chloride meq q d times days aspirin mg q d glucophage mg q d coumadin mg q d keflex mg q i d times days amiodarone mg t i d times one day then mg b i d times days then mg q d times days protonix mg q d alphagan eye drops xalatan eye drops percocet to tablets po q to h p r n colace mg b i d discharge status the patient is discharged to a rehabilitation facility the patient will have q d inr checks until his inr is between and and the coumadin dose will be appropriately adjusted the patient will followup with the primary care physician in three weeks and dr in four weeks laboratory data data on discharge revealed the following white blood cell count hematocrit platelet count inr sodium potassium chloride bicarbonate bun creatinine glucose physical examination examination revealed the following cor regular rate and rhythm abdomen soft nontender nondistended lungs lungs were clear to auscultation sternum stable no drainage saphenous vein graft site clean dry and intact final diagnosis status post avr and cabg times two hypertension hypercholesterolemia m d dictated by medquist d t job,"{
""Diagnoses"": [""cardiothoracic"", ""anginal"", ""chest"", ""pain"", ""claudication"", ""orthopnea"", ""edema"", ""paroxysmal"", ""nocturnal"", ""dyspnea"", ""lightheadedness""],
""Medications"": [""monopril"", ""klor-con"", ""meq"", ""flomax"", ""aspirin"", ""prevacid"", ""sublingual"", ""nitroglycerin""]
}"
65267,admission date discharge date date of birth sex m service medicine allergies patient recorded as having no known allergies to drugs attending chief complaint cholangitis major surgical or invasive procedure right jugular line history of present illness mr is a year old male with hx of metastatic colon cancer in remission copd and recurrent biliary obstruction who presented to the ed with a day of abdominal pain and fevers he states he started feeling unwell last night with hours of chest abdominal pain and subjective fevers this morning he took tylenol with some response but then around pm he developed fevers rigors and worsening abdominal chest pain he described his abdominal pain diffuse and sharp he admitted to some nausea but denied vomiting he then took another tylenol and also a dose of ciprofloxacin of note he has had over twenty ercps in the past for recurrent biliary stent blockages he states this is the sickest he has ever felt prior to in the ed initial vs were t p bp r o sat patient was given zosyn l ns and started on a levophed drip due to hypotension on exam he had ruq tenderness and was guaiac negative during his ed course he put out cc in his foley currently he denies abdominal pain nausea chest pain or shortness of breath review of systems per hpi denies headache sinus tenderness rhinorrhea or congestion denies cough shortness of breath or wheezing denies chest pressure palpitations or weakness denies dysuria frequency or urgency denies arthralgias or myalgias denies rashes or skin changes past medical history colon cancer metastatic to liver s p left colectomy s p left liver lobe segmentectomy s p chemotherapy currently in remission recurrent biliary obstruction due to fu per recent pcp note the patient reports that he has ercps every months to remove biliary sludge copd schizophrenia gerd macular degeneration right temporal adnexal carinoma s p removal and skin graft repair by derm s p appendectomy s p cholecystectomy social history he lives alone he is on disability quit smoking and drinking in family history his mother died of colon cancer physical exam vitals t bp p r o on ra cvp general alert and oriented speech is somewhat slow but he is appropriate heent sclera anicteric mmm oropharynx clear neck supple jvp not elevated no lad lungs breathing comfortably crackles present bilaterally at the bases cv regular rate and rhythm normal s s no murmurs rubs gallops abdomen well healed midline scar presnt hyperactive bowel sounds soft nondistended slight tenderness to palpation in the ruq no reboung or guarding gu foley with light yellow urine ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs na k cl bun cr glu ca mg phos trop alt ast ap tbili alb lip wbc hct plt n l m pt ptt inr lactate micro ua negative for leuk or nitr bcx x pending images cxr impression status post placement of a right sided ij terminating within the upper svc there is no pneumothorax ekg normal sinus rhythm nl axis with no ste or std impression previously placed metal stents were noted on fluoroscopy in the chd and cbd evidence of a previous sphincterotomy was noted in the major papilla a single periampullary diverticulum with small opening was found at the major papilla cannulation of the biliary duct was performed with a balloon catheter using a free hand technique multiple filling defects were noted in the biliary tree within the metal stents large amount of stone and sludge debris was removed with a balloon catheter after multiple sweeps of the metal stents occlusion cholangiogram revealed further fixed filling defect at the proximal edge of the metal stents and the r hepatic duct hilum area likely hyperplastic overgrowth of tissue related to the metal stents a cm by fr double pigtail plastic biliary stent was placed successfully with the proximal edge in the left hepatic duct contrast and bile drainage was noted after placement of the pigtail stent recommendations continue with iv antibiotics pt may resume diet pt will be transferred back to under the care of the icu team in months to re evaluate biliary tree remove stent and clean debris brief hospital course year old male with hx of metastatic colon cancer in remission copd and recurrent biliary obstruction who presented to the ed with a day of abdominal pain and fevers concerning for cholangitis cholangitis and septic shock the patient has metal biliary stents in place which tend to have an occlusion every months his lfts were mildly elevated the patient s hypotension was most likely due to his cholangitis he required fluid resusitation pressors antibiotics and bowel rest he was stabilized and able to undergo on he had a successful drainage of stone and sludge debris from the stents in the common bile duct and the patient also had a pigtail catheter placed in the left hepatic duct his hypotension resolved after and he was able to be transferred to the floor he will need to finish a day course of antibiotics ciprofloxacin and flagyl as an outpatient it was recommended that he continue taking ursodiol chest pain the patient had an episode of chest pain which was felt to be most likely pain referred from his abdomen his cardiac enzymes were negative and he did not have any ekg changes the following medical issues remained stable during this hospitalization thrombcytopenia copd schizophrenia gerd and constipation medications on admission albuterol mcg inhaler puffs qid prn alprazolam mg po daily prn anxiety advair mcg mcg inh daily gabapentin mg mg po qhs misoprostol for constipation miralax propranolol mg po bid ranitidine mg po bid risperidone mg po qafternoon and mg qhs ursodiol mg po tid ziprasidone mg po bid melatonin discharge medications misoprostol oral atrovent spray non aerosol nasal fluticasone salmeterol mcg dose disk with device sig one disk with device inhalation times a day gabapentin mg capsule sig three capsule po hs at bedtime gabapentin mg capsule sig two capsule po bid times a day ranitidine hcl mg tablet sig one tablet po bid times a day risperidone mg tablet sig one tablet po at bedtime risperidone mg tablet sig three tablet po qafternoon ursodiol mg capsule sig one capsule po tid times a day ziprasidone hcl mg capsule sig one capsule po bid times a day ciprofloxacin mg tablet sig one tablet po every twelve hours for days disp tablet s refills metronidazole mg tablet sig one tablet po every eight hours for days disp tablet s refills albuterol sulfate mcg actuation hfa aerosol inhaler sig puffs inhalation four times a day as needed for shortness of breath or wheezing alprazolam mg tablet sig one tablet po every hours as needed for anxiety ipratropium bromide spray non aerosol sig sprays nasal three times a day as needed for runny nose propranolol mg tablet sig three tablet po twice a day discharge disposition home discharge diagnosis primary diagnoses cholangitis secondary diagnoses chest pain noncardiac etiology thrombocytopenia copd schizophrenia gerd hyphosphotemia hypocalcemia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted with an infection from your gallbaldder like the infections that you have had before you were treated with strong iv antibiotics because your blood pressure was very low you needed to stay in the intensive care unit you had an procedure that removed gall stones and sludge from your gallbladder your blood pressure came back to normal with iv medication antibiotics and fluids and you stayed overnight on the regular hospital floor you did not eat or drink anything until you had your after your procedure you drank just clear liquids you ve done well and now you can go back to a normal diet your antibiotics will change from iv to medicines that you should take by mouth for days do not stop taking the anitbiotics when you feel better it is important that you finish all the pills completely followup instructions provider md phone date time provider st gi rooms date time provider md 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 fever major surgical or invasive procedure history of present illness east hospital medicine attending admission note date time the patient is a y o m with pmhx of paranoid schizophrenia copd colon cancer in remission s p colectomy with liver wedge resection recurrent biliary obstruction s p ercps in past years with plan for repeat next week presents to the ed with fever patient reports fever to at home today also with nausea no vomiting and generalized weakness he denies any abdominal pain or diarrhea no change in color of skin or urine he endorses dysuria he also reports one month of uri symptoms was diagnosed with acute sinusitis by his pcp last week and was taking a three week course of amoxicillin which he said improved his symptoms he also endorses mild sob at rest which is worse with movement his chronic cough is unchanged he denies chest pain orthopnea pnd or le edema he requires ercps every months for removal of biliary sludge in he required icu for cholangitis and septic shock on pressors regarding patient s schizophrenia he endorses racing thoughts but denies any si or hi in ed p ra he was given unasyn and tylenol labs showed elevated tbili ruq u s done read pending was consulted his blood pressures dropped shortly after being admitted and he was transferred to the icu where his antibiotics were broadened to zosyn and he received ivfs neosynephrine and levophed which were weaned off at pm he remained hemodynamically stable off of pressors and ivfs for hours and was subsequently transferred to the medical floor for further monitoring on the floor he reported no pain n v diarrhea cp sob he endorsed insomnia and requested something to help him sleep review of systems per hpi denies fever chills night sweats recent weight loss or gain denies visual changes headache dizziness sinus tenderness neck stiffness rhinorrhea congestion sore throat or dysphagia denies chest pain palpitations orthopnea dyspnea on exertion denies shortness of breath cough or wheezes denies nausea vomiting heartburn diarrhea constipation brbpr melena or abdominal pain no dysuria urinary frequency denies arthralgias or myalgias denies rashes no increasing lower extremity swelling no numbness tingling or muscle weakness in extremities no feelings of depression or anxiety all other review of systems negative past medical history colon cancer metastatic to liver s p left colectomy s p left liver lobe segmentectomy s p chemotherapy currently in remission recurrent biliary obstruction due to fu per recent pcp note the patient reports that he has ercps every months to remove biliary sludge copd schizophrenia gerd macular degeneration right temporal adnexal carinoma s p removal and skin graft repair by derm s p appendectomy s p cholecystectomy social history lives alone spends time with sister on weekends quit tobacco years ago pack year history no alcohol or illicits on disability family history mother deceased from colon cancer father had melanoma physical exam vs pain gen no apparent distress heent no trauma pupils round and reactive to light and accommodation 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 peripheral iv present neuro alert and oriented to person place and situation cn ii xii intact motor function globally derm no lesions appreciated pertinent results pm glucose urea n creat sodium potassium chloride total co anion gap pm alt sgpt ast sgot alk phos tot bili pm lipase pm albumin pm wbc rbc hgb hct mcv mch mchc rdw pm neuts lymphs monos eos basos pm plt count pm urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk tr pm urine rbc wbc bacteria none yeast none epi trans epi pm urine mucous rare ruq u s read pending cxr emphysema possible nodule in the left lower lung recommend non emergent ct to assess further no signs of pneumonia or chf pm blood culture blood culture routine preliminary escherichia coli 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 escherichia coli ampicillin s ampicillin sulbactam s cefazolin s cefepime s ceftazidime s ceftriaxone s ciprofloxacin r gentamicin s meropenem s piperacillin tazo s tobramycin s trimethoprim sulfa s aerobic bottle gram stain final reported to and read back by pm gram negative rod s brief hospital course mr is a yo m with pmh of colon cancer s p colectomy and liver wedge resection in remission paranoid schizophrenia emphysema recurrent biliary obstruction s p ercps admitted with fever and hyperbilirubinemia from likely biliary obstruction and cholangitis cholangitis shortly after admission patient became hypotensive with sbp in the s not responsive to several ivf boluses most likely septic shock given fevers and possible source of biliary tract given elevated transaminases and tbili ddx for shock etiologies include hypovolemic hemorrhagic or cardiogenic pt appears dry but without obvious fluid loss this is less likely pt has anemia but no obvious source of bleeding cardiogenic less likely given lungs clear jvp flat and no evidence of peripheral edema cvo lactate given obstructive picture cholangitis is most consistent with his presentation fevers elevated bilirubinemia right upper quadrant abdominal pain patient was transferred to the icu given several more ivf boluses and he was started on neosynephrine cvl was placed and patient was transitioned to levophed with good response patient s antibiotics were broadened to zosyn for gram negative and anaerobic coverage for abdominal sources the following morning patient was taken for which showed biliary sludge no frank purulence bile duct was cleared and stent was placed patient was weaned off pressors several hours later and blood pressure remained stable for the remainder of his icu stay on of blood cultures from grew gram negative rods sensitivities to cefepime ceftriaxone tobramycin and gentamicin were documented and thus the patient was switched to ceftriaxone and then to cefpodoxime high dose with a plan for day total course of antibiotics biliary obstruction pt with rising bilirubin in setting of fevers as above pt has had s in the past requiring multiple dilatations most recently months prior patient was taken for on multiple balloon sweeps distal to the stricture extracted copious amounts of debris sludge and stone fragments stent was placed in bilary tract lfts and bili trended down s p repeat recommended in months shortness of breath pt reported mild sob on evaluation initially in the ed ddx includes pulmonary edema vs pna vs pe vs anxiety despite fluids unlikely pulmonary edema given lungs clear pna possible given recent fevers but without cough or infiltrate on cxr this is less likely pe possible though not tachycardic and no chest pain so cardiac etiology is unlikely pt was mildly anxious at the time as well and seemed to improve with reassurance pt maintaining o sats without worsening symptoms shortness of breath resolved on transfer from icu anemia normocytic pt has no acute signs of bleeding pt has received multiple fluid boluses prior to most recent hct plts mildly low though pt has had thrombocytopenia previously from likely liver dysfunction recommend continued work up as an outpatient acute sinusitis suspect fever due to biliary process as opposed to sinus disease given patient s subjective improvement of symptoms while on amoxicillin amoxicillin held while on unasyn zosyn and then ceftriaxone then cefpodoxime continued saline nasal spray emphysema continued advair and prn nebs schizophrenia continued home meds however propranolol was acutely held due to hypotension lung nodule seen on cxr will need non emergent evaluation with ct as an outpatient medications on admission albuterol hfa alprazolam mg qhs prn amoxicillin mg tid x weeks advair gabapentin mg mg qhs miralax daily propranolol mg ranitidine mg risperidone mg daily mg qhs actigall mg tid ziprasidone mg discharge medications cefpodoxime mg tablet sig two tablet po q h every hours for days disp tablet s refills albuterol sulfate mcg actuation hfa aerosol inhaler sig inhalation every hours as needed alprazolam mg tablet sig one tablet po qhs once a day at bedtime as needed for anxiety advair diskus mcg dose disk with device sig one inhalation twice a day gabapentin mg capsule sig two capsule po bid times a day gabapentin mg capsule sig three 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 constipation propranolol mg tablet sig one tablet po twice a day ranitidine hcl mg tablet sig one tablet po bid times a day risperidone mg tablet sig three tablet po daily daily risperidone mg tablet sig one tablet po at bedtime actigall mg capsule sig one capsule po three times a day ziprasidone hcl mg capsule sig one capsule po bid times a day discharge disposition home discharge diagnosis cholangitis e coli bacteremia anemia discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted with signs and symptoms of cholangitis which you have had before you were transfered to the icu for treatment of this you improved with an which you have had done before you are being discharged on antibiotics for your infection please take these antibiotics for more days all of your other home medications are the same followup instructions on tuesday please call your primary care doctor a follow up appointment in the next two weeks also on tuesday please call gastroenterology to an in months department psychiatry hmfp when tuesday at pm with md building ra complex campus east best parking main garage,"{
""Diagnoses"": [""cholangitis"", ""major surgical or invasive procedure"", ""right jugular line"", ""copd"", ""recurrent biliary obstruction""],
""Medications"": [""tylenol"", ""ciprofloxacin"", ""zosyn"", ""levophed"", ""guaiac""]
}"
99791,admission date discharge date date of birth sex m service medicine allergies penicillins arterial line in right radial attending chief complaint s p failed gallstones removal c b gallbladder perforation major surgical or invasive procedure ir guided attempted removal of gallstones and fragmented cholecystostomy tube failed attempt complicated by perforation of the gallbladder history of present illness mr is a y o male with h o htn copd chronic renal disease on hd s p aaa repair and cholecystitis who was admitted to the micu after a failed attempt to remove stones biliary dilation and removal of previous catheter fragment that was complicated by gallbladder cystic duct perforation the patient presented with acute cholecystitis on and underwent percutaneous cholecystostomy at that time as based on his comorbidities he was not felt to be a good surgical candidate since then he has undergone ercp x with sphincterotomy as well as failed laparoscopic cholecystectomy because of adhesions on his cholecystostomy tube came out accidentally and a new percutaneous tube was replaced on unfortunately this cholecystostomy tube was severed by vna leaving him with a cathetar fragment at his ostomy site of note all of his prior care has been at he was referred to ir dr for a cholangiogram via his existing cholecystostomy tube stone extraction catheter fragment removal and sphincteroplasty the procedure performed yesterday was unsuccessful in removing the gallbladder stones or the catheter fragment and was also complicated by gallbaldder cystic duct perforation pt was hemodynamically stable complaining only of ruq pain this morning pt had episodes of hypotension with sbp s to the s prior to dialysis pt was mentating well tmax of pt not currently complaining of abdominal pain pt was transferred to the micu because of concern for sepsis following perforation past medical history hypertension copd on home oxygen l chronic renal disease on hd t th sat schedule last hd on saturday open aaa repair in c b abdominal wall hernia repaired with mesh thoracic aortic aneurysm s p endograft repair s p lue avf cholelithiasis sleep apnea hypercholesterolemia cva recent diagnosed via mri arthritis social history tobacco packs day x years alcohol very heavy drinker x years illicits none family history no family history of gallstones kidney stones brothers physical exam vitals t bp p r o l general alert interactive oriented no acute distress heent sclera anicteric mucus membranes oropharynx clear eomi neck supple cv regular rate and rhythm normal s s gii systolic and diastolic murmer at rusb gii holosystolic and diastolic murmer at lsb no rubs gallops lungs clear to auscultation bilaterally no wheezes rales ronchi abdomen soft non tender mild distension ostomy site clean with bandage in place and cholecystostomy drain with serosanguinous drainage in bag bs ext warm well perfused pulses no clubbing cyanosis or edema micu admission exam vitals t bp p r o on ra general alert oriented no acute distress heent sclera anicteric dry mucous membranes 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 mild tenderness to palpation in the ruq 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 admission labs pm 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 macrocy normal microcy polychr ovalocy schisto occasional tear dr pm blood glucose urean creat na k cl hco angap am blood calcium phos mg am blood alt ast ld ldh alkphos totbili pm blood pt ptt inr pt am blood cortsol am blood vanco micro bcx pending bcx negative ucx negative am bile bile final report gram stain final no polymorphonuclear leukocytes seen no microorganisms seen fluid culture final enterococcus sp rare growth enterococcus sp rare growth second morphology sensitivity testing performed by sensititre sensitivities mic expressed in mcg ml enterococcus sp enterococcus sp ampicillin s s penicillin g s s vancomycin s s anaerobic culture final no anaerobes isolated imaging ct abd pelvis phlegmonous change within the gallbladder fossa with one intact pigtail catheter in place there is also a fragment present laterally within no drainable collection identified adjacent inflammatory fat stranding and pericholecystic fluid moderate duodenal diverticulum simple cysts within both kidneys multiple stable subcentimeter hepatic hypodensities which are too small to characterize intrahepatic ductal dilation with enhancement of the intrahepatic duct suggestive of cholangitis stable aneurysmal aorta and right common iliac artery sigmoid and ascending colon diverticulosis without evidence of acute diverticulitis tte the left atrium is mildly dilated 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 number of aortic valve leaflets cannot be determined there is no aortic valve stenosis no aortic regurgitation is seen the mitral valve appears structurally normal with trivial mitral regurgitation there is mild pulmonary artery systolic hypertension there is no pericardial effusion rue ultrasound no evidence of deep venous thrombosis in the right upper extremity cxr normal size of the cardiac silhouette no lung parenchymal disease brief hospital course yom with h o htn copd chronic renal disease on hd s p aaa repair and cholecystitis who was admitted after failed attempts by ir to remove stones and previous catheter fragment complicated by gallbladder cystic duct perforation and sepsis hypotension perforated gallbladder common bile duct the patient was admitted on following a failed ir attempt to remove gallstones and a cholecystostomy catheter fragment which was complicated by gallbladder cystic duct perforation with contrast seen extravasating from the gallbladder post procedure bps were in the s from a baseline of systolic attributed to sedation with slow clearance in the setting of liver failure he was covered with ceftriaxone and flagyl however he then became hypotensive with sbp s s the following morning on with low grade fever and increasing white count and he was broadened to vanc for concern for early peritonitis and sepsis blood pressures did not respond to several boluses of ivf and he was transferred to the micu where he received l ns his blood pressures stablilized and white count down trended fever resolved on vanc ct was concerning for cholangitis but lfts did not show a cholestatic picture ercp was consulted and did not have plans to intervene unless the patient developed a cholestatic hepatitis surgery was consulted and is planning to perform an open cholecystectomy when he becomes medically stable gb was determined to be adequately decompressed with his cholecystostomy tube at this time and lfts were wnl he was discharged with a plan to continue vancomycin meropenem for a week course bile culture grew enterococcus sensitive to vancomycin the patient was given acetaminophen and oxycodone was increased for pain control gemfibrozil was discontinued as this can precipitate gallstone formation the day of discharge there was question of whether the patient s insurance would cover his vancomycin and meropenem as an outpatient but the patient refused to remain in house to wait for confirmation of insurance approval he will follow up with his pcp as an outpatient regarding this as he was refusing to remain in house for this issue despite knowing the risks of leaving the day after discharge on the patient was called and he confirmed that the vna just finished giving him the iv antibiotics and confirmed that his insurance would cover enough antibiotics for days for a full course anemia the patient had hct on initial presentation that slowly down trended to post op likely dilutional in the setting of missing hd due to hypotension vs slow blood loss from ostomy vs anemia of esrd without epo repletion given recent initiation of hd he was transfused units prbc in the micu with subsequent increased and stable hcts he will receive epo with hd per renal r hand ischemia while in the micu the patient developed cyanosis of the right hand which was attributed to a line insertion in the setting of visualized small caliber vessel perfusion returned s p removal of the line surgery hand consulted felt there were no concerning findings s test normal hd dependent esrd the patient was initially on a t th sat hemodialysis schedule but while in the micu his schedule was switched to m w f he received an extra dose of hd in house after being called out to the floor as he initially missed hd while in the micu for sepsis continued sodium bicarb mg tid sevelamer mg tid with meals renal was following in house hypertension patient was recently hypotensive in the setting of sepsis and his home lisinopril and metoprolol were held until follow up with his pcp copd on home oxygen l patient is currently asymptomatic with no shortness of breath or wheezing the patient is on l at home chronically but has been non compliant with his oxygen use at home he was intermittently on l nc in house his home regimen of tiotropium and albuterol were continued in house hypercholesterolemia pt currently on simvastatin mg daily continued in house cva recent diagnosed via mri continued home aspirin mg daily code full code transitions of care vancomycin to be continued until needs confirmation that insurance will cover outpatient medication meropenem to be continued until needs confirmation that insurance will cover outpatient medication f u bp re start lisinopril and metoprolol as bp tolerated tamsulosin was stopped for hypotension follow up pcp or nephrologist prior to re starting this medication furosemide was stopped for hypotension follow up with nephrologist prior to re initiation percocet was increased in frequency temporarily for pain control post procedure gemfibrozil was stopped as this can cause gallstones genasyme was held follow up with nephrologist or pcp before medications on admission aspirin mg daily flovent puff twice daily furosemide mg genasyme lisinopril mg qd metoprolol mg gabapentin mg tab x tabs tid ursodiol mg sevelemer mg tid meclizine mg darbepoetin injections on thursday oxycodone acetaminophen prn simvastatin mg dialy spiriva daily budesonide puffs twice daily gemfibrizol mg tamsulosin sodium bicarbonate mg x tabs three times daily discharge medications aspirin mg tablet chewable sig one tablet chewable po daily daily fluticasone mcg actuation aerosol sig one puff inhalation times a day gabapentin mg capsule sig two capsule po three times a day ursodiol mg capsule sig one capsule po bid times a day sevelamer carbonate mg tablet sig two tablet po tid w meals times a day with meals meclizine mg tablet sig one tablet po bid times a day darbepoetin alfa in polysorbat injection oxycodone acetaminophen mg tablet sig one tablet po every six hours as needed for pain for days you should not drive or do anything that requires alertness while taking this medication you should avoid drinking alcohol while taking this medication disp tablet s refills simvastatin mg tablet sig one tablet po daily daily tiotropium bromide mcg capsule w inhalation device sig one cap inhalation daily daily budesonide mcg actuation aerosol powdr breath activated sig two puffs inhalation twice a day b complex vitamin c folic acid mg capsule sig one cap po daily daily disp cap s refills sodium bicarbonate mg tablet sig two tablet po three times a day meropenem mg recon soln sig five hundred mg recon soln intravenous q h every hours for days last dose on disp mg recon soln s refills vancomycin in d w gram ml piggyback sig mg intravenous hd protocol hd protochol for days last dose on disp mg refills normal saline flush syringe sig one injection injection twice a day cc of normal saline flush before and after meropenem infusion disp injections refills discharge disposition home with service facility acclaim discharge diagnosis perforated gallbladder common bile duct sepsis acute on chronic renal failure 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 while you were at you came to the hospital to have interventional radiology remove stones and a catheter fragment from your gallbladder unfortunately the procedure was very difficult and it was not possible to remove the stones nor the catheter fragment during the procedure your gallbladder was perforated and you had to be admitted to the hospital for observation while you were in the hospital your blood pressure dropped most likely due to your body reacting to a bacteria in the blood your antibiotics were switched and you were in the intensive care unit until your blood pressure stabilized you will be discharged on a course of antibiotics to be taken at home you will have the vna who will be doing the antibiotic infusion daily the infusion company called home therapy will be calling you tomorrow in the morning to set up the delivery time of your antibiotic however we were not able to get it approved by your insurance today given it is we do not know the cost of your copay we have recommended that you stay inpatient until this is cleared tomorrow morning but you have refused it is extremely important that you get the antibiotic meropenem tomorrow in the afternoon if you have any problems please call our floor at while in the hospital your kidney function was found to be abnormal likely due to dehydration and your kidney function improved after receiving intravenous fluids please call your dialysis unit on monday morning at am to make sure if you will need to go on monday or back to your regular schedule tues thurs sat schedule the following changes were made to your home medications vancomycin was started to be continued until meropenem was started to be continued until nephrocaps was started sevelamer was increased percocet was increased in frequency temporarily gemfibrozil was stopped as this can cause gallstones tamsulosin was stopped please follow up with your kidney specialist or your primary care physician before this medication furosemide was stopped please follow up with your kidney specialist or your primary care physician before this medication genasyme was held please follow up with your kidney specialist or your primary care physician before this medication lisinopril was stopped please follow up with your kidney specialist or your primary care physician before this medication metoprolol was stopped please follow up with your kidney specialist or your primary care physician before this medication followup instructions department hemodialysis please call your dialysis unit on monday morning at am to make sure if you will need to go on monday or back to your regular schedule please call your primary care physician and arrange to follow up with him within days of discharge from the hospital please call dr in the surgery department at at and arrange to follow up with him within weeks after discharge to discuss removing your gallbladder,{}
18341,admission date discharge date service medicine allergies benzodiazepines attending chief complaint mental status changes major surgical or invasive procedure intubation r knee arthrocentesis history of present illness per review of medical record as patient was already intubated upon arrival to the floor year old woman with alzheimer s and recent right subdural hemorrhage sdh treated with burr holes then craniotomy at and transferred to a nursing home on last night she had a witnessed fall to the ground without loss of consciousness and minimal trauma to her upper lip she was alert oriented to self and place but not time baseline and was taken to there routine laboratory studies see below were unremarkable and head ct was stable compared to ct prior to discharge from recent admission for right sdh she was loaded with dilantin gram also received ativan mg and versed mg prior to ct for sedation she was then transferred to for further neurosurgical evaluation during transfer to it is reported that the patient developed acute mental status changes previously although not following commands she was alert responsive moving all extremities with good strength in the ed she initially had elevated blood pressures to the s given the mental status changes she was intubated for airway protection and also mild hypoxia after intubation she was on propofol and sbp s quickly dropped into the the s she was given cc bolus and levoquin for possible uti her sbp increased to the range she then had another episode of bradycardia to with a bp for this she was given atropine and started on dopamine subsequently she developed tachycardia to the s with bp of the dopamine was stopped and she was given diltiazem and versed heart rate and bp stabilized past medical history alzheimer s dementia hypertension atrial fibrillation not on coumadin right subdural hemorrhage as above cm in diameter with mm midline shift prior to neurosurgical intervention s p g tube s p hip replacement social history lives in a nursing home supported by her daughter recent history of smoking alcohol or drugs family history nc physical exam t bp hr rr o sats vent ac gen sedated intubated heent c collar in place mmm right pupil mm with minimal reaction left pupil mm w brisk reaction lungs good airmovement bilaterally cardiac irregular no m r g abd soft nt bs extrem warm and well perfused neuro mental status sedated cranial nerves pupils described above corneal reflexes bilaterally no obvious facial asymmetry motor moves arms and legs spontaneously sensation withdraws to painful stimuli x extremities reflexes bilateral upgoing toes no clonus pertinent results am pt ptt inr pt 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 tsh am albumin phosphate magnesium am lipase am alt sgpt ast sgot ld ldh alk phos amylase tot bili am estgfr using this am glucose urea n creat sodium potassium chloride total co anion gap am urine rbc wbc bacteria occ yeast many epi am urine blood neg nitrite neg protein neg glucose neg ketone neg bilirubin neg urobilngn neg ph leuk sm am urine color straw appear hazy sp am urine bnzodzpn pos barbitrt neg opiates neg cocaine neg amphetmn neg mthdone neg am urine hours random am o sat am lactate am type art po pco ph total co base xs am plt count 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 pm lactate pm type art po pco ph total co base xs brief hospital course year old woman with known right subdural hemorrhage presents with mental status changes after fall the following issues were investigated during this hospitalization mental status changes pt was seen by neurosurgery in the ed and they felt that the head ct revealed stable hemorrhage size compared to osh scan thus the acute mental status changes at were not readily attributable to the sdh and there were no neurosurgical issues other considerations were seizure cva toxic metabolic causes and infections patient did not have any observed seizure like behavior and is incontinent of urine at baseline making it more difficult to determine if she was postictal but was overall unlikely given clincial picture likewise the patient was not febrile and did not have a physical exam suggestive of meningitis pt was found to have a ua suggestive of a uti which in this patient with dementia could be the etiology behind acute mental status changes and was the leading differential work up otherwise for thyroid or liver abnormalities was negative because of ms changes the patient was intubated but later successfully extubated in the interim she was treated for presumed uti with ciprofloxacin and after extubation was reported to be better than baseline mental status per family completed day course of cipro for dirty ua on but became somewhat somnolent and ua continued to be dirty on so she was switched to ceftriaxone on for continued somnolence and ms appeared to return to baseline d c ed after day course urine cultures from negative and ms stable from to discharge g tube placement pulled by pt in am replaced by ir pulled out again after discussion with daughter decided against replacing again given likelihood of taking it out again encouraging po intake with good result r knee effusion palpable effusion tapped unclear etiology about cc removed wbc s with pmn inflammatory septic no crystals noted gs and culture negative for organisms on effusion palpable on lateral aspect but non tender watched on abx as wbc trending down pt afebrile and from to discharge no effusion palpable no joint pain hypotension pt had episodes of hypotension in the ed which appear to have occurred in the setting of propofol and intubation post extubation this was resolved and patient was restarted on a beta blocker trauma pt fell at nh which prompted admission no pelvic fracture per xray trauma service saw patient in the ed and recommended no abd pelvic ct required as fast neg and there was no mechanism she had imaging of the c spine that showed a likely chronic anterolisthesis of c t she had c spine clearance clinically and her hard collar was removed alzheimer s patient was maintained on outpatient dose of namenda atrial fibrillation pt was not anti coagulated given bleed once bp was stable she was rate controlled with metoprolol heme the patient presented with a baseline hct of this level transiently declined to and quickly returned to and was at time of discharge the patient had no signs of active bleeding palpable cord in the left upper extremity unilateral left upper extremity ultrasound was negative for any signs of dvt dispo family meeting with daughter nurse intern case manager daughter is committed to taking care of her mother hours day she came in and spent time with her learning from the nurses including turning feeding by mouth transfers and general mobility d c ed with vna home care medications on admission metoprolol mg qday namenda mg cozaar mg qday colace mg senna discharge medications memantine mg tablet sig two tablet po bid times a day senna mg tablet sig one tablet po bid times a day as needed docusate sodium mg ml liquid sig one po bid times a day cozaar mg tablet sig one tablet po once a day prednisolone acetate drops suspension sig one drop ophthalmic qid times a day metoprolol succinate mg tablet sustained release hr sig one tablet sustained release hr po once a day bacitracin zinc unit g ointment sig one appl topical asdir as directed for days apply to g tube site daily for days disp tubes refills discharge disposition home with service facility discharge diagnosis mechanical fall uti r knee effusion dementia stable subdural hemorrhage hypertension atrial fibrillation discharge condition stable discharge instructions you were admitted after a fall there were no signs of new bleeding you are being discharged home with the care of your daughter follow up with dr appointment below take all medications as prescribed call your doctor or return to the hospital for any new or worsening fevers chills nightsweats headache nausea vomiting loss of consciousness or any other concerning symptoms followup instructions dr pm completed by,"{
""Diagnoses"": [""Alzheimer's disease"", ""Right subdural hemorrhage""],
""Medications"": [""Dilantin"", ""Ativan"", ""Versed""]
}"
3032,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 cabgx lima lad svg diag mediastinal lymph node biopsy cardiac catheterization history of present illness the patient is a year old man who presented with angina he has had a history of several lad stents placed with recurrent thrombosis this was angioplastied under dr with good flow to the distal vessel in addition the patient has a left upper lobe lung lesion most likely carcinoma he now presents for surgical revascularization past medical history cad s p lad stent s p anterolateral mi stent occlusion s p lad stent hypercholesterolemia smoker prior knee surgeries right arthroscopic rotator cuff surgery medication non compliance social history patient is single and has a significant other he works in property maintenance family history mother died of mi at age had first mi at earlier age father w cad died accident uncle had cabg in s when he passed away oldest brother had angina physical exam vitals bp hr rr sat on room air general well developed male in no acute distress heent oropharynx benign good dental health neck supple no jvd transmitted murmur to carotid noted heart regular rate normal s s ii vi diastolic murmur lungs clear bilaterally abdomen soft nontender normoactive bowel sounds ext warm le edema no varicosities pulses distally neuro nonfocal pertinent results am pt ptt inr pt am plt count am glucose urea n creat sodium potassium chloride total co anion gap am ck mb mb indx ctropnt am plt smr normal plt count am wbc rbc unable to hgb hct mcv unable to mch unable to mchc unable to rdw unable to am alt sgpt ast sgot alk phos tot bili 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 am blood hct am blood plt ct am blood glucose urean creat na k cl hco angap cardiac catheterization selective coronary angiography in this left dominant circulation demonstrated one vessel coronary artery disease the lmca had mild luminal irregularities the proximal lad had a stenosis the proximal lad stents were totally occluded with some retrograde filling of the distal and mid lad by left to left collaterals the lcx was a large dominant vessel and had mild luminal irregularities the om was a moderate size vessel with moderate diffuse disease the om was also a moderate size vessel without significant obstructive disease the l pda was without any significant flow limiting disease the rca was not engage because it was known to be a diminuitive vessel resting hemodynamics from right and left heart catheterization demonstrated moderate elevation of right and left heart filling pressures rvedp mmhg lvedp mmhg there was moderate pulmonary arterial hypertension there was no mitral stenosis appreciated there was no transaortic pressure gradient upon catheter pullback from the left ventricle to the ascending aorta the calculated cardiac output by the fick method was l min with a cardiac index of intravascular ultrasound interrogation of the proximal lad verified that the occlusion was secondary to thrombus formation and that the previously deployed stents were well opposed successful catheter thrombectomy and balloon angioplasty using a mm balloon in the proximal lad late stent thrombosis final angiography demonstrated no residual stenosis no angiographically apparent dissection and normal flow see ptca comments echo 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 mass thrombus is seen in the left atrium or left atrial appendage no atrial septal defect is seen by d or color doppler no left ventricular aneurysm is seen there is moderate regional left ventricular systolic dysfunction overall left ventricular systolic function is moderately depressed resting regional wall motion abnormalities include mid anterior anterior septum and septum moderately hypokinetic the inferior wall is mildly hypokinetic the remaining left ventricular segments contract normally right ventricular chamber size and free wall motion are normal there is 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 bypass the lv function was unchanged and rv function is preserved aorta was in tact post decannulation cxr no acute cardiopulmonary process ekg sinus rhythm with ventricular premature depolarizations low qrs voltage in the limb leads extensive anteroseptal and lateral myocardial infarction compared to the previous tracing of multiple abnormalities as previously noted persist without major change brief hospital course mr was admitted to the on for further work up of his chest pain he underwent a cardiac catheterization which was significant for severe single vessel coronary artery disease given the severity of his disease the cardiac surgical service was consulted for surgical management mr was worked up in the usual preoperative manner heparin was continued for anticoagualtion given his new history of a right upper lobe nodule the thoracic surgery service was consulted for assistance in his care a mediastinal lymph node biopsy was recommended during his bypass surgery on mr was taken to the operating room where he underwent coronary artery bypass grafting to two vessels afterward he was transferred to the cardiac surgery recovery unit in stable condition and awakened neurologically intake he was weaned from ventilator support extubated and pressors were weaned on pod he was then transferred to the stepdown unit for further recovery his chest tubes were removed without complication he was gently diuresed to his preoperative weight beta blockade and aspirin therapy were resumed and physical therapy service was consulted to assist with his postoperative strength and mobility electrolytes were repleted as needed on pod he his epicardial pacing wires were removed without complication he continued to improve his ability to ambulate including climbing stairs without respiratory distress or chest pain a chest xray demonstrated a left lower lobe consolidation for which he was placed on empiric levaquin on pod mr was at his preop weight with good exercise tolerance no sob or chest pain his blood pressure was stable his sternotomy and leg incision were clean dry and intact without evidence of infection he was discharged home on pod with services in good condition levaquind mg po qd for five days cardiac diet sternal precautions and instructed to follow up with his pcp and cardiologist in weeks he will follow up with dr in four weeks medications on admission asa zocor toprol lisinopril plavix discharge medications levaquin mg tablet sig one tablet po once a day 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 ranitidine hcl mg tablet sig one tablet po bid times a day disp tablet s refills simvastatin mg tablet sig two tablet po daily daily disp tablet s refills fluticasone mcg actuation aerosol sig two puff inhalation times a day disp qs mdi refills metoprolol tartrate mg tablet sig one tablet po bid times a day disp tablet 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 discharge disposition home with service facility vna discharge diagnosis coronary artery disease anterior stemi s p ptca and stenting hypercholesterolemia htn lung mass discharge condition good discharge instructions monitor wounds for signs of infection these include redness drainage and increased pain report any weight gain of greater then pounds in hours or pounds in week report any fever greater then no lifting more then pounds for weeks no driving for month followup instructions follow up with dr in month follow up with your cardiologist in weeks follow up with your primary care physician weeks call all providers for appointments completed by,"{
""Diagnoses"": [""cardiothoracic"", ""angina"", ""history of present illness"", ""carcinoma"", ""revascularization""],
""Medications"": [""cad"", ""s p lad stent"", ""p anterolateral mi stent"", ""s p lad stent hypercholesterolemia"", ""smoker"", ""non compliance""]
}"