TEXT
stringlengths 178
48.3k
| ICD9_CODE
sequence |
|---|---|
Admission Date: [**2117-9-11**] Discharge Date: [**2117-9-17**] Date Birth: [**2082-3-21**] Sex: F Service: MEDICINE Allergies: Levaquin Attending:[**First Name3 (LF) 2195**] Chief Complaint: nausea, vomiting Major Surgical Invasive Procedure: none History Present Illness: 35F w/ poorly controlled Type 1 diabetes mellitus w/ neuropathy, nephropathy, HTN, gastroparesis, CKD retinopathy, recently hospitalized orthostatic hypotension [**2-3**] autonomic neuropathy [**Date range (1) 25088**]; DKA hospitalizations [**6-12**] [**7-12**], returning w/ 5d history worsening nausea, vomiting coffee-ground emesis, chills, dyspnea exertion. Last week fall hit right face. also 1 day diarrhea, resolved early last week. Found DKA AG 30 bicarb 11. . ED inital vitals 09:00 0 98.2 113 181/99 22 100% RA. K 4.7, HCO3 11, Anion Gap 30, Cr. 2.7 (baseline 1.6-2.0) 3rd L NS. Insulin srip 5 units/hr. home 22 levemir 12 difficult control sugars. BPs high. Given 30 mtroprolol tartrate ED. started insulin drip 5 units/hr 3L NS boluses. Also aspirin 325mg PO Morphine 4mg IVx1 pain. CXr clear. EKG NAD. . Review systems: otherwise negative. Past Medical History: Type 1 diabetes mellitis w/ neuropathy, nephropathy, retinopathy - 2 episodes DKA [**6-12**] [**7-12**] HTN - 5 years gastroparesis - 1.5 years CKD - stage III, baseline Cr 2.4-2.5, proteinuria L1 vertebral fracture - [**2117-7-17**] Systolic ejection murmur Social History: Patient lives home [**Location (un) **] 8 y/o daughter boyfriend. history EtOH, tobacco, illicit drug use. currently unemployed seeking disability. Family History: parents HTN T2DM. Grandfather MI 40s. Physical Exam: GEN: Awake, alert, oriented HEENT: PERRLA. MMM. JVD. neck supple. cervical LAD Cards: RRR, S1/S2 normal. II/VI systolic ejection murmur heard best L upper sternal border. Pulm: CTABL crackles wheezes. Abd: BS+, soft, NT, rebound/guarding, HSM, [**Doctor Last Name 515**] sign Extremities: wwp, edema. radials, DPs, PTs 2+. Skin: rashes bruising. skin tenting. Neuro: CNs II-XII intact. Upper extremities: Power [**5-6**] bilaterally. Le: left power: 4.5/5 right: power [**3-6**]. Bilateral symmetric, reduced sensation distal LE ankles. Pertinent Results: Admission Labs: [**2117-9-11**] 09:22AM WBC-11.9* RBC-4.58 HGB-13.0 HCT-36.5 MCV-80* PLT COUNT-466* LIPASE-22 ALT(SGPT)-10 AST(SGOT)-16 ALK PHOS-105 TOT BILI-0.5 GLUCOSE-260* UREA N-48* CREAT-2.7* SODIUM-137 POTASSIUM-4.9 CL-101 CO2-11* LACTATE-1.9 Discharge Labs: [**2117-9-16**] 07:10AM WBC-6.8 RBC-3.67* Hgb-10.4* Hct-30.2* MCV-82 Plt Ct-298 Glucose-118* UreaN-20 Creat-2.3* Na-137 K-3.7 Cl-104 HCO3-23 AnGap-14 Calcium-8.7 Phos-3.5 Mg-2.0 Radiology: CXR: evidence pneumonia pathological abnormalities. pleural effusions. pulmonary edema. Normal size cardiac silhouette. Microbiology: Urine culture negative, blood cultures growth date, stool C.difficile negative Brief Hospital Course: 35 yo F HTN & poorly controlled type DM, c/b neuropathy, gastroparesis, nephropathy ?????? CKD, retinopathy presents DKA hypertension SBP 200s. . # Diabetic ketoacidosis: Patient controls diabetes home Humalog SS long acting Levemir. Sugars home recently 250s. ED, glucose 466. UA +ve ketones ?????? corrected 200s, rose 300s. treated insulin drip transitioned subq tolerated POs. electrolytes repleted received aggressive volume resuscitation. [**Last Name (un) **] saw gave sliding scale recommendations implemented. source DKA found, beleived [**2-3**] gastroparesis. Nausea managed ativan, compazine, promethazine. discharged home Insulin sliding scale instructions follow-up [**Last Name (un) **]. # HTN: Hypertensive SBP 190s initially, attributed DKA, experienced past. improved blood pressures normalized re-started home Lopressor Midodrine regimen. # Coffee grounds emesis: Emesis started clear, prolonged wretching, started coffee-grounds vomiting. also occurred prior admissions DKA associated vomiting. hematocrit remained stable hematemesis self-resolved, work-up deferred outpatient setting. # Acute chronic kidney disease, Stage III: Patient's Cr admission 2.7, trending 2.1-2.3 following fluids, consistent known CKD secondary diabetic nephropathy. Medications Admission: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levemir 100 unit/mL Solution Sig: Twenty Two (22) units Subcutaneous every AM. 3. Levemir 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous bedtime. 4. Humalog 100 unit/mL Solution Sig: sliding scale directed Subcutaneous four times day: Please use sliding scale directed MD [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) **]. 5. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily): take evening. 6. promethazine 25 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) needed nausea. 7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*2* 8. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily): Please take 1 capsule daily (30 mg) first 2 weeks treatment. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 9. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every eight (8) hours needed pain. 10. midodrine 5 mg Tablet Sig: 1.5 Tablets PO every four (4) hours: hold sleeping. Disp:*270 Tablet(s)* Refills:*2* Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO Daily 6 PM. 5. midodrine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Levemir 100 unit/mL Solution Sig: directed [**Last Name (un) **] units Subcutaneous directed. Discharge Disposition: Home Discharge Diagnosis: Diabetic keotacidosis Hematemesis (blood vomit) Hypertension Chronic renal insufficiency Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: admitted hospital DKA, hypertension, blood vomit. initially treated ICU insulin drip, blood sugars improved. blood pressure medications adjusted better control blood pressure DKA, re-started home regimen discharge. blood vomit likely secondary mechanical trauma repeated wretching, follow-up primary care doctor discuss whether undergo evaluation upper endoscopy. Given complaints chronic cough heartburn, also discuss beginning trial proton pump inhibitor Nexium Prilosec see helps symptoms. insulin regimen adjusted [**Last Name (un) **] team here. continue follow-up questions concerns regarding insulin management. Followup Instructions: Please call Dr.[**Last Name (STitle) 805**]' office schedule follow-up appointment within 7-10 days discharge. office number [**Telephone/Fax (1) 85219**]. also continue follow-up [**Last Name (un) **] doctors needed. | [
"5849",
"V5867",
"40390"
] |
Admission Date: [**2150-4-17**] Discharge Date: [**2150-4-21**] Date Birth: [**2090-5-19**] Sex: Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[**First Name3 (LF) 12174**] Chief Complaint: coffee ground emesis Major Surgical Invasive Procedure: EGD Right IJ CVL History Present Illness: Mr. [**Known lastname 52368**] 59M w HepC cirrhosis c/b grade I/II esophageal varices portal gastropathy (last EGD [**3-/2150**]), p/w coffee-ground emesis melena x2 days. . Pt USOH 2-3 days PTA, began experiencing intermittent nausea. 2-3 episodes coffee-ground emesis 1 episode tarry black stool morning admission. reports lightheadedness new, denies frank hematemesis, BRBPR, abdominal pain, fever, chills, significant increases abdominal girth. denies drinking medication non-compliance. also reports taking naproxen back pain 2-3 times day recent past. . ED, vitals 97.4, 93/41, 69, 18, 100% RA. given 4L NS IV, protonix 40mg IV, started octreotide drip. guaiac positive brown stool rectal exam. seen liver fellow ED felt unlikely variceal bleed recommended work infection. NG tube attempted, however, patient unable tolerate ED. Abdominal ultrasound done showed patent portal vein, scant ascites enough tap. BP dropped 80/34, pt transferred MICU hemodynamic monitoring. . MICU, pt given 3 pRBC, Hct bumped 21.3 28. Started norepinephrine gtt hours, BP stabilized. transfer floor, remains hemodynamically stable. Feels good, denies tarry bloody BMs, emesis. Past Medical History: HCV Cirrhosis (tx interferon x2 response) Portal Gastropathy Grade II Esophageal varices HTN Social History: lives alone. drinking alcohol, usually one session per week. four five drinks per session. told completely abstain alcohol, effective today. smokes 20 cigarettes per day. Family History: NC Physical Exam: ADMISSION: VS: T95.9 HR 71 BP 83/36 RR 11 96% 2L NC Gen: somnolent, oriented x 3, unable assess asterixis given somnolence HEENT: PERRLA, EOMI Neck: supple, JVP angle jaw (fluid bolus running wide open) CV: RRR s1 s2 appreciable murmur Lungs: CTAB Abd: distended, non tender, rebound guarding, bowel sounds positive Ext: 1+ pitting edema bilaterally Skin: warm, diaphoretic, rash lesions noted Pertinent Results: LABS ADMISSION: [**2150-4-17**] 01:30PM BLOOD WBC-17.9*# RBC-2.78* Hgb-8.5* Hct-26.0* MCV-94 MCH-30.6 MCHC-32.7 RDW-20.6* Plt Ct-186 [**2150-4-17**] 01:30PM BLOOD Neuts-61.2 Lymphs-28.8 Monos-6.9 Eos-2.2 Baso-0.9 [**2150-4-17**] 02:13PM BLOOD PT-17.7* PTT-34.5 INR(PT)-1.6* [**2150-4-17**] 01:30PM BLOOD Glucose-92 UreaN-51* Creat-1.3* Na-131* K-5.7* Cl-104 HCO3-21* AnGap-12 [**2150-4-17**] 01:30PM BLOOD ALT-126* AST-260* LD(LDH)-426* AlkPhos-157* TotBili-3.3* [**2150-4-17**] 06:41PM BLOOD Calcium-7.5* Phos-3.8 Mg-1.9 . LABS DISCHARGE: [**2150-4-21**] 05:00AM BLOOD WBC-10.7 RBC-2.94* Hgb-9.6* Hct-27.0* MCV-92 MCH-32.6* MCHC-35.6* RDW-21.2* Plt Ct-110* [**2150-4-21**] 05:00AM BLOOD PT-17.4* PTT-35.6* INR(PT)-1.6* [**2150-4-21**] 05:00AM BLOOD Glucose-84 UreaN-15 Creat-1.0 Na-132* K-4.4 Cl-99 HCO3-25 AnGap-12 [**2150-4-21**] 05:00AM BLOOD ALT-113* AST-210* AlkPhos-111 TotBili-3.6* [**2150-4-21**] 05:00AM BLOOD Calcium-8.1* Phos-3.8 Mg-1.7 . LABS: [**2150-4-18**] 06:25AM BLOOD CK-MB-9 cTropnT-<0.01 [**2150-4-17**] 06:41PM BLOOD CK-MB-11* MB Indx-4.9 cTropnT-<0.01 [**2150-4-17**] 01:30PM BLOOD Lipase-85* . URINE: [**2150-4-17**] 11:01PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 [**2150-4-17**] 11:01PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG [**2150-4-17**] 11:01PM URINE RBC-63* WBC-7* Bacteri-NONE Yeast-NONE Epi-<1 . MICROBIOLOGY: Blood, urine cultures - negative H.pylori serum antibody - negative . CARDIOLOGY: . TTE ([**4-18**]): Conclusions left atrium dilated. Left ventricular wall thicknesses cavity size normal. Left ventricular systolic function hyperdynamic (EF>75%). Right ventricular chamber size free wall motion normal. aortic valve leaflets (3) mildly thickened aortic stenosis present. aortic regurgitation seen. mitral valve leaflets mildly thickened. Mild (1+) mitral regurgitation seen. moderate pulmonary artery systolic hypertension. pericardial effusion. IMPRESSION: Hyperdynamic LV systolic function. Mild mitral regurgitation. Moderate pulmonary artery systolic hypertension. . EKG ([**4-17**]): Sinus rhythm Prolonged QT interval nonspecific clinical correlation suggested previous tracing available comparison Intervals Axes Rate PR QRS QT/QTc P QRS 70 160 96 462/479 70 55 52 . GI: EGD ([**4-20**]): 1. Varices lower third esophagus middle third esophagus. 2. Erythema erosion antrum pylorus compatible non-steroidal induced gastritis. 3. Bleeding pyloric ulcer pylorus compatible non-steroidal induced ulcer (injection, thermal therapy). 4. Normal mucosa duodenum. 5. Otherwise normal EGD third part duodenum . RADIOLOGY: . CXR ([**4-17**]): prominent bulge right heart border could due pericardial effusion, _____ cyst, enlarged right atrium. mediastinal vascular engorgement suggest cardiac tamponade. Pulmonary vasculature normal. lungs clear pleural effusion. Overall heart size normal. Right jugular line ends junction brachiocephalic veins. pneumothorax pleural effusion. . ABD U/S ([**4-17**]): IMPRESSION: 1. son[**Name (NI) 493**] evidence portal venous thrombosis. Portal vein flow hepatopetal wall-to-wall. 2. significant ascites. sliver perihepatic ascites. 3. Persistent coarsened echotexture liver consistent known history cirrhosis. 4. Splenomegaly Brief Hospital Course: Mr [**Known lastname 52368**] 59M w HCV cirrhosis w grade II esophageal varices admitted w coffee-ground emesis melena concerning UGIB, s/p MICU stay hypotension. . # UGIB: Pt bleeds hospital. EGD revealed erythema erosion antrum pylorus compatible non-steroidal induced gastritis. Pt remember taking increased doses naproxen backache. Started pantoprazole 40mg PO BID one week repeat endoscopy scheduled one week ([**4-30**]). Recommended take tylenol (max daily dose 2gm) pain instead NSAIDs. Blood pressure meds held first, given MICU admission hypotension, restarted discharge. . # HCV Cirrhosis: appears progressing liver failure, elevated INR 1.6, decreased albumin 2.6, tbili slightly elevated 3.6, chronic LE edema. Pt continued prophylactic medications. . # FULL CODE Medications Admission: FUROSEMIDE 20mg daily LISINOPRIL 10 mg daily SPIRONOLACTONE 100 mg daily Discharge Medications: 1. Phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous membrane PRN (as needed). 2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times day). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO day. 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**6-15**] hours needed: 6 tablets regular strength tylenol per day. 8. Terbinafine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times day) 1 weeks. Disp:*qs * Refills:*0* 9. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice day 1 weeks: take 1 tablet daily. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times day) needed itching. Disp:*qs * Refills:*0* 12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO day. Discharge Disposition: Home Discharge Diagnosis: Peptic ulcer GI bleed Discharge Condition: asymptomatic Discharge Instructions: admitted bleeding ulcer stomach. ulcer least partially caused naproxen. stop taking naproxen take tylenol pain. take NSAIDS pain including ibuprofen, naproxen, aleve, motrin, aspirin, toradol, advil. okay take tylenol take 4 extra strength tylenol day (2gram daily maximum). . following medication changes made: take naproxen Take pantoprazole 40 mg twice daily one week. take 40 mg daily. . scheduled get repeat endoscopy next week. Prior procedure anything drink eat midnight. . Please return ER chest pain, lightheadeness, fever, chills, bloody black stools concerning symptoms. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2150-4-30**] 1:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2150-4-30**] 1:30 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2150-5-7**] 11:00 Completed by:[**2150-4-24**] | [
"2851",
"4019"
] |
Admission Date: [**2108-4-6**] Discharge Date: [**2081-4-7**] Date Birth: [**2059-5-7**] Sex: F Service: MED CHIEF COMPLAINT: Dyspnea. HISTORY PRESENT ILLNESS: 48 year old African American female history multiple myelomas admitted respiratory distress. patient recently discharged one week ago outside hospital ([**Hospital3 7900**]) respiratory distress. Back [**Hospital3 7362**], given nebulizer, antibiotics steroids. also elevated INR given medication lower INR although evidence bleeding. Last night, reports increased difficulty breathing. also cough. denies fever chills. patient admitted decreased p.o. intake recently sedimentary. denies swelling legs. patient noted wheezing took Albuterol inhaler without effect. Prednisone taper reports coughing thick sputum. went primary care provider today could say sentence sent Emergency Department. Emergency Department, tachypneic wheezing heart 120 blood pressure 127/82. received Solu-Medrol continued nebulizer treatment. improved, seemed tiring. ABG done showed pH 7.41; PCO2, 40; PO2, 92. speak full sentences still making wheezing. requiring continued nebulizer treatment denies chest pain, nausea, vomiting, diarrhea abdominal pain. feels weak general. PAST MEDICAL HISTORY: 1. Multiple myeloma diagnosed [**2107-12-9**], increase protein bone marrow biopsy. receive Decadron 40 mg q every week. 2. Pulmonary embolism, [**2108-1-2**]. 3. Asthma. PFTs ..................... 4. History steroid psychosis. 5. Pneumonia requiring intubation [**2107-12-9**]. MEDICATIONS UPON ADMISSION: 1. Coumadin 2.5 mg p.o. q d. 2. Serevent two puffs q.i.d. 3. Albuterol inhaler one two puffs q 6 hours prn. 4. Dexamethasone 10 mg p.o. q d. ALLERGIES: known drug allergies. SOCIAL HISTORY: Socially, lives children works home home health aid. twenty years two pack day smoking history quit [**2107-12-9**]. drinks occasional alcohol. FAMILY HISTORY: Family history shows father died myocardial infarction. Sister ovarian cancer. PHYSICAL EXAMINATION UPON ADMISSION: Temperature, 96.6; heart rate, 122; blood pressure, 127/82; respiratory rate, 24; O2 saturation, 99%. Head, eyes, ears, nose throat, pupils equal, round, reactive light accommodation extraocular movements intact. accessory muscles used. Neck supple without lymphadenopathy. Pulmonary, diffuse wheezing bibasilar crackles left greater right. Cardiac, regular rate rhythm normal S1 S2. murmurs thrills noted. Abdomen soft, nontender, nondistended normal active bowel sounds. Extremities, edema, cyanosis clubbing noted. Neurologically, patient somnolent oriented x 3. focal defects noted. LABORATORIES UPON ADMISSION: White count, 9.6; neutrophils, 66%; lymphocytes, 5%; bandemia, 21%; monocytes, 1%. Sodium, 131; potassium, 4.4; chloride, 92; bicarbonate, 24. BUN, 14; creatinine, 0.8. Glucose, 131. INR, 1.3. PTT, 29.1. ABG, 7.41; PCO2, 40; PO2, 92. HOSPITAL COURSE: 1. Pulmonary - Dyspnea secondary chronic obstructive pulmonary disease/emphysema hospital course. Briefly, patient received BIPAP, ...................., intravenous Solu-Medrol, nebulizer treatment inhaler treatment Intensive Care Unit. able weaned oxygen back room air, sating 93 94 percent. Though chest x-rays show hyperinflation signs infection, given five days worth Zithromax. echocardiogram rule cardiac wheezes showed ejection fraction greater 55%, mild right ventricular dilation mild pulmonary arterial pressure. Pulmonary function tests performed showing obstructive pattern FEC 2.56 93% predicted FEV1 0.9 43% predicted FEV1 FEC ratio 46%. patient transferred Medical Floor, CT performed showed evidence pulmonary embolism show signs emphysema. Sputum cultures sent showed growth organism. Alpha antitrypsin sent still pending. 2. Pulmonary Embolism - patient continued Coumadin INR 2 3. Since subtherapeutic, started Lovenox became therapeutic Coumadin. 3. Psychiatry - Anxiety. patient quite anxious hospital course. Psychiatry called consult recommended Risperidone 0.25 mg q hs. patient well medication. 4. Oncology - Multiple myeloma. protein electrophoresis done showing monoclonal IGG capa gammaglobulinopathy (60% total protein [**2108-1-8**], 66% total protein [**2108-4-9**], despite q weekly Dexamethasone treatment. Bone marrow biopsy done revealing 70 80 percent plasma cells. Given findings, patient transferred [**Hospital Ward Name 516**] start chemotherapy Vincristine, ................... Decadron preparation bone marrow transplant done. [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**] Dictated By:[**First Name3 (LF) 30667**] MEDQUIST36 D: [**2108-4-17**] 15:47 T: [**2108-4-17**] 15:46 JOB#: [**Job Number 30668**] | [
"51881",
"486",
"2761",
"V1582"
] |
Admission Date: [**2145-3-31**] Discharge Date: [**2145-4-7**] Date Birth: [**2071-6-4**] Sex: F Service: SURGERY Allergies: Penicillins / Dilantin Attending:[**First Name3 (LF) 301**] Chief Complaint: Severe abdominal back pain Unable take oral intake. flatus bowel movement. Abdominal distention. Major Surgical Invasive Procedure: Exploratory Laparotomy Lysis adhesions Small Bowel Resection Jejunosotomy History Present Illness: Ms [**Known lastname **] 73 year old female history multiple abdominal surgeries, pancreatitis previous SBO. presented Emergency Department [**2145-3-30**] complaints [**11-10**] abdominal pain, radiating back began morning. complains distention, inability bowel movement, inability take oral intake, fever, chills diarrhea. Past Medical History: Chronic Pancreatitis Migraines Surgical history: Pancreatic diversion, cholecystectomy, appendectomy, small bowel obstruction. Social History: Married, lives husband retired pediatric infectious disease doctor. Family History: Father: deceased, leukemia Brother: colon cancer Physical Exam: T: 97.9 HR: 79 BP: 153/60 RR: 22 Spo2 100% RA Constitutional: pain Head/Eyes: mucous membranes dry ENT/Neck: neck supple Chest/Respiratory: Clear auscultation Bilaterally GI/Abdominal: Tender light palpation. Multiple well healed scars + guarding, hypoactive bowel sounds GU: costovertebral angle tenderness Musculoskeletal: WNL Skin: Dry Neuro: alert & oriented Pertinent Results: [**2145-3-30**] 09:15PM BLOOD Glucose-116* UreaN-16 Creat-0.8 Na-139 K-3.8 Cl-103 HCO3-25 AnGap-15 [**2145-3-31**] 10:26AM BLOOD WBC-12.3*# RBC-4.01* Hgb-12.3 Hct-37.1 MCV-93 MCH-30.6 MCHC-33.0 RDW-14.2 Plt Ct-259 [**2145-3-30**] 09:15PM BLOOD ALT-12 AST-22 AlkPhos-89 Amylase-169* TotBili-0.3 [**2145-4-2**] 06:15AM BLOOD Amylase-107* [**2145-3-31**] 10:26AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.6 [**2145-3-31**] 12:44AM BLOOD Lactate-3.1* [**2145-4-2**] 02:10PM BLOOD Lactate-1.9 [**2145-3-30**] 11:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG . ABDOMEN (SUPINE & ERECT) IMPRESSION: Nonspecific bowel gas pattern without evidence obstruction. . CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST IMPRESSION: 1. High grade small-bowel obstruction. Unusual configuration loop small bowel mid abdomen concerning closed loop obstruction. moderate amount free fluid within abdomen. 2. Ill-defined opacity right middle lobe representing infection BAC evaluated PET CT. 3. Thickening first portion duodenum, uncertain clinical significance. . CHEST (PORTABLE AP) [**2145-4-2**] 1:51 PM IMPRESSION: Right lower lobe airspace opacity, could represent pneumonia appropriate clinical setting. Small bilateral pleural effusions. Followup assure resolution recommended. . CT Chest [**2145-4-2**] IMPRESSION: 1. New right lower lobe pneumonia. Small bilateral pleural effusion left basilar atelectasis. 2. Ill-defined opacity right middle lobe representing either infection BAC evaluated acute issues resolve. 3. evidence pulmonary embolus aortic dissection. 4. Small mediastinal axillary lymph nodes, meet CT criteria pathologically enlargement. CXR [**2145-4-6**] IMPRESSION: 1. Improving airspace consolidation right lower lung field consistent resolving pneumonia. 2. Small bilateral pleural effusions. Brief Hospital Course: Ms [**Known lastname **] admitted emergency room [**2145-3-31**] taken operating room. underwent uncomplicated exploratory laparatomy small bowel resection, jejunosotomy lysis adhesions, see op report details. stabilized PACU, transferred SICU POD#1. extubated, pain well controlled morphine PCA, remained NPO NGT foley catheter. initiated Cefazolin/Flagyl x 24 hours. POD#2 developed confusion decreased oxygen saturation, requiring 3L nasal cannula. Narcotics stopped, CXR CT chest obtained revealed right lower lobe pneumonia, see pertinent results details. Vanc/Levo/Flagyl initiated well ID medicine consult. transferred SICU. POD#[**4-4**] remained SICU, mental status respiratory status improved. POD#4 NGT removed transferred [**Hospital Ward Name 121**] 9, weaned room air. pain well controlled tylenol small doses oxycodone. POD#5 reported flatus followed multiple loose stools. Stool C diff negative. started sips, tolerated easily. POD#6 tolerated clear liquids longer wanted take antibiotics due frequent stools. CXR repeated showed resolving pneumonia. tolerated regular diet evening without difficulty. Infectious disease team recommended completion 7 days Levofloxacin. Clips removed POD#7, discharged home stable condition antibiotics, pain medication appropriate follow appointments. Medications Admission: Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) needed. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 6. Trileptal Resume home dose trileptal Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 0.5-1 Tablet PO Q4-6H (every 4 6 hours) needed. Disp:*30 Tablet(s)* Refills:*0* 2. Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) needed. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 6 hours) needed. 5. 7. Levaquin 500 mg Tablet Sig: One (1) Tablet PO day. Disp:*7 Tablet(s)* Refills:*0* Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 6. Trileptal Resume home dose trileptal Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Internal hernia necrotic jejunum Pneumonia Discharge Condition: good Discharge Instructions: Please call surgeon develop chest pain, shortness breath, fever greater 101.5, foul smelling colorful drainage incisions, redness swelling, severe abdominal pain distention, persistent nausea vomiting, inability eat drink, symptoms concerning you. tub baths swimming. may shower. clear drainage incisions, cover dry dressing. Leave white strips incisions place, allow fall own. Activity: heavy lifting items [**11-15**] pounds follow appointment doctor. Medications: Resume home medications. problem constipation, take stool softener, Colace 100 mg twice daily needed. given pain medication may make drowsy. driving taking pain medicine. Followup Instructions: Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2145-4-20**] 2:00 appointment see Dr. [**Last Name (STitle) **] Friday, [**2145-4-23**] 3:30. Phone #: [**Telephone/Fax (1) 2723**]. Please see primary care physician regarding follow CT scan within 1 month. CT results Discharge summary faxed her. Completed by:[**2145-4-7**] | [
"486",
"4019"
] |
Admission Date: [**2162-5-16**] Discharge Date: [**2162-5-21**] Date Birth: [**2101-7-30**] Sex: Service: CARDIOTHORACIC Allergies: Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Angina Major Surgical Invasive Procedure: [**2162-5-17**]: CABGx4 LIMA-> LAD, RSVG-> Diagonal, Posterior Descending Artery, Obtuse marginal [**2162-5-19**]: Right Atrial lead placement History Present Illness: 60yo man known coronary disease (AMI [**2143**] [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LCx [**2155**]). well last week developed angina initially exertion progressed rest angina. episode releived SL NTG, episode lasting 5 minutes. presented cardiologist treatment. admitted MWMC, cardiac catheterization revealed 3 vessel disease. transferred [**Hospital1 18**] coronary bypass grafting. Cardiac Catheterization: Date: [**2162-5-11**] Place: MWMC -LAD- chronic total occlusion proximally(distal filling via collaterals) -RCA- chronic total occlusion non-dominant RCA 90% -LCx- new complex 90% stenosis prox LCx involving bifurcation LCx proper large OM2. Old stent LCx widely patent -mod LV systolic dysfx, anterior, apical, infero-apical AK reduced EF 30% LVEDP 36mmHg valvular dz Past Medical History: CAD-(AMI [**2143-7-3**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LCx [**6-/2155**]) Cardiomyopathy- EF 35-45% depending study Ventricular tachycardia s/p AICD [**8-/2155**] Atrial flutter s/p ablation [**8-/2155**] Hypertension Dyslipidemia Insulin dependent diabetes Mellitus Obesity Conduction disease-LAFB Peripheral vascular disease s/p Right fem-[**Doctor Last Name **] bypas [**3-/2161**] Left leg claudication Right thigh tumor s/p radiation excision [**2141**]'s Social History: Race: caucasian Last Dental Exam: Lives with: wife Occupation: [**Name2 (NI) 56028**] owns company Tobacco: 2ppd x20 yrs quit [**2143**] ETOH: occaisional Family History: Father died 50yo cirrhosis, mother died 42yo MI Physical Exam: Pulse: 58 Resp: 16 O2 sat: 97%-RA B/P Right: 124/76 Left: Height: 5'[**62**]" Weight: 259 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema -none Varicosities: None [x]. Well healed right vein harvest site. Neuro: Grossly intact Pulses: Femoral Right: +2 Left:+2 DP Right:+2 Left:+2 PT [**Name (NI) 167**]: +2 Left:+2 Radial Right: +2 Left:+2 Carotid Bruit none Right: +2 Left:+2 Pertinent Results: [**2162-5-17**]: Prebypass left atrium dilated. spontaneous echo contrast seen body left atrium left atrial appendage. spontaneous echo contrast seen body right atrium. atrial septal defect seen 2D color Doppler. Left ventricular wall thicknesses normal. left ventricular cavity severely dilated. moderate regional left ventricular systolic dysfunction hypokinesis apex septum. Overall left ventricular systolic function mildly depressed (LVEF=30-35%). estimated cardiac index depressed (<2.0L/min/m2). Focal abnormalities seen mid apical anteroseptal wall, apical anterior wall, mid apical inferoseptal wall, apical inferior wall. thrombus seen LV apex. Right ventricular chamber size free wall motion normal. descending thoracic aorta mildly dilated. aortic valve leaflets (3) mildly thickened focal calcification non-coronary cusp moves poorly. minimally increased gradient consistent minimal aortic valve stenosis. aortic regurgitation seen. mitral valve leaflets mildly thickened. Mild moderate ([**1-3**]+) mitral regurgitation seen. mitral valve prolapse flail segments. pericardial effusion. Postbypass patient A-paced phenylephrine infusion. Biventricular systolic function unchanged. Mitral regurgitation remains mild-to-moderate. thoracic aorta intact post decannulation. [**2162-5-20**] 05:00AM BLOOD WBC-10.9 RBC-3.73* Hgb-11.2* Hct-31.7* MCV-85 MCH-30.1 MCHC-35.4* RDW-13.9 Plt Ct-114* [**2162-5-20**] 05:00AM BLOOD Glucose-151* UreaN-19 Creat-0.7 Na-135 K-3.9 Cl-100 HCO3-28 AnGap-11 [**2162-5-16**] 05:00PM BLOOD ALT-66* AST-55* LD(LDH)-206 AlkPhos-73 TotBili-0.3 Brief Hospital Course: patient admitted hospital brought operating room [**2162-5-17**] patient underwent Coronary artery bypass graft x 4. See operative note details. Overall patient tolerated procedure well post-operatively transferred CVICU stable condition recovery invasive monitoring. POD 1 found patient extubated, alert oriented breathing comfortably. Electrophysiology team consulted due non capturing atrial lead permanent pacemaker initially interrogated epicardial wires removed. Ventricular lead ICD functioning appropriately. right atrial lead revised [**5-19**] without complication. follow device clinic [**Hospital1 **] 2 weeks - operative note given patient bring follow appointment. patient neurologically intact hemodynamically stable inotropic vasopressor support. Beta blocker initiated patient gently diuresed toward preoperative weight. Lisinopril restarted better blood pressure. patient transferred telemetry floor recovery. Chest tubes discontinued without complication post operative day 3. patient evaluated physical therapy service assistance strength mobility. time discharge POD 4 patient ambulating freely, sternal pacer pocket wound healing pain controlled oral analgesics. continue 1 week antibiotics per EP s/p atrial lead placement. patient discharged home VNA services good condition appropriate follow instructions. follow appointments arranged. Medications Admission: Lisinopril 20' Atenolol 100' Vytorin [**10/2131**] QHS Fenofibrate 200' ASA 325' NTG-sl/PRN Insulin-NPH 22u QAM/24u QPM- followed [**Last Name (un) **] Insulin- Humalog SS MVI Calcium 600' Plavix - last dose:[**2162-5-12**] Allergies: NKDA Discharge Medications: 1. fenofibrate 160 mg Tablet Sig: One (1) Tablet PO day. Disp:*30 Tablet(s)* Refills:*0* 2. simvastatin 80 mg Tablet Sig: One (1) Tablet PO day. Disp:*30 Tablet(s)* Refills:*2* 3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*1* 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*100 Tablet(s)* Refills:*0* 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) needed constipation. 7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times day). Disp:*60 Tablet(s)* Refills:*2* 8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) needed pain. Disp:*65 Tablet(s)* Refills:*0* 9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) 7 days. Disp:*28 Capsule(s)* Refills:*0* 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO day 7 days. Disp:*7 Tablet(s)* Refills:*0* 12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO day 7 days. Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0* 13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times day). Disp:*60 Tablet(s)* Refills:*2* 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) needed pain. 15. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1) Subcutaneous twice day: Take 22 units 24 units PM. Disp:*QS 1 month * Refills:*0* 16. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary Artery Disease CAD-(AMI [**2143-7-3**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LCx [**6-/2155**]),Cardiomyopathy- EF 35-45% Ventricular tachycardia s/p AICD [**8-/2155**], Atrial flutter s/p ablation [**8-/2155**], Hypertension, Dyslipidemia,Insulin dependent diabetes Mellitus, Obesity, Conduction disease-LAFB, Peripheral vascular disease s/p Right fem-[**Doctor Last Name **] bypas [**3-/2161**], Left leg claudication, Right thigh tumor s/p radiation excision [**2141**]'s Discharge Condition: Alert oriented x3 nonfocal Ambulating steady gait Incisional pain managed Percocet Incisions: Sternal - healing well, erythema drainage Leg Left - healing well, erythema drainage. 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently mild soap, baths swimming cleared surgeon. Look incisions daily redness drainage Please lotions, cream, powder, ointments incisions morning weigh evening take temperature, written chart driving approximately one month taking narcotics, discussed follow appointment surgeon able drive lifting 10 pounds 10 weeks Please call questions concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office questions concerns [**Telephone/Fax (1) 170**]. Answering service contact call person hours** Followup Instructions: scheduled following appointments Surgeon: Dr [**Last Name (STitle) **] [**6-10**] 1:45pm [**Telephone/Fax (1) 170**] Cardiologist: Dr. [**Last Name (STitle) 1295**] [**6-14**] 3:30pm EP [**Hospital 19721**] Clinic [**Hospital1 **] [**1-3**] weeks: Call appointment - [**Telephone/Fax (1) 6256**] Wound check appointment [**Hospital **] Medical office building [**Telephone/Fax (1) 170**] Date/Time:[**2162-5-26**] 12:00 Please call schedule appointments Primary Care Dr. [**Last Name (STitle) 27187**] [**4-6**] weeks [**Telephone/Fax (1) 3658**] Follow [**Hospital **] [**Hospital 982**] Clinic arranged patient **Please call cardiac surgery office questions concerns [**Telephone/Fax (1) 170**]. Answering service contact call person hours** Completed by:[**2162-5-24**] | [
"41401",
"25000",
"V4582",
"V1582",
"2859",
"4019",
"2720",
"V5867"
] |
Admission Date: [**2177-8-29**] Discharge Date: [**2177-9-12**] Date Birth: [**2156-2-27**] Sex: Service: SURGERY Allergies: Patient recorded Known Allergies Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: Helmeted motocyclist hit tree Major Surgical Invasive Procedure: [**2177-8-29**] 1. Irrigation debridement inclusive bone, right open femur fracture. 2. Retrograde intramedullary nailing Synthes 11 x 360 nail. 3. Open reduction internal fixation patella fracture K-wires figure-of-8 tension band construct. [**2177-9-4**] Tracheostomy IVC filter [**2177-9-12**] PICC right bascilic vein History Present Illness: 21 y.o. male helmeted moped rider struck tree reported GCS 6 scene. Patient transported OSH noted right sided open femur fracture. received antibiotics intubated prior transfer. Patient transported radiographic studies performed showed right femur fracture, SAH, grade II liver lac, pulmonary contusions, small PTX. Patient reportedly received 1 unit pRBCs ED placed traction splint RLE. Past Medical History: None Social History: tobacco none ETOH none Family History: Non-contributory. Physical Exam: 96.9 130 150/97 20 100% intubated sedated HEENT - L eye abrasions, pupils nonreactive bilaterally CTA b/l rapid HR, regular rhythm SNDNT pelvic fracture + palpable distal pulses Pertinent Results: [**2177-8-29**] 04:35AM BLOOD WBC-17.7* RBC-4.76 Hgb-15.2 Hct-45.5 MCV-96 MCH-32.0 MCHC-33.5 RDW-13.2 Plt Ct-314 [**2177-8-30**] 12:50AM BLOOD WBC-7.6 RBC-2.73* Hgb-9.0* Hct-25.0* MCV-92 MCH-32.8* MCHC-35.9* RDW-13.5 Plt Ct-188 [**2177-8-31**] 01:49AM BLOOD WBC-9.4 RBC-2.42* Hgb-7.8* Hct-21.7* MCV-89 MCH-32.1* MCHC-35.9* RDW-14.5 Plt Ct-148* [**2177-9-1**] 03:13AM BLOOD WBC-9.2 RBC-2.87* Hgb-9.0* Hct-25.6* MCV-90 MCH-31.6 MCHC-35.3* RDW-15.0 Plt Ct-128* [**2177-9-2**] 01:40AM BLOOD WBC-7.7 RBC-2.78* Hgb-8.8* Hct-24.6* MCV-88 MCH-31.5 MCHC-35.7* RDW-15.4 Plt Ct-164 [**2177-9-3**] 12:53AM BLOOD WBC-8.9 RBC-2.94* Hgb-9.3* Hct-26.2* MCV-89 MCH-31.8 MCHC-35.6* RDW-15.7* Plt Ct-220 [**2177-9-4**] 01:08AM BLOOD WBC-7.7 RBC-2.99* Hgb-9.5* Hct-27.3* MCV-91 MCH-31.7 MCHC-34.7 RDW-15.5 Plt Ct-313 [**2177-9-5**] 02:32AM BLOOD WBC-8.4 RBC-2.91* Hgb-9.0* Hct-26.9* MCV-92 MCH-30.9 MCHC-33.5 RDW-15.6* Plt Ct-412 [**2177-9-6**] 01:58AM BLOOD WBC-12.1* RBC-2.86* Hgb-9.0* Hct-26.5* MCV-93 MCH-31.6 MCHC-34.0 RDW-15.2 Plt Ct-418 [**2177-9-7**] 02:12AM BLOOD WBC-14.4* RBC-3.00* Hgb-9.3* Hct-27.6* MCV-92 MCH-30.9 MCHC-33.7 RDW-14.7 Plt Ct-556* [**2177-9-8**] 01:59AM BLOOD WBC-14.7* RBC-3.25* Hgb-10.0* Hct-29.7* MCV-91 MCH-30.6 MCHC-33.6 RDW-14.5 Plt Ct-748* [**8-29**] CT head - Multiple foci parenchymal hemorrhage well small amount likely subarachnoid hemorrhage. location foci [**Doctor Last Name 352**]-white matter interface concerning diffuse axonal injury CT Cspine - fracture traumatic malalignment cervical spine CT torso - Extensive pulmonary contusions, worse right left. Hepatic lacerations small amount abdominal pelvic free fluid intermittent density. Bilateral rib fractures. Right femur/knee xrays - mid shaft femoral fracture mild varus angulation distal fragment relative proximal. also medial subluxation ~ 1 cortical width. [**9-2**] MRI cspine - Edema interspinous ligaments C3-C4 C7-T1, without evidence distraction. lobal central canal narrowing due congenital short pedicles. slightly exacerbated disc bulge C3-4. cord signal abnormality. Moderate right C4-5 neural foramen narrowing due uncovertebral osteophytes. [**9-3**] Bilateral LE LENIs - deep venous thrombosis involving right left lower extremity. LUE LENI - deep venous thrombosis left upper extremity. [**9-7**] CT Abdomen/Pelvis - Right pleural effusion associated compressive atelectasis. Considerable improvement appearance right lobe liver laceration. Small amount free fluid pelvis. Fractures left first right fourth fifth ribs. Fracture right transverse process T1. Brief Hospital Course: patient admitted trauma ICU. [**8-29**] - Patient admittd ICU. taken operation room ortho ORIF right femur (see operative report full details). Neurosurgery consulted ICP placed. started dilantin q1 hour neurochecks. [**Date range (1) 58392**] - patient transfused 4u PRBC decreasing Hct. right femur hematoma expanding limb soft fear compartment symdrome. Hct stabilized. Head CT stable. [**9-1**] - ICP discontinued neurosurgery signed off. Head CT stable. [**9-2**] - MR head c-spine performed. [**9-3**] - Bilateral LE LUE LENIs performed demonstrated DVT. [**9-4**] - patient went acute care service tracheostomy IVC filter placement. [**9-6**] - Patient dc'ed dophoff tube twice. [**9-7**] - CT A/P done persistent fevers rising white count. source fevers identified. Patient put trach collar. [**9-8**]: Awake, off-versed, following commands. Passed S&S regular diet Passy [**Last Name (un) 87596**] Valve. BAL cultures grew MRSA, kept Vanc now. Patient ready transferred floor, waiting bed. ` Following transfer Surgical floor continued make slow progress. trach tube plugged PMV tolerated well. confirming aspiration video swallow tolerating regular diet thin liquids. Physical Therapy Occupational Therapy services followed daily basis increase mobility increase cognitive abilities. memory decreased occasionally confusion improving day. PICC line placed [**2177-9-12**] IV antibiotics require Vancomycin thru [**2177-9-16**] MRSA pneumonia. minimal secretions undergoing nebulizer treatments. Potentially IVC filter removed Dr. [**Last Name (STitle) **] evaluate weeks therefore need return [**Hospital 2536**] Clinic. also follow Neuro cognitive clinic Dr. [**First Name (STitle) **] following discharge rehab. lonfg hospitalization transferred rehab [**2177-9-12**] therapy goal return home soon. Medications Admission: None Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) needed temp > 101.5. 2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) needed constipation. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times day). 4. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times day) needed abrasions. 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times day). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Vancomycin 1,000 mg Recon Soln Sig: 1500 (1500) mg Intravenous every eight (8) hours: thru [**2177-9-16**]. 10. Morphine Concentrate 20 mg/mL Solution Sig: Fifteen (15) mg PO Q2H (every 2 hours) needed pain. 11. HYDROmorphone (Dilaudid) 1-2 mg IV Q2H:PRN pain Please use breakthrough PO/NG MSIR. 12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush 10mL Normal Saline followed Heparin daily PRN per lumen. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: S/P scooter v tree 1. Left eye abrasion 2. Rib fractures right [**5-5**], left 1 3. Bilat pulmonary contusions 4. Grade 2 liverlaceration 5. Open right femur fracture 6. Right thigh laceration 7. Right patellar fracture 8. Right metatarsal neck fracture [**3-7**] 9. Small SAH 10.Right TP fracture T1 11.[**Doctor First Name **] 12.Acute blood loss anemia Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Bed assistance chair wheelchair. Discharge Instructions: * admitted hospital multiple injuries following accident including head trauma, rib fractures, knee fracture liver laceration. * made alot progress need rehabilitation return home. * breathing well trach tube plugged hopefully removed improve. * Continue work physical therapy increase mobility. Followup Instructions: Please follow [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP orthopaedics 1 month, please call [**Telephone/Fax (1) 1228**] schedule appointment. Call [**Hospital 2536**] Clinic [**Telephone/Fax (1) 600**] follow appointment [**3-5**] weeks Call Vascular Surgery Clinic [**Telephone/Fax (1) 1237**] appointment 2 weeks Dr. [**Last Name (STitle) **]. Call [**Hospital 4695**] Clinic [**Telephone/Fax (1) 1669**] follow appointment 6 weeks Dr. [**First Name (STitle) **]. need Head CT prior appointment. secretary book you. Call Dr. [**First Name (STitle) **] Neuro cognitive Clinic [**Telephone/Fax (1) 1690**] appointment discharge rehab Completed by:[**2177-9-12**] | [
"2851"
] |
Admission Date: [**2177-3-12**] Discharge Date: [**2177-3-22**] Date Birth: [**2109-6-26**] Sex: Service: CARDIOTHORACIC Allergies: Shellfish Attending:[**First Name3 (LF) 1505**] Chief Complaint: exertional angina Major Surgical Invasive Procedure: [**2177-3-14**] Coronary ARTERY BYPASS GRAFTING x3 with: Left Internal Mammary Artery Left Anterior Descending Artery, Saphenous Vein Graft Obtuse Marginal Artery, Saphenous Vein Graft Posterior Descending Artery History Present Illness: 67 year old man known coronary artery disease-s/p stents x 6(2004x5 [**11-21**]) developed exertional angina walking [**3-9**]. Angina resolved w/ rest minutes. Angina recurred [**3-11**], patient brought [**Hospital **] Med Ctr enzymes negative. cardiac catheterization showed: tapering distal LM,70% osteal LAD,90% mid RCA. LVEF 60% LVgram. transferred [**Hospital1 18**] surgical management coronary artery disease. time transfer pain free. Past Medical History: Coronary artery disease(PCI/stents x6), Hypertension, HYPERCHOLESTEROLEMIA, CA- Left vocal cord(RT/chemo)[**3-20**] PSH:Left knee arthroscopy, Left chest Portacath Social History: Works administrator [**University/College 33918**]. Married, 2 children. Tob: Former smoker, quit 30 yrs ago. ETOH: Drinks beers cocktails per night. drugs Family History: Brother: MI 60, uncle: MI 50 Mother: htn Physical Exam: Pulse: Resp: O2 sat: B/P Right:130/72 Left: 128/72 Height: 70" Weight:175# General:WDWN, NAD Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x]glasses Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur n Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [**Name (NI) 167**]:2 Left:2 Radial Right:2 Left:2 Carotid Bruit Right:n Left:n Pertinent Results: Admission Labs: [**2177-3-12**] 04:05PM PT-11.7 PTT-23.8 INR(PT)-1.0 [**2177-3-12**] 04:05PM PLT COUNT-199 [**2177-3-12**] 04:05PM NEUTS-78.7* LYMPHS-9.6* MONOS-5.6 EOS-5.6* BASOS-0.5 [**2177-3-12**] 04:05PM WBC-6.9 RBC-3.93* HGB-14.0 HCT-38.2* MCV-97# MCH-35.6* MCHC-36.6* RDW-13.5 [**2177-3-12**] 04:05PM %HbA1c-5.2 eAG-103 [**2177-3-12**] 04:05PM ALBUMIN-4.1 MAGNESIUM-1.7 [**2177-3-12**] 04:05PM ALT(SGPT)-36 AST(SGOT)-24 LD(LDH)-148 ALK PHOS-100 TOT BILI-2.0* [**2177-3-12**] 04:05PM GLUCOSE-123* UREA N-14 CREAT-1.0 SODIUM-137 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14 [**2177-3-12**] 04:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2177-3-12**] 04:33PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 Discharge Labs: Radiology Report CHEST (PORTABLE AP) Study Date [**2177-3-17**] 7:29 Final Report: Comparison study [**3-15**], monitoring support devices removed except left subclavian catheter right IJ sheath. chest tube removed, evidence pneumothorax. Residual opacification left base consistent atelectasis effusion. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 55% >= 55% Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: Color-flow imaging interatrial septum raises suspicion atrial septal defect, could confirmed basis study. LEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Borderline normal RV systolic function. AORTIC VALVE: Three aortic valve leaflets. AS. Trace AR. MITRAL VALVE: MS. Mild (1+) MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve well seen. PERICARDIUM: Small pericardial effusion. GENERAL COMMENTS: TEE performed location listed above. certify present compliance HCFA regulations. patient general anesthesia throughout procedure. TEE related complications. patient appears sinus rhythm. Results personally reviewed MD caring patient. Conclusions Focused Intraoperative TEE chest exploration post-operative bleeding. Color-flow imaging interatrial septum raises suspicion atrial septal defect, could confirmed basis study. Regional left ventricular wall motion normal. Overall left ventricular systolic function normal (LVEF>55%). Borderline normal RV free wall function. three aortic valve leaflets. aortic valve stenosis. Trace aortic regurgitation seen. Mild (1+) mitral regurgitation seen. small pericardial effusion. Dr. [**Last Name (STitle) **] notified person results. Brief Hospital Course: Mr [**Known lastname 732**] transferred fro [**Hospital **] Med Ctr surgical management coronary artery disease. usual pre-operative workup brought operating room coronary artery bypass grafting [**2177-3-14**]. Please see operative report details. summmary had: Coronary Artery Bypass Grafting x3 Lwft Internal Mammary Artery Left Anterior Descending Artery, Saphenous Vein Graft Obtuse Marginal Artery, Saphenous Vein Graft Posterior Descending Artery. cardiopulmonary bypass time 51 minutes crossclamp time 39 minutes. tolerated operation well post-operatively transferred cardiac surgery ICU stable conditio. remained hemodynamically stable immediate post-op period. woke anesthesia neurologically intact extubated operative day. POD1 continued significant drainage chest tubes brought back operating room mediastinal exploration-no source bleeding found. tolerated procedure well returned cardiac surgery ICU stable condition. recovered anesthesia extubated shortly surgery completed. remained hemodynamically stable throughout period. tubes lines drains removed per cardiac surgery protocol. POD 3 transferred ICU stepdown floor continued post-op care recovery. Physical therapy worked patient advance activities daily living improve strength endurance. POD # 4, Pt develope drainage sternal incision. started IV Vancomycin. Betadine cleanse TID started. POD # [**4-19**], pts wound improved. discharged PO keflex x 10 days. wound DC without drainage. POD 10 discharged home visiting nurses. follow Dr [**Last Name (STitle) **] 3 weeks, sternal check [**3-26**] [**Hospital Ward Name **] 6. follow cardiologist, appt made, also instructed follow PCP. Medications Admission: Lisinopril 20mg daily, Lipitor 80mg daily, Plavix 75 mg [**Last Name (LF) **], [**First Name3 (LF) **] 325mg daily, Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). Disp:*60 Capsule(s)* Refills:*2* 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 4. [**Last Name (un) 1724**] Lisinopril 20mg daily,EcASA 325mg daily,Lopressor 25mg [**Hospital1 **],Plavix 75mg daily,NTG prn,Lipitor 80mg daily 5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times day). Disp:*180 Tablet(s)* Refills:*2* 7. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times day) 7 days. Disp:*14 Tablet(s)* Refills:*0* 8. potassium chloride 8 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice day 7 days. Disp:*14 Tablet Extended Release(s)* Refills:*0* 9. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times day 10 days. Disp:*40 Capsule(s)* Refills:*0* Discharge Disposition: Home Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Bypass Grafting x3 PCI/stents(6) PMH: Hypertension, HYPERCHOLESTEROLEMIA, CA- left vocal cord(RT/chemo)[**3-20**] PSH:lt knee arthroscopy, LT chest Portacath Discharge Condition: Alert oriented x3 nonfocal Ambulating steady gait Incisional pain managed Incisions: Sternal - healing well, erythema drainage Leg Right/Left - healing well, erythema drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently mild soap, baths swimming cleared surgeon. Look incisions daily redness drainage Please lotions, cream, powder, ointments incisions morning weigh evening take temperature, written chart driving approximately one month taking narcotics, discussed follow appointment surgeon able drive lifting 10 pounds 10 weeks Please call questions concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office questions concerns [**Telephone/Fax (1) 170**]. Answering service contact call person hours** Followup Instructions: scheduled following appointments Surgeon: Dr [**First Name (STitle) **] [**Name (STitle) **] [**2177-4-10**] 9AM [**Hospital1 **] Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5874**] [**2177-4-16**] 3PM Please call schedule appointments Primary Care Dr [**Last Name (STitle) **],[**First Name3 (LF) 488**] J. [**Telephone/Fax (1) 8036**] [**4-15**] weeks wound check scheduled [**5-26**] 1000 hrs, please come [**Hospital Ward Name **] 6 scheduled time. Thw midlevelers look wound see stable. **Please call cardiac surgery office questions concerns [**Telephone/Fax (1) 170**]. Answering service contact call person hours** Labs: PT/INR Coumadin ?????? indication Goal INR First draw Results phone fax Completed by:[**2177-3-22**] | [
"41401",
"4019",
"2720",
"V1582",
"V4582"
] |
Admission Date: [**2188-5-24**] Discharge Date: [**2188-5-30**] Date Birth: [**2132-11-19**] Sex: Service: MEDICINE Allergies: Ampicillin / Thorazine Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Respiratory Failure Major Surgical Invasive Procedure: Trach change Mechanical ventilation History Present Illness: Mr. [**Known lastname 89172**] 55 yo man PMH significant Downs Syndrome, MRSA pneumonia respiratory failure [**10/2187**] resulting tracheostomy reversed [**2188-5-13**], transferred s/p intubation [**Hospital1 **] [**Location (un) 1110**] today. Patient predominantly rehab since developing MRSA pneumonia [**10/2187**] (first [**Last Name (un) **] [**Hospital 5279**] Rehab Centers) presented [**Hospital1 **] rehab respiratory distress. started Rocephin [**5-22**] presumed pneumonia Rehab setting labored breathing. Patient intubated [**Hospital1 **] labored breathing, accessory muscle use. Per report, may failed attempt OSH ED re-open tracheostomy prior intubation. . OSH, patient received, levoquin 750mg @ 03:25, Vancomycin 1g @ 5:09 pneumonia. ordered 4L NS received least 2.5L. CXR CT Chest appeared show fluid overload. Patient difficult maintain sedation; blood pressure dropped propofol, patient briefly dopamine sedation switched versed boluses prn, tolerated well. Trach site serosanguinous fluid leakage, covered guaze tegaderm. Respiratory therapist ED confirmed air leakage ventilator. Patient transfered [**Hospital1 18**] management. . ED, initial VS follows: 99.9 (Rectal temp) 101 174/100 22 98% ventilator 100%FiO2. given 1amp D50 blood sugar 69. also received 250cc IVF 2.5mg bolus IV versed sedation ventilated. EKG showed sinus tach rate 103. CXR showed fluid overload possible consolidation, CTA chest done characterize ?consolidation rule PE. CTA showed signs PE confirmed RUL RML pneumonia, well fluid filled esophagus, suggesting aspiration. CT also showed moderate left small right effusions, pulmonary edema. Vitals ED prior transfer ICU follows: 99.8F HR 91 BP 92/53 RR 16 O2sat100% cpap FIO2 60%, PS 10, PEEP 5. . arrival unit, patient mechanically ventilated appears comfortable. accompanied sister able corroborate story. note, patient non-verbal baseline make signs, eats icecream [**Last Name (un) **] tea mouth (for pleasure) otherwise fed tube feeds. . Past Medical History: - Downs Syndrome - MRSA Pneumonia complicated tracheostomy [**10/2187**] - reversed [**2188-5-13**] - C Diff Colitis - [**2188**] - Pseudomonas Colitis - [**2188**] - dx colonoscopy, tx w cipro G-tube - Adrenal Insufficiency - Seizure History, per sister [**Name2 (NI) 89173**] hospitalization [**11-3**] - keppra - Hx transaminitis - presumed secondary antiepileptics - Hx HBV - Membranoproliferative Glomerulonephritis Social History: Lives Group Home, spent significant amount time Rehab since [**10/2187**] presented [**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) **]. [**Last Name (NamePattern1) 6961**] guardians, sister [**Name (NI) **] also involved care finances. Family History: NC Physical Exam: ADMISSION EXAM: GEN: Comfortable appearing, opens eyes command HEENT: ETT place. NECK: Tegaderm placed anterior neck; difficult assess opening skin. drainage erythema. CV: RRR, murmur LUNGS: Rhonchi anteriorly R>L, CTAB laterally sides ABD: Soft, non-tender distended. Central G-tube covered gauze tube feeds draining around opening. Ostomy erythematous, raw. erythema surrounding skin. EXT: LE cachectic, LE edema. DISCHARGE EXAM: GEN: Comfortable appearing, opens eyes command, distress HEENT/Neck: EOMI, trach place sputum surrounding, mild erythema around site CV: RRR, murmur LUNGS: Rhonchi anteriorly, CTAB laterally sides ABD: Soft, non-tender distended. Central G-tube covered gauze. Mildly erythematous around opening. EXT: LE cachectic, LE edema. Pertinent Results: ADMISSION LABS: . [**2188-5-24**] 11:50AM PT-18.8* PTT-31.4 INR(PT)-1.7* [**2188-5-24**] 11:50AM URINE RBC-28* WBC-7* BACTERIA-FEW YEAST-NONE EPI-0 TRANS EPI-<1 [**2188-5-24**] 11:50AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM [**2188-5-24**] 11:50AM WBC-11.7* RBC-2.84* HGB-10.5* HCT-31.6* MCV-111* MCH-37.1* MCHC-33.4 RDW-18.9* [**2188-5-24**] 11:50AM GLUCOSE-69* UREA N-54* CREAT-1.0 SODIUM-136 POTASSIUM-5.0 CHLORIDE-107 TOTAL CO2-24 ANION GAP-10 [**2188-5-24**] 12:00PM LACTATE-2.0 . DISCHARGE LABS: . [**2188-5-30**] 03:56AM BLOOD WBC-8.1 RBC-2.32* Hgb-8.9* Hct-26.7* MCV-115* MCH-38.5* MCHC-33.5 RDW-17.4* Plt Ct-130* [**2188-5-30**] 03:56AM BLOOD Glucose-83 UreaN-29* Creat-1.1 Na-135 K-3.7 Cl-108 HCO3-24 AnGap-7* [**2188-5-30**] 03:56AM BLOOD Calcium-7.3* Phos-2.5* Mg-1.5* [**2188-5-30**] 03:56AM BLOOD Vanco-25.0* . MICRO: C. diff negative Urine culture - growth Blood culture x2 - growth date IMAGING: CXR [**2188-5-24**]: 1. Endotracheal tube terminating carina. 2. Mild pulmonary interstitial edema. 3. Right upper zone opacity may reflect aspiration pneumonitis developing pneumonia. CT-A [**2188-5-24**]: IMPRESSION: 1. RUL RML pneumonia, possible due aspiration since esophagus fluid filled dilated. 2. PE. 3. Moderate left small right effusions, pulmonary edema. 4. Mediastinal lymphadenopathy 5. Acute left 7th rib fracture. G/GJ/GI TUBE CHECK FINDINGS: Supine radiographs demonstrate jejunostomy tube tip junction distal duodenum proximal jejunum. Contrast seen passing distally jejunum without evidence leak. Bowel gas pattern normal without evidence leak. Imaged portion lungs clear. Surgical clips noted overlying base heart. IMPRESSION: Jejunostomy tube appropriate position normal passage contrast without evidence leak. Brief Hospital Course: 55M hx Downs Syndrome, MRSA pneumonia c/b respiratory failure tracheostomy, s/p tracheostomy reversal 10d prior admission, transferred [**Hospital1 18**] hypoxic respiratory failure [**2-27**] RUL/RML aspiration PNA . # Aspiration PNA/respiratory distress: PE ruled potential cause respiratory distress. Imaging demonstrated RUL/RML pneumonia secondary aspiration, well airway narrowing site prior tracheostomy. Likely secondary aspiration, patient also noted fluid filled esophagus CT scan. Patient treated hospital acquired community acquired pneumonia Vancomycin, Levoquin Cefepime (8-day course). Cultures urine blood OSH showed growth. Aspiration may related overflow g-tube site. Tube feeds initially held, G tube study ordered showed jejunostomy tube appropriate position normal passage contrast without evidence leak. Patient steroids home adrenal insufficiency, PCP prophylaxis home bactrim daily started. Patient arranged transferred [**Hospital Ward Name 517**] ICU service extubation potential IP intervention site airway narrowing. IP found 0.8 cm focal area stenosis dynamic collapse 2nd tracheal ring. granulation tissue debrided IP replaced percutaneous trach existing stoma. Patient need evaluation tracheal resection/reconstruction IP o/p f/u 2 weeks. Post-procedure CXR showed multifocal PNA, unchanged bilateral effusions, trach appropriate position. Patient remained stable new trach place well prior discharge. last day levaquin cefepime [**2188-5-31**]. . # Recent history colitis: Reported recent history C.diff Pseudomembranous colitis. Patient several episodes lose stool. C. diff checked negative. . # syndrome/Anxiety: baseline, pt nonverbal. Pt restarted home dose ativan given evidence anxiety aggitation w/groups people intubated. . # Adrenal Insufficiency: History unclear patient currently prednisone 20 daily - patient outpatient endocrine evaluation. per [**Hospital 228**] rehab facility steroids started treat low sodium. Patient currently normal blood pressures. Steroid dose tapered 10mg daily 1 week outpatient follow electrolytes. Patient started PCP prophylaxis, remain going continue steroids long term. Patient follow-up endocrinology work-up possible renal insufficiency. OSH records faxed endocrinology department appointment made. . # Hx seizure disorder: Reportedly first seizure [**11-3**] time hospitalization MRSA pneumonia. Continued home dose Keppra. . #FEN: Concern leaking J tube site. Tube feeds held concern leaking feeding tube. Surgery consulted sutured tube place clamp. Dressing place tube site. . # Prophylaxis: SubQ heparin, Famotidine . # Contact: [**Name (NI) 6961**] = guardians, [**Name (NI) 449**] [**Name (NI) **] ([**0-0-**]), Sister [**Name (NI) **] [**Telephone/Fax (1) 89174**]. . # Code Status: FULL CODE (Confirmed family) Medications Admission: Prednisone 20mg daily Omeprazole 20mg [**Hospital1 **] Keppra 500mg [**Hospital1 **] (do crush) Ativan 0.25-0.5mg via PEG Q8h PRN (for moderate severe anxiety) Duonebs prn wheezing oxycodone Zinc Bacitracin ointment Bowel Regimen prn Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) 1110**] Discharge Diagnosis: Primary diagnosis: Subglottic stenosis Hosptial acquired pneumonia . Secondary diagnoses: ? Adrenal insufficiency Down's syndrome Seizure disorder Discharge Condition: Level Consciousness: Alert interactive. Activity Status: Bedbound. Mental Status: Confused - sometimes. (baseline) Discharge Instructions: pleasure participate care Mr. [**Known lastname 89172**]. admitted [**Hospital1 18**] evaluation respiratory failure. found narrowing trachea. taken procedure replace tracheostomy. also treated pneumonia. . concern G tube working appropriately. Surgery evaluated fixed J tube. . started steroids outpatient facility low sodium. decreased dose steroid started Bactrim prevent type lung infection called PCP. [**Name10 (NameIs) **] follow-up endocrinology evaluate need take steroids. . MEDICATION CHANGES: START Cefepime 2gm Q24 one day START Levofloxacin 750mg daily one day START Bactrim SS daily prophylaxis PCP DECREASE Prednisone 10mg daily Followup Instructions: Department: Thoracic Multi [**Hospital 4094**] Clinic When: TUESDAY [**2188-6-10**] 2:30 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: Thoracic Multi [**Hospital 4094**] Clinic When: TUESDAY [**2188-6-10**] 3:00 PM With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES - Endocrinology When: WEDNESDAY [**2188-6-11**] 3:15 PM With: MALA [**Last Name (NamePattern4) 16956**], MD [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2188-6-10**] 2:30 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2188-6-10**] 3:00 PM With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: WEDNESDAY [**2188-6-11**] 3:15 PM With: MALA [**Last Name (NamePattern4) 16956**], MD [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2188-5-30**] | [
"5070",
"51881"
] |
Admission Date: [**2176-8-29**] Discharge Date: [**2176-9-6**] Date Birth: [**2121-2-13**] Sex: Service: MEDICINE Allergies: Penicillins / Keflex Attending:[**First Name3 (LF) 1928**] Chief Complaint: Upper extremity weakness Major Surgical Invasive Procedure: C5-C6 anterior cervical decompression fusion, C1 tumor removal History Present Illness: 55-year-old man diabetes mellitus type 2, hypertension, severe peripheral [**First Name3 (LF) 1106**] disease s/p R SFA stent angioplasty L SFA stent placement, congenital pulmonic valve stenosis, CAD s/p BMS stents, diastolic CHF, atrial fibrillation s/p ablation warfarin, stage 3 diabetic nephropathy, intradural tumor compressing spinal cord C1/C2, admitted [**2176-8-29**] neurosurgery anterior cervical decompression C5/6 fusion ([**8-29**]) extradural tumor removal C1 intradural tumor ([**8-30**]). patient post-operatively managed ICU dexamethasone taper. developed small subdural hematoma ([**8-30**]) new neurologic symptom. Aspirin heparin SC restarted. Clopidogrel, L SFA stent, scheduled restarted POD#5, [**2176-9-4**], warfarin, atrial fibrillation, restarted [**2176-9-9**]. Patient extubated [**9-1**], coming furosemide drip dCHF. [**Month/Day (4) **] following patient mottled right foot recent [**Month/Day (4) 1106**] procedures. Patient's medical issues diabetes, HTN, CKD (Cr 1.1), atrial fibrillation (HRs 70s-80s), CAD s/p stent "chronic hyponatremia" (Na 138) stable. Transfer requested ongoing management diastolic CHF. evaluation SICU transfer, patient sleeping arousable, complaining old back pain constipation. Vital signs stable O2 saturation 98% 3L. Past Medical History: (1) Type 2 diabetes mellitus, requiring insulin, complications years poor glycemic control: -hypertension -severe peripheral [**Month/Day (4) 1106**] disease -peripheral neuropathy -pressure, venous stasis, neuropathic ulcers right left lower extremities -stage 3 diabetic nephropathy -renal insufficiency (baseline creatinine 1.5 1.7) (2) Atrial fibrillation status post ablation [**2169**] [**2174**], coumadin (3) Congenital pulmonic valve stenosis status post two childhood surgeries -history RV failure -history peripheral edema anasarca (4) Chronic hyponatremia (5) Chronic low back pain status post car accident (6) Spinal cord meningioma compressing spinal cord C1/C2 (7) COPD (8) Coronary artery disease status post stenting [**2169**] (bare metal stent Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] ([**Telephone/Fax (1) 8725**])) repeat stenting [**Hospital1 18**] [**2174**] (bare metal stent - see d/c summary [**2175-2-7**]) (9) MI [**2161**] Social History: patient married two adult sons live home. lives [**Hospital1 1474**], MA. wife works 60 hours week, left home day. bedbound several years. visiting nurse come week change dressings lower extremity ulcers. sons struggle alcoholism heroin abuse. younger son recently threatened suicide homicide (against patient's wife), source much stress home. used work "bouncer" construction, enjoyed riding motorcycle. patient says tries keep positive attitude condition. says feels depressed, says interested therapy medication depression. seen primary care physician [**Last Name (NamePattern4) **] 2 years travel ambulance PCP's office touch patient wife weekly. -[**Name2 (NI) **] 2 pack per year smoking history "several years" -He drinks alcohol occasionally, never problem alcoholism -He denies recreational IV drug use Family History: Heart disease unspecificed family members. Physical Exam: Physical exam admission: Gen: obese, deconditioned, pain movement extremities. Extrem: B LE edema Neuro: Mental status: Awake alert, cooperative exam. Language: Speech fluent good comprehension repetition. Naming intact. dysarthria paraphasic errors. Motor: Patient severe bilateral wasting muscles hand. UE's: FI's:[**2-1**] 4+/5 Grip 4+/5 Bi4+/5 Tri 4+/5. RLE: [**1-4**] PF/DF 0/5 LLE: IP3/5 PF/DF 0/5 Pertinent Results: [**2176-8-29**] 12:10PM GLUCOSE-94 UREA N-42* CREAT-1.2 SODIUM-133 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-28 ANION GAP-14 [**2176-8-29**] 12:10PM estGFR-Using [**2176-8-29**] 12:10PM WBC-7.6 RBC-3.91* HGB-9.7* HCT-30.5* MCV-78* MCH-24.9* MCHC-31.9 RDW-13.6 [**2176-8-29**] 12:10PM PLT COUNT-206 IMAGING STUDIES: # C-spine Xray [**8-29**]: Single lateral view cervical spine obtained portably OR, labeled #1. C1 C4/5 disc space visualized. C5 vertebral body faintly seen -- bony structures lower obscured overlying soft tissues. However, surgical markers seen overlying anterior aspects C4-5 C5-6 disc spaces, anterior approach. Support tubing temperature probles noted. # C-spine CT [**2176-8-29**]: 1. New interval C5-C6 anterior fusion intervertebral disc spacer, immediate hardware complication. Post-surgical changes soft tissue subcutaneous emphysema mostly right submandibular region. 2. Mass C1 level associated cord compression consistent known meningioma better described recent MRI. 3. Soft tissue thickening right lung apex, fully characterized current CT. comparison CT neck [**2176-8-9**], increased size. CT chest recommended evaluate further, clinically warranted. # Head CT [**2176-8-30**]: 1. New interval left frontal subdural hyperdense extra-axial fluid collection new interval subdural subfalcine extra-axial hyperdense fluid collection, indicating subdural hemorrhage, likely post-surgical clinical correlation recommended. 2. Pneumocephalus distribution basilar cisterns, mostly left sylvian fissure, bifrontally falx, likely post-surgical, additionally posterior fossa near site occipital craniotomy. 3. Post-surgical changes left craniotomy occipital bone laminectomy C1 subcutaneous emphysema hyperdense products, likely post-surgical. 4. Soft tissue hyperdensity posterior parietal, occipital soft tissue region, could small post-surgical hematoma. . # C-spine MRI [**2176-8-31**]: Status post resection C1 extradural tumor, likely meningioma expectorated postoperative changes. large intraspinal hematoma seen. remains persistent narrowing spinal canal C1 level indentation posterior aspect spinal cord. Continued followup recommended. Mild spinal cord atrophy could secondary chronic myelomalacia. . # LE arterial Duplex [**2176-9-3**]: peak systolic velocity involving native right common femoral artery 104 cm/sec. Velocities within superficial femoral artery range 85 234 cm/sec within popliteal artery right, 25 cm/sec. left, peak systolic velocity within common femoral artery 132 cm/sec, SFA, velocities range 146-75 cm/sec within popliteal artery 85 cm/sec. IMPRESSION: Findings stated indicate widely patent common femoral, superficial femoral popliteal arteries bilaterally. . PATHOLOGY: # C1 tumor [**2176-8-30**]: Cervical medullary junction tumor: Meningioma, psammomatous subtype (WHO Grade I). tumor composed meningothelial cells numerous psammoma bodies collagen deposition typical features mitotic activity. Brief Hospital Course: 55-year-old man diabetes mellitus type 2, severe peripheral [**Month/Day/Year 1106**] disease, CAD, diastolic CHF, atrial fibrillation, presented planned anterior cervical decompression C5-6 removal C1 meningioma. # Cervical myelopathy meningioma: Patient underwent anterior cervical decompression C5/6 fusion [**2176-8-29**] removal C1 meningioma [**2176-8-30**]. patient post-operatively managed ICU dexamethasone taper. developed small subdural hematoma [**2176-8-30**] new neurologic symptom. Per neurosurgery recommendations, aspirin heparin SC restarted. Clopidogrel, recent left SFA stent, restarted POD#5, [**2176-9-4**], warfarin, atrial fibrillation, restarted [**2176-9-9**]. note, concern developed LE weakness procedure, re-evaluation neurosurgery team felt strength legs baseline change. continued work PT hospitalization. # Diastolic heart failure: patient experienced acute exacerbation diastolic heart failure likely secondary significant fluid administration surgery. placed furosemide gtt SICU, transitioned home dose lasix floor. discharge slightly admission weight 115kg O2 sats mid 90's room air. # Peripheral [**Date Range **] disease. patient recently underwent bilateral SFA angioplasties Left SFA stenting. preparation neurosurgery, plavix held pre-procedure subsequently re-started [**2176-9-4**]. underwent bilateral arterial ultrasound [**2176-9-3**] demonstrated patent SFA femoral arteries. # Atrial fibrillation: patient atrial fibrillation hospitalization. Given need neurosurgery coumadin held. scheduled restarted 10 days post-procedure ([**2176-9-9**]). well rate controlled time discharge. # DM II. patient's insulin regimin adjusted 50 units insulin glargine nightly humalog insulin sliding scale achieved good control blood sugars (FSBS 100-180). # Pressure ulcers. patient 2x2cm right heel full thickness ulcer without odor drainage. right dorsum small 1x1cm partial thickness ulcer. Wound care nursing consult obtained. Pressure ulcer care performed repositioning, skin cleansing conditioner application, cover ABD kerlex. # Coping. pt expressed staff members mood poor coping well surgery. never expressed suicidal ideations. expressed extremely frustrated hospitalization inability walk function independently. Discussed possibility talking psychiatrists hospital, declined. felt feeling persisted would pursue psychiatric care. number psychiatric services provided discharge. # Chronic pain syndrome: patient continued home regimen dilaudid 4mg PO Q3H:prn # Chronic hyponatremia. patient history chronic hyponatremia although sodium remained 130-140 admission. Medications Admission: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID: PRN needed constipation. 2. Furosemide 10 mg/mL Solution Sig: Sixty (60) mg Injection [**Hospital1 **] (2 times day): Hold SBP<100. 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice day. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times day): Hold SBP<100 HR<60. 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) needed insomnia. 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) needed fever. 8. Petrolatum Ointment Sig: One (1) Appl Topical DAILY (Daily): Please apply leg wounds per wound care orders. thank you! . 9. Methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO QID (4 times day). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation q6H: PRN needed shortness breath wheezing. 11. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) needed pain: Hold RR<12 sedation. 12. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 14. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO q6H: PRN needed itching. 15. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen (17) g PO BID: PRN needed constipation. 16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed constipation: hold diarrhea. 17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed anxiety. 18. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) needed dry mouth, sore throat. 19. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times day): Please apply upper forehead scalp seborrheic dermatitis (day 1 = [**2176-8-11**]). Also, please apply wound left shin overlying fungal infection(day 1 = [**2176-8-15**]). Thank you! . 20. Glycerin (Adult) Suppository Sig: One (1) Suppository Rectal PRN (as needed) needed constipation. 21. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) needed headache: Hold somnolence. 22. Heparin drip Heparin IV Sliding Scale (please see included scale): Diagnosis: DVT/A-fib, Patient Weight: 114.76 kg, Initial Bolus: 0 units IVP, Initial Infusion Rate: 1450 units/hr, Target PTT: 60 - 100 seconds, . PTT <40: 4600 units Bolus Increase infusion rate 450 units/hr, PTT 40 - 59: 2300 units Bolus Increase infusion rate 250 units/hr, PTT 60 - 100*:, PTT 101 - 120: Reduce infusion rate 250 units/hr, PTT >120: Hold 60 mins Reduce infusion rate 450 units/hr, 23. Insulin sliding scale Glargine 46 units bedtime; Humalog sliding scale per included sliding scale. Discharge Medications: 1. Hydroxyzine HCl 25 mg/mL Solution Sig: One (1) Intramuscular Q6H (every 6 hours) needed pruritis. 2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 3. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times day). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed constipation. 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice day. 9. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO Q4H (every 4 hours). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-1**] Inhalation every 4-6 hours needed shortness breath wheezing. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 12. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO Q3hr:prn. 13. simvistatin 10mg Qday 14. Petrolatum Ointment Sig: One (1) Appl Topical DAILY (Daily). 15. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times day). 16. Outpatient Lab Work Chem 10 monitor electrolytes creatinine taking lasix 17. Turn reposition back prn limit sit time 1hour time using pressure redistribution cushion. Cleanse skin wound cleanser NS pat dry nad apply aquafor gluteals legs feet daily 18. heel lateral foot ulcer apply thin layer duoderm wound gel, cover dorsum lateral wound adaptic heel gauze followed ABD pad, wrap iwth kerlix change daily 19. headrest occiput frequent repositioning 20. please remove sutures posterior neck tuesday [**9-10**] [**2175**] 21. Please start warfarin [**2176-9-9**] (post op day 10) monitor INR prn 22. check weight Qday Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Cervical myelopathy C1 tumor cervical myelopathy Acute chronic diastolic heart failure Discharge Condition: Stable, afebrile Discharge Instructions: admitted [**Hospital1 18**] [**2176-8-29**] worsening upper extremity weakness due spinal tumor. underwent operation remove tumor. also underwent operation decrease pressure spinal cord neck. need staples surgical site [**2176-9-10**], rehab facility. appointment made follow Dr. [**Last Name (STitle) **] 6 weeks. Please return Emergency department fever, chills, difficulty breathing, worsening upper extremity weakness, worsening symptoms. Followup Instructions: 1. [**Last Name (STitle) **] LAB [**Hospital1 18**] [**Hospital Unit Name **], [**Location (un) **] [**Location (un) **] surgery Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2176-9-26**] 3:15 2 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD LM [**Hospital Unit Name **], [**Location (un) **] [**Location (un) **] surgery Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2176-9-26**] 4:15 3. Dr. [**Last Name (STitle) 47032**] [**Name (STitle) **] address: [**Doctor First Name **] [**Hospital Unit Name **] [**Location (un) 470**] [**Hospital Unit Name **] phone: [**Telephone/Fax (1) **] appointment: [**2176-10-8**] 1:15PM 4. Psychiatry Clinic [**Hospital1 18**] Psychiatry Clinic Please call bottom number schedule appointment mood sad taking pleasure life: [**Telephone/Fax (1) **] | [
"2761",
"5119",
"4280",
"42731",
"V5861",
"41401",
"V4582",
"496",
"412"
] |
Admission Date: [**2138-6-9**] Discharge Date: [**2138-6-12**] Date Birth: [**2111-2-28**] Sex: Service: Cardiothoracic Surgery PREOPERATIVE DIAGNOSIS: 1. Bicuspid aortic valve. 2. Dilated aorta. 3. Aortic insufficiency. HISTORY PRESENT ILLNESS: patient heart murmur since childhood found bicuspid aortic valve echocardiogram, recently increase size ascending aorta. Otherwise, patient denies medical problems. [**Name (NI) **] surgery [**2124**] undescended testicle. SOCIAL HISTORY: Denies smoking history. Occasional alcohol, maybe per week. FAMILY HISTORY: Noncontributory. MEDICATIONS ADMISSION: Prophylactic antibiotics. ALLERGIES: known drug allergies. LABORATORY ADMISSION: Preoperative vital signs heart rate 78, blood pressure 102/68, respiratory rate 18. healthy, 27-year-old male. Lungs clear. Heart 3/6 systolic ejection murmur. Otherwise, examination within normal limits. HOSPITAL COURSE: So, [**2138-6-9**], patient underwent homograft aortic root replacement, resection, grafting proximal aortic arch. underwent general anesthesia. intraoperative complications. Postoperatively, patient transferred recovery room nitroglycerin drip normal sinus rhythm. transferred recovery room Intensive Care Unit, postoperative day one transferred floor, continued uncomplicated postoperative course. patient experience tachycardia heart rate around 117. tachycardia patient's beta blockers increased, respond. beta blockers increased 75 mg p.o. b.i.d. Potassium repleted. patient diuresing 4 liters per day. patient good pain control. ambulating around halls without difficulty own. CONDITION DISCHARGE: Stable. DISCHARGE STATUS: Discharged home prescription. services needed. MEDICATIONS DISCHARGE: 1. Lopressor 75 mg p.o. b.i.d. 2. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 40 mEq p.o. q.d. times five days. 3. Iron sulfate 325 mg p.o. t.i.d. 4. Percocet 5 one two tablets p.o. q.6h. p.r.n. 5. Aspirin 81 mg p.o. q.d. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 8344**] MEDQUIST36 D: [**2138-6-12**] 23:01 T: [**2138-6-13**] 18:17 JOB#: [**Job Number 13750**] | [
"4241"
] |
Admission Date: [**2142-11-30**] Discharge Date: [**2142-12-10**] Date Birth: [**2084-5-2**] Sex: Service: MEDICINE Allergies: Percocet / Bactrim Ds / Lisinopril Attending:[**First Name3 (LF) 898**] Chief Complaint: hypotension Major Surgical Invasive Procedure: none History Present Illness: Mr. [**Known lastname 25925**] 58 yo w/ multiple sclerosis seizure disorder presented OSH delusions AMS x 2 days. OSH, noted Na 124. history hyponatremia; Na 117 [**2-27**] mid 130s since then. seen nephrology. OSH, approx 45sec generalized tonic clonic seizure, received 1mg Ativan, transferred ED [**Hospital1 18**]. also history seizures especially setting infection hyponatremia. unclear seizures without inciting event. currently weaned Keppra Gabapentin started Tegretol. ER, VS were: 97.5; 189/105; 78; 16; 95% 3L. given 2L NS. Given AMS setting infection known chronic UTIs [**12-24**] indwelling suprapubic catheter neurogenic bladder, blood urine cultures obtained well CXR. urine culture [**11-28**] grew pseudomonas CXR showed possible infiltrate treated vancomycin cefepime. head CT negative. Past Medical History: MS - since [**2119**], progressive, quadriplegic, neurogenic bladder suprapubic catheter, restrictive PFT's History Aspiration PNAs Esophageal Ulcer - [**12-24**] NSAIDs, [**2139**], small bowel bx negative Recurrent UTIs CHF (EF > 65% moderate LVH '[**39**]) HTN Legally Blind Social History: married 32 years lives wife home. three children three grandchildren. professor [**First Name (Titles) **] [**Last Name (Titles) 25949**] engineering [**University/College 25932**], retired disability [**2128**] spring semester due MS. [**Name13 (STitle) **] wheelchair-bound. denies tobacco, alcohol, recreational drug use. personal care assistant. Family History: Father CAD CVA. Mother [**Name (NI) 2481**] disease. Brother diabetes. Physical Exam: General: Alert, oriented, acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated, LAD Lungs: Clear auscultation bilaterally, wheezes, rales, ronchi CV: Regular rate rhythm, normal S1 + S2, murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, rebound tenderness guarding, organomegaly Ext: Warm, well perfused, 2+ pulses, clubbing, cyanosis edema Pertinent Results: [**2142-11-29**] 10:47PM BLOOD WBC-6.4 RBC-3.99*# Hgb-11.8*# Hct-33.1* MCV-83# MCH-29.7 MCHC-35.7* RDW-15.0 Plt Ct-235# [**2142-12-10**] 05:50AM BLOOD WBC-8.8 RBC-3.54* Hgb-10.8* Hct-31.0* MCV-88 MCH-30.5 MCHC-34.7 RDW-15.3 Plt Ct-424 [**2142-12-7**] 05:50AM BLOOD PT-13.6* PTT-34.1 INR(PT)-1.2* [**2142-11-29**] 10:47PM BLOOD Glucose-102 UreaN-11 Creat-0.6 Na-126* K-4.5 Cl-88* HCO3-29 AnGap-14 [**2142-11-30**] 06:58AM BLOOD Glucose-89 UreaN-11 Creat-0.7 Na-125* K-4.6 Cl-90* HCO3-28 AnGap-12 [**2142-11-30**] 12:40PM BLOOD Na-128* [**2142-11-30**] 09:45PM BLOOD Na-127* [**2142-12-1**] 07:40AM BLOOD Glucose-79 UreaN-11 Creat-0.7 Na-131* K-4.0 Cl-93* HCO3-29 AnGap-13 [**2142-12-1**] 03:00PM BLOOD Glucose-101 UreaN-16 Creat-0.8 Na-131* K-4.5 Cl-94* HCO3-30 AnGap-12 [**2142-12-2**] 05:45AM BLOOD Glucose-81 UreaN-15 Creat-0.7 Na-133 K-4.6 Cl-95* HCO3-28 AnGap-15 [**2142-12-2**] 04:10PM BLOOD Glucose-98 UreaN-15 Creat-1.0 Na-131* K-4.9 Cl-93* HCO3-27 AnGap-16 [**2142-12-3**] 06:20AM BLOOD Glucose-121* UreaN-21* Creat-1.2 Na-131* K-4.3 Cl-93* HCO3-28 AnGap-14 [**2142-12-3**] 05:40PM BLOOD Glucose-115* UreaN-25* Creat-1.3* Na-134 K-4.4 Cl-96 HCO3-27 AnGap-15 [**2142-12-4**] 07:18AM BLOOD Glucose-101 UreaN-23* Creat-0.8 Na-135 K-4.0 Cl-98 HCO3-27 AnGap-14 [**2142-12-5**] 05:30AM BLOOD Glucose-83 UreaN-21* Creat-0.7 Na-135 K-3.9 Cl-96 HCO3-26 AnGap-17 [**2142-12-6**] 05:30AM BLOOD Glucose-96 UreaN-19 Creat-0.8 Na-134 K-4.2 Cl-97 HCO3-28 AnGap-13 [**2142-12-7**] 05:50AM BLOOD Glucose-102 UreaN-21* Creat-0.8 Na-137 K-4.2 Cl-97 HCO3-26 AnGap-18 [**2142-12-8**] 07:00AM BLOOD Glucose-89 UreaN-15 Creat-0.9 Na-136 K-3.9 Cl-99 HCO3-27 AnGap-14 [**2142-12-9**] 06:30AM BLOOD Glucose-96 UreaN-14 Creat-0.9 Na-140 K-4.0 Cl-101 HCO3-28 AnGap-15 [**2142-12-10**] 05:50AM BLOOD Glucose-99 UreaN-18 Creat-1.0 Na-140 K-4.5 Cl-102 HCO3-26 AnGap-17 [**2142-11-29**] 10:47PM BLOOD Osmolal-260* [**2142-11-30**] 12:40PM BLOOD Osmolal-264* [**2142-12-8**] 07:00AM BLOOD ALT-23 AST-16 LD(LDH)-213 AlkPhos-87 TotBili-0.2 [**2142-12-10**] 05:50AM BLOOD Calcium-9.3 Phos-2.8 Mg-2.4 U/A [**11-28**]: nit +, LE +, WBC 55, RBC 6, Epi 1, bact U/A [**11-29**]: sm bld, 100 prot/gluc; WBC [**1-24**], RBC [**1-24**], Epi [**1-24**], bact mod U/A [**12-2**]: sm LE, WBC 10, RBC 2, Epi 1, bact none U/A [**12-5**]: 30 prot, 10 ket, lg LE; WBC 99, RBC 11, Epi 1, bact U/A [**12-6**]: 30 prot, mod LE; WBC 22, RBC 8, Epi 3, bact none U/A [**12-8**]: neg leuk CULTURES: BCx [**11-29**] x2: neg BCx [**12-2**] x2: neg UCx [**11-28**]: PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML UCx [**11-29**] pseudomonas UCx [**12-2**] yeast Ucx [**12-5**] neg Ucx [**12-6**] yeast Ucx [**12-8**] neg c.diff neg x 2 - CXR [**12-2**]: Patchy opacity left base noted, significance setting low inspiratory volumes uncertain. - CTA [**12-2**]: PE. Scattered patchy ground-glass opacities may represent expiratory state air trapping. - Renal u/s [**12-2**]: evidence abscess, hydronephrosis mass - abd xray [**12-3**]: non-specific bowel gas pattern, stool throughout colon, free air - abd xray [**12-4**]: Stool- air-filled loops large small bowel consistent ileus. - Liver u/s [**12-5**]: Hypoechoic right hepatic mass, measuring 4.2 cm size - CT abd: prelim read: Arterially enhancing liver lesion cannot fully characterized, may represent adenoma, FNH, less likely HCC. Brief Hospital Course: 58 yo male w/ progressive multiple sclerosis admitted AMS seizure 45s GTC OSH responded 1mg Ativan. negative head CT found Na level 126. hyponatremic past often caused changes mental status. ED, treated 2L NS concern hypovolemic hyponatremia. time, urine osm 423 serum osm 263. also CXR prelim concern pneumonia cause ADH like effect (the final read neagtive). Neurology consulted AMS seizure felt hyponatremia likely related recent initiation carbamezapine sensory illusions. Carbamezapine known ADH like effect cause hyponatremia. Following discontinuation carbamezapine along fluid restriction, Na increased. several days, pt appeared slightly dehydrated fluid restriction lifted. time discharge, serum Na 140. . past, seizures instigated underlying infection. However, upon admission afebrile leukocystosis. likely source either pneumonia UTI. suprapubic catheter [**12-24**] neurogenic bladder day prior admission, urine sample grew pseudomonas, bacteria past. also several pneumonias past, likely [**12-24**] frequent aspirations first CXR concerning lung infiltrate. treated one dose vancomycin cefepime pneumonia. Ultimately, repeat CXR CTA negative pneumonia. . pseudomonal bacteriuria, started ciprofloxacin. urine culture drawn prior abx inititian also grew pseudomonas. afebrile leukocytosis thought may actually colonization opposed infection. However, treated full course cipro complicated UTI. catheter changed cultures remained negative. . admission, pt afebrile hypertensive 180-200. However, shortly arriving floor, episode hypotension 70's systolic. time mentating well, complaints, denied chest pain, headache, visual changes. IVFs given, however hypotension initially respond, however came eventually prior getting ICU. labile blood pressure likely secondary patient's autonomic dysfunction secondary SPMS. considerations infection possible sepsis, however patient continued afebrile. Blood urine cultures negative. monitored ICU 24 hours stable swings BP asymptomatic consistent autonomic dysfunction. Changed clonidine dosing 0.2mg [**Hospital1 **] 0.1mg TID. Maintained blood pressure medications home doses. . next day, transferred MICU returned floor. Shortly arrival, developed fever. blood urine cultures sent negative. Pneumonia ruled UTI treated medication appropriate per sensitivities. CTA negative PE. However, started meropenem treated 2 days. still slightly febrile meropenem discontinued concern drug fever. defervesced without treatment. . However, mental status continued fluctuate despite afebrile, obvious source infection, eunatremic. occasionally aggressive would say murdered kidnapped. Neurology reconsulted feel symptoms related keppra think subclinical seizures. continued repetitive shaking moves head conscious able speak episodes. Also, despite Keppra, continued sensory illusions, mostly centered around feeling bowel movement (when actually not). . work source infection source AMS, CTA revealed liver lesion. ultrasound multiphase liver CT describe lesion cannot MRI [**12-24**] implanted baclofen pump. Mr [**Known lastname 25925**] family decided biopsy lesion time ruled completely malignancy, although unlikely. work also KUB concerning ileus continued BMs kept regular diet. . Prior discharge, mental status completely returned baseline alert oriented x 3 longer aggressive towards staff. definite etiology elucidated hypothesized could result progression established disease. Medications Admission: BACLOFEN 2,000 mcg/mL Kit -pump BRIMONIDINE Dosage uncertain CARVEDILOL - 25 mg Tablet [**Hospital1 **] CARBAMEZAPINE - 100mg [**Hospital1 **] CLONIDINE - 0.2 mg Tablet [**Hospital1 **] CLOTRIMAZOLE-BETAMETHASONE - 1 %-0.05 % Cream tid FENTANYL - 12 mcg/hour Patch 72 hr FUROSEMIDE - 40 mg Tablet qd IPRATROPIUM-ALBUTEROL prn LACTULOSE prn MINOCYCLINE - 100 mg Tablet [**Hospital1 **] MODAFINIL [PROVIGIL] 50 [**Hospital1 **] OMEPRAZOLE 20 [**Hospital1 **] OXYBUTYNIN CHLORIDE - 15 mg qhs SIMVASTATIN - 40 mg qd TRAVOPROST1 drop L eye day ACETAMINOPHEN prn ASCORBIC ACID 500 [**Hospital1 **] BISACODYL hs CALCIUM 500 mg Tid CRANBERRY 475 mg Capsule [**Hospital1 **] ERGOCALCIFEROL (VITAMIN D2)400 [**Hospital1 **] MINERAL OIL prn OMEGA-3 FATTY ACIDS [**Hospital1 **] PSYLLIUM [METAMUCIL] prn SENNA - 8.6 mg Tablet prn Discharge Medications: 1. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 2. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) needed. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) needed. 6. Oxybutynin Chloride 5 mg Tablet Sig: Three (3) Tablet PO QHS (once day (at bedtime)). 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day) needed. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed. 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times day). 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times day). 12. Simvastatin 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 13. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times day). 14. Modafinil 100 mg Tablet Sig: 0.5 Tablet PO BID (2 times day). 15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) 6 days: [**2142-12-13**]. 16. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times day). 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed. 18. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 19. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) inh Inhalation twice day needed. 20. TRAVATAN Z 0.004 % Drops Sig: One (1) Ophthalmic day: Left eye. 21. Cranberry 475 mg Capsule Sig: One (1) Capsule PO twice day. 22. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO twice day. 23. Ergocalciferol (Vitamin D2) 400 unit Tablet Sig: One (1) Tablet PO twice day. patient allergy listed ACE Inhibitors, therefore discharged ACE Inhibitor. communicated PCP. Discharge Disposition: Home Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: 1. Multiple Sclerosis 2. Urinary Tract Infection, complicated 3. Hyponatremia . Secondary: 1. Chronic Diastolic CHF Discharge Condition: Stable vital signs. Discharge Instructions: admitted altered mental status found low sodium urinary tract infection. started antibiotics urinary tract infection (cipro) complete 2 week course. sodium corrected adjusting medications reducing water intake. . found abnormality liver. CT scan results pending final interpretation. provided phone number schedule appointment [**Hospital **] clinic. may necessary reimage liver take biopsy lesion seen CT scan. . medications changed. switched tegratol keppra. Please review recent medication list take medications, discard old medications list. . Please return hospital develop fevers, chills, worsening symptoms. Followup Instructions: 1. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2143-1-8**] 1:30 . 2. [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2143-1-15**] 4:00 . 3. [**Hospital **] CLINIC [**Hospital1 18**]: ([**Telephone/Fax (1) 2233**] Completed by:[**2142-12-13**] | [
"5990",
"2761",
"5849",
"4280",
"4019",
"53081"
] |
Admission Date: [**2109-8-17**] Discharge Date: [**2109-10-16**] Date Birth: [**2054-10-24**] Sex: Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: B/L ankle fractures, s/p fall Major Surgical Invasive Procedure: [**8-18**] . 1. Closed reduction left pilon fracture. 2. Application multi-planar external fixator left lower extremity. 3. Closed treatment calcaneus fracture mild amount manipulation. 4. External fixation Right Pilon fracture . [**8-30**] Adjustment external fixator R pilon fracture . [**9-17**] ORIF right intra-articular distal tib-fib fracture R History Present Illness: 54 year old Spanish speaking male, US vacation, questionable PMH liver disease presents jumping?falling? window. Per daughter drinking alcohol son reported feeling someone kill him. locked second-story bedroom later found daughter crawling outside. initially seen [**Hospital3 **] found opiates cocaine UA emergency department there. transported [**Hospital1 18**] b/l ankle fractures. Per family, pt confused home. [**Name (NI) **], pt aggitated received haldol ativan. later somnolent. EKG demonstrated atrial flutter HRs 110-140's, rate controlled ED IV diltiazem. Patient poor historian, information obtained daughter ROS: + b/l ankle pain, -CP, -SOB, -Abdominal pain Past Medical History: "Gets yellow" High ammonia HTN questionable anginal history depression, family states see psychiatrist Social History: EtOH abuse, polysubstance abuse, one ppd mayn years Urine positive cocaine opiates ED married Daughter involved care Family History: Noncontributory Physical Exam: Vitals: 96.7 140/90 76 16 99% 2L NPO/1000 Physical Exam: General: sleepy arousable, oriented place person, able name months year forwards, backwards, oriented current month/year HEENT: icteric sclerae, dry MM, + c-collar CVS: irregular rate, tachy, murmurs/rubs/gallops appreciated Pulm: CTA b/l, wheezes, rales rhonchi Abd: soft, NT, mild hepatosplenomegaly, +BS Ext: b/l ankle splints, mild bruising b/l knees, - asterixis GU: + foley Pertinent Results: CT C-Spine: negative fracture Left tib/fib: Comminuted fracture calcaneus. Dense sliver bone along medial aspect proximal fibula, seen single view. could represent additional calcification intraosseous ligament, small cortical fracture fragment, foreign body. Right tib/fib: Comminuted, intraarticular, impacted, displaced fractures distal tibia well fracture distal fibula detailed above. . CT bilat LE 1. Comminuted intra-articular distal right tibial fracture. 2. Comminuted distal right fibular fracture displacement. 3. Comminuted left calcaneal fracture. . RUQ U/S: FINDINGS: liver coarse echotexture without evidence focal lesion. gallbladder distended due nonfasting stage. evidence gallstones. evidence intra- extra-hepatic biliary ductal dilatation common duct measures 3 mm. pancreas well visualized due bowel gas. evidence free fluid. main portal vein patent antegrade flow. IMPRESSION: evidence cholecystitis. . Head CT ([**8-21**]) IMPRESSION: evidence acute intracranial pathology, including sign intracranial hemorrhage. . CXR ([**8-21**]) previous studies comparison. Low lung volumes. Heart size difficult evaluate semi-upright AP film. could LVH evidence CHF lungs clear. Questionable slight impression right margin tracheal air column better evaluated standard PA lateral chest films condition permits. . Chest CT ([**8-23**]): 1. juxtatracheal mass left upper lobe lesion questioned chest radiograph report. 2. Three foci ground glass, right upper lobe, detectable routine radiographs, nonspecific finding. Six- month CT follow recommended look change, bronchoalveolar cell carcinoma, though unlikely, cannot excluded. 3. Borderline size mediastinal hilar lymph nodes checked followup CT. 4. Mild atherosclerotic coronary artery calcification. Chest CTA ([**8-24**]): 1. pulmonary embolism. 2. Relatively unchanged appearance multiple ill-defined opacities tiny nodules right upper lobe. Follow-up stated examination 1 day prior recommended. 3. New foci opacification present lung bases compared examination one day prior likely related aspiration. Layering debris present within right main stem bronchus suggestive aspiration well. Clinical correlation recommended. 4. Recommend advancing NG tube least 4-5 cm. current position elevates risk aspiration. . CT RLE contrast ([**8-24**]): IMPRESSION: Comminuted distal tibial fibular fractures intra- articular involvement tibial plafond lateral displacement talus respect tibia. Posterior displacement distal fibular fragment. . CT LLE without contrast ([**8-24**]) Comminuted left calcaneal fracture. Lentiform area fluid attenuation skin posterolateral aspect left foot. significance latter finding uncertain, may due skin blister possibly dressing material within cast. Clinical correlation requested. . CXR ([**8-26**]) 1. NG tube could advanced several centimeters standard positioning, described prior exams. 2. New perihilar opacities, likely due acute aspiration superior segments. . Head CT ([**9-3**]) IMPRESSION: evidence hemorrhage CT evidence acute infarct. . CT abd/pelvis ([**9-22**]): IMPRESSION: CT evidence pyelonephritis abscess within abdomen/pelvis. . CT LLE without contrast ([**9-26**]) 1. Markedly comminuted fracture calcaneus wide distraction dispersal fracture fragments above. 2. Non-displaced fractures sustentaculum tali middle facet talus. 3. fracture identified medial malleolus. 4. Non-displaced fractures anterior aspect inferior aspect lateral malleolus. 5. Non-displaced fracture cuboid. 6. fracture identified navicular. 7. fractures identified within remainder mid foot forefoot. 8. Lateral subluxation peroneal tendons respect fibula. 9. Probable tear anterior talofibular ligament. . Echo ([**9-26**]): left atrium mildly dilated. Left ventricular wall thickness, cavity size regional/global systolic function normal (LVEF >55%) Transmitral tissue Doppler imaging suggests normal diastolic function, normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size free wall motion normal. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic regurgitation. mitral valve appears structurally normal trivial mitral regurgitation. mitral valve prolapse. estimated pulmonary artery systolic pressure normal. pericardial effusion. IMPRESSION: Normal global regional biventricular systolic function. Brief Hospital Course: course hospitalization, pt put CIWA scale EtOH withdrawal given thiamine, folate multivitamin, AFib RVR initially treated metoprolol, diltiazem, high ammonia levels treated lactulose. b/l ankle fractures followed orthopedics. patient severely agitated one occassion hospitalization, requiring three codes puples called well requiring restraints protection patient staff. patient originally sent floor MICU delirium unknown cause severe agititation. required increased amounts sedation returned floor NG tube placed. returned floor, patient required less sedation, taken benzodiazipines intermittently needed restraints. patient remained somnolent delerious. pulled NG tube. also febrile rhoncorous floor. initially treated vancomycin flagyl, changed azithro/ceftriaxone/flagyl. scheduled return revision right external fixation. preop holding, found hypoxic sent MICU. MICU COURSE: Morning [**8-28**], patient scheduled return revision externally fixated RLE. Upon transport PACU, patient became somnolent reported "agonal breathing". O2 sats 83% 2LNC NRB applied O2 sats 100%. BP 90s/60s, HR 80s, RR 17-19. ABG drawn: 7.38/58/90. stay MICU, patient coughed large amount thick sputum improved respiratory status. Surgery postponed patient transferred MICU monitoring. MICU, respiratory status remained stable Sp02 high 90s room air. Pt hemodynamically stable chronic a-flutter. Called floor [**8-29**]- intensive care needs identified. MICU, patient started Zosyn restarted Vancomycin wiht marked improvement respiratory status. Within days returning floor, Vancomycin zosyn stopped CXR showed resolution questionable aspiration pneumonia - felt likely pneuomonitis resolved. . MICU, patient's delirium started improve, worsened returned removal external fixation. developed fevers 102F post-operatively likely worsened delirium. Source fevers unclear - note patient recently developed VRE urine infectious disease feel active infection. received three days antibiotics (daptomycin linezolid). stopped became afebrile delirium began lift. . #Aggitation mostly controlled haldol. Zyprexa tried two weeks seem help acute aggitation. QTc monitored patient antipsychotics stable approximately 420-440msec. Overall etiology delirium remained unclear thought multifactorial due part chronic alcohol use, hepatic encephalopathy, benzodiazepine use, post-operative delririum. Although spanish-speaking 1:1 sitters interpreters employed much possible, language also likely contributed persistance delirium. Delirium completely resolved patient restraint sitter free. haldol stopped. past period etoh withdrawal. recommended patient follow alcohol abuse counseling. . #Afib/flutter febrile, afib/flutter complicated frequent episodes rapid ventricular rate. controlled IV metoprolol needed also increasing PO metoprolol diltiazem. Treating fever tylenol also seemed help. briefly put therapeutic lovenox atrial fibrillation, stopped felt eligible CHADS criteria also high fall risk. Patient transitioned beta blockers placed Diltiazem 120mg daily. . #Urinary retention patient failed several voiding trials. also pulled foley several occasions, causing hematuria. Intermittent straight catheterization tried reduce infection risk long-term indwelling foley. However given delirium aggitation untenable. resolved reductions haldol. Patient able void freely own. History VRE urine culture, signs infection, dyruria, increased urinary frequency. evidence based literature clinical indications treat asymptomatic bacteuria time. . #Fractures patient followed orthopedics admission. L ankle fractures treated casting, however repeat plain films CT scan 4-6 weeks post-op showed fractures initially visualized. Orthopedics felt casting still appropriate indication surgery. R pilon fracture managed initially external fixation system skin breakdown making internal fixation difficult. One month hospitalization ex-fix removed tibial fibular plates placed. remain Non-weight bearing total one month hospital discharge. Patient completed necessary course lovenox.He follow appointment scheduled orthopaedic surgeon Dr. [**Last Name (STitle) **] [**11-28**] 1030am, [**Hospital3 **] [**Hospital Ward Name **], [**Location (un) 1385**] [**Hospital Ward Name 23**] building. . Transfer [**Hospital **] Rehab Hospital. Medications Admission: Diltiazem 180 mg one daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times day) needed. Disp:*30 Tablet, Chewable(s)* Refills:*0* 5. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule, Sustained Release(s)* Refills:*1* 6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) needed. Disp:*15 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Primary: 1) Bilateral Lower Extremity fractures a. Closed left tibial plafond fracture/pilon fracture. b. Dislocation left tibiotalar joint. c. Right calcaneus fracture, intra-articular 2) Persistent agitated delirium ?????? resolved 3) Aspiration Pneumonitis - resolved 4) Alcoholism ?????? continuous 5) Delirium Tremens 6) Polysubstance Abuse (cocaine, opiates, alcohol) 7) Atrial Fibrillation/Atrial Flutter 8) Abnormal CT chest ?????? follow-up ([**2111-1-5**]) recommended 9) Liver Failure ?????? presumed secondary alcoholism (No evidence HBV HCV infection) a. Thrombocytopenia presumed secondary thrombopoitin deficiency. evidence splenomegaly imaging. 10) Elevated AFP level ?????? etiology yet undetermined Secondary: 1) Hypertension 2) Urinary retention ?????? resolved 3) Bactiuria ?????? asymptomatic, colonized Vancomycin resistant enterococcus Contact information: [**First Name8 (NamePattern2) **] [**Known lastname 1794**] (daughter): [**Telephone/Fax (1) 74301**] [**Female First Name (un) 74302**] & [**First Name9 (NamePattern2) 74303**] [**Known lastname 1794**](son) cell [**Telephone/Fax (1) 74304**] Follow-up: 1) Repeat CT scan chest [**2111-1-5**] f/u 3 foci ground glass RUL well borderline mediastinal hilar lymphadenopathy 2) Assess etiology elevated alpha-fetoprotein 3) evaluate etiology pancyctopenia ?????? consider bone marrow aspirate well HIV testing Discharge Condition: Stable, Non-weight bearing legs one month starting [**10-15**] Discharge Instructions: transferred [**Hospital1 18**] emergency room large fall. found bilateral ankle fractures. CT scan head show acute bleed. came emergency room heart rate fast, given medications help slow down. . [**8-18**] operation left leg heel ankle fracture, several pins placed left leg. left leg casted. . [**8-30**] operation R tibula fibula fracture stabilized leg externally. . [**9-17**] operation right tibula fibula screws placed help leg heal. . hospital stay. confused placed many psychiatric medications, became agitated times,and restrained times. resolved longer psychiatric medications. . hospital developed breathing problems. [**Name (NI) **] spent time intensive care unit, worry might pneumonia, started antibiotics, breathing problems improves, chest xray improved. thought pneumonia antibiotics normal. . also found bacteria urine called VRE, having, burning urination. infectious disease doctors thought bacteria treated. . transferred rehab facility. important rehab facility you, follow get counseling problems alcohol abuse. . follow appointments schedule orthopaedics new primary care physician. [**Name10 (NameIs) **] important follow appointments. . also important put weight legs next month. Please return hospital emergency room condition worsens way. abnormal chest x-ray/CT scan repeated [**2111-1-5**] make sure lung cancer. blood counts low stable hospitalization. see Hematologist (Blood Doctor) consider testing HIV. elevation marker blood called AFP (alpha fetoprotein). significance know. may related underlying liver disease evaluated specialist. absolutely refrain use alcohol, cocaine illicit drugs explicitly prescribed physician. Ten??????as una exploraci??????n anormal [**Doctor First Name **] pecho x-ray/CT [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (un) 7214**] esto repetido en diciembre de [**2110**] para cerciorarse de t?????? [**Last Name (un) 7214**] pulm??????n c??????ncer. Tus cuentas de sangre [**Doctor First Name **] [**First Name9 (NamePattern2) 74305**] [**Last Name (un) **] [**First Name9 (NamePattern2) 74306**] [**Last Name (un) 33761**] tu hospitalizaci??????[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7213**] [**Last Name (un) **] un hemat??????logo (el doctor [**Last Name (Titles) **] [**Last Name (Prefixes) 74307**]) sobre esto considerar el probar para el VIH. Ten??????as una elevaci??????n de un marcador en tu sangre llamada AFP (alfa fetoprotein). [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 74308**]??????n de esto es saber. Puede ser relacionado con tu enfermedad [**Doctor First Name **] higado [**First Name9 (NamePattern2) 74309**] [**Last Name (un) **] debe ser m??????s futuro evaluado por un especialista. [**Last Name (un) 7213**] refrenarse absolutamente [**Doctor First Name **] uso adicional [**Doctor First Name **] alcohol, de [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]??????na de cualquier droga il??????cita prescritos expl??????citamente ti por un m??????dico. Followup Instructions: Ten??????as una exploraci??????n anormal [**Doctor First Name **] pecho x-ray/CT [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (un) 7214**] esto repetido en diciembre de [**2110**] para cerciorarse de t?????? [**Last Name (un) 7214**] pulm??????n c??????ncer. Tus cuentas de sangre [**Doctor First Name **] [**First Name9 (NamePattern2) 74305**] [**Last Name (un) **] [**First Name9 (NamePattern2) 74306**] [**Last Name (un) 33761**] tu hospitalizaci??????[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7213**] [**Last Name (un) **] un hemat??????logo (el doctor [**Last Name (Titles) **] [**Last Name (Prefixes) 74307**]) sobre esto considerar el probar para el VIH. Ten??????as una elevaci??????n de un marcador en tu sangre llamada AFP (alfa fetoprotein). [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 74308**]??????n de esto es saber. Puede ser relacionado con tu enfermedad [**Doctor First Name **] higado [**First Name9 (NamePattern2) 74309**] [**Last Name (un) **] debe ser m??????s futuro evaluado por un especialista. [**Last Name (un) 7213**] refrenarse absolutamente [**Doctor First Name **] uso adicional [**Doctor First Name **] alcohol, de [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]??????na de cualquier droga il??????cita prescritos expl??????citamente ti por un m??????dico. Please follow Dr. [**Last Name (STitle) **] orthopedic surgery appointment scheduled [**2112-11-28**]:30 am, [**Location (un) 1385**] [**Hospital Ward Name 23**] building [**Hospital Ward Name **] [**Hospital1 771**]. Please call [**Telephone/Fax (1) 9769**] would like change appointment. Please follow new primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 15259**] [**2109-11-19**] 3pm [**Hospital Ward Name 23**] Center [**Location (un) **] [**Hospital Ward Name 516**] [**Hospital1 1170**]. abnormal chest x-ray/CT scan repeated [**2111-1-5**] make sure lung cancer. blood counts low stable hospitalization. see Hematologist (Blood Doctor) consider testing HIV. elevation marker blood called AFP (alpha fetoprotein). significance know. may related underlying liver disease evaluated specialist. | [
"4019",
"42731",
"2875",
"5990",
"5070",
"5180"
] |
Admission Date: [**2170-9-19**] Discharge Date: [**2170-9-25**] Date Birth: [**2099-5-27**] Sex: Service: CARDIOTHORACIC Allergies: Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: Dyspnea exertion fatigue Major Surgical Invasive Procedure: [**2170-9-19**] Coronary artery bypass graft x 4 (Left internal mammary artery diagonal, saphenous vein graft left anterior descending, saphenous vein graft obtuse marginal, saphenous vein graft posterior descending artery) History Present Illness: 71 year old male presented PCP [**Name Initial (PRE) **] routine visit complaints recent onset fatigue, dyspnea exertion, exertional throat discomfort left arm. denied rest pain reports discomfort dyspnea occur minimal activities showering. found hypertensive started Atenolol 25mg daily. EKG normal sent nuclear stress test. underwent nuclear stress test [**2170-8-1**] revealed inferolateral ischemia moderate inferior, inferolateral, posterolateral perfusion abnormality. refereed cardiac catheterization. referred cardiac surgery revascularization. Past Medical History: Hypertension Right rotator cuff tear Compound fracture left arm/plated child Benign colon polyps Arthritis s/p right rotator cuff repair s/p repair left arm fracture, plated Social History: Race:Caucasian Last Dental Exam:"a long time ago", recall Lives with:Wife Contact:[**Name (NI) **] (wife) Phone #[**Telephone/Fax (3) 74913**] Occupation:self employed painter Cigarettes: Smoked [x] Tobacco use:denies ETOH: stopped drinking [**12-20**] Illicit drug use:denies Family History: premature coronary artery disease Physical Exam: Pulse: 56 Resp:13 O2 sat:97/RA B/P Right:173/82 Left:164/76 Height:5'9" Weight:200 lbs General: NAD, WG, WN Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] none_ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: Left: bruits Pertinent Results: [**2170-9-25**] 06:35AM BLOOD WBC-10.9 RBC-2.94* Hgb-9.3* Hct-26.3* MCV-89 MCH-31.6 MCHC-35.3* RDW-13.5 Plt Ct-261 [**2170-9-24**] 06:20AM BLOOD WBC-13.4* RBC-3.27* Hgb-10.1* Hct-28.7* MCV-88 MCH-31.0 MCHC-35.3* RDW-14.2 Plt Ct-197 [**2170-9-25**] 06:35AM BLOOD Na-139 K-4.0 Cl-99 [**2170-9-24**] 06:20AM BLOOD Glucose-118* UreaN-26* Creat-0.9 Na-139 K-4.0 Cl-98 HCO3-31 AnGap-14 [**2170-9-23**] 05:00AM BLOOD UreaN-25* Creat-0.9 Na-137 K-4.3 Cl-99 Brief Hospital Course: Mr. [**Known lastname **] day admit [**9-19**] brought operating room underwent Coronary artery bypass graft x4 (left internal mammary artery diagonal saphenous vein grafts left anterior descending, obtuse marginal, posterior descending arteries) Dr.[**First Name (STitle) **]. CARDIOPULMONARY BYPASS TIME:104 minutes. CROSS-CLAMP TIME:93 minutes. Please see operative report surgical details. Following surgery transferred CVICU intubated sedated critical stable condition. Later day weaned sedation, awoke neurologically intact extubated without incident. weaned pressor support beta blocker/Statin/Aspirin diuresis initiated. Chest tubes epicardial pacing wires removed per protocol. POD#1 transferred step-down unit monitoring. Physical Therapy consulted evaluation strength mobility. postoperative course developed atrial fibrillation treated beta blockers amiodarone. Anticoagulation initiated Coumadin. developed phlebitis IV Amio placed course Keflex x 7 days. slowly improving. pulmonary status waxed waned strong productive cough wheezing, improved time discharge. continued nebulizer treatments. CXR showed small bilateral pleural effusions atelectasis, infiltrate density. pulmonary status slowly improved day discharge. POD 4 developed tender erythematous right knee treated colchicine presumed gout. improved time discharge colchicine discontinued. POD 6 afebrile, ambulating assistance, tolerating full po diet wounds healing well. POD 6 discharged Lifecare Center [**Location 15289**] stable condition. follow appointments advised. Medications Admission: ATENOLOL 25 mg Daily ASPIRIN 325 mg daily FISH OIL-DHA-EPA 1,200 mg-144 mg-216 mg Daily MV-FA-CA-FE-MIN-LYCOPEN-LUTEIN [A THRU Z HIGH POTENCY] 400 mcg-162 mg-18 mg-300 mcg-250 mcg Tablet Daily NAPROXEN SODIUM [ALEVE]PRN Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) needed constipation. 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) needed pain/temp. 6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours needed pain. 7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times day): x 1 week 200 [**Hospital1 **] x 1 week 200 mg daily directed caridologist. 8. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times day). 9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) needed constipation. 10. simvastatin 20 mg Tablet Sig: One (1) Tablet PO day. 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 13. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) needed coughing . 14. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) 7 days: right arm phlebitis. 15. Lasix 40 mg Tablet Sig: One (1) Tablet PO day 14 days. 16. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO day 14 days. 17. warfarin 2 mg Tablet Sig: Two (2) Tablet PO (Once): Give 4 mg [**9-26**] directed INR goal 2.0-2.5 fib. Discharge Disposition: Extended Care Facility: Life Care Center [**Location 15289**] Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft x 4 Past medical history: Hypertension Right rotator cuff tear Compound fracture left arm/plated child Benign colon polyps Arthritis s/p right rotator cuff repair s/p repair left arm fracture, plated Discharge Condition: Alert oriented x3 nonfocal Ambulating steady gait Incisional pain managed oral analgesia Incisions: Sternal - healing well, erythema drainage Leg Right/Left - healing well, erythema drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently mild soap, baths swimming cleared surgeon. Look incisions daily redness drainage Please lotions, cream, powder, ointments incisions morning weigh evening take temperature, written chart driving approximately one month taking narcotics, discussed follow appointment surgeon able drive lifting 10 pounds 10 weeks Please call questions concerns [**Telephone/Fax (1) 170**] Females: Please wear bra reduce pulling incision, avoid rubbing lower edge **Please call cardiac surgery office questions concerns [**Telephone/Fax (1) 170**]. Answering service contact call person hours** Followup Instructions: scheduled following appointments Surgeon: Dr. [**First Name (STitle) **] [**10-29**] 1:15pm, #[**Telephone/Fax (1) 170**] Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] [**9-25**] 2:00pm Please call schedule appointments Primary Care Dr. [**Last Name (STitle) **]. Nikolaos Michalacos [**4-17**] weeks **Please call cardiac surgery office questions concerns [**Telephone/Fax (1) 170**]. Answering service contact call person hours** Labs: PT/INR Coumadin ?????? indication atrial fibrillation Patient given 4 mg Coumadin [**2170-9-25**] Goal INR 2.0-2.5 First draw [**2170-9-26**] Please arrange follow PCP cardiologist prior discharge rehab [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2170-9-25**] | [
"41401",
"5119",
"5180",
"4019",
"42731"
] |
Admission Date: [**2191-7-13**] Discharge Date: [**2191-7-15**] Date Birth: [**2191-7-13**] Sex: Service: NEONATOLOGY HISTORY: Baby [**Name (NI) **] [**Known lastname 1661**] born 39 weeks gestation 32-year-old gravida 1, para 0 1 woman. mother's prenatal screens blood type positive, antibody negative, rubella immune, RPR nonreactive, hepatitis surface antigen negative, group B strep negative. infant crying intubated meconium suctioned cords. given brief period bag mask ventilation good responses. Apgars 8 two minutes 9 five minutes. birth weight 3885 grams, birth length 20 [**1-19**] inches, birth head circumference 34 cm. transferred Newborn Intensive Care Unit four hours age hypoglycemia. blood dextrose stick 36. PHYSICAL EXAMINATION: Reveals vigorous, non-dysmorphic, term-appearing infant. Anterior fontanel open flat, cranial molding present, small caput posteriorly, palate intact. Respirations unlabored, lung sounds clear equal. Heart normal heart sounds murmur. Femoral brachial pulses +2 equal. Soft abdomen masses. Normal external male genitalia testes descended. Symmetric tone reflexes. HOSPITAL COURSE SYSTEM: 1. Respiratory: infant remained room air throughout Newborn Intensive Care Unit stay. apnea, bradycardia desaturations. 2. Cardiovascular: remained normotensive throughout Newborn Intensive Care Unit stay. cardiovascular issues. 3. Fluids, electrolytes nutrition: infant required supplemental intravenous fluid, weaned successfully 28 hours age, maintaining euglycemia feedings Enfamil 20 ad lib schedule, taking approximately one ounce every three four hours. last blood glucose four hour mark 59. 4. Gastrointestinal: infant passing meconium. 5. Sensory: Hearing screening performed automated auditory brain stem responses, infant passed ears [**2191-7-15**]. 6. Psychosocial: parents involved infant's care Newborn Intensive Care Unit stay. DISCHARGE STATUS: infant discharged Newborn Nursery. CONDITION DISCHARGE: condition good time discharge. PRIMARY PEDIATRIC CARE: provided Dr. [**Last Name (STitle) 43003**] [**Name (STitle) 17494**] [**Hospital3 **] Medical Center, telephone number [**Telephone/Fax (1) 17663**]. CARE RECOMMENDATIONS: 1. Feedings: Enfamil 20 ad lib schedule. 2. Medications: infant discharged medications. 3. state screening drawn yet. 4. infant yet received hepatitis B vaccine. DISCHARGE DIAGNOSIS: 1. Resolved hypoglycemia 2. Term male infant [**Name6 (MD) **] [**Name8 (MD) 38353**], M.D. [**MD Number(1) 38354**] Dictated By:[**Last Name (NamePattern1) 37333**] MEDQUIST36 D: [**2191-7-15**] 01:36 T: [**2191-7-15**] 02:18 JOB#: [**Job Number 43004**] | [
"V053"
] |
Admission Date: [**2142-12-23**] Discharge Date: [**2142-12-30**] Date Birth: [**2070-6-15**] Sex: F Service: SURGERY Allergies: Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 371**] Chief Complaint: Right upper quadrant pain Major Surgical Invasive Procedure: [**2142-12-23**]: ERCP sphincterotomy stent placement [**2142-12-28**]: cholecystectomy History Present Illness: 72 year-old female history mild mental retardation, presents RUQ started AM. Pt back pain. Pt went [**Hospital1 **] found fever 102.9 elevated LFTs. RUQ u/s concern stone CBD. WBC 9.4 56% bands, tbili 8.7, dbili 5.3 given levo/flagyl, tylenol, IVF transfered [**Hospital1 18**] presumed cholangitis. orientated person "hospital". Lives home. ED, VS arrival 97.3 82 132/74 20 96% 2L NC. Pt given IVF, unasyn, zofran, morphine. Labs showed WBC 31, lactate 3.2, bili 7.7 elevated LFTs. ERCP surgery consulted. ERCP wanted pt [**Hospital Unit Name 153**] ERCP tonight. Surgery requested u/s CT abd contrast. CXR concern LLL PNA, resp sx. RUQ u/s prelim showed: gallstones, evidence acute cholecystitis. Angiomyolipoma left upper pole, 1.5cm. CT prelim showed: intrahep bil dil. Slight enhancement normal caliber cbd, cbd raises possibility cholangitis. Pulmonary bronchiectasis. Pt admitted surgery [**Hospital Unit Name 153**]. VS transfer 98 66 104/39 16 99% 2LNC. Pt went ERCP showed pus bile duct small stone causing obstruction. also stricture 1/3rd way CBD. Malignacy ruled out. stent placed need removal 3 weeks. Pt given 3 liters LR time arrived post procedure [**Hospital Unit Name 153**] including ER IVF. Past Medical History: -Mild mental retardation -Arthoscopy knee -Hysterectomy -Low plts [**Hospital1 2025**] [**2129**], dx ITP -Cataract surgery -Right 3rd nerve palsy -Esophageal web, food obstruction removed past Social History: Lives sister, brother-in-law, mother. [**Name (NI) **] tobacco etoh use. Ambulates independently. Enjoys watching TV news Today show. Family History: bleeding plt disorders Physical Exam: Vitals: 98.8 87 97/36 13 94%RA GEN: Well-appearing, acute distress HEENT: mild sclera ictericus, MMM, OP Clear NECK: JVP 5-6cm, bruits, cervical lymphadenopathy, trachea midline COR: RRR, soft SEM Rt 2nd ICS, radial pulses +2 PULM: Lungs coarse crackles right bsea decreased BS left base crackles ABD: Soft, NT, ND, +BS, HSM, masses, neg Murphys EXT: C/C/E, palpable cords NEURO: alert, oriented person time, "hospital". Moving ext, right third nerve palsy (in abduction rest elevation past midline adduction) pupil asymetric offcenter contract; CN otherwise grossly intact. SKIN: Mild jaundice Pertinent Results: Admission labs- [**2142-12-23**] 04:54PM BLOOD WBC-31.3* RBC-5.04 Hgb-13.2 Hct-38.0 MCV-75* MCH-26.1* MCHC-34.7 RDW-13.9 Plt Ct-162 [**2142-12-23**] 04:54PM BLOOD Neuts-57 Bands-30* Lymphs-6* Monos-2 Eos-0 Baso-0 Atyps-2* Metas-3* Myelos-0 [**2142-12-23**] 04:54PM BLOOD PT-16.0* PTT-27.9 INR(PT)-1.4* [**2142-12-23**] 04:54PM BLOOD Glucose-106* UreaN-18 Creat-0.8 Na-141 K-3.4 Cl-108 HCO3-20* AnGap-16 [**2142-12-23**] 04:54PM BLOOD ALT-263* AST-184* AlkPhos-172* TotBili-7.7* [**2142-12-23**] 04:54PM BLOOD Lipase-14 [**2142-12-24**] 12:08AM BLOOD Calcium-7.7* Phos-3.2 Mg-1.7 [**2142-12-23**] 05:08PM BLOOD Lactate-3.2* [**2142-12-23**] Liver US : Gallstones, without gallbladder wall thickening pericholecystic fluid suggest acute cholecystitis. biliary dilation. [**2142-12-23**] CT Abd/pelvis : 1. intrahepatic biliary ductal dilatation, gallstones, gallbladder normal appearance. 2. Slight mural hyperenhancement nondilated common hepatic common bile duct - seen cholangitis. 2. Diverticula, evidence diverticulitis. [**2142-12-23**] ERCP : Esophageal web Periampullary diverticulum Successful biliary cannulation. single stricture 6 mm long seen middle third common bile duct. irregular appearance lining bile duct, likely secondary cholangitis. Sucessful sphincterotomy performed Small 4mm stone extracted. Pus seen exiting bile duct. Successful plastic biliary stent placement Otherwise normal ercp third part duodenum Possible Mirizzi's versus tumor cause stricture. [**2142-12-26**] CXR ; 1. New small-to-moderate right-sided pleural effusion parenchymal opacity could probably explained compressive atelectasis, although pneumonia additional differential consideration. 2. Similar left lower lung opacity chronic finding. [**2142-12-28**]: INDICATION: CBD stricture unclear etiology. Evaluate pancreatic mass. COMPARISON: CT abdomen [**2142-12-23**] ERCP [**12-23**], [**2142**]. TECHNIQUE: Multidetector helical scanning abdomen performed prior following administration 200 cc IV Optiray contrast. Coronal, sagittal, volume-rendered MIP reformats displayed. CTA ABDOMEN: Left lower lobe bronchiectasis small bilateral pleural effusions unchanged prior exam. pneumobilia common bile duct stent place traversing mid CBD stricture seen ERCP. soft tissue surrounding CBD definitively suggest biliary malignancy. mild intrahepatic biliary ductal dilation. 8-mm low-density lesion within segment V/VI liver (3A:43), small characterize likely cyst. intrahepatic lesions. portal vein patent. hepatic arterial anatomy conventional. pancreas enhances homogeneously evidence pancreatic mass. superior mesenteric artery vein patent normal caliber course. prominent 12 mm portal hilar lymph node (3B:110), likely reactive. also 13-mm precaval node (3B:119). spleen, gallbladder, adrenal glands normal. kidneys enhance excrete contrast symmetrically multiple subcentimeter hypoattenuating lesions small characterize likely cysts. 16-mm exophytic fat-containing left renal lesion consistent angiomyolipoma (3A:66). left extrarenal pelvis. ascites. mesenteric adenopathy. small bowel loops normal. moderately extensive colonic diverticula. bones mildly osteopenic degenerative changes, however, concerning lytic sclerotic lesions. IMPRESSION: Mild biliary dilation stent within CBD, pancreatic biliary mass identified. study report reviewed staff radiologist. DR. [**First Name (STitle) 18394**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18395**] DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**] Approved: SAT [**2142-12-29**] 10:56 PM Brief Hospital Course: 72 year-old female presented acute cholangits transfered ERCP surgery evalaution. # Acute Cholangitis: Pt elevated LFTs bili RUQ pain fever 102.9 OSH. transfered ERCP surgery eval. Pt appearance sepsis due WBC 9.4 56% bands OSH WBC 31.3 30% bands [**Hospital1 18**] ER fevers. ERCP showed stone obstruction drainage pus, stent placed. Pt admitted [**Hospital Unit Name 153**] post procedure remained NPO. LFTs started trend post ERCP. 2 hours post ERCP developed hypotension BP dropping mid 90s 70s. mentating making urine. given IVF bolus LR BP improved 90-100. given IVF needed maintain UO SBP>90. abd pain post procedre. continued tx unasyn. [**2142-12-23**] OSH blood cx growing GNR 2/4 bottles [**2142-12-24**] 9AM. transferd SICU per request surgery team. # CBD Stricture: ERCP pt found stricture unclear cause. pancreatic protocol CTA, showed Mild biliary dilation stent within CBD, pancreatic biliary mass identified. # Cholelithiasis: Following ERCP sphincterotomy stone extraction, pt clincally stabilized LFTs gradually returned [**Location 213**]. point, taken operating room definitive management cholelithiasis. Pt found acute suppurative cholecystitis laproscopic cholecystectomy performed. recovered uneventfully procedure. # Atrial fibrillation: developed RAF 150 [**2142-12-25**] given IV lopressor subsequently Diltiazem conversion NSR. episodes. # Possibe PNA: clear resp sx hypoxia. CT Abd showed lower lung fields pulm bronchiectasis, may expalin ER findings CXR. 3 liter oxygen requirment likely IVF given setting sepsis. Following transfer Surgical floor continued make good progress. remained free arrhythmias gradually weaned oxygen adequate saturations. ambulating independently voiding without difficulty. diet gradually advanced regular well tolerated. Medications Admission: Multivitamin Discharge Medications: 1. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three times day 2 days. Disp:*6 Tablet(s)* Refills:*0* 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times day). Disp:*30 Tablet(s)* Refills:*0* 3. multivitamin Tablet Sig: One (1) Tablet PO day. 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours needed pain. Disp:*25 Tablet(s)* Refills:*0* 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice day: Take using oxycodone avoid constipation. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: cholangitis choledocholithiasis gram negative bacteremia paroxsymal atrial fibrillation Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * admitted hospital abdominal pain due stone bile duct. underwent ERCP stent placement. * surgery gallbladder removed. * continue eat regular diet stay well hydrated. * Take antibiotics prescribed. * irregular heartbeat short time ICU. normalized medication called lopressor. continue Dr. [**Last Name (STitle) 39288**] evaluates thge office. * develop abdominal pain symptoms concern you, please call doctor return Emergency Room. * need stent removed later on. Please call number schedule appointment. General Discharge Instructions: Please resume regular home medications, unless specifically advised take particular medication. Please take new medications prescribed. Please take prescribed analgesic medications needed. may drive heavy machinery taking narcotic analgesic medications. may also take acetaminophen (Tylenol) directed, exceed 4000 mg one day. Please get plenty rest, continue walk several times per day, drink adequate amounts fluids. Avoid strenuous physical activity refrain heavy lifting greater 10 lbs., follow-up surgeon, instruct regarding activity restrictions. Please also follow-up primary care physician. Incision Care: *Please call surgeon go emergency department increased pain, swelling, redness, drainage incision site. *Avoid swimming baths cleared surgeon. *You may shower wash incisions mild soap warm water. Gently pat area dry. *If staples, removed follow-up appointment. *If steri-strips, fall own. Please remove remaining strips 7-10 days surgery. Followup Instructions: Call Acute Care Clinic [**Telephone/Fax (1) 600**] follow appointment [**12-27**] weeks. Call GI unit [**Telephone/Fax (1) 1983**] schedule appointment repeat ERCP stent removal 3 weeks. Call Dr. [**Last Name (STitle) 39288**] follow appointment 2 weeks. | [
"0389",
"42731",
"2875"
] |
Admission Date: [**2185-4-17**] Discharge Date: [**2185-5-2**] Date Birth: [**2185-4-17**] Sex: F Service: Neonatology HISTORY: [**First Name4 (NamePattern1) 14552**] [**Known lastname **], twin #2, born 34-2/7 weeks gestation 40-year-old gravida 3, para 2 four woman spontaneous vaginal delivery. mother's prenatal screens blood type O+, antibody negative, rubella immune, RPR nonreactive, hepatitis surface antigen negative, group B Strep unknown. pregnancy achieved in-[**Last Name (un) 5153**] fertilization resulting dichorionic-diamniotic twin. mother received betamethasone 23 weeks gestation due cervical shortening. pregnancy also complicated hypertension urinary tract infection x2 unknown organism, mother also chronic smoker. labor ensued spontaneous rupture membranes 12 hours delivery twin #1. twin emerged vigorous. Apgars eight one minute eight five minutes. birth weight 2,125 grams, birth length 44.5 cm, birth head circumference 31.5 cm. parameters 25-50th percentile gestational age. ADMISSION PHYSICAL EXAM: Reveals vigorous preterm infant. Anterior fontanel soft flat. Sutures proximated. Positive bilateral red reflex. Mild subcostal-intercostal retractions, positive grunting. Breath sounds equal. Heart regular, rate, rhythm, rhythm. Pink well perfused. Soft abdomen positive bowel sounds, three vessel umbilical cord. Normal preterm female genitalia, femoral pulses +2, nonfocal neurological examination. HOSPITAL COURSE SYSTEMS: Respiratory: infant initially grunting flaring retracting resolved hours life. occasional episodes desaturation first two days life, apnea, bradycardia, desaturation. examination, respirations comfortable. always remained room air throughout NICU stay. Cardiovascular: infant remained normotensive throughout NICU stay. cardiovascular issues. Fluids, electrolytes, nutrition: time discharge, weight 2,180 grams, length 45 cm, head circumference 31.5 cm. Enteral feeds begun day life #1 advanced without difficulty full volume feeding day life #2. time discharge, eating adlib schedule 24 calories/ounce breast milk Enfamil breast feeding mother present. Gastrointestinal: one bilirubin drawn day life #3 total 6.4 direct 0.3. never required phototherapy. Hematology: time admission, hematocrit 46.8. never received blood product transfusion NICU stay. Infectious disease: [**Doctor First Name 14552**] started ampicillin gentamicin time admission sepsis risk factors. antibiotics discontinued 48 hours blood cultures negative, infant clinically well. Neurology: neurological issues. Audiology: Hearing screening performed automated auditory brain stem responses, infant passed ears. Psychosocial: Parents involved infant's care throughout NICU stay. infant discharged good condition home parents. PRIMARY PEDIATRIC CARE: provided Dr. [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **] [**Hospital1 1562**], telephone #[**Telephone/Fax (1) 49156**]. CARE RECOMMENDATIONS DISCHARGE: 1. Feedings: 24 calories/ounce breast milk Enfamil breast feeding maintain consistent weight gain. MEDICATIONS: 1. Iron sulfate (25 mg/ml elemental iron) 0.2 cc po q day. infant passed car seat oxygenation test. State newborn screens sent [**4-21**] [**2185-5-1**]. infant yet received immunizations attempt keep twins immunization schedule twin yet reached 2 kg weight recommendation first hepatitis B vaccine. RECOMMENDED IMMUNIZATIONS: 1. Synagis RSV prophylaxis considered [**Month (only) 359**] [**Month (only) 547**] infants meet following three criteria: 1) Born less 32 weeks, 2) born 32 35 weeks plans daycare RSV season, smoker household, preschool siblings, 3) chronic lung disease. 2. Influenza immunization considered annually fall preterm infants chronic lung disease reach six months age. age, family caregivers considered immunization influenza protect infant. FOLLOW-UP APPOINTMENTS INFANT: 1. [**Hospital6 407**] [**Hospital3 **], telephone #1-[**Telephone/Fax (1) 46331**]. 2. Lactation consultant Learning Center [**Hospital1 **], telephone #[**Telephone/Fax (1) 47507**]. DISCHARGE DIAGNOSES: 1. Prematurity 34-2/7 weeks. 2. Twin #2. 3. Status post transitional respiratory distress. 4. Sepsis ruled out. [**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**] Dictated By:[**Last Name (NamePattern1) 37333**] MEDQUIST36 D: [**2185-5-2**] 15:03 T: [**2185-5-2**] 06:58 JOB#: [**Job Number 49158**] | [
"7742",
"V290"
] |
Admission Date: [**2199-12-3**] Discharge Date: [**2199-12-19**] Date Birth: Sex: Service: CHIEF COMPLAINT: Hypoxia HISTORY PRESENT ILLNESS: 33 year old male significant past medical history initially presented [**Company 191**] Outpatient Clinic [**11-27**] four days high fevers (103 degrees F), nonproductive cough, malaise, diffuse myalgias, mild resting dyspnea, exposure ill contacts. [**2199-11-27**] vital signs office temperature 99.5, blood pressure 120/85, heartrate 113 respiratory rate 20, oxygen saturation 89% room air. Weight 238 lbs. Nonspecific pulmonary examination appreciated time. prescribed Levaquin 500 mg p.o. q.d. discharged home. represented outpatient [**Hospital 191**] Clinic [**2199-12-3**] complaining persistent fever 102 degrees F, weakness, bilious emesis, worsening dyspnea, nonproductive cough. Vital signs office temperature 97.3, blood pressure 108/70, respiratory rate 20, heartrate 108, oxygen saturation 70% room air. wheezes noted examination. given 1 gm Ceftriaxone sent Emergency Department received normal saline 1 gm Vancomycin. denied pleuritic chest pain. risk factors human immunodeficiency virus. denies history seizure disorder, alcohol use, recent somnolence, symptoms gastroesophageal reflux disease. transferred Intensive Care Unit arrival. PAST MEDICAL HISTORY: significant past medical history surgical history. ALLERGIES: known drug allergies. MEDICATIONS ADMISSION: Levofloxacin 500 mg p.o. q.d. SOCIAL HISTORY: Originally [**Male First Name (un) 1056**]. bus driver, lives wife daughter, alcohol, elicit drug use. Rare alcohol use. FAMILY HISTORY: Father diabetes mellitus. PHYSICAL EXAMINATION ADMISSION: General, moderately obese, sitting bed, accessory muscle use. Vital signs, temperature 99.0, heartrate 92, blood pressure 137/74, respiratory rate 16, oxygen saturation 100% 100% nonrebreather. Head, eyes, ears, nose throat, pupils equal, round reactive light, extraocular muscles intact, anicteric, oropharynx clear, fair dentition. Neck, lymphadenopathy. Chest, rhonchi, right greater left, crackles, wheezes. Normal E ratio, egophony, fremitus, dullness percussion. Cardiac, regular rate rhythm, murmurs, rubs gallops. Abdomen, obese, normoactive bowel sounds, nontender, nondistended, masses. Neurological, cranial nerves II XII grossly intact. Alert oriented times three. Conversant appropriately. Strength 5/5 extremities. LABORATORY DATA: Laboratory findings admission revealed white blood cell count 8.4, 73% neutrophils, 0 bands, 19 lymphocytes, 6 monocytes, hematocrit 43.8, platelets 104, MCV 83, RDW 13.0, sodium 137, potassium 3.4, chloride 92, bicarbonate 29, BUN 13, creatinine 0.8, glucose 129. Arterial blood gases 100% nonrebreather, PH 7.49, carbon dioxide 39, oxygen 77. Imaging: [**2199-11-27**], chest x-ray, normal, acute cardiopulmonary process. Chest x-ray [**2199-12-3**], (on admission), patchy right upper lobe, right middle lobe infiltrate diffuse right greater left interstitial pattern, normal mediastinum, effusion. HOSPITAL COURSE: 33 year old male past medical history originally admitted Intensive Care Unit hypoxia, bilateral pneumonia, received Ceftriaxone Azithromycin, Doxycycline added since parakeet home (he also rats home). underwent bronchoscopy computed tomographic angiography thorax demonstrated right middle lobe right lower lobe pulmonary emboli question infarction. subsequently heparinized. human immunodeficiency virus test negative. received Bactrim steroids days stopped human immunodeficiency virus test came back negative. hypercoagulability workup pending arrived floor stable condition. arrival floor clinically improving heparin drip, Ceftriaxone, Azithromycin, Doxycycline. studies obtained Intensive Care Unit included [**First Name8 (NamePattern2) **] [**Doctor First Name **] negative, ANCA negative, hepatitis panel negative. LENIS demonstrated deep vein thrombosis, thrombosis right lesser saphenous vein, echocardiogram obtained well [**12-6**], demonstrated ejection fraction 50%, mildly dilated right ventricle mild tricuspid regurgitation. chest computerized tomography scan mentioned [**12-4**] demonstrated multiple small pulmonary emboli (right lower lobe right middle lobe) bilateral atypical pneumonias. Workup organism said pneumonia undertaken. negative viral culture, negative Chlamydia, negative leptospirosis, negative C. Psittaci negative mycoplasmas. Blood cultures negative well. maintained Azithromycin completed 14 day course pneumonia. Doxycycline withdrawn. completed ten day course Ceftriaxone. Regarding pulmonary emboli, remained hemodynamically stable heparin drip throughout admission. repeat computerized tomography scan thorax demonstrated bilateral expanded heterogenous soft tissue densities within rectus abdominis muscle ? hematomas, partial resolution bilateral perihilar ground-glass opacities, left SVC, however, pulmonary emboli. Given discrepancy [**12-4**] [**12-11**], computerized tomography scans, would difficult prove pulmonary emboli [**12-4**] film. decision anticoagulate three six months pursue evaluation made. Regarding anticoagulation workup, patient positive anticardiolipin IgM (46.9). intermediate range value. IgG anticardiolipin value 1.6. patient normal PTT admission. make diagnosis anticardiolipin syndrome single value, finding stands nonspecific, however, anticardiolipin panel repeated six weeks. patient subsequently continued anticoagulation pulmonary emboli. heparin drip discontinued discharge bridged Coumadin Lovenox. Regarding rectus hematomas noted computerized axial tomography scan, finding commonly seen setting anticoagulation. patient concurrently fevers maximally 101 degrees F. concern perhaps fevers may attributable hematoma local infection thereabouts. started Clindamycin conjunction Infectious Disease Consult Service's recommendations. completed ten day course Clindamycin. Finally, patient noted drop hematocrit anticoagulation. guaiac negative. source bleed identified. likely bled abdominal hematoma attributing drop hematocrit. patient also intermittently hyponatremic stay, likely secondary syndrome inappropriate antidiuretic hormone secondary thoracic processes (namely bilateral pneumonia, pulmonary embolisms) admission. DISCHARGE DIAGNOSIS: 1. Bilobar pneumonia atypical fevers 2. Pulmonary embolus 3. Rectus hematoma 4. Anticardiolipin antibody IgM positive 5. Hyponatremia 6. Anemia FOLLOW UP: patient follow primary provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] week following discharge. MEDICATIONS DISCHARGE: discharged Lovenox bridge Coumadin. also discharged Clindamycin complete ten day course. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Name8 (MD) 17844**] MEDQUIST36 D: [**2200-5-7**] 17:14 T: [**2200-5-7**] 19:08 JOB#: [**Job Number **] | [
"486",
"2761",
"2859"
] |
Admission Date: [**2140-11-11**] Discharge Date: [**2140-11-24**] Service: CARDIOTHORACIC HISTORY PRESENT ILLNESS: patient scheduled admission aortic aneurysm repair. 81 year old woman history hypertension, recurrent pericarditis pleuritis requiring percutaneous drainage [**2137**]. echocardiogram [**2137-12-13**], showed normal left ventricular function dilated aortic root 48mm, mildly thickened aortic valve mild aortic regurgitation. Follow-up [**2140-9-12**], echocardiogram showed ejection fraction 60% dilated aortic root 55mm, mild aortic sclerosis, mild aortic regurgitation, bilateral atrial enlargement. Cardiac catheterization done [**2140-10-26**], showed ejection fraction 80% normal wall motion, severe aneurysmal dilatation ascending aorta arch, recurrent dilatation descending aorta dissection, 1+ aortic regurgitation, normal coronaries. PAST MEDICAL HISTORY: 1. Hypertension. 2. Raynaud's disease. 3. Phlebitis. 4. Osteoporosis. 5. Tonsillectomy. 6. Spinal fusion. 7. Umbilical hernia repair. 8. Appendectomy. 9. Cholecystectomy. 10. Total abdominal hysterectomy. MEDICATIONS ADMISSION: 1. Metoprolol 100 mg twice day. 2. Hydrochlorothiazide 25 mg daily. 3. Lisinopril 10 mg daily. 4. Enteric Coated Aspirin 81 mg daily. 5. Centrum Silver one daily. 6. Calcium 600 daily. 7. Nexium 40 mg daily. ALLERGIES: Stated allergy Codeine caused bad abdominal cramps adhesive tape causes rash. SOCIAL HISTORY: patient lives home husband. [**Name (NI) 1139**] one half pack per day times eighteen years, quit forty-five years ago. Alcohol one drink per day, none times past four weeks. PHYSICAL EXAMINATION: time preadmission testing, heart rate 74 beats per minute, blood pressure 148/80, respiratory rate 18, oxygen saturation 96% room air, height four feet eleven inches, weight 106 pounds. general, appears younger stated age acute distress. Skin - breaks rashes. Head, eyes, ears, nose throat - pupils equal, round, reactive light accommodation. Extraocular movements intact. Pharynx clear. neck supple jugular venous distention, bruits, carotid pulses 2+ bilaterally. chest clear auscultation bilaterally. heart regular rate rhythm, murmurs, rubs gallops. abdomen soft, nontender, nondistended, positive bowel sounds, hepatosplenomegaly, well healed surgical scars. Extremities without cyanosis, clubbing edema. Left upper extremity nodularity old intravenous site near left wrist. varicosities lower extremities. Neurologically, patient alert oriented times three, grossly intact. Pulses - femoral indicated. Dorsalis pedis 1+ bilaterally. Posterior tibial detected. Radial 2+ bilaterally. carotid bruits bilaterally. HOSPITAL COURSE: stated previously, patient direct admission operating room [**2140-11-11**], time underwent supracoronary ascending aortic graft resuspension aortic valve. Please see operative report full details. patient tolerated operation well transferred operating room Cardiothoracic Intensive Care Unit. Circ arrest time eleven minutes. time transfer, patient Milrinone 0.4 mcg/kg/minute, Amiodarone 1 mg per minute, Neo-Synephrine dose indicated Propofol, also dose indicated. patient well immediate postoperative period. anesthesia reversed. weaned ventilator. morning postoperative day one, successfully extubated. postoperative day number one, cardioactive medications begun weaning beginning Amiodarone Milrinone. postoperative day two, patient maintained minimal amounts Amiodarone, Milrinone Nipride. postoperative day two, patient's Milrinone discontinued. Amiodarone changed p.o. Nipride discontinued initiation beta blockade. chest tubes removed. maintained Cardiothoracic Intensive Care Unit monitoring hemodynamic pulmonary status. postoperative day three, patient continued well. remained hemodynamically stable. transferred Cardiothoracic Intensive Care Unit [**Hospital Ward Name 121**] Two continuing postoperative care cardiac rehabilitation. floor, noted patient gone sustained atrial fibrillation heart rate 100 110, hemodynamically tolerated well. seen electrophysiology service maintained p.o. Lopressor well p.o. Amiodarone continued monitored floor. next two days, patient atrial fibrillation. remained hemodynamically stable throughout periods. postoperative day five, noted patient drop hematocrit guaiac positive stools. seen gastroenterology service. time, also transferred back Cardiothoracic Intensive Care Unit close monitoring. patient underwent KUB read normal. also stools sent Clostridium difficile negative. empirically started Flagyl time. patient remained Intensive Care Unit next several days monitor gastrointestinal status make sure guaiac positive stools. postoperative day seven, transferred floor continuing postoperative care. Prior transfer Intensive Care Unit, noted patient left upper extremity swelling. underwent ultrasonography upper extremities time rule thrombosis. Ultrasound showed right internal jugular cephalic thrombus. Following transfer, vascular service consulted recommended oral anticoagulation Coumadin, begun time. next several days, exception intermittent atrial fibrillation, patient uneventful hospital course. seen electrophysiology service given episodes atrial fibrillation, last episode lasting greater 24 hours. patient additionally begun Heparin given duration episode atrial fibrillation. patient scheduled direct current cardioversion, however, prior cardioversion, patient spontaneously converted normal sinus rhythm. postoperative day twelve, decided patient remained rate controlled rhythm next 24 hours, would stable ready transferred rehabilitation. time dictation, patient's physical examination follows; vital signs revealed temperature 98.2, heart rate 71, sinus rhythm, blood pressure 147/68, respiratory rate 20, oxygen saturation 98% room air. Weight preoperatively 50 kilograms transfer rehabilitation 53 kilograms. Laboratory data [**2140-11-23**], white blood cell count 11.7, hematocrit 34.5, platelet count 219,000. Prothrombin time 15.0, partial thromboplastin time 25.0 Heparin off. INR 1.5. Sodium 129, potassium 4.8, chloride 95, CO2 29, blood urea nitrogen 16, creatinine 0.8, glucose 183. patient alert oriented times three, moves extremities, follows commands. Respiratory revealed scattered rhonchi. Cardiac regular rate rhythm murmur. sternum stable incision Steri-strips open air, clean dry. abdomen soft, nontender, nondistended positive bowel sounds. Extremities warm well perfused edema. Right upper arm minimal edema resolving last several days. MEDICATIONS DISCHARGE: 1. Colace 100 mg p.o. twice day. 2. Amiodarone 200 mg p.o. three times day times one week 200 mg p.o. daily times one month. 3. Metoprolol 100 mg twice day. 4. Lasix 20 mg daily times ten days. 5. Potassium Chloride 20 meq daily times ten days. 6. Prilosec 40 mg p.o. daily. 7. Heparin 600 units per hour keep partial thromboplastin time 40 60 INR therapeutic. 8. Warfarin maintain INR 2.0 2.5. patient received 2 mg Coumadin two days prior discharge Coumadin one day prior discharge 2 mg Coumadin night discharge. check INR morning dose Coumadin day transfer rehabilitation center. CONDITION DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Status post supracoronary ascending aortic graft resuspension aortic valve. 2. Hypertension. 3. Raynaud's disease. 4. Phlebitis. 5. Osteoporosis. 6. Status post tonsillectomy. 7. Status post spinal fusion. 8. Status post umbilical hernia repair. 9. Status post inguinal hernia repair. 10. Status post appendectomy. 11. Status post cholecystectomy. 12. Status post total abdominal hysterectomy. DISCHARGE STATUS: patient discharged [**Location 50742**]. FO[**Last Name (STitle) **]P: follow-up Dr. [**First Name (STitle) **] two three weeks follow-up Dr. [**Last Name (STitle) 1159**] one month follow-up Dr. [**Last Name (Prefixes) **] one month. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2140-11-23**] 16:44 T: [**2140-11-23**] 18:31 JOB#: [**Job Number 50743**] | [
"4241",
"42731",
"4019",
"53081"
] |
Admission Date: [**2164-4-23**] Discharge Date: [**2164-4-27**] Date Birth: [**2096-1-7**] Sex: Service: CARDIOTHORACIC Allergies: Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest pain shortness breath Major Surgical Invasive Procedure: [**2164-4-23**] Coronary artery bypass grafting x3 left internal mammary artery left anterior descending artery reverse saphenous vein graft posterior descending artery obtuse marginal artery. History Present Illness: 68 year old male history MI 25 years ago. treated medication since then. well years 3 weeks ago started notice diaphoresis, shortness breath right sided chest discomfort occurred exertion yard work taking trash. symptoms resolve rest. also one episode chest pain, diaphoresis back pain occurred rest large meal. episode lasted little longer episodes prompted patient contact Dr. [**Last Name (STitle) 1270**]. sent stress echo abnormal referred cardiac catheterization. found three vessel disease referred cardiac surgery revascularization. Past Medical History: diabetes type II -diagnosed [**2160**]; controlled oral agents hyperlipidemia hypertension MI [**2138**] psoriasis Social History: Race:Caucasian Last Dental Exam:[**1-/2164**] Lives with:Wife Contact:[**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 90854**] Occupation:Retired FDA field investigator consultant Cigarettes: Smoked [] yes [x] Hx:smoked 2ppd 28 years quit [**2138**] Tobacco use:denies ETOH: < 1 drink/week [x] [**12-27**] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: Premature coronary artery disease- unknown-adopted Physical Exam: Pulse:61 Resp:16 O2 sat:100/RA B/P Right:138/86 Left:135/74 Height:6'2" Weight:230 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [x] _____ Varicosities: (L)LE superficial varicosities Neuro: Grossly intact [x] Pulses: Femoral Right: Left: DP Right:2+ Left:2+ PT [**Name (NI) 167**]: Left: Radial Right: Left: Carotid Bruit -none appreciated, pulses Right:2+ Left:2+ Pertinent Results: [**2164-4-23**] Echo: PRE-BYPASS: spontaneous echo contrast seen body left atrium left atrial appendage. atrial septal defect seen 2D color Doppler. Left ventricular wall thicknesses normal. left ventricular cavity size top normal/borderline dilated. mild regional left ventricular systolic dysfunction hypokinesis basal distal inferoseptal anteroseptal walls. Overall left ventricular systolic function mildly depressed (LVEF= 50-55 %). Right ventricular chamber size free wall motion normal. simple atheroma aortic arch. simple atheroma descending thoracic aorta. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic stenosis aortic regurgitation. mitral valve leaflets mildly thickened. Mild (1+) mitral regurgitation seen. pericardial effusion. Dr. [**Last Name (STitle) **] notified person results time surgery. POST-BYPASS: patient sinus rhythm. patient inotropes. Biventricular function unchanged. Mitral regurgitation unchanged. aorta intact post-decannulation. [**2164-4-27**] 04:44AM BLOOD WBC-11.7* RBC-3.00* Hgb-9.8* Hct-28.3* MCV-94 MCH-32.5* MCHC-34.5 RDW-14.0 Plt Ct-323 [**2164-4-27**] 04:44AM BLOOD Plt Ct-323 [**2164-4-27**] 04:44AM BLOOD Glucose-121* UreaN-22* Creat-1.0 Na-139 K-3.8 Cl-102 HCO3-28 AnGap-13 [**2164-4-27**] 04:44AM BLOOD Mg-2.3 COMPARISON: [**2164-4-25**] 10:45 a.m. FINDINGS: noted previously, similar-sized left apical pneumothorax. left chest tube removed interim. Left basilar atelectasis remains. cardiac silhouette mediastinal contours unchanged. Median sternotomy wires unchanged. IMPRESSION: Unchanged small left apical pneumothorax, status post left chest tube removal. Brief Hospital Course: Mr. [**Known lastname **] 68 yr old male history MI developed worsening chest pain, underwent cath revealed significnat CAD. seen cardiac surgery service accepted CABG. day admit [**4-23**] brought directly operating room underwent coronary artery bypass graft x 3. Please see operative note surgical details. Following surgery transferred CVICU invasive monitoring stable condition. Later day weaned sedation, awoke neurologically intact extubated. weaned Neo overnight started beta-blocker POD#1. diuresed towards preoperative weight. POD#1 transferred step unit monitoring. continued progress well floor. Physical Therapy consulted evaluation strength mobility. remainder postop course essentially uneventful. cleared discharge home VNA services POD#4. Follow-up appts arranged. Medications Admission: ATENOLOL 50 mg Daily LIPITOR 20 mg Daily PLAVIX 75 mg Daily (started [**2164-4-14**]), LD [**4-17**] DILTIAZEM HCL 240 mg Daily ENALAPRIL MALEATE takes 10mg qam, 5mg qhs HYDROCHLOROTHIAZIDE 25 mg Daily METFORMIN 1,000 mg [**Hospital1 **] NITROGLYCERIN 0.4 mg Tablet PRN Aspirin 325mg Daily Centrum Silver Multivitamin 1 tablet daily Discharge Medications: 1. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO day 2 weeks. Disp:*60 Tablet Extended Release(s)* Refills:*2* 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) needed pain. Disp:*40 Tablet(s)* Refills:*0* 5. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). Disp:*1 * Refills:*2* 6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times day). Disp:*90 Tablet(s)* Refills:*2* 7. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). Disp:*120 Tablet(s)* Refills:*2* 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). Disp:*60 Capsule(s)* Refills:*2* 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO day 2 weeks. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 3 Past medical history: diabetes type II -diagnosed [**2160**]; controlled oral agents hyperlipidemia hypertension MI [**2138**] psoriasis Discharge Condition: Alert oriented x3 nonfocal Ambulating steady gait Incisional pain managed oral analgesia Incisions: Sternal - healing well, erythema drainage Leg Right/Left - healing well, erythema drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently mild soap, baths swimming cleared surgeon. Look incisions daily redness drainage Please lotions, cream, powder, ointments incisions morning weigh evening take temperature, written chart driving approximately one month taking narcotics, discussed follow appointment surgeon able drive lifting 10 pounds 10 weeks Please call questions concerns [**Telephone/Fax (1) 170**] Females: Please wear bra reduce pulling incision, avoid rubbing lower edge **Please call cardiac surgery office questions concerns [**Telephone/Fax (1) 170**]. Answering service contact call person hours** Followup Instructions: scheduled following appointments Wound Check: [**2164-5-8**] 10:00 Surgeon: Dr. [**Last Name (STitle) **] [**2164-5-31**] @ 1pm Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1270**] [**Telephone/Fax (1) 1144**] Date/Time:[**2164-5-15**] 10:30 **Please call cardiac surgery office questions concerns [**Telephone/Fax (1) 170**]. Answering service contact call person hours** Completed by:[**2164-4-27**] | [
"41401",
"25000",
"2724",
"4019",
"412",
"V1582"
] |
Admission Date: [**2115-2-22**] Discharge Date: [**2115-3-19**] Date Birth: [**2078-8-9**] Sex: Service: MEDICINE Allergies: Vicodin Attending:[**First Name3 (LF) 4891**] Chief Complaint: Post-cardiac arrest, asthma exacerbation Major Surgical Invasive Procedure: Intubation Removal chest tubes placed outside hospital R CVL placement History Present Illness: Mr. [**Known lastname 3234**] 36 year old gentleman PMH signifciant dilated cardiomyopathy s/p AICD, asthma, HTN admitted OSH dyspnea admitted MICU PEA arrest x2. patient initially presented LGH ED hypoxemic respiratory distress. OSH, received CTX, azithromycin, SC epinephrine, solumedrol. OSH, became confused subsequently episode PEA arrest intubated. received epinephrine, atropine, magnesium, bicarb. addition, bilateral needle thoracostomies report air return left, subsequently bilateral chest tubes placed. approximately 15-20 minutes rescucitation, ROSC. received vecuronium started epi gtt asthma cooling protocol, transferred [**Hospital1 18**] evaluation. note, patient admitted LGH [**1-4**] dyspnea, subsequently diagnosed CAP asthma treated CTX azithromycin. Per family, also multiple admissions winter asthma exacerbations. . [**Hospital1 18**] ED, 35.3 102 133/58 100%AC 500x20, 5, 1.0 ABG 7.16/66/162. CTH unremarkable. CTA chest, afterwhich went PEA arrest. Rescucitation last approximately 10-15 minutes multiple rounds epi bicarb, ROSC. admitted MICU management. . Currently, patient intubated, sedated, parlyzed. Past Medical History: Asthma Dilated cardiomyopathy Multiple admissions dyspnea winter ([**1-26**]). Anxiety/depression CKD HLD Obesity HTN Social History: Unknown Family History: Unknown Physical Exam: ADMISSION: VS: 35.9 124 129/67 99% AC 480x24, 5, 1.0 Gen: ETT place, intubated, sedated. HEENT: ETT place. CV: Tachy S1+S2 Pulm: Poor air movement bilaterally. Diffuse wheezes bilaterally. Abd: S/D hypoactive BS Ext: 1+ edema bilaterally Neuro: Unresponsive. . Discharge: 98.5 102/65 76 20 95-98% RA cage bed prevent patient falling bed. Occasionally calling out. Lungs clear without wheezes. Pertinent Results: Labs Admission: [**2115-2-22**] 08:50AM BLOOD WBC-19.5* RBC-4.76 Hgb-14.9 Hct-44.3 MCV-93 MCH-31.4 MCHC-33.7 RDW-12.9 Plt Ct-201 [**2115-2-22**] 08:50AM BLOOD PT-14.1* PTT-25.9 INR(PT)-1.2* [**2115-2-22**] 08:50AM BLOOD Glucose-306* UreaN-21* Creat-1.2 Na-144 K-4.1 Cl-111* HCO3-28 AnGap-9 [**2115-2-22**] 08:50AM BLOOD Albumin-3.4* Calcium-6.2* Phos-5.5* Mg-2.2 [**2115-2-22**] 09:32AM BLOOD calTIBC-320 Ferritn-1129* TRF-246 [**2115-2-22**] 07:17AM BLOOD Type-ART pO2-162* pCO2-66* pH-7.16* calTCO2-25 Base XS--6 Intubat-INTUBATED . Labs Discharge [**2115-3-18**] 11:34AM BLOOD Type-ART pO2-95 pCO2-33* pH-7.54* calTCO2-29 Base XS-5 Intubat-NOT INTUBA [**2115-3-5**] 05:35AM BLOOD ALT-49* AST-23 AlkPhos-53 TotBili-0.9 [**2115-3-19**] 04:45AM BLOOD Glucose-73 UreaN-25* Creat-1.4* Na-133 K-4.1 Cl-95* HCO3-21* AnGap-21* [**2115-3-19**] 04:45AM BLOOD WBC-12.4* RBC-4.47* Hgb-14.3 Hct-41.3 MCV-93 MCH-32.0 MCHC-34.6 RDW-13.3 Plt Ct-352 [**2115-3-19**] 04:45AM BLOOD Neuts-56 Bands-0 Lymphs-38 Monos-3 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 . CXR (in MICU): Mr read - cardiomegaly, RIJ SVC, ETT 4.5 cm carina. Blunting costophrenic angles bilaterally low lung volumes. Loss retrocardiac diagphragm bilateral opacities (L>R) . CXR: 1. NG tube 7.2 cm carina. [**Month (only) 116**] consider advancing optimal placement. 2. Severe cardiomegaly globular shape. absence prior comparison, differential broad, including moderate pericardial effusion, mediastinal hemorrhage, acute cardiac failure. Recommend clinical correlation. . CTH: read, acute bleed . CTA Chest: 1. evidence pulmonary embolism, although evaluation subsegmental branches limited. 2. Moderate cardiomegaly without pericardial effusion. 3. Bilateral dependent atelectasis. 4. Multiple nondisplaced rib fractures right, subacute. Also possible subtle nondisplaced fractures left ribs. 5. Nondisplaced acute sternal fracture addition subacute nondisplaced sternal fracture. . TTE: left atrium moderately dilated. estimated right atrial pressure 10-20mmHg. Left ventricular wall thicknesses normal. left ventricular cavity severely dilated. LV systolic function appears depressed (ejection fraction ? 30 percent) regional variation. considerable beat-to-beat variability left ventricular ejection fraction due irregular rhythm/premature beats. right ventricular free wall thickness normal. right ventricular cavity dilated depressed free wall contractility. aortic root mildly dilated sinus level. ascending aorta mildly dilated. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic stenosis aortic regurgitation. mitral valve leaflets structurally normal. mitral valve prolapse. Mild (1+) mitral regurgitation seen. pulmonary artery systolic pressure could determined. pericardial effusion. . ECG (post-arrest): Sinus 1:1 conduction. LAA. LAD, RBBB, LAFB. STD V4-V6. . ECG (pre-arrest): Sinus 1:1 conduction. LAD, bifascicular block. lateral STD. . ECG (OSH, unclear pre/post arrest): Sinus 1:1 conduction. Bifascicular (RBBB, LAFB) block. STD V5-6. . EEG [**2-27**] IMPRESSION: abnormal video EEG telemetry due slow disorganized background 6.5 Hz bursts generalized slowing showed clear reactivity. findings indicate severe encephalopathy. may consistent patient's history anoxia; however, toxic/metabolic disturbances, infection, medication effects also among frequent causes encephalopathy. clear epileptiform discharges seizures seen. LUMBAR SPINE [**2115-3-11**] CLINICAL INFORMATION: Evidence fracture, seizure, fall, low back pain. FINDINGS: Three views lumbar spine demonstrate mild narrowing left femoroacetabular joint. mild scoliosis thoracolumbar spine. ventricular lead pacemaker identified. fracture L2 L5 identified. However, compression fracture L1, compression superior endplate, sclerotic fracture line. Given mechanism fall, acute pain referable L1, would considered acute finding. apparent retropulsion posterior margin L1 spinal canal. fractures identified time. Facet joints aligned. early calcification aorta. IMPRESSION: Compression fracture L1 anterior wedge deformity, likely acute finding. fractures identified. EKG: Normal sinus rhythm. Complete right bundle-branch block left anterior fascicular block. Diffuse ST-T wave changes laterally. CT Head: COMPARISON: [**2115-2-22**]. TECHNIQUE: Non-contrast axial images obtained brain. FINDINGS: intracranial hemorrhage, edema, loss [**Doctor Last Name 352**]/white matter differentiation. Ventricles sulci normal size configuration. basilar cisterns compressed. Paranasal sinuses demonstrate fluid sphenoid air cells right posterior ethmoid air cell, likely related prolonged hospitalization. Mastoid air cells well aerated. IMPRESSION: evidence acute intracranial abnormalities. Brief Hospital Course: Mr. [**Known lastname 3234**] 36 year old gentleman PMH signifciant dilated cardiomyopathy s/p AICD, PE anticoagulation, asthma, HTN admitted OSH dyspnea transferred [**Hospital1 18**] MICU PEA arrest x2. # PEA arrest subsequent anoxic brain injury.: Suspect original OSH PEA arrest due hypoxemia acidosis, [**Hospital1 18**] ED PEA arrest due acidosis admission pH 7.16 arrival. TTE evidence RV failure suggest PE. LVEF 30% known dilated cardiomyopathy. cooled per protocol. Initially, EEG concerning without evident brain activity. hospital day 3, comatose activity prognosis guarded. However, patient able weaned vent course next three days mental status improved. alert, oriented place day week moving 4 extremities. became interactive transfer floor, initially speaking spanish English always making sense started responding appropiately following commands. hospital day 11 witnessed grand mal seizure given ativan started Keppra neurology consult. mental status worse 24 hours seizure slowly returned recent baseline. somewhat aggitated Keppra switched Topiramate. subsequent seizure [**3-18**] LUE tonic clonic activity impaired consciousness resolved spontaneously 1-2 minutes. contineud topamax per neuro recommendations. OT PT consulted worked patient likely require long rehabilitation course. time discharge patient alert, oriented (though always date), following commands impulsive poor motor planning leading several falls. Neurology notes indicate patient potential toimprove neurologic standpoint. also may recurrent seizures treated ativan IV IM neccessarily indicate patient needs return hospital unless continue greater 5 minutes multiple recurrent seizures complications aspiration. -patient Topiramate 25mg PO BID [**3-22**] PM increase 50mg po BID seven days increase 75mg [**Hospital1 **] ongoing. -patient follow Dr. [**Last Name (STitle) **] [**Name (STitle) **] s/p arrest neurology clinic -patient require intensive PT OT anoxic brain injury unit. . # Respiratory failure: Believed due status asthmaticus, although inciting event unclear. [**Name2 (NI) 227**] multiple cardiac arrests, also concern development ARDS. patient initially treated broadly vancomycin, cefepime, flagyl, cipro, oseltamavir. treated IV soludemedrol albuterol MDI. ventialted according ARDS-Net protocol. admission, two chest tubes placed pneumothoraces. removed hospital day 1. first several days, respiratory status comprimised lobar collapse, first RUL RML. extubation initially limited agitation requiring sedation requirements high PEEP maintain oxygenation. oxygenation improved diuresis agitation better controlled seroquel. extubated [**3-1**] respiratory status stable. Asthma treated standing PRN albuterol ipratriopium slow prednisone taper l completed [**2115-3-18**] restarted Advair -patient may require additional nebs top standing advair though respiratory status stable, without wheezing last week. - would like benefit outpatient PFTs scheduled see pulmonologist follow up. . # Ventilator associated pneumonia: Patient developed fever [**2-27**] new infiltrates chest xray intubated. initially covered vanc/cefepime cipro. Cipro eventually discontinued. grow organisms yeast sputum. completed 8 day course Vanco/Cefepime. . # Myoclonus: mental status improved, noted myoclonic jerks. per neurology, likely [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] Syndrome anoxic injury purkinje cells. jerks continued one week became rare. . # dilated [**Last Name (LF) 89982**], [**First Name3 (LF) **] 30%. s/p ICD. Patient diuresed IV lasix ED transitioned PO lasix, home dose, floor. respiratory status remained stable. Also continued home dose carvedilol Lisinopril ACE downtitrated 40 20 elevated Cr 1.9 [**3-18**] slightly low BPs high 90s/60s. BP improved 100s/60s. . #Hypertension: Patient's home regimen continued floor, SBP dipped high 80s low 90s lisinopril decreased 20mg po daily SBP remained 100-130. . # L1 compression fracture: patient fell, complaining low back pain L-spine Xray performed showed L1 compressin fracture cord impingement imaging. patient localizing deficits serial neuro exam. treated pain medication including low dose ultram, standing tylenol lidocaine patch. Calcitonin tried pain compression fracture seem help symptoms discontinued. . # Leukocytosis: WBC >20 persistently MICU even treated infection. Since new infection found presumed [**12-26**] steroids leukocytosis improved prednisone taper. WBC 12 day discharge . # Hyperglycemia: Patient known diabetic felt [**12-26**] steroids, sugars controlled sliding scale insulin hospital longer insulin requirements prednisone tapered. . #. [**Last Name (un) **]: Cr 1.9 [**3-18**] 1.2 improved 1.4 [**3-19**] decreasing ACE 500cc bolus. repeat creatinine labs [**3-22**] ensure stability. # Guardianship: Guardianship paperwork started hospital. Medications Admission: Carvedilol 25 [**Hospital1 **] Lasix 80 mg po bid Xanax 0.25 mg 1-2 tabs prn albuterol MDI Ibuprofen prn Benadryl prn Advair diskus Lsinopril 40 daily Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed Constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed Constipation. 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) needed pain/fever. 4. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 6. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 7. lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: [**11-25**] Tablet, Rapid Dissolves PO QHS (once day (at bedtime)) needed sleep. 9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times day). 10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times day) needed pain/fever. 12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hours 12 hours every 24 hour period. 13. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours. 14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization Sig: One (1) neb Inhalation every six (6) hours. 15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) needed SOB. 16. topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times day) 3 days: 1 [**Hospital1 **] [**3-22**] PM increase 2 tablets [**Hospital1 **] 7 days 3 tablets [**Hospital1 **] ongoing. 17. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) needed back pain. 18. fluticasone-salmeterol 250-50 mcg/dose Disk Device Sig: One (1) inh Inhalation [**Hospital1 **] (2 times day). 19. lorazepam 2 mg/mL Syringe Sig: 1-2 mg Injection twice day needed seizure last longer 5 minutes. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Anoxic Brain Injury s/p PEA arrest x2 Status Asthmaticus Ventilator Associated Pneumonia Chronic Systolic Heart Failure L1 compression fracture Seizures hypoxic brain injury Discharge Condition: Mental Status: Confused - sometimes. Level Consciousness: Alert interactive. Activity Status: Ambulatory - requires assistance aid (walker cane) poor motor planning Discharge Instructions: came hospital cardiac arrest asthma exacerbation. another cardiac arrest hospital admitted MICU. required intubation able wean machine breathe own. treated pneumonia asthma. mental status slowly improved, though 2 seizures, last [**3-18**]. started ons eizure medications this. . Please take medications prescribed follow doctors [**Name5 (PTitle) 7928**]. Followup Instructions: Department: PULMONARY FUNCTION LAB When: WEDNESDAY [**2115-4-3**] 1:10 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: WEDNESDAY [**2115-4-3**] 1:30 PM With: DR [**Last Name (STitle) **]/DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: COGNITIVE NEUROLOGY UNIT When: THURSDAY [**2115-4-11**] 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD [**Telephone/Fax (1) 1690**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage | [
"51881",
"5849",
"2762",
"2760",
"5180",
"49390",
"40390",
"5859",
"4280"
] |
Admission Date: [**2187-7-13**] Discharge Date: [**2187-7-23**] Date Birth: [**2104-8-30**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillin V / Methyldopa Attending:[**First Name3 (LF) 165**] Chief Complaint: general malaise Major Surgical Invasive Procedure: dental extractions [**2187-7-15**] redo sternotomy/AVR (#19 CE Magna)-[**2187-7-17**] History Present Illness: 82 yo F s/p CABG [**2177**] severe recent NSTEMI, preop [**Hospital 1291**] transferred [**Hospital3 **] SOB, recurrent pulmonary edema. Past Medical History: Right carotid endarterectomy CABG [**Hospital6 **] [**2181**] (LIMA LAD, SVG RCA, SVG first diagonal, SVG OM2) NSTEMI [**2187-5-1**] Renal insufficiency (baseline creatinine 1.5) Hypertension Severe Aortic stenosis Dementia Peripheral Vascular Disease Anemia (baseline hematocrit 32-34) Social History: Social history significant absence current tobacco use. history alcohol abuse. Family History: mother died heart attack age 61. dad died CVA age 47. sister diabetes. son passed away. six miscarriages. Physical Exam: HR 64 RR 20 BP 129/44 NAD Lungs scattered rales Heart RRR 3/6 SEM radiating neck Extrem warm 62" 72 kg Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT GENERAL COMMENTS: TEE performed location listed above. certify present compliance HCFA regulations. patient general anesthesia throughout procedure. TEE related complications. Resting bradycardia patient. See Conclusions post-bypass data post-bypass study performed patient receiving vasoactive infusions (see Conclusions listing medications). Conclusions PRE-BYPASS: 1. left atrium dilated. Mild spontaneous echo contrast seen body left atrium. left atrial appendage thrombus cannot excluded. atrial septal defect patent foramen ovale seen 2D, color Doppler saline contrast maneuvers. 2. mild symmetric left ventricular hypertrophy. left ventricular cavity size normal. Overall left ventricular systolic function low normal (LVEF 50-55%). 3. Right ventricular chamber size free wall motion normal. 4. simple atheroma ascending aorta. complex (>4mm) atheroma aortic arch. complex (>4mm) atheroma descending thoracic aorta. 5. three aortic valve leaflets. aortic valve leaflets severely thickened/deformed. severe aortic valve stenosis (area 0.5 cm2). aortic regurgitation seen. 6. mitral valve leaflets mildly thickened. Mild (1+) mitral regurgitation seen. 7. small left pleural effusion. Dr. [**Last Name (STitle) **] notified person results OR. POST-BYPASS: post-bypass study, patient receiving vasoactive infusions including phenylephrine AV paced. 1. well-seated bioprosthetic valve seen mitral position normal leaflet motion gradients (mean gradient = 11 mmHg cardiac output 2.6 L/min). Trivial central aortic regurgitation seen. 2. Regional global left ventricular systolic function normal. 3. Right ventricular systolic function post-bypass moderately hypokinetic. 4. intra-atrial septum dynamic. 5. Aortic contours intact post-decannulation. [**Known lastname **],[**Known firstname 24357**] L [**Medical Record Number 41597**] F 82 [**2104-8-30**] Radiology Report CHEST (PORTABLE AP) Study Date [**2187-7-19**] 2:14 PM [**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2187-7-19**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 41598**] Reason: ? ptx s/p ct removal [**Hospital 93**] MEDICAL CONDITION: 82 year old woman s/p cabg REASON EXAMINATION: ? ptx s/p ct removal Final Report STUDY: Single portable AP chest radiograph. INDICATION: 82-year-old female status post CABG chest tube removal. COMPARISON: [**2187-7-18**]. FINDINGS: Patient extubated removal right basilar chest tube Swan-Ganz catheter/NG tube. Atelectasis left lower lobe improved. Small left pleural effusion remains. upper lungs remain clear. Bilateral subclavian artery calcifications noted. Median sternotomy wires remain stable condition. IMPRESSION: 1. Interval removal multiple lines tubes without pneumothorax. 2. Improvement left lower lobe atelectasis. 3. Residual small left pleural effusion. study report reviewed staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name 4391**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] Approved: [**Doctor First Name **] [**2187-7-19**] 4:49 PM Imaging Lab Brief Hospital Course: admitted cardiac surgery. Dental consult called tooth extractions recommended. [**7-15**] 5 teeth extracted. [**7-17**] taken operating room [**7-17**] underwent redo sternotomy AVR. transferred ICU stable condition. extubated POD #1. Chest tubes removed transferred floor POD #2 begin increasing activity level. gently diuresed toward preop weight. Beta blockade titrated. Pacing wires removed POD #3.She several episodes fib coumadin started. Target INR 2.0-2.5. continued make good progress cleared discharge rehab POD #6. Pt. make followup appts. per discharge instructions. Medications Admission: ASA 325, lopressor 25", lipitor 10, lovenox 40, norvasc 5, diovan 160,acidophilus [**Hospital1 **] Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours needed pain. 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times day). 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times day). 9. Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) units SC Subcutaneous day. 10. Warfarin 3 mg Tablet Sig: One (1) Tablet PO (Once) 1 doses: 3 mg today [**7-23**]; dosing per rehab provider;target INR 2.0-2.5. 11. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO BID (2 times day): hold K >4.8.[**Month (only) 116**] DC lasix stopped. Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: s/p AVR R CEA, CABG [**Hospital6 **] [**2181**] (LIMA LAD, SVG RCA, SVG first diagonal, SVG OM2), NSTEMI [**Month (only) 547**] [**2187**], Renal insufficiency (baseline creatinine 1.5), Hypertension, Severe AS, dementia, PVD, Anemia (baseline hematocrit 32-34) ;postop Fib Discharge Condition: Stable. Discharge Instructions: Call fever, redness drainage incision weight gain 2 pounds one day five one week. Shower, baths, lotions, creams powders incisions. lifting 10 pounds. driving follow surgeon least one month. Followup Instructions: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] 2 weeks Dr. [**First Name (STitle) **] 4 weeks [**Telephone/Fax (1) 170**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2187-7-23**] | [
"4241",
"9971",
"2762",
"4280",
"42731",
"5859",
"40390",
"41401"
] |
End of preview. Expand
in Dataset Viewer.
- Downloads last month
- 4