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6,084 | CHIEF COMPLAINT: slurred speech and left facial droop
PRESENT ILLNESS: Mrs. [**Known lastname 78838**] is a 61 y/o female with remote history of seizures, HTN and detatched retina who was in good health until evening of [**2107-4-30**] when she began to demonstrate slurred speech and left facial droop. No falls or trauma surrounding this event, and she did not have a headache or loss of consciousness during this time. She then developed left sided weakness and was taken to [**Hospital1 18**] ER by family. Head CT without contrast revealed approximately 5x4x4 cm right frontal/insular hemorrhage with some effacement of the right lateral ventricle.
MEDICAL HISTORY: hyperlipidemia Hypertension detached retina - right eye
MEDICATION ON ADMISSION: lipitor unknown BP med
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Admission: Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema
FAMILY HISTORY: No strokes or bleeds. Son is congenitally deaf. DM and HTN in family.
SOCIAL HISTORY: Works in a sub-[**Location (un) 6002**] shop. Remote tob 20 yrs ago, social etoh. | 0 |
36,896 | CHIEF COMPLAINT: Altered mental status, drug overdose (?Flexeril)
PRESENT ILLNESS: 47yo female h/o depression with past suicide presenting s/p overdose of flexeril. Per report patient was found "asleep" on couch by boyfriend. Unclear how long had been unattended (~24hr). Boyfriends Empty flexeril bottle found next to patient. unclear how many pills were ingested. EMS administered narcanx3. Initially presented to an OSH. Intubated for airway protection. Started on levophed for persistent hypotension. Labs creatinine 3.9, K: 5.8, WBC 17 with 21% bandemia. CK 51K. Utox + methadone. R IJ as well as 3 peripherals placed for access. Received 9L of NS, vanc, zosyn for presumed aspiration. Started on nac bolus + ggt for planned 24hr though tylenol negative. Patient transferred to [**Hospital1 18**] ED, initial VS: afebrile, 112HR, 112/61 (MAP 73) on 0.5 levophed, 70% 400/14/30. Sedated on fentanyl and versed. Labs with K: 6.7. Kayxelate administered. No QT prolongation, no peak Twaves. NaBicarb not started. CXR c/w ARDs and patient started on ARDs net protocal.
MEDICAL HISTORY: Depression with past suicide attempts
MEDICATION ON ADMISSION: None (previously on SSRIs, but no current meds)
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Admission exam: T 97.4 HR 110 BP 118/68 RR 24 O2 Sat 98% on CMV with PEEP of 15 Vt 400 Gen: intubated, non-responsive HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
FAMILY HISTORY: unknown
SOCIAL HISTORY: history of heavy alcohol abuse Smokes 1 ppd Lives with her boyfriend | 0 |
60,180 | CHIEF COMPLAINT: shortness of breath, chest pain
PRESENT ILLNESS: his is a 78 year old male who was recently discharged [**10-11**] for Vtach with pacer/ICD placement, NSTEMI with PMH of CHF with EF=30-40%, afib on Coumadin HTN, Aortic Stenosis ([**Location (un) 109**] 1.07, mean Grad 21 mmHg), CAD with 3VD s/p several PCIs with stenting, dyslipidemia, presenting with a 1 day history of dyspnea. He had his usual anginal chest pain which responded to nitro last night in addition to shortness of breath when laying down. He usually has 2 pillow orthopnea and paroxysmal nocturnal dyspnea, but he had increased shortness of breath than usual last night. He has also notice more swelling in his legs than usual. He was seen in clinic today and referred for evaluation for his bibasilar crackles and LE edema. In the ED his trop 0.07, BNP is [**Numeric Identifier 39474**], and mild hyponatremia. Lasix 20 mg IV x 1; ECG: no change from prior. CXR: effusion, edema. Initial vitals: 98.2, 64, 128/63, 18, 100%. . On review of systems, he denies any prior history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills, or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of palpitations, syncope or presyncope.
MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -> CAD: NSTEMI [**2172**] PCI- DES of the r-PLV and LCx/OM, [**10-29**] PCI- BMS to LAD; [**2174**]- PCI ([**Hospital1 3278**]) [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **] for possible ISR -> Aortic Stenosis ([**Location (un) 109**] 1.07, mean Grad 21 mmHg), EF 50% on ETT [**2172**] -> Atrial Fibrillation -> Ventricular tachycardia s/p ICD placement [**10-2**] -> 3 vessel disease 3. OTHER PAST MEDICAL HISTORY: [**2172**]- CVA with residual speech difficulties Anemia GIB Anxiety Appendectomy Right Inguinal hernia
MEDICATION ON ADMISSION: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: one half tablet every third day. 8. Metoprolol Succinate Oral 9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain. 10. Outpatient Lab Work Please check INR on Monday [**10-14**] and call results to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 719**]. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*6 vils* Refills:*0*
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS: T=97.9, BP=120/65, HR=78, RR=22, O2 sat=98% RA GENERAL: Pleasant elderly male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI, MMM. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, no LAD. JVP of 12 cm. Normal carotid upstroke without bruits. CARDIAC: irregularly irregular. 3/6 SEM heard at RUSB. LUNGS: Resp were unlabored, no accessory muscle use. Crackles at bases bilaterally, no wheezes or rhonchi. ABDOMEN: Soft, NT, ND. No HSM, BS+. EXTREMITIES: Trace edema bilaterally. No clubbing, cyanosis. PULSES: Right: Carotid 2+ DP/PT 1+ Left: Carotid 2+ DP/PT 1+
FAMILY HISTORY: Father died of a myocardial infarction in his early 70's. His sister underwent a CABG and died from a CVA at the age of 78. His brother died of a myocardial infarction at the age of 39.
SOCIAL HISTORY: Married with 1 adult son. [**Name (NI) **] is retired. Prior to retiring he was a construction worker. Quit smoking 30 years ago. Prior to quitting he smoked <1ppd for approximately 20-25 years. Denies drinking alcoholic beverages or recreational drug use. | 0 |
16,901 | CHIEF COMPLAINT: Hypoglycemia
PRESENT ILLNESS: Ms. [**Known lastname 6105**] is a 56 year-old woman with developmental delay, diabetes, asthma, Crohn's disease on prednisone, latent TB on INH and hepatitis B on lamivudine with recent MRSA bacteremia initially on vancomycin and transitioned recently transitioned to daptomycin secondary to drug rash who presented today after being found unresponsive at her facility with a blood sugar of 40s. Of note 2 days prior to admission, her oral hypoglycemics including Actos and glipizide were doubled. . Initial vital signs in the ED were 97.5 100 97/64 18 100% BG 43. She received glucagon and 1 amp of D50 and repeat BG was 80. She then ate dinner and repeat BG was 78. Prior to transfer the patient was started on D5 1/2 NS at 125mL/hr. Vitals on transfer were 98.0 84 14 100/49 14 98% on RA. . On the medical floor the patient appear comfortable and was without additional complaint. . ROS: Denied fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
MEDICAL HISTORY: Crohns Disease, newly diagnosed, on prednisone Asthma - never been intubated glaucoma DM2 - not on insulin Barretts Esophagus Systolic murmur ? s/p cholecystectomy s/p jaw surgery
MEDICATION ON ADMISSION: Isoniazid 300 mg daily Day #1 = [**2131-8-16**] for 9 months Pyridoxine 50 mg daily Day #1 = [**2131-8-16**] for 9 months Omeprazole 20 mg daily Lamivudine 100 mg daily Day #1 = [**2131-8-14**] Sertraline 250 mg daily Daptomycin for MRSA bacteremia Day 1 = [**2131-8-12**] to be complete [**2131-9-22**] Lisinopril 10 mg daily Fluticasone-salmeterol 100-50 mcg 1 puff [**Hospital1 **] Latanoprost 0.005 % OU HS Metformin 1000 mg [**Hospital1 **] Metoprolol succinate ER 75 mg daily Januvia 100 mg daily Pioglitazone 30 mg Glipizide 10 mg daily Prednisone 30 mg dialy Pancrealipiase TID Zyrtec 10 mg daily Trazodone 50 mg QHS
ALLERGIES: Iodine / Sulfa (Sulfonamide Antibiotics) / vancomycin
PHYSICAL EXAM: PHYSICAL EXAM ON ADMISSION: Vitals: 98.3 87 70 14 100% on RA GENERAL: Comfortable in NAD, answers questions appropriately HEENT: Pupils equal, round, reactive to light. Extraocular muscles intact. Sclerae are anicteric. Mucous membranes moist. Oropharynx is clear. No oral ulcers. NECK: No lymphadenopathy. LUNGS: Clear to auscultation bilaterally. No wheezing or rhonchi noted. CARDIOVASCULAR: Regular rate, [**4-4**] holosystolic murmur, loudest at left upper sternal border. Normal S1, S2. ABDOMEN: Soft, nontender, nondistended, active bowel sounds. EXTREMITIES: Warm and well perfused. SKIN: Diffuse morbilliform rash, most prominent on the posterior aspect of her arms bilaterally. Consistently blanchable. Mild edema in lower extremities. No ulcers appreciated.
FAMILY HISTORY: Her father died of heart disease around age 60; her mother was reportedly an alcoholic and is still alive, but they have not been in touch since Ms. [**Known lastname 6105**] was very young. She has many siblings (5 or 6), and at least 3 of them are also developmentally delayed / special needs.
SOCIAL HISTORY: Pt has cognitive delay; she lives alone and attends an adult day program at Triangle Day Care (Telephone: [**Telephone/Fax (1) 90811**]) in [**Location (un) 3786**] 5 days a week. Her case manager from Nexus Inc, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28003**] (office [**Telephone/Fax (1) 90812**], cell [**Telephone/Fax (1) 90813**]) has known her for >20 years and is her HCP. Pt reportedly can shop and cook for herself, but [**First Name8 (NamePattern2) **] [**Doctor First Name **], the agency that [**Doctor First Name **] works for will often step in and help with cooking. Even when they help her cook, she winds up eating out -- mostly tuna subs, macaroni, and donuts. She has a boyfriend of 11 years who is also developmentally delayed, and she is very close to him. | 0 |
68,844 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 55-year-old male with history of chronic stable angina and coronary artery disease, who presented to the ER after pain on rest. The patient was admitted on [**2116-9-9**] on the Medicine Service. Cardiac catheterization was done at the time showing the following: Left main normal. LAD 80% occluded. RCA 40% occluded at the mid portion. LCX collateralized by RCA.
MEDICAL HISTORY: History was significant for stable angina, status post cardiac catheterization in [**2111**] and hypertension.
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
27,528 | CHIEF COMPLAINT: subdural hematoma, CLL
PRESENT ILLNESS: Mr. [**Known lastname 1820**] is a 79 yo M with CLL s/p chemo, HTN, HL and COPD p/w acute on chronic subdural hematoma. Pt recently began treatment for his CLL, admitted to [**Hospital6 **] for pancytopenia requiring transfusions. Noted to have some confusion and left facial droop/hand weakness, head CT done showing acute right subdural hematoma. Plt count was 12 at OSH, received 6 pack of platelets prior to transfer for further care. . In the ED inital vitals were, 99.1 84 108/60 16 95% and neurosurgery was consulted. Their recommendations were repeat CT head now and at 24 hours; SBP<140, plt goal 100k; start keppra 1g IV now and then begin 500mg [**Hospital1 **]; admission to ICU for further management. CT head done in ED and per prelim read is stable from OSH scan (could not be uploaded to PACS). Patient received another unit of platelets and his plts came up to 53. . On arrival to the ICU, pt appears little sleepy but able to wake up to voice. Able to relate some of the history, says that he went "loopy" last Saturday in the hospital. Per discharge summary, pt was agitated the morning of admission, received ativan/haldol, complained of headache which resolved with tylenol. When he was working with PT, he was noted to have L sided face droop and weakness of left hand/arm and CT scan showed multiple small subdural hematoma as above. . Review of systems: (+) Per HPI (-) Denies fever, chills. Denies headache, blurry vision, or paresthesia. Denies sore throat, cough, shortness of breath, or wheezing. Denies chest pain, palpitations. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes.
MEDICAL HISTORY: Past Medical History (per PCP [**Name Initial (PRE) **]): - CLL (CHRONIC LYMPHOBLASTIC LEUKEMIA) on CHEMO XXX - COPD - HYPERCHOLESTEREMIA - HYPERTENSION - GERD (GASTROESOPHAGEAL REFLUX DISEASE) - HISTORY OF ASBESTOS EXPOSURE (pleural plaques by CT) - HISTORY OF COLONIC POLYPS - OSTEOARTHRITIS - SPINAL STENOSIS IN CERVICAL REGION - CERVICAL RADICULOPATHY - GENERALIZED OSTEOARTHRITIS OF MULTIPLE SITES - PARKINSON'S DISEASE - CHRONIC CONSTIPATION - HELICOBACTER PYLORI GASTRITIS, dx on [**12-15**] treated - s/p inguinal hernia repair
MEDICATION ON ADMISSION: Medications (per discharge summary from [**Hospital1 392**], not confirmed): - folic acid 1 mg Tab Oral 1 Tablet(s) Once Daily - omeprazole 20 mg Tab, Delayed Release Oral 1 Tablet, Delayed Release (E.C.)(s) Once Daily - Celexa 20 mg Tab Oral 1 Tablet(s) Once Daily - simvastatin 20 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime - Symbicort 2 HFA Aerosol Inhaler(s) Twice Daily - carbidopa-levodopa 25 mg-100 mg Tab Oral 1.5 Tablet(s) Three times daily - Miralax [**12-5**] Powder in Packet(s) Once Daily, as needed - Senokot 8.6 mg Tab Oral 1 Tablet(s) Once Daily - Colace 100 mg Cap Oral 1 Capsule(s) Twice Daily - prednisone 5 mg Tab Oral 1 Tablet(s) Once Daily - Lotrimin cream to penis - Nystatin swish/swallow
ALLERGIES: Penicillins
PHYSICAL EXAM: ADMISSION EXAM: . General: Alert, oriented to person, place and time (knows [**2-3**], initially says "12th year" - [**2096**], but corrects to [**2196**]. No acute distress HEENT: PERRL, difficulty following commands for extraocular motion. Sclera anicteric, MMM, oropharynx clear. Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Scattered petechiae. Neuro: PERRL (3mm -> 2mm bilaterally), difficulty following commands for extraocular motion but saccades intact to right, does not look to left as much. L facial droop, asymmetric mouth opening from facial droop, uvula/tongue midline. SCM intact bilaterally. Motor: pt able to lift his LUE parallel to ground antigravity and resist somewhat 3+/5, with antigravity, elbow flexion about [**3-9**], elbow extensor 3+/5, fingergrip [**3-9**]. RUE elbow flexor/extensor/finger grip [**4-8**], +resting tremor. LLE hip flexor 4+/5, knee flexor/extensor and ankle flexor/extensor [**4-8**]. RLE [**4-8**] throughout. Sensation: grossly intact to light touch bilaterally Reflexes: biceps/patellar 2+ bilaterally, downgoing babinski Gait deferred. . DISCHARGE EXAM: l.ARM 4/5 weakness. .
FAMILY HISTORY: non-contributory
SOCIAL HISTORY: - Tobacco: history of smoking, quit while ago - Alcohol: occasional - Illicits: denies | 0 |
61,191 | CHIEF COMPLAINT: abdominal pain, distension, decreased ostomy output
PRESENT ILLNESS: 49F with EtOH cirrhosis recently admitted to [**Hospital1 18**] for multiple abdominal abscesses and peritonitis, ultimately found to have perforated sigmoid colon, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3379**] procedure on [**2191-12-25**]. Discharged to rehab 7 days ago on tube feeds and broad spectrum IV antibiotics. For the past 4 days she has had increasing abdominal distension and pain, and has apparently gained 25 lbs. Per report her ostomy output has significantly decreased. She reports several episodes of emesis 2 days ago but has not vomited since. She is currently not nauseous. She does report low grade fevers.
MEDICAL HISTORY: Appendectomy at age 19, [**2191-12-14**] Exploratory laparotomy, drainage of subdiaphragmatic bilateral abscess, drainage of pelvic abscess, drainage of pericolic gutter abscess both on the right and left side. Drainage interloop abscess. [**2191-12-16**] 1. Exploratory laparotomy. 2. Washout, drainage interloop abscess and component separation. 3. Ventral hernia repair with mesh. (open abdomen) [**2191-12-22**] Exploratory laparotomy, abdominal washout. [**2191-12-25**] Exploratory laparotomy, Hartmann's procedure, and rigid sigmoidoscopy for distal sigmoid perforation
MEDICATION ON ADMISSION: Albuterol, Ergocalciferol, folate, oxycodone, rifaximin 550'', spironolactone 100', lasix 40', azithromycin 500', flagyl 500''', micafungin 100', zosyn 4.5''', famotidine 20'', glargine 6 QHS, RISS,
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Admission Physical: Gen: NAD. A&Ox3. HEENT: Anicteric. Tacky mucosal membranes. Neck: No JVD. No LAD. No TM. CV: RRR. Pulm: CTAB. Abd: distended and tense with + fluid wave. large ventral wound granulating nicely, no active drainage. diffusely mildly tender to palpation. nonperitoneal. no hernias/masses. LLQ ostomy with scant air and small amount of fluid. Ext: Warm and well perfused. B/L LE edema to knee. Neuro: Motor and sensation grossly intact.
FAMILY HISTORY: Non-contributory
SOCIAL HISTORY: Widowed (husband committed suicide 1 year after daughter died from brain tumor at age 6) - Previous to prior admit- Tobacco: [**1-16**] pack per day, extensive history - none since previous to prior admit-Alcohol: 6 drinks per day, last drink 1 week ago - Illicits: Denies | 0 |
54,479 | CHIEF COMPLAINT: chest discomfort
PRESENT ILLNESS: Mr. [**Known lastname 20179**] is a 56 yo smoker and recovering alcoholic who presented to the [**Hospital1 18**] ED with chest discomfort. He felt well until returning home from dinner. While watching TV, he developed L sided chest "tightness" that was [**2124-5-22**] in intensity, nonradiating, constant, and not pleuritic or positional in quality. He initially ascribed the sensation to "indigestion." He did not have any associated dyspnea, lightheadedness/dizziness, palpitations, diaphoresis. He did subsequently have nausea without vomiting. After the chest discomfort persisted for approximately 20 minutes, he called EMS and was brought to the [**Hospital1 18**] ED. . He has had very infrequent similar episodes of left chest discomfort in the past (a few times a year) that were less intense and not activity-related. He does not regularly use aspirin. . In the ED, his initial vital signs were pulse of 83, blood pressure 140/80, respiratory rate 14, oxygen saturation 98% on room air. His EKG revealed ST-segment elevations in leads II, III and avF inferiorly and V4-6 anterolaterally with depressions in I, aVL, V1-V3. He was administered aspirin 325 mg PO, clopidogrel 600 mg PO, heparin and eptifibatide intravenously and transferred emergently to the cath lab. Angiography revealed a mid-RCA lesion. He had 2 bare metal stents implanted. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope.
MEDICAL HISTORY: Former alcoholic, no drinks in 12 years
MEDICATION ON ADMISSION: chondroitin
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: CCU exam T afebrile P 89 BP 122/77 RR 18 O2 98% on RA General: Lying in bed, no acute distress HEENT: no JVD Pulm: Lungs clear anteriorly without rales or wheezes CV: Regular rate S1 S2 no m/r/g Abd: Soft, nontender, +BS Groin: sheath in place L side, no active bleeding Extrem: Warm, well perfused, no edema 2+ distal pulses Neuro: Alert and interactive
FAMILY HISTORY: His father had a stroke in his 80's.
SOCIAL HISTORY: Social history is significant for approximately 20 pack year history of tobacco use. He is a former alcoholic, with no drinks in 12 years. | 0 |
95,914 | CHIEF COMPLAINT: S/P fall
PRESENT ILLNESS: Pt is a [**Age over 90 **] yo female with atrial fibrillation on coumadin, HTN, and CSF who fell at her nursing home and went to an OSH where head CT showed a L temporal SAH, chronic R SDH. The patient fell on the tile floor of her bathroom at 8:30 PM last night. She may have briefly passed out though she is not completely sure. She fell on the left side of her head. She complaining of left rib pain as well. CT at the OSH showed the above findings. Her INR was 2.2 and she was given FFP and vitamin K. She was then transferred to [**Hospital1 18**].
MEDICAL HISTORY: Past Medical History: atrial fibrillation on coumadin, HTN, CHF, PVD, CKD, osteoporosis, peripheral neuropathy, MVR.
MEDICATION ON ADMISSION: Digoxin 0.125 [**Last Name (LF) **], [**First Name3 (LF) **] 81 mg q day, Metoprolol 25 mg [**Hospital1 **], Coumadin 3 mg q day, Lasix 40 mg q day, MVI.
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Vitals: T 97.9; BP 144/76; P 70; RR 18; O2 sat 96%
FAMILY HISTORY: non contributory
SOCIAL HISTORY: Lives in a nursing home No tobacco No ETOH | 0 |
61,444 | CHIEF COMPLAINT: spinal stenosis- admitted [**2165-1-11**] by ortho for lumbar laminectomy/fusion of L3-5 shortness of breath, hyponatremia Transfer to medicine [**2165-1-17**] following episode of hypoxia on [**2165-1-15**]
PRESENT ILLNESS: 74 year old gentleman with a history significan for ulcerative colitis s/p colectomy ([**2159**]), partial small bowel obstruction, GERD, and lumbar spinal stenosis who underwent lumbar fusion on [**2165-1-11**]. On post operative day 4 he was noted to be hypoxic and diaphoretic. ABG at that time revealed a significant A-a gradient and values of 7.52/30/60. CT Angiography was negative for pulmonary embolus, but showed a multifocal pneumonia with small bilateral pleural effusions. Patient was transferred to the surgical intensive care unit for increased oxygen requirement. 9 AM labs on [**2165-1-15**] revealed a significant hyponatremia (114) compared to [**2165-1-12**] labs (sodium of 138). He was started on 3% saline and NaCl tabs PO for hyponatremia correction. Subsequent lab results showed a sodium correction to 131 in 26 hours. He was started on levoquin for multilobar pneumonia and his O2 saturation improved. He also developed ileus from [**Date range (1) 99392**] and now has watery green stool. ROS: Denies abdominal pain, chest pain, shortness of breath. Able to walk more then 2 blocks or more then 2 flights without symptoms at baseline. No hematochezia or melena.
MEDICAL HISTORY: 1. Ulcerative colitis s/p total proctocolectomy with a J-pouch in [**2160-8-24**], status post an ileostomy takedown in [**2160-10-24**]. 2. Gastroesophageal reflux disease. 3. History of partial small-bowel obstruction (4/[**2160**]). 4. Hiatal hernia. 5. Obstructive sleep apnea on home CPAP (16 mm Hg) but uses CPAP very rarely. 6. Lumbar spinal stenosis s/p laminectomy on [**2165-1-11**] 7. Osteoporosis on Fosomax 70 mg once per week 8. S/P appendectomy (ca. [**2134**]) 9. S/P hernia repair (ca [**2159**]) 10. anemia (refused for blood donation for autologous transfusion)
MEDICATION ON ADMISSION: darvocet imodium motrin tylenol liprex vitamin e vitamin c glucosamine
ALLERGIES: Relafen
PHYSICAL EXAM: Temp: 98.4 BP: 124/60 HR:84 RR: 18 93% on 4 L O2 General: NG tube in place, sleeping comfortably HEENT: atraumatic, normocephalic. No scleral icterus. EOMI. PERRL. Dry mucus membranes. Neck supple with good range of motion. No lymphadenopathy CV: S1 S2 normal. No murmurs, rubs, gallops PULM: Ronchi at bases extending 1/3 up lung fields. Diffuse soft ronchi in upper R field. No wheezing appreciated. ABD: Mildly distended. Bowel sounds present but diminished. EXT: Warm and well perfused upper extremities. Lower extremities cool to touch. Good cap refil <2 seconds. . No edema. Pneumoboots in place. 2+ radial and DP pulses bilaterally. No clubbing or cyanosis. NEURO: Alert and oriented x3. CNII-XII grossly intact. [**3-28**] plantar flextion and extension bilaterally.
FAMILY HISTORY: Diabetes in grandmother. Pancreatic cancer in grandmother. [**Name (NI) 6419**] [**Name2 (NI) **] died of "old age" in their mid 80s.
SOCIAL HISTORY: married-lives with wife, non-[**Name2 (NI) 1818**], no alcohol, works as water filtration treatment person. Smoked 1 1/2 packs per day for 20 years. Quit 40 years ago. | 0 |
79,481 | CHIEF COMPLAINT: bloody diarrhea
PRESENT ILLNESS: 43Fwith a history of hypertension and peritoneal TB s/p treatment who presented with bloody diarrhea after 4 days of brown diarrhea. She began having diarrhea 4 days prior to admission. On the day prior to admission she began passing bloody stool with each bowel movement, approximately 4-5 times during the course of the day. The blood was bright red and there are some clots mixed in by report. She denies any abdominal pain, chest pain, chest pressure, palpitations, or DOE. Otherwise she has not complaints. She denies taking any aspirin or NSAIDs. . In the ED, initial VS were: pain 0, T 96, HR 114, BP 157/90, R 16, 100% on RA. Rectal exam was notable for bright red blood, anoscopy only showed a skin tag. Gastroenterology was notified and she was started on a PPI IV BID. The patient received 3L NS. Vitals on transfer were BP 144/93, HR 105, RR 30. On the medical floor, she was transfused two units of pRBC for a HCT of 25.8 with a goal HCT of 30. However, her post transfusion HCT was 23.8. She then had a large BM with BRB, but flushed it down the toilet. A repeat HCT was 24.3. An OG lavage was attempted, but she vomited bright red blood. She was started on a pantoprazole drip in place of PPI IV BID. Given her ongoing BRBPR, hematemasis, and unchanged HCT despite 2 units pRBCs she was transfered to the MICU for urgent EGD and colonoscopy. Of note, review of records revealed a known R colonic vascular ectasia in [**2132**]. She also has a history of miliary TB with peritoniteal involvement. . Review of systems: (+) Per HPI (-) Denies fever. Denies headache, lightheadedness or dizziness. Denies sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness. Denied vomiting, constipation or abdominal pain. No dysuria. Denied arthralgias or myalgias.
MEDICAL HISTORY: - Peritoneal TB, s/p treatment with RIPE and B6 under direct observation therapy, completed in ?[**2135**] - Hypertension on lisinopril + HCTZ - Hemorrhoids - s/p tubal ligation - s/p surgery for "intestinal blockage" - sounds like bowel obstruction that complicated her last pregnancy.
MEDICATION ON ADMISSION: - Lisinopril/hydrochlorothiazide, 20 mg/25 mg daily
ALLERGIES: Ibuprofen
PHYSICAL EXAM: General: Tachypneic, shivering under multiple sheets. Alert, oriented, mild distress. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: well-healed midline incision, decreased bowel sounds, soft, non-tender, non-distended, no organomegaly Ext: Cool, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact.
FAMILY HISTORY: Mother died at 55 of an accident, father died at 65. One sister, one brother, four children without illness.
SOCIAL HISTORY: Ms. [**Known lastname **] lives in [**Location 3786**] with her husband and 4 children. She was born in [**Country 84632**], [**Country 480**] but immigrated to the US in [**2115**]. She works as a CNA. No recent travel. She denies any tobacco, rare alcohol, no IVDA. | 0 |
81,135 | CHIEF COMPLAINT: Status post fall. The patient was found unresponsive.
PRESENT ILLNESS: The patient is a 76 year old gentleman, who presented to the [**Hospital1 188**] Emergency Department status post fall. After the fall, the patient became unconscious and was emergently intubated prior to arriving in the Emergency Department. Otherwise, the patient has multiple medical problems. The patient had a history of Parkinson's, arthritis, cataract and knee fracture. He is status post appendectomy in the past. On presentation, the patient had GCS of 7.
MEDICAL HISTORY: 1. Parkinson's disease. 2. Arthritis. 3. Cataract. 4. Knee fracture. 5. Status post appendectomy. 6. Hypertension.
MEDICATION ON ADMISSION: 1. Aspirin 81 mg p.o. once daily. 2. Tylenol. 3. Celebrex. 4. Diovan 80 mg p.o. once daily. 5. Sinemet three times a day.
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 1 |
69,083 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is an 86 year old female with a chief complaint of abdominal pain, possibly secondary to an IM Lovenox injection. The patient has a pertinent past medical history of atrial fibrillation with a St. [**Male First Name (un) 1525**] mitral valve and has recently been admitted for a labile INR and is now on Lovenox. She was well until 8 p.m. the day prior to admission when one hour after Lovenox administration, she developed severe abdominal pain. She presented to the ER for further evaluation. The pain is constant and bilateral without radiation.
MEDICAL HISTORY: 1. Sick sinus syndrome with pacemaker. 2. Ventricular tachycardia. 3. Atrial fibrillation. 4. Congestive heart failure. 5. Hypertension. 6. Hypercholesterolemia. 7. Embolic CVA. 8. Chronic renal insufficiency. 9. Possible past GI bleeding. 10. Normal EGD and colonoscopy in [**2165-11-8**].
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
42,171 | CHIEF COMPLAINT: shortness of breath
PRESENT ILLNESS: 68 yo F w/ Class III systolic HF with EF of [**10-17**]% s/p BiV-ICD placement, severe asthma and back pain who presents from the holding area of the cath lab with dyspnea/tachypnea prior to exchange of LV lead. Pt had recent admission for polymorphine VT with her ICD discharging 5 times and she was found to have malpositioned anterior LV lead. After she was stabilized and breathing had improved she was discharged on [**6-2**] with plan to come back in for scheduled outpatient LV lead exchange which was today. Her weight at the time of discharge was 160lbs. Pt reports she felt fine when leaving on [**6-2**] but quickly started to all of a sudden feel "worse". Pt reports feeling sick from then until now. She describes it as feeling fatigued, with worsened breathing, and nausea. Her weight was decreasing while at home and she was 156 at home on the day of admission. She reported worsening breathing, with a coughing fit the day prior. She denies any fevers or chills or sick contacts. She was recently treated for a pneumonia on her previous admission. She denies any dietary indiscretions or problems with the milrinone pump. Her VNA reported that she heard crackles the day prior to admission. Of note at the time of discharge the following changes were made to her regimen (stopped digoxin, stopped valsartan, stopped gabapentin, decreased metoprolol from 75mg to 50mg, increased torsemide prn from 40 to 50mg,decreased sertraline from 200-->100), and the patient reports not problems with physically making these changes. In the holding area to the cath lab the patient was noted to be acute tachypnic to the 40s with crackles in the lungs posteriorly with JVP elevated to the mandible. She received 80IV Lasix x1 and placed a foley. Dr. [**First Name (STitle) 437**] evaluated the patient in the hodling area and felt she required further evaluation and management with lasix drip and milrinone drip On arrival to CCU she reports feeling 100% better. She continues to feel a little nauseus and denies any chest pain or palpitations. She is feeling overwhelmed with her illness and her multiple hospitalizations recently. And complaining of back pain. On review of systems, she reports improved swelling in her legs bilaterally, no abdominal pain, last moved her bowels the day prior to admission, no hematuria or dysuria. She reports her mood is stable compared to prior to the change in her medications. She reports she cannot sleep flat because of back pain and problems getting comfortable.
MEDICAL HISTORY: 1. Severe nonischemic cardiomyopathy with LVEF of 10% s/p BiVICD placment -BiVICD is [**Company 1543**] Model: [**Name6 (MD) 39503**] XT CRT-D,implanted at [**Hospital3 **] Medical Center on [**2141-1-3**] last interrogated [**2146-5-24**] and set to 1:1AV conduction 2. Severe mitral regurgitation, severe tricuspid regurgitation and moderate pulmonary hypertension. 3. PAF status post ablation. 4. Severe asthma. 5. Old compression fractions of T8 and T10. 6. Venous stasis disease. 7. Anxiety, depression. 8. Restless legs syndrome. 9. Recent septic bursitis of the right knee.
MEDICATION ON ADMISSION: 1. fluticasone-salmeterol 500-50 mcg/dose Disk [**Hospital1 **] 2. multivitamin qday 3. aspirin 81 mg qdya 4. pantoprazole 40 mg ER qday 5. magnesium oxide 400 mg (hold while inpatient) 6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation every six (6) hours as needed for SOB. 7. montelukast 10 mg PO HS 8. cholecalciferol (vitamin D3) 800 U qday 9. ropinirole 0.25 mg po qhs (hold while inpatient) 10. Milrinone continuous infusion for weight of 160lbs, at 0.38mcg/kg/min 11. ferrous sulfate 325 mg (65 mg iron) qday 12. sertraline 100 mg po qday. 13. prednisone 10 mg prn for asthma attack (hold while inpatient) 14. Tums 200 mg calcium 1000mg po qday 15. metoprolol succinate 50 mg ER (switch to 25mg po tartrate while inpatient) 16. torsemide 50 mg prn if you gain 3 lbs in 1 day: (hold while inpatient) 17. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. (prn while inpatient) 18. Coumadin 2.5mg po qday 19. albuterol sulfate neb 20. loratadine 10 mg qday. (hold while inpatient) 21. spironolactone 12.5mg po qday 22. oxycodone 5 mg Tablet q6h prn pain 23. potassium chloride 20 mEq (hold while inpatient)
ALLERGIES: Ciprofloxacin / Zometa / Keflex / Tetracycline / erythromycin / Iodine Containing Agents Classifier / nuts / fish derived / lisinopril
PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: VS: 97.8, 107, 79/53, 13, 985 3L NC Wt 155lbs GENERAL: sitting up in bed, changing positions often, appears uncomfortable but not in distress HEENT: PEERLA, sclera anicteric, MMM, no oral lesions NECK: Supple with JVP of 10 cm. CARDIAC: Irregular and tachycardic, Systolic murmur at the left upper sternal border and at the apex, with diffuse PMI at the 6th intercostal 2cm lateral to midclavicular LUNGS: No chest wall deformities,Pt is kyphotic. Crackles at the left base but not the right. Moving good air bilaterally, no wheezes but hollow breath sounds throughout. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Darkned skin bilaterally on the extremities. No peripheral edema, 2+DP pulses bilaterally. PICC in the LUE without erythema at hte site. NEURO: AAOx3, CNII-XII grossly intact, 5/5 strength biceps, triceps, wrist, knee/hip flexors/extensors, 2+ reflexes biceps, brachioradialis, patellar, ankle. DISCHARGE PHYSICAL EXAM Tm 98.6 Tc 97.6 HR 77-81 RR 18-20 BP 87-96/50-66 I/O1490/1525 Weight 70.7 O2 96%RA GEN: AAOx3, fatigued appearing, but affect much improved HEENT: JVD 1/2 up to mandible. Right scar c/w prior IJ. HEART: RRR. Dressing left side chest c/d/i LUNGS: Crackles at left base ABDOMEN: Soft, NT, NABS EXT: 1+ edema L>R NEURO: Nonfocal SKIN: Right PICC without erythema or exudate
FAMILY HISTORY: Father may have had a heart attack, but died from a blood clot to the brain. Mother had diabetes and cirrhosis. Son with [**Name2 (NI) 14595**]-1 antitrypsin deficiency.
SOCIAL HISTORY: The patient used to work as a jeweler and makes jewelry. She lives with her husband. Remote smoking history, quit over 40 years ago, occasional ETOH and no illicit drug use | 0 |
33,168 | CHIEF COMPLAINT: 3rd degree heart block
PRESENT ILLNESS: Ms. [**Known lastname 4886**] is a 61 year old female with history of seizures, hypothyroidism, CAD who presents from OSH with third degree heart block. Patient is sedated and family not available to provide history. Reportedly this AM patient was found down after using the bathroom. She was taken to [**Hospital3 5365**] and found to be minimally responsive with HR 30s, low BP. She was given atropine x1 with reported improved perfusion. Right IJ placed and patient started on levophed. BP improved after atropine so levophed d/c'd. She was given 4L IVF and started on dopamine gtt. It was determined at [**Hospital1 **] to transfer to [**Hospital1 18**] for further managment. Medics began transcutaneous pacing, placed Aline and intubated patient in transport. Of note, she reportedly had CP in AM but refused to go to ER for evaluation. . The patient denies any chest pain or pressure, new exertional dyspnea, orthopnea, PND or leg edema, palpitations or syncope, claudication-type symptoms, melena, rectal bleeding, or transient neurologic deficits. No change in weight, bowel habit or urinary symptoms. No cough, fever, night sweats, arthralgias, myalgias, headache or rash. All other review of systems negative. In the ED here, HR 70, BP 160/80, vented on AC 100% FiO2. Labs notable for INR 2.1. She was seen by EP. RIJ was exchanged for cordis and temporary wire was placed with good capture. She was also sent for CT head which was negative for acute bleed but showed evidence of subacute/chronic occipital and parietal infarcts. . On arrival to the CCU, the patient was intubated and paced at a rate of 70s. Dopamine was quickly weaned off and BPs have remained stable. She was responsive to some commands.
MEDICAL HISTORY: CAD s/p 3v CABG, MI [**2176**] Hypertension Seizure disorder Hypothyroidism
MEDICATION ON ADMISSION: Sertraline 100mg daily Dilantin 100mg daily 3 capsules three times/day Coumadin 5mg daily 1-1.5 tablets daily Simvastatin 80mg daily ASA 81mg daily Avandia 4mg daily Levothyroxine 100mcg daily Isosorbide mononitrate 30mg daily Metoprolol 50mg 1 tablet in AM, [**12-29**] tablet qPM Folic acid 1mg Plavix 75mg daily Metformin 500mg [**Hospital1 **] Glimepiride 2mg daily
ALLERGIES: Codeine / Morphine / Penicillins / Iodine; Iodine Containing / Prednisone
PHYSICAL EXAM: Gen: Intubated female, responds to commands. HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. CV: RR - paced, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Clear anteriorly. Abd: Soft, nondistended. Ext: No c/c/e. No femoral bruits. 2+ DP pulses bilaterally. Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
FAMILY HISTORY: FHx noncontributory
SOCIAL HISTORY: No tobacco, EtOH or drug use. | 0 |
78,435 | CHIEF COMPLAINT:
PRESENT ILLNESS: Mr. [**Known lastname 13448**] is a 71-year-old ambidextrous, though mainly left handed, male who was in his usual state of health until the morning of [**5-24**]. He awoke and was doing some work at his desk when he leaned over to get some papers and fell to the ground secondary to left sided weakness. He could not do anything with the left arm at all and had some movement of the left leg. He could not bear weight on the left leg. He lay on the ground for a few hours until his son came home and called 911. He denied any headaches, nausea, vomiting, numbness or tingling. He stated that he thought he had double vision intermittently, but could not be more specific. The double image was of objects seen side to side, but he could not say if any particular direction of gaze made this worse. He was seen in the Emergency Department by the neurology and stroke service where his exam was notable for a right gaze preference, left homonymous hemianopia versus left hemi-spacial visual neglect, a left facial droop, flaccid left arm with strength in all muscle groups except for minimal movement of the fingers and 4 to 4+/5 strength in left hip flexion and hamstrings. There was minimal left foot dorsiflexion. There was extinction to double .............. stimulation on the left. An MRI revealed a 2 cm right sided basal ganglia bleed with some extension to the thalamus. His blood pressure initially was 190/110, so he was admitted to the Intensive Care Unit for intravenous labetalol and frequent neurologic checks. He did well over the first night with rapidly improved strength in the left arm. He no longer had any complaints of diplopia. He was therefore transferred to the neurology floor for further care.
MEDICAL HISTORY: 1. Hypertension for at least five to six years, but he stopped taking Norvasc six months ago secondary to presyncopal feeling. 2. Known right ICA stenosis 3. Status post left carotid endarterectomy - unclear if this was symptomatic or not. Performed by Dr. [**Last Name (STitle) 1476**] in [**2189**]. 4. Status post coronary artery bypass graft in [**2191**] 5. Possible hypercholesterolemia
MEDICATION ON ADMISSION:
ALLERGIES: No known drug allergies.
PHYSICAL EXAM: VITAL SIGNS: Blood pressure 130/80, heart rate 70s, temperature 98??????. HEAD, EARS, EYES, NOSE AND THROAT: Head was normocephalic, atraumatic. NECK: Supple without bruits. CARDIOVASCULAR: Regular rate and rhythm with no murmurs. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Warm without cyanosis, clubbing or edema. NEUROLOGIC: He was alert, oriented and attentive. He was able to do the months of the year backwards without difficulty. Language was fluent with intact naming, [**Location (un) 1131**], repetition and comprehension. Praxis was normal and there was no right left confusion. Cranial nerve exam: The right pupil was 1.5 mm, left 2 mm. Both were reactive to light. Visual fields were full, though he explores the left hemi-space less and requires encouragement to look to the left. Extraocular movements revealed some limitation of vertical gaze with both up and down gaze. There was some improvement to down gaze with vestibular ocular reflex (tilting head backwards). Smooth pursuit was interrupted by saccades when pursuing to the right. Saccadic eye movements were hypometric to the left. There is a flattened nasolabial fold on the left. Sensation was intact in the face. Tongue and palate movements were normal. Sternocleidomastoid and trapezius were full. Bulk and tone were full. There was a left pronator drift and isolated asterixis of the left hand, as well as occasional myoclonic movements of the left hand. Strength was [**3-12**] in the left deltoid, 5-/5 triceps, 4+/5 finger extensors and hand intrinsics. Strength was full in the left lower extremity and muscle groups on the right were full. Reflexes were 3+ on the left, 2+ on the right in both the arms and legs. There was a withdrawal response to plantar stimulation with the left foot, but right plantar reflex was flexor. Pinprick was mildly decreased in a patchy distribution over the left arm and leg. Joint position sense was intact throughout. Vibration was decreased to the knees bilaterally. Rapid alternating movements and fine finger movements were slow on the left. There was some dysmetria out of proportion to weakness with finger to nose testing on the left arm. MRI revealed acute hemorrhage in the right basal ganglia extending into the thalamus. There was changes of small vessel disease. There was absence of flow signal in the right intracranial internal carotid artery with markedly diminished flow signal within the right middle cerebral and anterior cerebral arteries.
FAMILY HISTORY:
SOCIAL HISTORY: More than 50 pack year smoker, drinks one to two cans of beer per day, works as a doorman a few days per week and lives with his wife. [**Name (NI) **] has seven children and four grandchildren. | 0 |
68,723 | CHIEF COMPLAINT: chest pain
PRESENT ILLNESS: 69 y/o male who initially on day of admission was "not feeling well" throughout the day. Patient went out in the evening to shovel snow and then came back inside to eat dinner. While eating he started to feel sick, nauseous and diaphoretic and then developed chest pain. His wife called 911 and gave him an aspirin. EMS called in a STEMI and he was sent to the cath lab through the ED. In the cath lab patient went into pulseless VT, he was awake and was shocked out of VT while awake. Patient also had heart block and had temp pacer placed during procedure. Cath revealed occluded RCA with thrombus, had 2 cypher stents placed in the RCA.
MEDICAL HISTORY: GERD hyperlipidemia
MEDICATION ON ADMISSION: atorvastatin
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: T afebrile HR 94 BP 106/79 RR 12 O2Sat 99% on 3L Gen: NAD, lying flat Heent: PERRL, sclera anicteric, OP clear Neck: no carotid bruits Lungs: Clear ant/lat Cardiac: S1/S2 no murmurs Abdomen: soft NT Ext: +2 DP and PT pulses, no edema Neuro: AAOx3
FAMILY HISTORY: non-contributory
SOCIAL HISTORY: Engineer for [**Company **] Married with 3 children tob: quit [**2157**]; smoked 2ppd x 20years etoh: 2-3 beers/day drug use: none | 0 |
39,725 | CHIEF COMPLAINT: pedestrian struck by train
PRESENT ILLNESS: This is a 35 year old female with past medical history significant for paranoid schizophrenia. She jumped in front of a train per witness reports. She was intubated in the field and was initially taken to [**Hospital **] hospital but was deemed to unstable and was medflighted to [**Hospital1 18**] for further evaluation. She was found to have a left subdural hematoma.
MEDICAL HISTORY: paranoid schizophrenia
MEDICATION ON ADMISSION: unknown
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: On Admission: O: T:98.1 BP: 180/111 HR:88 R 18 O2Sats 96% Gen: WD/WN, comfortable, NAD. HEENT: large hematoma right parietal/occipital Pupils: 2mm minimally reactive EOMs unable to assess Neck: c-collar Neuro: Mental status: intubated and sedated
FAMILY HISTORY: NC
SOCIAL HISTORY: She lives in group home. Family members actively involved in her life. | 0 |
34,891 | CHIEF COMPLAINT: Nausea
PRESENT ILLNESS: Mr. [**Known lastname 1557**] is a pleasant 58yo gentleman with multiple myeloma day +20 s/p auto transplant who was recently dischared [**2187-5-17**]. His hospital course was complicated by typhlitis, and he was discharged home to complete a course of Flagyl when symptoms improved. He was seen in clinic the day after discharge. He complained of nausea with the Flagyl tablets, so given clinical resolution of typhlitis, Flagyl was d/c'ed. He reports poor appetite at home. He and his wife went on a trip to [**Hospital3 635**] yesterday to visit his mother and he reported feeling nausea at the dinner, not being able to eat much. Reports diarrhea x1 day. Highest temperature the day prior to admission was 100.2, so they waited at home over night and came in the morning. The fever had gone down to 99 this morning. Feeling anxious.
MEDICAL HISTORY: Past Oncologic History: The patient developed anemia in [**2174**] which was treated with iron for 3 years without satisfactory improvement. A more extensive workup of his anemia revealed an IgG lambda monoclonal component on his SPEP and UPEP. A bone marrow biopsy in [**10/2178**] showed 8% plasma cells and his skeletal survey was negative. He was followed for MGUS and remained relatively stable. . In late [**2186-7-19**] he developed skin lesions on his arms, legs, and back and continued to have fatigue. Re-evaluation by his PCP at that time revealed worsened anemia and new mild renal insufficiency. SPEP in late [**2186-9-18**] revealed a significant increase of IgG lambda to greater than 6 grams. . He was first seen in the oncology clinic in late [**2186-10-18**] and was shortly after diagnosed with multiple myeloma, IgG lambda, with plasma cells = 80% of marrow cellularity on [**2186-11-13**]. A skeletal survey was negative, and cytogenetics were notable for a deletion at 13q14.3. . [**2186-12-22**] = C1D1 bortezomib 1.3 mg/m2 d1,4,8,11 + dexamethasone 20mg d1,2,4,5,8,9,11,12 of 21 days cycle. Complicated by vomiting and d11 bortezomib was held. Zometa 3.3mg q4wks started. . [**2187-1-12**]: C2D1, no complications. . [**2187-2-2**]: C3D1, Zometa increased to 4mg. . [**2187-2-23**]: C4D1. Monoclonal IgG decreased by >90% (still detectable in blood and urine), and bone marrow biopsy with <5% plasma cells, indicating VGPR. Plan was made to proceed withautologous stem cell transplant followed by PD-1 treatment, as part of clinical trial 09-061. . [**2187-4-5**]: Admit for high dose cytoxan stem cell mobilization. [**2187-4-15**]: Admit for fever [**12-20**] neupogen tx . Other Past Medical History: - Sleep apnea - [**2175**] - Hemorrhoids - [**2151**] - Anemia - [**2174**] - Fainting at high altitudes - since childhood - Asthma - since childhood - Seasonal allergies - since childhood - Low Back pain - [**2176**] - resolved with acupuncture in [**3-/2185**] - Gout - [**2161**] - Kidney stones - [**2161**] - Eczema - since childhood - MGUS - [**10/2178**], now Multiple Myeloma [**2185**] Surgical Hx: - Cholecystectomy [**2180**]
MEDICATION ON ADMISSION: acyclovir 400 mg Tablet, One (1) Tablet by mouth three times a day. loratadine 10 mg Tablet, One (1) Tablet by mouth once a day as needed for allergy symptoms. metronidazole 500 mg Tablet, One (1) Tablet by mouth every eight (8) hours for 8 days. montelukast 10 mg Tablet, One (1) Tablet by mouth DAILY (Daily). salmeterol 50 mcg/dose Disk with Device One (1) Disk with Device Inhalation every twelve (12) hours. ondansetron 4 mg Tablet, Rapid Dissolve One (1) Tablet, Rapid Dissolve by mouth every eight (8) hours as needed for nausea. lorazepam 1 mg Tablet, One (1) Tablet by mouth every six (6) hours as needed for nausea. ranitidine HCl 75 mg Tablet, One (1) Tablet by mouth once a day as needed for heartburn.
ALLERGIES: sulfites / [**Doctor Last Name 5942**] Juice, Lime Juice, Sauerkraut
PHYSICAL EXAM: Physical Exam at Admission: VS: T 99.6, BP 110/76, HR 108, RR 22, 98% RA GEN: AOx3, in mild distress, lying on his side on bed HEENT: PERRLA. MM dry, OP clear. no LAD. no JVD. neck supple. No cervical, supraclavicular, or axillary LAD Cards: RR S1/S2 normal. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes Abd: BS+, soft, distended, not firm; NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**] sign Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes or bruising Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. sensation intact to LT, cerebellar fxn intact (FTN, HTS). . Physical Exam at Discharge: VS: T 96.6, BP 108/68, HR 90, RR 20, 94% RA GEN: AOx3, lying in bed HEENT: PERRLA. MM dry, OP clear. no LAD. no JVD. neck supple. No cervical, supraclavicular, or axillary LAD Cards: RR S1/S2 normal. no murmurs/gallops/rubs. Pulm: CTAB, mild bibasilar crackles, no wheezes Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**] sign Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes or bruising Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. sensation intact to LT, cerebellar fxn intact (FTN, HTS). .
FAMILY HISTORY: (from OMR) - Mother alive at 80, no family history of cancer, hypothyroid, aortic aneurism - Father died at 86 from lung cancer - 3 brothers, one died from drug overdose, other two alive and well
SOCIAL HISTORY: (from OMR, patient) - Lives at home with wife, [**Name (NI) **]. They just rented a new apartment near the hospital in [**Location (un) **]. Used to split his time between an apartment in [**Location (un) 7349**] and [**Location (un) 86**] when he started a new job 6 mo ago working for lower [**Location (un) 21601**] Arts Council - Married for 28 years - Has 2 sons age 21 and 24 - Never smoker - Has about 1 alcoholic drink per week - Very distant history of drug use - Has some dietary restrictions since cholecystectomy | 0 |
43,298 | CHIEF COMPLAINT: Shortness of breath
PRESENT ILLNESS: Ms. [**Known lastname 26172**] is a 79 year-old woman with h/o end-stage COPD discharged from the MICU yesterday after admission for pneumonia and COPD exacerbation. During last admission patient was treated for pneumonia and COPD exacerbation. Patient's dyspnea was persistent throughout hopsitalization. Palliative care was consulted and patient's wishes were to focus on comfort. Patient was dicharged yesterday to [**Hospital 100**] Rehab to finish antibiotic course with plans for hospice. Today at rehab Ms. [**Known lastname 26172**] felt worsening shortness of breath and noted scant hemoptysis. She was not happy with the rehab and she and her family decided to return to the [**Hospital1 18**] ED. . In the ED, initial vs were: HR 97, BP 116/75 R 40 O2 sat 84% on 4L. Her oxygen saturation improved to mid 90s on 3L over time. Labs were notable for HCT of 17.1 down from 25.1 yesterday, WBC of 20, and lactate of 1.6. On exam, patient had left sided crackles and guaiac positive black stools. In the ED she received 1L IVF and was T&C for 2 units PRBC (first unit started in ED. She received protonix bolus and then was started on protonix gtt. She received nebs, steroids, vanc, and cefepime in ED. On transfer: HR: 98, 131/47, 25, 95% on 4L. . On the floor, patient reports dyspnea is improved from eariler today. She reports that she has been coughing up blood, not vomiting blood.
MEDICAL HISTORY: # COPD on 2L O2 at home: FEV1 0.43 L on [**2111-11-2**], FEV1/FVC 46% # CAD, status post remote inferior MI at age 45 per pt report # Hypertension # Hypercholesterolemia # Hyperglycemia in the setting of steroid use # Osteoporosis # Lung nodules seen on CT in [**2103**], which have been followed # Restless leg syndrome # Insomnia # s/p carpal tunnel release
MEDICATION ON ADMISSION: - bisacodyl 10 mg Tablet daily PRN constipation - fluticasone-salmeterol 500-50 mcg 1 puff [**Hospital1 **] - sulfamethoxazole-trimethoprim 400-80 mg 1 tab daily - omeprazole 40 mg daily - docusate sodium 100 mg daily - montelukast 10 mg daily - albuterol sulfate 2.5 mg /3 mL (0.083 %) every 6 hours - albuterol sulfate 2.5 mg /3 mL (0.083 %) every 2 hours Q2H PRN shortness of breath or wheezing - fluticasone 50 mcg nasal spray [**Hospital1 **] - verapamil 120 mg daily - prednisone 35 mg daily - polyethylene glycol 1 dose daily PRN constipation - clonazepam 0.5 mg QID - lorazepam 0.5 mg q6H PRN Anxiety - senna 8.6 mg [**Hospital1 **] - tiotropium bromide 18 mcg daily - olanzapine 2.5 mg qHS - Dilaudid 1-2 mg Q2H PRN dyspnea, pain - vancomycin 1 gram Q12 - cefepime 2 gram q12 H - ciprofloxacin 400 mg IV q12H - Lantus 8 units qHS - Zofran 4 mg TID
ALLERGIES: Penicillins / Morphine / Clindamycin / Dilaudid
PHYSICAL EXAM: On admission: Vitals: T: 96.4 BP: 147/61 P: 100 R: 22 O2: 85% on 4L General: Elderly woman, appears chronically ill, anxious, pursed lip breathing HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Rhonchi on left, prolonged expiratory phase CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: thing extremities, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
FAMILY HISTORY: No family history of lung problems.
SOCIAL HISTORY: She has 4 children and 4 grandchildren. She is a retired travel [**Doctor Last Name 360**]. Tobacco: quit tobacco 14 years ago, 80-plus-pack-year history. ETOH: occasional ethanol. | 1 |
7,790 | CHIEF COMPLAINT: Abdominal pain
PRESENT ILLNESS: 89 year-old woman with history of multiple CBD stones and ERCP's most recently [**2201-3-25**] in addition to HTN, gout, bioprothetic valve replacement, hpothyroidism and GERD now transfered from OSH with epigastric pain and elevated LFTs. Patient initially presented to [**Hospital3 **] with a 1 day history [**8-4**] epigastric abdominal pain. Patient further endorses 1 episode of non bloody vomiting the morning of presentation. She reports subjective fevers (temp of 99.3 at [**Hospital1 46**]) in addition to anorexia and a 40 lb wt loss over the past few months. Patient denies loose stools, melena or BRBPR. She further notes a non productive cough. On arrival BP and pulse were elevated to 190/80 and 105 respectively in the setting of pain. Initial labs at [**Hospital1 46**] were notable for a Tbili of 5.5. She was given Zosyn, IVF, and morphine for pain and transferred to [**Hospital1 18**] for further management.
MEDICAL HISTORY: Bioprosthetic valve Hypothyroidism GERD Hypertension - Gout Type II DM, currently off medication Atrial fibrillation on aspirin only History of stroke Skin ca S/p appy/chole S/p multiple ERCPs with stent placement most recently [**3-8**]
MEDICATION ON ADMISSION: Calcium and vitamin D daily Allopurinol 100 mg daily Lisinopril 10 mg daily Amlodipine 10mg daily Potassium 20meq daily Lopressor 100mg [**Hospital1 **] Levothyroxine 50 mcg daily ASA 81 mg q2days [**Hospital1 **] Medications: 1. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO twice a day. 2. Vitamin D3 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 3. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Lopressor 100 mg Tablet Sig: One (1) Tablet PO twice a day. 7. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO EVERY OTHER DAY (Every Other Day). [**Hospital1 **] Disposition: Extended Care
ALLERGIES: Sulfa (Sulfonamide Antibiotics) / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
PHYSICAL EXAM: ADMISSION EXAM: Vitals: See metavision General: Alert, oriented, no acute distress HEENT: Sclera icteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, [**3-2**] holosystolic murmur Lungs: Crackles [**1-26**] way up bilaterally Abdomen: Soft, non-distended, mildly TTP in LUQ bowel sounds present, no organomegaly, No tenderness to palpation, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred. Skin: Diffuse juandice
FAMILY HISTORY: DM in several family members
SOCIAL HISTORY: Patient lives alone in her trailer home. Her granddaughter helps with her medication. She previously worked in an automobile factory on the line and retired at 80. She reports occasionaly smoking in the past but denies alcohol or illicit drug use. | 0 |
66,019 | CHIEF COMPLAINT: Chief Complaint: cough Reason for MICU transfer: septic shock
PRESENT ILLNESS: 43 year old man who presented to [**Hospital3 4107**] on [**2178-4-13**] with productive cough, fever and pleuritic chest pain. He was found to be hypoxemic on arrival with sats 86% on RA, ABG 7.36/32/71/18. He reported associated pleuritic chest pain, generalized weakness, diaphoresis and anorexia. Initially was noted to be in SVT, given adenosine with conversion to sinus. CXR showed moderate RLL consolidation, small RUL consolidation, patchy infiltrates in LUL (differential included pneumonitis, pulmonary hemorrhage versus ARDS). He was intubated for respiratory failure and concern for ARDS. Sedation was difficult and required fentanyl, ativan, propofol and vecuronium. He was ventilated on pressure control. He had hypotension requiring both norepinephrine and vasopressin for pressor support. He was given ceftriaxone, azithromycin and vancomycin. Sputum culture grew Strep pneumonia and [**Female First Name (un) **] albicans on [**2178-4-13**]. Bronchoscopy showed diffuse thick dark yellow secretions throughout the entire tracheobronchial tree. BAL grew Strep pneumonia (PCP and fungal cultures pending). Influenza negative. Fungal cultures including acid fast bacilli cultures are pending. Blood cultures were positive for Strep pneumonia on [**2178-4-13**]. Opportunisitic infections were considered, but HIV testing was not obtained. He was also noted to have acute kidney injury with creatinine 3.7 and BUN 64. He was seen by nephrology at the OSH who suspected ATN and recommended continued IV hydration. Creatinine trended down to 1.9 prior to transfer. . On arrival to the MICU, he was intubated and sedated, on pressure support ventilation, comfortable appearing. Pressors weaned on arrival with MAP >65. . Review of systems: unable to obtain due to sedation and intubation
MEDICAL HISTORY: ruptured appendix and appendectomy
MEDICATION ON ADMISSION: Medications HOME: none Medications on transfer: hydrocortisone 100mg q8H lorazepam 2mg q6H metoclopramide 10mg q6H vasopressin drip acetaminophen 650mg q4H PRN vancomycin 1000mg IV BID fentanyl drip norepinephrine drip azithromycin 500mg daily heparin SQ 5000 units TID NS continuous artificial tears QID chlorhexidine TID Insulin regular sliding scale levalbuterol 1.25mg nebs q4H propofol drip vecuronium PRN q8H ceftriaxone 1g daily pantoprazole 40mg daily
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: ADMISSION EXAM: Vitals: 98.7 92 109/68 on pressure control, changed to AC 26 450mL 100% FIO2 and PEEP 10 on arrival, sedated with fentanyl and propofol General: intubated, sedated, not responding to voice HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL Neck: supple, right subclavian line c/d/i CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: rhonchi anteriorly, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . DISCHARGE EXAM:
FAMILY HISTORY: Mother died age 73 of pancreatic cancer. Father had PMR, died age 75.
SOCIAL HISTORY: Works as a realtor, lives with a male partner. Smokes 1 pack/day for past 20 years. Drinks one drink 4 times per week. Sexually active with partner, has been HIV negative by report in past. | 0 |
15,432 | CHIEF COMPLAINT: Hypotension
PRESENT ILLNESS: Patient is a 79 year-old Russian male with a past medical history significant for multivessel CAD s/p MI '[**45**], s/p OM PCI to LCX '[**60**], s/p BMS to D1 of LAD '[**66**] with stable exertional angina, atrial fibrillation on coumadin, diastolic heart failure, PVD, hypertension, hyperlipidemia, DM2, long history of medication non-compliance presented with CHF exacerbation, elevated INR, now transferred to CCU due to asymptommatic hypotension during diuresis. . Per patient, had N/V/Diarrhea 3 days ago reported to be self-resolving. After resolution, noted worsening LE edema, orthopnea, fatigue and decreased PO intake. No PO intake since illness. On day of admission, he was so weak that he crawled to phone to be brought to ED. In the ED was found to have slow atrial fibrillation, unchanged EKG. CXR with e/o of pulmonary edema and right sided pleural effusion. INR was 19. Due to back bruise, CT scan done which was negative for RP bleed. However, did note moderate pericardial effusion. Echo with no tamponade physiology. Recieved 10 mg Vitamin K to reverse INR, Lasix 80 mg IV with 75 cc UOP and admitted to the floor. . Overnight, he was placed on lasix gtt with subsequent hypotension this morning. Urine output total 261 cc in 12 hours. Lasix gtt was discotninued and blood pressures improved to mid-90's, however, no urine output. Blood pressure slowly declined to mid-80's off the lasix gtt and now transferred to CCU. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, constipation, BRBPR, melena, hematochezia, dysuria. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope.
MEDICAL HISTORY: -- Multivessel CAD - s/p MI '[**45**], s/p OM PCI to LCX '[**60**], s/p BMS to D1 of LAD '[**66**]; stable exertional angina, rare with climbing hills, stairs; MIBI ETT in [**2166**] - anignal symptoms with no ischemic changes, 52% predicted max HR -- Chronic AF - on warfarin -- Diastolic HF - orthopnea, paroxysmal nocturnal dyspnea, exertional dyspnea; Echo in [**2166**] - mild MR, normal EF; normal spirometry testing in [**2168**] -- PVD - calf claudication bilaterally -- Hypertension - normally 161-170/80 mmHg at home -- Dyslipidemia - most recent cholesterol 98, LDL 46 -- Diabetes. Most recent A1c was 7.7 -- Proteinuria -- Chronic anemia -- BPH -- H/o TB. -- Medication noncompliance. -- asthma -- DVT [**2170**] while on coumadin
MEDICATION ON ADMISSION: HOME MEDICATIONS: warfarin 3 mg daily Lipitor 40 mg/day cilostazol 50 mg [**Hospital1 **] Vitamin B12 doxazosin 4 mg qhs, Lasix 40 mg/day ImDur 90 mg/day insulin lisinopril 5 mg daily Toprol XL 100 mg/day NTG prn aspirin 81 mg/day Protonix 40 mg/day iron . MEDICATIONS ON TRANSFER - Metolazone 2.5 mg [**Hospital1 **] - Lasix 15 mg/h IV gtt - Tylenol 325-650 mg q6h prn pain - ASA 81 mg daily - Pantoprazole 40 mg q24h - Insulin sliding scale - Atorvastatin 20 mg daily
ALLERGIES: Insulin,Beef
PHYSICAL EXAM: Admission physical exam: VS: T= Afebrile BP= 108/61 HR= 51 RR= 18 O2 sat= 92% pulsus [**8-5**] GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: left eye conjunctiva injected, [**Last Name (un) **], MMM (but lips appear dry). NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of *** cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . Discharge physical exam
FAMILY HISTORY: [**Name (NI) **] CA - father
SOCIAL HISTORY: Retired electrician, widowed, has no children, lives alone in [**Location (un) 86**]. He quit smoking many years ago and does not drink alcohol nor use other drugs. He has had occupational lead exposure. | 1 |
14,840 | CHIEF COMPLAINT: Positive stress test
PRESENT ILLNESS: This is a 71 year old male with polycystic kidney disease, dialysis dependent who was in the process of kidney transplant evaluation. The patient had CT chest on [**2127-10-1**] revealing a 2.2 x 2.1 x 2.4 cm right upper lobe lung nodule, which was treated with antibiotics. He then had a repeat CT chest [**2127-11-6**] revealing increased size to 2.9 x 2.5 x 2.6 cm. Patient was being worked up for a right upper lobe nodule removal and was found to have a positive stress test. Upon telephone interview with patient he states he gets fatigue very easily, he denies chest discomfort. Patient complains of shortness of breath on exertion for the past six months.
MEDICAL HISTORY: Hypertension COPD Polycystic Kidney Disease on HD since [**1-5**] 3x week M-W-F Left leg claudication Ventral Hernia Hypercholesterolemia Cardiac Arrest [**2124**] GERD Arthritis Past Surgical History Cerebral artery aneurysm clipping [**2114**] Abdominal Aortic aneurysm repair [**2124**] at [**Hospital1 112**]
MEDICATION ON ADMISSION: Medications - Prescription ALBUTEROL SULFATE - (Prescribed by Other Provider) - 90 mcg HFA Aerosol Inhaler - [**12-28**] every four (4) hours as needed for shortness of breath or wheezing B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - (Prescribed by Other Provider) - 1 mg Capsule - one Capsule(s) by mouth daily CALCIUM ACETATE - (Prescribed by Other Provider) - 667 mg Capsule - two Capsule(s) by mouth three times daily EPOETIN ALFA [EPOGEN] - (Prescribed by Other Provider) - 2,000 unit/mL Solution - 2400 units 3x/week FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth daily LABETALOL - (Prescribed by Other Provider) - 300 mg Tablet - 1 Tablet(s) by mouth twice a day PARICALCITOL [ZEMPLAR] - (Prescribed by Other Provider) - 2 mcg/mL Solution - 3mcg three times a week with dialysis REMVELA - (Prescribed by Other Provider) - - two tablets three times daily SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth daily VERAPAMIL - (Prescribed by Other Provider) - 180 mg Cap,24 hr Sust Release Pellets - 0.5 (One half) Cap(s) by mouth four times a week, S,T,T, S Medications - OTC DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth twice a day FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65 mg iron) Tablet - one Tablet(s) by mouth daily FIBER - (Prescribed by Other Provider) - 0.52 gram Capsule - 2 (Two) Capsule(s) by mouth twice daily
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Pulse: 67 Resp: 14 O2 sat: 99% RA B/P Right: 184/78 on nitro Height:6'1" Weight:214lbs
FAMILY HISTORY: Family History:adopted, family history unknown
SOCIAL HISTORY: Lives with:Married with a son and daughter [**Name (NI) 2270**] who is his health care proxy, his wife has [**Name (NI) 2481**]. Occupation:retired Tobacco:denies (quit 3 years ago), smoked 1ppd for 50 yrs ETOH:denies (quit 3 yrs ago) | 0 |
73,534 | CHIEF COMPLAINT: s/p bilateral thrombectomy attempt iliac veins
PRESENT ILLNESS: 66 y/o F with PMHx of advanced endometrial stromal tumor, s/p hysterectomy complicated by extensive DVT and PE. Pt was put on Lovenox and had IVC filter placed [**2184-1-13**], and underwent further ex- lap on [**2183-1-20**]. Pt was found to have iliac vein thrombus that extends from the level IVC filter to common iliac vein on left and and external iliac on the right. Pt was taken for elective IR thrombolysis and thrombectomy with local tPA infusion. Pt tolerated the procedure well but developped lower back pain that she felt was related to lying flat on the procedure table for >4hrs. She reports that she has developed a similar pain in the past that she relates to her osteopenia. Pt was admitted for overnight monitoring post tPA infusion. Per IR report, thrombectomy was unsuccessful and there is no need for continued tPA or repeat venogram in the am. . On arrival to the CCU, pt was describing nausea and [**4-1**] lower back pain that improved with dilaudid. She denies CP, palpitations, HA, abd pain, lower extremity pain/weakness.
MEDICAL HISTORY: PAST MEDICAL HISTORY: Significant for thyroid cancer.
MEDICATION ON ADMISSION: Levoxyl 125 mcg daily Colace 100 mg every day as needed Lovenox 60 mg twice daily Megace 80 mg a day Ativan as needed Multivitamin Calcium Magnesium
ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Codeine / Prochlorperazine
PHYSICAL EXAM: Vitals: BP: 148/89 P: 77 RR: 12 O2: 98% on 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM Neck: supple Lungs: CTA anterior/laterally, no wheezes, rales, ronchi CV: RRR normal S1/S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, NABS, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Groin: femoral caths bilaterally
FAMILY HISTORY: Mother died of lymphoma at 78 No family history of ovarian, uterine, colon, or prostate CA
SOCIAL HISTORY: The patient does not smoke. She drinks occasionally. She is a medical transcriptionist. | 0 |
19,362 | CHIEF COMPLAINT: Right groin pain with fevers, chills, nausea and vomiting for over two months and right cold lower extremity.
PRESENT ILLNESS: The patient is a 48-year-old white male with type 1 diabetes who presented with increased fevers, nausea, vomiting, chills, and groin pain. There months prior to admission, the patient had claudication symptoms in his right leg. The patient was treated for cellulitis at that time with Keflex. The patient saw a podiatrist at that time who felt that his problem was vascular in nature. Two months prior to admission, the patient developed a cold right lower extremity over the course of several days while on vacation. He was admitted to the hospital and had a thrombectomy as well as and endarterectomy of his superficial femoral artery on the right side. The patient had an angiogram at that time and developed acute renal failure with a creatinine of 2.8 secondary to the intravenous dye load. Five days prior to admission, the patient developed fevers, chills, nausea, and vomiting associated with diarrhea, and fingersticks were 300 to 400. His gastrointestinal symptoms improved with Pepto-Bismol, but the fevers, chills, and rigors continued. Three days prior to admission, the patient developed groin pain with some radiation to the right knee. The patient continued to have fevers and chills. The patient denies abdominal pain, right upper quadrant pain, light stools, dark urine, jaundice, chest pain or shortness of breath. The patient was seen by Vascular Surgery who felt the patient had a right groin cellulitis, soft tissue infection, without evidence of collection requiring surgical intervention at the time of admission; although, Vascular Surgery continued to follow the patient throughout his stay.
MEDICAL HISTORY: (The patient's past medical history includes) 1. Type 1 diabetes complicated by chronic renal insufficiency with a baseline creatinine of about 1.3, peripheral vascular disease and retinopathy. 2. Acute arterial occlusion of the right leg. 3. Testicular cancer in [**2114**], status post orchiectomy, lymphadenectomy, and radiation therapy. 4. Status post appendectomy in [**2138**]. 5. Hypertension.
MEDICATION ON ADMISSION: The patient's medications on admission included quinapril 20 mg p.o. b.i.d., atorvastatin 10 mg p.o. q.d., clopidogrel 75 mg p.o. b.i.d., enteric-coated aspirin 325 mg p.o. q.d., irbesartan 300 mg p.o. q.d. ............ 100 mg p.o. b.i.d., Lantus 24 units, Humalog sliding-scale.
ALLERGIES: He has no known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY: Family history of hypertension and cerebrovascular accidents.
SOCIAL HISTORY: The patient is an accountant. He drinks one drink per day and three cigars per week; which he quit in [**2144-4-8**]. | 0 |
1,002 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 57 year old male involved in an unhelmeted motorcycle versus motor vehicle collision on [**2135-6-21**], the date of admission. According to the patient he was hit by a car and thrown several feet away. The patient did not report any loss of consciousness or head trauma. He complained of pain in both lower extremities. The patient was brought to [**Hospital1 346**] via [**Location (un) **]. Radiographs of the right shoulder revealed a scapular and proximal humeral fracture, a comminuted angulated fracture of the right distal femur, and a midshaft fracture, oblique comminuted fracture of the left femur and left proximal tibia, involving the plateau, and also left distal tibia/fibula open and comminuted fracture. CT scan of the abdomen, pelvis, head and cervical spine were normal.
MEDICAL HISTORY:
MEDICATION ON ADMISSION:
ALLERGIES: Codeine.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient lives in [**Location (un) 3844**] with his wife and two daughters in their 20s. | 0 |
73,875 | CHIEF COMPLAINT:
PRESENT ILLNESS: Mrs. [**Known lastname **] is a 48 year old female with a 16 year history of HIV; recent CD4 count of 2 and viral load of 34,000, who was admitted on [**3-3**], with a diagnosis of a subcapsular renal hematoma. Mrs. [**Known lastname **] has developed an acidosis and hypokalemia over the past several months and had a rising BUN and creatinine. On [**2-27**], she had a left renal biopsy which was apparently tolerated without incident. She was discharged home and did well until [**3-3**], when she returned to the Emergency Department with left lower quadrant pain, nausea and vomiting. A CT scan in the Emergency Room revealed a left renal subcapsular hematoma and labs revealed a hematocrit of 18. She was transfused two units of packed red blood cells and given two units of fresh frozen plasma and transferred to the Intensive Care Unit. In the Intensive Care Unit, her hematocrit rose to 27 and she was stable overnight. On the morning of [**3-4**], she was called out to the [**Location (un) 2655**] Medicine Firm where we took care of her from that point on.
MEDICAL HISTORY: 1. Human Immunodeficiency Virus for 16 years. She has had both fungal and viral infections; a fungal infection of her esophagus, Pneumocystis carinii pneumonia about four years ago and shingles times two. 2. Anemia believed to be multi-factorial in nature due to both HIV infection as well as anti-viral medications. Iron studies in [**5-/2181**], suggested iron deficiency is not a significant cause of this anemia, although the patient does state that her menstrual periods sometimes have a heavy flow. The patient's erythropoietin level on [**12/2181**] was high, reducing the possibility of a renal etiology. Baseline creatinine was 2.7 on the day of renal biopsy. 3. History of hypertension.
MEDICATION ON ADMISSION:
ALLERGIES: Allergies include sulfa drugs.
PHYSICAL EXAM:
FAMILY HISTORY: Father died of brain aneurysm. Mother is alive with chronic obstructive pulmonary disease.
SOCIAL HISTORY: The patient lives with her two sons. She does not work. She denies tobacco, alcohol, or intravenous drug abuse history. She reports she contracted HIV through sexual contact. | 0 |
46,763 | CHIEF COMPLAINT: Diarrhea
PRESENT ILLNESS: Pt. is a 73yo woman with metastatic pulmonary neuro-endocrine carcinoma, large-cell type, progressive following two cycles of palliative chemotherapy with carboplatin and etoposide. Most recently on irinotecan weekly, last dose on [**3-10**]. Patient has been progressing through recent chemo. She also has a h/o HTN and recent MAT with hospitalization from [**Date range (1) 31835**] during which her BB was increased from daily to tid. She was recently referred to hospice care. At home the patient reports that she has been having diarrhea while getting chemo. Stools 3-4 times per day. Also with nausea and decreased PO. One episode of vomiting a few days ago. She reports that VNA noted her to be more tachycardic yesterday and encouraged her to come in. She continues to have baseline SOB and gets daily pleural fluid drained from her pleurex catheter. She denies fevers, chest pain or cough. In the ED VS were T 96.7 BP 79/62 HR 140 RR 8 100% RA. She was given 1.5L of IVF with improvement in HR to 120s. Patient initially refusing admission, however husband insisted given need to see her oncologist in am. Given hypotension and tachycardia, need for CVL was discussed with patient and patient refused. Labs were notable for ARF with Cr 3.4 and K 5.8. She was given 1 amp D50 and insulin 10 units. On admission the patient appeared tired. She had no complaints. She refused central line placement.
MEDICAL HISTORY: 1. L4/L5 spondylolisthesis with synovial cyst resected in 01/[**2154**]. 2. Left piriformis syndrome. 3. Hypertension. 4. Status post total hysterectomy in [**2147**] for leiomyomata with foci of atypical hyperplasia of the endometrium, focally involving an endometrial polyp. 5. Pulmonary neuroendocrine carcinoma diagnosed as below in [**1-2**] 6. s/p R pleurex catheter placement [**2156-2-6**] . Past Oncology History: - Initial symptoms: cough, supraclavicular lymph node, nodular mass lower abdomen - CXR demonstrated R hilar mass. CT on [**2156-1-1**] showed 3.5 X 3.7 cm R hilar mass with marked narrowing of the right upper lobe bronchus and apparent obstruction of the posterior bronchus to the right upper lobe. Bulky bilateral mediastinal lymphadenopathy was noted. The dominant lymph node mass in the right paratracheal region measured 2.9 x 2.7 cm, with a dominant conglomerate nodal mass in the precarinal lesion measuring 3.3 x 2.8 cm. Multiple lymph nodes were identified throughout the mediastinum including the prevascular space bilaterally, the posterior subcarinal space, and the right hilum. There was a moderate dependent right pleural effusion and a small left pleural effusion as well as a small pericardial effusion. Also noted was a 2.8 x 1.9 cm nodule within the periphery of the right upper lobe. Heterogeneous enhancement of the left adrenal gland was seen, measuring 1.9 x 1.8 cm. In addition, an enlarged left supraclavicular lymph node measured 1.4 x 1 cm. Several lucent vertebral body lesions were identified in the lower thoracic spine. - Excisional biopsy of the right supraclavicular lymph node on [**2156-1-5**]. - Pathology: poorly differentiated neuroendocrine carcinoma of pulmonary origin, probably best characterized as large cell type, although there is considerable variation in cell size. No e/o lymphoproliferative disorder.
MEDICATION ON ADMISSION: (per OMR): Hydrocodone-acetaminophen [**12-26**] q6hr prn Lorazepam 1mg prn Toprol 25mg daily Mirtazapine 15mg [**12-26**] qhs prn Ondansetron 8mg q8hr prn Prochlorperazine 10mg q6hr prn Tylenol prn ASA 81mg daily Colace 100mg [**Hospital1 **] Ibuprofen 600mg [**Hospital1 **] prn
ALLERGIES: Penicillins / Latex
PHYSICAL EXAM: Vitals: T: 95.8 BP: 84/49 HR: 127 RR: 6 O2Sat: 91% 2L GEN: Chronically ill-appearing, tired, lying in bed with eyes closed, arousable, no acute distress HEENT: EOMI, PERRL, sclera anicteric, MM dry, OP Clear NECK: No JVD, no lymphadenopathy, trachea midline COR: Regular, tachy, no M/G/R PULM: Decreased BS [**12-26**] way up on R, crackles [**12-27**] way up on L ABD: Soft, firm soft tissue mass present on anterior abdominal wall, NT, ND, hyperactive BS EXT: 1+ edema bilateral LE NEURO: oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 4+/5 in upper and lower extremities.
FAMILY HISTORY: The patient's mother died at age 86 from squamous cell carcinoma of the oral cavity. Her father died of congestive heart failure at age 85. She has no siblings. Her paternal aunt was diagnosed with breast cancer in her 70s.
SOCIAL HISTORY: The patient is married and lives in [**Location **] with her husband. They have a 47-year-old son who lives in [**Name (NI) 108**]. She spends her time playing cards and socializing. She has smoked cigarettes for the past 60 years, approximately a pack per day on average. She drinks two glasses of wine each night. | 1 |
90,004 | CHIEF COMPLAINT: Bilateral PE, recent SDH
PRESENT ILLNESS: Mr [**Known lastname 1794**] is a 69 year old with past medical history significant for multiple prior Deep Vein Thrombosis, Pulmonary Emboli, L. hip replacement and recent CVA, presenting from OSH ([**Hospital 6451**] Hospital) with bilateral pulmonary emboli. He was recently discharged from the NSG service on [**2142-2-19**] s/p SDH evacuation to Rehab. Regarding the pt's [**2-13**] - [**2-19**] admission: he was admitted to NSG at [**Hospital1 18**] after he had complained of a headache for several days and had multiple episodes of vomiting. His head CT revealed a large left SDH. He was taken to the OR on [**2142-2-13**] for a Left craniotomy for SDH evacuation. He became febrile to 101.8 early am on [**2142-2-15**], sputum cultures were positive for Gram + cocci in pairs, and LENIS showed a Left superficial femoral DVT that was determined to be a new partially occlusive DVT (with the pt's last documented DVT having occured in [**2139**], after which he was begun on Coumadin 6mg daily). No anticoagulation was safe to be administered in the immediate post-operative setting of SDH/surgery. SQ heparin on HD2 and levofloxacin 4d course was started in the setting of low grade fever and sputum with gram + cocci. Pt was discharged to rehab [**2142-2-19**] on Heparin 5,000 unit/mL TID, and instructed to hold coumadin until [**2142-2-26**]. While at rehab, he had sudden onset SOB at PT on [**2142-2-23**]. He was taken to an OSH and had a CTA that demonstrated large PEs in both main pulmonary arteries and segmental branches with RV dilitation. The patient was started on a Hep gtt at the OSH, with a large bolus (8700 units) and was continued on Heparin gtt. He was trasfered to [**Hospital1 18**] for further management. . Patient was transferred to [**Hospital1 18**] with initial VS 99, 135/94, 97, 24, 97% on [**10-16**] 100% FiO2 on BiPap.
MEDICAL HISTORY: HTN hyperlipidemia h/o Pulmonary Embolism -- previously on warfarin -- s/p IVC filter placement L4-5, L5-S1 stenosis hip replacement Left subdural hematoma Left Superficial Femeral Deep Vein Thrombosis Left PCA infarct
MEDICATION ON ADMISSION: MEDICATIONS AT HOME: 1. Acetaminophen 325 mg Tablet PO Q6H (every 6 hours) 2. Simvastatin 10 mg Tablet PO DAILY 3. Verapamil 120 mg Tablet Sig: 0.5 Tablet PO Q8H 4. Levetiracetam 750 mg Tablet PO BID 5. Heparin (Porcine) 5,000 unit/mL TID 6. Insulin Lispro 100 unit/mL Solution 7. Aspirin 325 mg Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 12.5 mg PO Q6H 9. Hydrocortisone Acetate 1 % Ointment 10. Bisacodyl 5 mg Tablet PO BID 11. Lactulose 10 gram/15 mL (30) ML PO Q6H 12. Magnesium Hydroxide 400 mg/5 mL Thirty (30) ML PO Q6H (every 6 hours) as needed for Constipation. 13. Senna 8.6 mg Tablet PO BID 14. Docusate Sodium 50 mg/5 mL 15. Polyethylene Glycol 16. Famotidine 20 mg Tablet 17. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Tablet(s) 18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 19. Ondansetron 4 mg IV Q8H:PRN nausea 20. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain.
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: GENERAL: Agitated. HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: JVP 7cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. II/VI mid systolic murmur at LLSB. No thrills, lifts. No S3 or S4. LUNGS: CTA anterolaterally, no crackles, wheezes or rhonchi. ABDOMEN: Tympanitic, NT. Distended. Hypoactive BS. EXTREMITIES: No c/c. 1+ LLE edema. PULSES: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+
FAMILY HISTORY: No family history of early CAD or sudden cardiac death.
SOCIAL HISTORY: warehouse worker forced to quit 1 [**1-13**] yrs ago due to L hip pain. no tobacco, no ETOH | 0 |
28,808 | CHIEF COMPLAINT: OSH transfer for evaluation of abdominal pain
PRESENT ILLNESS: Ms [**Known lastname 6185**] is a 77F w DM2, HTN, HL, CAD (s/p CABG), PVDz, known celiac/SMA stenosis, pAF (on home Coumadin), chr sys CHF (EF 20% [**3-/2112**]), sinus bradycardia (s/p PPM), recent admission to [**Hospital1 18**] and OSH for SOB (s/p MICU and intubation), who originally presented to OSH 4 days ago w acute on chronic abdominal pain, and is now transferred to [**Hospital1 18**] for further evaluation. . Pt reports chronic RLQ abd pain x [**1-12**] mos. Pain is intermittent, sharp, worse w food, better w not eating, gradually worsening. Associated w nausea and NBNB vomiting at least once daily. She also reports chronic diarrhea ([**1-12**] loose stools per day, yellow, non-bloody/tarry in general, though occasional drops of red blood). No fevers, but often feels cold. Sxs have been worse in the last 2 weeks, which prompted presentation to OSH 4 days prior to transfer. . At OSH, pt was started empirically on metronidazole (d1=[**5-6**]) for C. diff colitis, though C diff toxin negative. CT A/P w/o contrast showed diffuse thickening of colon (left, transverse, rectosigmoid). GI there recommended evaluation by [**Month/Year (2) 1106**] surgery for mesenteric ischemia, and likely GI here for colonoscopy. . Now still having diarrhea, but less, and nausea and vomiting resolved. Of note, sister has similar sxs recently. No recent travel, no sick contacts, no new food items. No urinary sxs.
MEDICAL HISTORY: CAD s/p CABGx3 and s/p inf MI Chr sys CHF (EF 20% in [**3-/2112**]) pAF (on home Coumadin) Sinus bradycardia (s/p PPM in [**2107**]) HTN HL DM2 H/o TIAs PVD severe celiac/SMA stenosis Gout COPD CKD Stage 2 (creatinine 1.2) s/p hemigastrectomy for PUD in remote past
MEDICATION ON ADMISSION: HOME MEDS: Coumadin 2mg PO daily Furosemide 40mg PO daily Spironolactone 25mg PO daily Isosorbide Dinitrate 20mg TID Metoprolol 25mg PO BID Atorvastatin 20mg PO daily Glipizide 10mg PO daily Advair 100/50 INH [**Hospital1 **] Colchicine 0.6mg PO daily Omeprazole 20mg PO daily . TRANSFER MEDS: Metronidazole 500mg PO TID Coumadin 4mg PO daily Isosorbide Dinitrate 20mg TID Ranolazine 1000mg PO daily Metoprolol 25mg PO BID Atorvastatin 20mg PO daily Niacin ER 500mg PO daily SLNTG PRN for chest pain RISS Advair 100/50 INH [**Hospital1 **] Albuterol 2.5mg INH q6h:prn SOB/wheezing Colchicine 0.6mg PO daily Allopurinol 300mg PO daily Omeprazole 20mg PO daily Ondansetron 4mg IV q6h:prn N/V Tylenol PRN pain/fever Tramadol 50mg PO q4h:prn pain Zolpidem 5mg PO qhs:prn insomnia
ALLERGIES: Morphine / Ace Inhibitors
PHYSICAL EXAM: Exam on Admission: VS: 99.3, 94/50, 69, 20, 96% RA GEN: pleasant, ill-appearing elderly woman lying in bed supine in NAD HEENT: NC/AT, PERRL, EOMI, MMM, OP clear NECK: supple, no LAD, normal JVP CV: irregular, S1S2, no M/R/G CHEST: diffuse crackles b/l midway up ABD: +TTP in RLQ, non-distended, NABS EXTR: WWP, no C/C/E, 2+ DP/rad pulses b/l NEURO: AOx3, CNII-XII intact, [**4-12**] Motor strength in UE/LE b/l
FAMILY HISTORY: Heart disease and cancer. She is 1 of 12 children but only 4 of them are living.
SOCIAL HISTORY: Lives alone in a housing complex in [**Location (un) 14663**] in a single floor apartment w/ an elevator in the building. She pays her own bills. Patient states she quit smoking 1 month ago, was smoking [**1-12**] cigarettes per day for most of life (denies smoking more than this). Previously had 1 EtOH drink per day. | 0 |
87,840 | CHIEF COMPLAINT: Anemia
PRESENT ILLNESS: Mr. [**Known lastname 95715**] is an 88 year old man with paroxysmal atrial fibrillation and atrial tachycardia which are now persistent, coronary disease status post inferior MI in [**2092**], status post dual-chamber pacemaker for impaired AV nodal conduction in [**Month (only) 116**] [**2104**], and chronic kidney disease who presents today from [**Hospital3 9475**] Care Center a HCT of 23. HCT in the ED found to be 23*. EKG showed slow atrial fibrillation without P waves, with atypical RBB, leftward axis, and some T wave flattening in the precordium (normally has Twave inversion across precordium). 2 large bore IVs placed. Guaiac positive from below with black stool, assumed to be secondary to the patient ingesting blood. The patient was consented for blood, and a CXR showed a worsening and possibly loculated R pleural effusion. He also received 1 U PRBC in the ED. At rehab, his labs on [**11-19**] in the AM were notable for Cr 1.4, K 5, HCT of 23, INR 4.2 Of note, 3 weeks ago he was admitted to [**Hospital 4199**] Hospital where he was diagnosed with pneumonia. He was discharged to rehab where he has been for several weeks. While at rehab, he developed a bloody nose from his right nares and has undergone packing which needs to remain in place until Friday [**11-20**]. He had been receiving amoxicllin clavulonic acid as part of his regime for packing.
MEDICAL HISTORY: - Dilated cardiomyopathy with an EF of 25% with chronic systolic and diastolic heart failure - Mitral regurgitation status post bioprosthetic MVR, - Persistent atrial fibrillation and atrial tachycardia - Coronary artery disease status post IMI in [**2092**] with a most recent left heart catheterization in [**2100-11-21**] showing no flow-limiting disease - AV conduction disease status post dual-chamber pacemaker in [**2105-3-21**] - Chronic kidney disease stage IV with baseline creatinine of 1.8 - Trigeminal neuralgia status post trigeminal nerve ablation - Gastritis and duodenitis - Orchiectomy for a testicular mass in [**2074**], and diverticulosis
MEDICATION ON ADMISSION: amoxicillin/clavulanate 875/125 mg twice a day for 7 days (started [**2106-11-11**]) Multivitamin PRN Carvedilol 12.5 mg twice daily Lasix 20 mg daily DuoNeb PRN Lorazepam 0.5 mg at bedtime as needed for insomnia Simvastatin 80 mg daily Coumadin 5 mg as instructed for goal INR 2 to 3 Aspirin 81 mg daily
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: ADMISSION PHYSICAL EXAM VS - Temp F, BP 115/49 HR 61 RR 28 )2 Sat 100% on 2 L GENERAL - NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM NECK - supple, no thyromegaly, no JVD appreciated LUNGS - Dullness to percussion on the R, crackles at the L base, mild accessory muscle use HEART - irreigularly irreigular, nl S1/S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, 1+ peripheral edema B, 2+ peripheral pulses (radials, DPs) SKIN - eccymosis on the L hand NEURO - awake, A&Ox3 DISCHARGE PHYSICAL EXAM
FAMILY HISTORY: There is no family history of premature coronary artery disease, heart failure, or sudden death.
SOCIAL HISTORY: Social and family history were reviewed and remain unchanged. He was living with his family, but is now at a rehab. He is a former probation officer. He has no history of tobacco or drug use and drinks occasional alcohol. | 0 |
68,161 | CHIEF COMPLAINT: shortness of breath and cough
PRESENT ILLNESS: Ms. [**Name14 (STitle) 98099**] is a 72 y/o female limited stage SCLC, s/p four cycles of cisplatin and etoposide with concomitant external beam radiation who presented to [**Hospital **] hospital with 3-4 day h/o cough and congestion. Chest xray showed "white out" and she was intubated for respiratory distress with etomidate/succinylcholine. She received vancomycin, zosyn, and solumedrol. R-IJ placed at OSH. Her normal care is at [**Last Name (un) 4068**]. She has completed therapy over three and a half years ago and has had no evidence of disease recurrence. She continues to see pulmonary regarding her reactive airway disease and eosinophilic pneumonia. Other chronic physical complaints include intention tremor with her right hand, and proximal muscle weakness impeding body position changes. Was admitted to [**Hospital1 **] in [**6-/2159**] and treated for CAP. . In the ED admission vitals: 92 99/69 18 97% on ventilator. She arrived intubated on a fentanyl and midazolam gtt. She received 300cc in the ED and 1L at the OSH. Most Recent Vitals: 90, 88/49, 16, 96% on vent settings: 400, 16, 5 PEEP, 50% fiO2. . On the floor, patient was intubated and accopmpanied by her husband and daughter. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes.
MEDICAL HISTORY: IPMT (intraductal papillary mucinous tumor) chronic eosinophilic pneumonia:no prior pulm notes in our system; followed by Dr. [**Last Name (STitle) **] at [**Hospital1 18**] [**Location (un) 620**] Pulmonary HTN gastritis depression herpes zoster s/p appy s/p cholecystectomy . Past Oncologic History per oncology notes: SCLC- routine MRCP performed in follow up of her IPMT on [**2155-3-19**], which showed a possible right posterior rib lesion. She had a chest CT performed on [**2155-4-23**], which showed a 2.7 x 1.7 cm soft tissue density that extended to the posterior segment of the right upper lobe. This corresponded to the abnormality seen on the MRCP. In addition, there were lymph nodes noted in the prevascular, peritracheal, subcarinal, and mediastinal stationed in the right hilum. FDG/PET imaging showed intensely FDG avid dominant right lung nodule and intensely FDG avid right hilar, right peritracheal, and precarinal lymph nodes. She underwent mediastinoscopy and lymph node biopsy showed small cell lung cancer. She was staged as limited stage and has since completed four cycles of cisplatin and etoposide with concomitant XRT in addition to prophylactic cranial irradiation (PCI), completing on [**2155-10-10**].
MEDICATION ON ADMISSION: Prednisone 15mg long-term Levaquin 500 mg a day for 3 more days Robitussin 5 mL q.6 hours p.r.n. ferrous sulfate 325 mg daily Neurontin 100 mg 3 times per day advair 250/50 one puff twice per day Ultram 25 mg 3 times per day DuoNebs q. 4 hours p.r.n. Colace 100 mg twice per day as needed Tylenol 650 every 6 hours as needed heparin subcu 5000 units q8 hours until increased ambulation, Caltrate 600 mg twice per day Protonix 40 mg daily Zyrtec 5 mg daily Sanctura 60 mg daily Zoloft 50 mg daily vitamin B12 one tablet daily Lasix 40 mg daily - held x 2 days. Per [**5-/2159**] dc summary felodipine 5 mg Tablet Extended Release 24 hr fluticasone 50 mcg Spray, Suspension 2 sprays nasal daily in each nostril fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose Disk with Device 1 puff inh twice a day hydrocodone-homatropine ipratropium bromide prednisone 15mg daily sertraline 50 mg Tablet 1 Tablet(s) by mouth daily acetaminophen [Acetaminophen Extra Strength] 500 mg Tablet 1 to 2 Tablet(s) by mouth once a day as needed ascorbic acid [Vitamin C] 500 mg Tablet 1 Tablet(s) by mouth daily calcium carbonate-vitamin D3 [Calcium 500 + D] 500 mg (1,250 mg)-400 unit Tablet, Chewable 1 Tablet(s) by mouth twice a day cyanocobalamin (vitamin B-12) 250 mcg Tablet One Tablet(s) by mouth twice a day (OTC)
ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Iodine-Iodine Containing
PHYSICAL EXAM: Tmax: 37 ??????C (98.6 ??????F) Tcurrent: 37 ??????C (98.6 ??????F) HR: 78 (78 - 86) bpm BP: 98/49(67) {98/49(67) - 98/49(67)} mmHg RR: 18 (13 - 20) insp/min SpO2: 97% Heart rhythm: SR (Sinus Rhythm)
FAMILY HISTORY: 3 brothers with CAD s/p stents palced in 60s-70s. Father died in his 90s of "old age". has one brother with DM. Mother died of heart problems in her 60s. No FH lung disease or other malignancy.
SOCIAL HISTORY: Lives with husband. Formerly employed in formulating specs for valve company. Quit smoking 45 years ago. Smoked 2ppd x 10 years. Denies IVDU. Has children who are healthy. | 0 |
45,995 | CHIEF COMPLAINT:
PRESENT ILLNESS:
MEDICAL HISTORY: Chronic lymphocytic leukemia. The patient's baseline white count is between 30 and 60,000 with increased lymphocytes. She was diagnosed in [**2132-5-16**]. She is status post splenectomy for ITP- and received monthly IGG infusions at the [**Hospital3 328**] Cancer Institute. She has a history of hypertension, Type II diabetes mellitus. The patient has no history of coronary artery disease. She had a transthoracic echo done in [**3-20**] which showed an ejection fraction of greater than 55% with no focal wall motion abnormalities. The patient had a history of bronchiectasis with recurrent pneumonia, history of gastroesophageal reflux disease with recurrent abdominal pain, rheumatoid arthritis on Methotrexate and Prednisone, osteoporosis, atypical chest pain, aortic insufficiency, depression, stress incontinence, cystocele, atrophic vaginitis, post herpetic neuralgia, chronic low back pain, status post fall recently with a right humerus fracture.
MEDICATION ON ADMISSION:
ALLERGIES: Phenazoline, Clonidine, Codeine, Effexor, Penicillin, Azithromycin, Sulfa.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient lives with her husband. Denies any tobacco or alcohol use. | 0 |
12,509 | CHIEF COMPLAINT: new onset seizure
PRESENT ILLNESS: She is a 52-year-old right-handed woman with multiple medical problems who last week suffered her first ever seizures. Both of these lasted relatively short periods of time. The first of these episodes sounds as if it was psychomotor in nature but during the second episode, the patient states she was fully awake but unable to speak. The patient was brought to an outside hospital where her Lamictal was increased. She has been previously taking Lamictal (to stabilize her mood), the patient was sent for imaging which reveals a left-sided meningoma along the convexity in the region of the primary motor cortex. The patient presents today to be evaluated for this lesion. Aside from these two seizures, the patient denies new weakness, nausea or vomiting. The patient has a history of chronic headache but she does not feel her headaches have changed in any way. She has had no further seizures since the two episodes that occurred last week.
MEDICAL HISTORY: headache, bipolar disease, hypothyroism, LBP
MEDICATION ON ADMISSION: aspirin, lithium, Caltrate, meloxicam, Synthroid, Topamax, Lamictal, Percocet and OxyContin
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: On ADmission: The patient is a normally developed woman who appears her stated age. She is alert and oriented toall spheres. Her expressive and receptive language functions arenormal. Pupils are equal and reactive to light. Her extraocular movements are full. Her face is symmetric. Her tongue and palate are midline. Her motor tone and bulk are normal. Her strength is [**4-19**] throughout. There is no upper extremity drift. The patient ambulates on a narrow base. She can turn on a dime. Romberg is negative. Sensory exam is grossly intact. Coordination is normal and toes are downgoing. The patient has perhaps brisk knee reflexes on the right compared to the left.
FAMILY HISTORY: NC
SOCIAL HISTORY: The patient received an associate's degree. She is married and has two children. She does not smoke and she drinks alcohol rarely. | 0 |
12,905 | CHIEF COMPLAINT: Chest pain
PRESENT ILLNESS: 50 year old man with hypercholesterolemia, hypertension, cigarette smoking, FHx of early MI presented with CP to OSH; found to have inferior STEMI, was transferred to [**Hospital1 18**] for emergent cardiac catheterization. . Patient developed SSCP [**6-17**] while working on his motorcycle, assoc w/ diaphoresis and right arm numbness. His wife called EMS and he was brought to [**Hospital3 3583**] where he received NTG and ASA. He was found to have inferior ST elevations on EKG was started on Plavix, a Heparin gtt, and Integrillin gtt. . Next, patient was transferred to [**Hospital1 18**] for cath. Cardiac cath showed a RCA and LCX dz with 80% OM1 and 100% OM2 lesions. His OM2 was stented with a DES, resulting in resolution of his chest pain. He is now admitted to the CCU for monitoring. . Currently, he feels well w/ only mild lingering chest pressure. No chest pain, dyspnea, palpitations, abd pain, leg pain, or leg weakness or numbness.
MEDICAL HISTORY: - HTN - hyperlipidemia - depression
MEDICATION ON ADMISSION: - ASA 81mg qd - Lisinopril/HCTZ 10/12.5mg daily - Lipitor 10mg daily - Prozac 40mg/80mg alternating daily
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS: T , BP 120/77, HR 79, RR 12, O2 sat 99% RA Gen: healthy appearing man lying flat in bed, pleasant and conversational, NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear w/ MMM. Neck: Supple with no JVD. CV: reg s1/s2, no s3/s4/m/r Pulm: CTA b/l, no crackles or wheezes. Abd: obese, +BS, soft, NT. Left fem puncture site w/ no oozing, tenderness, or bruit. Ext: warm; 2+ DP b/l, no edema, no femoral bruits. Neuro: a/o x 3
FAMILY HISTORY: - CAD: father died of MI at 61, brother had MI at 40.
SOCIAL HISTORY: significant for tobacco use, > 20 pack-years, currently [**1-10**] ppd. There is no history of alcohol abuse. No cocaine or IVDU. | 0 |
15,682 | CHIEF COMPLAINT: Shortness of breath, Dyspnea on exertion
PRESENT ILLNESS: This is a 63 yo male with cirrhotic liver disease, atrial fibrillation and known pericardial calcification/constriction referred for evaluation for pericardial stripping and possible Maze procedure. Denies orthopnea and PND. No history of chest pain. His shortness of breath does improve following paracentesis.
MEDICAL HISTORY: - Liver Cirrhosis, complicated by Ascites. Liver bx [**10-29**] showed chronic venous outflow obstruction/constrictive pericarditis. - Alcoholism, quit [**2187**] - Hypertension - Chronic Atrial Fibrillation - Chronic Venous Insufficiency - History of Gout(resolved when quit ETOH) - External Hemorrhoids Past Surgical History: - s/p Paracentesis on frequent basis, currently Q3-4 weeks - s/p Bilateral Inguinal Hernia - s/p Umbilical Hernia - Polypectomy(complicated by GI Bleed)
MEDICATION ON ADMISSION: Ciprofloxacin 250mg po daily since [**4-29**] Furosemide 20mg po TID Spironolactone 100mg po BID **Warfarin 7.5mg po daily** STOPPED [**2196-2-23**]
ALLERGIES: Penicillins
PHYSICAL EXAM: Pulse: 87 Resp: 20 O2 sat: 99% B/P Right: 115/81 Left: 115/84 Height:6'0" Weight:175 lbs
FAMILY HISTORY: Father died of liver disease at age 69. Mother died of stroke at age 83. No premature CAD.
SOCIAL HISTORY: Race: Caucasian Lives with: Alone in [**Location (un) 39908**]. Partner is [**Name2 (NI) **]. Occupation: Retired Machinist Tobacco: Denies ETOH: None since [**2187**]. History of heavy use. | 0 |
15,690 | CHIEF COMPLAINT: Intraoperative blood loss. I&D right hip THA
PRESENT ILLNESS: This 56 year male unilingual russian speaker w/ a hx of hep B/C, cirrhosis, hypersplenism and pancytopenia was taken to the OR today for complex revision total right hip replacement because of debilitating right hip pain. The surgery was intended to be exploratory to see if there were any loose parts from previous surgeries that might be causing pain and could be removed. The patient's hip was opened and no such loose parts were found. Orthopedics feels the patient is not a candidate for any further surgical intervention. The procedure could not be completed due to heavy bleeding from the surgical site in the context of platlets of 34 and an INR 1.6. He lost an estimated 4L of blood, but got most of this back as cell [**Doctor Last Name 10105**]. He was also transfused 3 units PRBC, 6 units FFP and 5 units of platlets. He remained hemodynamically stable throughout the OR and never became hypoxic. Vanc and ancef were given intra-op and a drain was placed in the operative site before closing the hip. Post-op, he is admitted to [**Hospital Unit Name 153**] for resuscitation and monitoring in the context of heavy bleeding intra-op. . On the floor, he is intubated and sedated w/ pressure wrappings over his right hip and a drain in place. He remained stable in the [**Hospital Unit Name 153**] and was tranferred to the general orthopedic floor. Remainder of his hospital stay was unremarkable. He progressed with PT and was discharged to home with services in stable condition.
MEDICAL HISTORY: -Motor vehicle accident: failed ORIF acetabulum in [**2160**] requiring complex right total hip replacement in [**2160**]. -Hep B serology pos, DNA neg -Hep C presumed [**1-5**] transfusion after MVA in [**2160**]. s/p 6mo Interferon and Ribavirin tx, but hep C recurred -Liver cirrhosis: followed by GI. no focal lesions on U/S in [**2168-6-2**] -Cholelithiasis, no acute cholecystitis -hypersplenism -pancytopenia: felt to be secondary to marrow suppression from HCV and hypersplenism, not considered a candidate for epo tx per report -s/p appendectomy -s/p right hand surgery -s/p left shoulder surgery
MEDICATION ON ADMISSION: Oxycodone-acetaminophen 5/325 mg 1 tab up to TID prn pain
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: On arrival to ICU, Vitals: stable General: Intubated and sedated HEENT: Sclera anicteric. Right eye with cataract. Left pupil 1mm Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, distended, bowel sounds present GU: foley draining clear fluid Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Skin over feet is darker brown bilaterally. incision C/D/I Skin: diffuse macular papular [**Country **] over shoulder, neck legs and abdomen. Chest is spared.
FAMILY HISTORY: Unknown
SOCIAL HISTORY: Originally from [**Country 532**]. - Tobacco: None per anesthesia report - Alcohol: None per anesthesia report - Illicits: None per anesthesia report | 0 |
81,644 | CHIEF COMPLAINT:
PRESENT ILLNESS: Mr. [**Known lastname **] is a 42 year old diabetic male with no known prior cardiac history, who was referred for an outpatient cardiac catheterization to further evaluate new onset exertional angina and a positive stress test. The patient reported that, over the past three to four weeks, he had been experiencing chest pressure while playing volleyball. He also noted once, while carrying boxes up and down the stairs, he had anginal type symptoms that relented after stopping exertion. He denied any chest discomfort at rest, however. The patient was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for a stress test on [**2132-10-22**]. He exercised for approximately five minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol and had 3 to [**Street Address(2) 45253**] depression and chest pain. His blood pressure dropped from 160 systolic to 100 systolic and was therefore referred for cardiac catheterization to further evaluate this. At the time of cardiac catheterization on [**2132-10-22**], the catheterization showed severe three vessel disease, including a totally occluded left anterior descending artery in a diabetic, with a normal left ventricular ejection fraction. The patient likely require revascularization versus percutaneous intervention given the fact that his left anterior descending artery, right coronary artery and left circumflex were all involved. With diabetes, his mortality benefit was much greater with coronary artery bypass grafting, particularly in the setting of three vessel disease and left internal mammary artery replacing his left anterior descending artery lesion would give him an excellent revascularization potential. The left main coronary artery was not obstructed. The left anterior descending artery was totally occluded proximally, filled back to the proximal left anterior descending artery via collaterals from the right coronary artery. The left circumflex was not obstructed. The obtuse marginal one had an 80% proximal stenosis, obtuse marginal two had an 80% mid-vessel stenosis and the right coronary artery had an 85% to 90% mid-vessel lesion. The right coronary artery filled with the left anterior descending artery back to its proximal aspect by right-to-left collaterals. The patient was therefore admitted on [**2132-10-23**] and was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**], who stated that the patient was an excellent candidate for coronary artery bypass grafting. The patient's preoperative hematocrit was 42.5, BUN and creatinine 15 and 1.2, and INR 0.76. His chest x-ray showed no acute cardiopulmonary disease. Electrocardiogram showed normal sinus rhythm, no Q waves, and no ST-T segment changes were noted at this time.
MEDICAL HISTORY: 1. Noninsulin dependent diabetes mellitus times three years. 2. Upper respiratory infection, being treated with Zithromax. 3. No history of hypertension or hypercholesterolemia, no tobacco use; positive family history for coronary artery disease, has a brother who died of congenital heart disease at age ten. 4. No history of transient ischemic attack, stroke, melena or gastrointestinal bleed.
MEDICATION ON ADMISSION: Aspirin 325 mg p.o.q.d., Glucophage 850 mg p.o.b.i.d., glyburide 2.5 mg p.o.q.d., Toprol XL 50 mg p.o.q.d., Imdur 30 mg p.o.q.d. and Z-Pack, day three of three, completed on day of admission.
ALLERGIES: The patient has no known drug allergies; no shellfish or dye allergy.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
77,861 | CHIEF COMPLAINT: Transferred from [**Hospital6 8283**] for respiratory failure
PRESENT ILLNESS: Pt is a 62 yo male with history of lung cancer (s/p RUL lobectomy), COPD O2 dependent (3 L), history of MRSA and psuedomonal PNA who is a transfer from [**Hospital3 **]. Per EMS notes, last night they were called to patient's house for difficulty breathing which had been ongoing for 45 minutes. He was found to be sitting up in bed in stridorous and diaphoretic. He was unable to speak; albuterol neb treatments were tried without much success. He was brought to [**Hospital6 **] where he was admitted to the ICU and started on BIPAP, IV solumedrol, and levaquin. He required increasing amounts of O2 on BIPAP and was tachypnic in the 30s. 7.30/45/63 on 60% BIPAP with O2 90%. Pt was intubated at 7:40 am on day of admission and transferred to [**Hospital1 **]. BP 219/90 per report, HR 90-136. Post-intubation he was give 8 mg IV dilaudid, 4 mg ativan, 150 mcg fentanyl, 2 mg versed, and nitropaste. Also received fentanyl in med flight though records unavailable now. Pt was hospitalized at [**Hospital6 **] [**Date range (1) 56565**] for shortness and breath and COPD exacerbation. He was given prednisone and levaquin. Most recent hospitalization at [**Hospital1 **] was in [**2181-12-20**] for when he had a pneumothorax from his severe emphysema. Prior to that, in [**2181-9-19**] patient was in the ICU at [**Hospital1 **] for MRSA and psedomonal pneumonia. The patient received linezolid for a 21 day course for MRSA PNA and cefepime for 21 day course for pseudomonas. Amikacin was added for synergy. This was all in the setting of a three week prior hospitalization for COPD/PNA with sputum growing MRSA and pseudomonas treated with bactrim and levaquin.
MEDICAL HISTORY: 1. Non-small cell lung cancer, s/p R upper lobectomy, partial R fifth rib resection c/b chronic pain. No chemo or radiation. 2. COPD w/ severely reduced DLCO, FEV1 42%, and FEV1/FVC ratio 59%; stage= moderate IIB 3. h/o MRSA and pseudomonas PNA 4 Ulcerative colitis - s/p multiple surgeries, most recently in late 80s. S/P total colectomy and ileostomy 5. Steroid induced hyperglycemia 6. PFO 7. h/o cardiomegaly 8. h/o depression 9. Spirometry [**7-/2181**] Actual Pred %Pred FVC 2.87 4.01 72 FEV1 1.21 2.86 42 MMF 0.70 2.87 24 FEV1/FVC 42 71 59 LUNG VOLUMES Actual Pred %Pred TLC 6.19 6.12 101 FRC 4.59 3.42 134 RV 4.09 2.12 193 VC 2.10 4.01 52 IC 1.60 2.70 59 ERV 0.50 1.31 38 RV/TLC 66 35 191 He Mix Time 0.00 DLCO Actual Pred %Pred DSB 6.62 25.62 26 VA(sb) 4.46 6.12 73 HB 12.70 DSB(HB) 7.02 25.62 27 DL/VA 1.58 4.19 38
MEDICATION ON ADMISSION: Medications at home (per [**Hospital6 56566**]): Neurontin 300 mg po tid Spiriva 1 puff qday Prednisone 10 mg po qday Paroxetine 20 mg po qday Oxycontin 20 mg po bid Medications on transfer to [**Hospital1 **] : Solumedrol 125 mg IV q 6 hours combivent nebs q4 hours Paroxetine 20 mg po qday Oxycontin 20 mg po bid Neurontin 300 mg po tid Levaquin 500 mg po IV qday Albuterol nebs q2 prn Ativan 1 mg IV qhs prn morphine 2 mg IV q2 prn Dilaudid 8 mg Iv x 1 am on admission versed 2 mg IV x 1 nitropaste 1 inch at 8:25 am morning of admission
ALLERGIES: Penicillins
PHYSICAL EXAM: Initial physical examination:
FAMILY HISTORY: F died of lung cancer; M died of Alzheimer's. Has 3 sisters, all older than him, healthy
SOCIAL HISTORY: Married, 2 daughters, lives on the [**Name (NI) **]. Not current smoker, quit in [**2177**] w/ dx of lung cancer, 40 pack-yr history. Occasional EtOH use. Worked as a paiting contractor, retired after lung cancer surgery. | 0 |
39,880 | CHIEF COMPLAINT: Left third toe ulcer cellulitis.
PRESENT ILLNESS: This 74 year-old male initially evaluated from [**8-31**] to [**2153-9-5**] for persistent cellulitis of the left third toe, which was refractory to a three week course of Amoxicillin. He was treated and evaluated accordingly. On [**9-3**] he underwent arteriogram, which showed superficial femoral artery disease with three vessel run off. Vein mappings were obtained. He had patent left cephalic, basilic and lesser saphenous. He also underwent a cardiac evaluation on [**9-4**]. His stress was negative for anginal symptoms or ischemic electrocardiogram changes. The dobutamine echocardiogram showed an ejection fraction of less then 15% with bilateral atrial enlargement and severe overall left systolic dysfunction. He has severe global hypokinesis. The right ventricle was mildly dilated with systolic function of the right ventricle depressed. He had MR 2+, TR 3+. There was slight improvement of the basilar wall with a dobutamine infusion. All other walls remained unchanged. There was no inducible ischemia. The patient was discharged to home and returns now for revascularization. There has been no interval changes since last seen. He denies any chest pain, paroxysmal nocturnal dyspnea, orthopnea. He does admit to leg cramps and calf cramps at one block and a history of myocardial infarction in the past without any symptoms at this time.
MEDICAL HISTORY: Coronary artery disease, myocardial infarction remote. Hypertension. Type 2 diabetes over twenty five years, Lyme disease, peripheral vascular disease, chronic renal insufficiency. He is blind in the left eye. Hyperlipidemia.
MEDICATION ON ADMISSION: Lasix 40 mg daily, Lanoxin 0.25 mg daily, aspirin 81 mg daily, Lipitor 10 mg at h.s., Neurontin 300 mg t.i.d., insulin 70/30 40 units q.a.m., and a regular insulin sliding scale at meals. Levofloxacin 250 mg q.d.
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: He is a smoker two pack per day times sixty six years. He is now down to four cigarettes per day and is still smoking. He denies alcohol use. | 0 |
90,236 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old female with coronary artery disease (status post ST-elevation myocardial infarction), congestive heart failure (with an ejection fraction of less than 20%), 4+ aortic regurgitation, and a moderate large pericardial effusion who presented with respiratory failure. The patient was in her usual state of health until one day prior to admission when she began experiencing chest pain and shortness of breath. The patient took 10 sublingual nitroglycerin tablets for chest pain. She went to [**Hospital6 4299**] where was intubated and started on intravenous nitroglycerin, heparin, and given Lasix and levofloxacin. A chest computed tomography was done to rule out dissection and was negative. The patient became hypotensive with nitroglycerin, so she was switched to nitroglycerin paste. her first set of cardiac enzymes was negative. An electrocardiogram revealed a left bundle-branch block (which was old). An arterial blood gas revealed a pH of 7.33, a PCO2 of 41, and a PO2 of 185 on an FIO2 of 1. A computed tomography scan showed bilateral pleural effusions with a pericardial effusion and a thoracic aortic aneurysm. The chest x-ray showed left lower lobe and left lingular collapse. The patient was transferred to [**Hospital1 188**] for a bronchoscopy. On arrival, the patient's vital signs were stable. A bronchoscopy was performed which showed moderate secretions in the posterior right lower lobe and a left upper and left lower lobe obstruction by a mucous plug. The mucous plug was aspirated, and a repeat chest film showed re-inflation of the lung. A bronchoalveolar lavage specimen showed 2+ polymorphonuclear lymphocytes and no organisms. The patient was initially hypertensive on admission. She was given fluids and Lopressor. She then experienced transient hypotension which led to an emergent echocardiogram which showed 4-chamber enlargement, severely depressed left ventricular function with an ejection fraction of 20%, a large pleural effusion, and a moderate pericardial effusion without echocardiogram evidence of tamponade. There was also severe aortic insufficiency, mild mitral regurgitation, and mild tricuspid regurgitation, with a dilated aortic root. The patient ruled in for a myocardial infarction by cardiac enzymes with a peak troponin of 0.83, and a heparin drip was started. The patient then developed hematuria, and as the troponin leak was thought to be due to demand ischemia the heparin was dropped. The patient's respiratory status improved, and the patient was extubated and transferred to the floor. The patient had been hypertensive and was treated with hydralazine. Initially, the patient's ACE inhibitor was held for acute renal failure.
MEDICAL HISTORY: 1. Coronary artery disease. 2. Congestive heart failure (with an ejection fraction of less than 20%). 3. Aortic regurgitation. 4. Thoracic aortic aneurysm. 5. Recurrent pneumonia. 6. Left bundle-branch block. 7. Pericardial effusion (since [**2185-9-27**]). 8. Left ventricular hypertrophy.
MEDICATION ON ADMISSION: (Medications at home included) 1. Lisinopril 5 mg by mouth once per day. 2. K-Dur 20 mEq by mouth every day. 3. Imdur 45 mg by mouth once per day. 4. Lasix 20 mg by mouth once per day. 5. Aspirin 81 mg by mouth once per day.
ALLERGIES: PENICILLIN.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
79,891 | CHIEF COMPLAINT: nausea, pain
PRESENT ILLNESS: HPI: 78yo woman with history of DM2, PMR on chronic steroids, and recent admission for urosepsis now presents with two days of minimal nausea and diffuse non-specific pain. She did not have any hematemesis, melena/hematochezia. She denied any specific abdominal pain, fever, chest pain, shortness of breath. She had no specific urinary complaints. . She was just discharged to [**Hospital3 537**] from [**Hospital1 18**] on [**9-26**] after a complicated hospital course with E. coli (pan-sensitive) sepsis, likely from urosepsis. She was initially treated with levo/flagyl, but changed to zosyn after there was concern for a reaction (wheezing, neck swelling) to levaquin. The plan was to complete a 3 week course of zosyn. Her hospital course was complicated by hypotension, likely shock liver, and development of a peri-hepatic hemorrhage with Hct dropping to 22 and requiring multiple PRBC transfusions. . In ED, initial vitals were 99.0, 93, 74/48, 15, and 97% on RA. She had an abdominal CT which demonstrated resolving peri-hepatic fluid and pneumobilia, and a RUQ US demonstrating no acute biliary pathology. UA was grossly positive for UTI. She had a RIJ sepsis line placed, and was given nearly 3L in NS boluses. IVF were running at 75cc/hr in ED. Her CVP upon transfer to MICU was [**3-15**]. She was also given Ceftriaxone 1g, Ceftazadime 1g, Vancomycin 1g, levaquin 500mg, and flagyl 500mg.
MEDICAL HISTORY: 1. PMR, on chronic steroids, has been on methotrexate in the past 2. Type 2 DM, on glucophage 3. EF 50% from cath [**2196**] (clean coronaries) 4. Osteoarthritis 5. DVT [**9-14**], rx w/coumadin which was stopped one month ago 6. UGI bleed 20 years ago [**2-12**] NSAIDs 7. Depression 8. Hx extrapulmonary Tb as a teenager 9. Hx gallstone pancreatitis [**9-14**] 10. Asthma 11. Recent urosepsis
MEDICATION ON ADMISSION: Meds: 1. Levothyroxine Sodium 125 mcg QD 2. Albuterol 90 mcg/Actuation Aerosol Q6 PRN 3. Pantoprazole 40 mg QD 4. Bisacodyl 10 mg PRN. 5. Metoprolol Tartrate 12.5 mg [**Hospital1 **] 6. Prednisone 35 mg Tablet QD 7. Nystatin 100,000 unit/mL Suspension QID 8. Albuterol Sulfate Q4H PRN 9. Acetaminophen 325 mg PO Q4-6H 10. Furosemide 40 mg QD 11. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Hospital1 **] 12. Piperacillin-Tazobactam Na 2.25 gm IV Q6H (also ? ceftriaxone, levaquin (started [**10-15**] and [**10-17**] at NH).
ALLERGIES: Iodine; Iodine Containing / Scopolamine / Levofloxacin
PHYSICAL EXAM: . Meds: 1. Levothyroxine Sodium 125 mcg QD 2. Albuterol 90 mcg/Actuation Aerosol Q6 PRN 3. Pantoprazole 40 mg QD 4. Bisacodyl 10 mg PRN. 5. Metoprolol Tartrate 12.5 mg [**Hospital1 **] 6. Prednisone 35 mg Tablet QD 7. Nystatin 100,000 unit/mL Suspension QID 8. Albuterol Sulfate Q4H PRN 9. Acetaminophen 325 mg PO Q4-6H 10. Furosemide 40 mg QD 11. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Hospital1 **] 12. Piperacillin-Tazobactam Na 2.25 gm IV Q6H (also ? ceftriaxone, levaquin (started [**10-15**] and [**10-17**] at NH). . Allergies: iodine/scopalamine/(? reaction to levaquin on last admission) . PE: Vitals: T 97.1 HR 84 BP 90/60 RR 18 99% on RA Gen: pleasant, cooperative HEENT: NCAT dry MM Neck: supple, no LAD, no thyromegaly Cor: RRR no m/r/g Pulm: course bilaterally Chest: left breast with ulcer in intertriginous region Abd: soft, obese, mildly distended no rebound/guarding, RUQ TTP
FAMILY HISTORY: F: died at age 89 from gastric CA. Also had HTN and gout. M: died at age 88 from a stroke. Also had DM, HTN, and arthritis. 4 siblings, all deceased: emphysema, breast CA, lymphoma, DM.
SOCIAL HISTORY: Currently living at [**Hospital3 2558**]. Never married. Has a niece who checks in on her frequently. Retired nurse. No tobacco or alcohol. | 0 |
65,594 | CHIEF COMPLAINT: respiratory distress, hypotension
PRESENT ILLNESS: Mr. [**Known lastname 39953**] is a 73 yoM on HD-anuric, h/o AFib not currently on coumadin (though is on at home), who is being transferred from the neurology service for respiratory distress and hypoxia. He was admitted on [**2191-8-12**] after a fall resulting in acute on chronic SDH on the left; his course is complicated by seizure and he has been started on fosphenytoin & phenytoin. This evening he was noted to be in acute respiratory distress with desats to the low to mid 90's on 3LNC (reportedly desatting to the mid 70's on room air; has had a variable O2 requirement since being admitted). His blood pressure dropped to the 70's systolic and was responsive to the 80's and then 100's after a 250 cc NS bolus. he was febrile to 101.9. The neurology and medicine MERIT teams were concerned for an aspiration event vs. volume overload vs. PE. CXR is c/w volume overload; however it is grossly unchanged from earlier films. His normal schedule is M-W-F though he did not get dialyzed on Friday [**8-19**] because he was having focal motor seizures. He was last dialyzed Saturday [**2191-8-20**] for a shorter cycle b/c of low blood flow from the HD catheter(per renal note). His mental status has been poor since being in the hospital. Of note, on arrival to MICU pt was being treated with vanco/gent for a possible line infection given recent fevers. Nothing has grown out of numerous blood cultures since [**2191-8-12**] yet he continues to spike. he was briefly in MICU green on [**8-17**] - [**8-18**] for fevers and hypotension to the 70's. Since arriving to the MICU satting in the upper 90's on NRB, code status was confirmed with his wife on the phone and he was intubated with vecuronium and etomidate. He is currently on AC 500x14 with PEEP 5 at 50% FiO2. Peri-intubation, MAP's dropped to the 50's and he was started on low dose levophed through his right PICC.
MEDICAL HISTORY: Atrial fibrillation on coumadin CHF-- no EF in our system CAD s/p CABG DM ESRD on HD Glaucoma Cataracts Asthma ? gout (per med list)
MEDICATION ON ADMISSION: Medications on transfer: Gentamicin 90 mg IV QHD-- since [**8-17**] Vancomycin 500 mg IV QHD-- since [**8-17**] Fosphenytoin 100 mg PE IV BID Fosphenytoin 200 mg PE IV QHS (Q8 hours) Phenytoin 1000 mg IV x 1 given this afternoon . Acetaminophen 650 mg PO Q6H:PRN SSI + Lantus 20 Qam, 10 QHS Citalopram 40 mg QD Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing Simvastatin 40 mg PO DAILY Allopurinol 100 mg PO BID Calcium Acetate [**2182**] mg PO TID W/MEALS Fish Oil (Omega 3) 1000 mg PO BID FoLIC Acid 1 mg PO DAILY Fluticasone Propionate NASAL 1 SPRY NU DAILY Cyanocobalamin 50 mcg PO DAILY Lorazepam 1-2 mg IV Q4H:PRN seizure > 5 minutes Gabapentin 100 mg PO BID Neomycin/Polymyxin/Dexameth Ophth Susp. 1 DROP LEFT EYE Q6H Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE [**Hospital1 **] Atropine Sulfate Ophth 1% 1 DROP LEFT EYE [**Hospital1 **] Timolol Maleate 0.25% 1 DROP RIGHT EYE [**Hospital1 **] Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
ALLERGIES: Hydromorphone / Metoclopramide
PHYSICAL EXAM: PHYSICAL EXAM UPON TRANSFER TO MICU: ==================================== Vitals T 99.9 BP 122/31 HR 79 RR 19 02sat 94%3L NC GENERAL: NAD, resp non-labored HEENT: Surgical pupils bilat NGT in place NECK: supple no JVD, LAD CARDIAC: reg rate nl S1S2 no m/r/g LUNGS: coarse bibasilar breath sounds scattered bilat rhonchi on anterior auscultation ABDOMEN: soft obese NTND normoactive BS EXT: warm, dry diminished distal pulses no c/c/e; R brachial PICC and L HD cath sites c/d/i no erythema, tenderness NEURO: Somnolent but arousable with eye-opening to verbal stimuli; nonverbal; wiggles L toes to command; R upper and lower extremity hemiparesis; toes mute
FAMILY HISTORY: Non-contributory
SOCIAL HISTORY: wife is HCP; no illicits including no tobacco | 0 |
69,918 | CHIEF COMPLAINT: SOB and cough
PRESENT ILLNESS: In brief, 77yo M w/ non-ischemia CMP, CHF (EF=15%, [**12-14**]), AF, DM, and CKD p/w intermittent SOB and exacerbation of non-productive cough. . He was discharged 2 days PTA for FTT to rehab. Pt admits to chronic intermittent non-productive cough, which has been exacerbated for last 2 days and now associated with increased SOB. Patient has a history of DOE, stable 1-pillow ONP, and no SOB lying on 2 pillow. . He has no CP, diaphoresis, palpitations. He denies F/C/S. No URI symptoms of sore-throat or nasal congestion. No hemoptysis. No abdominal pain/N/V/D, but complains of constipation on admission. No melena/BRBPR. No symptoms of GERD. Pt explains that he was unsatisfied with his experience at [**Last Name (un) 2299**] house, and requested return to the [**Hospital1 **] ED. . In the ED, his vitals were 97.7, HR68, BP92/63, RR26, 91% on RA. He spiked a fever of 101.4, demonstrated leukocytosis 12.5, elevated D-dimer, and RLL patchy opacity on CXR. .
MEDICAL HISTORY: Past Medical History: non ischemic restrictive cardiomyopathy EF 15% Afib Chronic Kidney Disease Pulmonary Hypertension Diabetes
MEDICATION ON ADMISSION: Amiodarone 200 mg PO DAILY Cholecalciferol 400 unit PO BID Levothyroxine 25 mcg PO DAILY Carvedilol 12.5 mg PO BID Lactulose 30ml PO q8hr PRN constipation Furosemide 160 mg PO BID Insulin sliding scale
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Vitals - T97, BP88/60, HR64, RR18, 99% on 2LO2, FS 126 General - sleeping comfortably, well appearing, able to finish full sentences, no labored breathing HEENT - EOMI, anicteric, OP wnl Neck - supple, JVD 7cm CVS - RRR, nl s1/s2, +s3 Lungs - mildly decreased breath sounds on right side, no egophony. Abdomen - soft, NT/ND, +bowel sounds, liver border 1cm below costal margin, no ascites Extremities - No C/C/E bilaterally, 2+ DP/PT Skin - no rashes or lesions noted. neuro - sleeping but arouseable, A+Ox3, CNII-XII grossly intact, marked decreased bulk with preseverd strength and tone. Sensation intact to light touch in periphery, no asterixis.
FAMILY HISTORY: Mother with congestive heart failure.
SOCIAL HISTORY: Patient currently at rehab s/p recent hospital admission. Usually lives with wife and daughter in [**Location (un) 686**]. Used to be the navy as a cook. Quit smoking 25 yrs ago. He drinks 4-5 beers per week. | 0 |
40,279 | CHIEF COMPLAINT: Headache, dizziness
PRESENT ILLNESS: 80 yo F h/o DM, HTN, ESRD on HD, seizures, h/o SDH and IPH in [**9-25**] who awoke from sleep with c/o headache this morning. Per her sister she was acting differently the night before, and this morning was confused prior to presentation to the ED. She was scheduled for a line placement today due to recently clotted [**Month/Year (2) 2286**] line. The patient and her sister deny any falls, syncope, photophobia, seizure, nausea or vomiting. No loss or change reported from pt in bowel or bladder habits. . In the ED: T 98.0 BP 186/80 HR 62 RR 126 100%@3L. Patient denied dizziness, reported only hunger and headache. Found to have hyperkalemia to 6.8 (already scheduled for [**Month/Year (2) 2286**] today) with peaked T waves on EKG. She was given Labetalol 10mg x1, Ca Gluconate, D50 with regular insulin, Kayexalate and Dilantin 1g IV load. K improved to 5.7. Head CT demonstrated subdural bleeds, full report below. Her mental status declined from full sentences to 1 word answers. Transferred to MICU with Neurosurg consulted. . On admission to the ICU, the patient is somnolent but responsive to questioning. She denies any active pain or discomfort at this time.
MEDICAL HISTORY: DM CAD PVD HTN (labile) h/o SDH and IPH in [**9-25**]. [**9-25**] s/p syncopal fall resulting in acute SDH and IPH (non surgical) Lower extremity edema/venous insufficiency Arthritis Lumbar disc disease Chronic kidney disease on HD, previously via left UE fistula but that was infected [**6-25**] at an area of repaired aneurysm so no via tunnelled HD cath Pulmonary hypertension Toxic Multinodular Goiter Anemia- low iron and EPO s/p Breast biopsy s/p Hysterectomy, s/p excision of a left ear mass s/p right toe amputation of digits one, two, three, four, and five
MEDICATION ON ADMISSION: ASA 81mg PO QDay Atorvastatin 10mg PO Qday Labetalol 200mg PO BID PRN Colace 100mg PO BID PRN Heparin 5000 units SC TID Lantus Methimazole 15mg PO Qday Phenytoin 125mg PO Q8 Starlix 60mg TID AC Sensipar 20mg PO Qday Fosrenol 2g TID QAC
ALLERGIES: Lisinopril / Verapamil / Beta-Adrenergic Agents
PHYSICAL EXAM: T 97.3 HR 51 BP 141/54 RR 17 100%@2L Sp02 Weight 74kg General: Somnolent, breathing comfortably on 2L HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink Neck: supple, trachea midline, no thyromegaly or masses, no LAD Cardiac: RRR, s1s2 normal, no m/r/g, no JVD Pulmonary: CTAB, [**Name (NI) **] cath in R anterior chest Abdomen: +BS, soft, nontender, nondistended, no HSM Extremities: warm, 1+ DP pulses, no edema Neuro: A&Ox3, speech limited to few word answers, CNII-XII intact, moves all extremities, Slow finger to nose, possible poor cooperation
FAMILY HISTORY: Diabetes
SOCIAL HISTORY: Lives with her sister. [**Name (NI) 1351**], denies tobacco/etoh or illicit drug use | 0 |
10,289 | CHIEF COMPLAINT: headache and eyelid droop
PRESENT ILLNESS: HPI: 78 eyar old female who has been otherwise healthy who developed an inability to open her right eye since wednesday. She also notes that she began experiencing blurry vision about a week and a half prior to the first noticing the ptosis. At the time of the onset of the right ptosis she was evaluated in the emergency department of an OSH where a Head CT was done as well as lab work and she was sent home. Last evening she developed a sharp shooting headache above her right orbit that radiated slightly posteriorly and has worsened overnight into today. She also noted that her ability to move her right eye to the left, up, and down was limited. She presented again to an OSH where MRI/A of the head and neck were done which showed an 8mm x 5mm Right PCOMM aneurysm. After the results of the imaging she was sent to [**Hospital1 18**] for further evalaution. She denies nausea, vomiting, dizziness, alteration in bowel or bladder, sensation deficits.
MEDICAL HISTORY: DVT's 20 years ago, Uterine tumor 15 years ago
MEDICATION ON ADMISSION: lisinopril 40mg asa 81mg ? statin (pt doesnt know which one) something for gerd
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: O: T:98.6 BP: 163/61 HR:61 R:18 O2Sats:100% Gen: WD/WN, comfortable, NAD. HEENT: NCAT Pupils: Right ptosis, right pupil 5mm and NR L pupil [**1-17**] EOMs: no up or leftward gaze with Right eye, limited downgaze with right eye, full left gaze. left pupils EOM's full Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors.
FAMILY HISTORY: non-contributory
SOCIAL HISTORY: Lives with husband, + tobacco, occasional etoh | 0 |
65,773 | CHIEF COMPLAINT: Sudden onset L facial droop, L 1 and [**12-23**] syndrome.
PRESENT ILLNESS: History obtained from pt's daughter: 42yo RH woman originally from [**Country 7192**] w HO seizures x 18years ([**12-23**]/months usually around the time of her periods with GTCs) had a another seizure last night around 7pm. This was her first this month, and she just had her period recently, according to her daughter. She was stiff in all her extremities and became confused and "out of it" for a short while, and as usual, she complained of some HA. She was "OK" afterwards and there is little history about her condition afterwards, but according to the daughter, her mom was not having any problems with her facial asymetry etc. However, her dad awakened the daughter at 7am saying that the mother is not feeling good. They saw facial asymetry with problems closing the eye on the left and with droop on the same side. Problems moving the eyes as well. She was brought to the ED.
MEDICAL HISTORY: Seizures
MEDICATION ON ADMISSION: Neurontin 300mg daily for seizures
ALLERGIES: Ivp Dye, Iodine Containing
PHYSICAL EXAM: Vitals: 98, 130s/60s, 60sreg, 100% on 2L
FAMILY HISTORY: No history of strokes
SOCIAL HISTORY: Lives w family. Has three kids. Smoking: none ETOH: none Illicit drugs: none Cannot write or read. | 0 |
14,962 | CHIEF COMPLAINT: Chest pain
PRESENT ILLNESS: Mrs. [**Known lastname **] is a 65-year-old woman with hypertension and history of chest pain for the past few months. She was investigated with stress exercise which was positive and she had angiogram which demonstrated single-vessel disease with an occluded left anterior descending artery as well as a left main stenosis. She is now admitted for surgical management.
MEDICAL HISTORY: HTN, Elevated lipids, OA, GERD, Asthma
MEDICATION ON ADMISSION: atenolol 100', Flonase 2", HCTZ 25', KCL 10', Simvastatin 40', Valsartan 160', ASA 81", MVI
ALLERGIES: Penicillins / Lisinopril
PHYSICAL EXAM: HR: 55 BP: 170/90 RR: 20 General: Well developed, no distress Eyes: PERRL, pink conjunctivae, no xanthelasma ENT: Normal dentition, MMM without pallor or cyanosis Neck: Normal carotid upstrokes, no carotid bruits, no jugular venous distention, no goiter Lungs: Clear, normal effort Heart: RRR, normal S1 and S2, no m/r/g, PMI normal, precordium quiet Abd: Soft, NTND, NABS, no organomegaly, normal aorta without bruit Msk: Normal muscle strength and tone, normal gait and station, no scoliosis or kyphosis Ext: No c/c/e, normal femoral and pedal pulses Skin: No ulcers, xanthomas or skin changes due to arterial or venous insufficiency Neuro: A and O to self, place and time, appropriate mood and affect
FAMILY HISTORY: Sister and father both died of [**Name (NI) 5290**] in their early 60's.
SOCIAL HISTORY: Retired and lives with husband. [**Name (NI) 4084**] smoked and drinks 1 glass of wine daily. | 0 |
86,491 | CHIEF COMPLAINT: elevated blood pressures
PRESENT ILLNESS: Mrs [**Known lastname 48716**] is a 41 y/o G7P0151 at 32w4d with IVF mono/di twins with [**Last Name (un) **] [**2118-8-26**]. Her medical history is significant for paroxysmal nocturnal hemaglobinuria and presents for admission because she is actively hemolyzing and has been having continued elevated blood pressures. She denies any headaches, visual changes or RUQ pain. She denies leaking of fluid, vaginal bleeding, contractions. Active fetal movement.
MEDICAL HISTORY: PRENATAL COURSE: (1)Dating: [**Last Name (un) **] [**2118-8-26**] by IVF dating (2)Labs: A+/Ab-/RPRNR/RI/HbsAg-/GBSunk (3)AMA Screening: nl FFS x2, nl ERA x 2 (4)Multiple ultrasounds: -[**2118-6-23**] EFW A 1468g (24%) B 1665g (44%) ([**Location (un) 805**]) -[**2118-7-4**] vtx/vtx, BPP [**8-24**] x 2, NST reactive x 2 -Betamethasone complete on [**6-30**] (5)hx paroxysmal nocturnal hemoglobinuria; hx PP hemorrhage; followed by Dr [**First Name (STitle) 1557**] (heme/onc) no hx of thromboembolism; on therapeutic Lovenox 80mg [**Hospital1 **]; c-hyst planned due to high risk of PP hemorrhage (6)hx preeclampsia: c/s at 33wks with 1st delivery due to pre-E -current pregnancy: elevated BP since 22wks, 24hr urine protein: 308 in [**Month (only) 958**]/07, 559mg on [**6-23**] (7)GDMA1: nl GLT at 24wks; elev BG discovered during routine labwork. s/p nutrition consult PAST OBSTETRIC HISTORY -([**2116**])c/s at 33wks for preeclampsia (no mag) - PP course complicated by bleeding requiring an embolization. Pt received 9 units of blood/blood components. She also developed CDiff requiring treatment. -SAB x 5 PAST GYNECOLOGIC HISTORY +abnl pap->s/p colpo, repeat wnl (last pap neg [**4-22**] Dr. [**Last Name (STitle) 656**] denies STDs PAST MEDICAL HISTORY -paroxysmal nocturnal hemoglobinuria; no hx thromboembolism -heart murmur (nl echo [**9-/2116**], EF >55%) PAST SURGICAL HISTORY -LTCS x 1 -LSC x 2 -D&C x 2
MEDICATION ON ADMISSION: Folic acid Lovenox 80mg [**Hospital1 **] Ferrex TID PNV
ALLERGIES: Sulfa (Sulfonamides)
PHYSICAL EXAM: VITALS: T 97.8, HR 90, RR 20, BP 142/93, 148/95 GENERAL: NAD HEART: RRR LUNGS: CTAB ABDOMEN: soft, gravid, NT, scattered ecchymoses on abdomen EXTREMITIES: 1+ LE edema FHR: A base 140, mod ltv, + accels, no decels B base 140, mod ltv, + accels, no decels TOCO: irregular SVE: deferred BPP [**8-24**] x 2 fluid wnl x 2
FAMILY HISTORY: no hx of PE, hypercoagulable state, or cancer
SOCIAL HISTORY: married; denies tobacco, alcohol, illicit drug use | 0 |
73,107 | CHIEF COMPLAINT: Abdominal Pain
PRESENT ILLNESS: [**Age over 90 **] y.o. female w/ PMH of AF w/ RVR, depression/anxiety, chronic C2 dens fracture, and chronic headaches who presents with abdominal distension and nausea vomiting from rehab. Per daughter pt was discharged from rehab four days ago and had severe constipation/obstipation during that stay. She was manually disimpacted prior to discharge. Since her return to rehab, however, pt has continued to take poor PO and has had some increasing abdominal distension. On the day of presenetation she received an enema but with no notable stool output, with nausea and vomiting. Daughter notes no fevers or chills, no respiratory symptoms.
MEDICAL HISTORY: -Hypertension -Depression -Hyponatremia -C2 Vertebral fracture -Osteoporosis -Migraine -AF not anticoagulated due to recurret falls -Gait disorder -Recurrent falls -Aspiration -Anxiety
MEDICATION ON ADMISSION: -oxycodone 5 mg PO every four hours PRN pain -Vitamin D 1,000 unit PO once a day. -Calcium 500 mg PO three times a day. -Ensure PO three times a day. -diltiazem HCl 30 mg PO QID -spirin 325 mg PO once a day. -acetaminophen 1000 mg PO three times a day. -Iprtroprium-Albuterol inhaled Q4-6 PRN SOB/wheezing -Guaifenesin 5 ml PO three times a day PRN cough -Docusate 100 mg PO twice a day. -senna 8.6 mg PO twice a day. -Lansoprazole 30 mg PO once a day. -metoprolol tartrate 100 mg PO twice a days (AM and PM) -metoprolol tartrate 50 mg PO Q afternoon -bisacodyl 10 mg rectal once a day PRN constipation -Nutritional supplement can PO three times a day. -trazodone 12.5 mg QHS PRN insomnia -Probiotics 250 mg PO twice a day
ALLERGIES: Clindamycin / Neomycin / Penicillins / triamterene-hydrochlorothiazid / Sulfa (Sulfonamide Antibiotics) / Ace Inhibitors
PHYSICAL EXAM:
FAMILY HISTORY: Daughter with grave's disease and grandson with tourette's and ocd.
SOCIAL HISTORY: The patient lives in [**Location 582**] with her husband of 69 years. Baseline MS [**First Name (Titles) **] [**Last Name (Titles) 84116**] to person and place, often forgetting names and others. - Tobacco: None - Alcohol: None - Illicits: History of barbituate abuse for >20 yrs | 1 |
39,180 | CHIEF COMPLAINT: dyspnea, cough
PRESENT ILLNESS: 66 yo male with history of hypertension, hyperlipidemia, congestive heart failure with EF 30-40% in [**2177**] by recent evaluation NYHA Class I, presents with acute onset dyspnea this AM. The patient reports the last few days he has awoken with some dyspnea at rest. This has resolved through the course of the day prior to today. Today, his symptoms progressed to being unable to speak in full sentences. He denies any associated chest pain, palpitations, diaphoresis, abd pain, or nausea. He does report over the same amount of time he was experiencing left leg pain, around his left knee which he attributed to gout. He reports bilateral leg swelling, to which he normally takes lasix PRN for. . In the ED, initial vitals were T 98.6 HR 78 BP 120/75 RR 35 O2Sat 94% on BiPAP. He had a chest x-ray showed marginal evidence of volume overload. He was given lasix 40mg IV X1 and levaquin 750mg IV X1. The patient has had 800ccs of urine output since the lasix. As he was grossly hypoxic, he was placed on BiPap with decreased work of breathing and increased O2 sat. Attempts to remove BiPap resulted in increased work of breathing and hypoxia down to 82% on RA. An ABG was sent off Bipap which showed marked hypoxia and non-anion gap metabolic acidosis and respiratory alkalosis. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope.
MEDICAL HISTORY: # EtOH cirrhosis - Abd U/S [**8-31**]: small liver, large amt of ascites - HAV(+). HBV(-). HCV(-). # Hypertension # Cardiomyopathy ([**8-31**] EF 35-40%) # h/o pancreatitis in 10/00 and [**2-/2172**] # h/o left thalamic cerebrovascular accident - no residual symptoms # EtOH abuse (currently 1 pint vodka/day; 40+ years) # Gout (not on PPx therapy) # Glucose Intolerance # s/p appy
MEDICATION ON ADMISSION: FOLIC ACID 1 mg [**Hospital1 **] FUROSEMIDE 40 mg PRN weight gain (takes 2 times per week) INDOMETHACIN 25 mg PRN gout METOPROLOL SUCCINATE 100 mg QD NIFEDIPINE 90 mg QD POTASSIUM CHLORIDE 20 mEq PRN when taking lasix SIMVASTATIN 20 mg QD VALSARTAN 80 mg [**Hospital1 **] ASPIRIN 325 mg QD CYANOCOBALAMIN 1,000 mcg QD MAGNESIUM OXIDE 400 mg TID
ALLERGIES: Lisinopril
PHYSICAL EXAM: GENERAL: Unable to speak in full sentences, on BiPAP. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Brother alive and well. Sister with breast cancer. Other brother died of unknown cause. Father with prostate cancer in his 70s. Mother alive and well.
SOCIAL HISTORY: Mr. [**Known lastname 25559**] lives with his girlfriend. [**Name (NI) **] is not currently working. -Tobacco history: 10 cigarettes per day. -ETOH: One half to one pint per day. -Illicit drugs: None | 0 |
39,203 | CHIEF COMPLAINT: Seizure, fevers
PRESENT ILLNESS: Mr. [**Known lastname **] is a 68 yo M w/PMHx x for seizures and mental retardation who was admitted from the ED as a transfer from an OSH after a 40 minute episode of status epilepticus. He was in his USOH at his nursing home today when he developed acute onset of seizures for approx 40 minutes prior to arrival of EMS. He was given Valium and versed and brought to [**Hospital 81472**], where he was intubated for airway protection, and given Dilantin, Ativan, and ceftriaxone and vancomycin. He was noted to have fevers to 105 at [**Hospital3 3583**]. From there, he was transferred to our ED, where he was extubated without difficulty. He was noted to have elevated cardiac enzymes, and a bedside echo was performed which showed no acute wall motion abnormalities. An LP was attempted and was unsuccessful. Patient is currently nonverbal. . ROS: Limited [**2-27**] patient currently nonverbal
MEDICAL HISTORY: Seizures Mental retardation DVT [**2-27**] PE CHF Depression Anxiety GERD
MEDICATION ON ADMISSION: Warfarin 6 mg qd Furosemide 60 mg qd Metolazone 2.5 mg qd Senna 2 tabs qd Phenytoin 200 mg [**Hospital1 **] Phenytoin 100 mg qd Fluoxetine 20 mg qd
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: On Presentation:
FAMILY HISTORY: NC
SOCIAL HISTORY: Lives at a nursing home. Family nearby, including brother. Sister in [**Name (NI) 108**]. No alcohol, drugs or smoking per family. | 0 |
8,433 | CHIEF COMPLAINT: SAH
PRESENT ILLNESS: Patient is an 80 yo F with hx of HTN/HL who presents with headache as transfer from OSH with SAH. Per patient, yesterday she had the abrupt onset of posterior/occipital HA at around 5pm that lasted 30 minutes and then resolved on own. No associated neurological changes with headache. Today, at around 4pm she had again the sudden onset of posterior/occipital HA with radiation down neck. This time the headache was much more severe and associated with a worsening of her baseline tinnitus. No N/V. No weakness or numbness sensation. No visual changes. She was taken to an OSH where a CT head was performed which showed a SAH in the basal cistern without hydrocephalus. She was transferred to [**Hospital1 18**] for Neurosurgical evaluation. Neuro exam at OSH on presentation intact with baseline L facial droop.
MEDICAL HISTORY: Past Medical History: hypertension hypercholesterolemia asthma on advair history of GI bleed felt likely [**1-4**] ischemic colitis per [**2126**] DC summary from [**Location (un) **] depression (on bupropion) T10 left discectomy on [**9-6**].
MEDICATION ON ADMISSION: Lipitor 10mg' Advair 250/50 1puff daily Senna 8.6mg [**Hospital1 **] Cartia XT 120mg q24 Calcium 500mg [**Hospital1 **] Cyclobenzaprine 10mg TID Colace 100mg po BID oxycodone 5mg po q4prn Aleve 220mg po PRN Gabapentin 400mg TID
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: On admission: PHYSICAL EXAM: GCS E: 4 V: 5 Motor 6. Hunt and [**Doctor Last Name 9381**] 2. [**Doctor Last Name 957**] 2 O: T: 97.4 BP: 152/71 HR: 92 R 15 O2Sats 98%2L Gen: WD/WN, comfortable, NAD. HEENT: Pupils: R surgical 4-3 L [**2-1**] EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E.
FAMILY HISTORY: Noncontributory
SOCIAL HISTORY: Lives at home alone without services. She has 5 children, several grandchildren and 8 great grandchildren. Retired behavioral optometry assistant. Never smoked. Rare etoh | 1 |
54,616 | CHIEF COMPLAINT: Right intracerebral hemorrhage
PRESENT ILLNESS: Patient is a 51 year-old right-handed man with a history of untreated HTN, hep A/B w/?cirrhosis, EtOH use who presented to OSH with large R frontal bleed. Per medical records, pt w/HA for several weeks, taking ASA. On [**2167-7-25**], awoke at 5am with severe HA not relieved by ASA and was brought to [**Hospital3 17162**] ED. There, he had left facial droop, slurred speech and altered mental status, and he was intubated for airway protection. SBP 150-170. Emergent head CT showed a large right frontal/basal ganglia bleed with extension into ventricles, and 3-5 mm of midline shift (per report) and he was transferred to [**Hospital1 18**] for further management. Started on dilantin and mannitol during med flight. On arrival in our ED, BP 176/66, peaked at 224/118, with low of 87/60. Neuro exam with sluggish pupils, 3.5mm on left, 2.5 mm on right, swollen left optic disc, left facial droop, right corneal reflex, moving right arm and leg spontaneously, extensor posturing to pain except localizes on right upper extremity. Labs with platelets of 88k and INR 1.6. [**Hospital1 **] pressure was controlled with nipride drip, given additional mannitol, sedated. Also given FFP and vitamin K for elevated INR, platelets for goal >100k. Had witnessed seizure activity in ED, and given additional dilantin, and then admitted to the neuro ICU.
MEDICAL HISTORY: 1. Untreated hypertension 2. Hypercholesterolemia 3. Hepatits A and B, with ?cirrhosis 4. Alcoholism
MEDICATION ON ADMISSION: Aspirin
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: T 95.6 HR 97 BP 173/88 RR 22 100% intubated General: intubated HEENT: no carotid bruit CV: rrr, no murmur Chest: clear to auscultation bilaterally ABD: soft, nontender eXt: no clubbing, cyanosis or edema Neuro intubated, grimaces to sternal rub Pupil 3.5 on left and 2.5 on right, left fundus showing swollen optic disc (unable to see right fundus). Sluggish pupil reaction to light bilaterally. No blink to visual threat bilaterally. No doll's but has right corneal reflex. Left facial droop. Positive gag. Moves right arm and leg spontaneously increase tone in lower extremities Localizes pain in right arm but extensor postures with rest of extremities.
FAMILY HISTORY: Non-contributory
SOCIAL HISTORY: Lives in [**Location (un) 5503**], works as technician. Smokes 1.5 packs per day, unknown how long. Drinks EtOH, unknown how much. Smokes marijuana, unknown how much. ?other drugs. | 1 |
40,719 | CHIEF COMPLAINT: hypotension, pulmonary emboli
PRESENT ILLNESS: Ms. [**Known lastname **] is a 63 year old female with past medical history significant for lung cancer with brain metastasis, HTN, hyperlipidemia, and history of PEs on home coumadin which was recently stopped for surgery and re-started 2 days ago who presents now to ED as transfer from her outpatient brain XRT appointment after notable hypotension today to 70s systolic range with mild dizziness and new complaints of shortness of breath and feeling "winded". She explains having fairly acute onset of her dyspnea while lying in bed at rest last night and shortness of breath has been constant over the past 24 hours. . Patient had been holding her home coumadin since recent neurosurgery last month (~[**6-14**]) and only restarted her coumadin without bridging 2 days ago. Of note, Ms. [**Known lastname **] was diagnosed with brain mets in [**Month (only) 116**] after presenting with unsteady balance, nausea and emesis. She is s/p open brain resection on [**2126-6-5**] with drain-placement and later CSF diversion procedure with placement of a VP shunt on [**2126-6-14**]. . In the ED, initial vital signs were: T97.4F, systolic 70/palp, HR 120, RR 23 and O2 sat 89% RA. She complained of shortness of breath but denied any dizziness, chest pains, headaches, nausea or emesis. Stated she did have some nausea earlier in morning at her brain XRT appointment. In ED, she was initially given IV order for IV vanco/zosyn which was soon stopped after CTA confirmed large saddle emboli as cause for her hypotension. She was fluid responsive and BPs came up to 109-130s/50-80s range after 2L IVFs. O2 sats were improved to 97-100% on 3-5L NC. CT head showed no intraparenchymal hemorrhages and revealed stable post-operative changes in posterior fossa. . Neurosurgery was consulted regarding her ability to safely start heparin gtt given her metastatic brain lesions and felt it was safe to start with plan for no bolus dose, PTT goal 40-60 and repeat head CT once she was in this PTT range. In ED, bedside TTE done and showed no overt effusions, no RV strain or collapse. EKG showed rate 118, sinus, TWIs in V1-V2 with deep T-waves and RV strain. . On arrival to the [**Hospital Unit Name 153**], initial vital signs were: afebrile, HR 117, BP 130/95, RR 21, 98% on 3L NC. She was fully alert and oriented and denied any pain. Complained of feeling occasionally winded even with nasal cannula in place. Appeared to be in no acute distress. Denies dizziness.
MEDICAL HISTORY: Parkinsons Disease -Stage IIIa (T1N2MO) right-sided lung CA s/p chemoradiation (CT-guided biopsy [**2125-1-8**] at [**Hospital 1474**] Hospital revealed adenocarcinoma. Flexible bronchoscopy and lymph node sampling here on [**2125-1-25**] showing metastatic carcinoma. Now s/p neoadjuvant cisplatin and etoposide, followed by chest irradiation. Mediastinoscopy on [**2126-5-2**] showed residual carcinoma. Now undergoing brain XRT for recent discovered brain mets to cerebellum. -resection, craniotomy & placement of a VP shunt [**5-/2126**] -PE on lovenox/coumadin -Hyperlipidemia -HTN
MEDICATION ON ADMISSION: Medications - Prescription CARBIDOPA-LEVODOPA [SINEMET] - 25-100 mg Tablet - 1 Tablet(s) by mouth three times a day DEXAMETHASONE - (Prescribed by Other Provider) - 2 mg Tablet - 1 Tablet(s) by mouth once a day FAMOTIDINE - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth twice a day METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth twice a day PRAMIPEXOLE [MIRAPEX] - (Dose adjustment - no new Rx) - 0.50 mg Tablet - 1 Tablet(s) by mouth three times daily SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth daily Medications - OTC ACETAMINOPHEN - (Prescribed by Other Provider) - 325 mg Tablet - 2 Tablet(s) by mouth every four (4) hours as needed DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth twice a day MULTIVITAMIN-MIN-CALCIUM-FA [VIACTIV MULTI-VITAMIN] - (Prescribed by Other Provider; OTC) - Dosage uncertain SODIUM CHLORIDE - (Prescribed by Other Provider) - 1 gram Tablet - 2 Tablet(s) by mouth three times a day
ALLERGIES: Levaquin / Quinolones
PHYSICAL EXAM: Vitals: afebrile, HR 117, BP 130/95, RR 21, 98% on 3L NC. General: Fully alert and oriented x 3, no acute distress, scalp with large healed scar and head half shaved. HEENT: PERRL, EOMI. Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP 9cm-10cm, no LAD Lungs: Slight bibasilar crackles, no wheezes, rhonchi CV: rapid rate but regular. S1 + loud S2 appreciated , no clear murmurs but limited due to rapid rate. No rubs. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: slightly cool, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs [**2-8**] grossly in tact. Sensation to light touch in tact. Toes downgoing bilaterally. Upper extremity strength 5/5. Slight tremor with upper ext.
FAMILY HISTORY: Mother died at age 85 from CHF. Sister is 53 years of age and she has breast cancer. She has 3 daughters and a son, and they are all healthy
SOCIAL HISTORY: Lives in [**Hospital1 1474**] with her husband. Retired manager from insurance business. Smoked 1PPW cigarettes x 22 years and quit in [**2100**]. No ETOH, no illicit drugs. Has 4 children. Walks with a walker at baseline now | 0 |
96,334 | CHIEF COMPLAINT: Dyspnea.
PRESENT ILLNESS: 28 y/o F w/ [**First Name3 (LF) **] syndrome (Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy, and Deafness) which is a progressive disease thought to be caused by mitochondrial dysfunction with aspects of demyelination, and as a result autonomic dysfunction w/ orthostatic hypotension, recurrent PNA and UTIs, and subacute on chronic worsening of respiratory status with associated fatigue and lethargy as well as OSA p/w 1 month of increasing fatigue, lethargy, and hypoxia. She was recently admitted to the [**Hospital Unit Name 153**] from [**Date range (1) 17815**] for similar presentation, reportedly discharged for the holidays. In the [**Hospital Unit Name 153**], she was treated w/ supplemental O2 to 4L NC and BIPAP was attempted, but pt could not tolerate [**3-14**] claustrophobia. She was discharged home on 4L O2 on [**2-2**] for the holidays. At that time neurology was consulted to comment on her progressively worsening respiratory status as well as difficulty speaking and swallowing which they did not feel was [**3-14**] GBS, MG or MS. This was thought to be [**3-14**] [**Month/Day (2) **]'s disorder as pts w/ this often develop severe polyneuropathy, and some may develop a progressive central hypoventilation syndrome. . She presents from home this time for worsening dyspnea w/ exertion and shortness of breath at rest sometimes desatting to the 90s while speaking, while on 4L NC. She reports fatigue w/ minimal exertion such as getting up to go to the bathroom. Reports her respiratory status is similar to her presentation in the [**Hospital Unit Name 153**] a few days ago. She denies fevers/chills/ nausea/vomiting or sick contacts. She reports her boyfriend, with whom she lives has been sick but had been on antibiotics. She went to see Dr [**Last Name (STitle) **] her pulmonologist in clinic today who recommended she come to the ED for evaluation. In the [**Name (NI) **] pt was tired but satting 95% on 4 L NC. Sleep medicine (Dr [**Last Name (STitle) 4507**] was consulted and they convinced pt to try BIPAP. . In the ED VS: T 98.2 HR 103 BP 125/72 RR 18 SaO2 95% 4L NC. CXR was done which was unchanged from prior. ABG was 7.35/ 68/ 102/ 39/ 8 (on 4L). NIF -80, Vital capacity 1.15 L. Labs were unremarkable. . On presentation to the ICU, pt reports fatigue due to poor sleep over the past few nights but her breathing has been the same as the last time she was in the ICU. . ROS: Positve per above. Denies CP, painful breathing, bleeding, bowel incotninence. Positive chronic bladder difficulty with voiding, requiring intermittent straight caths.
MEDICAL HISTORY: 1. [**Last Name (STitle) **] Syndrome (DIDMOAD; neurodegenerative d/o caused by mitochondrial defects and/or defects in myelination, the latter similar in effect to multiple sclerosis) .....a.Diabetes Mellitus type I (poorly controlled, on insulin) .....b.Diabetes Insipidus (on DDAVP) .....c.Optic atrophy .....d.High-frequency hearing loss. .....e.SVT, AVNRT (s/p ablation x2) .....f.Overflow incontinence (h/o self catheterization in past) 2. Orthostatic hypotension 3. Depression 4. Asthma (albuterol 1xyear; typically in setting of infection) 5. Obstructive sleep apnea 6. Recurrent UTIs - VRE ([**5-18**]), cipro/bactrim resistant E.coli ([**2107**]) 7. Recurrent pneumonias - ([**2109**], [**2111**] (requiring MICU stay, intubation and bronchoscopy x6)).
MEDICATION ON ADMISSION: 1. Albuterol Sulfate 90 mcg Inhaler 1-2 puffs q4-6 hours prn 2. Desmopressin 10 mcg/spray Aerosol, 2 Nasal spray [**Hospital1 **] 3. Levemir 100 unit/mL Solution Sig: Eighteen (18) units Subcutaneous twice a day. 4. Humalog 100 unit/mL Solution Sig: As directed units Subcutaneous four times a day: Please follow your sliding scale with meals and before bed. 5. Midodrine 5 mg Tablet 1 Tablet PO twice a day. 6. Multivitamin 1 Capsule PO once a day. 7. Drospirenone-Ethinyl Estradiol 3-0.03 mg 1 Tablet PO qday
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: GEN: Pleasant, NAD HEENT: Anicteric sclera. pink conjunctiva. mmm CV: Tachycardic. RESP: Decreased BS at bases. CTABL. ABD: Protuberant abdomen. NBS. Soft, NT. No organomegaly. EXT: LLE edema 1+ pitting edema >R (chronic) NEURO: AOx3. MAE.
FAMILY HISTORY: Father w/ narcolepsy. Mother with breast cancer. MGM w/ breast cancer and PGM w/ bladder cancer. PGF w/ bone cancer. Brother w/ [**Name2 (NI) **] syndrome.
SOCIAL HISTORY: Lives w/ her boyfriend and mom. Denies tobacco/drugs. EtOH drinks ~ 1-2 drinks/week. On disability. Able to perform her ADL's. Pt does not drive. | 0 |
48,438 | CHIEF COMPLAINT: fevers, multiple liver masses
PRESENT ILLNESS: 64M with a history of DM and HTN presents with a fever to 103.1 today. He states he has been having fevers intermittently over the past 3 weeks. They have been as high as 102.9 at home. Initially he and his wife attributed the fevers to his wife's illness 3 weeks ago. She states she had a "flu-like" illness that consisted of fevers, which resolved in 3 days. His fevers started soon after hers had resolved. They come intermittently, generally every 2-3 days. He went to his PCP to have this evaluated an a CT scan was performed, which showed multiple hypodensities within his liver. He was scheduled to see Dr. [**Last Name (STitle) **] in clinic but when his fever went to 103 he was advised to come to the Emergency Room for evaluation. His only complaints are of these fevers and some occasional nausea. He denies chills, emesis, abdominal pain, diarrhea, melena, dysuria, cough or sputum production. He denies any change in his bowel or bladder habits. He has no recent sick contacts or exposures. He had a colonoscopy 5 years ago and this was normal. He does report a 25lb weight loss over the past 10 months but he attributes this to dietary changes to help with diabetes control. . Review of systems: All 10 systems reviewed and negative except as noted above in the HPI.
MEDICAL HISTORY: PMH: HTN, DM, irritable bowel disease, cervical neck degeneration, chronic renal insufficiency, colonoscopy 5 years ago that was reportedly normal . PSH: lap chole .
MEDICATION ON ADMISSION: januvia 50mg daily, dicyclomine 10mg [**Hospital1 **], diovan 80mg daily, aspirin 81mg daily, benefiber 3 tablets daily, [**Doctor First Name 130**] 180mg daily
ALLERGIES: Sulfa (Sulfonamide Antibiotics)
PHYSICAL EXAM: 103.1, 134, 114/75, 22, 99% on room air Gen: no distress, diaphoretic, alert and oriented x 3 HEENT: PERLA, EOMI, anicteric Neck: no lymphadenopathy Chest: tachycardic, no murmur, lungs clear bilaterally Abdomen: soft, nontender, nondistended Rectal: normal tone, guaiac negative, no masses Ext: no edema, palpalble pulses Msk: no axillary or inguinal lymphadenopathy . Labs: - WBC 9.6, Hct 37.2, Plt 244, neutrophils 81, lymphs 11 - INR 1.2 - Na 131, K 4.8, Cl 98, HCO3 21, BUN 17, crea 1.6, glu 160 - ALT 81, AST 109, AP 172, TB 0.9 - Lipase 64 - Urinalysis negative . Imaging: - CT torso: 1. Innumerable hypodensities scattered throughout the liver, which are incompletely characterized. The differential diagnosis includes diffuse hepatic metastases. However, infection may have a similar appearance in some unusual cases such as neutropenic infection but there is no indication of abscess formation or biliary dilatation. The cause of likely malignant. 2. Mild splenomegaly. 3. Mild non-specific inflammatory stranding within the porta hepatis, with prominent periportal and peripancreatic lymph nodes. 4. Enlarged mediastinal and pericardial lymph nodes. .
FAMILY HISTORY: Father with a history of throat cancer
SOCIAL HISTORY: Nonsmoker, occasional ETOH. He is retired. Daughter is a PACU nurse here at [**Hospital1 18**]. | 0 |
86,590 | CHIEF COMPLAINT: Left leg weakness
PRESENT ILLNESS: HPI: 72 yo LHM with a prior SAH ([**2106**]), HTN, HLD, was out bowling today, as he does routinely on a Wednesday morning at 10 am, and while attempting to bend down and aim the ball, his left leg suddenly felt weak, numb, and heavy. He could not move his left leg, and the EMS took him to his nearest hospital. He was found to have a 3.4 x 2.4 cm new parenchymal hemorrhage at the right vertex in the parietal lobe with a small amount of blood tracking along the falx, with associated sulcal effacement without midline shift in his CT head.
MEDICAL HISTORY: Admitted to medicine with a SAH and stroke in [**2106**] (Small SAH over the right cerebral convexity with an evolving cortical infarct, 7 x 5 mm calcified mass in the R CP angle likely a meningioma) HTN HLD Polio with no residual paralysis
MEDICATION ON ADMISSION: Keppra [**Hospital1 **], dose unknown Lisinopril 5 mg (dose uncertain) Simvastatin
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: T-97 BP-189/110 HR-90 RR-16 O2Sat-99% Gen: Lying in bed, talking incessantly, R eye pterygium HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema
FAMILY HISTORY: Father : valve replacement Mother : died of pancreatic Ca.
SOCIAL HISTORY: Non-smoker, drinks 1-4 beer daily, lives with his wife. | 0 |
79,363 | CHIEF COMPLAINT: septic shock and respiratory failure
PRESENT ILLNESS: This is a 70 year old man who was discharged after a 3 month complicated hospitalization who presents with hypotension and respiratory failure. His recent medical problems started after he sustained a C7 vertebral fracture in [**12-21**]. He underwent a ORIF of C6-7 with posterior fusion, laminectomy, and iliac crest bone graft with wire placement in [**1-21**]. His course was complicated by a CSF leak which was repaired, but then followed by development of MRSA meningitis, cerebritis, sinusitis, and mastoiditis, PE/DVT, NSTEMI, acute interstitial nephritis and hypersensitivity desquamative dermatitis believed secondary to vancomycin or rifampin, respiratory failure from pneumonia, ICU neuropathy/myopathy, candidemia, and mental status changes. . He now presents following an episode of depressed mental status and hypotension at [**Hospital1 **]. Fluid was given and EMS was called. He had an ABG of 7.14/74/83 on unknown O2 settings and was found to be satting 91% on NRB mask and have systolic pressures from 40-60, so he was intubated and transported to [**Hospital1 18**]. His pressures stauyed in the 40-60's and he was started on levophed and fluids. With his hypotension, lactate of 3.8 and WBC 28 with 17% bands, a code sepsis was called. He was given 4L more fluid and a right IJ sepsis line was placed with CVP from [**5-23**]. Urine and blood cultures were drawn. He was transferred to the MICU.
MEDICAL HISTORY: 1. Diabetes Mellitus Type II Uncontrolled w/ Complications 2. Coronary Artery Disease s/p CABG x 3 3. Hypertension 4. Anxiety 5. Hypercholesterolemia 6. L3-L4 Surgery 7. BPH 8. Recent hospitalization notable for: Traumatic Comminuted C7 Verterbral Fracture [**2182-1-2**] ORIF/Laminectomy/Instrumentation/Posterior Fusion [**2182-1-23**] CSF Leak - Wound infection s/p drainage and dural repair [**2182-2-9**] Incision and drainage and hardware exchange [**2181-2-12**] MRSA Meningitis MRSA Pneumonia Left Heart Failure Non-ST Elevation Myocardial Infarction Left Occipital Stroke vs MRSA Cerebritis RLE Deep Venous Thrombosis Pulmonary Embolism Non-Sustained Ventricular Tachycardia Hypersensitivity Desquamative Dermatitis (Rifampin vs Vancomycin) Eosinophilia Hypoxic Respiratory Failure Septic vs. Anaphylactic Shock Delirium Cholestasis RUE Paresis Bilateral Lower Extremity Myopathy Dysphagia GI Bleed Nosocomial LLL Pneumonia Anemia - multifactorial: Illness, blood loss, CKD. Sacral and Heel Ulcers MRSA/VRE Colonization Candidemia decub ulcer Hep C RP bleed
MEDICATION ON ADMISSION: Acetaminophen 325 mg PO Q4-6H Aspirin 325 mg PO DAILY Nystatin 100,000 unit/g Cream Topical [**Hospital1 **] Zinc Oxide-Cod Liver Oil 40 % Ointment [**Hospital1 **] Mupirocin Calcium 2 % Cream Topical [**Hospital1 **] Albuterol Sulfate 0.083 % Solution Q2H as needed. Ipratropium Bromide 0.02 % Solution Inhalation Q6H (every 6 hours) as needed. Sodium Chloride [**12-17**] Sprays Nasal TID (3 times a day). Amlodipine 10 mg PO DAILY Hydrochlorothiazide 25 mg PO DAILY Lansoprazole 30 mg PO DAILY Metoprolol Tartrate 100 mg PO TID Folic Acid 1 mg PO DAILY Epoetin Alfa 10,000 unit/mL QMOWEFR (Monday -Wednesday-Friday). Doxycycline Hyclate 100 mg PO Q12H (every 12 hours). Captopril 25 mg PO TID Voriconazole 200 mg Intravenous Q12H through [**5-1**] Insulin sliding scale Heparin sliding scale coumadin since [**4-26**] linezolid started at [**Hospital1 **] [**5-1**]
ALLERGIES: Vancomycin / Rifampin
PHYSICAL EXAM: V: Tm 103.5 Tc 96 P70 BP 121/44 R12 100% CVP 6-8 Vent: AC 450x16 60% P5 PIP 21 Plat 16 Gen: intubated, sedated but appears comforatable HEENT: Pupils reactive bilaterally. ETT in place. Neck: no JVD Resp: clear bilaterally no rhonchi CV: RRR nl s1s2 + [**2-18**] WEM LUSB Abd: Soft NTND G tube in place Ext: warm, 1+ edema hands, no edema legs Back: stage 2 sacral decub ~8 cm Neuro: not following commands.
FAMILY HISTORY: NC
SOCIAL HISTORY: No smoking, etoh or IVDA. Was plumber. Lived with wife until [**Name (NI) 404**], but was at [**Hospital3 **] since C spine fusion, then [**Hospital1 18**], then [**Hospital1 **] | 0 |
97,444 | CHIEF COMPLAINT: unresponsiveness
PRESENT ILLNESS: Patient is a 65 year-old male with a history of COPD on 3L home O2 (not used in weeks), HCV, EtOH encephalopathy, neuropathy/chronic pain on methadone and oxycodone presenting from dentist's office after becoming unresponsive "with eyes open" during a dentist visit. He explains that this morning he woke up and felt nauseated which he often does. No vomiting. He didn't eat anything and he didn't take any of his home medications. He went on a short walk with his girlfriend and afterwards he left for a dentist appointment. Per report the girlfriend said that on the way to the dentist he was swerving into curbs while driving and was not paying attention to lights changing, and per ED had "slumped over" by the time of arrival. According to his dentist (who I spoke to in person) he seemed fine when he arrived and remained so until a few minutes after he gave him an arcticain (similar to lidocaine) shot in preparation for a cavity he was about to fill. No complications with the injection, no excessive bleeding, and he is confident he was in the gums. He was then suddenly nonresponsive but with his eyes wide open. His dentist called EMS who arrived within minutes. He was given .5 mg narcan while en route by EMS and started to wake up. On arrival to the ED, initial vitals were 98.5 100 103/66 16 99% 3L. He was apparently "sleeping with his eyes open" and snoring. He was given 2 x .4 mg narcan, became responsive afterwards. His labs were notable for a Cr of 1.9, up from a baseline of .6, Hct 33 with baseline around 33-35, mild AG acidosis, ALT/AST of 116/115 (last ALT 155 AST 99 on [**8-10**]). He received 2 L of fluid down in the ED. He had a Tmax of 100.2 On transfer, he is awake and alert. He is being admitted to the MICU for nursing concern.
MEDICAL HISTORY: COPD on 3L O2 at home Sepsis, unknown source, in [**Hospital1 112**] ICU 2y ago per family Chronic HCV: VL 3.6 million in [**2-6**], no fibrosis on biopsy in [**2116**] Hypercholesterolemia CAD, s/p MI in the setting of sepsis Depression w/ h/o suicide attempt by slashing wrists, years ago PTSD, improved 3 yrs after retirement Recurrent aspirations status post PEG in [**2122**], now removed Peripheral neuropathy Several traumatic head injuries with LOC during military work and firefighting. One fall down stairs with head strike and LOC in [**2123-4-30**]. Cervical spine fracture Moderate chronic cervical and lumbosacral polyradiculopathies on the right Prior alcohol abuse c/b Barrett's esophagus, gastritis, duodenitis, esophageal varices BPH OSA, not tolerant of CPAP
MEDICATION ON ADMISSION: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from webOMR. 1. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN as needed 2. Thiamine 100 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Fluoxetine 20 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. Gabapentin 600 mg PO BID 7. Methadone 5 mg PO TID please hold for RR<12 or oversedation 8. Mirtazapine 45 mg PO HS 9. Multivitamins 1 TAB PO DAILY 10. OxycoDONE (Immediate Release) 20 mg PO Q6H:PRN pain please hold for RR<12 or oversedation 11. Temazepam 30 mg PO HS:PRN insomnia please hold for RR<12 or oversedation 12. Thiamine 100 mg PO DAILY 13. Vitamin B Complex 1 CAP PO DAILY 14. Megace ES *NF* (megestrol) 625 mg/5 mL Oral [**Hospital1 **] 15. Loratadine *NF* 10 mg Oral daily
ALLERGIES: Lyrica
PHYSICAL EXAM: MICU ADMISSION EXAM: Vitals: T: 99.5 BP: 107/53 P: 102 R: 13 O2: 98/4L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: crackles right mid and lower zones, none appreciated on left, no wheeze Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: slight tremor, CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact
FAMILY HISTORY: His mother died at 72. He does not know his father's history. His sister is 64 and healthy. His daughter is 35 and healthy.
SOCIAL HISTORY: He is retired. He served in the Marines and saw combat in [**Country 3992**]. He lives alone. He has smoked for 40 years. He does not currently drink, but did so heavily in the past as outlined above. He has no history of drug use. Has a daughter who is close by. Retired 2 years ago. Smoked until 9 months ago. Drank EtOH but not regularly any more, last drink [**8-2**]. | 0 |
1,019 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 58 year-old female with a past medical history of type 1 diabetes mellitus, hypertension, hypercholesterolemia, end stage renal disease, coronary artery disease status post coronary artery bypass graft who presented from an outside hospital with hypotension likely secondary to sepsis. She was recently admitted at [**Hospital1 69**] from [**1-5**] to [**1-21**] when she had a coronary artery bypass graft done for three vessel disease with normal EF. Her postoperative course was complicated by respiratory failure requiring a tracheostomy, atrial fibrillation, renal failure, requiring hemodialysis and an embolic cerebrovascular accident diagnosed on the CT of the head as a right MCA inferior division stroke. The patient had a G tube placed and was discharged to [**Hospital3 7665**] [**Hospital3 417**] and as an outpatient she had been treated for an Enterobacter line infection with Vancomycin and Cefepime. Cultures seemed to have been negative. On the 29th the patient had fevers and hypotension. She was transferred from [**Hospital3 417**] to [**Hospital3 **]. A right femoral line was placed and cultures were done. The patient had ID consulted and they recommended discontinuing the dialysis line as they suspected that was the source of her sepsis and elevated white blood cell count. The patient was started on neo-synephrine for her hypotension and transferred to [**Hospital1 69**].
MEDICAL HISTORY: 1. Type 1 diabetes mellitus. 2. Hypertension. 3. Hypercholesterolemia. 4. End stage renal disease. 5. Transient ischemic attack eleven years ago. 6. C section. 7. History of AV fistula. 8. Coronary artery disease status post coronary artery bypass graft [**2119-1-2**]. 9. Cerebrovascular accident [**2119-1-6**]. 10. Tracheostomy [**2119-1-14**]. 11. G tube placed on [**2119-1-18**]. 12. Atrial fibrillation postop. 13. Legally blind.
MEDICATION ON ADMISSION:
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: She does not smoke, drink or use drugs. She lives at [**Hospital3 **]. | 0 |
61,267 | CHIEF COMPLAINT: 45M w/ no real h/o headaches c/o worse headache he has ever had after visiting his ophthalmologistwhen she gave him an IV injection of an unknown substance to test his vision. He states that HA was constant and localized to posterior area. He denied vision changes, dizziness, N/V, SOB,CP, weakness, numbness/tingling.
PRESENT ILLNESS: 45M w/ no real h/o headaches c/o worse headache he has ever had on Tuesday a few hours after visiting his ophthalmologist when she gave him an IV injection of an unknown substance to test his vision. He states that HA was constant and localized to posterior area. He denied vision changes, dizziness, N/V, SOB, CP, weakness, numbness/tingling. He also noted skin color changes at various areas over his arms including the injection site (yellowish). He did not have any relief with Advil that he took for one day. He went to [**Location (un) 745**] [**Hospital 3678**] Hospital earlier today where reportedly, the CT head was negative for bleed and his LP showed xanthochromia. He was transferred here for further neurosurgical evaluation.
MEDICAL HISTORY: hypercholesterolemia (diet-control), mild hypertension
MEDICATION ON ADMISSION: NONE
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: On admission:
FAMILY HISTORY: NC
SOCIAL HISTORY: Assistant manager at [**Company **]'s, smoked for 25 yrs,quit 2yrs ago, EtOH - 40oz beer per night, no IVDU | 0 |
86,176 | CHIEF COMPLAINT: Altered mental status
PRESENT ILLNESS: The patient is a 66 yo M with DM, HTN, HCV, PVD with chronic heel ulcers, h/o prostate cancer in [**2194**] s/p XRT and Lupron, chronic foley presents with altered mental status. The patient lives at a rehab and per report is AAOx3, ambulates and performs ADL's at baseline. He was found at his nursing home to be altered and minimally responsive. he was also noted to have a fever to 101. They drew labs and they were significant for leukocytosis of 14.2, Cr 1.6, Calcium 12.1 and glucose 270. He was sent to the ED for further evaluation. He has recently stopped his Linezolid/Zosyn after 13 weeks of treatment of .
MEDICAL HISTORY: Past Oncologic History: Diagnosed with prostate cancer in [**2194**]. He had a biopsy at that time with 12 out of 12 cores, positive for 4 +4 with no other evidence of metastatic disease other than some right pelvic iliac lymph nodes. He received neoadjuvant hormonal therapy and radiation. The external beam started on [**2195-10-27**] and lasted [**2196-2-4**] to a total of 7200 [**Doctor Last Name 352**]. He initiated therapy with Lupron in the setting of a PSA rise and he was recently admitted to the [**Hospital1 18**] on [**2199-7-15**] and discharged on [**2199-7-22**]. On [**2199-8-1**], he received a 3 month Lupron depot shot and the plan was to see his oncologist again in 3 months. . Other Past Medical History: DMII HTN HCV genotype Ib acquired via IV drug use in the 70s Rhabdomyolysis [**1-22**] statins in [**2195**] and immobility in [**2196**] PVD s/p chronic heel ulcerations hx of osteomyelitis hx of cocaine abuse PVD anxiety R tibioperoneal trunk angioplasty (04) R AKpop-PT bypass ([**8-24**], failed 06)non-reversed greater saphenous vein R PT angioplasty (06) Bilateral hallux arthroplasty Right fifth digit debridement (06) Exlap for auto accident Hx of tracheostomy TURP [**2197**] Incision and drainage left hallux Bilateral total knee replacements
MEDICATION ON ADMISSION: Lantus 25U qhs Oxycodone 100mg q12 Lopid 600mg [**Hospital1 **] Klonopin 1mg qhs colace 100mg [**Hospital1 **] [**Hospital1 10687**] [**Hospital1 **] Ferrous Sulfate 325mg [**Hospital1 **] Lisinopril 20mg daily Venlafaxine 150mg [**Hospital1 **] Neurontin 300mg qhs Doxazosin 8mg qhs ASA 81mg daily MV Thiamine 100mg daily HCTZ 25mg daily Folic Acid 1mg daily Famotidine 20mg daily Percocet 2 tabs q6:prn Combivent QID Colace [**Hospital1 **] Tylenol 325mg q6 MOM Lactulose 30ml prn
ALLERGIES: Simvastatin / Nitrofurantoin
PHYSICAL EXAM: VS: afebrile, 156/80 GEN: Alert, oriented to place, disoriented to time, mildly agitated HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. Cards: RRR S1/S2 normal. no murmurs/gallops/rubs. Pulm: inspiratory wheeze on right, mild expiratory wheeze, no crackles Abd: soft, distended, NT, +BS. no rebound/guarding. neg HSM. neg [**Doctor Last Name 515**] sign. Extremities: wwp, no edema Skin: no rashes or bruising Neuro/Psych: CNs II-XII grossly intact, able to move all extremities, followed simple commands.
FAMILY HISTORY: Diabetes in both mother and father
SOCIAL HISTORY: Smokes half pack per day; does not drink any alcohol. Currently living in a nursing home, previous history of cocaine abuse. | 1 |
48,227 | CHIEF COMPLAINT: right groin wound infection
PRESENT ILLNESS: The patient [**Known lastname **] is a 36 year-old gentleman with HIV with a CD4 count of 550 who presented to the [**Hospital1 1170**] emergency room with a two to three day history of right thigh pain that started on the inner aspect of his thigh. The pain became increasingly more severe and erythema began to spread. On presentation in the emergency room the patient was profoundly tachycardic with significant amounts of cellulitis without crepitance in his right thigh. There was an area of prominence near his perineum which was concerning. However, there was no evidence of any gas within the tissue. The area did not appear to involve the rectum. The patient was treated aggressively with intravenous fluid hydration, intravenous antibiotics and the patient was observed to see if his cellulitis would decrease. This was observed for several hours and the cellulitis indeed on the outer thigh did improve. However, upon serial examinations there appeared to be an area near his middle inner thigh close to the inguinal ligament that remained persistently erythematous and persistently tender. There was also new noted bogginess and edema of the tissue below it and because of this the patient was then taken emergently to the operating room for debridement to rule out a necrotizing soft tissue infection for Fournier's gangrene. The risks and benefits were discussed with the patient and with the significant other in detail including the possibility of death. The patient understood and wished to proceed.
MEDICAL HISTORY: HIV since [**2145**] migraine headaches
MEDICATION ON ADMISSION: Divalproex Sodium 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID (3 times a day). Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0*
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VITAL SIGNS: pulse 129 blood pressure 118/63,O2 sat on room air 97%. HEENT: Head, eyes, ears, nose, and throat are unremarkable. CHEST: Clear to percussion and auscultation. NECK: Supple. There is no thyromegaly or lymphadenopathy HEART: tachycardic without gallop, thrill, heave, murmur, or rub. ABDOMEN: soft, non-tender, non-distended EXTREMITIES: No cyanosis, clubbing, edema, or cord. GROIN: right-sided cellulitis from groin crease to mid-thigh. Mild erythema five inches in groin crease. Not fluctuant but indurated. The scrotum is not involved.
FAMILY HISTORY: non-contributory
SOCIAL HISTORY: non-contributory | 0 |
43,003 | CHIEF COMPLAINT: right hip pain, s/p fall
PRESENT ILLNESS: 81F with history of DMII, HTN, Hyperthyroidism and COPD who presents after a fall. The patient does not remember the details of fall, but patient told daughter that she tripped and fell at home into a plate of glass. She hit the right side of her forehead and hit her right elbow and hip. No post ictal state, no incontinece of bowel or bladder. She also denies lightheadedness, vision changes, chest pain, palpitations, shortness of breath, tongue biting, dizziness, nausea and vomiting. This event happened at approximately 10pm last night and she initially was taken to [**Hospital 1474**] Hospital where by report a head CT, c-spine films, CXR were negative. A hip CT was notable for a fracture of the superior ramus and acetabulum. She was transferred to [**Hospital1 18**] for management of her hip fracture. She was initially on the medicine service but was stable and was transferred to orthopedics for definitive operative management. Pre-operatively she was briefly hypotensive in the setting of narcotics for pain, and responded well to IVF and 3 units PRBCs. She underwent right acetabular ORIF on [**2140-6-19**] and [**2140-6-22**]. Post-operatively, her course was complicated by UTI s/p cipro, and CHF. She required a left CVL for access which was subsequently removed and was replaced by a left sided PICC line. On [**2140-6-25**] the patient desaturated to 75% on a 40% facemask and was transferred to the MICU for management. A CTA was negative for PE but showed multifocal opacities and pleural effusions, L>R. She was started on vanco/zosyn for ?aspiration PNA, was placed on BIPAP, and was diuresed ~3.4 liters with good response and quick clearing of CXR. She was called out of the MICU on [**2140-6-26**] to the medical service.
MEDICAL HISTORY: 1. DMII 2. HTN 3. Hyperthyroidism 4. Hypercholesterolemia 5. COPD
MEDICATION ON ADMISSION: Zoloft 100mg daily Lisinopril 20mg daily Isosorbide 30mg daily Actos 45mg daily Immodium prn Methimazole 10mg daily Mon-Sat ASA 81mg daily Metformin 500mg [**Hospital1 **] Lipitor 20mg qhs
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Admission Vitals: T 100.0 BP 119/53 HR 104 RR 18 87-88% RA -> 99%RA Gen: well-appearing elderly woman in NAD, sleepy HEENT: right forehead laceration, PERRL, EOMI Neck: supple, FROM Lung: +air movement bilaterally, no wheeze on anterior exam Cor: RRR, nml S1S2, 3/6 SEM over precordium radiating to carotids (per dtr, patient has h/o murmur) Abd: NABS soft NTND Ext: right elbow abrasion approx 4cm with reproducible mild tenderness, right hip pain, with good cap refill, 2+ DP/PT pulses bilaterally Neuro: alert and oriented, CN II-XII intact, muscle strength is [**5-19**] throughout though limited in RLE due to pain, sensation intact to LT throughout, DTR 2+ Transfer T 98 HR 70-80s BP 100-120s/30-40s RR 17-25 O2Sat 95% 2L NC I/O [**Telephone/Fax (1) 61569**] over 24 hours, [**Location 10226**]4345 GEN: NAD, reclining in bed, awake HEENT: MMM, OP clear, EOMI, CN 2-12 grossly intact CV: regular, loud diastolic murmur over precordium Lungs: coarse breath sounds anteriorly, crackles at right base otherwise clear Abd: soft, NTND, +bs Ext: small 4-5cm incision in suprapubic region, +staples, c/d/i; ~15cm incision over right hip c/d/i, healing well. 1+ pitting edema to shins and in hands. Sacral decub covered with dsg - did not take down. Neuro: alert and oriented to "[**Hospital3 **]" and "[**2140-6-15**]" pleasant. Moving all extremities, CN 2-12 grossly intact.
FAMILY HISTORY: NC
SOCIAL HISTORY: Pt lives with her daughter. [**Name (NI) **] term smoker, currently smoking ~1 ppd. Denies ETOH, IVDU. Ambuatory at home without walker/cane. | 0 |
70,942 | CHIEF COMPLAINT: fever, neck pain, headache
PRESENT ILLNESS: 57 yo F with metastatic non-small cell lung CA and leptomeningeal disease s/p ommaya placement on [**2196-11-11**] s/p cycle 6 Pemetrexed completed [**11-30**], admitted [**Date range (1) 38706**] for staph meningitis treated with ~10 days of vancomycin and removal of ommaya, presenting to clinic [**12-2**] with fever 101/neck pain/HA, admitted for suspected recurrent meningitis. . Since discharge, pt had been doing well although continued to have hip and leg pain. She was seen in clinic by heme-onc and rad onc this past week and was started on dexamathasone (took 1 dose) and radiation (1 dose). Last night, she developed fever to 101 and neck pain prompting her to return to the ED. In the ED, she was afebrile with a leukocytosis of WBC 13.3 (N87%). CXR and U/A unrevealing. LP was attempted but was unsuccessful. Neurosurgery consulted and recommend IR guided LP (the fluctuant mass over omaya site cannot be used for CSF sampling). She was started on vanc, cefepime, amp. Patient has been alert and oriented throughout with morphine for pain control. . On arrival to the floor, she is comfortable and in NAD. She has some pain which she says responded to the morphine. VS: T 96.4, 140/80, HR 98, 95%RA.
MEDICAL HISTORY: Met. NSC Lung CA HL Depression, Anxiety migraines
MEDICATION ON ADMISSION: 1. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 2. oxycodone 5-10 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. zolpidem 5-10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. celexa 20 daily 10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 11. oxycontin 10 q8
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS: T 96.4, 140/80, HR 98, 95%RA. GEN: AOx3, NAD HEENT: PERRL. MMM. neck supple. no oral lesions, mild tenderness at back of neck Cards: RRR S1/S2 normal. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes Abd: soft, NT, +BS. no rebound/guarding. Extremities: warm, well perfused, no edema. Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. nl gait
FAMILY HISTORY: non-contributory
SOCIAL HISTORY: Divorced, currently in a relationship. Has 2 daughters and 3 grandchildren. Living w/ one of her daughters. They have been very supportive. | 0 |
87,085 | CHIEF COMPLAINT: Chest pain and rectal bleeding.
PRESENT ILLNESS: The patient is a [**Age over 90 **] year-old female with a past medical history significant for coronary artery disease status post non ST segment elevation myocardial infarction in [**2152-5-9**], which was medically managed. The patient presented to an outside hospital with rectal bleeding and chest pain on [**8-25**]. Baseline hematocrit is approximately 35%. Cardiac enzymes were negative. Rectal bleeding was stopped. She was treated with aspirin, iron and Metamucil. Colonoscopy done previously on [**2152-8-21**] showed diverticulosis and internal hemorrhoids. Diagnostic catheterization done on [**8-25**] at outside hospital showed three vessel coronary artery disease. The patient was transferred to [**Hospital1 69**] for intervention. In the catheterization laboratory the patient had an episode of chest pain, which was relieved with sublingual nitroglycerin with evidence of ST depressions on her electrocardiogram. Angiography showed diffuse disease of the right coronary artery and total occlusion of the mid right coronary artery and 90% stenosis of the left anterior descending coronary artery and discreet lesions in the obtuse marginal one. Her distal left anterior descending coronary artery demonstrated TIMI three flow without significant obstructive disease. Three overlapping stents were placed in the mid left anterior descending coronary artery with no residual stenosis. Obtuse marginal one had one stent placed with no residual stenosis and the right coronary artery lesion had evidence of collaterals, therefore no stent was placed. In the Coronary Care Unit the patient was somewhat somnolent, admitted to chest pain for the past three weeks prior to admission relieved with sublingual nitroglycerin. On her recent admission to the outside hospital for bleeding she states she was washing dishes and noted a pool of bright red blood on the floor. This was associated with nausea, chest pain 9 out of 10 nonradiating. She was medically managed at this time at the outside hospital and eventually transferred to [**Hospital1 69**]. Currently post catheterization the patient is not describing any further chest pain.
MEDICAL HISTORY: 1. Coronary artery disease as described above. 2. Congestive heart failure. 3. Osteoarthritis. 4. Chronic renal failure. 5. Hyperlipidemia. 6. Hypothyroidism. 7. History of anemia secondary to internal hemorrhoids.
MEDICATION ON ADMISSION: 1. Imdur 60. 2. Prinivil 20. 3. Metoprolol 12.5 b.i.d. 4. Lipitor 20. 5. Synthroid 100 micrograms. 6. Colace 100 b.i.d. 7. Aspirin.
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient lives at home with her 70 year-old son. [**Name (NI) **] tobacco. No alcohol. Uses a cane for walking. | 0 |
2,994 | CHIEF COMPLAINT: ABDOMINAL PAIN
PRESENT ILLNESS: This 63 yo female with a history of prior trauma presented with acute, sudden onset, intense pain in her epigastrium associated with nausea and vomiting. The pain was very severe. She had no diarrhea. She had no fever or chills. The pain was ongoing and continues at the time of this evaluation. It can be controlled with narcotic pain medications. . The patient has history of severe trauma in [**2129**] after being hit by a truck. She had multiple fractures that required surgical repair. She also required a hip and knee replacement. At the time of her initial trauma an IVC filter was placed prophylactic. She had a significant pelvic fracture putting her at high risk for DVT. However, she did well with no clots at that time. She has no previous history of clots. Recently she has been very physically active working out at a gym 3 times a week and swimming on weekends. She says she has been more fatigued recently.
MEDICAL HISTORY: Obesity Atrial Fibrilation Hypertension
MEDICATION ON ADMISSION: tegretol 100', lisinopril 40'
ALLERGIES: Percocet / Latex / Ciprofloxacin
PHYSICAL EXAM: At discharge: Vitals- T 98.4, HR 74, BP 100/56, RR 18, O2sat 98% RA Gen- NAD, alert Head and neck- AT, NC, soft, supple, no masses Heart- RRR, no murmurs Lungs- CTAB, no rhonchi, no crackles Abd- soft, ND, NT, + BS Ext- warm, well-perfused, no edema
FAMILY HISTORY: non contributory to this admission
SOCIAL HISTORY: social drinker, and denies tobacco | 0 |
22,641 | CHIEF COMPLAINT: Hematemesis and bright red blood per rectum
PRESENT ILLNESS: 78 yr old man with PMH sig for Left main CAD, COPD, HTN, hypercholesterolemia, admitted on [**2131-7-16**] with coffee-ground emesis, BRBPR, followed by weakness, lightheadedness, and CP. No LOC. Denies SOB/HA. Pt was recently discharged from [**Hospital1 18**] [**2131-7-12**] for chest pain. On that prior admission had r/o'd for MI; CP was reproducible with palpation.
MEDICAL HISTORY: 1. CAD (2 vessel dz, 70% occluded L main, occluded RCA)-refused CABG, EF 70% 2. HTN 3. COPD 4. NIDDM (not treated) 5. hypercholesterolemia 6. depression w/ h/o suicidal ideation ??????refuses tx 7. h/o bladder CA ??????99 not treated, Basal cell CA of nose s/p removal, Prostate CA s/p TURP '[**21**] 8. GERD 9. DJD with chronic low back pain
MEDICATION ON ADMISSION: 1. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO once a day. 2. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 3. Vioxx 25 mg po bid 4. Tylenol #3 i tab po tid 5. ASA po qd
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Done in ICU: Tc: 98.1 BP: 110/63 HR: 93 RR: 15 O2Sat. 100% 3L NC
FAMILY HISTORY: No CAD hx
SOCIAL HISTORY: 3 ppd tobacco hx x 60 yrs, quit ~decade ago. Denies EtOH use. Lives alone. Has daughter in [**Name (NI) 3844**]. | 0 |
54,880 | CHIEF COMPLAINT: L [**2-25**] rib fxs Right [**1-26**] rib fractures Open left supracondylar femur fracture Right distal tib/fib ankle fracture Right patellar fracture
PRESENT ILLNESS: 53 year old woman with a history seizure disorder s/p motor vehicle crash after a seizure. She was taken to [**Hospital 8641**] Hospital and found to have multiple injuries including a right patella fracture, R pilon fracture, L open intra-articular distal femur. Also with bilateral pneumothoraces, rib fractures, and pulmonary contusions. She was then transferred to the [**Hospital1 18**] for further evaluation and care.
MEDICAL HISTORY: Hypertension, seizures, hypothyroidism, rheumatoid arthritis
MEDICATION ON ADMISSION: Metoprolol 25mg [**Hospital1 **], celexa 40mg qd, levoxyl 75mcg qd, klonopin 2mg qd, methotrexate 2.5mg qd, folic acid 1mg qd
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Upon discharge Alert and oriented Cardiac: Regular rate rhythm Chest: Lungs clear Abdomen: Soft non-tender non-distended Extremities: BLE: L knee inicison clean and dry, RLE splint intact/knee incision intact. +sensation/movement, +pulses.
FAMILY HISTORY: Non-contributory
SOCIAL HISTORY: + tobacco, denies EtOH or illicits | 0 |
36,497 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 69 year old white female with complicated medical history including diabetes mellitus, peripheral vascular disease, coronary artery disease, hypertension, blindness, history of arterial thrombus versus embolus who was hospitalized repeatedly for Methicillin-resistant Staphylococcus aureus bacteremia and osteomyelitis infection of the right hip. The patient is status post multiple hip surgeries. Her previous cultures grew Methicillin-resistant Staphylococcus aureus, Vancomycin-resistant Enterococcus, MSFA, Pseudomonas Proteus. The patient was supposed to be on suppressive prophylactic Vancomycin which was stopped in [**2142-6-11**] while at her nursing home. The patient was to be restarted on the Vancomycin in early [**2142-7-12**] after a two week hiatus. The patient was admitted to [**Hospital6 2003**] for increased drainage from the left hip wound and fevers complicated by lowgrade fevers. The patient was restarted on Vancomycin and was taken to the Operating Room on [**2142-9-29**] for removal of the total hip on the left and drainage of the complex abscess. The patient was transferred to the Surgery Intensive Care Unit postoperatively. The patient was with Phenylephrine for a short period of time. The patient had decreased urine output during her Surgery Intensive Care Unit stay which improved with intravenous fluids. The hematocrit was found to be 25 and she was transfused for 2 units of packed red blood cells.
MEDICAL HISTORY: 1. Diabetes mellitus with triopathy. 2. Peripheral vascular disease, status post left femoral-popliteal. 3. Coronary artery disease/congestive heart failure. 4. Cerebrovascular accident. 5. Osteoarthritis. 6. Methicillin-resistant Staphylococcus aureus, positive left hip abscess. 7. Atrial fibrillation. 8. Depression. 9. History of upper extremity arterial thrombus. 10. Blindness secondary to diabetes mellitus.
MEDICATION ON ADMISSION: Hydromorphone 1 to 2 mg intravenously q. 6 hours prn, Ativan 0.5 mg q. 6 hours prn, Warfarin 2.5 mg q.d., Lovenox 30 mg b.i.d., regular insulin sliding scale, Vancomycin 1 gm q. 12 hours, Celexa 20 mg q.d. Morphine sustained release 30 mg q. 12 hours, Megestrol 400 mg b.i.d., Senna 1 tablet b.i.d., Dulcolax suppository, Metoprolol 12.5 mg b.i.d., Captopril 25 mg b.i.d., Folic acid 1 mg q.d., Multivitamin q.d., Aspirin 325 mg q.d., Protonix 40 mg q.d., Amiodarone 300 mg q.d.
ALLERGIES: Penicillin, Cephalosporins, Percocet, intravenous dye, Codeine, Betadine, Glucophage.
PHYSICAL EXAM:
FAMILY HISTORY: The patient's family history is noncontributory.
SOCIAL HISTORY: The patient is a former registered nurse. She has a supportive family who would like to the patient home. They are generally pleased with her current facility. | 1 |
25,989 | CHIEF COMPLAINT: unstable angina, CAD
PRESENT ILLNESS: Mr. [**Known lastname **] is a 68year old male with exertional angina x12 years, which is relieved with rest. He had a routine stress in [**2163-4-19**]; the ETT showed 3-4mm ST depression in inferior and lateral leads with moderated fixd inferior wall defect; EF was 49%. He was initially reluctant to undergo surgery but has had increasing amounts of chest pain episodes. Cardiac cath on [**5-15**] showed 60% proximal RCA, 90% mid RCA, 70% R-post-lat, 50%LM, 90% proximal LAD, 80% distal LAD, 80% proximal LCX, and 90% OM.
MEDICAL HISTORY: unstable angina CAD HTN hypercholesterolemia GERD
MEDICATION ON ADMISSION: Lopressor 50mg QID Norvasc 5mg daily Zocor 80mg daily ASA 325mg daily Lisinopril 20mg daily Rolaids
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: On Discharge: Temp 99.4, HR 79, BP 150/56, R20, 93%RA NAD RRR; incis: no SOI CTA-B s/nt/nd; +BS LE incis: c/d/i, no SOI
FAMILY HISTORY: Dad: died at age 41 of MI
SOCIAL HISTORY: retired lithographer <15 pack year history, quit 35 years ago 2drinks/day beer+wine lives with wife in [**Name (NI) 1411**], MA | 0 |
63,314 | CHIEF COMPLAINT: Tracheobroncheomalacia.
PRESENT ILLNESS: Mr. [**Known lastname **] is a 46yM who presents for evaluation of progressive SOB. He first noticed his SOB approximately 3 years ago, however it was minimal at that time. He reports that he was still able to perform all of his daily activities, work in contruction and interact with his children at that time but did notice some dyspnea with exertion. He was seen by a multitude of pulmonologists who performed a variety of PFT's and he was treated for asthma/COPD with inhalers. He reports that his symptoms continued to get worse while on this regimen. Approximately 3 months ago, his symptoms became much more severe and he can no longer walk up stairs, go to the gym or play with his children. He has had to stop working. . Mr [**Known lastname **] then came for follow up after having a stent trial for TBM. Stent was placed 5 days ago and he feels that "he was born again". He can walk on the street in the open air which he has not done in a while. His cough is better, in addition, he has much less secretions. No fevers, still has some sore throat. He is on prednisone 10mg daily, which he has been on for a while. Due to his great response to an airway stent trial. The thoracic surgery team planned to proceed with stent removal and posterior tracheobronchoplasty.
MEDICAL HISTORY: sleep apnea, COPD, thyroid nodules . lumbar disc herniation, R shoulder reconstruction
MEDICATION ON ADMISSION: prednisone 5mg daily albuterol 90mcg inhaler, 2 puffs qid prn alprazolam 2mg omeprazole 40mg daily Ambien 10mg qhs
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: ON ADMISSION: ------------- wt 219lb T 98 HR 90 BP 145/92 RR 18 Oxygen sat 99% RA GENERAL [x] All findings normal [ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings: HEENT [x] All findings normal [ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric [ ] OP/NP mucosa normal [ ] Tongue midline [ ] Palate symmetric [ ] Neck supple/NT/without mass [ ] Trachea midline [ ] Thyroid nl size/contour [ ] Abnormal findings: RESPIRATORY [ ] All findings normal [ ] CTA/P [ ] Excursion normal [ ] No fremitus [ ] No egophony [ ] No spine/CVAT [ ] Abnormal findings: coarse breath sounds bilaterally, + expiratory wheezing CARDIOVASCULAR [x] All findings normal [ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema [ ] Peripheral pulses nl [ ] No abd/carotid bruit [ ] Abnormal findings: GI [x] All findings normal [ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia [ ] Abnormal findings: GU [x] Deferred [ ] All findings normal [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] All findings normal [ ] Strength intact/symmetric [ ] Sensation intact/ symmetric [ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact [ ] Cranial nerves intact [ ] Abnormal findings: MS [x] All findings normal [ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl [ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl [ ] Nails nl [ ] Abnormal findings: LYMPH NODES [x] All findings normal [ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl [ ] Inguinal nl [ ] Abnormal findings: SKIN [x] All findings normal [ ] No rashes/lesions/ulcers [ ] No induration/nodules/tightening [ ] Abnormal findings: PSYCHIATRIC [x] All findings normal [ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect [ ] Abnormal findings:
FAMILY HISTORY: Grandparents: DM
SOCIAL HISTORY: Cigarettes: [x] ex-smoker, pack-yrs: 25, quit: [**2172**] ETOH: [x] No Drugs: denies Exposure: [x] Other: concrete dust (construction worker) Occupation: on disability Marital Status: [x] Married Lives: [x] w/ family | 0 |
91,117 | CHIEF COMPLAINT: hypotension, septic shock
PRESENT ILLNESS: 59M with MMP inlcuding CAD s/p MI, chronic systolic CHF (EF 30-35%), DM2 on insulin, HTN, and ESRD on HD, who was brought to the ED on [**2-3**] after being found lethargic at home by partner. [**Name (NI) **] his partners report, he had been progressively "sicker" over the last day, with more general malaise, weakness, and lethargy. He was dialyzed on Monday and was fine there, but complained of foot pain. He went out with his son-in-law today, but when he returned, he felt ill and was too weak to walk back in the house by himself. Took FSG, was 241. He had N/V x 2. His partner eventually called EMS for a change in mental status, decreased responsiveness. On EMS arrival he was noted to hypotensive and altered. By his partners report, no fevers but + shaking chills and weak, with diaphoresis. Did complain of being cold and some SOB but no CP or abdominal pain. Had a new cough productive of phlegm. Had diarrhea x 1. No sick contacts. . In ED, patient arrived in extremis, VS 97.1 88 50/palp 18 100% NRB. Was immediately intubated for altered mental status and airway protection. A CVL was placed in the RIJ, and vasopressors were started (dopamine and levophed). He received 2L IVF, and dopa was gradually weaned down, but remained on levophed at 0.12 mcg/min. Initial labs revealed venous lactate of 8.2 and non-hemolyzed K of 6.7. EKG was without peaked T waves, but pt received calcium and insulin. There were no acute ischemic EKG changes (has RBBB, old inferior Q waves). 1st set of CE's revealed flat CKs with baseline elevated troponin. CXR showed ? development of bilateral early infiltrates. He is anuric so no urine studies were able to be obtained. Serum tox was negative. Blood cultures were drawn and he was empirically covered broadly with vanco/zosyn/flagyl. CT head showed no ICH, and CT abdomen showed no acute intraabdominal process, but revealed LLL atelectasis vs PNA. He was then admitted to the ICU. . On arrival to the ICU the patient is intubated and sedated. Full ROS is unable to be obtained at this time
MEDICAL HISTORY: #. Type II diabetes mellitus - on insulin #. CAD s/p MI - cath in [**9-21**] with non-flow-limiting CAD #. CHF with EF 30-35% #. history of multiple admissions for chest pain with negative work up. Past chest pain syndromes have been in the setting of crack/ cocaine use. Most recently admitted [**Date range (1) 32600**] for the same. #. Hypertension #. Dyslipidemia #. h/o atrial tachycardia s/p EPS [**9-21**] and ablation x 2 for left sided, triggered (not re-entrant) Atachs #. Hisrory of gastrointestinal bleed: multiple previous workups have included at least six endoscopies, three colonoscopies, one enteroscopy, and a capsule camera study, and all have been negative, except for small AVM's in the duodenum s/p thermal therapy #. Chronic pancreatitis #. Hepatitis C #. GERD #. ESRD on [**Month/Year (2) 13241**] (Tues/Thurs/Sat, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] Dialysis, [**Location 1268**], [**Telephone/Fax (1) 69669**]) #. Gout, s/p arthroscopy with medial meniscectomy [**5-/2149**] #. Depression, s/p multiple hospitalizations due to SI #. Polysubstance abuse: crack cocaine, EtOH, tobacco #. Erectile dysfunction, s/p inflatable penile prosthesis [**5-/2148**]
MEDICATION ON ADMISSION: #. Labetalol 100 mg PO TID #. Amiodarone 200 PO DAILY #. Lisinopril 10 mg PO DAILY #. Atorvastatin 20 mg PO DAILY #. Cinacalcet 30 mg PO DAILY #. Pantoprazole 40 mg PO Q24H #. Sertraline 100 mg PO DAILY #. Multivitamin PO DAILY #. Gabapentin 300 mg PO Q48H #. DILT-XR 180 mg PO once a day. #. Dextromethorphan-Guaifenesin 5ML PO Q6H prn cough. #. Diphenhydramine HCl 25 mg PO Q6H. #. Insulin NPH: 15 units Subcutaneous [**Telephone/Fax (1) **], 10 units Subcutaneous qpm. #. Insulin Lispro sliding scale. #. Acetaminophen 325-650 mg Tablet PO Q4H
ALLERGIES: Morphine
PHYSICAL EXAM: Vitals - 95.0 74 124/63 20 100% on AC 500/14/5/100% GENERAL: intubated, sedated, does not respond to voice HEENT: AT/NC, EOMI, PERRLA(surgical pupil on L), muddy sclera, MMM NECK: RIJ in place, JVP not grossly elevated CARDIAC: RRR, no murmur/r/g. LUNG: anteriorly rhonchorous, clear posteriorly and at bases. No crackles ABDOMEN: soft, no rebound/guarding, + hepatomegaly 7cm below costal margin, no obvious fluid wave EXT: cool extremities, no cyanosis, clubbing or edema SKIN: no excoriations, no rashes. LLE with superficial knee abrasion
FAMILY HISTORY: Father with alcoholism. Mother with type 2 diabetes, renal failure, died at age 58. Son with diabetes. Cousin with [**Name2 (NI) 14165**] cell disease.
SOCIAL HISTORY: He lives with a female partner in [**Location (un) 686**], MA. 42 pack-year smoking history, recently up to 6 cigarettes per day. He has a history of alcohol abuse, with DTs and detoxification, with last drink on [**Holiday 1451**]. History of crack cocaine use. | 0 |
59,570 | CHIEF COMPLAINT: OSH MICU transfer
PRESENT ILLNESS: 59 F transfer from [**Hospital3 3583**] with partial SBO and hypotension. . On [**4-21**], she presented to [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **] with nausea, vomiting, and diarrhea x 2 days. That evening, she acutely became hypoxic. While undergoing a CT-PA to r/o PE, went into respiratory distress necessitating intubation and mechanical ventilation. She was fluid rescusitated and started on vasopressin and dopamine. Transferred to [**Hospital1 18**] for further management. . Laboratory data at [**Hospital1 46**] were significant for hyponatremia with Na 120, renal insufficiency with cr 2.2, Trop-I 0.28[nl 0-0.04, pos > 0.40], and CK 339. Of note, she did not have leukocytosis (WBC 6.9 with 81% polys). A CT scan (details below) was consistent with a partial SBO. . Of note, the patient had previously been hospitalized at [**Hospital1 3325**] in [**2140-12-9**] with cholecystitis. She had an NSTEMI during that admission and was transferred to [**Hospital 15629**] for catheterization which showed 3 vessel disease. She was initially planned to undergo CABG, but intubation was complicated by airway perforation, left pneumothorax, and cardiopulmonary arrest (hypoxia and bradycardia). CABG was cancelled. She subsequently came to [**Hospital1 18**] in [**2141-1-9**] for flexible bronchoscopy with debridement of necrotic tissue. A TTE at that time showed an overall normal EF with no wall motion abnormalities. Decision was made to pursue CABG as elective procedure at a later date.
MEDICAL HISTORY: 1. CAD with 3 vessel disease (70% LAD, 80% RCA, 80% Circ) 2. HTN 3. CHF 4. Obstructive sleep apnea 5. Morbid obesity 6. DM 7. Rheumatoid arthritis 8. Psoriasis 9. Hyperlipidemia 10. Cholelithiasis 11. Spinal stenosis 12. s/p airway perforation, left pneumothorax, and cardiopulmonary arrest ([**12-14**]) during intubation attempt (OSH)
MEDICATION ON ADMISSION: Home Medications: Labetalol 200 mg [**Hospital1 **] Lisinopril 40 mg qday Aspirin 325 mg Imdur 30 mg qday Atorvastatin 80 mg Albuterol Sulfate 0.083 % Solution q4 PRN Tiotropium Bromide 18 mcg Capsule DAILY Pantoprazole 40 mg q24 Ranitidine 150 [**Hospital1 **] Senna 8.6 mg Tablet Docusate Sodium 100 mg [**Hospital1 **] Zolpidem 5 mg HS PRN Duloxetine 40 mg EC qday Neurontin 300 mg [**Hospital1 **] Methocarbamol 750 tid Ibuprofen 800 tid Ativan 0.25 prn Mag Ox 200 mg [**Hospital1 **] Spiriva qd Triamcinalone 0.1% paste Niferex 150 qd HISS, Lantus 100 U qHS Enbrel 2x/week . Meds on Transfer from OSH: Insulin gtt Dopamine gtt Vasopressin gtt Propofol gtt
ALLERGIES: Codeine
PHYSICAL EXAM: ADMISSION EXAM Vitals - T 100.2, BP 136/65, HR 100, wt 119 kg SaO2 100% on AC 600x14, FiO2 0.6, PEEP 5 General - intubated & sedated, but easily arousable and responds simple questions by nodding HEENT - sclera anicteric, PERRL, EOMI, R IJ TLC C/D/I, JVP difficult to appreciate given body habitus CV - tachy, but regular, no mur appreciated Chest - ventilated breath sounds without crackles or wheezes Abdomen - obese, soft, diffusely tender throughout; no organomegaly; scab to R of umbilicus Neuro - responds to simple questions by nodding; moves extremities x 4
FAMILY HISTORY: The patient is adopted; FH unknown.
SOCIAL HISTORY: The patient lives alone, but her daughter ([**Name (NI) **]) lives nearby with her 3 children; they have a very close relationship. The patient has homemaker services. Fiance- Mark. 15 pack year smoking history, she quit 2 years ago. Denies alcohol use. | 0 |
4,034 | CHIEF COMPLAINT: Esophageal Adenocarcinoma
PRESENT ILLNESS: The patient is a 65-year-old gentleman with a T2, N0 cancer of the gastroesophageal junction. He is being admitted for esophageal resection.
MEDICAL HISTORY: Hypertension CVA without residual
MEDICATION ON ADMISSION: Lipitor 80 mg daily, ASA 325 mg daily, HCTZ 25 mg daily, lisinopril 5 mg daily, Ascorbic Acid 500 mg daily, MVI daily, Omega-3 1,000mg daily, Vitamin E 400 unit daily
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS: T 98.0 HR: 72 SR BP: 112/66 Sats: 97% RA General: 65 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR normal S1,S2 no murmur/gallop or rub Resp: crackles right 1/3 up, left crackles LLL GI: benign. J-tube site clean Incision: Right minimal invasive site clean well approximation Neuro: non-focal
FAMILY HISTORY: Significant for mother with heart problems, father with a stroke. Brother with cancer, which she believes is a melanoma.
SOCIAL HISTORY: He quit smoking 15 years ago. He was also a heavy alcohol user, but quit 25 years ago. He lives at home with his wife. [**Name (NI) **] states that he does some yard work, but is not that physically active. | 0 |
9,576 | CHIEF COMPLAINT: Angina
PRESENT ILLNESS: 62 year old gentleman with h/o esophageal adenocarcinoma s/p transhiatal esophagectomy in [**2-6**]. He has had recurrent angina which prompted an ETT which was positive. A cardiac cath was performed which showed severe three vessel disease. He was subsequently refered for surgical revascularization.
MEDICAL HISTORY: GERD, hypertension, and orally controlled diabetes, esophageal adenocarcinoma, Renal artery stenosis, neuropathy
MEDICATION ON ADMISSION: lopressor 200', metformin 500', nifediac 90', protonix 40", simvastatin 10', erythromycin 400"', imdur 30', lisinopril 10'
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS: 98.9, 135/87, 91SR, 18, 96%RA Gen: NAD, [**Male First Name (un) 4746**] Pulm: LCTAB CV: RRR, no murmur or rub abd: NABS, soft, non-tender, non-distended Ext: warm, trace edema Incisions: [**Doctor Last Name **]- c/d/i, no erythema or drainage, sternum stable, EVH- c/d/i, no erythema or drainage Neuro- non-focal
FAMILY HISTORY: Noncontributory
SOCIAL HISTORY: He works as an electrician and has a remote 20-pack-year smoking history. He quit drinking one year ago, but drank a 6-pack of beer per week prior to that. | 0 |
67,164 | CHIEF COMPLAINT: Mitral Regurgitation, coronary artery disease
PRESENT ILLNESS: This 55 year old black male was found to have a murmur on a routine check up. Further testing showed mitral regurgitation. He had an elective catheterization on [**2169-1-27**] that showed significant coronary disease. He was asymptomatic. He denies shortness of breath.
MEDICAL HISTORY: Mitral regurgitation Hyperlipidemia Emphysema coronary artery disease
MEDICATION ON ADMISSION: SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth at bedtime
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: PE: 97.3, 130/85, 132/84, 73, 16, 100% RA Ht: 6 ft 2 inches, Wt: 185lbs
FAMILY HISTORY: Non contributory
SOCIAL HISTORY: Patient is divorced and has four sons. [**Name (NI) **] is a program administrator Tobacco: denies ETOH: rarely Recreational drugs: Denies [**Name (NI) **] [**Name (NI) 23096**] (brother) cell # [**Telephone/Fax (1) 92161**] | 0 |
55,268 | CHIEF COMPLAINT: Transferred with STEMI
PRESENT ILLNESS: 84 year old male with PMH of CAD, hx MI ([**2134**]), DM, presented to OSH ED with N/V and SOB x a few days. EKG showed ST elevations in V2 with Qs in II and aVF and hyperacute T waves in V3 with ST depression in V5-6. Troponin was 15.65 and CK was 603 and MB was 123. He also had a transaminitis, a Cr of 1.8 and a U/A positive for Leuk Esterase and WBCs. The pt was given levoquin 500IV x 1, heparin gtt, integrillin, reglan. He was hypotensive with a SBP of 80-100 s/p 1500cc fluid bolus. He was then transferred to [**Hospital1 18**]. Here he underwent a cardiac catheterization where he was found to have a total occlusion of the mid LAD, subtotal occlusions of the LCx, and a diffusely calcified RCA. A balloon was passed and inflated in the mid LAD but unable to pass 80% stenosis distally. No stent placed secondary to ASA allergy. Hemodynamics demonstrated increased filling pressures with decreased CO/CI. The pt was started on dobutamine and IABP for cardiogenic shock.
MEDICAL HISTORY: Prostate CA (brachytherapy) NIDDM CAD s/p MI ([**2134**])
MEDICATION ON ADMISSION: Plavix, HCTZ, spironolactone 25, flomax, lasix, digoxin, pravachol
ALLERGIES: Aspirin / Penicillins / Zocor
PHYSICAL EXAM: 96, HR 99, BP 97/45, RR 31 100% O2 Gen: Pale, minimally responsive man in bed HEENT: Perrla, EOMI, MMM CV: RRR S1,S2 Holosystolic murmur, No R/G Lung: Rales Abd: Soft, NT, ND, BSNA Ext: No C/C/E Skin: No lesions Neuro: CN II-XII intact, A and O x 3
FAMILY HISTORY: Noncontributory
SOCIAL HISTORY: Married, HCP nephew and [**Name2 (NI) 802**] | 1 |
50,731 | CHIEF COMPLAINT: Fatigue/Dypsnea
PRESENT ILLNESS: 62 yo F h/o Crohn's Disease, HTN, who presents with complaints of SOB and fatigue since this morning. Patient reportedly awoke Sunday morning with fatigue. She complained of dyspnea on exertion on the walk from the parking lot to church. During church she felt cold and more fatigued. Due to her progressive symptoms, her husband brought her to the [**Name (NI) **] around 1500 today. The day prior to presentation, the patient and family were vacationing in [**Hospital1 789**] and per the family, the patient felt well. She complained only of constipation the day prior which resolved Saturday evening. . She had a recent hospitalization [**2-22**] in [**State 108**] for RLL PNA and anemia (Hct 23 and received 4 units prbcs). She completed a course of levofloxacin. She was also started on hydralazine at that time. She saw her PCP [**3-24**] and was reportedly feeling well. Her dypsnea complaints were improving and a CXR at that time showed a RLL opacity, but otherwise clear. Also started on atenolol on [**3-24**] due to palpitations the patient was experiencing. . In the ED, initial VS were: 99.6 77 127/98 16 95% RA. She immediately triggered on arrival due to marked nursing concern. On arrival she was initially A&Ox3, but shortly thereafter became more obtunded, BP trended down quickly to 60s/40s then lost pulses, received CPR x 1-2 min w/ 1 dose epi. Intubated. Given succinylcholine for intubation. R IJ line and left femoral A-line placed under sterile conditions. Started on on dopamine and levophed as well as a fentanyl/versed gtt. She received 4 liters NS. Also given 10 mg IV decadron. Reportedly dyssyncrochonus with the vent and biting tube with O2 sat high 80s and gave vecuronium with good effect. She was also ordered for levofloxacin but has not yet received. . Cr: 2.2 (1.6 on [**3-1**]) K: 6.4, Lactate: 3.1. ABG: 7.12/46/144. She was given calcium gluconate, insulin/d50, and bicarb and repeat K 4.9. EKG: SR 76, STD/TWI V4-6. Cardiology fellow performed a bedside echo with reportedly good pump function. . VS prior to transfer: 99 105/57 20 100% on AC 350 x 20, 10 PEEP and FiO2 100%.Currently on dopa at 20 and norepi at 1. Fentanyl at 25 and versed at 2. Notably spiked to 102 rectally. . The patient was quickly weaned off of pressors in the ICU. She was difficult to ventilate due to increased airway resistance requiring paralysis. The patient was continued on antibiotics, she was extubated, and then diuresed. The patient had some bursts of atrial fibrillation and she was started on a heparin gtt. She was stabilized and transfered to the floor.
MEDICAL HISTORY: Crohn's Disease with TI thickening, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 572**] Iron Deficiency Anemia Hypertension ?Asthma/Chronic Bronchitis OSA not on CPAP Depression Migraine Headaches
MEDICATION ON ADMISSION: per OMR Albuterol HFA 1-2 puffs q4-6 hours prn Atenolol 12.5 mg daily Diltiazem ER 300 mg daily Diphenoxylate atropine 2.5-0.025 1-2 tabs prn diarrhea Advair 250-50 1 puff [**Hospital1 **] Gabapentin 600 mg [**Hospital1 **] Hydralazine 10 mg TID (recently started in [**Month (only) 404**]) Lorazepam 0.5 mg daily prn anxiety Potassium chloride 40 meq [**Hospital1 **] Trazadone 25 mg qhs prn Effexor XR 225 mg daily Zomig 5 mg prn migraines Acetaminophen prn Calcium Carbonate B12 Colace prn Omega 3 Polysaccaride iron complex 150 mg daily Levofloxacin q 48 hours (reportedly on a long course per family, uncertain when this was stopped).
ALLERGIES: fentanyl
PHYSICAL EXAM: Vitals: T: BP:110/67 P: 70s R: 18 O2: General: Intubated/sedated HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, equal breath sounds bilaterally. ronchi in anterior lung fields bilaterally. Abdomen: soft, non-tender, distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2 + pulses in Radial and PT/DP Bilaterally. Neuro: moving all extremities and responding to yes/no questions on 25 of fentanyl and 2 of versed DISCHARGE EXAM Afebrile, BP 130s/70s, HR 80s, O2 94% RA Gen: NAD, AOx3 Heart: RRR, 2/6 systolic murmur at apex Lungs: scattered crackles but better aeration, no wheezes, no dyspnea or accessory muscle use Abd: soft, NT, ND Ext: trace peripheral edema Neuro: nonfocal
FAMILY HISTORY: daughter with crohn's disease
SOCIAL HISTORY: h/o remote tobacco in mid 20s, rare etoh use. | 0 |
53,595 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 74-year-old female with a history of hypertension, transferred from [**Location (un) **] [**Hospital1 **], where she was admitted with a sudden onset of drowsiness after an occipital nerve block for occipital neuralgia. Per the patient's neurologist's notes, she complained of feeling weak, and then became unresponsive and had some jerking eye movements to the right. Her oxygen saturations dropped, and the patient was subsequently intubated. The examination showed response to pain bilaterally, and bilateral plantar flexor response. Initial head CT was negative. The events occurred at 9 A.M., and the patient was transferred to [**Hospital1 188**] at approximately noon. She was initially admitted to the Medical Intensive Care Unit, and then subsequently transferred to the Surgical Intensive Care Unit.
MEDICAL HISTORY: As above. Previous occipital blocks have relieved occipital neuritis. Hypertension for 25 years, cervical spondylosis.
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 1 |
75,031 | CHIEF COMPLAINT: Chest Pain
PRESENT ILLNESS: 42 year old male with history of polysubstance abuse and PTSD, current smoker who presents with chest pain. He reports that the chest pain started this morning at 2am. It was located in the left anterior chest and radiated to his neck, not back. It was severe [**6-30**] and lasted for approximately an hour. Nothing seemed to make it better, no change with position or deep inspiration. He sat up and rested for a while and eventually it went away. He went to his PCP's office this morning and again had chest pain. It developed while he was on the subway. It was worse with walking around. He reported some associated nausea, SOB and dizziness. His PCP did an EKG and was concerned re: STE in V2 & V3; unfortunately, this EKG was not sent with the patient to the ED. He was given aspirin 325mg and NTG at PCP's office with no relief of CP per patient. The chest pain did not go away until he was in the ED and got some morphine. Of note, patient reports that his last cocaine use was 4 days prior to admission
MEDICAL HISTORY: Polysubstance abuse, most recent crack cocaine use was 1.5 months ago History of Depression and PTSD
MEDICATION ON ADMISSION: None
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: ADMISSION PHYSICAL EXAM VS: T= 97.5 BP= 124/39 HR= 53 RR= 16 O2 sat= 98% ra. GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
FAMILY HISTORY: non-contributory
SOCIAL HISTORY: works in landscaping lives with girlfriend [**Name (NI) 1139**] history: currently smokes [**11-22**] PPD ETOH: currently drinks 1 beer/day Illicit drugs: cocaine, last used 4 days ago. | 0 |
21,474 | CHIEF COMPLAINT: CC:[**CC Contact Info 80451**] Major Surgical or Invasive Procedure: none
PRESENT ILLNESS: HPI: 88F h/o HTN, s/p unwitnessed fall. Pt found down with large amount vomitus, around 4hours ago. Taken to [**Hospital6 **] and intubated. Found to have right 6mm fixed pupils and a large right IPH. Transferred to [**Hospital1 18**] for further eval.
MEDICAL HISTORY: PMHx: Stomach Ca, HTN
MEDICATION ON ADMISSION: unknown
ALLERGIES: No Drug Allergy Information on File
PHYSICAL EXAM: PHYSICAL EXAM: O: T: BP: 189/75 HR:65 R:16 O2Sats:100% CMV 0.99 470x17 Peep 5 Gen: unresponsive. Intubated. GCS3 HEENT: Pupils:R-5 nonreactive L-3 nonreactive Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: unresponsive to noxious stimuli Orientation: unable to obtain
FAMILY HISTORY: nc
SOCIAL HISTORY: Social Hx: no tobacco, etoh or alcohol | 1 |
86,130 | CHIEF COMPLAINT: Palpitations.
PRESENT ILLNESS: She is a 76-year-old female with a history of hypertrophic cardiomyopathy, status post alcohol, septal ablation in [**8-4**] at the [**Hospital1 18**]; history of MI and pulmonary hypertension, who presented to the [**Hospital6 10443**] on [**2102-1-27**] after noting left precordial chest pain associated with shortness of breath and palpitations, three days prior to admission to the outside hospital. There, the patient was found to be in new-onset atrial fibrillation with EKGs revealing LVH with strain pattern and ischemia could not be ruled out at the time. Given her history of atrial fibrillation, unstable angina, the patient was started on IV nitroglycerin, IV heparin and was rate controlled with beta blockers and remained chest pain free thereafter. The patient's cardiac enzymes revealed a CK of 277, MB of 2.0, troponin of 0.57. Chest x-ray was negative for CHF, positive for cardiomegaly. A V/Q scan was done, given her shortness of breath and was low probability for PE.
MEDICAL HISTORY: Significant for: 1. Hypertrophic cardiomyopathy, status post septal ablation in [**2100-8-2**] with alcohol. 2. History of hypertension. 3. History of hypercholesterolemia. 4. Status post vertebral/T4 osteoporosis. 5. History of COPD. 6. Asthma. 7. History of MI. 8. History of left hip dislocation. 9. History of pulmonary hypertension.
MEDICATION ON ADMISSION: Included: 1. Percocet, one to two tablets q.4h. p.r.n. 2. Zofran, 8 mg IV p.r.n. 3. Sublingual nitroglycerin p.r.n. 4. Reglan 5.0-10 mg IV q.4h. p.r.n. 5. MON p.r.n. 6. Colace 100 p.o. b.i.d. p.r.n. 7. Tylenol 325 one p.o. q.4h. p.r.n. 8. Ambien 5.0 mg one p.o. q.h.s. p.r.n. 9. Prednisone 50 mg one p.o. b.i.d. 10. Aspirin 160 mg one p.o. q.d. 11. Toprol XL 5.0 mg p.o. (question b.i.d. or q.d.) 12. Calcium 500 mg one p.o. b.i.d. 13. Coumadin 5.0 mg one p.o. q.h.s.
ALLERGIES: No known drug allergies
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
35,664 | CHIEF COMPLAINT: Lower extremity cellulitis.
PRESENT ILLNESS: Mr. [**Known lastname 85084**] is a 52-year-old man with history of cirrhosis and alcoholic hepatitis who was admitted to [**Hospital1 18**] on [**4-20**] due to LLE cellulitis. He was started on IV antibiotics at that time (eventually broadened to vanc/zosyn) and had his left foot I&D'd by podiatry. Wound cultures from left foot were positive for pansensitive klebsiella. [**Hospital **] hospital course was also complicated by SBP, for which he was given 5 days of treatment. Repeat diagnostic paracentesis were negative. On [**4-29**], patient began complaining of worsening abodminal pain and his mental status began to deteriorate; he also spiked a fever to 101. He subsequently had a bright red bowel movement. In the context of this clinical change, Mr. [**Known lastname 85084**] was transferred to the MICU for further care. In the ICU, patient had an EGD, which showed severe gastritis and enteropathy. He had one non-bleeding grade I varix; a flex sig showed bleeding hemorrhoids. CT scan on [**5-1**] showed pneumotosis intestinalis thus, patient was unable to receive lactulose. Mr. [**Known lastname 85084**] was eventually intubated due to worsening mental status and inability to protect airway. NG tube was placed for bowel decompression and TPN was started. ID suggested broad spectrum antibiotics including: dapto, flagyl, zosyn, and cefepime. Klebsiella grew in wound and in sputum, but all cultures are otherwise NGT. Antibiotics were tailored to just cefepime. On [**2189-5-5**], patient self-extubated. He was transferred back to [**Hospital Ward Name 121**] 10 on [**5-6**]. Upon examination in the MICU, patient is oriented only to self. He cannot accurately explain where he is, but does think it is the "17th" instead of the "16th" of [**Month (only) **].
MEDICAL HISTORY: 1) EtOH abuse 2) Cirrhosis (diagnosed in [**2185**]) EGD screening for varicies on [**2189-4-9**] showed portal hypertensive gastropathy without esophageal or gastric varicies 3) GERD 4) VRE screen positive 5) Psoriasis 6) Onychomycosis
MEDICATION ON ADMISSION: 1) Omeprazole 40 mg daily 2) Prednisone 20 mg daily w/ taper (starting [**4-17**], taper by 5mg q5 days) 3) Multivitamins 4) Rifaximin 400 mg tid 5) Folate/thiamine/multivitamin 6) Simethicone prn 7) Lactulose tapered to [**12-24**] bowel movements daily
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS: T 100.2, HR 112, BP 150/68, RR 17, O2 99% RA GEN: Inattentive, NAD HEENT: Sclera icteric, PERRL, NECK: Supple, JVP ~10 cm with respiratory variation PULM: Anterior exam with decreased breath sounds and crackles at bilateral bases CARD: Tachy, nl S1, nl S2, III/VI murmur across precordium ABD: BS+, distended, mildy tender epigastrum, tympanitic GU: Foley in place EXT: 2+ pitting edema of BLE above level of knees, L foot bandaged with strikethrough serosanguinous fluid on bandage, expanding erythema from L foot up L calf, bilateral DP and PT dopplerable, R foot with erythema (non-blanching) and a scaling rash on dorsum of foot NEURO: Oriented to location and clinic situation, though unable to correctly report date, asterixis present
FAMILY HISTORY: Father: pancreatic cancer - deceased. Sister: breast cancer Brother: bladder cancer
SOCIAL HISTORY: Living with mother and sister since hospitalization in [**Month (only) 116**]. TOBACCO: Quit [**2188-11-26**]. Prior 6 cigs/day x 25 years. EtOH: 1 pint - [**11-22**] qt per day of whisky x 20 years. Last drink per patient was [**3-/2189**] immediately prior to hospitalization. Denies alcohol use since hospitalization. DRUGS: Denies history of cocaine or IVDU HIV: Negative 2 years ago | 0 |
94,653 | CHIEF COMPLAINT: weakness
PRESENT ILLNESS: 70F with grade II ER+/Her2neu neg infiltrating intraductal carcinoma recently on Xeloda and Zometa s/p failure of Doxil [**12-26**] hypersensitivity, with questionable medical compliance who presents to [**Hospital1 18**]. She was transferred from an OSH after 2 episodes of weakness and not being able to get off the floor. the first instance happened on the day before admission where the patient slid from a sitting position to the floor and was unable to get off the floor until her daugher got home at 4:30 in the afternoon. She said that she was unable to move her legs but was able to move her arms. reports some slight dizziness. She also reports headache for the past 2 weeks. She denies any LOC, incontinence, seizure, syncope, CP, SOB, abdominal pain, vomiting, hemoptysis, hematochezia. After help from her daughters, she was able to ambulate with the assistance of a cane. There was no change in her ambulation and she reports that since her stroke she has had some residual L-sided weakness. On the morning of admission the patient reports that she was incontient at 0300 and felt dizzy when trying to change her undergarments and fell back to the bed and went to sleep. After arising, she was sitting on the bed getting dressed and again slipped to the floor from a seated position. Again, she felt weak and was unable to get up. Prior to this she had showered, had a headache and took some aspirin and ibuprofen with mild relief. She denies any LOC, seizure, chest pain, SOB, abdominal pain, or overt blood loss. She was helped up by her daughters and was subsequently brought to an OSH ED. Her vital signs were stable, labs were remarkable for an elevated alk phos. While in the ED she was given Decadron 10 IV and a Head CT was obtained. She was then transferred to [**Hospital1 18**] for further management.
MEDICAL HISTORY: Oncology History: 1. [**2195-3-24**] diagnosed with grade 2 infiltrating ductal carcinoma, lymphovascular invasion present, ER positive, HER2/neu negative. 2. [**2195-4-24**] bony metastasis noted on bone scan, started on Arimidex. 3. [**2196-6-23**] tumor markers rose changed to tamoxifen. 4. [**2197-8-23**] rising tumor markers, changed to Aromasin. 5. [**2197-11-23**] changed to Faslodex because of rise in tumor markers. 6. [**2198-7-25**] increasing disease on bone scan started on Zometa and Xeloda [**2198-9-24**]. 7. [**2200-5-24**] started on Doxil & Zometa. Patient received Doxil x 3 with discontinuation during the 3rd dose [**12-26**] (back pain & dizziness), placed back on Xeloda and Zometa. Most recent tumor markers ([**2200-8-15**]) CEA 570 & CA27.29 1076. Peak levels were CEA 802 ([**2200-7-15**]) CA27.29 1216 ([**2200-5-26**]). . . . Breast Cancer [**2194**])with mets to bone HTN NIDDM Stroke [**2185**] L partial mastectomy .
MEDICATION ON ADMISSION:
ALLERGIES: Doxil
PHYSICAL EXAM: Vitals - T:97.4 BP:166/74 HR:62 RR:14 02 sat:98% GENERAL: obese women, pleasant, jovial, laying bed, 2 daughters present SKIN: multiple sebhorrheic dermatoses on back, no other ulcerations, excoriation HEENT: AT/NC, EOMI, moist mucus membranes, no oral ulcers, left sided posterior cervical lymphadenopathy, supple [**Doctor Last Name **], no decreased ROM CARDIAC: RRR, SEM @ RUSB, S1/S2, no rubs or gallops LUNG: CTAB, no adventitious sounds ABDOMEN: obese, +BS, nondistended, nontender, no rebound/guarding M/S: 3/5 strength in RUE, [**12-29**] in LUE, [**1-26**] RLE, [**1-26**], LLE [**12-29**], moving all extremities well PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII grossly intact;
FAMILY HISTORY: Noncontributory
SOCIAL HISTORY: Denies any EtOH, tobacco, or illicit drug use. | 0 |
75,387 | CHIEF COMPLAINT: Increasing SOB and fatigue
PRESENT ILLNESS: Ms. [**Known lastname 9449**] is a lovely woman with severe AS and significant family history of CAD who has been followed with serial ECHO's since her cath in [**2170**]. The last was done at [**Hospital3 **] [**2174-10-21**] (reportedly showed severe AS which was a change from ECHO done [**5-/2174**] - no report is available). Her primary cardiologist Dr. [**Last Name (STitle) 39288**] has referred her for cardiac catheterization as part of her pre-op work-up for AVR. Currently, she states she has not had not any chest pain but she has had a significant increase in SOB and fatigue over the past two months. She is SOB after walking 40 feet, climbing one flight of stairs and carrying in empty trash cans from the curb, none of these activities bothered her over the summer. She denies chest pain and resting SOB. She has mild swelling in the ankles d/t a broken ankle a long time ago. Cardiac catheterization on [**10-31**] confirmed severe AS with mean gradient of 32 mmHg and [**Location (un) 109**] of 0.73 cm2. Selective coronary angiography showed a right dominant system. There was no true left main coronary artery as the left coronary ostium only supplied the left anterior descending artery. The left anterior descending artery had angiographic evidence of a 40% stenosis in the proximal vessel. The left circumflex artery arose from a separate ostium at the right aortic valve cusp. This ostium is separate from the RCA ostium, but connectsvertically to the ostium of the RCA. The left circumflex artery does not have angiographic evidence of coronary artery disease in the proximal segment. There is angiographic evidence of 40-50% in-stent restenosis in the mid-LCX. The right coronary artery had a proximal [**Doctor Last Name 45655**] crook with a 40% stenosis. There was no evidence of significant flow limiting stenosis in the mid or distal RCA. Left ventriculography revealed mildly depressed left ventricular systolic function. There was severe hypokinesis/akinesis of the lateral and inferiobasal walls. There was mild global hypokinesis elsewhere. Based on the above results, arrangements were made for cardiac surgical intervention.
MEDICAL HISTORY: Aortic stenosis, Coronary artery disease - s/p coronary stenting, Hypertension, High Cholesterol, Diabetes mellitus, Hypothyroidism, History of Kidney Stones, s/p TAH/BSO, Hard of Hearing
MEDICATION ON ADMISSION: Atenolol 25 qd, Lisinopril 40 qd, Lipitor 40 qd, Levoxyl 88mcg qd, Aspirin 325 qd, Metformin 1000 qam and 500 qpm
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Vitals: BP 150/70, HR 69, RR 14, SAT 96% on room air General: eldeerly female in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, transmitted murmur to carotid noted Heart: regular rate, normal s1s2, 3/6 systolic ejection murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal
FAMILY HISTORY: Significant for premature CAD. Father had MI at age 61. Older sister died of MI at age 56. [**Name (NI) **] sister died of [**University/College **] at age 62. Brothers had nonfatal MI at ages 62 and 36. One daughter had MI with stent at age 39.
SOCIAL HISTORY: Widowed two years ago. Now lives with her daughter. She has six children. | 0 |
25,663 | CHIEF COMPLAINT:
PRESENT ILLNESS:
MEDICAL HISTORY: Patient is a 28-year-old male who was an unrestrained driver with loss of consciousness prior to the crash secondary to a chlorine spill in the car. It was a low-speed MVA. There was significant front-end damage and the windshield was starred. He initially had some cardiac ectopy, but has been in sinus rhythm. Since then is complaining of some knee pain in the field.
MEDICATION ON ADMISSION:
ALLERGIES: He has no known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
41,098 | CHIEF COMPLAINT: Tremors, confusion
PRESENT ILLNESS: 81 yo F with CAD s/p past PCI, CKD, hypertension, recent diagnosis of heart failure, was discharged from the hospital on [**2157-3-11**] after a presentation for chest pain. She reports that she had 7 good days following discharge and then started feeling poorly on Thursday [**2157-3-17**]. Symptoms began with unsteadiness and tremulouness. She reports some mild confusion in last week. Patient also began to notice worsening LE edema as well as weight gain from 148 pounds at discharge on [**2157-3-11**] to 153 pounds on morning of presentation here. In the two days prior to admission, the patient developed a right-sided CP, non-radiating, which she reports was similar to the CP she had at last presentation. Of note, patient reports a week of constipation prior to having formed bowel movement two days prior to presentation as well as loose stool on morning prior to admission. She notes abdominal distension, some abdominal pain, loss of appetite, and early satiety. She has had poor PO intake in the last two weeks, but reports that she has been strictly adhering to a low sodium diet and has been drinking lots of water daily. In the ED, initial vital signs were T 97.5, HR 62, BP 168/60, RR 18, 95% RA. For her CP received nitro SL and morphine and became chest pain free. First set of cardiac enzymes was negative. CXR was taken with note of small bilateral pleural effusion, not significantly changed from CXR at prior admission on [**2157-3-9**]. Was identified as having hyponatremia with serum sodium of 112. For her hyponatremia, received a 250 mL NS bolus. Upon transfer to the floor, the patient was comfortable and chest pain free. Denied confusion, though reported some increased tremulousness.
MEDICAL HISTORY: 1. CAD s/p PCI to mid LAD, LCx, mid RCA c/b in stent restenosis of mid LAD rx'ed with POBA and brachytherapy. 2. Chronic diastolic heart failure 3. CRI - baseline Cr 1.8-2.3 4. Hypercholesterolemia. 5. Hypertension. 6. ? h/o Gallstones. 8. Basal cell CA to R eye 9. Osteoporosis 10. Spinal Stenosis
MEDICATION ON ADMISSION: MEDICATIONS AT HOME: (per recent discharge on [**2157-3-11**]) 1. Atorvastatin 80 mg PO daily 2. Clopidogrel 75 mg PO daily 3. Aspirin 325 mg daily 4. Tramadol 50 mg PO BID PRN pain 5. Omeprazole 20 mg PO daily 6. Calcium Citrate-Vitamin D3 315-200 mg-unit [**Unit Number **] tabs PO BID 7. Acetaminophen 325 mg 1-2 Tablets PO Q6H as needed 8. Amlodipine 10 mg PO daily (patient was not taking 15 mg as instructed in recent cardiology notes) 9. Metoprolol Tartrate 50 mg PO BID 10. Lasix 20 mg PO daily 11. NitroQuick 0.3 mg Tablet PRN 12. Trimethoprim-Sulfamethoxazole 800 mg-160 mg Tablet [**Hospital1 **] starting on [**2157-3-3**] for chronic sinusitis
ALLERGIES: Oxybutynin
PHYSICAL EXAM: VS: T: 95.9 BP: 154/56 HR: 69 RR: 16 O2sats: 94% 2L NC GEN: NAD HEENT: PERRL, EOMI, oral mucosa moist, oral pharynx without erythema NECK: Supple, unable to appreciate JVP elevation in short neck PULM: Rare bibasilar crackles, dullness to percussion at both lung bases CARD: Bradycardic, nl S1, nl S2, II/VI holosystolic murmur, no chest pain ellicited with palpation of chest wall ABD: BS+, soft, distended, tympanitic, diffusely tender, no rebound or guarding EXT: 3+ pitting edema of LE bilaterally with venous stasis changes and broken skin NEURO: Oriented to "[**Hospital3 **] Intensive Care", date, year, current president. Able to recite days of week backward with fluidity.
FAMILY HISTORY: The patient's parents both died of a myocardial infarctions in their 60s. The patient's only sibling, a sister, died of breast cancer.
SOCIAL HISTORY: The patient is a retired dental hygienist. Tobacco: Denies present or former use EtOH: One per day Illicits: Denies | 0 |
55,773 | CHIEF COMPLAINT: left arm numbness
PRESENT ILLNESS: 65M with history of Hypertension. He has developed left arm numbness with exertion over the previous months. This has progressed recently, coming on nocturnally and associated with shortness of breath. Stress test was markedly positive for ischemia and terminated at 3.5 minutes of the standard [**Doctor First Name **] Protocol. Cardiac cath revealed multi-vessel CAD, including 60% left main stenosis. He is referred for surgical myocardial revascularization.
MEDICAL HISTORY: Past Medical History: Coronary Artery Disease, Hypertension, Obesity, Hyperlipidemia
MEDICATION ON ADMISSION: Atenolol 50mg daily,ecASA81mg daily,Pravastitn 40mg daily
ALLERGIES: Percocet / Penicillins / adhesive tape
PHYSICAL EXAM: Physical Exam Pulse: Resp: O2 sat: 94% RA B/P Right:150/78 Left:154/84 Height: Weight:278 General:WDWN in NAD Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [] Full ROM [] 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 [] no Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: Left: DP Right:2 Left:2 PT [**Name (NI) 167**]:2 Left:2 Radial Right:2 Left: 2 Carotid Bruit Right:N Left:N
FAMILY HISTORY: Family History: No Premature coronary artery disease Father MI < 55 [] Mother < 65 []
SOCIAL HISTORY: Lives with: Wife (ill, requiring transfusions), mother-in-law in nsg home, son- suicide last year Occupation: Accounting Cigarettes: Smoked no [x] yes [] Hx: Other Tobacco use:never ETOH: < 1 drink/week [] [**1-28**] drinks/week [x] >8 drinks/week [] Illicit drug use: denies | 0 |
73,493 | CHIEF COMPLAINT:
PRESENT ILLNESS: This 79-year-old with history of coronary artery disease, chronic low back pain, and constipation was transferred from [**Hospital 6138**] Hospital for development of hyponatremia and mental status changes. He had been admitted there on [**8-25**] for malaise and weakness, as well as lightheadedness, with an episode of supraventricular tachycardia in the Emergency Department which was converted to a paced rhythm with Lopressor. The patient ruled out for myocardial infarction. The patient continued to have difficulty with lower back pain, severe constipation associated with narcotic usage including phentanyl and OxyContin. Over the course of the patient's admission, he was noted to have a drop in his sodium over a course of days from 130 to as low at 117. This had been difficult to correct and recently the patient had been started on 3% saline. The patient's urine sodium had been measured as high as 133. The patient was diagnosed with a pneumonia.
MEDICAL HISTORY: 1. Chronic lower back pain with lumbar spine spondylosis. 2. Hypertension. 3. Reactive airway disease. 4. Benign prostatic hypertrophy, status post transurethral resection of prostate. 5. Coronary artery disease with three vessel disease, status post stent in [**2192-3-15**]. 6. Status post DDD pacer in [**2191-10-16**] for complete heart block. 7. Peptic ulcer disease. 8. B12 deficiency. 9. Dysphasia. 10. Status post CVA. 11. Constipation. 12. Depression.
MEDICATION ON ADMISSION:
ALLERGIES: Codeine and morphine.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient lives in [**Location 29897**] with his friend, [**Name (NI) 26196**] [**Name (NI) 5108**]. He denies alcohol or tobacco use. | 0 |
73,348 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 40-year-old gentleman with a prior history of two myocardial infarctions, non-insulin-dependent diabetes mellitus, and hypercholesterolemia. He had increasing shortness of breath prior to his presentation as well as chest pain on the morning of presentation. He was admitted for cardiac catheterization prior to this admission which was performed on [**2191-3-11**]. The patient was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] for his cardiac disease.
MEDICAL HISTORY: 1. Non-insulin-dependent diabetes mellitus. 2. Myocardial infarction times two. 3. Hypercholesterolemia.
MEDICATION ON ADMISSION: Medications included atenolol, Lipitor, aspirin, lisinopril, gemfibrozil, Glucotrol-XL, metformin, folate, and vitamin E.
ALLERGIES: PERTINENT LABORATORY VALUES ON PRESENTATION: Preoperative laboratories revealed glucose was 71, blood urea nitrogen was 29, creatinine was 1, sodium was 136, potassium was 5.2, chloride was 98, and bicarbonate was 22. Anion gap was 21. ALT was 18, AST was 19, LDH was 193, alkaline phosphatase was 79, and total bilirubin was 0.5. White blood cell count was 8.4 and hematocrit was 40.1, and platelet count was 314,000. Prothrombin time was 12.3, partial thromboplastin time was 23.6, and INR was 1.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
51,201 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 58 year old man with a history of a two vessel coronary artery bypass graft in [**2129**], who presented to an outside hospital with substernal chest pain and was sent here for catheterization. The patient reports that at the time of presentation that his pain was epigastric, started the morning prior to presentation and was described as ten out of ten. The patient had diaphoresis, nausea and vomiting but no lightheadedness. The pain lasted into the next morning. The patient's EKG at the outside hospital showed ST elevation in the anterior V1 through V3 leads. The patient was sent here for catheterization. Catheterization showed total occlusion of the left anterior descending, open LMCA, 80% obtuse marginal 1 lesion, total occlusion of the proximal right coronary artery, 30% mid saphenous vein graft to the obtuse marginal 1. The left anterior descending was stented. Of note, there was no left internal mammary artery graft. The patient's EKG after the procedure showed normal sinus rhythm at 80 beats per minute and normal axis. There was persistent ST elevation in V1, V2 and V3, greater than 3 mm. In addition, the patient had small Q waves in II, III and AVF and large Q waves in V1 and V2, a right atrial abnormality was evident. In the catheterization laboratory the patient had a run of nonsustaining ventricular tachycardia and was started on a lidocaine drip. He was transferred to the Cardiac Care Unit.
MEDICAL HISTORY: 1. Seizure disorder; last seizure seven months prior to admission. 2. Coronary artery disease status post coronary artery bypass graft in [**2129**] (question two vessels).
MEDICATION ON ADMISSION:
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY: Mother died of myocardial infarction at 80. Father died of myocardial infarction at 73. No diabetes mellitus, no cerebrovascular accident.
SOCIAL HISTORY: The patient denies any tobacco use. He has occasional alcohol use now but had a greater amount in the past but the patient cannot quantify. The patient recently retired from Lucent. He walks two miles daily. | 0 |
35,823 | CHIEF COMPLAINT: Scheduled CoreValve procedure
PRESENT ILLNESS: 80yo male with h/o CABG x4, CVA, 100% L carotid occlusion, known aortic stenosis now symptomatic. Patient reports shortness of breath after walking 1 block, must rest after climbing 1 flightof stairs. He admits to 1 witnessed syncopal episode while havingIV's started in an upright position, 1 syncopal episode 6 months ago while getting into shower (also found to have pneumonia). He denies chest pain. Cardiac cath showed three patent grafts.Echocardiogram revealed [**Location (un) 109**] 0.8cm2, mean gradient 36mmHg. Noncontrast chest CT showed heavily calcified aorta prohibitive for conventional surgical AVR. . He was consented for participation in the Corevalve TAVI study. He met all inclusion criteria and did not meet any exclusion criteria. He reported cold-like symptoms of head congestion, no fever. He saw his PCP and [**Name9 (PRE) 40018**] was initiated. His symptoms are improving, he remains fever free and he was cleared by his PCP. [**Name10 (NameIs) **] dose Plavix [**12-14**]. . He underwent succesful CoreValve placement today. His transvenous pacing was placed through the femoral line and the valve was placed through subclavian access. He was sedated with fentanyl and versed and required Neosynephrine for blood pressure supporet at the beginning of the procedure but was weaned off by the end. During balloon dilation he developed LBBB with a paced rhythm. He was given Vancomycin and cefazolin during the procedure. He was extubated prior to arrival to the CCU. He is currently mildly sedated but appropriately responding to commands. . He does have a history of post op N/V from previous surgeries. He also has some residual sensory deficit from prior CVA but no motor deficits. He has a history of esophageal stricture so can not get TEE. . NYHA Class: II
MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - CABG:Coronary artery disease s/p Coronary artery bypass graft x 4 [**2151**] - Aortic stenosis - PERCUTANEOUS CORONARY INTERVENTIONS: none - PACING/ICD: [**Company 1543**] 3. OTHER PAST MEDICAL HISTORY: Past Medical History: - Sepsis secondary to aspiration pneumonia - Lumbar radiculopathy with L4-L5 disc herniation - AAA - Carotid stenosis - CVA from left common carotid occlusion - Esophageal stricture s/p multiple dilatations - Obstructive sleep apnea on CPAP (doesn't use) - GERD - Degenerative joint disease - Pseudomonas bacteremia from UTI - Anxiety - Spinal stenosis - Benign prostatic hypertrophy - Neurogenic pseudo-claudication Past Surgical History: - s/p Left shoulder surgery - s/p Back surgery - s/p Tonsillectomy - s/p Cataract surgery - s/p TURP - s/p Right elbow surgery - s/p Right knee surgery
MEDICATION ON ADMISSION: Medications - Prescription AVALOX 400mg daily x 10 days (start date [**12-15**]) AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth DAILY EZETIMIBE [ZETIA] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth DAILY FEXOFENADINE [[**Doctor First Name **]] - (Prescribed by Other Provider) - 60 mg Tablet - 1 (One) Tablet(s) by mouth twice a day PRN allergies HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 12.5 mg Tablet - 1 (One) Tablet(s) by mouth once daily in the morning LOSARTAN - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth once a day OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day ROPINIROLE [REQUIP] - (Prescribed by Other Provider) - 0.25 mg Tablet - 1.5 (One and a half) Tablet(s) by mouth once a day ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once a day TAMSULOSIN [FLOMAX] - (Prescribed by Other Provider) - 0.4 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth once a day TRAMADOL [ULTRAM] - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth AS NEEDED FOR PAIN Medications - OTC ASPIRIN [BABY ASPIRIN] - (OTC) - 81 mg Tablet, Chewable - 1 (One) Tablet(s) by mouth once daily in the evening CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other Provider) - 1,000 unit Capsule - 1 Capsule(s) by mouth once a day GLUCOSAMINE-CHONDROITIN - (Prescribed by Other Provider) - Dosage uncertain LACTOBACILLUS ACIDOPHILUS [FLORAJEN] - (Prescribed by Other Provider) - 460 mg (20 billion cell) Capsule - 2 Capsule(s) by mouth daily NIACIN - (Prescribed by Other Provider) - 500 mg Capsule, Extended Release - 1 Capsule(s) by mouth once a day
ALLERGIES: Protonix / Accupril / Pravachol / Mevacor
PHYSICAL EXAM: ADMISSION EXAM: BP=141/43 HR=61 RR=18 O2 sat= 96% GENERAL: NAD. mildly sedated but responding appropriately to commands. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, trachea midline,bilat bruits vs referred murmer. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, No MRG. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Anterior exam CTAB, posterior exam deferred. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+
FAMILY HISTORY: father deceased secondary to trauma, mother deceased [**Age over 90 **]yo.
SOCIAL HISTORY: Lives with wife on upper level of house, daughter lives on lower level (13 stairs). | 0 |
69,666 | CHIEF COMPLAINT: Transfer from OSH with SDH
PRESENT ILLNESS: 71F tx from OSH with chronic R SDH with midline shift. Patient fell on [**10-15**] and was evaluated at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in which a head CT was negative. She reports that she has become weak on the left side over the last 4-5 days, and has required a wheelchair. She has also been experiencing confusion which is new for her. Patient had waited so long to be evaluated as she is the caregiver for her husband, a neighbor became alarmed that she had a stroke and called EMS.
MEDICAL HISTORY: Hypothyroidism
MEDICATION ON ADMISSION: Levoxyl 100mcg daily
ALLERGIES: Latex
PHYSICAL EXAM: O: T: 96.5 BP: 154/116 HR: 77 R 20 O2Sats 98%
FAMILY HISTORY: NC
SOCIAL HISTORY: Lives with husband who is disabled, she is the primary caregiver. Adult children - all live away. Neighbor/friend has been a source of support and transportation. | 0 |
62,595 | CHIEF COMPLAINT:
PRESENT ILLNESS: Ms. [**Known lastname 6483**] is a 44 year-old female who was evaluated by the Transplant Center for a right donor hepatectomy for her sister [**Name (NI) **] [**Name (NI) 41841**]. Ms. [**Known lastname 6483**] is otherwise in excellent health. She presented to [**Hospital1 69**] for a donor liver transplant. Preoperative risks and complications were reviewed prior.
MEDICAL HISTORY: Migraines. Otherwise there is no cardiac or pulmonary disease noted.
MEDICATION ON ADMISSION:
ALLERGIES: Percocet and Codeine, which gives the patient gastrointestinal upset.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
17,750 | CHIEF COMPLAINT: Abdominal pain
PRESENT ILLNESS: 70 year old female who was admitted to Dr [**First Name (STitle) 2819**] on [**2200-1-30**] for gastroenteritis. Reports from the outside hospital included a diagnosis of possible internal hernia and SBO. Repeat abdominal CT at [**Hospital1 18**], however, demonstrated only wall thickening and fat stranding of a 23cm segment of the mid small bowel. There was no sign of SBO, and the patient had no peritoneal signs and she was discharged with a running diagnosis of gastroenteritis on [**2-3**]. She is on Coumadin for a mechanical valve and while in the hospital she was on a heparin drip. She was discharged from the hospital on 5 mg of Coumadin daily and taking Lovenox. She was told by her [**Hospital 197**] clinic that her last dose of Lovenox was to be taken yesterday. She denies any trauma. She comes in because she was having similar abdominal pain. She was having lower abdominal which was similar to her previous symptoms. She denies nausea or vomiting. Last bowel movement was two days ago. She is passing flatus. Denies melena or bright red blood per rectum.
MEDICAL HISTORY: PMHx: 1st degree AV block and episodes of 2nd degree AV block (Wenckiebach); HTN; hemolytic anemia; question of TIA when she had endocarditis 18 yrs ago; Hypothyroidism; Hyperlipidemia, HTN, OA, Hashimoto thyroiditis. . PSHx: CABG, mechanical MVR [**2175**], reoperative MVR St. [**Male First Name (un) 923**] [**2194**], open tubal ligation.
MEDICATION ON ADMISSION: Lipitor 80mg qday Lovenox 120mg qday HCTZ 12.5mg qday Levothyroxine 125mcg qday Lisinopril 20mg qday Metoprolol Tartrate 50mg [**Hospital1 **] Cipro 250mg [**Hospital1 **] until [**2-5**] Metronidazole 500mg [**Hospital1 **] until [**2-5**] Coumadin 5mg alternating with 7.5mg daily ASA 81mg daily
ALLERGIES: Penicillins / Vancomycin / Cephalosporins
PHYSICAL EXAM: On Admission: Vitals: 97.0, 128/88, 78, 18, 95% RA. General: Alert, oriented, no acute distress, conversational. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, click heard with S1 at LLSB, harsh systolic murmur IV/VI heard throughout precordium
FAMILY HISTORY: Non-contributory
SOCIAL HISTORY: Married. Has 4 daughters, has grandchildren. Family involved. Lives with husband in [**Name (NI) 392**]. Retired. Like to go down to a nearby beach with her husband. Denies smoking, alcohol, drugs. Safe at home. | 0 |
3,712 | CHIEF COMPLAINT:
PRESENT ILLNESS: An 83-year-old female, with a past medical history of hypertension, but no other cardiac history, went to [**Last Name (un) 4068**] Emergency Department with 30 minutes of substernal chest pain that was associated with nausea, shortness of breath and diaphoresis. EKG at that time showed ST elevation in the anterior and high lateral leads, and ST depression inferiorly. She was started on Integrilin, heparin, Nitroglycerin drip and IV Lopressor. She was transferred to [**Hospital1 18**] for cardiac catheterization. In the cardiac catheterization laboratory she was found to have three-vessel disease with 100% proximal LAD lesion which was stented, a 60% mid left circumflex lesion, and a 60% mid right coronary artery occlusion. Her pressures were right atrium 12, PA 40/23, and PCW 24. Her procedure was complicated by a right groin hematoma.
MEDICAL HISTORY: Hypertension.
MEDICATION ON ADMISSION:
ALLERGIES: No known drug allergies.
PHYSICAL EXAM: Blood pressure 101/53, pulse 52, respirations 16, 98% on 4 liters nasal cannula. Exam significant for elderly female in no acute distress. Moist mucous membranes. A 12 cm JVP. Lungs clear to auscultation. Normal S1, S2 with a II/VI systolic ejection murmur at the apex. Abdomen benign. Extremities warm without any peripheral edema. 1+ dorsalis pedis and posterior tibial pulses bilaterally. Circumscribed tender and firm hematoma in the right groin that was nonexpanding.
FAMILY HISTORY:
SOCIAL HISTORY: The patient lives alone. She has no family. She is very active in her church and has a lot of social support through them. She does not cook her own meals, and usually eats out for her meals. She exercises daily by walking. She does not have a history of smoking, alcohol, or drug use. | 0 |
95,007 | CHIEF COMPLAINT: s/p Motor vehicle crash
PRESENT ILLNESS: 31 M HIV+ s/p motor vehicle crash vs tree + LOC, GCS 14 at scene, intubated for combativeness with multiple discrete foci of hemorrhagic contusion and tiny left subdural hemorrhage. He was transported to [**Hospital1 18**] for further care.
MEDICAL HISTORY: HIV+
MEDICATION ON ADMISSION: 1. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO QHS 2. efavirenz 600 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)).
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: T:100.6 BP:124 / 69 HR:60 R:23 CPAP 40% 5/5 O2Sats: 100
FAMILY HISTORY: Noncontributory
SOCIAL HISTORY: | 0 |
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