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22,216 | CHIEF COMPLAINT: Bradycardia
PRESENT ILLNESS: 80 yoF with severe AS (valve area 0.6), CAD, ESRD on HD who was intially admitted to [**Hospital3 **] [**2116-2-2**] with CHF. The patient responded to dialysis. The patient was transferred to [**Hospital1 18**] CT surgery [**2116-2-5**] for consideration of cardiac catheterization and valve repair. She underwent cardiac cath on [**2-6**] revealing severe AS and 3-v CAD; plan was for OR Monday [**2-17**] for CABG/AVR. The day of transfer to the CCU, telemetry showed complete heart block without ventricular escape rhythm for 45 seconds. She was symptomatically fatigued, dizzy and nauseated. Code blue was called. The patient was trancutaneously paced and electively intubated. . On arrival to the CSRU, a transvenous pacemaker was placed. EKG after transfer showed sinus rhythm at 92, 1st degree AV block, RBBB, ST depressions in V4-V6, unchanged from previous to this episode. Echocardiogram was performed showing the pacemaker wire terminated at or within the lateral free wall of the right ventricle and not at the apex. The patient was weaned off the ventilator and extubated soon after transfer.
MEDICAL HISTORY: CAD status post NSTEMI [**10/2115**] Congestive heart failure, EF 40% Aortic stenosis, AV area 0.6 cm2 Left CEA [**2109**] Hypertension Right bundle branch block Diabetes mellitus, type 2 (diet-controlled) ESRD on HD since [**11-19**] Hypothyroidism Hemorrhoids Status post vein stripping Status post appendectomy Status post TAH-BSO . Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension . Cardiac History: CAD status post NSTEMI [**10/2115**] Congestive heart failure, EF 40% Aortic stenosis, AV area 0.6 cm2 Left CEA [**2109**] Hypertension . Cardiac History: CABG, none. . Percutaneous coronary intervention, none. . Pacemaker/ICD, none. . Other Past History: As above.
MEDICATION ON ADMISSION: At home: ASA Metoprolol 12.5 [**Hospital1 **] Lipitor 20 QD Synthroid 175 QD Zolpidem 5 QD Meclizine 25 TID Nephrocaps . On transfer: Senna 2 TAB PO DAILY Bisacodyl 10 mg PO/PR DAILY:PRN Lanthanum 1500 mg PO TID W/MEALS Oxycodone-Acetaminophen [**12-17**] TAB PO Q6H:PRN Docusate Sodium 100 mg PO BID Sevelamer 1600 mg PO TID W/MEALS Ciprofloxacin HCl 250 mg PO Q24H Duration: 7 Days for UTI Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY Insulin SC Sliding Scale Nephrocaps 1 CAP PO DAILY Levothyroxine Sodium 175 mcg PO DAILY Aspirin EC 325 mg PO DAILY Metoprolol 12.5 mg PO BID, Hold on the morning of dialysis Atorvastatin 40 mg PO DAILY Meclizine 25 mg PO TID Acetaminophen 650 mg PO Q4-6H:PRN pain
ALLERGIES: Heparin Agents
PHYSICAL EXAM: Blood pressure was 90/34 mm Hg supine. Pulse was 90 beats/min and regular, respiratory rate was 12 breaths/min. Generally the patient was well developed, well nourished and well groomed. The patient was intubated. . There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. The neck was supple with JVP of 7 cm. The carotid waveform was parvus et tardus. There was no thyromegaly. The were no chest wall deformities, scoliosis or kyphosis. The respirations were not labored and there were no use of accessory muscles. The lungs had crackles [**12-18**] bilateral lung fields. . PMI not palpated. There were no thrills, lifts or palpable S3 or S4. The heart sounds revealed a normal S1 and the S2 was normal. There was a III/VI systolic crescendo-decrescendo murmur heard at the RUSB radiating to the carotids. There were no rubs, clicks or gallops. . The abdominal aorta was not enlarged by palpation. There was no hepatosplenomegaly or tenderness. The abdomen was soft nontender and nondistended. The extremities had 2+ pitting edema to knees bilaterally, but no pallor, cyanosis, or clubbing. There were no abdominal, femoral or carotid bruits. Inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 1+ Radial 2+ DP 1+ PT 1+ Left: Carotid 1+ Radial palpable DP 1+ PT 1+
FAMILY HISTORY: No h/o early MI or cancer.
SOCIAL HISTORY: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. There is no family history of premature coronary artery disease or sudden death. Lives with her daughter who has medical problems of her own. Plans to move in with her other daughter within the next month. No tobacco or alcohol use. | 1 |
24,063 | CHIEF COMPLAINT: SOB
PRESENT ILLNESS: HPI: 85 yo lady w/ dementia, living at hospice brought in by EMS when daugther reversed code status this evening to full from CMO. Patient has been reportedly febrile, hypoxic at hospice. Daughter called PCP and reversed code status. Patient was given ceftriazone 1 g IV x 1, labs sent, then called 911, wanted all measures done. Upon arrival to ED, sats in 80's, patient not arousable with frothy, secretions. Intubation x2 was attempted in the field but successful intubation happened on arrival in ED. BP noted to be 80/P, P 100, sats 80%, rectal temp 104. ED placed femoral line, started levophed for low bp's, gave levoflox and clindamycin for pna coverage. Admitted to the [**Hospital Unit Name 153**].
MEDICAL HISTORY: Severe dementia on hospice care Multiple UTIs with episode urosepsis Embolism/thrombosis GERD Hypothyroidism Sacral decubitus ulcuer Heart failure Iron def anemia Osteoporosis CHronic airway obstruction FTT Pneumonia
MEDICATION ON ADMISSION: prevacid 30 mg po qd colace 100 mg [**Hospital1 **] lasix 40 mg [**Hospital1 **] remeron 15 qhs synthroid 100 mcg qd MOM 30 cc tiw Iron sulfate albuterol mdi prn SL morphine prn scolopomine prn duragesic patch jevity tube feeds
ALLERGIES: Sulfa (Sulfonamides)
PHYSICAL EXAM: PE: T 100 BP 72.42 --> 96/25 P 100 VENT: AC 450 x 16 fio2 0.5 PEEP 5 VBG on 100% 7.37/50/41 Gen: not arousable, ill-appearing elderly woman, contracted arms HEENT: mm very dry, ETT in place, eyes tracking but not to command neck: large and unable to assess JVP, soft CV: distant heart sounds, regular, tachy ABD: PEG in place, soft, nabs Chest: anteriorly coarse EXTRM: no clonus, minimal edema, warm; right groin line c/d/i minimal ooze NEURO: minimally arousable, tracks w/ eyes, not moving extrm spontaneously; minimally arousable to pain, sternal rub; completely contracted upper extremities.
FAMILY HISTORY: not elicited
SOCIAL HISTORY: SOCIAL: lives at [**Hospital 2188**]; DNR/DNI/hospice care until tonight On her face sheet, patient listed as NO hospitalization, NO IV or IM antibiotics; NO IV fluids for hydration; Enteral feedings ok; advance care planning sheet in chart states that no laboratory testing or hospitalization should be done-- on hospice/comfort care only; DTR reversed all of this tonight. | 1 |
21,532 | CHIEF COMPLAINT: Motor vehicle crash, splenic laceration, cervical spine fracture
PRESENT ILLNESS: The patient is a 22 year old male status post a motor vehicle crash in [**Location (un) 3844**] who was the unrestrained passenger. The vehicle was impacted on the passenger front side where the patient was seatied. The air bags were not deployed, the pateint had a loss of conciousness at the scene, where he was found to be hemodynamically stable and he was taken to [**Hospital 8641**] Hospital. There he had a full work up including a chest xray, CT of the c-spine, CT of the head, CT of the abdomen. His main complaints included a headach, neck and back pain.
MEDICAL HISTORY: 1. Motor vehicle crash in [**4-/2130**] with a concussion
MEDICATION ON ADMISSION: None
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Temperature 102, Pulse 91, blood pressure 124/67, Respirations 20, Oxygen saturation 100% on room air. General: alert and oriented times 3, GCS 15 Head and neck: head atraumatic, normocepahalic. Pupils equal round and reactive to light. Extraoccular movements intact. No oropharyngeal injuries. tympanic membranes clear bilaterally. C collar in place. Trachea midline, neck supple. Positive for lower cervical spine tenderness. Chest: clear to auscultation bilaterally Back: no steopoffs, no deformities. Some lower lumbar spine tenderness. Abdomen: soft, positve for Left lower quadrant tenderness, no obvious injuries. Positive for right flank tenderness. No rebound Pelvis: pain on anterior and lateral compression with no instability Rectal: heme negative with good tone Extremities: Palpable pulses bilaterall lower extremeties. Left hip 6cm laceration.
FAMILY HISTORY: As above in social history, otherwise noncontributory
SOCIAL HISTORY: The patient smokes 1 pack per day, occasional alcohol, no illicit drugs. The patient recently experienced the death of thsi 17 year old brother 2 weeks ago, in a plane crash, and his father was paralyzed in the same accident | 0 |
42,449 | CHIEF COMPLAINT: fall
PRESENT ILLNESS: HPI: 55 y/o male with PMH significant for seizures thought to be dueto perinatal hypoxia, mild mental retardation, and probable sleep apnea presents to ED following fall. His seizures began at age 5 and were characterized as generalized tonic clonic with associated urinary incontinence and occasional falls. He had poor seizure control throughout his childhood. He was started on tegretol at around age 30, after which he was seizure free until [**2178-7-13**]. It is unclear what triggered seizure recurrence at that time, but since then the seizures became progressively more frequent. Previous MRI showed a small left frontal lesion c/w prior trauma or cavernous angioma. Initially, he had presented to the ED with fall secondary to seizure and his tegretol was increased; after another seizure within that month,he was started on neurontin as well, which was increased to 900mg daily. Over the course of the next 6 months, the tegretol was increased from 1200mg daily (his dose over the 20 years seizure-free) to 2200mg daily. He continued to have seizures and was started on keppra, which was titrated up to 3500mg daily. Tegretol was then decreased for concern that it could be exacerbating his seizures. In [**2180-4-11**] he was admitted for LTM and medication adjustment. He was found on EEG to have "frequent bursts of generalized spike and slow wave discharges, predominant in the bilateral frontal and parasagittal regions, suggestive of a primary generalized epilepsy." Today the patient was attending a Red Sox game when he fell backwards, striking his head. Seizure activity was witnessed by a bystander, and he was transferred to [**Hospital1 18**] ED for evaluation.
MEDICAL HISTORY: Seizures as above. Has been on phenobarbital and tegretol in the past and possibly other meds per his father.
MEDICATION ON ADMISSION: Medications - Prescription CARBAMAZEPINE [TEGRETOL] - 200 mg Tablet - 1 Tablet(s) by mouth 8/d No substitute; brand name medically necessary - No Substitution LEVETIRACETAM [KEPPRA] - 500 mg Tablet - 1 Tablet(s) by mouth 8/day ZONISAMIDE [ZONEGRAN] - 100 mg Capsule - 1 Capsule(s) by mouth 6/d - No Substitution Medications - OTC CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D] - 315 mg-200 unit Tablet - 2 Tablet(s) by mouth [**Hospital1 **] with meals --------------- --------------- --------------- ---------------
ALLERGIES: Dilantin
PHYSICAL EXAM: Gen:NAD. HEENT:MMM. Sclera clear. OP clear CV: RRR, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Ext:No cyanosis/edema
FAMILY HISTORY: No seizures in the family.
SOCIAL HISTORY: Lives alone. Works as courier for law firm. His father is involved in his medical care. He denies EtOH and tobacco use. | 0 |
37,677 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 47-year-old male with a history of human immunodeficiency virus, CD4 count of 338, viral load of 1620 on [**12-12**], with hepatitis C cirrhosis, who is status post resection of nuchal mucosa and was now transferred to the Intensive Care Unit with probable transfusion reaction. Fairly recently he underwent removal of a squamous cell carcinoma from the left tongue a nuchal mucosa with tongue flap reconstruction. The patient presented to the Emergency Department complaining of coughing up blood with clots times two to three days. Examination by ENT revealed several torn sutures with some active bleeding. Hemostasis achieved with tannic acid and cautery. Subsequent hematocrit found to be down to 22 from 32 baseline. There was a plan to transfuse packed red blood cells, platelets, and fresh frozen plasma. In the Emergency Department, at the end of the first unit, the patient was found to be unresponsive, shaking, blood pressures in the 180s/40s, and heart rate of 130 to 180. It was felt to be supraventricular tachycardia, and he was given adenosine 6 mg and then 9 mg with no affect. Several boluses of intravenous diltiazem were given. Heart rate decreased to the 140s with a blood pressure of 120/70. The patient then began to seem congested with bronchospasm. He was given 0.6 mg of epinephrine, 50 mg of intravenous Benadryl, 75 mg of intravenous Zantac, 120 mg of intravenous Solu-Medrol for presumptive anaphylaxis transfusion reaction. The patient continued to remain unresponsive and tachypneic, and the Medical Intensive Care Unit team was called to assess.
MEDICAL HISTORY: The [**Hospital 228**] medical history was significant for human immunodeficiency virus diagnosed in [**2172**] secondary to intravenous drug abuse, hepatitis C diagnosed in [**2178**] with cirrhosis of his liver diagnosed in [**Month (only) 1096**] of this year. He had marked ascites, question of varices. Squamous cell carcinoma in [**2182-9-23**] biopsy of plaque, and status post resection with tongue flap reconstruction. A congenital pyloric stenosis, ethanol abuse, bronchospastic lung disease, deep venous thromboses in the right, and syphilis in [**2150**].
MEDICATION ON ADMISSION: Medications on coming in were Bactrim-DS, Agenerase, lamivudine, nasalide, ritonavir, Roxicet, Serevent, Singular, stavudine, and Ventolin.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY: Family history was noncontributory.
SOCIAL HISTORY: Social history significant for a 60-pack-year history of smoking, intravenous drug abuse in the [**2140**] and [**2150**], ethanol abuse. Currently working in the shipping docks. | 1 |
58,423 | CHIEF COMPLAINT: respiratory distress and tachycardia
PRESENT ILLNESS: History of present illness: Ms. [**Known lastname 13621**] is a 55 yo woman with metastatic adenocarcinoma of unknown primary, hypertension, h/o DVT s/p IVC filter and recently discharged after having acute shortness of breath thought [**1-12**] atrial fibrillation with rapid ventricular response who presented to the [**Hospital1 18**] ED today with acute-onset shortness of breath at about 6 p.m. on the day prior to admission. . She denies fever, chills, sweats, cough, increased sputum production. . Of note, two days prior to admission, the pt had a CT scan of her torso that revealed progression of her disease throughout, including interval progression in abnormal pulmonary densities involving all lobes. They now have a more interstitial and consolidative appearance, greatest in the lower lobes. . In the ED, her initial VSs were 132 100/70, 28-32, 97% with neb. She received continuous nebs, methylprednisolone 125 mg IV, furosemide 20 mg, levofloxacin and ceftriaxone. She was admitted to the [**Hospital Unit Name 153**] for further management.
MEDICAL HISTORY: - Tuberculosis treated in [**2145**] with normal chest x-ray at [**Hospital1 2025**] in [**2162**]. - GYN: G2 P2. Tubal ligation [**2156**]. Stopped menstruating at age 50, normal pap's per patient - Hypertension. - History of mild asthma, inhalers not used for several years. - normal mammogram less than one year ago. - normal colonoscopy 2/[**2178**]. - recent pericardial effusion/tamponade - right pleural effusion - large common femoral DVT - adenocarcinoma of unclear primary
MEDICATION ON ADMISSION: Calcium Carbonate 500 mg qid Cholecalciferol (Vitamin D3) 800 unit daily Fentanyl 25 mcg/hr Patch 72 hr Lidocaine patch Capecitabine 1500 mg [**Hospital1 **] Loperamide 2 mg qid prn Docusate Sodium 100 mg [**Hospital1 **] Senna 8.6 mg Tablet [**Hospital1 **] Megestrol 400 mg daily Hexavitamin daily Enoxaparin 60 mg/0.6 mL syringe [**Hospital1 **] Levalbuterol HCl nebs prn Ipratropium Bromide nebs Diltiazem HCl 120 mg daily
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: GENERAL: Tachypneic, speaking in [**3-16**] word sentences, pain well-controlled, lying in bed HEENT: dry MM, CARD: Tachycardic RESP: Using accessory mucles ABD: Mildly distended and tympanic, nontender, decreased bowel sounds EXT: Warm, well-perfused, 2+ DP pulses bilaterally; no pedal edema. NEURO: Alert & appropriate
FAMILY HISTORY: Her father died of stomach cancer at age 72. Mother died of colon cancer at age 63. She is the 10th of 13 children. She has lost 3 siblings to motor vehicle accidents.
SOCIAL HISTORY: She worked as a nursing assistant. Lives with her husband. [**Name (NI) **] 2 Children. | 0 |
77,945 | CHIEF COMPLAINT: headache
PRESENT ILLNESS: Ms. [**Name14 (STitle) 78849**] is an 81 y/o female s/p ground level fall. She was transferred to an outside hospital where a head CT revealed a 7 mm right temporal-parietal subdural hematoma. She had no focal neurological deficits. She was transferred to [**Hospital1 18**] for neurosurgical care.
MEDICAL HISTORY: pancreatic cancer
MEDICATION ON ADMISSION: ambien ASA cozaar diltiazem os-cal percocet premarin synthroid fentanyl morphine lexapro lidoderm patch motrin decadron
ALLERGIES: Mobic / Cyclobenzaprine / Clonidine / Prednisone
PHYSICAL EXAM: PERRLA EOMI FC all 4 extremities sensation to LT intact all around A & O x 3 gait unsteady, uses walker to ambulate no evidence of dysmetria cranial nerves II - XII grossly intact no clonus negative babinski
FAMILY HISTORY: noncontributory
SOCIAL HISTORY: denies tobacco, EtOH, or IVDU | 0 |
97,430 | CHIEF COMPLAINT: Autoimmune hepatitis HCC
PRESENT ILLNESS: The patient is a 68-year-old male with a history of auto-immune hepatitis and cirrhosis who developed right upper quadrant abdominal pain. An ultrasound demonstrated a large mass in the right lobe of the liver that on biopsy was consistent with hepatocellular carcinoma. His AFP was 336. A CT scan of the chest and abdomen demonstrated no evidence of pulmonary metastases. The patient had a large mass lesion measuring 12.7 x 9.2 x 11.2 cm arising primarily in the medial segment of the left lobe. The middle hepatic vein was not visualized but the right hepatic vein and the left lateral segment hepatic veins were identified. The mass lesion superiorly appears to abut not invade the right lobe of the liver. The patient does not have evidence of portal hypertension. The patient after informed consent is now brought to the operating room for left hepatic lobectomy, possible left trisegmentectomy, caudate lobe resection and cholecystectomy.
MEDICAL HISTORY: hyperchol, HTN, CAD s/p CABG (echo --> EF 50%), NIDDM
MEDICATION ON ADMISSION: metoprolol 25mg [**Hospital1 **] lisinopril 5mg daily HCTZ 12.5mg daily pravachol 40mg daily prilosec 20mg daiy ISS
ALLERGIES: Codeine / Meperidine / Iodine Containing Agents Classifier
PHYSICAL EXAM: DISCHARGE PE: Vitals: 98.9 82 133/74 20 96% room air NAD RRR CTAB soft, ND, appropriately tender Incision: c/d/i no c/c/e
FAMILY HISTORY: diabetes, hypertension, prostate cancer, colon cancer. His mother is alive at age 88. His father died at age 88 of prostate cancer.
SOCIAL HISTORY: He has no history of alcohol use, smoking, IV drug use, tattoos, or marijuana use. BS degree. Retired in [**2127**]. He was an accountant for over 48 years with [**Company 2676**]. He has seven children and 20 grandchildren. | 0 |
5,639 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is an 87-year-old woman with history of COPD who presents with decreased mental status, mumbling, anorexia, and dyspnea for the last 2-3 days. In [**2101-10-8**] the patient was admitted to the [**Hospital1 69**] MICU for COPD exacerbation and pneumonia, intubated for respiratory failure times 24 hours, given Levaquin and steroids and then discharged on [**2101-11-1**]. She was recently readmitted to the MICU on [**2102-1-29**] with an ABG of 7.18, PCO2 122, PO2 217 on non invasive ventilation with improvement in mental status and ABG to 7.4/63/56. Her hypercarbia was thought to be secondary to Opioids and Benzos. She was not given steroids during that admission. Now patient presents with decreasing mental status, mumbling, anorexia and dyspnea times 2-3 days. No fevers, chills, nausea, vomiting, chest pain, palpitations, abdominal pain or cough. The patient arrived by ambulance from home, was somnolent but arousable to verbal stimuli. Her vital signs on admission, temperature 98.8, blood pressure 126/34, pulse 91, respiratory rate 30 and O2 sats of 75% on room air, with increasing to 93% on four liters of oxygen. Her ABG at that time was PH 7.22, PCO2 95, PO2 85 on four liters of oxygen. Bi-pap ventilation was initiated with increase in sats to 93 to 97%. She was more awake with the bi-pap ventilation. Her next gas showed improvement with PH 7.24, PCO2 87 and PO2 of 62. Upon initial presentation to the MICU her white blood cell count was 20.4 and subsequently she was given one dose of Levaquin. She was hydrated with D5 normal saline. Upon stabilization of her respiratory status, she was transferred to the [**Hospital1 139**] service on [**2102-2-14**].
MEDICAL HISTORY: COPD, on home O2 2-3 liters for last four years. Adenocarcinoma of the rectum, status post resection, LAR [**4-/2098**]. Lower back pain. Osteoarthritis. Anxiety. Migraine headaches. SIADH. Osteoporosis. Old lacunar infarct in the right coronary radiata.
MEDICATION ON ADMISSION:
ALLERGIES: Doxycycline.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient is divorced, lives with her two sons at home. History of tobacco use, quit 20 years ago, prior to that 40 pack year history. No ethanol, no IV drug use, no exercise. | 0 |
42,413 | CHIEF COMPLAINT: tachypnea
PRESENT ILLNESS: 65 yo with hx of COPD/asthma p/w tachypnea X 1 day but minimal complaints. Pt. denied CP or SOB but a friend noted her to be breathing fast. . Friend, [**Name (NI) **], interviewed as patient was a poor historian. She answered, "I don't know." to most questions. [**Male First Name (un) **] states that patient woke from sleeping night of [**1-25**] and felt very weak and could not move. He helped her to the bathroom multiple times. Her weakness and respiratory rate worsened over the day on the 16th which led to her presentation to the emergency room. [**Male First Name (un) **] notes that she might be mildly more confused than usual but is stubborn at baseline. [**First Name8 (NamePattern2) **] [**Male First Name (un) **], no sick contacts, no fevers, cough and sputum at baseline. Patient denies any urinary sxs or taking any drugs or medications incorrectly. [**Male First Name (un) **] notes that the past week a VNA has been arranging her medications but that the patient does not like how the VNA does it [**First Name8 (NamePattern2) **] [**Male First Name (un) **] says that he fixes them after the VNA leaves. He could not provide the names of the medications but said that he handed them in on a form. Per EMS, home oxygen saturation of 91% on RA. . Pt. has multiple admissions for asthma/COPD exacerbations but none since [**8-19**]. She was intubated for 1 day during [**8-19**] with uncomplicated extubation. . In the emergency department VS 98.0, HR 85, BP 127/82, RR60, 98% on RA which she remained during ED course. An ABG was, 7.39/47/66 (though resident thought it might not be arterial). Patient was noted to be using accessory muscles. Blood cultures were sent. CXR significant for hyperexpanded lungs without consolidation or pleural effusion. . She refused nebs (so given combivent X2), and was given Methylprednisole 125mg IV X1, Ceftriaxone 1G IV X1, Levofloxacin 750mg X1. . Vitals prior to transfer to the ICU were: T afebrile, HR 90, BP 141/77, RR 40s, O2Sat 98% RA. . REVIEW OF SYSTEMS: (-)ve: fever, chills, night sweats, loss of appetite, fatigue, chest pain, palpitations, rhinorrhea, nasal congestion, cough, sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, nausea, vomiting, diarrhea, constipation, hematochezia, melena, dysuria, urinary frequency, urinary urgency, focal numbness, focal weakness, myalgias, arthralgias
MEDICAL HISTORY: 1. COPD/emphysema: no PFTs in our system; intubated in [**8-19**] 2. pulmonary HTN 3. schizophrenia 4. psychogenic polydipsia 5. osteoarthritis 6. s/p hernia repair [**7-/2118**] 7. hx of fecal and urinary incontience without spinal cord injury 8. atrial arrythmia (MAT vs. wandering pacemaker) 9. positiive PPD
MEDICATION ON ADMISSION: (per [**8-19**] d/c summary) Citalopram 40 mg daily Trazodone 50 mg HS (at bedtime) as needed for insomnia Aripiprazole 10 mg QAM Fluticasone-Salmeterol 250-50 mcg/Dose Disk [**Hospital1 **] Aspirin 325 mg DAILY Acetaminophen 650mg Q6H prn pain Diltiazem HCl 120 mg Capsule, Sustained Release daily Combivent 18-103 mcg/Actuation Aerosol 1-2 puffs Q6H prn SOB Advair Diskus 250-50 mcg/Dose Disk [**Hospital1 **] Albuterol Sulfate 90 mcg/Actuation HFA Q6H prn SOB Spiriva 18 mcg Capsule daily
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: 97.2 94 102/66 97%/4L . . PHYSICAL EXAM GENERAL: dishelved, cachectic woman HEENT: Normocephalic, atraumatic. No scleral icterus. Would not cooperate with light in eyes but pupils appeared to track and to be of normal size. Poor dentition but would not open mouth. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: very shallow breaths, clear ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema. Bilateral calf tenderness. 2+ dorsalis pedis pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. CNs intact. Grossly sensation and motor intact. No rigidity. Would not participate in cerebellar signs. PSYCH: Flat affect. Labile mood but directable.
FAMILY HISTORY: per OMR: Father with CAD.
SOCIAL HISTORY: Pt is former psychiatric nurse, currently on SSDI. Lives with partner named [**Name (NI) **] ("[**Name2 (NI) **]") who provides her with support including helping with medications. Smoking 1PPD currently. Previous notes report 2ppd X 50 years and hx of ETOH abuse, last drink 15 years ago recorded. Denies illicit drugs. . | 0 |
75,103 | CHIEF COMPLAINT: s/p Pedestrian struck by auto
PRESENT ILLNESS: 40F pedestrian vs auto w/ ?LOC GCS 14 on arrival with mild confusion. Transported to [**Hospital1 18**] for further care.
MEDICAL HISTORY: HTN
MEDICATION ON ADMISSION: unknown BP med
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Upon exam: O: T:97.2 BP: 168/107 HR:98 R20 O2Sats100%ra Gen: WD/WN, comfortable, NAD, sedated-given fentanyl recently for fx's HEENT: Pupils: perrl, pinpoint bilat. EOMs intact bilat Neck: Supple. c collar in place Extrem: Warm and well-perfused. Neuro: Mental status: Awake, cooperative with exam, sedated Orientation: Oriented to person, place, and date.
FAMILY HISTORY: Noncontributory
SOCIAL HISTORY: | 0 |
94,809 | CHIEF COMPLAINT: s/p PEA arrest
PRESENT ILLNESS: This is a 84 year old female with a PMH significant for diabetes, HTN, HL, hypothyroidism, who presents status cardiac arrest at her nursing home. Per family report, patient was seen choking by family and quickly beceame unresponsive. Nursing staff called EMS, who found the patient sitting upright in a chair, cyanotic, and pulseless. CPR was initiated at 1:30 PM and patient received 1mg IV epinephrine and 1mg IV atropine with return of pulses. Patient was noted to have tonic/clonic jerking and was intubated en route to [**Hospital3 **]. . At [**Hospital3 **], patient underwent head CT which was indeterminate and chest radiograph was with report of aspiration pneumonia. Patient was given 500 cc NS bolus. Patient was transferred to [**Hospital1 18**] to further evaluate possible subarachnoid hemorrhage. . At the [**Hospital1 18**] ED, initial vital signs were: 98.8, 78, 121/99, 24, 96% on AC FiO2 100%, 450, 14, Peep 5. Patient was initially not on any sedation and was withdrawing to pain with pupils 5-6 mm bilaterally and sluggish. Labs notable for a leukocytosis of 16.2, 5 bands, ALT: 304, AST: 272, Trop: 0.12, MB 7, lactate of 2.1. Repeat head CT without acute bleed. Chest radiograph with no acute process. CTA was without PE but with bilateral multifocal pneumonia. Patient was given vancomycin 1gram IV, 500 mg IV flagyl, and ceftriaxone 1g IV X 1. Post-cardiac arrest team was consulted and hypothermia protocol was initiated. Vecuronium 10mg IV X 1 was given due to shivering.
MEDICAL HISTORY: (as per nursing home list) - diabetes mellitus II - depression - rheumatoid arthritis - HTN - history of SVT documented - hyperlipidemia - hypothyroidism - osteoporosis - stress incontinence - s/p right shoulder dislocation
MEDICATION ON ADMISSION: (as per nursing home list): - alendronate 70mg PO qWednesday - fluoxetine 20mg PO daily - levoxyl 75mch PO daily - glimepiride 1mg PO daily - simvastatin 10mg PO daily - metformin 850mg PO daily - colace 100mg PO BID - buproprion ER 100mg PO BID - captopril 25mg PO BID - multivitamin - folic acid 1mg PO daily - calcium/vitamin D .
ALLERGIES: Penicillins
PHYSICAL EXAM: VS: Temp: BP: 184/100 HR: 95 RR: 13 O2sat: 98% on AC GEN: intubated HEENT: PERRL, 5mm, sluggishly reactive to light, dry mucous membranes, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits RESP: auscultated anteriorly, sounds CV: RRR, nl S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: Pupil exam as above.
FAMILY HISTORY: Unable
SOCIAL HISTORY: Unable | 1 |
43,417 | CHIEF COMPLAINT: Renal failure, colitis, s/p colectomy/ostomy
PRESENT ILLNESS: In brief, patient is a 63 yo Cambodian male with h/o HTN, COPD, past CVA who was transferred from an OSH after presenting with left sided weakness on [**2179-6-11**], s/p AAA repair (5.5cm) on [**2179-6-17**] c/b PNA, renal failure requiring intermittent HD, colitis, and HIT. . Patient intially presented on [**2179-6-11**] with 10-15 minutes of inability to move his left arm, which had happened previously. He was ruled out for MI and stroke. He was seen by surgery and had repair of a 5.5 cm juxto-renal AAA with aorto-bifemoral bypass on [**2179-6-17**]. His post-op course was subsequently complicated by acute renal failure, requiring multiple sessions of HD with Tessio cath. He also developed necrotic/[**Last Name (un) **] gangrene of toes b/l s/p surgery, no intervention was performed. He also initially had persistent nausea, for which he was scoped from above and below. He was started on TPN due to poor nutritonal status. During the middle of his hospitalization, he developed PNA (sputum + for enterobacter) and was treated with IV antibiotics. He also developed loose stools and a distended abdomen; stools were positive for c-diff and he was started on po flagyl. Due to worsening abdominal symptoms and increasing WBC from 16 to 36 since [**7-8**], he underwent a sigmoidoscopy on [**7-8**] which demonstrated pseudomembranous plaques, c/w C diff. The patient was then changed from po flagyl to IV flagyl and po vanc. However, he did not respond to treatment, and his WBC worsened and abdominal exam also worsened in terms of tenderness and absence of bowel sounds; therefore, concern for ischemic colitis was raised. He subsequently became more lethargic and was transferred back to the ICU at the OSH and sent directly to the MICU at [**Hospital1 18**] for further management. Options of colectomy were raised at the OSH, however there was concern that the patient would be too high-risk. His last HD was [**2179-7-7**] and was stopped as patient was making approximately 1 L urine/day. . ROS: As per HPI, otherwise negative
MEDICAL HISTORY: 1. HTN 2. Hypercholesterolemia 3. 5.5 cm juxto-renal AAA, s/p aorto-bifemoral bypass on [**2179-6-17**] complicated by ATN from underperfusion 4. Old large R-posterior MCA infarct 5. COPD 6. Acute renal failure due to ATN from AAA repair 7. h/o Inf wall MI with EF 46% - repeat TTE with EF 30-35% and depressed global/LV systolic dysfunction 8. Septic emboli to feet with gangrene 9. C. diff infection with toxic megacolon, s/p subtotal colectomy on [**7-11**] with end ostomy placement
MEDICATION ON ADMISSION: Atenolol (non-adherent)
ALLERGIES: Heparin Agents
PHYSICAL EXAM: VS: T 97.5, BP 124/68, HR 91, RR 20, 95%RA Gen: elderly Cambodian male, smiling, alert and talking softly HEENT: EOMI, PERRL, anicteric sclera, MMM, OP difficult to appreciate Neck: supple, full ROM, no LAD, JVP at 2cm above neck Lung: Good air movement, scant fine bibasilar crackles, Heart: RRR, no m/r/g, nl S1 S2 Abd: soft, mild tenderness throughout abdomen with mild guarding. Well healing midline surgical scar with staples intact. Ostomy pink with gas and output. + BS Back: No tenderness to palpation Ext: warm, well perfused. Dry gangrenous toes bilaterally, no pitting edema or calf tenderness Skin: warm, no rashes noted Neuro: CN II-XII intact, moving all extremities. Difficult to perform detailed aspects of exam given patient's cooperation
FAMILY HISTORY: Non-contributory
SOCIAL HISTORY: Pt from [**Country **] originally, now living in the U.S for over 22 years. Pt worked as a machinist. + smoker, occasional EtOH. Pt is married with 5 children and 11 grandchildren | 0 |
52,544 | CHIEF COMPLAINT: Back pain. Right sided sensory loss.
PRESENT ILLNESS: This is a 48 y.o. woman with pmh significant for metastatic thyroid cancer, s/p median sternotomy, T1 & T2 Corpectomy w/ T1-T3 Fusion/Cage, with subsequent bilateral pulmonary embolism, being transferred to medicine for optimization of anticoagulation. The patient presented on [**2142-11-14**] complaining of right sided back pain, along with weakness and diminshed sensation on the right side of her body. Imaging at the time revealed tumor infiltration of her thopracic spine, and she underwent median sternotomy, T1 & T2 Corpectomy w/ T1-T3 Fusion/Cage. Her post-operative course was complicated by bilateral pulmonary emboli. She was begun on anticoagulation and is now s/p IVC filter placement.
MEDICAL HISTORY: papillary Thyroid Cancer diagnosed 10yrs ago, s/p thyroidectomy, 4 radioactive iodine trwatments. . Thyroidectomy.
MEDICATION ON ADMISSION: Levoxyl 150 Ibuprofen 800 q6h Vicodin 5mg/500mg q6h prn pain prednisone 10 mg daily
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Vitals: T:98.0 P:72 BP:124/76 R:16 SaO2:94%RA General: Awake, alert, NAD. Hard Cervical collar on HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP Neck: Hard collar Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -sensory: No deficits to light touch throughout. -cerebellar: No nystagmus, dysarthria, intention or action tremor
FAMILY HISTORY: father with [**Name2 (NI) 499**] cancer
SOCIAL HISTORY: lives with husband and 4 kids. Alcohol [**3-10**] drinks a week. Smoking 5 cig day - 5 years | 0 |
47,704 | CHIEF COMPLAINT: Transfer from [**Hospital1 **] for pericardiocentesis with pigtail catheter placement.
PRESENT ILLNESS: Mr. [**Known lastname **] is a 57 year old male with history of hyperlipidemia and GERD, who is transferred to [**Hospital1 18**] from [**Hospital1 **] for urgent pericardiocentesis with drain placement. His symptoms began 1 week prior to admission, when he awoke with malaise, cough, and sore throat. His malaise became worse through the week, and he complained of fevers/chills, as well as n/v/d the day before presentation to [**Hospital1 **] on [**2152-12-30**]. + anorexia. At [**Location (un) 620**] he was noted to be tachycardic to 110 bpm, and hypoxic at 92% on RA, though afebrile. A CXR revealed RLL and RUL infiltrates, and his wbc count was 13.2 with mild L shift. Rapid influenza was negative, and he was started on levaquin, later changed to ceftriaxone and zithromax. He was additionally noted to be in ARF with creatinine 1.8. Clinically he worsened rapidly; on the second day of admission he was noted to be dyspneic, cyanotic, with ABG 7.45/19/65, and patient intubated with serosanguinous secretions. An echo done later that night showed a large pericardial effusion, and decision was made to transfer patient to [**Hospital1 18**] for pericardiocentesis and pigtail catheter placement. On [**Last Name (LF) **], [**First Name3 (LF) **] patient's family, he was in his usual state of health prior to this illness. They deny that he complained of any previous cough, no previous n/v/d, no anorexia or weight loss. He did have hematochezia approximately 3 weeks ago, however attributed it to a hemorrhoid, and it resolved. Last colonoscopy 1 year ago, normal per wife. Unsure if he has ever had a PPD test. Smoked 2 PPD x 30 years, but quit 13 years ago.
MEDICAL HISTORY: Hyperlipidemia, on lipitor. GERD, on a PPI or H2 blocker - unsure.
MEDICATION ON ADMISSION: Ranitidine Atorvastatin
ALLERGIES: Asparagus
PHYSICAL EXAM: VS: 97.5, 106/72, 98, RR 30 on AC 100%, 600/30. PAP 32/19. CO 4.6, CI 2.2. Gen: Overweight caucasian male lying supine in bed, intubated, sedated. HEENT: Pupils pinpoint, reactive, edematous conjunctiva. CVS: RR, normal rate, faint rub, S3 vs. split S2. Lungs: Difficult to auscultate over ventilator, from anterior chest. Loud upper airway sounds. Chest: Pigtail catheter site clean/dry, dressings in place. Abd: NABS, soft, obese, no dullness to percussion. No hepatosplenomegaly. Extr: No c/c/e. L great toe cyanotic, R great toe pale, DP/PT non-palpable but present with doppler. Hands cold. Multiple lines in R groin.
FAMILY HISTORY: Did not elicit.
SOCIAL HISTORY: "Heavy" smoker until 13 years ago - smoked 2 PPD x 30 years. Also used to be an alcoholic, but quit 20 years ago. Uncertain PPD status. Last colonoscopy 1 year ago, normal. Married to his second wife, 2 children. | 0 |
85,546 | CHIEF COMPLAINT: Left flank pain
PRESENT ILLNESS: 51M anuric ESRD due to Lithium nephrotox on HD x7 yr with LEU AV fistula on ASA325 (last dose Wed AM) transferred from OSH following CT scan showing Left perinephric hematoma. Onset L flank pain Tues 1AM. Underwent full [**First Name3 (LF) 2286**] Wed without hemodynamic issues. Denies dizziness, fever, chills, N/V. H/O chronic back pain. Recently taken off all anti-hypertensives. AV fistula manipulated by surgeon last week. Last BM Tuesday. Initial Hct at OSH 30, repeat 26 --> 1u PRBC in transit, initially 26.6 with blood hanging. Premedicated for repeat CT Abd/pelvis. NO signs of bleeding. Serial HCT stable.
MEDICAL HISTORY: PUD s/p EGD and medical management (PPI) in [**2142**], bipolar, idiopathic enlarged spleen, ESRD on MWF [**Year (4 digits) 2286**] in [**Location (un) 47**], chronic back pain, HTN, anxiety, s/p splenectomy in [**2141**]
MEDICATION ON ADMISSION:
ALLERGIES: Betadine
PHYSICAL EXAM: (On transfer to medicine [**2145-4-9**]) Vitals: T: 100.7 BP: 117/74 P: 76 RR: 21 O2: 92% RA General: Pale, thin male, alert, oriented, no acute distress HEENT: Sclera anicteric, slight anisocoria, 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, II/VI systolic murmur loudest at RUSB Abdomen: soft, non-tender, slightly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well-perfused, 2+ pulses, no clubbing, cyanosis or edema. LUE fistula appears patent and non-infected with bruit. Skin: macular rash on chest, appears like tinea versicolor.
FAMILY HISTORY: Non-contributory
SOCIAL HISTORY: Lives with his mother, denies EtOH, tobacco or illicit drugs. | 0 |
71,678 | CHIEF COMPLAINT: Chest pain and dyspnea on exertion .
PRESENT ILLNESS: Mr. [**Known lastname **] is a 60 year-old male with no significant past medical history who presents with exertional chest pain since yesterday. He first noted chest discomfort while running up 2 flights of stairs 2 days ago. He developed SOB, chest discomfort that felt like a "cramp" or a "bruise" (unable to quantify), and had to stop to catch his breath. The chest discomfort is mid-chest and non-radiating. Normally he can run up the steps without difficulty. Yesterday, he developed the same symptoms while loading up the car for a trip to [**State 3914**]. When he arrived in [**State 3914**], he again had the same symptoms while unloading suitcases from his car. He reports that the shortness of breath and chest discomfort last for minutes and resolves with rest. He had associated diaphoresis. Per his wife, he was clutching his chest and looked "ashen". No lightheadedness, dizziness, pre-syncopal sensation. No palpitations. He also notes pain in his left calf since yesterday. Initially it felt like a sprained muscle and he took 2 alleve with some relief. The pain has since migrated to the back of his knee. . He travels twice per week to [**Location 8398**]for work, which is a 50 minute train ride. He has also been on 2 long plane flights recently-- to [**State 32155**] in early [**Month (only) **] and to [**State 3908**] on [**11-24**]. No personal or family history of cancer. No history of PE. . Of note, the patient had one episode of similar symptoms back in early [**Month (only) **]. He was on a vacation in [**First Name4 (NamePattern1) 1661**] [**Last Name (NamePattern1) **], [**State 32155**] and developed a "cramp"-like sensation associated with SOB while carrying bags to his hotel room. At the time he attributed this to the high altitude. Also, around [**Holiday 944**] he had an episode of syncope. He reports that he was walking downstairs in his house and all of a sudden he passed out and fell against the wall. He denies any pre- or post-syncopal symptoms. No LH, palpitations, incontinence, or post-ictal confusion. He did not have any work-up of these events. The patient did put himself on the treadmill around New Year's and was able to run 5 miles without chest discomfort or SOB. . He did not have any further symptoms this morning. He took 325mg of ASA x 4. The patient called his PCP who recommended that he come to the ED. He reports he had another similar episode this afternoon, however, while walking from his car to triage. . In the ED, T 97.9, BP 139/94, HR 97, RR 18, SaO2 97% on RA. EKG revealed ST depressions in the inferolateral leads and there was concern for unstable angina. He received metoprolol 5mg IV x 1 and 25mg PO x 1. He was also started on a heparin drip. CXR was negative. Evaluated by cardiology fellow in the ED who recommended admission to [**Hospital Unit Name 196**] for further evaluation. On his way up to the floor, he had LENIs done which revealed LLE DVT. On arrival to the floor, he has no complaints. Denies chest pain, shortness of breath, lightheadedness. Denies f/c, cough recently. .
MEDICAL HISTORY: None
MEDICATION ON ADMISSION: ALLERGIES: NKDA . HOME MEDICATIONS: Aspirin 81mg daily, most days Alleve prn .
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS - T 97.9 BP 153/99 HR 76 RR 18 O2sat 98% on 2L --> 97% on RA
FAMILY HISTORY: His father had type 1 Diabetes from the age of 20 and developed heart problems in his 60s; died of "complications from his Diabetes" at 74. His mother is alive, age 80, with osteoporosis. There is no family history of premature coronary artery disease or sudden death. No known family history of cancer.
SOCIAL HISTORY: He lives in [**State **] with his wife. [**Name (NI) **] travels to [**Location 53193**]2x/week by train (50 min) for work. Social history is significant for the absence of current tobacco use. He drinks an occasional glass of wine. | 0 |
77,460 | CHIEF COMPLAINT: UTI- Indwelling Catheter, Fever and R UVJ stone
PRESENT ILLNESS: 64M with long standing paraplegia who was admitted on [**7-27**] with fevers, on zosyn since [**7-30**] for pseudomonal UTI. Due to persistent fevers, CT abdomen was obtained on [**7-28**] which was significant for R UVJ stone. Pt is s/p IR perc nephrostomy tube placement on [**7-31**]. He had also had an episode of ~500cc BRBPR on [**7-29**] and is s/p colonoscopy on [**7-31**] as well, findings notable for ulcerative colonic mass. That evening he reported an episode of chills without rigoring, then triggered for fever to 101.9 with hypotension to 80/D. Abx coverage was broadened with the addition of daptomycin given history of VRE swab positive. He was given 2.5L of IVF and placed in trendelenberg. Repeat BP was 70/50. The patient was alert and oriented, mentating normally. Continued to have brisk urine output. His Hct had been stable during the admission despite the GIB at around 28-30. He was transferred to the MICU. In the MICU, patient received pressors via a central line. He received 2 units of PRBCS, and his Zosyn and Daptomycin were continued. He clinically stabilized and was transferred back to medicine on [**8-3**], after waiting for a bed for two days. The day of discharge, Mr. [**Known lastname 3803**] was pleasant and in no apparent distress. He was able to tolerate food well. A PICC line was placed for him to continue Zosyn at home, and ID recommended switching the daptomycin to Augmentin. The pathology from his colonic biopsy will be followed with GI and Surgery. Also, he is to follow-up with Urology for definitive treatment of his nephrolithiasis after his infection is fully treated. His other chronic conditions are stable.
MEDICAL HISTORY: #. paraplegia- Pt is a C5-C6 paraplegic secondary to a waterskiing injury in [**2109**]. He is wheelchair bound. He has a PCA at home but is very high functioning. Pt was involved in a MVA in [**3-23**] and was found to have a C2 odontoid fracture. Unclear if this is new or subacute. He was treated with a hard collar and repeat imaging on [**6-23**] was stable. Most likely an old non-[**Hospital1 **] from an old fracture. Pt was offered fusion at that time but has declined. #DVT: After noting Left lower extremity edema was found to have chronic DVT of the Left Lwer extrmity on [**2150-6-5**], which was shown to be persistent on repeat LE Venous Dupplex on [**2150-7-3**]. Coumadin stopped [**2150-8-19**]. #. Vertebral osteomyelitis- Pt had vertebral osteo in 06/[**2145**]. At that time, he had high grade S aureus bacteremia. A spinal MR showed thoracic discitis which was thought to be the source. Repeat MR in [**7-/2145**] showed progression with some vertebral collapse and cord impingement despite antibiotic treatment. Pt required surgical debridement. Subsequent path was consistent with osteomyelitis. Cultures were negative. The treatment course was complicated by Pseudomonas and [**Female First Name (un) 564**] line infections. #. Neurogenic bladder- Secondary to quadriplegia. Low pressure system with bladder sphincter dysnergia. Pt with suprapubic tube in place. Replaced on every six days by his wife. [**Name (NI) **] by Dr [**Last Name (STitle) **] [**Last Name (STitle) **] urology clinic. #. Depression #. Anxiety #. Hyponatremia- Baseline roughly 134. First noted in [**2146**]. Pt with normal ACTH stim test in 01/[**2148**]. Urine lytes and osm consistent with SIADH at that time. Thought to be due to pulmonary disease. #. Pleural effusions- Pt with refractory left pleural effusion in setting of osteo in 07/[**2145**]. Underwent talc pleurodesis x3 and had a prolonged chest tube. He now has chronic scarring and loculations s/p the talc. #. Osteoporosis #. Erectile dysfunction #. Colonic polyps- Found on screening colonoscopy in 01/[**2144**]. Plan repeat in [**5-28**] years. #. S/P right hip fracture- Occurred [**3-/2148**] after MVA. Treated with ORIF. Complicated by a distal femoral fracture which was treated with a fixed brace. #. Superficial thrombophlebitis- Diagnosed [**2149-2-13**]. Involved the greater saphenous vein extending to confluence with the deep femoral system. Coumadin stopped by PCP in [**2150-8-19**]. #Osteoporosis
MEDICATION ON ADMISSION: 1. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for fungal infection. 2. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO Q HS (). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TIDAC (3 times a day (before meals)). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for sob/wheeze. 8. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for bladder spasm. 9. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal QOD (). 12. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO QOD (). 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours)
ALLERGIES: Erythromycin Base / Zoloft
PHYSICAL EXAM: Vitals: T 98.2 BP 162/88 HR 59 RR 20 O2 sat 98% General: Pale, alert, articulate. No acute distress. HEENT: MMM Neck: R IJ in place, C/D/I Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Abdomen: Obese, soft, + BS. Suprapubic catheter in place. Ext: Perc nephrostomy drain in place on right flank, No extremitiy edema, some distal extremity wasting.
FAMILY HISTORY: [**Name (NI) **] Father died of prostate CA in age 90s Mother died of MI, aged 90s
SOCIAL HISTORY: Pt is married and lives with his wife, and has an adopted child who is 25. He works as a tax accountant. He has home help aides at home. He denies tobacco or drugs and occasionally drinks ETOH. | 0 |
46,156 | CHIEF COMPLAINT: Status Epilepticus
PRESENT ILLNESS: Mr. [**Known lastname 4882**] is a 20 year old man with severe traumatic brain injury in [**7-28**], now admitted for status epilepticus. Initial injury during roll-over MVA in [**7-28**], ejected from car, sustaining subdural hematoma, skull fracture, SAH, with midline shift requiring emergency hemicraniectomy for increased ICPs. Given severity of injury, he was on prophylactic levetiracetam, although no record of clinical seizures and continuous EEG monitoring for total of 6 days showed no electrographic seizures, but occasional right hemisphere and left frontal spikes. Discharged to rehab in [**2164-8-19**]. Had right cranioplasty and VP shunt in [**9-28**]. Was being tapered off Keppra because of sedation (to 250mg TID). Mother reported that at rehab he followed some commands, answered yes/no questions, spoke few word phrases, and had been able to sit, lift head, and stand with assistance. On [**1-19**] AM, was found to be unresponsive with posturing; given Ativan 4mg and taken to [**Location (un) 1121**], where he continued to have recurrent generalized seizures despite Ativan 10mg, Dilantin 1g, Keppra 2g. Transferred to [**Hospital1 18**] later on [**1-19**], where had continued right arm twitching, head deviation to right, eye twitching, which improved with propofol infusion and resolved with IV phenobarbital load.
MEDICAL HISTORY: Right subdural hematoma multiple brain contusions TBI s/p VP shunt L1 burst fracture s/p PEG, G-tube feeds only s/p Trach, now decanulated
MEDICATION ON ADMISSION: tylenol 650 mg GT Q6h prn amantadine syrup 125 mg GT q24h baclofen 10 mg GT tid chlorhexidine oral rinse [**Hospital1 **] clonidine 0.1mg GT tid colace 100 mg GT [**Hospital1 **] senna 2 tabs GT [**Hospital1 **] dulcolax suppository prn fleets enema prn ferrous sulfate 300 mg GT qday neurontin 300 mg GT tid ibuprofen 800 mg GT q8h prn fever labetalol 800 mg GT [**Hospital1 **] keppra 250 mg GT [**Hospital1 **] metoprolol 50 mg GT Q6h prn HR>110, SBP>160 oxycodone 10 mg GT q4h prn pain
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Initial exam:
FAMILY HISTORY: Noncontributory
SOCIAL HISTORY: Has been at [**Hospital3 **] in [**Hospital1 3597**]. | 0 |
30,070 | CHIEF COMPLAINT: Chest discomfort with exertion and lower extremity edema.
PRESENT ILLNESS: This is a 77 yo male patinet who had a NQWMI 5 years ago. He had been doing well until a few months ago when he started experiencing chest discomfort with exertion and lower extremity edema. An echo in [**Month (only) 958**] revealed moderate aortic stenosis. He was then referred for cardiac cath and subsequently for surgery.
MEDICAL HISTORY: [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**]. Hemorrhoid surgery. Coronary artery disease, s/p NQWMI in [**2150**]. Hypertension. Aortic stenosis. Skin CA. Hyperlipidemia. GERD. Benign Prostatic Hypertrophy. CHronic lower back pain.
MEDICATION ON ADMISSION: Felodipine 10 daily. Simvastatin 10 daily. Atenolol 25 daily. Proscar 5 daily. Terazosin 6 daily.
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS: 62SR 123/62 16 97%RA 5'[**64**]" 170# HEENT: EOMI, PERRL Heart: RRR +S1S2, 3/6 SEM heard throughout precordium and radiated to Bilat Carotids Lungs: CTAB, -w/r/r Abd: Soft, NT/ND Ext: Warm, well-perfused, [**1-22**]+ pitting edema, -c/c Pulses: RFA 2+ LFA 1+, BDP 1+, BPT 2+, BRA 2+ Neuro: Non-focal, MAE, 5/5 strength
FAMILY HISTORY: No history of coronary artery disease.
SOCIAL HISTORY: Married, lives in [**Location **]. Retired. | 0 |
24,194 | CHIEF COMPLAINT: ABDOMINAL PAIN
PRESENT ILLNESS: This is a 63 year old Portuguese-speaking man with extensive history of alcoholic cirrhosis, frequent admissions at [**Hospital1 18**], now here with right-sided abdominal pain, and increased ascites. Starting on Wednesday ([**8-2**]) he began having right-sided abdominal pain. His wife reported that he had increased fatigue, abdominal pain, abdominal girth, and one episode of non-bloody emesis. His wife and cousin denied that he had any episodes of confusion. They explained that he had "pain where they took the water out" on the right. They explained and he affirmed that he has been urinating less. I confirmed the essentials of this history with him during a brief Portuguese interpreter phone interview. . In the emergency department his initial vitals were: 97.9, 111/63, 18, 98% on room air. He was found to be guaiaic negative; and he had labs notable for lactate 9.1, WBC 21.3, Cr 7.6, Glu 15. With low glucose, a D5 drip was started. With consideration of ischemic colitis, the ED sent him for CT scan, ordered without contrast given his renal function; this did not show any signs of ischemia. Additionally, he received: 4.5 gm IV zosyn, octreotide 50 mcg IV and octreotide 25 mcg/hr gtt; as well as 1 amp of calcium gluconate. Liver and kidney services were consulted in the ED; liver fellow left recs in the ED chart and renal fellow planned for HD in the unit. A diagnostic paracentesis was performed in the ED; the liver service recommended against therapeutic tap for now.
MEDICAL HISTORY: Alcoholic cirrhosis known varices portal vein thrombosis s/p TIPS DM Hypothyroid Pituitary mass h/o nephrolithiasis h/o +PPD
MEDICATION ON ADMISSION: [**Month/Day (2) **] 400 mg TID Levothyroxine 100 mcg DAILY Calcium Carbonate 500 mg TID Cholecalciferol 800 unit DAILY Omeprazole 20 mg DAILY Glipizide 10 mg DAILY Lactulose 30-60 MLs PO QID Metformin 1,000 mg [**Hospital1 **] Propranolol 40 mg TID Warfarin 5 mg qHS
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: 97.9, 111/63, 18, 98% on room air comfortable, continues to moan periodically, [**Year (2 digits) **] abdominal pain Neuro: A0x3, asterixis CV: RRR LUNG: scattered rales with expiratory wheeze abd: +ve bs, marked distension ,tense abd, no rebound/no guarding EXT: trace edema
FAMILY HISTORY: Mother deceased, age 50, CVA. Father deceased, age 62, stomach problems. One brother living and in good health. Two sisters, both living and in good health
SOCIAL HISTORY: Lives w/ wife at home. Independent in ADLs and ambulation. Smokes [**12-23**] cigars per day. No alcohol for the last 5 months. [**Month/Day (2) 4273**] IVDU. No ETOH since [**10-29**]. | 0 |
12,561 | CHIEF COMPLAINT: tibial plateau fracture, [**First Name3 (LF) 8813**] stenosis
PRESENT ILLNESS: 71 year old woman with a medical history of A-fib on coumadin and sotalol and [**Month/Day/Year 8813**] stenosis. She was told by a doctor (presumably her cardiologist or cardiac surgeon) that she needed to have her [**Month/Day/Year 8813**] valve replaced. She was told this two months ago and because she is scared of the surgery has not scheduled a date for the surgery. She was walking and stepped on her left foot oddly, this caused her to stumble and fall on her left knee. Her daugher who lives with her was able to help her up and bring her to the ED at [**Hospital 39437**]. She is unable to walk across the room without getting short of breath. She does not get shortness of breath at rest, but consistently becomes short of breath with minimal exertion. She is now being referred to cardiac surgery for evaluation of an [**Hospital 8813**] vavle repelacment.
MEDICAL HISTORY: [**Hospital **] Stenosis Coronary Artery Disease PMH: A-fib Hypertension Hyperlipidemia [**Hospital **] Valve stenosis Mitral Valve problem Hypothyroidism Past Surgical History: s/p Left ankle fracture 10 years ago repaired with "10 screws and a bar" s/p Surgery for PUD causing gastric outlet obstruction s/p Tonsillectomy as child
MEDICATION ON ADMISSION: vitamin D 50,000 units once a week zestoretic daily levothyroxine 100 mcg daily lipitor 20 mg daily coumadin 5 mg daily sotalol AF 80 mg [**Hospital1 **] fish oil 1 gm [**Hospital1 **]
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Admission: VS: afebrile 87/62 145 96% RA GENERAL: WDWN F 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: Obesity Heart problems, pt not sure what kind Half sister had [**Hospital 8813**] valve repalcement at the age of 43 No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory
SOCIAL HISTORY: No Tob ever No EtOH No illicits Patient lives with daughter and granddaughter | 0 |
27,682 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 54-year-old male with a recent IMI/catheter in [**2-22**]. In late [**Month (only) 205**], the patient felt exertional chest pain and was started on Imdur. By the weekend, the patient was having rest angina, taking sublingual nitroglycerin every hour until [**6-29**]. The patient went to St. [**Hospital 107**] Hospital in [**Hospital1 189**] for chest pain, had a stress test which was stopped due to chest pain and ST elevation. The patient was admitted to the Coronary Care Unit and was started on an Aggrastat drip. The patient was transferred to [**Hospital1 188**] catheterization laboratory on [**6-30**] for intervention. The catheterization revealed a 70% proximal left anterior descending, mid-90% left circumflex, and subtotal right coronary artery which was stented due to ST elevations. The patient was transferred to the floor with a right arterial sheath. The patient continued to have chest pains with ST elevations, treated with intravenous nitroglycerin. The plan was to transfer the patient to the Coronary Care Unit for closer monitoring, management and for preoperative coronary artery bypass graft.
MEDICAL HISTORY: The patient's past medical history includes hypertension, hypercholesterolemia, status post myocardial infarction, unstable angina. The patient is a former smoker.
MEDICATION ON ADMISSION:
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
7,955 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 16 year old female with a history of cystic fibrosis status post bilateral lung transplants in [**2108-9-11**], who was admitted on [**2110-12-12**], following a rigid bronchoscopy with dilation and Mitomycin application to reduce swelling and scar tissue in the left main stem bronchus. Shortly after application of Mitomycin, the patient developed a stridor and was treated with Albuterol and racemic epinephrine treatment before transfer to the Post Anesthesia Care Unit for observation. While in the Post Anesthesia Care Unit, the patient acutely desaturated with a pulse oximetry of 60%, was given a nebulizer treatment, non-rebreather mask and failed to improve with hypoxia in a range of pAO2 of 44. The patient was on CPAP with a pressure support of 8 and PEEP of about 10 and FIO2 of 100, and her oxygen saturations improved to the 90s. The patient was transferred to the Medical Intensive Care Unit for observation. Initially, this was thought to be an allergic reaction to Mitomycin and was treated with intravenous steroids, Benadryl and Pepcid. For the next 36 hours in the Medical Intensive Care Unit, the patient could not be weaned off oxygen and would acutely desaturation if the FIO2 dropped below 90%. With the concern of her possible PE causing shunt, the patient was intubated on the third day of hospital stay for a CT scan. The patient acutely desaturated with oxygen of 60s while on the vent prior to having the CT scan. Multiple blood gases drawn showed pO2 in the 31 to 35 range. The decision was made for an emergent bronchoscopy at the bedside where a mucous plug was discovered in the left main stem bronchus. Once removed, the patient's oxygen saturations rapidly improved. The patient was extubated the following day with oxygen saturations in the 95 to 96% on room air. She was observed overnight and transferred to the Medical Floor. The patient was scheduled for a stent on Friday, [**2110-12-19**].
MEDICAL HISTORY: 1. Cystic fibrosis status post bilateral lung transplant in [**2108-9-11**]. 2. Asthma. 3. Gastroesophageal reflux disease. 4. Pancreatic insufficiency. 5. Seizures thought secondary to cyclosporin.
MEDICATION ON ADMISSION:
ALLERGIES: Multiple, multiple allergies including Imipenem, Zosyn, Piperacillin, penicillin, Estrianam, Vancomycin, .............and tobramycin.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient lives in [**Hospital3 **]. Sister also with cystic fibrosis. | 0 |
13,824 | CHIEF COMPLAINT: fatigue, elevated WBC
PRESENT ILLNESS: 75-year-old woman with no significant medical problems presented to her PCP complaining of "not feeling well". Patient reports that on [**6-2**] she saw her dentist because she had been feeling well for a few weeks. She basically states she was fatigued. Her son who accompanies her surgeries sleeping a lot during the day. She was found to have 3 abscessed teeth which were removed on [**6-5**]. She was begun on clindamycin 300 mg QID on [**6-2**] she took until [**6-12**]. For the last 3 nights she has had a fever with max temperature of 100.8. She denies cough, shortness of breath, abdominal pain, dysuria, frequency, stiff neck, headache. She has noted that her stools are a little bit looser, but has not had profuse diarrhea. She denies shaking chills, night sweats. . In the ED, initial vital signs were 98.3 88 130/69 16 100%. White blood cell count was 257K with 98% other forms, hematocrit 29, platelets 58K. Her LDH was 472. Creatinine was 0.8. BMT was consulted in the ED and recommended smear review and bone marrow biopsy, further recommendations pending. Patient was given allopurinol 300 mg PO x 1. She was planned [**Hospital Unit Name 153**] admit for pheresis. Vitals upon transfer were pulse 84, RR 18, BP 140/84, O2Sat 96% RA. . On arrival to the MICU, patient reports no problems. There is no dyspnea, headache or confusion.
MEDICAL HISTORY: Osteopenia Elevated blood pressure
MEDICATION ON ADMISSION: CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - (OTC) - COD LIVER OIL - (OTC) - Dosage uncertain MULTIVITAMIN - (OTC) - by mouth once a day
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: Vitals: T 98.4 BP 154/89 HR 90 R 19 Sat 93%RA General: Alert, orientedx3, no acute distress HEENT: Pupils equal round and reactive, extraocular movements intact, oropharynx clear w/o lesions or petechiae, good dentition, mild gingival hyperplasia NECK: JVP flat CV: nl s1s2, regular rate and rhythm, no murmur/rubs/gallops PULM: clear to auscultation bilaterally w/good air movement, no crackles/wheezes ABD: soft, non-tender, non-distended, +Bowel sounds, no hepatosplenomgaly LYMPH: no cervical LAD EXT: warm, well perfused, no cyanosis/clubbing/edema, no open lesions SKIN: no rashes NEURO: AOx3, 5/5 strength in all extremities,
FAMILY HISTORY: Mother had pancreatic cancer. Father had a myocardial infarction at age 82 and diabetes. Son w/ [**Name2 (NI) **] [**Location (un) **] syndrome. Sister with severe itching for 1 year, unexplained despite extensive testing
SOCIAL HISTORY: She is widowed and remarried. Her two sons are doing well (daughter-in-law [**Name (NI) 553**] [**Name (NI) **]). Has 4 granddaughters. Does not work. She lives in [**Location 14663**] for the summer. She does not use tobacco, EtOH, drugs. Walks 20 min every morning, and a few times a week walks in the evenings as well. | 0 |
90,183 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 34 year old woman who presented with a history of HIV and AIDS and a history of three episodes of diverticulitis and now presenting with feculent drainage from her vagina. The patient began having symptoms of abdominal pain, nausea and vomiting similar to previous episodes of diverticulitis three weeks ago and about a week later presented to the [**Hospital3 2358**] when she noted stool draining from her vagina and a CT scan at the outside hospital documented the enterovaginal fistula. She was given intravenous antibiotics, remained in the hospital and then subsequently, after about a week, was discharged on oral Levofloxacin and Flagyl. She did not take the Flagyl because of problems with nausea associated with it. She subsequently had increasing abdominal pain with occasional vomiting and temperatures to 100.0 F. She then came to the [**Hospital1 69**] because she was unhappy with her previous care at the outside hospital and decided to take up her care here. When she presented, which was on [**2136-9-2**], her last bowel movement was the day before. She did have fever, nausea and vomiting, and she thought she passed some blood with her bowel movement.
MEDICAL HISTORY: 1. Human Immunodeficiency Virus and AIDS 2. Diverticulitis. 3. Bipolar Disorder 4. Anxiety disorder. 5. Peptic ulcer disease. 6. Hypertension. 7. Status post a total abdominal hysterectomy and bilateral salpingo-oophorectomy for fibroids 8. Neuropathy with chronic pain. 9. History of Pneumocystis carinii pneumonia. 10. Thrush. 11. Hepatitis A virus. 12. Hepatitis B virus.
MEDICATION ON ADMISSION:
ALLERGIES: She states an allergy to codeine which causes nausea and any antibiotics with cyclin such as tetracycline, doxycycline, which causes rash, nausea, vomiting.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: Revealing for tobacco; no alcohol. She is unemployed and lives alone. | 0 |
30,543 | CHIEF COMPLAINT: Lethargy and Dizziness
PRESENT ILLNESS: Mr. [**Known lastname 58995**] is a 76 year old gentleman status post AVR/CABGx3 [**2176-12-31**] by Dr. [**Last Name (Prefixes) **]. He was discharged home on [**2177-1-6**] on coumadin for atrial fibrillation. He was also on plavix and amiodarone. Roughly a day after discharge, Mr, [**Known lastname 58995**] began to feel progressively tired. He denies any chest pain, syncope or palpitations however did experience dysnea with laying flat. On [**2177-1-10**], he noticed that he passed bloody urine. Incidently he had fallen on his rightside two days prior. He presented to an outside emergency room where a CT scan of his pelvis and kidneys was unremarkable. His INR was 6.4 and a chest x-ray revealed cardiomegally with a left sided pleural effusion. He was diuresed and claims to have felt better. The urology service saw him and was planning lithotripsy as an outpatient for nephrolithiasis given his past history. Mr. [**Known lastname 58995**] was subsequently transferred back to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical Center given his hematuria, congestive heart failure, anemia and supratherapeutic INR.
MEDICAL HISTORY: CABGx3/AVR [**2176-12-31**] Atrial Fibrillation Nephrolithiasis s/p stent Skin cancer Gout Knee arthroscopy Hyperlipidemia
MEDICATION ON ADMISSION: MEDS ON TRANSFER: Lopressor 12.5mg twice daily Lasix 40mg twice daily Protonix 40mg once daily Alopurinol 150mg once daily 2% nitropaste Pravachol 20mg once daily Cephalexin 250mg four time daily Iron and folic acid Coumadin(on hold)
ALLERGIES: Penicillins
PHYSICAL EXAM: Gen: Well developed man in no acute distress VS: 116/58 64 SR Afebrile HEENT: Anicteric sclera, PERRL, EOMI, Oropharynx benign NECK: Supple LUNGS: Few scattered rales CARDIAC: RRR, III/VI systolic murmur ABDOMEN: Soft, nontender, nondistended EXT: 2+ lower extremity edema DERM: small rash on back NEURO: Nonfocal
FAMILY HISTORY: Father died of CAD at age 56 Mother died of lung cancer
SOCIAL HISTORY: 18 pack years of smoking, past alcohol abuse. Lives with wife. | 0 |
22,970 | CHIEF COMPLAINT: L knee pain
PRESENT ILLNESS: 53M with HCV Cirrhosis, OSA on Bipap that was admitted for an elective left total knee replacements. Pt with hx of devastating knee dislocation. He is ligamentously stable now but has advancing osteoarthritis, tricompartmental. He has significant discomfort and pain. His operation was cleared through workmen's comp.
MEDICAL HISTORY: -Hep C cirrhosis with sustained virologic response, 1 cord of grade 1 varices -Thyroid cancer, status post thyroidectomy -Silent myocardial infarction in [**2142**] (per OMR, patient denies) with normal cardiac cath [**9-/2145**] -Nephrolithiasis -OSA on BiPAP -H/o MVA with chest and abdominal trauma -Deviated septum repair -Inguinal hernia repair as infant - ?COPD Pulmonologist: Dr. [**First Name8 (NamePattern2) 4580**] [**Last Name (NamePattern1) 41892**], [**Location (un) 8545**], MA
MEDICATION ON ADMISSION: furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). trazodone 50 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for Insomnia. zolpidem 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for Insomnia. Multi-Vitamins W/Iron Tablet, Chewable Sig: One (1) Cap PO DAILY (Daily). levothyroxine 137 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). citalopram 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
ALLERGIES: Bee Pollens
PHYSICAL EXAM: Admission Exam: Exam today demonstrates well-healed incisions. He is stable to varus and valgus stress and full extension. At about 20-30 degrees of flexion, he has mild opening medially. . Discharge Exam: Afebrile NAD, AOx3 Resp: Bibasilar dullness otherwise good airmovement without focal rales or rhonchi. Card: S1S2 No MRG Abd: Soft Obese NT ND BS+ Extr.....
FAMILY HISTORY: Mother died of congestive heart failure at the age of 51 and maternal grandfather died of a myocardial infarction at age 42. Two brothers with hypertension and increased cholesterol.
SOCIAL HISTORY: Quit smoking ~8/[**2153**]. History of [**2-9**]-1ppd since [**2130**]. Denies EtOH, has remote h/o drug use (cocaine), but no current use, no h/o IVDU. Works as an EMT. He can walk [**Age over 90 **] yds or climb one flight of stairs with groceries before getting SOB. As an EMT, he regularly lifts patients and stretchers. He also performs yard work, including stacking wood. He has no CP at rest or on exertion. Does have chronic ankle edema. | 0 |
11,352 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is an 85-year-old former smoker with hypertension but no other significant past medical history who presented to an outside hospital on [**3-7**] with months of increasing dyspnea on exertion. The patient also complained of approximately two days of intermittent left arm pain and throat tightness. The patient reported that on the morning of her admission to the outside hospital she woke up in a cold sweat with the left arm pain and chest tightness and was brought to the Emergency Department. At the outside hospital, the patient ruled in for a myocardial infarction by enzymes with a reported peak troponin I of 17. Electrocardiograms at the outside hospital reportedly with ST depressions in leads II, III, aVF, and V4 to V6. The patient was transferred to [**Hospital1 188**] on [**3-9**] for cardiac catheterization. Cardiac catheterization on [**3-9**] showed multivessel disease including an 80% left main stenosis, tight stenosis at the first diagonal with competitive flow, large ramus, but no significant disease in the left circumflex, and 70% mid right coronary artery, and 70% posterior descending artery origin stenosis. The patient was evaluated by Cardiothoracic Surgery but refused coronary artery bypass graft, and instead opted for a repeat cardiac catheterization with stent placement. Stents were placed at the left main, mid right coronary artery, and the posterior descending artery on [**3-9**] during her second cardiac catheterization. On admission to the Coronary Care Unit the patient had no complaints and denied any shortness of breath, arm symptoms, chest pain, or throat symptoms. The patient was in good spirits and had no complaints.
MEDICAL HISTORY: (Past medical history is significant for) 1. Hypertension; treated with one lone outpatient medication (presumably hydrochlorothiazide). 2. Smoking history of approximately one pack per day times 30 years. 3. History of cataracts.
MEDICATION ON ADMISSION: The only medication at home was believed to be thiazide diuretic.
ALLERGIES: Reportedly allergic to PENICILLIN (with unknown reaction, but the patient denies an anaphylactic reaction or any breathing compromise as far as she knows).
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
84,945 | CHIEF COMPLAINT: Palpitations
PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 75980**] is a 33 year old male with a history of spleen lac who is transfered from an OSH for evaluation of polymorphic VT, ?Brugada syndrome. He was in his usual state of health until about 2 weeks ago when he started having almost daily episodes of palpitations that would last for a couple of minutes. He initially thought these were related to caffeine or eating, but also came on in the absence of these triggers. He feels and notices a movement in his chest when he has these episodes. He did become lightheaded once when having palpitations. He tends to breath deeply during these episodes but does not feel short of breath. He had a holter study that showed polymorphic VT. He had a stress test that was cancelled when he developed VT. He had a cath at the OSH on [**8-22**] that showed clean coronaries. He developed a hematoma post-cath when he got up after the end of his bedrest period. Per report, Hct 42->41. . On arrival to the floor the patient was comfortable and pain free. . ROS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies cough, shortness of breath, or wheezes. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rashes. No numbness/tingling in extremities. No feelings of depression or anxiety. All other review of systems negative.
MEDICAL HISTORY: 1. Skiing accident [**12/2136**] resulting in splenic laceration that was treated conservatively, no surgery.
MEDICATION ON ADMISSION: None at home
ALLERGIES: Amoxicillin
PHYSICAL EXAM: VS: T98 BP 120/68 (101-120/56-68) HR 62 (49-62) RR 16 O2 sat 99RA Gen: NAD. Alert and oriented x3. Mood and affect appropriate. Pleasant and cooperative. Resting in bed. HEENT: NCAT. PERRL, EOMI, anicteric sclera. MMM, OP clear. Neck: Supple. JVP not elevated. CV: RRR. Normal S1, S2. No murmur, rubs, or gallops. Chest: Respiration unlabored, no accessory muscle use. CTAB. No wheezes or rhonchi. Abd: BS present. Soft, NT, ND. No HSM detected. Ext: WWP, no cyanosis or clubbing or edema. Digital cap refill <2 sec. Distal pulses radial 2+, DP 2+, PT 2+. Skin: No rashes, ecchymoses, or other lesions noted.
FAMILY HISTORY: Mom - "arrhythmia" GM - CABGx3 Father - HTN Uncle - diabetes ?type1?
SOCIAL HISTORY: Works as a firefighter. Married with a son. Social EtOH use. Recently quit smoking. No drug use. | 0 |
83,851 | CHIEF COMPLAINT: scheduled bronchoscopy
PRESENT ILLNESS: Ms [**Known lastname 107532**] is an 81 year old woman with past medical history significant for chronic low back pain, coronary artery disease, hypertension, hyperlipidemia, and question of vasculitis, transferred to medicine from PACU after undergoing bronchoscopy for workup or a right lower lobe mass and developing a new oxygen requirement. . Briefly, Ms [**Known lastname 107532**] began having a chronic cough and some hemoptysis this past [**Month (only) **]. Workup for this included a CT scan, which revealed a large (6cm) cavitary lesion. She underwent extensive evaluation for possible metastatic disease including head MRI, PetCT and bronchoscopy, however although Pet revealed markedly FDG avid right lower lobe mass with a satellite nodule, transbronchial biopsy and washings were non diagnostic. Patient was electively admitted today to have repeat rigid bronchoscopy with FNA of lymph nodes under ultrasound guidance. Patient was extubated without difficulty however she remained hypoxic and is still requiring supplemental oxygen. . Patient denies any pain, but reports being slightly disoriented still. Has a heavy cough and reports some difficulty breathing, no nausea. . In the PACU, 137/68 96 93% on 50% face tent. Patient was given Lasix 20mg IV and was admitted to MICU team for further management.
MEDICAL HISTORY: CAD Diastolic Dysfunction Low anterior resection [**2146**] for complicated diverticular disease HTN Hyperlipidemia Vasculitis? Lower extremity neuropathy
MEDICATION ON ADMISSION: Lasix 20 mg daily Lisinopril 20/HCTZ 12.5 mg a day Inderal 20 mg q.i.d. (for tremor) Gemfibrozil 600 mg b.i.d Simvastatin 20 mg a day Omeprazole 20 mg a day Caltrate 600 mg a day Iron 65 mg a day Aspirin 81 mg a day Protonix 40 mg a day Alprazolam 0.25 mg q.i.d. p.r.n. Lyrica 150 mg a day Darvocet p.r.n. SLNG as needed
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: On admission General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
FAMILY HISTORY: No family history of lung cancer Sister with breast cancer
SOCIAL HISTORY: Ex smoker, 20 pack year history. Denies alcohol or drug use. Lives with room mate, is originally from [**Country 4754**]. | 1 |
50,612 | CHIEF COMPLAINT: Fever of unknown origin.
PRESENT ILLNESS: Patient is a 61-year-old male with a history of atrial fibrillation, obstructive-sleep apnea, and right MCA stroke with result in hemiparesis, who has been in a nursing home environment since a stroke in [**2176-9-10**]. While at the nursing home, the patient had multiple Clostridium difficile infections and urinary tract infection treated with Bactrim and Augmentin. On [**2177-2-24**], the patient presented to the Emergency Room with fever, nausea, vomiting, diarrhea, and urgency. At [**Hospital 46516**] Hospital, urine culture at that time was positive for E. coli. The patient had mental status changes with fevers as 105. Patient was hypotensive requiring Levophed. The patient was intubated for airway protection at the outside hospital and taken to their Intensive Care Unit, where he was treated with Zosyn, Vancomycin, and Flagyl with a diagnosis of septic shock, Clostridium difficile, and blood cultures subsequently grew out Staph coag negative organisms on [**2177-2-26**] which were thought to come from an indwelling PICC line. At the outside hospital, this PICC line was subsequently removed, and revealed Staphylococcus aureus. Chest x-ray revealed bibasilar infiltrates and sputum revealed Staphylococcus aureus [**3-4**] and there was some concern for aspiration given the patient's poor mental status. The patient was made NPO at that time. A random cortisol level was drawn at that time and was 18. Patient was given hydrocortisone for borderline hypoadrenalism with improved blood pressures. The patient had persistent febrile episodes while on antibiotics and workup for tumor fever ensued. Abdominal and pelvic CT scan revealed bilateral pneumonia, no abscess, 3.5 cm abdominal aortic aneurysm, 1-1.5 cm paratracheal lymph nodes, mild asymmetry of the breast tissue on the right, splenomegaly with small posteroinferior infarct. Endocarditis was entertained. Echocardiogram revealed an ejection fraction of 55%, no wall motion abnormalities, no vegetations, but was a limited study. Hematology/Oncology was consulted. At that time tumor markers were done. CEA was normal. CA-125 was noted to be moderately elevated. Alpha fetoprotein and CA-99 were negative. A trial of Clinoril was performed with no improvement of the patient's fevers. CH-50, C3, and C4 were also done and were within normal limits. A Rheum consult was asked. Rheumatologist noted increased LDH of 1,522, ferritin of greater than 1,300. Rheumatoid factor and [**Doctor First Name **] were negative. Patient was subsequently extubated, though his pulmonary status remained tenuous. Patient remained afebrile on numerous antibiotics for 24 hours prior to transfer to [**Hospital1 1444**]. Patient was transferred to [**Hospital1 69**] for workup of his fever of unknown origin and treatment of his pneumonia, Clostridium difficile colitis, and urinary tract infection.
MEDICAL HISTORY: 1. Right MCA stroke with residual defects. 2. Prostate cancer status post radical prostatectomy. 3. Recurrent Clostridium difficile infections x5. 4. Cervical stenosis. 5. Atrial fibrillation. 6. Glaucoma. 7. Hypertension. 8. Sleep apnea on CPAP. 9. Osteoarthritis. 10. Diverticulitis. 11. Urinary retention. 12. Right hand injury. 13. Bilateral hearing aids. 14. Periodontal disease. 15. Coronary artery disease.
MEDICATION ON ADMISSION:
ALLERGIES: 1. IV dye. 2. Iodine. 3. Codeine.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 1 |
15,972 | CHIEF COMPLAINT: Hypertensive Urgency
PRESENT ILLNESS: 53yo M w/ longstanding DM, IgA & diabetic nephropathy on HD, frequent admission for fluid overload and hypertensive urgency, who was sent to the ED from angiography today w/ BP 230/120. The pt speaks only cantonese, therefore the interview was conducted with his daughter interpreting & with the aid of ED&renal notes. Mr. [**Known lastname 724**] [**Last Name (Titles) 58901**] to the angio suite for b/l subclavian angiography to evaluate for fistula today; at start of porcedure SBP=200-->230/120 after procedure. He was sent to ED. On arrival to ED, BP as stated above, increasing to 242/136, HR 179. HE was given labetolol 20mg IV x 1 (w/ 2 more subsequent doses for total of 60mg), started on a nitro drip, and given hydralzaine 50mg po X 2, asa 325mg. HIs ekg demonstrated TWI in I, aVL, V4-6 & 0.5mm ST depression in I. CE's elevated with initial CK = 333, MB 5, trop 0.39-->253, 0.36-->222, 0.4. CXR revealed cardiomyopathy & mild CHF. He was seen by renal who did not fell he needed HD acutely. He got a head CT to r/o stroke, which did not demonstrate acute pathology (however, it was limited by residual contrast from earlier study). He was briefly started on heparin, however, on informal discussion with cardiology, it was felt that his increased enzymes were [**3-8**] ESRD & CHF, therefore heparin was d/c'd. BP decreased to 160's systolic with above medications. Txf'd to CCU on nitro gtt. Pt denies medication non-compliance. Denies CP, SOB, weakness, sensory changes.
MEDICAL HISTORY: -Hypertension -IgA & Diabetic nephropathy on HD since [**6-9**] (Tues, Thurs, Sat) -Diabetes -hypercholesterolemia -anemia of chronic disease -impaired vision/legally blind (? [**3-8**] diabetic retinopathy) -Right upper extremity DVT ([**7-10**])
MEDICATION ON ADMISSION: -atorvastatin 40qd -asa 325qd -losartan 25qd -lisinopril 20qd -metoprolol SA 200qd -hydralazine 50 qid -metoclopramide 10tid -pantoprazole 40qd -epo 10,000 QHD -CaCO3 500 TID, -NPH/reg 15 qam/4 qpm -simethicone 80-160 tid prn -sevelamer 800 tid
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: T 97.7 HR 87 BP 177/97 RR 16 O2 97% wt 63.4kg gen-awake, alert, in mild distress HEENT-anicteric sclera, no lymphadenopathy, no JVD Chest-normal resp effort, decreased bs's at bases w/ rales ~[**4-7**] way up Cardio-rr, nml s1s2, no m/r/g GI-(+)bs, soft, NT/ND, no organomegaly Ext-1(+) LE edema Neuro-moving all extremities, responding to q's.
FAMILY HISTORY: No DM, CAD, Stroke, HTN, or Renal Disease
SOCIAL HISTORY: Social History: Cantonese speaking only, immigrated to the US 10 yrs ago, currently lives with wife and 3 children, works in a restaurant, no health insurance, no history of tobacco use, alcohol, or illicit drug use | 0 |
59,893 | CHIEF COMPLAINT: SOB, weakness x 1 week
PRESENT ILLNESS: 63M with h/o ESRD s/p CRT '[**98**] w/ recently worsening renal function, CAD s/p 3V CABG in '[**97**], moderate AS, DMII, dCHF presents to the ER with 1 week of SOB and weakness. He reports that his SOB has progressed over the past week - is worst when trying to lie flat but also when trying to exert himself. He finds it difficult to walk up steps or walk a block when he can usually do these things. He has had a dry cough at night for the past week. Also feels chest discomfort when lying flat (not w/ exertion) and endorses generalized weakness. He feels he has been urinating a normal amount. + anorexia, + constipation, + chills, + increased LE edema, endorses 3-pillow orthopnea (stable), denies increased salt intake, + constipation. He tells me he doesn't check his blood sugars at home - doesn't take insulin; is on orals at home. . In the ED, initial VS were: 97.4 60 117/52 18 95% on RA. Labs revealed Hct of 22.1 (bl 23-27 on Procrit), WBC 7.5 (92% PMNs), Na 132, BUN 135, Cr 6.7 (up from 114/6.1 on [**5-2**]), bicarb of 15; anion gap 21. Glucose was 352. BNP [**Numeric Identifier 100667**]. Trop 0.04. CXR showed worsening pulmonary edema, L pleural effusion and small R effusion (stable), LLL consolidation (atelectasis vs. infection). EKG showed NSR at rate of 60, nl axis, prolonged Qtc of 490 ms, TWF inferiorly (longer Qtc than priors). ?VBG showed 7.25/33/88 w/ lactate of 1.3. Blood cultures x 2 were sent. He was initially started on an insulin gtt (7U + 7U/hr) and given 40 mEq K. He was also given 1g Vanc and 2g Cefepime out of concern for pneumonia. Later, lytes showed gap of 19, glc 247. Insulin gtt was stopped after discussion with the ER about his prior acidosis from renal failure. He received 35U IV regular insulin and 20U Lantus in total (takes no insulin at home). Later on s/o, transfer VS were listed as AF 119/72 71 92% on NRB. Discussion was held about involving renal and diuresing. Renal recommended 150 mg IV Lasix bolus + gtt at 10 mg/hr and 2.5 mg metolazone. . Of note, he was admitted [**Date range (1) 7267**], in the ICU for pulmonary edema in the setting of dietary indiscretion for diuresis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.9 that admission. During that admission he received IV Lasix boluses. He initially responded well to IV diuresis but UOP then slowed. He was transitioned to lasix PO 80mg [**Hospital1 **] at discharge. He was ruled out for an MI. His glucoses were up to the 400s prior to discharge. . On arrival to the MICU, VS 97.6 61 129/59 16 98% on NRB --> 97% on 3L nc. The patient is breathing comfortably and speaks in full sentences. He is accompanied by his wife and daughter.
MEDICAL HISTORY: -ESRD secondary to DM and HTN. s/[**Name Initial (MD) **] AVF, CRT [**2199-7-19**] c/b delayed graft function requiring intermittent HD, maintained on tacrolimus; renal fn/acidosis recently worsening -BK virus infection: treated with cidofovir pheresis, leflunomide and cipro, last BK viral load [**2201-9-18**] 2170. -Aortic Stenosis: echo [**3-/2204**] with [**Location (un) 109**] 0.9 -Coronary Artery Disease: s/p PCI in [**2-6**], NSTEMI, s/p CABG [**2197**] LIMA to the LAD, SVG to D1, SVG to circumflex -Hyperlipidemia -HTN -Diabetes Mellitus: c/b retinopathy -Renal osteodystrophy -Iron Deficiency Anemia -Nephrotic syndrome with hypoabuminemia -Bells Palsy -History of Rhabdomyolysis -History of left lower lobe pneumonia -s/p Hydrocele repair
MEDICATION ON ADMISSION: calcitriol 0.25 mcg qday carvedilol 25 mg [**Hospital1 **] aranesp 60 mcg qmonth lasix 80 mg [**Hospital1 **] glipizide 10 mg qday leflunomide 50 mg qday nifedipine ER 30 mg [**Hospital1 **] pioglitazone 30 mg qday pravastatin 20 mg qday sevelamer 800 mg tid bactrim SS qday tacrolimus 3 mg [**Hospital1 **] ASA 81 mg qday NaBicarb 650 mg [**Hospital1 **]
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Vitals: 97.6 61 129/59 16 97% on 3L General: Alert, oriented, no acute distress; speaks in full sentences HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP elevated to jaw, no LAD CV: Regular rate and rhythm, 3/6 systolic murmur heard throughout precordium Lungs: diminished bs at L base; rales heard at both bases, unlabored Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, [**12-5**]+ PE in bil LE; 1+ PE in thighs Neuro: CNII-XII intact, 5/5 strength upper/lower extremities
FAMILY HISTORY: Mother: [**Name (NI) 3495**] Disease, Still Living at 80. Father: Died of Prostate Cancer, age 85. No known family history of renal problems.
SOCIAL HISTORY: Married, lives with wife. Previous history of tobacco - 1ppd x 9 years until age 21. No current use. Occasional EtOH. Denies other drugs including IVDU. | 0 |
55,576 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 44 year old female with a relatively complicated course who was transferred from an outside hospital to [**Hospital1 69**] for further management. Originally she was being conservatively treated for cholecystitis in [**2148-7-11**]. She then underwent a laparoscopic cholecystectomy on [**2148-8-22**], at [**Hospital6 3105**]. Her postoperative course was complicated by respiratory distress, hypoxia, decreased urine output, increased serum creatinine, increased abdominal pain and serum markers consistent with pancreatitis. An abdominal CT scan at that point was concerning for retained stone in the common bile duct with questionable cystitis. She was then intubated and subsequently sent to the [**Hospital1 69**] for further management on [**8-29**]. Upon arrival to our institution, the patient underwent an endoscopic retrogram cholangiopancreatography which revealed coffee ground emesis in the stomach and a large extravasation of contrast in the cystic duct suggestive of a postoperative bile leak. A biliary stent was placed and Interventional Radiology placed a drain in her peritoneal cavity. The patient was started on TPN for nutritional support as well as broad spectrum antibiotics. She had a prolonged Intensive Care Unit course, mostly due to difficulty with extubation. She was extubated on one occasion about two weeks into her stay but required reintubation fairly soon. She remained very difficult to extubate which continued to be the case until [**9-19**]. At that point she was extubated and transferred to the Medical Floor. Upon transfer to the Medical Floor, the patient was comfortable with no complaints. She was awake and alert and conversant although slightly confused. She complained of no abdominal pain, no chest pain, no shortness of breath. The only complaint was of dry mouth.
MEDICAL HISTORY: 1. Gunshot wound to the head resulting in blindness in the right eye. 2. Hepatitis C. 3. Diabetes mellitus.
MEDICATION ON ADMISSION:
ALLERGIES: To Demerol.
PHYSICAL EXAM:
FAMILY HISTORY: Significant for diabetes mellitus in her mother.
SOCIAL HISTORY: She smokes cigarettes but no alcohol or intravenous drug use. | 0 |
72,533 | CHIEF COMPLAINT: 65M s/p CABG [**6-6**] who returned with a pericardial tamponade and underwent R VATS with pericardial window on [**7-15**]. He was dishcarged on [**7-19**] and was doing well until the morning of admission when he had drainage from the R chest tube drain site.
PRESENT ILLNESS: This 65M had a CABG [**6-6**] and did well but had a pericardial effusion with tamponade on [**7-11**] and underwent pericardiocentesis followed by R VATS and pericardial window. He did well and was discharged on [**7-19**]. On [**7-21**] he had a large amount of serrous drainage from his R chest tube site and presented to the ED.
MEDICAL HISTORY: s/p CABGx3(LIMA->LAD< SVG->Ramus, Diag) [**2175-6-6**] [**Month/Day/Year **] ^chol. [**Month/Day/Year 5550**] Depression s/p spinal fusion
MEDICATION ON ADMISSION: Lopressor 25 mg PO BID Colace 100 mg PO BID Lisinopril 40 mg PO daily ASA 81 mg PO daily Norvasc 10 mg PO daily Lipitor 80 mg PO daily Prilosec 20 mg PO daily Fluoxetine 40 mg PO daily
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: WDWNWM in NAD AVSS HEENT: NC/AT, PERLA, EOMI, oropharynx benign Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+= bilat. without bruits. Lungs: R chest has decreased BS at base. CV: RRR without R/G/M, nl. S1, S2 Abd: +BS, soft, nontender without masses or hepatosplenomegaly Ext: without C/C/E Neuro: nonfocal
FAMILY HISTORY: Unremarkable.
SOCIAL HISTORY: Lives with wife, works as a carpenter. Cigs: quit in [**2138**] ETOH: 1-2 drinks/day | 0 |
28,667 | CHIEF COMPLAINT: s/p Motor Vehicle Crash
PRESENT ILLNESS: 48 yo male s/p motor vehicle crash versus stationary object at moderate speed. Severe damgage to vehicle, long extrication. Patient transported to [**Hospital1 18**] for continued trauma care.
MEDICAL HISTORY: None
MEDICATION ON ADMISSION:
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Gen: sedated, intubated HEENT: NCAT Neck: cervical collar. Chest: CTAB Cor: RRR Abd: soft, NT/ND Ext: no c/c/e, cast on L leg Neuro: MAE, sedated
FAMILY HISTORY: Noncontributory
SOCIAL HISTORY: | 0 |
26,994 | CHIEF COMPLAINT: Head bleed s/p fall
PRESENT ILLNESS: 49M portugese speaking, who fell 3 stories & was found wandering & confused (GCS 14). +emesis. Imaging at [**Location (un) 8641**] revealed basilar skull fracture & multiple ICH. Transferred to [**Hospital1 18**] for further care.
MEDICAL HISTORY: none
MEDICATION ON ADMISSION: none
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: 100.6 82 142/83 100% GCS 15 Occipital scalp laceration RRR CTA B soft NT, good rectal tone, guaiac neg lumbar spine tenderness moves all extremities
FAMILY HISTORY: none
SOCIAL HISTORY: none | 0 |
45,287 | CHIEF COMPLAINT: dyspnea
PRESENT ILLNESS: 60-year-old gentleman who presents today to the [**Hospital1 69**] for the workup of his dyspnea. The patient states that his shortness of breath started approximately 4-5 years ago and unfortunately he did not seek any medical help until approximately a year ago. A year ago he saw Dr. [**First Name (STitle) **] who diagnosed him with emphysema and the patient was placed on nebulizers and he felt relatively better as compared to prior. Unfortunately, his dyspnea kept on getting worse as time goes along and in [**2175-7-19**] he had to retire from his job as a truck driver because of severe dyspnea that he could not take it even at rest. The patient recently was prescribed oxygen to use 2 liters nasal cannula 24 hours a day. The patient states that a year ago he was able to walk 50 feet with some dyspnea, but lately he has not been able to do that level of activity without any extreme breathing limitation. The patient denies any symptoms of recurrent cough. He denies any fevers or chills. The patient denies any severe trauma to the chest. He denies any coughing up blood. He denies any history of palpitations of chest pain. In the past year, he has had 9 episodes of pneumonia and reports that prior to this he was never sick. He is referred to Dr. [**Last Name (STitle) **] by you and a tracheobronchial stent was placed. He reports that it felt like "a breath of fresh air." He is now able to quick cough up his secretions with vigor and he no longer uses oxygen. Prior to stent placement. He is on 2 L nasal cannula. Unfortunately, since the stent has been placed, it was partially dislodged because of severe coughing, but now coughing has subsided and his breathing is much improved.
MEDICAL HISTORY: Emphysema
MEDICATION ON ADMISSION:
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: AAO X3, NAD PERRLA, EOMI RRR S1+S2 CTA Bilat Soft, NT/ND No C/C/E
FAMILY HISTORY: Father died of lung cancer. Mother died of lung cancer. A brother died of brain cancer and has two healthy brothers and a sister. [**Name (NI) **] has one son and no grandchildren.
SOCIAL HISTORY: He is married, lives with his wife. [**Name (NI) **] worked as a truck driver and has 1 child. He has a heavy smoking history having smoked 3 packs a day for 30 years and quit 10 years ago. | 0 |
30,178 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 69-year-old male who presented for cardiac catheterization. He had exertional chest tightness in the past and presented for catheterization only.
MEDICAL HISTORY: 1. Bipolar disease 2. Question of silent anterior myocardial infarction 3. History of heavy drinking 4. Chronic back pain 5. He had coronary artery disease with a stent placed in the RCA
MEDICATION ON ADMISSION:
ALLERGIES: He had no known drug allergies.
PHYSICAL EXAM: LUNGS: Clear to auscultation. He had no jugular venous distention and no bruits. HEART: Regular rate with no murmurs, rubs or gallops. ABDOMEN: Soft, nondistended and nontender. EXTREMITIES: Warm and well perfuse with 2+ bilateral pulses.
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
20,346 | CHIEF COMPLAINT: weakness, SDH s/p fall
PRESENT ILLNESS: This is an 81 year old male with a PHMx consistent with hemochromatosis, HCC s/p cyberknife, thalassemia, and cirrhosis, who reports a 6 day history of generalized weakness and falls. He was actually seen by his PCP last week for increased confusion, but no specific cause was identified. He reports [**2-22**] falls over the past week, no loss of consciousness, with the most recent fall occurring at approximately 0200 this morning. He presents electively today with his ex wife.
MEDICAL HISTORY: - Cirrhosis [**1-23**] hemachromatosis - HCC s/p cyberknife in [**10-29**] - Beta Thalassemia (baseline Hct 23-25) with splenomegaly and destruction of RBCs (per Dr [**Last Name (STitle) 96482**] notes) - Hypertension (no longer active) - Diastolic dysfunction - BPH
MEDICATION ON ADMISSION: 1. Tamsulosin 0.4 mg qd 2. Milk Thistle 400 mg tid 3. Vitamin E 1,000 unit qd 4. Melatonin 1 mg qd 5. Levitra 2.5 mg qd 6. Calcium Carbonate 1 g qd 7. Androderm 5 mg/24 hr Patch 24 hr qd 8. Hydroxyzine HCl 10 mg prn-itching 9. Spironolactone 25 mg Tablet [**Hospital1 **] 10. Folic Acid 1 mg qd 11. Ranitidine HCl 150 mg [**Hospital1 **] 12. Nystatin 100,000 unit/mL Suspension qid* 13. Loperamide 2 mg qid 14. Hydrocodone-Acetaminophen 5-325 mg prn-pain 15. Rifaximin 16. Lactulose titrate to 2 bowel movements/day
ALLERGIES: Iodine; Iodine Containing / Tetracycline
PHYSICAL EXAM: PHYSICAL EXAM ON ADMISSION: O: T:98.6 BP: 133/55 HR:68 R:16 O2Sats:94% Gen: WD/WN, severly jaundiced. comfortable, NAD. HEENT:Normocephalic. Laceration above L eyebrow Pupils: PERRLA EOMs intact Neck: Supple. Abd: Soft, NT, No acites appreciated Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**2-21**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors.
FAMILY HISTORY: He has had multiple people in his family died from liver-related disease. His father died from liver cirrhosis (had hemochromatosis), thalassemia diagnosed in the father's family. He is of Italian descent.
SOCIAL HISTORY: Lives alone, does not smoke or drink alcohol, last alcohol 7 years ago. Smoked approx 1 PPD for 25 yrs but quit in [**2071**]. Smokes an occasional cigar. | 0 |
20,447 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is an 86 year old male with a history of prostate cancer, laryngeal cancer and lymphoma, congestive heart failure with an ejection fraction of 35%, who was admitted with a distal left femur fracture status post mechanical fall. He denies syncopal symptoms. No shortness of breath, no chest pain, no lightheadedness, no seizure activity, no tongue biting or loss of bowel or bladder dysfunction. He was reaching for an object, rotated and fell on his left leg which subsequently resulted in a left femur fracture. He has no complaints of left leg pain. He is admitted for a preoperative cardiac evaluation prior to orthopedic surgery.
MEDICAL HISTORY: 1. Prostate cancer status post XRT. 2. Laryngeal cancer, squamous cell carcinoma status post laryngectomy. 3. Lymphoma that is in remission. 4. Congestive heart failure with an ejection fraction of 35%. 5. History of pneumonia. 6. Status post bilateral hernia repairs. 7. Status post cholecystectomy. 8. Status post appendectomy. 9. Hypothyroidism.
MEDICATION ON ADMISSION:
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Two packs a day smoker times 30 years. He quit approximately 40 years ago. Drinks about two drinks a day. He lives alone. His children are in [**Location (un) 86**]. He functions well independently. He ambulates at basement and can walk up two flights of stairs. | 0 |
33,955 | CHIEF COMPLAINT: Gallstone pancreatitis/acute calculous cholecystitis
PRESENT ILLNESS: This is an 81 year-old male with a history of cardiomyopathy w/ EF 20% and Afib on Coumadin who presented to [**Hospital 8641**] hospital with gallstone pancreatitis/acute calculous cholecystitis now s/p cholecystectomy w/ retained CBD stone being transferred to [**Hospital1 18**] for repeat ERCP. His initial sx started on [**8-9**] while he was playing golf. He describes epigastric and RUQ abdominal pain followed by nausea and vomiting and was admitted to [**Hospital 8641**] Hospital on [**8-10**]. RUQ U/S performed on [**10-10**] showed innumerable gallstones, mild GB wall thickening and small amt of pericholecystic fluid with prominent CBD at 7mm. His labs were significant at that time for leukocytosis to 16.3 (N 87%, 11 bands), INR 3.8, lipase 9,856, TBili 1.6 (direct 0.4), and mild transaminitis. Both surgery and GI teams were consulted and felt that his presentation was most consistent with acute cholecystitis and acute pancreatitis (gallstone vs. EtOH). He was monitored for several days while pancreatitis improved and planned for cholecystectomy and intraop cholangiogram, during which time he was treated with Zosyn. His WBC trended down to 7.4, AST/ALT returned to [**Location 213**], lipase trended down to 500s, and TBili increased to 3.8 (DBili 1.0). His INR was reversed with Vit K and FFP and he was brought to the OR on [**10-14**] and gallbladder removed. He was found to have choledocholithiasis under fluoroscopy. ERCP was attempted post-operatively, and had a dilated pancreatic duct w/ apparent small stone, but team was unable to selectively cannulate CBD so plan was made to transfer to [**Hospital1 18**] for repeat ERCP. Also of note, the patient had difficult to control atrial fibrillation and cardiology c/s was obtained [**10-14**], recommending increased dose of Toprol to 100mg daily as well as digoxin 0.25mg daily. . On transfer, the patient reports diffuse abdominal pain ([**7-1**]), though no nausea, CP, palpitations or SOB. He required supplemental O2 in the ambulance. . ROS: + Redness/pain on medial aspect of L great toe started yesterday. The patient denies any fevers, chills, weight change, melena, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, focal weakness, rash.
MEDICAL HISTORY: - Non-ischemia cardiomyopathy - LVEF 20% range (recent abnormal stress test --> cardiac cath [**2117-9-1**] - nonobstructive coronary dz) - Atrial fibrillation on Coumadin - Hypertension - Hypothyroidism - Hyperlipidemia - Erectile dysfunction - B12 deficiency - s/p L inguinal hernia repain - Colonic polyposis
MEDICATION ON ADMISSION: Home Medications: Coumadin Levothyroxine 75 mcg daily Lisinopril 10mg po daily Toprol XL 100mg po daily Monthly B12 injections . Medications on transfer: Zofran prn Tylenol prn Zosyn 3.375mg IV q6hr Pantoprazole 40mg IV daily Metoprolol 5mg IV q6hr Percocet 1-2 tabs prn q4hr Digoxin 0.25mg IV q6hr One time dose of colchicine 0.6mg Synthroid 75 mcg daily
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Tmax: 38.4 ??????C (101.1 ??????F) Tcurrent: 37 ??????C (98.6 ??????F) HR: 98 (96 - 122) bpm BP: 155/90(106) {146/71(89) - 157/90(153)} mmHg RR: 24 (22 - 27) insp/min SpO2: 92% Heart rhythm: AF (Atrial Fibrillation) Height: 73 Inch
FAMILY HISTORY: Daughter recently diagnosed with colon cancer, brother with CAD
SOCIAL HISTORY: Lives alone in his home. He has cared for his wife who has dementia and now is in [**Hospital3 **]. Worked for [**Company **], now retired. Never smoked. Drinks 0-2 alcoholic beverages/day. | 0 |
64,273 | CHIEF COMPLAINT: Aortic Aneurysm, CP, DOE, AF, LE Edema
PRESENT ILLNESS: [**Known lastname 63347**] is a 73 year old male who had a routine physical exam which revealed bradycardia and a 6.7 cm aortic root aneurysm. He also complained of CP, DOE, and lower extremity edema. He has chronic atrial fibrilation. He has been referred for surgical management.
MEDICAL HISTORY: Hyperlipidemia AF BPH Glaucoma HOH
MEDICATION ON ADMISSION: Coumadin, verapamil total of 360 SR QD, lanoxin, cosopt, xalantan, niacin, lasix, kcl
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: NEURO: Grossly intact PULM: Lungs clear HEART: Irregularly irregular ABD: Benign EXT: Warm, 2+ LE edema, no varicosities.
FAMILY HISTORY: brother and son with prostate CA father with lung ca
SOCIAL HISTORY: Retired, lives with his wife. [**Name (NI) **] denies tobacco. Rare ETOH. | 0 |
43,700 | CHIEF COMPLAINT: fever, rash
PRESENT ILLNESS: Pt is a 79 yo female with history of hyperlipidemia, depression, who is also on anti-psychotics for psychiatric/behavior issues who presents with one week of rash and oral mucosal lesions. The rash was accompanied by fevers to 102 one day after the rash and flu-like illness inlcuding cough non-productive of sputum, nasal drainage, nausea, chills and rigors, headache. Patient reports onset of rash approximately one week ago on Sunday, when she noted an erythematous, maculopapular rash on her palms that eventually spread towards her trunk, arms, legs and back and soles. Rash also appeared targetoid in nature mostly on her abdomen. She was also have great difficulty swallowing due to the oral lesions in her mouth. Denies any issues with eye or vaginal lesions. Patient denies any sick contacts. The patient eventually became dehydrated and weak to the point that she was unable to rise from bed, so she presented to [**Hospital1 18**] [**Location (un) 620**] ED on [**2102-2-2**] evaluation and was started on Ciprofloxacin (after the rash started) for presumed UTI. She denied any other new medications including allopurinol, other antibiotics, or new anti-epileptics. She was taking NSAIDs (ibuprofen) for her fever. She is on anti-psychotics chronically including She followed up with her PCP [**Last Name (NamePattern4) **] [**2102-2-3**] who stopped the antibiotic. She was referred to the ED today by her PCP due to concern for progressing [**Doctor Last Name **]-[**Location (un) **]-Syndrome. . In the emergency department, VS were 98.4 125 123/86 16 97% RA. Pt received viscous lidocaine, Vancomycin 1 gram IV x1, Cefepime IV x1. Labs were significant for lactate of 3.6, ALT 132, AST 119, WBC 6.6, Hct of 30.9, Trop-T of 0.17. Lactate initially 3.6->2.4 with 1.5 L of IVFs. Dermatology was consulted in the ED, and thought rash was due to erythema multiforme , and recommended admission for supportive care, prednisone, and performed a punch biopsy of the skin lesions and DFA/culture of an oral mouth lesion. . Also in the ED, patient was initially in sinus tachycardia to 120s but would intermittently burst into paroxysms of atrial fibrillation with RVR into the 170s and would become tachypneic and short of breath, concerning for flash pulmonary edema. Cardiology was consulted for possible cardioversion, but pt converted spontaneously. Cards performed a bedside TTE which per ED report showed normal EF and no depressed global ventricular function. Cardiology recommended starting metoprolol or amiodarone for the atrial fibrillation.
MEDICAL HISTORY: Psychiatric/Behavioral Issues Dyskinesia (from psych meds) Hyperlipidemia Lumbar Spine DJD Osteoporosis Fatigue/Depression Lower Back Pain
MEDICATION ON ADMISSION: Perphenazine 6 mg PO daily Seroquel 25 mg PO QHS Risperdone 3 mg PO daily Simvastatin 20 mg PO daily Eye Drops
ALLERGIES: Penicillins
PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: Vitals: 98.4 125 123/86 16 97% RA GEN: elderly F no acute distress HEENT: PERRLA. MMM. small pearly oral lesions noted on roof of mouth. NECK: no LAD. neck supple PULM: CTAB no crackles or wheezes CARD: S1/S2 present, no m/g/r. ABD: soft NT +BS no g/rt. EXT: wwp no edema SKIN: maculopapular erythematous rash scattered on palms, soles, arms, legs, trunk, and back. targetoid lesions noted mostly on trunk. no nailbed lesions noted. NEURO: cns II-XII intact. 5/5 strength in upper and lower extremities. sensation grossly intact. reflexes [**1-29**]+ bilaterally biceps, achilles.
FAMILY HISTORY: father with stroke. Mother healthy. [**Name2 (NI) **] history of SJS or EN in family.
SOCIAL HISTORY: Lives with her husband in [**Name (NI) 620**], who has myasthenia [**Last Name (un) 2902**]. Denies illicits including tobacco, EtOH, or IVDU. No recent travel. No tick bites. | 0 |
34,028 | CHIEF COMPLAINT: Coffee ground emesis
PRESENT ILLNESS: Mr. [**Known lastname 97280**] is an 82 yo M with h/o CAD s/p CABG, moderate AS, and distant h/o PUD who acutely presents with coffee ground emesis and is being transferred to the MICU for further management. The patient was recently discharged from [**Hospital1 18**] on [**9-14**] after been admitted for chest pain and he underwent a cardiac catheterization. Cath showed native 3 vessel disease, patent grafts, and moderate aortic stenosis. No intervention performed at this time. He was NPO for the procedure but took a full dose aspirin (4 baby aspirin's). He was discharged home and immediately started to feel nauseous with multiple episodes of coffee ground emesis and intermittent lower abdominal pain. He denies any BRBPR or melena at this time. In the ED, NG lavage was attempted but the patient vomited up coffee grounds during the attempt so it was aborted. He was guaiac negative in the ED. GI was [**Name (NI) 653**], and he was started on Pantoprazole 40mg IV BID and then transferred to CC-7 for further work-up. This evening after eating a liquid meal he vomited up [**Date range (1) 61126**] cup of bright red blood with clots. His vitals at this time were BP 180/90 AR 94 RR 18 O2 sat 97% RA. He was then transferred to the MICU for closer monitoring. Patient denies any dizziness, chest pain, or SOB. He does admit to some mild lower abdominal pain. He denies any BRBPR or melena. He denies taking any NSAIDs on a chronic basis.
MEDICAL HISTORY: CAD, s/p CABG x 4 (LIMA-large diag, SVG-LAD, SVG-OM, SVG-PDA from dominant RCA)in [**2188**] Moderate aortic stenosis Hearing loss Peptic ulcer disease diagnosed approximatley 20 years ago, does not recall if treated for H. pylori Left eye loss now with prosthesis S/P kidney stones Inguinal hernia repair x 2 Spinal stenosis Anxiety S/P rotator cuff BPH, s/p TURP, recurrent BPH
MEDICATION ON ADMISSION: Lipitor 20 mg 1 tab daily Nitroglycerin 0.4 mg 1 tab sl q 5 min x 3 prn (does not use) Flomax 0.4 mg 1 tab daily ASA 81 mg 1 tab daily
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: vitals T 98.7 BP 165/86 AR 84 RR 11 O2 sat 97% on 2L NC Gen: Awake and alert, responsive to commands HEENT: Dry mucous membranes, anicteric sclera, L eyelid closed Heart: RRR, + 3/6 systolic murmur with radiation to carotids Lungs: CTAB, few scattered crackles at posterior lung bases Abdomen: Soft, NT/ND, +BS, no epigastric tenderness elicited Extremities: No edema, 2+ DP/PT pulses bilaterally
FAMILY HISTORY: Non-contributory
SOCIAL HISTORY: He is married with two grown children and remains very active walking on a regular basis and working with son in the construction business he used to own. He does not smoke or drink. | 0 |
6,359 | CHIEF COMPLAINT: Chest Pain
PRESENT ILLNESS: Mr. [**Known lastname 1458**] is a 71 y/o male transferred from [**Hospital3 **] after +ETT (had chest pain with EKG changes). Underwent cardiac cath which revealed severe three vessel disease.
MEDICAL HISTORY: Carotid Stenosis s/p Left Carotid Endarterectomy, Hyperlipidemia, Hypertension, Peripheral Vascular Disease, Peptic Ulcer Disease with GI bleed 12 yrs ago, Borderline Diabetes Mellitus, s/p Left Carotid Endarterectomy, s/p Hemorrhoidectomy
MEDICATION ON ADMISSION: Home: Crestor 40mg qd, Gemfibrozil, Atenolol 50mg qd At Transfer: Aspirin 325mg qd, Lopressor 12.5mg [**Hospital1 **], Nitro gtt, Norvasc 5mg qd, Imdur 30mg qd, Omeprazole 20mg qd, Crestor 40mg qd
ALLERGIES: Lipitor / Tricor
PHYSICAL EXAM: At Discharge: VS:T98 BP150/80 P69 RR20 I&O925/700+ Wt88.5kg 96% 2LNC Gen:NAD Chest:lungs CTA bilaterally Heart:RRR, no M/C/R Abd: S, NT, ND Ext:1+ edema, well perfused Incision: C/D/I, sternum stable
FAMILY HISTORY: Mother with MI at age 68.
SOCIAL HISTORY: Quit smoking less than 1 yr ago. Smoked x 30-40 years. Denies ETOH use. | 0 |
76,844 | CHIEF COMPLAINT: Right sided weakness
PRESENT ILLNESS: Pt is a 71 yo woman with h/o DMII, hyperlipidemia, and h/o episode of right facial numbness who presents as a code stroke after developing left sided weakness. She was in her USOH this morning at home when she awoke. She did her morning chores. Then at 11 am, she had the acute onset of "something going over me" in her head. She had no vertigo and no rocking feelings. She said it frightened her significantly, but can't describe this feeling better. She had no blurred or double vision with it. No LOC or presyncope. She hit her lifeline and sat on her steps. EMS found her staring glassy eyed. She noted that she was having trouble making a good fist in the left. She also noted that her left leg was not moving well. She had no HA, but did have the rishing feeling as described above. She had no LOC. She was brought in as a Code Stroke and brought to the CT scanner. A head CT showed no bleeding and CTA showed no obvious large vessel occlusion as interpreted by the stroke fellow. The patient refused an MRI due to claustrophobia. On exam, she was alert and oriented, but had clear LUE and LLE weakness, with normal right sided weakness. She also had hemibody sensory loss to temp and PP as well as vib on the left. Her language was normal. Based on a high clinical suspicion for lacunar subcortical stroke and after a discussion of risks(6-7% risk of ICH) and benefits of tpa, then pt and her son agreed to the infusion. She was given 90 mg tpa per protocol. She tolerated this well. She had no exclusionary conditions to lysis.
MEDICAL HISTORY: 1. Diabetes mellitus type 2 diagnosed ten years ago 2. Spinal stenosis and herniated disk status post laminectomies in [**2081**] and [**2088**], with no significant improvement in symptoms 3. Hypercholesterolemia 4. Hysterectomy in [**2078**] 5. She had right sided facial "numbness" and some unsteadiness in [**2098-9-16**] and was seen by neurology in f/u in [**2098-11-16**] without clear diagnosis and the MRI/A were normal. 6. Angioedema on ACE-I.
MEDICATION ON ADMISSION: Glucotrol 5 daily Lipitor 40 Glucophage 1500 daily Avandia 4 daily Toprol XL 100 daily Meclizine prn Ibuprofen 800 tid Norvasc 2.5 daily ASA 325 daily Diovan 80/12.5 daily Topamax, unknown dose
ALLERGIES: Shellfish / Ace Inhibitors
PHYSICAL EXAM: Vitals:94, 134/50, 21, 96% on RA Gen:NAD. HEENT:MMM. Sclera clear. OP clear Neck: No Carotid bruits CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Ext:No cyanosis/edema
FAMILY HISTORY: Mother died in her late 80s from CA. Father with renal failure. Brothers with lung cancer and bone cancer.
SOCIAL HISTORY: SOCIAL HISTORY: She has a 30 pack year tobacco history. Now quit. Occasional ETOH use. No other drug use. She is separated from her husband. [**Name (NI) **] is supportive. Pt is a retired nurse. | 0 |
49,304 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 43-year-old man with history of recurrent optic nerve schwannoma on the right side, status post several craniotomies, who presented to [**Hospital1 1444**] after having generalized tonic clonic seizure on [**10-30**]. The other day had fever of 101 and upper respiratory symptoms for about 7 days prior to the seizure. The patient received 5 mg of Valium in the Emergency Room, was intubated for lethargy and transferred to neuro ICU. His initial lab data revealed acidosis believed to be secondary to seizure. MRI revealed an area of enhancement posterior to the right orbital prosthesis which was thought to be residual tumor. Also found to have cervical lymphadenopathy and multiple sub cm lymph nodes seen throughout the neck. Head CT showed encephalomalacia in the right frontal and temple region most likely related to previous surgery. Three days after the admission he started to have spiking fever up to 101 on [**11-2**]. At this time he had been hospitalized in neurology service. Since that time his temperatures were in the range of 99 to T max 104. His work-up for fever was initiated. This included LP which revealed 40 white blood cells with predominance of lymphs, 87 RBC, protein 96 and glucose 92. Cultures were negative. He was treated with Ceftriaxone and Vancomycin from [**10-30**] which was discontinued on [**11-3**]. He developed rash which was believed to be secondary to either antibiotics or Dilantin. Antibiotics and Dilantin were discontinued and he was started on Depakote. After this change, rash did improve. His other work-up for fever included blood cultures which were negative, sputum from [**11-2**] showing gram negative rods, gram negative diplococci, urine culture was negative and Lyme was negative. Chest x-ray was also negative and ultrasound of the abdomen were also unremarkable. During the hospitalization on neurology service he also developed transaminitis for which had abdominal ultrasound and KUB, as well as EBV, RS, [**Doctor First Name **] and ESR which were within normal limits. For further work-up of fever he was transferred to medicine service.
MEDICAL HISTORY: Hypertension, recurrent Schwannoma of the right optic nerve, status post multiple surgeries.
MEDICATION ON ADMISSION:
ALLERGIES: Penicillin, Percocet and contrast dye after which he develops rash.
PHYSICAL EXAM:
FAMILY HISTORY: Unremarkable for history of Schwannoma.
SOCIAL HISTORY: Denies smoking or alcohol history. | 0 |
98,526 | CHIEF COMPLAINT: RUQ pain
PRESENT ILLNESS: 71F s/p R hemicolectomy on [**7-10**] for adenoCA (T3N1) returns with 9/10 abd pain and R shoulder pain. The pain is worse with movement. She was able to tolerate breakfast,lunch, and dinner yesterday. She reports an explosive, formed bm yesterday morning and then little flatus since then. She had one episode of dry heaves but no actual emesis. No fever or chills. No sob/chest pain.
MEDICAL HISTORY: PXE, diagnosed at age 42 c/b retinal hemorrhage OU, legally blind PVD, s/p bilateral SFA stenting Hypertension Hyperlipidemia (patient denies) Diastolic heart failure Mitral regurgitation, MVP Atrial fibrillation Polymalgia rheumatica Endometrial cancer, s/p TAHBSO Left carpal tunnel release Eczema Osteoporosis S/P fungal infection of right toes . Cardiac History: CABG: none Percutaneous coronary intervention: none Pacemaker/ICD placed: none .
MEDICATION ON ADMISSION: asa 81', atenolol 25', caltrate 1 tab', diovan 160/12.5', ferrous sulfate 325', fosamax 70', lasix 80', ativan 0.5 prn, mvi, omeprazole SR 20', prednisone 4'', plavix 75', simvastatin 20', tylenol pm, coumadin 2.5 ttss 5 mwf.
ALLERGIES: Chlorhexidine Gluconate/Brush
PHYSICAL EXAM: NAD breathing comfortably, heart regular rate and rhythm soft abdomen, minimal RUQ tenderness, non-distended, no rebound or guarding LE with trace peripheral edema and dopplerable pulses
FAMILY HISTORY: No family history of CAD.
SOCIAL HISTORY: She is married with two adult children. She does not smoke or drink alcohol. She is a homemaker. | 0 |
18,936 | CHIEF COMPLAINT:
PRESENT ILLNESS: Mrs. [**Known lastname 57118**] is a 74-year-old woman, with a several month history of shortness of breath leading to an echo which showed aortic stenosis as well as mitral regurgitation and tricuspid regurgitation. A cardiac cath done in [**2167-8-12**] showed minimal coronary artery disease. She had been admitted twice to the cardiothoracic service before, but was sent home for a yeast infection under her breast and an infection of the left forearm. She presented again on the day of admission, one day prior to her surgery for physical evaluation.
MEDICAL HISTORY: Significant for rheumatic heart disease, obesity, aortic stenosis, mitral regurgitation, osteoarthritis, cataracts, atrial fibrillation, congestive heart failure, neuropathy, and rheumatoid arthritis.
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM: Weight 103.9 kg, temperature 95.6, heart rate 64 sinus rhythm, blood pressure 135/56, respiratory rate 18, O2 sat 97 percent on room air. In general no acute distress. Neurological alert and oriented x3, nonfocal exam. Cardiac showed regular rate and rhythm. Respiratory was clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended with no hepatosplenomegaly. Extremities warm and well perfused with bilateral lower extremity edema.
FAMILY HISTORY: No significant history of CAD.
SOCIAL HISTORY: Lives in [**Hospital1 10478**] with her son, still lives independently, remote tobacco history and rare alcohol use. | 0 |
24,634 | CHIEF COMPLAINT:
PRESENT ILLNESS: Patient is a 28-year-old male with T12 paraplegia and decubitus ulcers, chronic renal insufficiency, who presented with fever and hypotension. Patient is status post recent admission to [**Hospital1 346**] Plastics Service from [**6-26**] to [**7-11**] for treatment of Stage IV right greater trochanter necrotizing ulcer and underwent operative procedure including closure to that area. He was also noted to have Enterobacter urinary tract infection. Patient's wound cultures grew Enterococcus and presumptive MRSA. He was treated with linezolid, cefepime, and Flagyl, and ultimately discharged on linezolid alone. Per the discharge summary, the patient was taking linezolid, however, the patient does not report taking this at home. The patient reports feeling somewhat fatigued three days prior to admission. On the day prior to admission, he noted fever to 104 while at home. He felt slightly nauseous, did not vomit, and denies abdominal pain. He had loose stools for one day, which is unchanged from his baseline. He denied shortness of breath or cough. Denied chest pain. Denied headache or mental status changes. He denied dysuria. He notes that he has not been straight cathing 4x a day as directed. In the Emergency Room, the patient was febrile to 103.7, and initially noted to be tachycardic to the 100's with a blood pressure of 128/60. Large decubitus ulcers were also noted and a white blood cell count of 12,000 was noted. A chest x-ray and urinalysis were negative. Hematocrit was found to be 18. He was transfused 2 units of packed red blood cells. Early in the morning, the patient was noted to have an oral temperature of 93.5 with a blood pressure of 64/32 and heart rate in the 70's. He was given 4 liters of normal saline, and his blood pressure improved into the 90's. He had appropriate urine output to this. The patient was also given linezolid at that time. The patient was then transferred to the MICU for further treatment of his presumed sepsis.
MEDICAL HISTORY: 1. T12 paraplegia from MVA in [**2165**]. 2. Decubitus ulcers Stage IV right greater trochanter, Stage II right ischial, Stage III left greater trochanter, Stage II left heel, Stage IV coccyx. 3. Status post flap closure bilaterally two trochanteric ulcers. 4. Recurrent urinary tract infections. 5. Chronic renal insufficiency secondary to obstructive uropathy, baseline creatinine of 2.7. 6. Seizure disorder with a normal electroencephalogram in [**2174-6-26**]. 7. Question of Clostridium difficile colitis. 8. MRSA.
MEDICATION ON ADMISSION: 1. Xanax one tid. 2. OxyContin 40 [**Hospital1 **]. 3. Percocet 1-2 tablets po q4-6h prn. 4. Depakote 1,000 [**Hospital1 **].
ALLERGIES: 1. Dilantin, seizing. 2. Vancomycin and levofloxacin which gives severe hives. 3. Bactrim hives and throat culture.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient lives in [**Location **] with his mother. Denies tobacco. Denies alcohol. Denies IV drug use. Denies HIV risk factors. | 0 |
34,174 | CHIEF COMPLAINT: respiratory distress
PRESENT ILLNESS: 82 yo M with dilated cardiomyopathy with EF 60%, severe TR, HTN, h/o VF, DM2, PAF, h/o PE and UGIB who presents with respiratory distress from rehab. He was supposed to be discharged from rehab today, but had this complication. His HCT was reportedly slow trending down, so he was given 1 unit of PRBC yesterday for HCT 27.9, and today developed respiratory distress. (Of note, HCT at nursing home increased to 31.9 this morning after transfusion.) Per nursing home notes, he desat to 88% with exertion and was given lasix 40mg x1 and then 80mg IV x1. An ABG was done and he was 7.46/54/78 on 50% ventimask. His vitals signs there were T 98, BP 106/66, HR 85, RR 20 and no recorded oxygen sat at that time. He was brought to the ED. . In the ED, his vitals were T98.2, BP 88/54, HR 50, RR 20, O2sat 99% 6L NC. Per ED notes, he was 88-96 on RA then placed on 3L NC with sats in the mid to upper 90's. He had an EKG and a CXR which showed fluid overload. His blood pressures were staying in the 90-100 range systolic and no diuretics were given for concern over hypotension. He was admitted to the MICU for further care.
MEDICAL HISTORY: 1. Paroxysmal atrial fibrillation 2. Dementia: hallucinates at night 3. Dilated cardiomyopathy with EF 55% 4. Hypertension 5. Ventricular fibrillation w/ AICD 6. Psoriasis 7. Diabetes, diet controlled 8. Macular degeneration 9. Basal cell carcinoma 10. Valvular heart disease (severe MR [**First Name (Titles) **] [**Last Name (Titles) **]) 11. Osteoarthritis w/ decreased mobility from pain 12. Varicose vein 13. PE - [**12-7**] RLL segmental 14. Recent UGIB [**2-5**] gastritis 15. Recurrent pleural effusion- unclear etiology, cytology negative in the past. 16. Asbestosis exposure.
MEDICATION ON ADMISSION: -Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID prn -Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS -Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet daily -Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, PO Q24H -Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID -Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY -Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS -Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) NEB Inhalation Q6H prn -Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB Inhalation Q6H prn -Metoprolol Tartrate 12.5mg PO BID -Bumetanide 2mg PO BID
ALLERGIES: Salsalate / Ace Inhibitors / Heparin Agents
PHYSICAL EXAM: Vitals: T 97.8, BP 98/62, HR 81, RR 18, O2sat 94% on 3L NC General: NAD lying in bed. alert and oriented to person, place and year. HEENT: MMM, PERRL, EOMI CV: irreg irreg 3/6 systolic murmur heard best at the base. PM on left chest wall. Lungs: diminished BS bilaterally about [**1-5**] way up. Then CTAB at the apices Abdomen: +BS, soft NTND Rectal in the ED per notes: guiac negative Extremities: venous statis changes bilaterally. 2+ edema bilaterally Skin: ecchymoses throughout. Dry skin on legs.
FAMILY HISTORY: Notable for a father who had macular degeneration. His mother lived to be 90 and was reported to be healthy. He has one younger sister who died from cancer. There is no family history of any memory disorders.
SOCIAL HISTORY: Denies tobacco, EtOH, illicits. Recently at [**Hospital3 **], but previously living with wife on [**Name (NI) 3146**] [**Name (NI) **]. Retired teacher and coach. | 0 |
8,248 | CHIEF COMPLAINT: Black Stools
PRESENT ILLNESS: [**Age over 90 **] yo M h/o gastric bleeding from Dieulafoy lesion in [**2148**] p/w 5 days black stools. He has been having 1 BM per day for the last 5 days which has been black. He reports dizziness on standing up and walking associated with fatigue. He denied any CP, SOB, nausea, vomiting, diarrhea, abdominal pain. . ED: His vitals were stable. He was frank guiac pos. His HCT was down to 26.2 from 34.7 in [**December 2150**]. He refused NG lavage. GI consulted who decided to scope him in the ICU. . *EGD [**12-12**]: Polyp in the fundus, Mild gastritis *EGD [**7-11**]: An oozing gastric Dieulafoy lesion was seen in the fundus. [**Hospital1 **]-CAP Electrocautery was applied for hemostasis successfully.
MEDICAL HISTORY: 1. HTN 2. CV ***Echo- [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated. Nl LVSF. Mild dilated ascending aorta. [**12-8**]+ AR. mod-sever MR. 3. Flailed of a posterior mitral valve leaflet 4. PVD with critical carotid stenosis on Left side 5. glaucoma 6. macular degeneartion 7. hyperlipidemia 8. BPH 9. h/o TIA in [**7-11**] 10. GIB-[**1-11**], [**7-11**] with Dielafoy's lesion and blood in the antrum 11. Sleep apnea 12. h/o epistaxis 13. GERD in remission 14. Claustrophobia
MEDICATION ON ADMISSION:
ALLERGIES: Protonix
PHYSICAL EXAM: 97.9, 70, 145/53, 17, 100%/2L GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: RRR, S1, no S2 heard, [**3-12**] holosystolic murmur at apex and LSB ABD: distended, tympanic, non-tender, no HSM EXT: no c/c/e, warm, good pulses SKIN: xerosis NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps RECTAL: guaiac positive
FAMILY HISTORY: Non contributory
SOCIAL HISTORY: Social History: Pt is retired from the textile industry. He lives at home with his wife. Quit smoking in [**2106**]. Smoked 1.5 ppd x 20 years. Drinks 4 oz bourbon per day. | 0 |
79,755 | CHIEF COMPLAINT: Right hip fracture status post fall.
PRESENT ILLNESS: This is an 82-year-old woman with a history of type 2 diabetes, hypertension, and end-stage renal disease on hemodialysis, who fell at home on [**11-16**]. She did not sustain any head trauma or loss of consciousness. She reported that she had been using a cane instead of her usual walker and lost her balance. There was no presyncope or palpitations. She noted some right groin pain following the fall, which was worse with walking. Patient was seen for the right groin pain at [**Hospital6 14430**] on [**11-18**]. There a CT scan showed a nondisplaced slightly impacted subcapital right femoral fracture. Patient left against medical advice and went to her usual dialysis in [**Location (un) **]. Patient reported taking Tylenol at home for the pain, which was minimal. On [**11-20**], patient presented to the [**Hospital1 346**] Emergency Department hoping to find Dr. [**Last Name (STitle) **] of Orthopedic Surgery, who had performed a previous hemiarthroplasty on the left in [**2158**] for the patient. At the time of admission, she denied nausea, vomiting, fevers, chills, chest pain, shortness of breath, abdominal pain, cough, right leg weakness or numbness.
MEDICAL HISTORY: 1. Type 2 diabetes, insulin dependent. 2. End-stage renal disease on hemodialysis (Tuesday, Thursday, and Saturday). 3. Hypertension. 4. Status post hemiarthroplasty of the left hip for displaced femoral neck fracture in [**2158-11-15**] by Dr. [**Last Name (STitle) **]. 5. Gout. 6. Secondary hyperparathyroidism.
MEDICATION ON ADMISSION:
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Patient smoked for many years, but quit several years ago. Denies alcohol use. She is widowed and has children in the area. She lives independently. | 0 |
28,517 | CHIEF COMPLAINT: Cholangitis
PRESENT ILLNESS: Mr. [**Known lastname **] is a 57 year old male with past medical history of hypertension. He was transferred here from an outside hospital where for further management of chloangitis. He states that the day prior to his admission he had nausea / vomiting and epigastric pain. He had no other symptoms, no bleeding, no melena, no BRBPR, no hematemesis, no SOB, no chest pain. Normal BM in the day prior to visit, also no PO intake x 24 hours. Currently feels well, no abd pain, no Nausea. . He presented to Northeast Hospitals/[**Hospital3 10310**] Hospital on [**2178-8-5**] for evaluation of epigastric pain, nausea, and vomiting He received two liters of intravenous fluids at that time, along with zofran, 3 grams of Unasyn, and 1 mg of Dilaudid. Laboratories there were notable for elevated total bilirubin of 4.3, direct bilirubin of 3.6, normal lipase, elevated alkaline phosphatase of 142, AST 662, and ALT 663. WBC was 12.9 with 94% PMN. His RUQ at that time demonstrated cholelithiasis, gallbladder sludge and normal common bile duct of 4 mm. His [**Doctor Last Name 515**] sign was positive. His vital signs at presentation were: 98.1, 100, 18, 135/80, 98% oxygen saturation. His blood pressure subsequently was systolics 90-95. . In the [**Hospital1 18**] ED, his initial vital signs were: temperature of 98.4, heart rate of 103, blood pressure 90/68, oxygen saturation 93% on room air. He recieved an additional two liters of IVF and 3 grams of Unasyn. . He was admitted to the SICU on the [**Hospital Ward Name 517**]. He was given intravenous fluids and Unasyn overnight. He was transferred to the [**Hospital Ward Name 516**] the morning after admission ([**8-6**]) to [**Hospital1 18**] for [**Hospital1 **]. . Upon arrival to the ICU after [**Hospital1 **], he reports that he feels well. He denies any abdominal pain, fever, chills, or shortness of breath. . Review of sytems: (+) Per HPI .
MEDICAL HISTORY: - Hypertension - GERD - BPH - Question of obstructive sleep apnea - Status-post TURP and appendectomy
MEDICATION ON ADMISSION: - Simvastatin - Detrol - Prilosec - 'Energy booster' - Vitamin C - Vitamin D/Calcium - Glucosamine - Citalopram (possibly)
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Vitals: T: BP: 103/66 P: 80 R: 16 18 O2: 96% on 3L General: Alert, oriented, no acute distress, slightly lethargic after [**Hospital1 **] but fully arousable and interactive HEENT: Sclera anicteric, slightly dry mucous membranes, 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, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Awake, alert x3, follows commands, speech coherent.
FAMILY HISTORY: NC
SOCIAL HISTORY: + Tobacco use Owns 65 snakes | 0 |
49,808 | CHIEF COMPLAINT: Hemoptysis
PRESENT ILLNESS: Pt is a 54yo male w/ thalasemia minor and recent bronchitis/PNA 2 weeks ago who presented to OSH w/ massive hemoptysis on [**3-28**]. Pt had been treated with antibiotics for recent bronchitis. Despite abx continued to have SOB and then developed hemoptysis with frank blood. He was seen at [**Hospital3 2783**] where he was intubated, sedated and paralyzed with a double lumen ETT to allow aeration of only the left lung. After intubation they suctioned blood out of the right lung as well as the stomach via NGT. CT showed a large mediastinal mass and adenopathy. At [**Hospital1 18**] ED, he got further paralytics then was transferred to MICU. Pt. w/ continued hemoptysis and was taken to OR by IP who found a large mass - non differentiated non small cell cancer - s/p debridement/coagulation of bleeding. He was then sent to [**Hospital Ward Name **] for radiation mapping and intiatiation of XRT. Thus far he has recieved 4 units of PRBC's.
MEDICAL HISTORY: Thalasemia minor
MEDICATION ON ADMISSION: Meds at home: MVI . Meds on transfer: Protonix 40mg qday, Cisatracurium gtt, propofol gtt, RISS .
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: 97.6 HR 88 104/60 AC600X16 .6 PEEP10 Gen: Intubated, sedated, paralyzed HEENT: PERRL, anicteric, mmm, + ETT, + NGT Lungs: Clear on left, rhonchi on right with decreased breath sounds at left base Heart: RRR no m/r/g Abd: Soft, ND, NT, no BS Ext: No edema
FAMILY HISTORY: NC
SOCIAL HISTORY: Ex smoker | 0 |
17,177 | CHIEF COMPLAINT: abdominal pain
PRESENT ILLNESS: 55 yo F w/ hx Hodgkin's s/p XRT in [**2094**] p/w severe abd pain x 3 weeks, worse over past week. She reports she woke up the day after [**Holiday 1451**] (~ 3 weeks ago) w/ LBP. She also had associated RLQ and LLQ pain. The pain is sharp, non-radiating, intermittent, no relationship to food, worse when she sits up and when she walks. She received flexeril and ibuprophen from her PCP w/out significant relief. She reports "lifelong" constipation w/ BM [**2-6**]/week, last BM was [**2129-1-18**], (small, non-diarrheal, non-bloody, non-mucoid). No fevers, chills, n/v/d, melena, hematochezia, knee, or other joint pain. + 4lb wt loss/2 weeks. She also reports neck pain x 3 days, no fevers, no rash, no HA, no photophobia, that is relieved by ibuprofen.
MEDICAL HISTORY: 1. Hodgkin's Lymphoma in the [**2094**], s/p XRT to mediastinum and splenectomy (no chemo) 2. PE on anticoagulation but d/c'ed [**3-9**] alveolar hemorrhage, s/p IVC filter [**2118**] 3. XRT-induced fibrosis and bronchiectasis, no baseline O2 requirement 4. CHF, admitted [**5-9**] with CHF exacerbation 4. s/p MVR, porcine. [**2118**] 5. hypothyroidism 6. s/p CCY 7. GERD 8. EtOH abuse (last drink reportedly mid-[**Month (only) **]) 9. Chronic fatigue syndrome 10. abd pain in [**2124**] s/p colonoscopy and CT abd negative 11. s/p E.Coli pyelonephritis [**2111**] 12. constrictive pericarditis s/p pericardial stripping [**2118**] 13. OSA 14. hx ARF 15. Gout
MEDICATION ON ADMISSION: flexeril, now d/c'ed lasix 10mg po q24h motrin now d/c'ed norvasc 5mg po q24h protonix 40mg po q24h ASA 325mg po q24h synthroid 100mcg po q24h acyclovir prn herpes mvit lotrimin cream
ALLERGIES: Codeine / Iodine; Iodine Containing / Amlodipine / Metoprolol Succinate / Latex
PHYSICAL EXAM: Tm: 98.9 Tc: 98.7 BP: 106/48 P: 98 RR: 18 O2sat: 95% on 3L I/O: [**Telephone/Fax (1) 98754**] Wt: 65.7 kg (no prior weight documented since arrival on [**Hospital Ward Name 517**]) GEN: thin female in no acute distress, breathing more comfortably HEENT: no photophobia, PERRL, OP clear, MMM Lungs: decreased breath sounds [**2-6**] way up bilaterally, dull to percussion [**2-6**] way bilaterally, worse than yesterday morning but improved from last night CV: RRR, S1/S2, no m/r/g ABD: BS+, ND, no masses, nontender EXT: no edema, + palmar erythema, no splinter hemorrhages, no osler nodes or [**Last Name (un) **] lesions
FAMILY HISTORY: No history of CAD, no hx of clotting disorders
SOCIAL HISTORY: unprotected sex over past 7 months after 10 yrs of abstinence. Has hx of ETOH abuse, but reports no EtOH since "mid [**Month (only) **]." | 1 |
45,090 | CHIEF COMPLAINT: found minimally responsive in bed by family
PRESENT ILLNESS: [**Age over 90 **] yo Russian speaking woman with afib and CHF on coumadin who was last seen well at 12 noon by her grandson, who was then later found at 3pm minimally responsive laying on her bed, thus EMS was called. Nursing noticed patient was neglecting the right side (staring to the left) and thus a code stroke was called at 3:57pm. Patient seen immediately as examiner was in the ED tending to another code stroke. NIHSS 20 - mute, not following commands, right dense neglect with fixed gaze, right facial droop, right hemiparesis. CT 4:16pm shows left frontal hypodensity, old right occipital infarct. Labs pending. No prior h/o strokes, was feeling well earlier today. At baseline, dresses herself but requires help with other activities. Cannot walk down stairs on her own. Lives with family. FULL CODE.
MEDICAL HISTORY: 1. Congestive heart failure with an ejection fraction of 40 to 45% with last echocardiogram in [**2167-9-8**]. 2. Chronic atrial fibrillation on anticoagulation. 3. Hypertension. 4. Status post total abdominal hysterectomy. 5. Status post appendectomy. 6. Arthritis of the knees. 7. Bilateral cataract surgeries 8. CRI with baseline ~1.7 . Echo ([**9-/2167**]): Dilated right atrium and left atrium, normal ventricular chamber sizes. Mild concentric left ventricular hypertrophy. Mildly depressed left ventricular function due to focal inferior-basal hypokinesis to akinesis. Mildly thickened 3 leaflet aortic valve with moderate aortic insufficiency. Mildly thickened mitral valve with moderate mitral regurgitation. Normal tricuspid valve with moderate tricuspid regurgitation and top normal pulmonary artery pressure. Small pericardial effusion.
MEDICATION ON ADMISSION: Meds on transfer: IV levoflox 500q24 IV flagyl 500q8h ASA 81 qd Digoxin 0.125qd Imdur 120 po qd Metop 50 po tid IV Heparin
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Vitals: 138/78, 64, 100% NRB -> 96% RA GEN: elderly woman in NAD laying in stretcher looking to the left HEENT: NC/AT, anicteric sclera, mmm NECK: supple, no carotid bruits CHEST: CTA bilat anteriorly CV: irregular irreg rhythm without mur (difficult to appreciate murmurs in the ED) ABD: soft, NT/ND EXTREM: no edema
FAMILY HISTORY: No family history of diabetes, coronary artery disease or hypertension.
SOCIAL HISTORY: lives with extended family, patient actually has no children, former kindergarten teacher, no tob/etoh/drugs ever. Russian speaking. FULL CODE. | 0 |
92,052 | CHIEF COMPLAINT: Eye Pain
PRESENT ILLNESS: Mr. [**Known lastname 4587**] is a 21 year old man with congenital dystonia and a deep brain stimulator. He had a recent hospitalization for sepsis from [**Female First Name (un) **] and bacillus. He reports feeling well since discharge. He had a previously scheduled followup appointment with ID today. He presented to the appointment and was noticed to be less interactive than normal. He also had swelling over the right eyelid and an injected conjunctiva. The patient stated that he had not noticed the edema or erythema. A note states that his mother noticed it since Saturday. He was referred to the ED for further evaluation. . In the ED, initial vs were: 99.0 93 94/66 16 100%. Ophthamology was consulted and examined his right eye and found a corneal ulcer. They recommended tobramycin and vancomycin eyedrops q15 minutes for one hour, then one drop every hour until they re-evaluate in the morning. He had a CT scan which showed pre-septal orbital cellulitis, but no post-septal spread. He was seen by ID who recommended placing him on vancomycin and zosyn for cellulitis. He did not have any fevers or hypotension in the ED. . In the ICU, he denied any pain. He reported feeling tired and wanting to sleep. He denied any blurry vision, headaches, nausea, fevers, or chills.
MEDICAL HISTORY: bilateral deep brain stimulators placed [**6-/2130**], revised in [**2130-11-15**] as a lead fracture was found s/p recent battery replacement in early [**2133-6-14**] s/p Botox injections for cervical dystonia anxiety depression s/p sepsis from [**Female First Name (un) 564**] and Bacillus
MEDICATION ON ADMISSION: -fluconazole 400 mg Tablet until [**8-23**] -lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H as needed for per home regimen for dystonia. -Percocet 2 tabs q 4 hours -prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO: 45 minutes before taking fluconazole as needed for nausea.
ALLERGIES: Pollen Extracts / Cat Hair Std Extract / Banana / Mold Extracts / Grass Pollen-Bermuda, Standard / vancomycin
PHYSICAL EXAM:
FAMILY HISTORY: - 2 maternal uncles with cerebral palsy - 3 cousins that have now been diagnosed with DYT1 dystonia - migraines in grandfather
SOCIAL HISTORY: The patient currently living by himself. He receives disability benefits. He meets with friends and often hangs out in a skater park during the day. He continues smoking about half a pack of cigarettes per day and smokes marijuana several times per week. He admits to drinking two alcoholic beverages per day on average. He denies other illicit substance abuse. He was married for a year but was divorced. He finished high school but is not currently working. Substance use. He has an extensive substance abuse history of marijuana, prescription drugs, and other illicit substances. Legal history. He has been arrested twice including a charge of hit and run with possession of prescription drugs. His licence was previously taken away for several accidents. He currently has it back. Gun posession. He no longer possesses a gun and states that while he used to have nine, all have been sold. | 0 |
42,184 | CHIEF COMPLAINT: Acute pancreatitis
PRESENT ILLNESS: Reason for Transfer: severe post-ERCP pancreatitis. . The patient is a 25 yo F with post-ERCP pancreatitis transferred from an OSH for further management. Pt describes sharp, stabbing, RUQ pain beginning ~[**1-10**] a/w N/V/fever. Pt underwent a lap chole in [**3-14**] for her 2 months of abdominal pain associated with nausea and vomiting. The pain persisted after the lap chole and her LFTs increased. One week PTA, the patient saw Dr. [**Last Name (STitle) 48587**] for a GI consult, and underwent an outpatient ERCP on [**2140-8-2**] which showed an 8mm dilated CBD and CBD stone. A sphincterotomy was performed and the stone was removed. Later that day, the pt complained of severe abdominal pain and presented to the [**Hospital1 189**] Emergency Room. Amylase returned at 3,818 and lipase at 12,148. She was given pain meds and fluids at 200cc/hr, however, pt continued to complain of pain and she began to third space all fluids. (hemoconcentration Hct 41-> 48%, intravascular depletion with Cr up to 1.4, borderline urine output at 30 cc/h, somewhat tachycardic, low grade-temps to 100). CT abdomen confirmed 3rd spacing, but showed pancreas still perfused. A PICC was placed for TPN and pt was on a dilaudid PCA. The patient was transferred to MICU for further management. . On arrival to the ICU, pt was complaining of severe pain and her HR was in the 140s. Over the next two days, she received a total of 12L and her pain was controlled with 1mg of dilaudid every 3hrs. She was alert and requesting liquids. She was transferred to the floor on HD#3. On the floor, pt was somnolent but arousable with HR into the 110s (up to 140s with pain), RR in the 20s but up to 30s with pain. O2 sats remained stable >92% with 2L. On night prior to txf back to MICU, pt triggered with acute SOB and HR up to 140s, 92% on 2L. She was given dilaudid, nebs and ativan and she improved both symptomatically and clinically. During her stay on the floor, her fluids were decreased from 200 cc/hr to 75 cc/hr due to increasing concern for third spacing and worsening pleural effusions. On day of transfer, pt's HR again increased to 140 with worsening abd pain, located in RUQ associated with more SOB. Again, the team tried nebs, ativan and dilaudid, this time with no improvement. Bld gas showed 7.4/33/55 on 2L with a lactate of 2.5. Temp spiked to 101.7 and bld cx were drawn. A CXR showed a large gastric bubble, low lung volumes and bilateral pleural effusions (but unchaged from prior CXR). The ICU was called to evaluate pt. . On txf back to the ICU, pt was somnolent, answering questions with one-word answers. She was very tachypneic with a RR in the 40s and diaphoretic. She complained of not being able to pull enough air in. She pointed to her RUQ when asked where she had pain. She denied nausea, vomiting or constipation. Last bowel movement yesterday. On ambulation to the bathroom, HR increased to 178. . Referring MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] via Dr. [**Last Name (STitle) 48587**] ([**Telephone/Fax (1) 67304**] cell phone number, [**Telephone/Fax (1) 67305**] endoscopy suite, [**0-0-**] direct pager) . [**Hospital3 36606**] [**Telephone/Fax (1) 67306**] PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Hospital1 189**])
MEDICAL HISTORY: none.
MEDICATION ON ADMISSION: TPN via PICC dilaudid pca
ALLERGIES: Vicodin
PHYSICAL EXAM: Upon admission to MICU: VS: HR 129 BP 90/60 O2 93%2L General - well nourished female lying in bed, mildly sedated from pain medication, but easily arousable and answers questions appropriately. HEENT - PERRL, no scleral icterus, mucous membranes dry. Neck - supple, no LAD, no JVD. CV - tachycardic, no murmurs, rubs or [**Last Name (un) 549**] appreciated. Chest - mildly decreased breath sounds at the bases (poor inspiratory effort [**3-10**] pain), otherwise clear, no rales. Abdomen - tender to palpation diffusely (worse on right and epigastric area). Ext - no c/c. Some puffiness around sight of right peripheral IV.
FAMILY HISTORY: Father with "gallbladder problem."
SOCIAL HISTORY: Denies tobacco or IVDU use. Occasional ETOH consumption ([**4-9**] times per year). Lives with Fiance. Works for Boys and Girls club of America. | 0 |
84,688 | CHIEF COMPLAINT:
PRESENT ILLNESS: Ms. [**Known lastname **] is a 30-year-old G0, P0 with fibroid uterus who presented with heavy vaginal bleeding times one day. The patient was undergoing medical therapy for symptomatic uterine fibroids including Depo-Lupron and OCP's daily. The patient reports her vaginal bleeding had been minimal on this regimen until the night prior to admission. The patient took two OCP's the night before admission secondary to increased bleeding, however on admission the patient was soaking and changing pads every 30 minutes. The patient stated that she had a mild headache and was lightheadedness, however she denied any shortness of breath, abdominal pain, constipation, diarrhea, fever, chills or recent sexual intercourse. She also complained of occasional heart palpitations. She was tolerating p.o. well. The patient stated that she was scheduled for a MRI later in the week of admission for preoperative evaluation prior to potential myomectomy.
MEDICAL HISTORY: 1. Iron deficiency anemia. 2. Hepatitis B.
MEDICATION ON ADMISSION:
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient is a pharmacy student. She is single and lives with a roommate. She denies any history of tobacco, alcohol or other drug use. | 0 |
52,201 | CHIEF COMPLAINT: The patient is status post pedestrian versus automobile.
PRESENT ILLNESS: The patient is a 65 year old male pedestrian versus motor vehicle, unresponsive in the field. The patient was transported to [**Hospital1 190**], hemodynamically stable and was intubated in the Emergency Department.
MEDICAL HISTORY: 1. Hypertension. 2. Osteoarthritis. 3. Chronic back pain. 4. Acoustic neuroma. 5. Knee pain.
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient is a social ETOH drinker and smoker. | 0 |
36,000 | CHIEF COMPLAINT: Alcohol Withdrawal
PRESENT ILLNESS: Mr. [**Known lastname **] is a 57 yo M with PMHx sig. for ETOH abuse without DTs and seizures who presents with ETOH withdrawal. He drinks a quart of vodka daily. His last drink was this morning at breakfast. He had ran out of alcohol. Soon thereafter, he began feeling tremulous and anxious. No hallucinations. He also started have a R-sided headache, which he often gets when he withdraws from alcohol. Of note, pt has been admitted 4 times in the past 2 months for alcohol withdrawal, all requiring initial ICU stays for high BZD requirements and often signs out AMA.
MEDICAL HISTORY: -Alcoholism, no h/o DTs or seizures -Depression, h/o suicidal ideation, none currently, no history of suicide attempts -ADHD -Hypertension -H/o SVT during ETOH withdrawal, last episode 6 mo ago -History of melanoma excised from L back -Degenerative joint disease, esp. L hip -Chronic Kidney Disease, baseline Cr of 1.1-1.2
MEDICATION ON ADMISSION: 1. Atenolol 25 mg PO DAILY 2. Lisinopril 20 mg daily 3. Venlafaxine 225 mg Sust. Release PO DAILY 4. Trazadone prn ? Verapamil and Amlodipine (from records - patient uncertain of medications)
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Vitals - T:96.9 BP:169/97 HR:94 RR:16 02 sat: 100 ra GEN: NAD, tremulous, somewhat anxious. Otherwise friendly and interacts appropriately. HEENT: EOMI, MMM, no scleral icterus, no nystagmus CV: RRR, no m/r/g, nl S1/S2 PULM: CTAB ABD: Soft, ND, NT, no HSM appreciated. +angiomas, no caput. EXT: No edema. WWP. NEURO: Tremulous. SKIN: Not jaundiced
FAMILY HISTORY: Family history of alcoholism among males on both sides: maternal uncle and grandfather; as well as his father and brother. His mother died of CHF in her 80's. Father died of lung cancer and CHF. No family history of premature CAD or sudden cardiac death. No known family history of liver disease.
SOCIAL HISTORY: He lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] paid by his millionaire lawyer sister. [**Name (NI) **] previously worked in "high-tech sales" selling "knowledge management" consulting software, but lost his job and started drinking then. He never smoked. He last used recreational drugs including IVDU in the 60's but none since then. He drinks a quart of vodka daily. | 0 |
87,691 | CHIEF COMPLAINT:
PRESENT ILLNESS: Mrs. [**Last Name (STitle) 47101**] is an 84-year-old right-handed white female with a past medical history of hypertension, atrial fibrillation with a pacemaker, high cholesterol, and a left MCA stroke three years ago with right-sided weakness that mostly recovered, leaving her with her family to have the acute onset of severe dysarthria with a right facial droop and arm and leg weakness. She was taken to [**Hospital6 33**] in the interest of having TPA started quickly. She arrived at [**Hospital6 33**] at 8:30 P.M. and, by reconstruction from her notes, her NIHSS was 18 to 20. A CT was done at 9:50 P.M., which ruled out hemorrhage, and she was given a bolus of 6.3 mg of TPA at 10:15 P.M. Her with a flaccid right-sided paralysis. She was transferred to [**Hospital1 69**] where, in the Emergency Room, the CT scan was repeated. Her blood pressure was 170/100, and she was able to grunt and say yes or no, and remained with a dense right hemiparesis.
MEDICAL HISTORY: 1. Hypertension 2. High cholesterol 3. Stroke three years ago, left MCA 4. Pacemaker for atrial fibrillation
MEDICATION ON ADMISSION:
ALLERGIES: Penicillin, Lipitor, Macrobid
PHYSICAL EXAM:
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Very active, widowed. | 0 |
98,690 | CHIEF COMPLAINT: tracheal stenosis s/p intubation. tracheal stent in place
PRESENT ILLNESS: 51-year-old female from [**Hospital1 189**] who had a stent placed one year ago in [**Last Name (LF) 14660**], [**First Name3 (LF) 108**], in her trachea secondary to tracheal stenosis. Her illness started in [**2187-11-7**] when she had an overdose requiring hospitalization and mechanical ventilation with intubation. She was reported to be intubated for approximately three days. She had no traumatic extubation. She did not self extubate, but gradually after her critical illness period, she developed increasing shortness of breath. This developed over three to five weeks post her hospital stay. Her cough has been gradually progressing. Currently, on a flat surface she can walk less than three to four gates at the airport, and she can walk up less than one flight of stairs. She has had recurrent airway stenoses which have been treated with serial dilation.
MEDICAL HISTORY: tracheal stenosis -multiple dilitations, s/p metal tracheal stent placement '[**86**]. depression w/ suicide attempt- intubation,
MEDICATION ON ADMISSION: prednisone 20, hydromet 1-2tsp'''
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: PHYSICAL EXAMINATION: Heart rate is 99, her blood pressure is 138/93, her respiratory rate is 22, her temperature is 97.9, her saturations are 95%. In general, she is a cushingoid-appearing Asian female. She has normal nasal mucosa and normal oropharynx. Her neck is cushingoid. Her chest is clear to auscultation bilaterally. Her cardiovascular exam is normal S1 and S2. Her abdomen is soft. There is no guarding, no rebound. Her extremities show no clubbing, cyanosis, or edema.
FAMILY HISTORY: n/c
SOCIAL HISTORY: She lives with family. She denies alcohol or tobacco use. | 0 |
54,442 | CHIEF COMPLAINT: Sepsis: Cholangitis
PRESENT ILLNESS: Pt is a 64 yo female with h/o of DM, HTN, anemia, who initailly presented to Bodowin St health ctr on [**2147-6-13**] b/c of 1d h/o N/V/D after having eaten out in NY. She was treated w/ Compazine and Imodium. . On [**2147-6-15**] the pt presented to [**Hospital **] hospital w/ jaundice, chills, N/V. In the [**Name (NI) **] [**Name (NI) **] pt was noted to have fever (106.4 in ED), abd. pain, vomiting, tachycardia 180's, and hypotension (130-->74). She was notably dehydrated and was treated with IVF. She was then xferred to ICU at OSH for delta MS and concern for sepsis. She was empirically treated with Amp/Gent. Labs were initially notable for %10 bandemia, Na134, K+3.9, cl 97, HCO 23.5, Ca++9.4, TB 5.5, AP 205, AST116, ALT 82, alb 3.3, TP 6.4. INR 1.2. Pt started c/o RUQ and epigastric pain. An US of Abd found to have CBD dil., CBD 1.1cm. She was dx w/ acute cholangitis and was referred to [**Hospital1 18**] for urgent evaluation/decompression of CBD. . ROS: abdominal pain, denied weight changes
MEDICAL HISTORY: PMH: -HTN -DM (dx 1 week prior to admission) -Pernicious anemia -Abnormal mammogram ([**2142**]-?abnormality) . Medications on transfer: (incomplete) Tylenol 625mg PR, Amp 2g Q4H, Gent x1 . Medications on admission to OSH: -Compazine 5-10mg Q6H PRN -Motrin 100mg Q8H PRN -Ferrous sulfate 325mg QD -Lisinopril 20mg QD -B12 500mg Qmonthly -Metformin (not started yet)
MEDICATION ON ADMISSION: Medications on transfer: (incomplete) Tylenol 625mg PR, Amp 2g Q4H, Gent x1 . Medications on admission to OSH: -Compazine 5-10mg Q6H PRN -Motrin 100mg Q8H PRN -Ferrous sulfate 325mg QD -Lisinopril 20mg QD -B12 500mg Qmonthly -Metformin (not started yet)
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Vitals: T:100.1 P:133 RR:33 BP:104/32 SaO2:100% 6L General: Awake, alert, agitated HEENT: NC/AT, PERRL, EOMI without nystagmus, bilateral scleral icterus, MMdry, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally with mild expiratory wheezing Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, mild RUQ tenderness, ND, normoactive bowel sounds, liver margin palpable 1cm below costal margin Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Neurologic: alert, not oriented x3, no focal neurologic deficits
FAMILY HISTORY: NC
SOCIAL HISTORY: Social Hx: Native of [**Country 15800**]. Mother of 6 children. Lives with daughter. [**Name (NI) 1403**] as a cafeteria monitor. No ETOH, no smoking. | 0 |
79,473 | CHIEF COMPLAINT:
PRESENT ILLNESS: Patient is a 52-year-old male with liver cirrhosis secondary to hepatitis C and alcohol abuse. He presented to [**Hospital1 69**] on [**2109-12-16**] for a living related liver transplant from his son, [**Name (NI) 44475**] [**Name (NI) 44476**]. The complications and risks of procedure were discussed in full with the patient prior to the surgery.
MEDICAL HISTORY: 1. Chronic hepatitis C cirrhosis. 2. Heavy alcohol use. 3. Herpes. 4. Status post tonsillectomy. 5. Status post thyroid cyst resection. 6. Status post appendectomy.
MEDICATION ON ADMISSION: 1. Prevacid 30 mg p.o. b.i.d. 2. Famvir 25 mg p.o. b.i.d. 3. Aldactone 50 mg p.o. q.d. 4. Nadolol 20 mg p.o. q.d. 5. Glucosamine one tablet p.o. q.d. 6. Multivitamin. 7. Escitalopram 10 mg p.o. q.d. 8. Migraine medication prn.
ALLERGIES: He has no known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
42,305 | CHIEF COMPLAINT: Status post high-speed MVC.
PRESENT ILLNESS: 21 yo female restrained driver, s/p motor vehicle crash. GCS 15 at scene. She was transported via [**Location (un) 7622**] to [**Hospital1 18**] for further care.
MEDICAL HISTORY: Denies.
MEDICATION ON ADMISSION: None.
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM:
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: | 0 |
95,748 | CHIEF COMPLAINT: tachycardia, tachypnea, dyspnea, and altered mental status
PRESENT ILLNESS: Please see the nightfloat admission note [**2200-7-4**] for full details. In short, this is a 38 M with EtOH abuse presenting from home with altered mental status and pneumonia. The patient recently moved back to the USA after being layed off from a pharmaceutical company in Europe and established medical care here. After a discussion in early [**Month (only) **], has apparently not had a drink for 2 weeks. Yesterday night he was confused at home, intermittently A&Ox3 and at other times making bizarre comments, but brought in by EMS after falling at home. Of note, he was recently treated with Levaquin for suspected pneumonia, and has been having both blood-tinged sputum and blood-streaked diarrhea. . Labs on admission notable for lactate of 2.9 (for which he received 2 L of IVFs), Cre of 1.3 with a gap of 19, NH4 of 15, AST of 240, ALT of 192, Tbili of 3.8, INR of 1.8. WBC of 10, Hct of 44, Plts of 196, MCV high normal of 98, but with occasinional schistocytes on RBC morphology (automated). The pt underwent RUQ U/S which showed trace peri-hepatic, peri-splenic ascites, no focal liver findings, and no acute cholecysitis, a Head CT with ?low hanging cerebellar tonsils versus artifact, and a CXR which confirmed a PNA and ?L pleural effusion. The pt received Vancomycin, CFTX, Azithromycin (first 2 abx for emperic meningitis coverage) and thiamine 100 mg PO x1. . On the floor overnight, patient became increasingly somnolent. He recieved several doses of valium overnight for presumed withdrawl. This morning, he became increasingly tachypneic to 30 and tachycardic to 120s-130s. He maintained adequate sats on room air. Lactate had also increased from 2.9 to 3.3. CXR also may have signs of possible abscess. ID consult was obtained and patient was transferred to the ICU for concern for developing SIRS/Sepsis. . Patient reports stopping drinking two weeks ago, followed by some tremulousness and headaches. He has felt unwell for 3 weeks or so with persistent cough. Has also had intermittent diarrhea and brown urine. Denies vomiting. Denies dysuria. Other ROS negative.
MEDICAL HISTORY: 1. Gout. 2. Non-hodgkin's lymphoma diagnosed at age 2, treated with several years of chemotherapy. Apparently had ? liver recurrence at age 6, but liver biopsy showed only scarring. 3. Elevated LFTs on recent lab work at [**Hospital1 2025**]. 4. Hyperlipidemia. 5. Alcoholism since his 20s. Always been very functional, working full time job. No history of withdrawal or rehab.
MEDICATION ON ADMISSION: 1. Prilosec 40 mg daily. 2. Cipralex 10 mg daily, this was prescribed in Europe (escitalopram) 3. Colchicine as needed. 4. Ambien as needed.
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: ADMISSION EXAM: Tmax: 36.2 ??????C (97.2 ??????F) Tcurrent: 36.2 ??????C (97.2 ??????F) HR: 107 (107 - 118) bpm BP: 106/71(80) {89/56(60) - 109/79(84)} mmHg RR: 27 (25 - 35) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) Height: 26 Inch
FAMILY HISTORY: History of diabetes in his father, history of asthma in his grandfather. [**Name (NI) **] history of early MI, malignancy, or stroke.
SOCIAL HISTORY: The patient lives with his wife in [**Name (NI) 86**]. They are monogamous. He has no concerns for STD at this time. He has no children. He works for a pharmaceutical development company. The patient reports drinking quite a bit alcohol, which includes five glasses of wine or beer each night seven nights a week for at least 8 years, likely more. He does realize he needs to cut down, as we discussed this at length today, and he seems willing to do so. He has 'the shakes' only for the first 5 days when he stops drinking. Denies blackouts, seizure activity, or hallucinations when he stops drinking. Denies any history of drug use. He smokes one to two cigarettes daily with alcohol. | 0 |
94,886 | CHIEF COMPLAINT: Chest Pain
PRESENT ILLNESS: Dr. [**Known lastname 18705**] is a 64-year-old male who underwent a stress test that was remarkably positive. He was taken to the cath lab urgently and that showed severe three- vessel disease with diffuse disease involving his LAD in multiple locations, even far out at its distal [**11-21**]. He also had a diffusely-diseased circumflex/marginal. His right coronary had moderate disease of about 60 to 70% in its mid course. He also had a diseased diagonal branch. His ejection fraction was preserved.
MEDICAL HISTORY: Hyperlipidemia NIDDM
MEDICATION ON ADMISSION: Aspirin Glucophage Glyburide Lipitor
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: NEURO: Grossly intact. No carotid bruits LUNGS: Clear HEART: RRR, Nl S1-S2 ABD: Benign EXT: Warm, no edema, no varicosities
FAMILY HISTORY:
SOCIAL HISTORY: Physician. [**Name10 (NameIs) 78079**] and lives with wife. [**Name (NI) 4084**] smoked and rarely drinks. | 0 |
10,157 | CHIEF COMPLAINT: FALL
PRESENT ILLNESS: This is an 85 year old man with history of dementia who lives at home with his daughter. Today he was in his driveway when he fell and struck his head. He went back into his house and called 911 for help. Upon EMS arrival he was in his usual state answering questions and oriented to himself and his family. Pt taken to OSH where he began to have mental status changes and became less responsive. He was intubated and CT of the head showed left sided SDH with midline shift and diffuse SAH with bifrontal contusions. He was transfered to [**Hospital1 18**] for further evaluation. He was taking ASA and plavix for a previous cardiac stenting. He did not receive any blood products prior to transfer.
MEDICAL HISTORY: s/p removal of duodenal adenoma dysplasia and pancreatic endocrine tumor [**5-/2099**] Depression Ankle fracture 3 wks ago Hypercholesterolemia Mild dementia GERD chronic constipation known urinary frequency
MEDICATION ON ADMISSION: ASA, Plavix
ALLERGIES: Bupropion Analogues
PHYSICAL EXAM: On admission: PHYSICAL EXAM: BP: 151/86 HR: 74 R 18 O2Sats Gen: Intubated and sedated HEENT: Pupils: 2-1.5mm EOMs Unable to evaluate Occipital laceration noted, not currently bleeding Neck: C collar in place Extrem: Warm and well-perfused.
FAMILY HISTORY: father: MI in his 70s uncle: died in 60s of MI
SOCIAL HISTORY: retired pathologist, no smkg, ETOH, drugs, married, lives at home with wife | 0 |
9,313 | CHIEF COMPLAINT: GIB
PRESENT ILLNESS: 63 year old male with past medical history of alcoholic cirrhosis complicated by ascites and variceal bleeding, duodenal ulcer, pancreatic mass, hepatic metastases, CAD, afib on coumadin who started his clinical decompesation in [**2180-3-26**] with inguinal hernia. He presented in [**2180-7-27**] with lower extremity edema and ascites which was attributed to his liver failure vs chronic systolic heart failure. . He had screening EGD done on [**2180-11-7**] which showed nonbleeding esophageal varices. He presented to [**Hospital **] clinic on [**2180-11-8**] where he had MRCP that showed cirrhosis, splenomegaly, pancreatic mass and hepatic metastases. A plan was formed to further evaluate this condition. Labs were drawn and were most notable for a HCT of 41, Ca19-9 of 461. . He had large volume paracentesis of 8L done on [**2180-11-10**]. He presented to OSH this morning after having episode of hematemesis and BRBPR. He was noted to have SBP of 77, HCT 20 and INR 2.3 (of note has been off coumadin for past 10 days). His BUN/CR was 50/1.3. He was given 3 units of PrBC with bump in his HCT to 27. He continued to be hypotensive requiring norepi gtt. He underwent endoscopy which showed gastric varices vs GEJ varix with clot in upper stomach which could be dislodged. He was continued on octreotide and protonix gtt and transferred to [**Hospital1 18**]. . On arrival to the MICU, he reports feeling better. GI scoped him as he continued to have BRBPR x 3 with increase in levo gtt. . 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: cirrhosis decompensated with ascites and variceal bleed pancreatic mass with metastases and elevated Ca19-9 diverticulitis with a colovesical fistula, which closed spontaneously. CAD Duodenal ulcer afib, on coumadin (not for last ten days) history of CHF
MEDICATION ON ADMISSION: ALLOPURINOL 200 mg daily ATENOLOL 50 mg Tablet daily ATROPINE 1% drops to left eye once a day DIGOXIN 250 mcg daily FENOFIBRATE 200 mg po qdaily Potassium chloride 20 meq po qdaily FUROSEMIDE 40 mg daily PREDNISOLONE 1% right eye three times a day SIMVASTATIN 40 mg daily WARFARIN 2.5 mg po qdaily (not taken in past 10 day) ASPIRIN 81 mg daily MV-FA-CA-FE-MIN-LYCOPEN-LUTEIN [CENTRUM] Fluticasone inhalation 1 puff [**Hospital1 **] sometimes
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: non-tender, distended but soft, 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
FAMILY HISTORY: Not contributory to current presentation
SOCIAL HISTORY: No Alcohol, Tobacco or drugs | 0 |
1,806 | CHIEF COMPLAINT: Chest and Abdominal Pain
PRESENT ILLNESS: 62 year old male with a pmh of ESRD s/p failed graft on HD, Hep C genotype 1, DMII, HTN, HLD who presents from an OSH with pericarditis complicated by pericardial effusion. . His OSH course is as follows: He had an admission prior to this [**Date range (1) 27855**] with pleuritic CP and rub, diagnosed with pericarditis. Also, new LBBB and tropI of 0.125. Echo showed small effusion and normal wall motion, mild AS, mild MR, unchanged from baseline. He was treated with NSAIDs. Due to LBBB, prolonged PR and underlying dCHF (between dialysis sessions) his dilt was stopped and coreg (3.125) was added. He was discharged on 50mg TID of indocin. . Several days after discharge he developed general weakness, vague diffuse low abd pain, and fatigue. Dialysis was complicated by hypotension (new) and required fluid. [**8-2**] admitted to OSH with hypotension of 75/50 and above symptoms. He was fluid resuscitated, fluid responsive. CT A/P showed diverticulosis (no inflammation) and a mod pericardial effusion (incidental). RUQ U/S with GB wall thickening, otherwise unremarkable. . He was admitted to the ICU, BPs maintained 100s-140s and HRs 50s-70s. Treated presumptively for adrenal insufficiency with hydrocortisone. Echo showed circuferential pericardial effusion (2.1-2.2 cm) reportedly without evidence of tamponade. His vitals remained stable and his labs were unremarkable (stable anemia HCT ~30) and WBC elevation of 19 after steroids. Creatinine 8.9, sodium 131. He was transferred from OSH ([**Hospital1 1562**]) to [**Hospital1 18**] for further management. . At [**Hospital1 18**], he was admitted to inpatient medicine. He is comfortable without any acute complaints. He does still have mild chest discomfort that has persisted throughout his admission at the OSH. He also has vague lower abdominal pain, but is otherwise without any acute complaints. No SOB, no orthopnea, no PND.
MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +Hypertension 2. OTHER PAST MEDICAL HISTORY: - ESRD secondary to FSGN, s/p failed graft placement and now temporarily off of the [**Hospital1 **] list (due to current illness) on hemodialysis from FSGS; AV graft is thrombosed (he is dialyzed now through temp groin line) - Hepatitis C genotype 1, biopsy showed fibrosis grade I - Gout - s/p Partial parathyroidectomy (adenoma) - Neuropathy
MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete Information was obtained from Patient 1. Indomethacin 50 mg PO TID (recently added for pericarditis) 2. Carvedilol 3.125 mg PO BID (this was started recently when dilt was being held, then it was held when dilt was restarted) 3. Omeprazole 20 mg PO DAILY 4. Diltiazem 60 mg PO QAM 5. Diltiazem 120 mg PO QPM 6. Calcium Acetate 667 mg PO TID W/MEALS 7. fenofibrate *NF* 160 mg Oral daily 8. Simvastatin 20 mg PO HS 9. Nephrocaps 1 CAP PO DAILY 10. Docusate Sodium 100 mg PO BID 11. Lisinopril 10 mg PO DAILY - also took Lactulose 15cc PRN constipation until recently - was also on Hydrocortisone recently at OSH for pericarditis
ALLERGIES: Compazine / Benadryl Decongestant
PHYSICAL EXAM: ADMISSION EXAM: Vitals: T:98.1 BP:120/72 P:64 R:18 18 O2: 99% - Pulsus 18 (doppler) General: Alert, oriented, no acute distress, mildly fatigued HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP ~8, no LAD Lungs: Clear to auscultation bilaterally, basilar crackles no wheezes, rales, ronchi CV: Normal rate, Regular rhythm, distant heart sounds Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, no clubbing, cyanosis, trace edema Neuro: Oriented. No gross deficits. . DISCHARGE EXAM: VS: Tm 98.1 BP 122/57 P 81-86, R18, 100%RA Pulsus: 8 Gen: well-appearing male in NAD HEENT: NCAT MMM EOMI anicteric Neck: Supple without LAD, JVD not discernable Pulm: CTA b/l without wheeze or rhonchi Cor: RRR (+)S1/S2 without m/g, former drain site c/d/i Abd: Soft, non-distended, non-tender to palpation, NABS Extrem: 1+ LE edema b/l, good distal pulses, warm and well perfused LUE fistula with palpable cords. RLE with increased edema, pain with passive movement. Neuro: CNII-XII grossly intact, moving all extremities, mentating well Lines/Drains: RUE PICC, tunneled HD catheter
FAMILY HISTORY: No renal disease in family, father with CAD age 50s. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory.
SOCIAL HISTORY: Lives in [**Hospital1 1562**] with his wife and daughter. [**Name (NI) **] is a former smoker that quit many years ago. No alcohol or drugs. He is a cab driver. | 0 |
96,846 | CHIEF COMPLAINT: Shortness of breath
PRESENT ILLNESS: This is a 89 year-old female with a history of MDS, hip fracuture [**2-16**], living at [**Doctor Last Name 5396**]Rehab who presents with shortness of breath. Per nursing home staff, patient has been coughing with chest congestion, fatigue, and poor PO intake for 1 week. Additionally, staff states that she is the 4th patient hospitalized for pnemonia and th 10th with chest cold symptoms and fevers. . CXR on [**11-6**] was without cardiopulmonary process and labs were significant for Hct of 60, WBC 26.3 (90%neut, 1%lymph), Cr of 1.5, and proBNP of 6000 (3000 1 month earlier). Patient was started on Lasix 40mg [**Hospital1 **] for presumed CHF exacerbation, but continued to have cough, fatigue, poor PO intake and on [**11-14**], desated to the 70's. . In the ED, patient's initial vitals were T 96.6, BP 111/58, HR 64, RR 30, sating 90% on NRB. While in ED she spiked to 101.8, with continued low sat on NRB and was placed on BiPAP as patient is DNR/DNI. BP dropped to 83/41 but responded to 1L NS back to 102/41. [**Month/Day (1) **] Cx sent and patient was given Vanc and Cefipime. . On ROS, patient was oriented x 2 (did not know which hospital). ROS likley inaccurate as patient denied Fevers/chills and SOB which were documented in ED. .
MEDICAL HISTORY: Myeloproliferative syndrome Hypothyroidism GI bleeds, diverticular, last [**6-15**] R bell's palsy Hypertension Osteoporosis s/p hip fracture with surgical treatment [**2-/2125**] ([**Hospital3 **]) One previous episode of atrial fibrillation .
MEDICATION ON ADMISSION: Milk of Mag PRN Tylenol 325-650 PRN Lorazepam 0.5mg HS PRN CaCO3 500mg TID MVI qday Docusate 100mg qday FeSO4 325mg qday KCL 20 mEQ qday Lasix 40mg [**Hospital1 **] (presumably started [**11-6**] with elevated BNP) Levothyroxine 150 mcg qday Metoprolol 12.5mg [**Hospital1 **] Omeprazole 40mg qday Alendronate 70mg qWed .
ALLERGIES: Enalapril / Amlodipine
PHYSICAL EXAM: Vitals: T: 98.5 BP: 102/42 HR: 97 RR: 17 O2Sat: 95% BiPAP 10/5 40% GEN: No acute distress, elderly woman, mildly somnolent with BiPAP mask on HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MM dry NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: Tachy but regular, no M/G/R, normal S1 S2, radial pulses +2
FAMILY HISTORY: The patient's mother died of peritonitis. The patient's father had an unknown cancer. No history of gastrointestinal bleeding in the family
SOCIAL HISTORY: Has lived in rehab at [**Doctor Last Name 5396**]in [**Hospital1 **] since hip surgery [**2-/2125**], ambulates with cane or walker. No smoking, quit 35 years ago, about 20-30 pack year history, no alcohol, no drug use. | 0 |
67,416 | CHIEF COMPLAINT: Increasing SOB and DOE
PRESENT ILLNESS: 68 year old male with known CAD, HTN, CRI, + smoking history, MI in '[**69**], s/p CABG x 5 in '[**79**] presented to OSH with unstable angina and was transferred to [**Hospital1 18**] for cath. Patient states that he has been experiencing increased fatigue over that last few weeks and that four days ago he experiences repeated episodes of chest pressure and shortness of breath while exerting himself (he experienced these episodes while walking up a [**Doctor Last Name **] and carrying groceries). After speaking with his cardiologist, he was eventually admitted to [**Location (un) **] ER and found to have EKG changes consistent with ischemia. Heparing was started and then the patient was transferred her for cath. During stenting of SVG to RCA, distal protection failed resulting in TIMI 1 flow. IC Dilt, Adenosine, NitroPrus. administered with TIMI 2 flow. Transfered to ICU for monitoring.
MEDICAL HISTORY: CAD HTN CABG in [**2179**] [**12-22**] Routine myoview- posterior lateral reversible defects CRF
MEDICATION ON ADMISSION: Aspirin 325 Lopressor 75 twice a day Diovan 160 Viagra 50 MVI
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Temp: 95.6 BP: 167/88 HR: 83 RR: 21 99% on 3 liters
FAMILY HISTORY: GM (heart problems - died in her early 70s)
SOCIAL HISTORY: Lives with wife Past [**Name2 (NI) 1818**] (quit 24 years ago) ETIH: 2 drinks per day Retired (worked in corporate finance) | 0 |
25,754 | CHIEF COMPLAINT: referred for evaluation of posterior mediastinal mass
PRESENT ILLNESS: This is a 55y.o. man with a significant smoking history and COPD who presented to an OSH with fatigue, 40lb wt loss since [**Month (only) **], weakness, and back pain; he was found to have a large posterior mediastinal mass concerning for malignancy, possibly lymphoma. Patient had failed a CT-guided biopsy in the past. Transferred to Medicine from Thoracic service after patient failed attempted EUS with biopsy. Main issues were pain management and respiratory optimization; in addition, he was extremely weak and unable to walk. The patient's symptoms began as back pain in [**2155-5-8**] when he was diagnosed with compression fractures of his spine after lifting boxes. Since that time the patient has had diffuse, vague pains in his chest, back and abdomen. More recently, over the past 3-5 weeks the patient has developed signficant loss of appetite and a 40 lb weight loss. . ROS: Denies significant new HA, blurred vision, diplopia, CP, SOB, edema, dizziness, lightheadedness, nausea, vomiting, abdominal pain, diarrhea, consitpation, urinary symptoms.
MEDICAL HISTORY: COPD, 80 pk/yr smoker Hypercholesterolemia s/p Appendectomy Hernias, s/p multiple repairs with current umbilical hernia Sebaceous cysts Lipomas s/p Arthroscopic knee surgery
MEDICATION ON ADMISSION: Vytorin 10/20 QD Pain meds, most recently morphine, prior to that percocet, vicodin as well as various muscle relaxants in the past, including tramadol.
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS 98.9 134/66 78 18 96%4L Gen: Ill appearing man older than stated age. Integumentary: No rashes. HEENT: PERRL. Red oral mucosa appearing raw. CV: RRR. Normal S1 and S2. No M/R/G. Pulm: Congested breath sounds in mid and lower lung fields bilaterally. Abd: Distended. Soft. Mild diffuse tenderness. Ext: No edema. Peripheral pulses in lower extremities intact. Neuro: A&Ox3. Lethargic.
FAMILY HISTORY: Mother with DM and died of colon CA at 64 Father with emphysema
SOCIAL HISTORY: >1ppd x40 yrs Separated from wife 4 months ago after 35 years of marriage. | 0 |
97,667 | CHIEF COMPLAINT: Acute onset of numbness and tightness in the left leg, below the knee.
PRESENT ILLNESS: This is a 59 -year-old female with a known history of atrial flutter who presents with numbness and tightness in the left leg, below the knee. She reports an abrupt onset of this feeling while lying in bed at 09:30 on the date of admission, [**2116-3-5**]. She complained of chronic knee pain secondary to osteoarthritis, but has never had this type of pain in the lower extremity. She denies any other symptomatology. Her motor, sensory is intact. The patient is now admitted for evaluation.
MEDICAL HISTORY: Includes hypertension, Crohn's disease, hypothyroidism, osteoarthritis, atrial flutter, cardioverted in [**2108**] and [**2112**]. Echocardiogram in [**Month (only) 1096**] of this year shows an ejection fraction of greater than 55% and left ventricular function was normal.
MEDICATION ON ADMISSION:
ALLERGIES: Red dye and shell fish.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
70,150 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is status post right breast mastectomy eight to nine months ago for right-sided breast cancer. The patient denies any coronary artery disease, diabetes mellitus, hypertension or peripheral vascular disease.
MEDICAL HISTORY:
MEDICATION ON ADMISSION: Elavil 100 mg p.o.q.d. and aspirin 325 mg p.o.q.d.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient admits to alcohol and tobacco use. The patient smokes one pack per day of cigarettes. | 0 |
26,638 | CHIEF COMPLAINT: seizure
PRESENT ILLNESS: Ms [**Known lastname 81114**] is a 21F w SLE with multisystem involvment including nephritis, myo-pericarditis, pancytopenia, recently admitted for 1-month at OSH for treatment of above. She presented here after focal seizures with visual auras and with secondary generalization and found to have new cerebral arterial ischemic strokes. . The patient was discharged [**12-6**] from OSH ([**Hospital 81115**] Hospital, [**State 5887**]) after 31-day long complicated stay for lupus flare notable for pericardial effusion with tamponade physiology requiring pericardial window, acute on chronic [**State **] failure (BUN/Cr 136/5.5), with [**State **] biopsy showing grade [**2-19**] membranoproliferative and membanous nephropathy, Citrobacter Freundii and bacteroides bacteremia, thrombocytopenia and anemia (required 4 units pRBC and 4 units platelets during stay), pleural effusion requiring thoracentesis and chest tube, peritonitis with ascites, and urinary tract infection discharged on ciprofloxacin and metronidazole. She was treated with high dose steroids and cellcept. The patient was found to develop worsening thrombocytopenia and bradycardia while on the cellcept, and it was discontinued 1 week ago. She returned to MA last night in the care of her mother. . After arriving home at approximately 2200, she complained of headache, floaters and seeing '[**Holiday 944**] trees'. Her eyes then deviated to the left and neck stiffened with rhythmic extension of arms and legs. There was lip biting and urinary incontinence. The episode lasted a few minutes. EMS was activated and she was taken to [**Hospital3 417**] Hospital for evaluation and had another witnessed seizure en route. . At OSH, a third seizure occurred similar to the others that terminated with 2mg lorazepam. FSGB at that time was 111. She was not dilantin loaded. Head CT at OSH showed ill defined hypodensity of left cerebellum, in addition to old infarcts in right occipital and parietal lobes. Labs notable for WBC 3.1, Hb 10.9, Plt 76, Na 142, K 2.9, Cre 2.1, Glu 121, Ca 7.4, CK 67, Trop 1.08, INR 1.1, negative urine toxicology screen. Transferred to [**Hospital1 18**] ED for neurology evaluation, where vitals were T-98.6 BP-127/96 HR-105 RR-16 O2Sat 96%. Concern for lupus cerebritis or sinus thrombosis. The patient refused lab draws and requested a PICC line. The neuro team recommended keppra load 750mg, changing antibiotics to zosyn from cipro/flagyl which may lower the seizure threshold, MRI/MRA/MRV brain, EEG, and formal echocardiogram (bedside ED echo showed effusion but no evidence of tamponade physiology). Potassium was repleted. Due to medical complexity, MICU admission was requested by the Neurology service. . Rheumatology was also consulted and they reccommended high dose solumedrol 1000mg daily times three days once infectious or vascular process has been ruled out. They also recommended evaluation for TTP. . On [**2185-12-7**] echo showed LVEF 20% with akinesis of the distal [**12-20**] of the LV, in addition to RV apical hypokinesis and a moderate pericardial effusion. These findings were thought secondary to lupus induced myopericarditis. Given the extent of her myopericarditis, she was transferred to the CCU service. . Currently she complains of feeling tired and back pain from lying flat all night. Review of systems is otherwise negative in detail including no SOB, chest pain, headache, nausea, vomiting, abominal pain, photophobia, visual hallucinations or other visual changes, numbness, weakness, rash. Reports chronic LE edema bilaterally but no calf pain. .
MEDICAL HISTORY: SLE complicated by nephritis, serositis (currently on prednisone, but previously on Cytoxan, Cellcept [**6-23**], and then transitioned to Paquinil; followed by Dr. [**Last Name (STitle) 19849**] in [**Doctor Last Name 40074**]and Dr [**Last Name (STitle) 81116**]/[**Location (un) 27598**] at [**Hospital 81115**] Hospital) Pericardial effusion ([**10-24**]) with tamponade physiology Pleural effusion, left Chronic [**Month (only) **] failure (not on HD but concern for HD needs at most recent hospitalization; [**Month (only) **] biopsy with mixed membranous glomerulonephritis stage 5; followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital 81115**] Hospital) Multiple ICU admissions
MEDICATION ON ADMISSION: 1. Prednisone 50 mg QDay 2. Zofran 4 mg QDay 3. Ciprofloxacin 500 mg [**Hospital1 **] 4. Metronidazole 500 mg Q8h 5. Phoslo 667 mg one tablet tid w meals 6. Sodium bicarb 1300 mf [**Hospital1 **] w meals 7. Celexa 10 mg QDay 8. Protonix 40 mg QDay
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: T-97.4 BP-112/85 HR-78 RR-15 O2Sat100% Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit. Right neck wound from IJ line which is removed. CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally ABd: distended, +BS soft, nontender, no organomegaly ext: Severe pedal edema, no calf swelling/edema Neurologic examination: MS: General: alert, awake, flat affect Orientation: oriented to person, place, date, situation Attention: +MOYbw. Follows simple/complex commands. Speech/[**Doctor Last Name **]: fluent w/o paraphasic errors; comprehension, repetition, naming and [**Location (un) 1131**] intact Memory: Registers [**1-17**] and Recalls [**1-17**] at 5 min L/R: Touches left thumb to right ear Praxis: Able to brush teeth CN: I: not tested II,III: VFF to confrontation, PERRL 3mm to 2mm III,IV,V: EOMI, no ptosis. No nystagmus V: sensation intact V1-V3 to LT VII: Facial strength intact/symmetrical VIII: hears finger rub bilaterally IX,X: palate elevates symmetrically, uvula midline [**Doctor First Name 81**]: SCM/trapezeii [**3-21**] bilaterally XII: tongue protrudes midline, no dysarthria Motor: Normal bulk and tone; no tremor, asterixis or myoclonus. No pronator drift. Delt [**Hospital1 **] Tri WE FE Grip IO C5 C6 C7 C6 C7 C8/T1 T1 L 4 4 4 4 4 4 4 R 4 4 4 4 4 4 4 IP Quad Hamst DF [**Last Name (un) 938**] PF L2 L3 L4-S1 L4 L5 S1/S2 L 4 4 5- 5 4+ 5- R 4 4 4- 5- 5- 5- Reflex: No clonus [**Hospital1 **] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 2 2 2 2 + Extensor R - 2 2 2 + Equivical Sensation: Intact to light touch, pinprick, vibration and proprioception throughout. No extinction to DSS. Coordination: finger-nose-finger normal RAMs normal. Gait: N/A Romberg: N/A
FAMILY HISTORY: Father with sarcoid, no family history of miscarriages/coagulation disorders/sickle cell trait
SOCIAL HISTORY: Lives with her mother (cell: [**Telephone/Fax (1) 81117**]) in [**Hospital1 1474**], MA. No tobacco, EtOH, illicit drug use. Pharmacy student in [**State 5887**]. | 0 |
81,893 | CHIEF COMPLAINT: pericardial effusion
PRESENT ILLNESS: 59 yo M with CAD was diagnosed with acute pericarditis on [**2152-11-18**] at an outside hospital. He presented with 'global' ST elevations, pleuritic chest pain, ESR 55, CRP 155. TTE at that time showed no effusion. He was discharged home on ibuprofen 800mg tid initially with good effect. He was also given Abx for abnormalities on a Chest CXR/CT, although he had no clinical signs of PNA and radiology reports described the posterior left base opacity as likely atelectasis. Two days after completing the 5 day course of ibuprofen 800mg tid which he was prescribed, he developed diffuse left sided chest pain different from his initial pleuritic pain (and not as intense). He recalls what his stable angina felt like 10 years ago prior to having stents placed in the proximal LAD and mid RCA; states this is different from his angina. Repeat ECHO done at [**Hospital1 **] showed a moderate effusion (report not available) which had evolved within 5 days--reportedly not concerning for tamponade. No pulsus on exam with BP 95-105/50-60. Pt was transferred to [**Hospital1 18**] for further mgt. On arrival, neck veins wnl, BP at baseline, no pulsus, prelim ECHO without diastolic collapse of RV. Of note, co-synotropin testing at [**Hospital1 **] showed that pt is adrenally insufficient s/p distant unilateral adrenalectomy after which he never followed up with an endocrinologist. 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 chills or rigors, although felt briefly febrile on the night prior to admission. 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: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -Hypertension 2. CARDIAC HISTORY: -CABG: NONE -PERCUTANEOUS CORONARY INTERVENTIONS: [**2136**]: Palmaz-[**Doctor Last Name 8030**] sents to mid-RCA and proximal LAD for stable angina -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: -Dyslipidemia -Unilateral Adrenalectomy for [**Location (un) 3484**] Syndrome; he was told that contralateral gland was hypoplastic, but her never followed with endocrine regarding this. Labs at OSH notable for inadequate co-synotropin stim.
MEDICATION ON ADMISSION: Simvastatin 10' Niacin (unsure about dose) 500'? ASA 81' Fish oil Folic Acid Vitamins
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: General Appearance: Well nourished Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal), No(t) Rub Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : left base) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Warm Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed
FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; Father and mother with CAD in 60s-70s
SOCIAL HISTORY: -Tobacco history: distant limited cigar smoking -ETOH: no ETOH abuse -Illicit drugs: none | 0 |
79,507 | CHIEF COMPLAINT: Aortic Stenosis
PRESENT ILLNESS: 87 year old woman with hypertension presented to [**Hospital3 110856**] after awakening with chest discomfort on [**4-12**]. She had had several months of progressive DOE and fatigue. She lives alone and at baseline is self-sufficient. She had never had chest pain before. She denied any history of syncope. At LGH, she was found to have severe AS and was transferred to [**Hospital1 18**] On [**2162-4-16**] for AVR.
MEDICAL HISTORY: Aortic Stenosis Hypertension Status post cholecystectomy 40yrs ago
MEDICATION ON ADMISSION: Lisinopril 40mg daily, Aldactone 25mg daily, nadolol 160mg daily
ALLERGIES: Vasotec
PHYSICAL EXAM: Pulse: Resp:14 O2 sat: 98% RA B/P Right:134/78 Left: Height:61" Weight:164 General:WDWN Skin: Dry [] intact [x] HEENT: PERRLA [] EOMI [x] Neck: Supple [] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [] Murmur [x] grade _4/6 SEM -> neck Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds +[x] Extremities: Warm [x], well-perfused [x] Edema [n] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [**Name (NI) 167**]:2 Left:2 Radial Right:2 Left:2
FAMILY HISTORY: non-contributory
SOCIAL HISTORY: Lives alone(5 sons near by, one in ajoining unit) Occupation:homemaker Cigarettes: never ETOH: less than 1 drink/week Illicit drug use none | 0 |
25,213 | CHIEF COMPLAINT: Chest Pain
PRESENT ILLNESS: Mr. [**Known lastname 74456**] is a 57 yo man with hypertension and smoking abuse who initally presentd to an OSH with chest discomfort. He developed the L sided chest achy discomfort around 4pm. He took some additional aspirin at that time. However the intensity of the discomfort increased, reaching ~[**5-17**] by 9pm. His wife says that he looked pale and sweaty and was complaining that "something didn't feel right." He denies experiencing any shortness of breath, nausea/vomiting, or palpitations. . He does recall experience several episodes of similar chest discomfort, lesser in intensity, over the last few weeks PTA. These symptoms were not clearly activity-related. . At the OSH, his intial VSs were 98.7, 56, 101/80, 16, 99% RA. Initial EKG did not reveal any significant ST-segment changes. After receiving SL nitro, he had a VF arrest. He received 2 shocks and had return to spontaneous circulation. During the arrest, he received 0.5 mg atropine. He was started on a lidocaine drip. His repeat EKG revealed ST-segment elevations in the inferior leads. He received aspirin 324, clopidogrel 600 mg, atorvastatin 80, and nitroglycerin drip. He was transferred to [**Hospital1 18**] for further management. In the [**Hospital1 18**] ED, he was started on an eptifibatide drip. . On initial angiography, there was a 90% stenosis of an obtuse marginal branch of the left circumflex artery. A sirolimus-eluting stent was implanted. In the cath lab, fluid was administered and a dopamine infusion begun for hypotension during the intervention. The dopamine was discontinued after the case. . Eptifibatide was discontinued [**2-9**] bleeding at the access site. . 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:
MEDICATION ON ADMISSION: ASA 81 daily
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS T afebrile P 67 BP 118/77 RR 19 O2 100% RA General: Tired appearing elderly man in no acute distress HEENT: No JVD Pulm: Lungs clear to auscultation on anterior exam CV: Regular rate S1 S2 no m/r/g Abd: Soft, nontender, +BS Groin: R groin with small amount of oozing post catheterization Extrem: Warm, well perfused, no edema 2+ peripheral pulses Neuro: Alert, interactive
FAMILY HISTORY:
SOCIAL HISTORY: Social history is significant for 40PY smoking hx. He drinks [**1-9**] drinks most days of the week. His father received a pacemaker for conduction system disease at age 44. He is physically active with yardwork and house maintenance. | 0 |
80,812 | CHIEF COMPLAINT: Chest Pain
PRESENT ILLNESS: 73 year old man who presented after 30 minutes of left-sided chest pressure, [**11-17**], non-radiating, that started after walking up stairs at church. He reports that he did not have any jaw or arm pain, or diaphoresis, and that the pain resolved after 30 minutes with rest. He reports that he has had similar chest pain but not as severe for several days, possibly 1 week. Initially he would have the pain with ambulating, going up stairs, and over the past two days he has had less severe chest pain wake him from sleep. One the day prior to admission he also had 30 minutes of chest pain when climbing the stairs in his house. On the day of admission, he had chest pain at church, and EMS was called. He was given ASA by EMS, and the pain had resolved by time of arrival to ED.
MEDICAL HISTORY: Coronary artery disease s/p Coronary artery bypass grafts Mitral regurgitation s/p mitral vlave repair acute kidney injury Acute diastolic heart failure insulin dependent Diabetes mellitus Dyslipidemia Hypertension s/p Cerebral vascular accident ([**2198**]) Glaucoma
MEDICATION ON ADMISSION: Hydralazine 25 mg by mouth TID Simvastatin 80 mg by mouth QHS Quinapril 40 mg by mouth daily Amlodipine 10 mg by mouth daily Diovan 320 mg by mouth daily Furosemide 80 mg by mouth daily Klor-con 10 mEq tablets, Sig: 2 tablets by mouth daily Dorzolamide-timolol 2-0.5 % Drops, Sig: one drop in each eye twice a day Bimatoprost 0.03 % Drops, Sig: one drop in both eyes at bedtime NPH insulin 30U [**Hospital1 **] and SSI
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Admission Exam: VS: T 97.9, 140/65, 72, 20, 98%RA GENERAL: WDWN obese elderly man 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: Lives with:wife Occupation: retired [**Name (NI) 2318**] bus driver Tobacco:denies ETOH:denies | 0 |
71,381 | CHIEF COMPLAINT: anemia
PRESENT ILLNESS: 81 year old Male with a history of CAD status post CABG, chronic systolic CHF (EF 15-20), hypertension, hyperlipidemia, and recent admission [**4-17**] for GIB with negative EGD/colonoscopy presents from home with dark red bloody diarrhea that developed overnight and subsequent weakness and lightheadedness. . He reports having had a cough for 5-7 days which has been procductive of [**Last Name (un) 30893**] sputum. He denies fever or chills. He began feeling weak and lightheaded 2 days ago. At that point he was having normal color bowel movements which were loose. He had vomited once non-bloody emesis two days ago. He has had no change in his CHF symptoms. Orthopnea is stable and no PND, weight increase or increase in LE edema. He denies sick contacts or [**Name2 (NI) 56616**], headache, sore throat or other symptoms. Last night he had "explosive" diarrhea and was unable to make it to the toilet. His wife reports that the stool was [**Last Name (un) 30212**] and that there was also a significant amount of bright red blood. There was also bright red blood on the toilet paper. He felt even more lightheaded and too weak to get up and EMS was called. . Recent medication changes include prescription of cough suppressants for cough but no antibiotics and increase of spironolactone from 12.5 to 25 one week ago. . On arrival to the ED, he was hypotensive to the 70s. After receiving 1L NS, his vitals were T 97.2 90 94/49 21 94% RA. An NG lavage with 500cc returned clear fluid. There was no blood, coffee grounds or bile. Rectal exam revealed [**Last Name (un) 30212**] stool. He was transfused 2 units pRBCs. He was also evaluated by surgery for a question of mesenteric ischemia, which was felt to be unlikely. Vitals on transfer were 96 124/56 16 99RA. . Review of systems: see metavision . <h3>[**Hospital1 139**] A PGY1 Daily Progress Note, [**2149-5-12**], 1600</h3> . <h3>Accept Note</h3> . <b>Brief HPI:</b> I have received verbal signout from the MICU resident, reviewed pertinent data and notes, and seen and examined the patient. See the MICU admission note for details of the H&P. . Briefly, this is an 81 yoM admitted to the ICU for maroon stools and presyncope whose PMH history includes history of chronic anemia due to erosive gastritis (discharged [**4-/2149**]), diverticulosis/itis s/p partial colectomy, sCHF (EF 15-20% [**7-/2148**]), s/p BiV pacemaker, s/p bioprosthetic MVR and tricuspid annuloplasty ring for iatrogenic endocarditis, DM2, and OSA. . Notes never having maroon stools before; endorses black stool, but takes iron supplement; denies coffee ground emesis. . Had an EGD in [**4-/2149**], which showed * Normal mucosa in the duodenum (biopsy) * Otherwise normal EGD to third part of the duodenum . Had a colonoscopy in [**4-/2149**], which showed * Diverticulosis of the sigmoid * Polyp in the terminal ileum (biopsy) * Otherwise normal colonoscopy to terminal ileum . ICU Course: -Presenting Hct 18 -4 units overnight into AM -Hct on transfer 30 -1 bottle positive for GPC in clusters . Also notes a cough productive of white sputum for a few weeks, less than a month; no fevers, chills, no sick contacts. Denies rhinorrhea, no seasonal allergies, no sore throat. Does not smoke. . <b>ROS:</b> No headache, CP, palpitations, SOB, wheeze, abdominal pain, dysuria, LE swelling, rashes. Endorses orthopnea; 3 pillow orthopnea stable.
MEDICAL HISTORY: History of erosive gastritis Diverticulosis/itis (13y ago) Chronic Systolic Congestive Heart Failure (EF 15-20%) Coronary Artery Disease CABG complicated by Mitral Valve endocarditis(Eneterococcus) Bioprosthetic MVR [**2148-2-7**] Tricuspid annuloplasty BiV pacemaker Hypertension Hyperlipidemia Type II Diabetes Mellitus (diet-controlled) Obstructive Sleep Apnea (patient denies having this dx) Cataracts Glaucoma bilaterally Pulmonary nodule left lower lobe Diverticulitis Ventral hernia
MEDICATION ON ADMISSION: torsemide 20 mg Tab 0.5 (One half) Tablet(s) by mouth every day spironolactone 25 mg Tab 1 (One) Tablet(s) by mouth daily metoprolol succinate ER 50 mg one-half Tablet(s) by mouth twice a day Aspirin 81 mg Tab 1 Tablet(s) by mouth one every evening lisinopril 5 mg Tab 0.5 (One half) Tablet(s) by mouth daily at night Simvastatin 40 mg Tab 1 Tablet(s) by mouth at bedtime for Pantoprazole 40 mg Tab, Delayed Release by mouth once a day Metamucil 3.3 gram/5.95 gram Oral Powder (dose uncertain) ascorbic acid 250 mg Tab 1 Tablet(s) by mouth twice a day ferrous gluconate 325 mg Tab 1 Tablet(s) by mouth twice a day Take with meals with Vitamin C 250mg
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Physical Exam: see metavision DRE: maroon stool and dark red [**Last Name (un) 30212**] blood, abd non tender . [**Hospital1 139**] Exam: Physical Exam: Unchanged Other than** Gen: Elderly male, not pale in NAD HEENT: NCAT, PERRL, EOMi, MMMs, OP clear Neck: Supple, no LAD; no elevated JVP Pulm: CTAB no wh/rh/ra, no accessory muscles use CV: RRR nml S1/2 no m/r/g Ab: +BS soft NTND no tender organomegaly Ext: 1+ bilateral pitting edema Neuro: CN2-12 intact FNFi . Discharge Exam: Unchanged other than Neck: JVP not elevated Pulm: Scant bibasilar crackles Ext: trace edema
FAMILY HISTORY: son with MI/CABG at 50; brother with MI @ 63
SOCIAL HISTORY: Lives with: wife Occupation: retired electrical engineer; designed the radio transmitter that was responsible for communication between the NASA lunar module and orbiting capsule during the space race of the [**2097**] Tobacco: quit 25 years ago; 40-60 PYHx ETOH: rare occ. | 0 |
2,407 | CHIEF COMPLAINT: MI
PRESENT ILLNESS: 71 yo male with 100py smoking history transferred from OSH for cath. The patient had not seen a doctor in over 50 years. he was seen by his wife's PCP on day of admission, and was found to have CHF by CXR. The patient was sent to [**Hospital3 3583**] ED and found to be hypertensive to 211/90 with EKG changes of inferior and lateral Q waves and ST elevations, 92% on RA, and positive cardiac enzymes (Trop I 0.038 --> 0.210). He was given NTP, lasix, aspirin, plavix 300mg x 1, heparin gtt, and lopressor 25mg po x1. he was transferred to [**Hospital1 18**] for cath. In the Cath lab, HD, RA 10, PC WP 27, CO2.0. He was found to have triple [**Last Name (un) 12599**] disease with mild LAD stenosis (feeding the Cx) so effective LM. Of note, pt had increased DOE x 2 weeks. No CP, palpitations. Occassional cough productive of yellow sputum. No fevers/chills, leg edema, orthopnea, PND, high salt intake or change in diet.
MEDICAL HISTORY: None
MEDICATION ON ADMISSION: none
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: HR: 78 BP: 154/71 RR: 17 92% on 4 liters
FAMILY HISTORY: nc
SOCIAL HISTORY: lives with wife 100 pack year smoking history remote etoh h/o asbestos exposure | 0 |
75,668 | CHIEF COMPLAINT: CC: weakness
PRESENT ILLNESS: HPI: 65 yr old female with hx of type I DM, hyperthyroidism, PVD who presents with weakness, difficulty controlling blood sugars. Pt states that her symptoms started on [**8-17**] when she noted severe fatigue. Since that time, her appetite has decreased but her fingersticks have been elevated, requiring higher doses of humalog. For example, this am, she required 45units (15U x 3) of Humalog for glucose>200 despite eating almost nothing. Pt also complains of dizziness, esp when standing, nausea and some mild lower abd cramping. No fevers, chills, night sweats, diarrhea, dysuria. Pt notes that her freq of urination has decreased and her po intake of fluids has also decreased as it causes nausea.
MEDICAL HISTORY: PMH: 1. Recurrent UTIs for which she takes prophylactic Bactrim. 2. type 1 diabetes. She was diagnosed 50 years ago. Her diabetologist is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Last Name (un) **] Center. Recent HbA1c 9.0 3. hypothyroidism. 4. Peripheral vascular disease, status post left lower extremity bypass. 5. High cholesterol 6. Aortic stenosis 7. Osteopenia 8. hx of tick bite last year (treated empirically)
MEDICATION ON ADMISSION: Meds: * AZITHROMYCIN 500MG--Take one pill one hour prior to dental procedures * BACTRIM SS qd * CALCIUM 500/VITAMIN D tid * HUMALOG sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) **] * LANTUS 17U qhs * LEVOXYL 50MCG qd * LIPITOR 20 mg qd (stopped 2 days ago)
ALLERGIES: Cephalexin
PHYSICAL EXAM: temp 98.6, BP 167/70 (lying) --> 166/80 (sitting), HR 100, R 12, O2 100% RA Gen: NAD, pleasant HEENT: PERRL, EOMI, MM dry Neck: jug veins flat CV: RRR, [**4-6**] harsh systolic murmur at RUSB, radiating to carotids Chest: clear Abd: +BS, soft, NTND Ext: no edema, 1+ DP on left, nonpalp on right; sensation intact Skin: tan but not hyperpigmented in creases; several areas of circular, blocthy erythema onn back, upper chest, legs, arms Neuro: CN 2-12 intact
FAMILY HISTORY: DM; mother died of CHF, father died of lung dz
SOCIAL HISTORY: no tobacco, no alcohol, lives alone (husband passed away sev months ago) | 0 |
71,631 | CHIEF COMPLAINT: Patient is a 64 year-old patient of Dr. [**Last Name (STitle) 17887**] transferred from [**Hospital 1474**] Hospital for cardiac catheterization and for exertional chest pain with shortness of breath.
PRESENT ILLNESS: Patient is a 64 year-old white female without significant past medical history who was transferred for cardiac catheterization, status post being admitted to [**Hospital 1474**] Hospital for three months with exertional chest discomfort hat was relieved with rest. She went to the emergency department for worsening shortness of breath and reported episodes of light headedness presyncopal symptoms a few months ago. She has not seen a doctor is several years. Patient has been very well but after development of exertional chest pain and presyncopal episodes as well as dyspnea on exertion patient's echocardiogram at [**Hospital 1474**] Hospital revealed an ejection fraction of 15 percent and repeat transfer catheterization showed an ejection fraction of 24percent with normal coronaries and mild mitral regurgitation.
MEDICAL HISTORY:
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY: Abdominal aortic aneurysm and chronic obstructive pulmonary disease.
SOCIAL HISTORY: Positive cigars, positive cigarettes [**12-11**] pack per day. | 0 |
22,823 | CHIEF COMPLAINT: left sided weakness
PRESENT ILLNESS: Mr. [**Known lastname 4033**] is a 67 yo M w/ h/o severe COPD, ETOH cirrhosis s/p TIPS [**2106**], CAD s/p CABG [**2106**], bladder CA s/p resection [**2104**], chronic neuropathy, GERD and h/o R CEA s/p left sided weakness [**2114**] who presents with right sided weakness for 4-5 days. . Of note, the pt was recently admitted to [**Hospital3 4107**] from [**Date range (1) 52350**]. Originally he presented with diarrhea and a COPD exacerbation. He was found to have pan-colitis on CT abdomen thought to be [**2-23**] c diff and started on flagyl and vanco. He was given gentle hydration in the ICU. He then developed a distended abd with ileus on KUB. He was made NPO and given golytely with some relief. He also had a paracentesis with 3.3 L removed resulting in improved respiration and ileus. He also recieved stress dose steroids and levoquin. The pt was treated for "borderline hypotension" thought to be [**2-23**] hypoalbuminemia, cirrhosis and sepsis with gentle hydration and albumin. Prior to d/c, he was placed back on aldactone and lasix. . Of note, the pt's d/c summary from [**Hospital1 **] noted "baseline" right arm weakness. The pt states he thinks this started around the time of his paracentesis at the OSH. Neuro was consulted in the ED who noted proximal > distal R sided weakness was well as likely chronic distal weakness 2/2 neuropathy. CT head showed hypodensity in the parietal corona radiata. Neuro thought pt may have had a watershed infarct during a period of hypotension, perhaps after large-volume paracentesis but also thought embolus couldn't be excluded. Thusly, neuro recommended CTA head and neck (which showed no e/o vascular aneurysm, occlusion or dissection), antiplatelet [**Doctor Last Name 360**], keep BP elevated, MRI, TTE, LENI on R to look for clot. . In the ED, CXR also showed ? pneumomediastinum for which CT [**Doctor First Name **] was consulted. On CT chest, this was thought to be [**2-23**] medial right sided subpleural bleb without pneumotosis and CT surgery signed off. . In the ED, initial vs were: T P BP R O2 sat. Patient was given Hydrocortisone at stress dose, levofloxacin 750mg IV, flagyl 500mg IV, vancomycin 1gm IV, Albuterol nebs x3, ipratropium nebs x2, lorazepam and 2L NS. Pt has free air on CT abd- there was concern for perf from colitis but thought more likely [**2-23**] persistent leak from para site. Leaking from parasite with ostomy on. Transplant surgery consulted in ED said NTD but they would continue to follow. Pressures have been stable in 80s-90s/40s-50. Vitals on transfer to ICU T 97.1 HR 85 BP 93/44 RR 14 O2 sat 99% on 3L NC. . On arrival to the ICU, the pt denies any pain. Pt states he is having some baseline SOB but feels better after neb in ED. Pt having liquidy stools.
MEDICAL HISTORY: - Coronary artery disease, s/p PTCA to mid LAD in [**2097**], CABG ([**2106**]) - Chronic obstructive pulmonary disease (no PFT's in system) - Alcohol cirrhosis status post TIPS in [**2106**] - Bladder carcinoma status post resection in [**2104**] - Umbilical hernia repair in [**2106**] - Depression - History of benign prostatic hypertrophy - History of carotid disease bilaterally, right greater than left with right carotid endarterectomy in [**10-28**] - History of left intertrochanteric hip fracture s/p ORIF ([**6-/2109**]) - Chronic back pain - Apparent past diagnosis of OSA, past BiPAP use
MEDICATION ON ADMISSION: - Folic acid 1mg qd - Multivitamin qd - Protonix 40mg qd - Finasteride 5mg qd - Guaifenesin 1200mg [**Hospital1 **] - Gabapentin 600mg TID - FeSO4 325 qd - NaCl nasal spray - Lactobacillus 1 tab [**Hospital1 **] - Nystatin swish and swallow TID - Aldactone 50mg qd - Vancomycin PO 500mg q6h - Flagyl 500mg q8h - Levaquin 500mg qpm x 10day (done on [**2117-5-30**]) - Prednisone 40mg qd taper - Percocet 2 tabs q6h - Lasix 20mg qd - Advair 500/50 INH [**Hospital1 **] - Albuterol/Atrovent NEBS PRN
ALLERGIES: Wellbutrin / Zithromax / Keflex
PHYSICAL EXAM: On admission to floor: VS: T97.6 BP 86/87 P84 R26 100% 4L NC FS 142 Wt 77.9kg Gen - Alert, interactive, cachectic, chronically ill appearing male in NAD HEENT - PERRL, no cervical LAD, thrush on tongue, mmm CV - Irregularly irregular, tachycardic, RV heave, no m/g/r Pulm - CTAB, poor air exchange b/l, no wheezes/rales/rhonchi Abdomen - Soft, moderately distended, non-tender, +BS Extr - 2+ pitting edema to above knees b/l Neuro - Strength 5/5 in LUE and LLE, [**4-26**] in RLE and RUE, CN II-VII grossly intact
FAMILY HISTORY: The patient was adopted and does not know his family history. .
SOCIAL HISTORY: The patient lives at a nursing home full time in [**Location (un) 1411**]. He is wheelchair and often bed bound secondary to fatigue from COPD. He does not walk at baseline. No family. He is still an occasional smoker (when he gets a chance) - he has a 2PPD x 50 year smoking history. Long prior h/o EtOH abuse, but none for 1 year, no drugs | 0 |
75,864 | CHIEF COMPLAINT: Blood in stool
PRESENT ILLNESS: Mr [**Known lastname 68135**] is a 66 year old man, originally from [**Country 3396**], with history of hypertension, hyperlipidemia and diverticulosis, presenting with bloody bowel movements for 5 days PTA. Patient reports he was in his otherwise good state of health when he began having diarrhea. Shortly thereafter, he noted his stool turned dark colored and the toilet water began turning red. He did not see any blood clots. Patient denies any recent travel, but does report recently trying cambodian food. Patient denies any nausea, vomiting, chest pain, but does report some dyspnea with exertion (going up the stairs) that has conincided with the above complaints. Denies feeling dizzy when he gets up, but does report some palpitations. In the ED, vital signs T 97.4, HR 75, BP 84/64, RR 16, O2 Sat 100% RA. Rectal vault with bright red blood. Two large bore IV placed on Bilateral UE, patient given 1L NS bolus and 1 unit of PRBC, with ipmrovement in SBP to 102/64. NG lavage performed; negative for blood. Patient admitted to MICU for further monitoring.
MEDICAL HISTORY: 1. Hypertension 2. Hyperlipidemia 3. Diverticulosis 4. Inguinal hernia s/p repair 5. Colonic adenomas s/p resection
MEDICATION ON ADMISSION: Lipitor 10mg Glucophage 500mg daily? Monopril 10mg daily Atenolol 50mg daily Lisinopril 20mg daily Vicodin 5/500mg PRN Colace 100mg daily
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Vitals Temp: HR: 77 BP: 126/68 RR: 20 O2 Sat: 100% RA GEN: Well appearing man in no distress HEENT: PERRL, sclera anicteric, pale conjunctiva CV: Regular rate, soft systolic flow murmur at apex, no rubs/gallops. Normal S1/S2 Lungs: Clear to auscultation bilaterally, no rales/rhonchi/wheezes Abdomen: Soft, non tender non distended, normoactive bowel sounds. No guarding, no hepato/spleno megaly Extremities: Cold, 2+ pulses, no clubbing cyanosis or edema.
FAMILY HISTORY: No familial history of colon cancer, no chronic medical conditions.
SOCIAL HISTORY: Patient originally from [**Country 3396**], lives with wife. [**Name (NI) **] etoh or cigarette use. | 0 |
34,327 | CHIEF COMPLAINT: Nausea, vomiting, diarrhea
PRESENT ILLNESS: 48 year old male with type 1 diabetes, PVD s/p right BKA, CAD, benign hypertension and CKD Stage II who presents with nausea, vomiting, diarrhea. The patient reports that he has felt unwell for 6 days. Initially he describes a cough with clear sputum production approximately 6 days prior to admission. His symptoms progressed within 24-48 hours to include nausea and non-bloody emesis. He reports inability to keep any food down for the 4-5 days prior to admission with the exception of a small amount of water [**1-24**] days prior to admission. He also noted non-bloody diarrhea, described as loose stool occurring approximately 2 times per day. He denies any known sick contact though notes that his symptoms started sometime after working with children at a day care facility. He denies clear fevers at home and denies chills or nightsweats. He does endorse a headache for 24 hours approximately 3-4 days prior to admission, however this self resolved. He notes some blurry vision on admission. There was some concern for neck stiffness in the ED, however he does thinks the neck tenderness that occurred while in the ED was similar to his prior pain with slipped discs in the neck. He was initially admitted to the [**Hospital Unit Name 153**], and was febrile with a leukocytosis and tachycardia concerning for SIRS, also with Acute Renal Failure. He was started on vancomycin and ceftriaxone. While in the [**Hospital Unit Name 153**], the patient had several blood cultures which were positive for staph aureus sensitive to Oxacillin (MSSA). CT chest, CT sinus, and TTE were negative for source of bacteremia. Podiatry was consulted for a foot ulcer as well and felt this not to the source of the septicemia/bactremia. After being discharged to the floor, the patient noted that he had a rash on his chest/abdomen after going to the gym frequently prior to admission, but no pustules. Denies leg pain, stump pain.
MEDICAL HISTORY: - Coronary artery disease s/p MI [**2179**], angioplasty c stent LAD '[**81**], radiation brachytherapy LAD '[**83**] - Type I DM since age 18 - Diabetic Retinopathy - Diabetic Nephropathy (baseline creatine 1-1.5) - HTN - Hypercholesterolemia - Hypothyroidism - Cervical Disc - Peripheral [**Year (2 digits) 1106**] disease s/p L AKpop--> dorsalis pedis with non-reversed saphenous vein graft '[**83**] - S/p Right AK to DP bypass with reversed greater saphenous vein [**12-26**] - Right BKA [**2187-11-21**] - Left trans metatarsal amputation '[**83**] - Appendectomy
MEDICATION ON ADMISSION: Medications (patient does not know any of his home meds, list from d/c summ [**2186**], also confirmed with pharmacy: CVS in [**Location (un) 932**] on [**Location (un) **]. [**Telephone/Fax (1) 98969**]): Metoprolol 50mg Daily Levothyroxine Sodium 100 mcg PO DAILY Simvastatin 20mg daily Aspirin 325 mg PO DAILY -> Not recorded at the pharmacy Lisinopril -> patient believes he takes this medication though pharmacy has no record of this. Insulin fixed dose: NPH 28U QAM, 0-10U QPM per sliding scale Humalog sliding scale
ALLERGIES: Tetracycline / Nafcillin
PHYSICAL EXAM: ROS: GEN: - fevers, - Chills, - Weight Loss EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, - Palpitations, - Edema GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, - Constipation, - Hematochezia PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache
FAMILY HISTORY: Father with 3 [**Name2 (NI) 12425**] CABG in his 70's, deceased at 86; also had DM Type 2, CAD, MI, PVD. Otherwise non-contributory.
SOCIAL HISTORY: Disabled prior employee of [**Company 98966**]. Denies EtOH, tobacco or drug use. Sexually active with 1 partner in the past year and 'always' uses protection against STD's. HIV tested many years ago and was negative. | 0 |
83,637 | CHIEF COMPLAINT: Nausea/Vomiting/Diarrhea
PRESENT ILLNESS: 47yoF w/ HIV/AIDS (last CD4 302 1/08per ED record), PCP pneumonia, HCV who had a syncopal episode while at a salon. Per EMS record & ED record, pt c/o of acute onset of abd pain, not described further. + bilious vomiting/ + diarrhea. No HA, no CP, no SOB. Per ED record, pt was vomiting profusely and had explosive darrhea. Hypotensive, given 5L IVF and started on Levophed. RIJ cvl placed. Pt was dyspneic, intubated.
MEDICAL HISTORY: HIV CD4 302 [**1-14**] at [**Hospital1 2177**] PCP Pneumonia HCV [**Name9 (PRE) 167**] proximal femur fracture s/p ORIF
MEDICATION ON ADMISSION: 1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Reyataz 300 mg Capsule Sig: One (1) Capsule PO once a day. 3. Norvir 100 mg Capsule Sig: One (1) Capsule PO once a day. 4. Truvada 200-300 mg Tablet Sig: One (1) Tablet PO once a day: NOTE, PATIENT ON 100-300 tablet daily NOT 200-300 tablet. 5. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ml PO once a day. 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 7. Reglan 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 8. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. Zantac 300 mg Tablet Sig: One (1) Tablet PO once a day. 10. Ultram 50 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for pain. 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0*
ALLERGIES: Codeine / Bactrim
PHYSICAL EXAM: per [**4-10**] Surgical Consult note:
FAMILY HISTORY: Noncontributory
SOCIAL HISTORY: Lives with daughter. | 0 |
29,819 | CHIEF COMPLAINT: worsening chest pain and shortness of breath
PRESENT ILLNESS: Mr. [**Known lastname **] is an 85 yo gentleman who has a known cardiac history and has had a h/o worsening chest pain and shortness of breath. He had an echocardiogram which showed an EF 40-45% and severe aortic stenosis. He underwent cardiac catheterization which showed an 80% LAD lesion, chronically occluded RCA, anneurysmal mid LCX w/50% lesion. He was refered to Dr. [**Last Name (STitle) 70**] for surgical treatment.
MEDICAL HISTORY: s/p MI [**2130**] AS h/o prostate CA s/p brachytherapy and hormone treatment hyperlipidemia HTN PAF h/o rectal bleeding s/p cauterization cholelithiasis s/p AAA repair '[**45**] s/p bilateral hernia repair s/p R lung surgery CRI chronic lung disease
MEDICATION ON ADMISSION: lasix 40mg q M-W-F Klorcon 10mEq q M-W-F Pepcid 40mg qd colexa 10mg qd metoprolol 50mg [**Hospital1 **] lipitor 20mg qd aspirin 325mg qd flovent 110mcg inhaler [**Hospital1 **] atrovent inhaler tid
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
13,011 | CHIEF COMPLAINT: Exertional angina
PRESENT ILLNESS: This 66 year old male was referred for cardiac catheterization to evaluate exertional chest pain for the last 2-3 weeks and an abnormal stress test. Chest pain has ocurred with brisk walking and shoveling snow. At times the chest pain radiates to lower jaw and skips to left arm. He denies chest pain at rest. He was seen by primary care physician [**Last Name (NamePattern4) **] [**2180-2-9**] and started on Imdur and Zocor with improvement. He underwent elective stress test today that showed ST elevation in inferior leads and V1-V2 accompanied by chest pain. The chest pain resolved with sl. Nitroglycerin. He was referred for catheterization direct from the lab.
MEDICAL HISTORY: Hypertension Glucose intolerance Hypertriglyceridemia
MEDICATION ON ADMISSION: Nadolol 40 mg daily calcium 500 mg daily Zocor 20 mg daily Imdur 30 mg daily Nitroglycerin 0.3 mg sl prn chest pain Aspirin 81mg Daily
ALLERGIES: Amoxicillin / Hydrochlorothiazide
PHYSICAL EXAM: admission: Pulse:57 Resp:16 O2 sat: 100/RA B/P Right:134/91 Height:5'8" Weight:156 lbs
FAMILY HISTORY: mother died of an abdominal aneurysm at age 64, older brother had CABG in 50's, Brother with [**Name (NI) 27349**], younger brother with CABG
SOCIAL HISTORY: Lives with:wife Occupation:[**Name2 (NI) **] lab cordinator Tobacco:quit in [**2139**], history of smoking for 12 years ETOH:occasioanl | 0 |
18,799 | CHIEF COMPLAINT: Acute onset of lower extremity paralysis
PRESENT ILLNESS: 57 yo F who presented to [**Hospital 1191**] hospital [**9-1**] for ambien overdose was transferred to [**Hospital1 18**] ED for sudden onset bilateral lower extremity paraplegia beginning yesterday afternoon. Patient reported loss of sensory and motor function. CT angiogram performed in the emergency department demonstrated infrarenal aortic occlusion with reconstitution of flow in the left common femoral and left profunda arteries. Pt was taken emergently to the OR.
MEDICAL HISTORY: Depression s/p intentional Ambien overdose and subsequent hospitalization at [**Doctor First Name 1191**], no previous known psych history. Hypertension Hypercholesterolemia CAD - s/p AICD placement [**Doctor First Name 2793**] insufficiency - s/p [**Doctor First Name **] artery stents Chronic low back pain
MEDICATION ON ADMISSION: Zestril 10mg daily Simvastatin daily Aspirin 81mg daily Celexa (started 2 days ago at [**Doctor First Name 1191**]). Pt was taking percocet and vicodin in the past for LBP, but none recently.
ALLERGIES: Morphine
PHYSICAL EXAM: Gen: Thin, NAD, paraplegic HEENT: NCAT, anicteric sclera, OP with dry MM, no lesions. Neck: No carotid bruits B/L, no vertebral bruits. No nuchal rigidity. CV: RRR, no MRG, AICD in left chest. Pulm: Course breath sounds bilaterally Abd: Soft, NT, softly distended at lower abdomen, + BS, ostomy draining liquid brown stool. groin wound exudative Extr: Bilateral medial and fasciotomy wounds closed. Vasc: DP/PT palpable bilaterally Neuro: PERRL 3 to 2mm and brisk. VFF to confrontation. There is no ptosis bilaterally. no papilledema or hemorrhages. EOMI without nystagmus. Normal saccades. Facial sensation intact to pinprick. No facial droop, facial musculature symmetric. Hearing intact to finger-rub bilaterally. Palate elevates symmetrically. 5/5 strength in trapezii and SCM bilaterally. Tongue protrudes in midline.
FAMILY HISTORY: Father with diabetes mellitus and CAD
SOCIAL HISTORY: Lives in [**Location 3786**] with her husband, various jobs in past, but not currently employed, one son who lives in the area. She smoked 1 ppd x 40 years. She denies any illicit or IV drug use. | 0 |
56,954 | CHIEF COMPLAINT: shortness of breath
PRESENT ILLNESS: 82 yo female with hx of afib s/p ablation x2 on amiodarone and coumadin, CAD, HTN, hyperthyroidism, chronic cough who presents with cough and SOB. Pt was recently hospitalized [**Date range (1) 2953**] for rapid afib suspectedly due to hyperthyroidism induced by amiodarone toxicity. She was started on methimazole, prednisone and metoprolol and completed 2 wks of methimazole but was continued continued on a prednisone taper although increased back to 15mg from 10mg due to climbing freeT4. She presented to her PCP [**Last Name (NamePattern4) **] [**2-13**] for increase in her baseline cough and change in the quality of her sputum to thick and green but no fever or chills. He held on antibiotics and obtained a CXR which revealed blunted CP angles with interstitial prominence but no infiltrate. This am she noticed irregular pulse so called her endocrinologist Dr. [**Last Name (STitle) 7852**] who consulted with her cardiologist Dr. [**Last Name (STitle) **] and told her to go to the ED. Her irregular pulses lasted 2 hours and resolved spontaneously before getting to the ED. She denied CP, CT, PND, orthopnea but did have increasing DOE. She also reports for the last 2 wks some nocturia with incontinence, but no frequency, urgency or dysuria during the day. In the ED, she was afebrile and VS were stable with CXR revealing RML opacity so she was given 750mg of levofloxacin, tessalon pearles and tylenol with codeine and admitted for PNA.
MEDICAL HISTORY: 1. CV: ---Atrial fibrillation, status post two ablations last in '[**52**] on amiodarone chronically as well as coumadin. ECG in [**2156**] with sinus bradycardia. ---Pump: Echo from [**2150**] with mild AR, mild MR, preserved LV function. ---CAD: Stress ECG in [**June 2157**] with borderline EKG evidence of myocardial ischemia in the absence of anginal symptoms with 6min on [**Doctor First Name **]. 2. Hypertension 3. Hypercholesterolemia 4. Status post total abdominal hysterectomy 5. Chronic cough followed by Dr. [**Last Name (STitle) 575**] 6. Anxiety 7. Back pain - DJD of L4-L5 and L5-S1 and spondylolisthesis followed by Dr. [**First Name (STitle) 4223**] of Ortho. .
MEDICATION ON ADMISSION: 1. Warfarin 1 mg qd 2. Pantoprazole 40 mg qd 3. Amlodipine 2.5 mg qd 4. Amiodarone 200 mg qod 5. Amiodarone 300 mg qod alternating with 200mg 6. Prednisone 15mg qd just increased 1 wk ago 8. Metoprolol Tartrate12.5 [**Hospital1 **] 9. MVI 10. Actonel 1x/wk 11. Ca and glucosamine
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: T 100.1 HR 70 BP 112/60 RR 20 O2Sat 89% RA 96% 2L NC Gen-mild resp distress HEENT-PERRLY, OP clear, MMM, overiding V waves Hrt-RRR nS1S1 [**1-22**] HSM at LUSB and LLSB, [**12-25**] SM at apex rad to axilla Lungs-rt ant crackles but otherwise no crackles or wheeze Abd-soft, tympanitic, NT, mod distended, no CVA tenderness Extrem-1+ dp pulses, 2+ rad pulses, chronic venous stasis changs of shins bilat, no LE edema Neuro-A and O x3, CN II-XII intact, [**3-22**] UE and LE strength Skin--mild erthema of upper chest and back without rash
FAMILY HISTORY: Positive for migraines, no heart disease, no lipid disorders, sister died of lung cancer, mother with breast cancer
SOCIAL HISTORY: She lives alone but in the same building that her son. She has never smoked, does not drink alcohol and had her flu shot in 11/[**2158**]. She also denies any TB contacts. | 0 |
81,905 | CHIEF COMPLAINT: Hepatitis C cirrhosis.
PRESENT ILLNESS: The patient is a 50 year old man with a history of hepatitis C cirrhosis, complicated by gastric varices; portal hypertension and encephalopathy. He is scheduled for a liver transplant on [**2-26**]. The patient's donor, who was his sister, was found to be inappropriate; however, and the patient presented to the liver clinic for follow-up on [**2-26**]. While in clinic, the patient was noted to be lethargic with a several day history of nausea, vomiting and poor appetite. The patient was sent to the Emergency Room where his total bilirubin was found to be increased to 19.9. The patient has a baseline T bili of 4 to 9 and a creatinine of 5.3 from a baseline of 1.0. The patient's white count was also noted to be increased to 18; sodium decreased to 127; potassium increased to 7.6. The patient was given albumin 50 grams and [**Doctor First Name 233**]-Exalate and the Intensive Care Unit was called for evaluation of his hepatorenal syndrome. On admission, the patient denied any fevers or chills. The patient did note that he has chronic abdominal pain in his right upper quadrant; history of chronic diarrhea, without any recent changes and increasing confusion in the several days prior to admission. The patient denied any dysuria.
MEDICAL HISTORY: The patient's past medical history includes hepatitis C cirrhosis, complicated by gastric varices; portal hypertension and encephalopathy. The patient also has a history of infectious colitis in [**2147-5-2**].
MEDICATION ON ADMISSION: Lansoprazole, ursodiol, levofloxacin 250 mg p.o. q.48 hours, octreotide 100 mg p.o. t.i.d., Flagyl 500 mg p.o. t.i.d., insulin, albumin 25 q.d., lactulose p.r.n.
ALLERGIES: The patient is not allergic to any medications.
PHYSICAL EXAM:
FAMILY HISTORY: The patient's brother had a myocardial infarction at the age of 50 and also has diabetes.
SOCIAL HISTORY: He lives alone at home. He has a 15 pack year tobacco history. He quit [**Holiday **] of [**2147**]. The patient does not have an alcohol history. The patient has a history of remote intravenous drug use years ago. The patient contracted hepatitis C, most likely through sexual contact according to the patient. The patient used to work for the [**Company 2318**] service. The [**Hospital 228**] health care proxy is his daughter, [**Name (NI) 11923**], whose phone number is [**Telephone/Fax (1) 106231**]. | 0 |
33,182 | CHIEF COMPLAINT:
PRESENT ILLNESS: This 82-year-old male has a history of coronary artery disease, atrial fibrillation, type 2 diabetes, and CHF. He had the sudden onset of substernal chest pain which lasted 30 minutes and resolved spontaneously. It was similar to his usual anginal pain and he presented to the Emergency Room. His EKG in the Emergency Room revealed new ST depressions in V4-6 but his first set of enzymes were negative. He was admitted for rule out MI.
MEDICAL HISTORY: 1. Colon cancer, status post right hemicolectomy five years prior to admission. 2. History of noninsulin-dependent diabetes times 13 years. 3. History of atrial fibrillation. 4. History of hypertension. 5. History of CAD, status post cardiac arrest in [**2108**] with a positive exercise tolerance test. 6. History of CHF. 7. BPH, status post TURP times two. 8. Status post appendectomy. 9. AAA 3 cm.
MEDICATION ON ADMISSION:
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY: Unremarkable.
SOCIAL HISTORY: He does not drink alcohol. He does not smoke cigarettes. | 0 |
97,619 | CHIEF COMPLAINT: Left leg weakness
PRESENT ILLNESS: 52yo RH F h/o smoking until recently and multiple recent ED visits for headache (LP negative for meningitis, SAH) and seen in neurology clinic with normal motor exam as recently as [**11-4**] by Dr. [**First Name (STitle) 6817**], who prescribed fioricet for combination migraine/tension headache. She began taking it on Friday, two days ago, and per her husband, she was too drowsy and disinhibited. He has not given it to her since. Her behavior has remained odd since then and her family, present at my interview, says she has been overly jovial for the past few days. Her headache, though, has ceased, apart from a "pricking" on the left side last night. At 11:30pm, she complained to her husband that her left leg was numb, meaning she had decreased sensation, and she felt it become that way acutely, in the absence of back pain. He pinched her in several places lightly and she said it felt different than usual. In addition, she said the left leg was weak and she has not been able to walk normally since; by this, her husband describes her standing up and her left leg buckling. She went to bed, apparently not alarmed, but also not denying her deficits, and she presents here after her leg has not gotten better. She denies neck pain or manipulation, no headache or backache, no visual difficulties or double vision apart from blurriness (corrected with pinhole on recent visit), no dysarthria, no speech difficulties, no dysphagia, no vertigo.
MEDICAL HISTORY: Sickle cell trait (later demonstrated not to be true by laboratory) Migraines (a/w visual aura, photophobia)
MEDICATION ON ADMISSION: Tylenol prn, had recently discontinued fioicet
ALLERGIES: Aspirin
PHYSICAL EXAM: 97.9 60 155/88 16 100% Gen Awake, poorly cooperative, NAD HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck Supple, no carotid bruits appreciated. No nuchal rigidity Lungs CTA bilaterally CV RRR, nl S1S2, no M/R/G noted Abd soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted Ext No C/C/E b/l Skin no rashes or lesions noted NEURO MS Awake, alert. Fully oriented. MOYB intact. Speech fluent, with normal naming, [**Location (un) 1131**], writing, comprehension and repetition. Normal prosody. There were no paraphasic errors. Able to follow both midline and appendicular commands. No apraxia. Interprets cookie theft picture appropriately. No dysarthria. She is quite disinhibited, however, laughing inappropriately (such as when I asked her to name my thumb). Unable to perform Luria sequencing. Requires several explanations to test for go-no go but then does it properly. CN CN I: not tested CN II: VFF to confrontation, no extinction. Pupils 3->2 b/l. Fundi clear CN III, IV, VI: EOMI no nystagmus or diplopia CN V: intact to LT throughout CN VII: full facial symmetry and strength CN VIII: hearing intact to FR b/l CN IX, X: palate rises symmetrically CN [**Doctor First Name 81**]: shrug [**5-29**] and symmetric CN XII: tongue midline and agile Motor Normal bulk and tone. No pronator drift D B T WE FE FF IP Q H DF PF TE TF L 5------------> 3 5 3 0 0 0 0 Holds left leg antigravity for at least 40 seconds (initially could not lift it by her report but then did so with coaxing) but does not cooperate with power testing. With coaxing, her right hamstring is [**5-29**]; she can bend the knee on the left but either cannot or will not contract her hamstrings further. She has no movement at the ankle or toes. Sensory intact to LT, PP, JPS, vibration throughout. No extinction. Reflexes Br [**Hospital1 **] Tri Pat Ach Toes L 2+ 2+ 2+ 2+ 2+ down R 2+ 2+ 2+ 2+ 2+ down Coordination FFM, RAMs, FTN, HTS all normal Gait sways wildly, c/w astasia-abasia but also at times circumducts the left leg, which she holds stiffly at the knee and ankle. Able to tandem with exaggeration
FAMILY HISTORY: Mom has migraines, o/w negative
SOCIAL HISTORY: Quit smoking three weeks ago after 15yrs. No etoh/illicits | 0 |
53,947 | CHIEF COMPLAINT: Hemoptysis x 3 weeks
PRESENT ILLNESS: 72yo F w/distant h/o TB who presents w/hemoptysis x 3 wks. Per pt's daughter, she had febrile illness ~1 month ago associated w/cough and had 2 episodes of hemoptysis with it. She coughed up 1 teaspoon of blood the first time ~4wks ago and she was treated with a z-pak for bronchitis; then another episode of coughing spasm 1 wk later w/~[**1-18**] cup blood she was treated with 10 days of levofloxacin for possible PNA. She went to [**Hospital1 2177**] and had a sputum AFB negative for TBx 1. The fever and cough seemed to resolve and she did not have any more episodes of hemoptysis until Wed night, 3 days prior to presentation. At that time She had coughing and small volume-1 teaspoon-of hemoptysis. It resolved until the next morning when she had another episode of hemoptysis which again was ~[**1-18**] cup and her daughter brought her to the [**Name (NI) **]. No recent fever/chills, no CP, but +SOB w/coughing. . In the ED, her vitals were T 98 BP HR 94 RR 18 sat 100%RA. She was intubated for airway protection. At 3pm had 200cc of hemoptysis in the ED. CT chest revealed dense colidation in LUL. Interventional Pulmonology was consulted and bronch was performed - blood clot was seen at the level of the carina, between the apicoposterior and anterior segments of the left upper lobe. No endobronchial lesions or active bleeding was noted. Pt's HCT was stable at that time, she was not transfused. Covered for PNA w/Azithromycin 250 mg, CeftriaXONE 1g. . On ROS, her daughter notes that prior to her febrile illness 1 month ago, she had been very well. She was active and did not have any ongoing medical problems. Since the illness, she has had a 10lbs weight loss. She had one recent episode of lightheadedness. No hematemesis/abdominal pain, no diarrhea/hematochezia. + night sweats with the febrile illness 4wks ago, none since or prior. . Pt was then transferred to the MICU. .
MEDICAL HISTORY: MEDICAL HISTORY: TB at age of 20 - treated with triple therapy for 1 year Thyroid dysfunction
MEDICATION ON ADMISSION: Medications at home: BP Medication - daughter can't remember name Chinese TaiChi
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: PHYSICAL EXAMINATION: Vitals: Tmax 98.8 Tcurrent 98.2 BP 144/79 HR 70-90s RR 19-27 O2sat 96% on 2LNC General: NAD, lying in bed HEENT: PERRL, EOMI, OP clear, voice hoarse whisper. Few remaining teeth. Neck: Supple, no LAD, no JVD CV: RRR, + systolic murmur loudest at apex. No rubs/[**Last Name (un) 549**]. Lungs: Bibasilar crackles Abdomen: +BS, NTND, soft, no guarding or rebound. Large echymosis over R hip and suprapubic region. Ext: no edema, 2+ pulses bilaterally Neuro: CN III-XII grossly intact.
FAMILY HISTORY: Noncontributory
SOCIAL HISTORY: Retired teacher, never worked in a factory, no known inhalant exposures, emigrated to US in [**2111**]. Lives with 2 daughters, never smoked, no etoh, no other drugs. Widowed 4 years ago. Recent travel to [**Country 651**] within the past couple of months to visit famiy. | 0 |
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