id
int64 1
100k
| text
stringlengths 153
65.4k
| hospital_expire_flag
int64 0
1
|
|---|---|---|
43,834 | CHIEF COMPLAINT: Syncope
PRESENT ILLNESS: 66 year-old male who came to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] complaining of an episode of loss of consciousness while sitting on the toilet. Pt had some stomach cramping, got up to go to the bathroom, had some back tightness and while sitting on the toilet became very diaphoretic and subsequently had an episode of loss of consicusness. He does have a h/o vagovasal episodes in the past. Of note, he does complain of a few months of intermittent substernal and left-sided chest and back tightness with exertion. No associated SOB. At the OSH 1st set of trop was negative, while second trop I postive at 0.35, 7.046, 24.696 and CK of 126, [**Telephone/Fax (1) 90445**]. Patient was loaded with 300mg of plavix in ED and was given aspirin and plavix prior to transfer. Pt was transferred directly to the catherization lab were severe two vessel disease was noted with a long mid-LAD occulsion and a mid-LCX occulsion. Decision was made not to intervene with stenting, but to have pt evaluated by C-[**Doctor First Name 147**] for possible CABG. On arrival to the floor, patient is chest pain free without complaint.
MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - erectile dysfunction - rhinitis
MEDICATION ON ADMISSION: - Fluticasone 50 mcg nasal spray 1-2 puffs daily - Hydrocortisone cream 2.5% topical PRN
ALLERGIES: Penicillins
PHYSICAL EXAM: Physical Exam on admission: 75.3 kg 67"
FAMILY HISTORY: Father died of colon cancer at 57. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory.
SOCIAL HISTORY: -Tobacco history: Never smoker -ETOH: Occasional -Illicit drugs: None | 0 |
92,953 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is an 81-year-old female with a history of recent CABG with AVR, CHF, protein S deficiency who presented from [**Hospital3 **] in the morning on [**2162-2-14**] with fever and respiratory distress. She was felt at [**Hospital1 **] to be in CHF versus pneumonia and was given levofloxacin, ceftriaxone, and Lasix. They were unable to contact her proxy and thus sent her to EMS, as her oxygen saturation decreased to 90 percent on nonrebreather. In the ambulance, she was given morphine and BiPAP was attempted, but her saturations decreased and she was intubated in the field.
MEDICAL HISTORY: Recent CAD, status post CABG and AVR in [**11-26**] complicated postoperatively by multiple recurrent episodes of congestive heart failure versus pulmonary disease of unclear etiology. Protein S deficiency with recurrent DVTs and PEs. Schizophrenia. Chronic renal insufficiency with creatinine ranging between 1.3 to 1.5. CHF with an EF of 25 percent by echo in [**11-26**]. COPD. Dementia. History of MRSA.
MEDICATION ON ADMISSION: 1. Singulair 10 mg by mouth every day. 2. Coumadin. 3. Colace 100 mg by mouth two times a day. 4. Aricept 10 mg at bedtime. 5. Aspirin 81 mg a day. 6. [**Doctor First Name **] 60 mg a day. 7. Protonix 40 mg a day. 8. Advair 100/50 mcg. 9. Prednisone 5 mg every other day. 10. Celexa. 11. Zyprexa 2.5 mg at bedtime. 12. Toprol XL 100 mg two times a day. 13. Neurontin two times a day. 14. Magnesium gluconate 1 g three times a day. 15. Lasix 60 mg two times a day. 16. Ceftriaxone 1 g. 17. Levofloxacin 500 mg.
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient quit tobacco several years ago, lived in [**Hospital3 **] prior to her hospitalization in [**Month (only) 1096**]; however, after her operation in [**Month (only) 1096**] had a prolonged hospital course with multiple attempts of extubation and difficulties with this resulting in severely deconditioned patient and need for [**Hospital3 **] afterwards. She has been in there since her discharge in [**Month (only) 404**]. Her husband lives in a nursing home. | 1 |
63,099 | CHIEF COMPLAINT: Skateboard vs. car
PRESENT ILLNESS: This is an 18 year-old Male who, per report, was skateboarding in the road and was involved in pedestrian vs. car strike and he was thrown approximately 100 feet. GCS on the scene was [**4-3**] and patient was vomiting, combative with intermittent LOC. Patient transfered to [**Hospital1 18**] from [**State 77532**] Ctr where he was intubated for inability to protect his airway. Per report, single episode of hypotension to the 40s systolic, with resolution. 3L IVFs prior to arrival.
MEDICAL HISTORY: PMH ADHD PSH R thumb surgery, bilateral tympanostomy tubes
MEDICATION ON ADMISSION: Adderall 30 mg daily
ALLERGIES: Penicillins
PHYSICAL EXAM: VITALS: T 98.5 BP 128/54 P 68 RR 15 O2sats 100% CMV/AS CMV/AC 550 / 16 / 5 / 0.4 GEN: Intubated, sedated not following commands (with sedation infusing), non-verbal, no eye opening, minimal withdrawal to pain with noxious stimuli HEENT: Left supraorbital region with 3-4-mm laceration with surrounding abrasion. Palpation reveals minimal step-off and deformity overlying supero-lateral aspect of the orbital roof, minimal visible deformity. Right superior eyelid with ecchymosis and swelling. Pupils pinpoint, minimally reactive 3-2 mm bilaterally. Nasal bones stable. Zygomatic complex without deformity or malalignment. CVS: Regular rate and rhythm, no murmurs, rubs or gallops. RESP: Clear to auscultation, no wheezes, rales or rhonchi. EXTR: 2+ pulses, no cyanosis, clubbing or edema
FAMILY HISTORY: non contributory
SOCIAL HISTORY: HS student, + ETOH, no tobacco | 0 |
64,563 | CHIEF COMPLAINT: s/p Fall
PRESENT ILLNESS:
MEDICAL HISTORY: Atrial fibrillation (on Coumadin) Coronary Artery Disease Ulcerative Colitis w/ colostomy Hypertension Pacemaker CVA [**2191**] w/ right sided weakness Cataracts, s/p cataract surgery s/p TURP
MEDICATION ON ADMISSION:
ALLERGIES: Iodine; Iodine Containing
PHYSICAL EXAM:
FAMILY HISTORY: Noncontributory
SOCIAL HISTORY: Lives with wife; +ETOH use | 0 |
52,316 | CHIEF COMPLAINT:
PRESENT ILLNESS: In brief, the patient is a 38 year old male with a long history of alcohol abuse and mood disorders who was admitted via the Emergency Department on [**2125-10-11**], with acute alcohol intoxication. The patient was found by ambulance services in the street with a bottle of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5261**] next to him. He smelled of alcohol and had a normal blood glucose level. He was markedly obtunded with a respiratory rate of 10 and no verbal responses to commands. He did respond with flexion to painful stimuli. He was brought to the [**Hospital1 69**] Emergency Department where he was found to have no gag reflex and marked decreased level of consciousness. He was electively intubated using rapid sequence induction and transferred for further care in the Intensive Care Unit. His alcohol level was subsequently found to be greater than 500 mg/deciliter.
MEDICAL HISTORY: 1. Alcohol abuse. 2. Mood disorder. He had recently completed an outpatient treatment program at [**Hospital 1191**] Hospital. 3. Hypertension.
MEDICATION ON ADMISSION:
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: As above. | 0 |
47,545 | CHIEF COMPLAINT: CAD
PRESENT ILLNESS: Mr. [**Known lastname 69998**] is a 59 year old male with hx of HTN, hyperlipidemia, and tobacco abuse who went to PCP for [**Name9 (PRE) **] clearance for cataract surgery. During the preop testing, he was found to have an abnormal EKG with some Q-waves in leads 3 and AVF, which were new. He subsequently went for a stress test, which was positive for reversible ischemia. He presented to LGH for elective coronary catherization which showed 3 vessel disease- no left main disease. Troponin at OSH was .078. He was asymptomatic at the time of presentation but did report that a few days prior to visit to PCP, [**Name10 (NameIs) **] did have several episodes of SOB. He was transferred to [**Hospital1 18**] for surgical evaluation of coronary revascularization.
MEDICAL HISTORY: Past Medical History: HTN, Hyperlipidemia, tobacco abuse Past Surgical History:none- awaiting left cataract surgery Past Cardiac Procedures:??? coronary angioplasty in [**Male First Name (un) 1056**] 10 yaers ago
MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete. Information was obtained from Patient d/c summary. 1. Lisinopril 20 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Pulse:74 Resp: 18 O2 sat:96% RA B/P Right:155/74 Left: Height: Weight:
FAMILY HISTORY: Family History:+ DM, Father had CABG and died at age 75. Mother died in 60's from GIB
SOCIAL HISTORY: Occupation: retired. Was working cleaning and packing fish on a fishing boat in [**Male First Name (un) 1056**] 10 years ago | 0 |
16,939 | CHIEF COMPLAINT: Dyspnea on Exertion
PRESENT ILLNESS: Mr. [**Known lastname 32283**] is a 56 year old gentleman with no known coronary artery disease. In [**2191-8-5**], he was diagnosed with thyroid cancer and underwent a thyroidectomy and radiation therapy. In [**2194-2-1**] a routine CT scan revealed coronary artery calcification and he was therefore referred for further evaluation. An exercise tolerance test on [**2195-12-18**] was positive with fatigue, dyspnea and ST depressions in the inferolateral leads. Scans showed a moderate reverisble defect in thebasilar and mid-inferior wall. His ejection fraction was predicted to be 66%. Mr. [**Known lastname 32283**] reports intermittant dyspnea on exertion for the past few months but denies ever experiencingany chest pain. He was admitted today [**2195-12-7**] for a cardiac catheterization which revealed an 80% stenosed left main, an 80% stenosed left anterior descending artery and a 90% stenosed right cronary artery. His ejection fraction was normal. Mr. [**Known lastname 32283**] is now being referred for surgical revascularization.
MEDICAL HISTORY: Hypercholesterolemia Thyroid cancer S/P Thyroidectomy Gout Right eye styes Glaucoma Past tonsillectomy Eye surgery to relieve pressure
MEDICATION ON ADMISSION: Synthroid 150mcg daily Timoptic one drop to both eyes at bed time Travatan one drop to both eyes at bed time Lipitor 20mg once daily Toprol XL 50mg once daily Doxycycline 50mg once daily Valium 5mg as needed at bed time Ecotrin 81mg once daily
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Ht 68" Wt 160 Temp- 98.1 128-147/70's 64 SR 100% room air sats GEN: Overall good health. Appears well in no acute distress. NEURO: Alert and oriented x3. Appropriate. Flat affect. Nonfocal. LUNGS: Bibasilar rales HEART: RRR, normal S1-S2. No murmur ABDOMEN: Soft, round, nontender, nondistended, normoactive bowel sounds EXTREMITIES: Warm, well perfused, no edema, no varicosities. PULSES: 1+ radial, dorsalis pedis and posterior tibial bilaterally.
FAMILY HISTORY: Father with myocardial infarction and CABG in his 60's. Aunts and [**Name2 (NI) 32284**] with coronary artery disease.
SOCIAL HISTORY: Live sin [**Location 17448**] with wife. Three children. WOrks full-time as a buisness analyst. Never smoked. Occasional alcohol use. | 0 |
92,948 | CHIEF COMPLAINT: 49 year old male with lifelong VSD followed by serial echos. He has progressive elevation of PA pressures and now a new ruptured sinus of Valsalva with aorta to RV fistula. This was diagnosed on [**5-25**].
PRESENT ILLNESS: 49 yo male with newly diagnosed aorta to RV fistula with longstanding history of VSD and now a ruptured sinus of Valsalva. he has had progressively elevated PA pressures and now presents for surgical repair.
MEDICAL HISTORY: ventricular septal defect ruptured sinus of Valsalva pulmonary nodules fused cervical vertebrae
MEDICATION ON ADMISSION: coreg 25 mg [**Hospital1 **] ASA 81 mg q.o.d many vitamins
ALLERGIES: Actifed / Amoxicillin
PHYSICAL EXAM: 68" tall, 210 pounds 123/ 65 HR 50 EOMI PERRLA NC/AT neck supple without JVD or bruit CTA bilat. with no adventitial sounds RRR with S1 , S2, III/VI SEM abd. soft, NT, ND + BS extrems warm with no C/C/E no varicosities noted neuro CN II-XII intact, alert and oriented X3 pulses 2+ bilat. fem, DP, PT, radials
FAMILY HISTORY: father died of CVA
SOCIAL HISTORY: computer consultant who lives with significant other no use of tobacco and has one glass of wine with dinner daily | 0 |
67,979 | CHIEF COMPLAINT: (R)UQ abdominal pain
PRESENT ILLNESS: 68M presented to [**Hospital **] Hospital on [**2179-2-12**] with RUQ pain and 2-3 episodes of non-bilious, non-bloody emesis. First noticed this pain two weeks ago. Experienced chills, and mild RUQ tenderness. Lasted about 30 minutes, not associated with food. Again on [**2179-2-11**] at 8:00 pm had chills and RUQ tenderness. He notes that he had a poor appetitite and had not eaten all day. On [**2179-2-12**], he had a third episode, this time lasting longer, with more severe pain that radiated into the epigastrum. He also noted dark [**Location (un) 2452**] urine. . He never recorded his temperature, or noted a subjective fever. He had mild constipation buy no change in stool color, and no hematochezia. . He presented to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where he was found to be febrile to 100.4. An abdominal ultrasound showed a distended gallbladder with stones, sludge c/w acute cholecystitis, and dilated intrahepatic and common bile duct, concerning for choledocholithiasis. He was treated with Unasyn 3g IV, Toradol, Dilaudid, and Zofran prior to transfer. . In the [**Hospital1 18**] ED, initial VS were 101.3 101 124/78 16 98%RA. He was given IV unasyn, 4 mg IV morphine for abd pain & 1L IVF. Surgery and ERCP were consulted, and recommended ERCP. Patient was admitted to the [**Hospital Ward Name 332**] ICU in anticipation of ERCP. VS on transfer were 98.7, 88, 131/75, 16, 99% RA
MEDICAL HISTORY: PMHx: Peptic Ulcer Disease, Peripheral Vascular Disease, Barrett's esophagus, Hypertension, Hypercholesterolemia . PSHx: BII Distal gastrectomy [**2140**], Aortobifem bypass [**2172**].
MEDICATION ON ADMISSION: Nexium 40 mg PO daily Lipitor 20 mg PO daily Atenolol 12.5 mg PO daily Lisinopril 20 mg PO daily ASA 81mg 1 tab PO daily MVI 1 tab PO daily Calcium with Vitamin D
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: On Admission: Vitals: T: 99.2 BP:90/58 P:95 R:17 O2:96/ra General: Alert, oriented, no acute distress HEENT: Sclera icteric, MM dry, oropharynx clear Skin: jaundiced 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, mildly TTP RUQ, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Midline and R subcostal surgical scars GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
FAMILY HISTORY: CAD in father, sister, paternal grandmother; no h/o ca
SOCIAL HISTORY: Has smoked 1 PPD x 50years. Few drinks on the weekend. Retired; used to work for GE. Lives alone, daughter living with him now. Mother, two brothers live in area. | 0 |
12,882 | CHIEF COMPLAINT: Chest pain.
PRESENT ILLNESS: A 41-year-old female with a history of coronary artery bypass graft x3 in [**2156**] who has experienced substernal chest pain over the past two days. Patient initially attributed her discomfort to a cold. This afternoon pain worsened then spread to her arms and neck. She planned to see her doctor tomorrow, but due to this worsening of the pain, the patient decided to come to the Emergency Department. At [**Hospital1 69**], the patient was brought to the Catheterization Laboratory. At cardiac catheterization, patient was found to have three vessel coronary artery disease. The LMCA had a distal 50% stenosis. The left anterior descending artery was totally occluded after giving off S1 and D1. The distal left anterior descending artery stent refilled via the left collaterals. The left LCA was totally occluded proximally. The right coronary artery was severely diffusely diseased proximally and totally occluded in its mid segment. Selective graft vessel angiography revealed a totally occluded saphenous vein graft to OM after giving off the free LIMA to distal left anterior descending artery. The distal left anterior descending artery supplied by the LIMA graft had mild-to-moderate diffuse disease, but had no flow limiting lesions. The saphenous vein graft to distal RVA was widely patent, but with TIMI-I flow and injection, and supplied diminutive distal right coronary artery. Resting hemodynamics revealed elevated right and left sided filling pressures. There was mild pulmonary hypertension. Cardiac index is mildly reduced at 2.2. The distal right coronary artery occlusion just beyond the saphenous vein graft, right coronary artery anastomosis was successfully treated by thrombectomy, angioplasty, and stenting with no residual stenosis, no intergraphic evidence of dissection, and TIMI-III flow. During procedure, the patient required administration of dopamine due to systolic blood pressures in the 70's. She was transferred to the CCU for further management.
MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft x3 in [**2156**]: LIMA to LAD, saphenous vein graft to OM, saphenous vein graft to PDA. 2. Sternal wound infection. 3. Hypothyroidism. 4. Nephrolithiasis. 5. Obesity. 6. Anemia. 7. Depression. 8. Gestational diabetes. 9. Repair of triple hernia.
MEDICATION ON ADMISSION:
ALLERGIES: Penicillin, succinylcholine, and sulfa.
PHYSICAL EXAM:
FAMILY HISTORY: Mother died at age 50 of a myocardial infarction. Multiple family members on her mother's side died in their 50's of coronary artery disease. Father has diabetes mellitus.
SOCIAL HISTORY: The patient lives in [**Location 4288**] with her husband. She smokes half a pack a day. She is currently not employed. | 0 |
15,411 | CHIEF COMPLAINT:
PRESENT ILLNESS: Transfer from [**Hospital **] Hospital for interventional coronary catheterization. A 48-year-old male with past medical history with end-stage renal disease on hemodialysis, hepatitis C, coronary artery disease, status post coronary artery bypass graft x2 vessels in [**2143-6-28**], transferred from outside hospital for interventional catheterization. Admitted to [**Hospital **] Hospital on [**2144-11-15**] with chest discomfort and dyspnea. Had laboratories there which showed a CK of 300, MB of 10, and troponin of 43. The patient underwent cardiac catheterization which showed a cardiac output of 8.7, wedge pressure 24, PA pressure of 65/30, a 70% stenosis in the left main coronary artery, and a totally occluded left circumflex artery, right coronary artery dominant system with 90% stenosis in the right coronary artery at the bifurcation of the PDA and PL branches. The patient had [**Female First Name (un) 899**] to left anterior descending artery graft and saphenous vein graft to OM-2 graft which were patent. The patient was then transferred for interventional cardiac catheterization at [**Hospital1 69**] and possible stent placement. At catheterization at [**Hospital1 346**], the patient had a cardiac output of 3.5, a wedge pressure of 32, PA pressure of 78/36, right coronary artery showed diffuse calcification, distal 90% lesion at the bifurcation of the PDA/PL. A stent was then placed in the distal right coronary artery. The patient was transferred to the CCU for further care because he continued to have searing 10/10 chest pain after stent placement.
MEDICAL HISTORY: 1. Chronic renal failure on hemodialysis on Monday, Wednesday, Friday reportedly secondary to hypertension. 2. Congestive obstructive pulmonary disease. The patient continues to smoke one pack per day. 3. Hepatitis C, open sores secondary to pruritus. 4. Coronary artery disease. 5. History of flash pulmonary edema. 6. Hypertension. 7. Gastritis.
MEDICATION ON ADMISSION:
ALLERGIES: Aspirin leads to bleeding. Norvasc leads to unknown reaction.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: Smoking greater than one pack per day. History of intravenous drug abuse. | 0 |
8,124 | CHIEF COMPLAINT: transfer from OSH for dental abscess
PRESENT ILLNESS: 45 year old male with past medical history of hypertesion and severe obesity who has not seeked regular medical or dental care presents to OSH with 10 day history of right lower tootache, fever and chills. He heard a [**Doctor Last Name **] one day ago with associated pain and progressive swelling which prompted him to go to [**Hospital 1562**] hospital. At [**Hospital **] hospital, CT neck showed soft tissure infection with phlegmon in the right perimandibular region likely originating from dental infection of tooth #7 in the right lower jaw. Labs significant for normal WBC and HgA1c of 12%. He was started on Vancomycin and Unasyn. He was also started on lantus 10 units qam. He was transferred to [**Hospital1 18**] as [**Hospital 1562**] hospital does not have OMFS service on call. On the floor, he reports dysphagia. He also reports having few episodes of unresponsiveness with drooping of face and slurring of his speech over past few years. Last episode one month ago.
MEDICAL HISTORY: 1. New diagnosis of diabetes mellitus 2. Hypertension 3. Severe obesity 4. Likely obstructive sleep apnea
MEDICATION ON ADMISSION: None
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Admission Physical Exam 100.2 149/90 92 20 95%RA Gen: Ill appearing obese male with right submandibular swelling
FAMILY HISTORY: Mother diet of breast cancer. He has 13 siblings of whom four passed away.
SOCIAL HISTORY: 1 ppd. Over 50 year pack year history of smoking. Social alcohol use. No IVDU. Lives with daughter and her husband. [**Name (NI) **] works as a [**Doctor Last Name **]. Has four dogs at home. | 0 |
73,356 | CHIEF COMPLAINT: Chest pain
PRESENT ILLNESS: This 49-year-old patient with a history of shoulder arm pain was investigated and had a positive stress test with subsequently angiogram demonstrating significant lesion in the left anterior descending artery and severe aortic regurgitation with dilated ascending aorta. The left ventricular function was well preserved with an ejection fraction of 55%, and he was electively admitted for coronary artery bypass graft, AVR and ascending aortic replacement.
MEDICAL HISTORY: HTN Hyperlipidemia Asthma AI Past Pneumonia Arthritis CAD Dilated aortic root
MEDICATION ON ADMISSION: Advair Zyrtec Singulair Flonase Avapro Nifedical XL Aspirin
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Vitals: BP 140-152/60-70, HR 78, RR 14, SAT 97% on room air General: well developed male in no acute distress. Obese HEENT: oropharynx benign, teeth in good repair Neck: supple, no JVD, transmitted murmur to carotid noted Heart: regular rate, normal s1s2, 3/6 systolic ejection murmur, II/VI diastolic murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds, Obese Ext: warm, trace edema, posterior varicosities noted, GSV otherwise appears suitable Pulses: 2+ distally Neuro: nonfocal
FAMILY HISTORY: Father w/ CABG at 50's.
SOCIAL HISTORY: Owns a gas station. Lives with wife and children in [**Name (NI) **], MA Quit 10 years ago. Drinks 2-3 6 packs over weekend. | 0 |
33,790 | CHIEF COMPLAINT: Mild fatigue and leg swelling
PRESENT ILLNESS: 40 yo M with rheumatic heart disease s/p MVR/TVR in [**2171**]. Presenting following cath and recent echo which showed 4+ AI, moderate mechanical valve MS and mild TR.
MEDICAL HISTORY: -s/p mitral valve replacement with a St. [**Male First Name (un) 923**] bileaflet prosthesis, tricuspid valve replacement with a porcine bioprosthesis in [**2172**] -Moderate-to-severe aortic regurgitation -Hx rheumatic fever -Diabetes Mellitus, Type 2 -Atrial fibrillation -Elevated cholesterol -HTN
MEDICATION ON ADMISSION: Coumadin 2 mg PO daily Lovastatin 20 mg PO daily Actos 15 mg PO daily Glyburide 5 mg PO daily Lisinopril 40 mg PO daily Metformin 1000 mg PO daily Digoxin 0.25 mg PO daily
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: WDWN in NAD Lungs CTAB Irregular rhythm, diastolic murmur Abdomen benign Extremities warm, 1+RLE edema
FAMILY HISTORY: There is no family history of premature coronary artery disease or sudden death. His father had diabetes.
SOCIAL HISTORY: Significant for the absence of current or former tobacco use. There is no history of alcohol abuse. He lives at home with several siblings and family members. [**Name (NI) **] works at [**Company 6692**] Airport as a baggage handler, where he has worked for >15 years. | 1 |
63,585 | CHIEF COMPLAINT: s/p fall, back pain
PRESENT ILLNESS: Pt is a 59 y/o F s/p fall down 12 stairs last night. On admission she was unable to move lower extremities and her upper extremities were weak. She had decreased rectal tone as well. She was initially hypotensive to the 80s requiring levophed.
MEDICAL HISTORY: hypertension, hypercholesterolemia
MEDICATION ON ADMISSION: HCTZ, Lisinopril, Effexor, Oxycodone, Hydrocodone
ALLERGIES: Sulfa (Sulfonamides)
PHYSICAL EXAM:
FAMILY HISTORY: noncontributory
SOCIAL HISTORY: lives with husband | 0 |
48,658 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 54-year-old female with epigastric pain, dyspareunia on exertion and burning. She had a positive exercise tolerance test and an ejection fraction of 45% by echocardiogram. She had some mild mitral regurgitation, three vessel coronary artery disease and severe pulmonary hypertension of 58/28 with a wedge of 21.
MEDICAL HISTORY: The past medical history was significant for diabetes, hypercholesterolemia, hypertension, left carotid endarterectomy in [**2121**] and left ankle injury in [**2124**].
MEDICATION ON ADMISSION: Glucotrol 10 mg p.o. t.i.d. Tiazac 180 mg p.o. q.d. Hydrochlorothiazide 50 mg p.o. q.d. Zoloft 50 mg p.o. q.d. Aspirin 81 mg p.o. q.d. Zantac 150 mg p.o. p.r.n. HO[**Last Name (STitle) **] COURSE: The patient was taken to the operating room by Dr. [**Last Name (Prefixes) **] on [**2126-10-7**] for coronary artery bypass grafting times four with a left internal mammary artery graft to the left anterior descending artery, a saphenous vein graft to the diagonal artery and sequential saphenous vein grafts to the first obtuse marginal artery and second obtuse marginal artery. The patient did well postoperatively. She was extubated on the same day and was able to tolerate having her chest tube taken out. The patient was transferred onto the floor on [**2126-10-8**], postoperative day #1. While on the floor, the patient did well. The only slight complication was that the patient was hyperglycemic and had a consultation with the [**Last Name (un) **] Diabetic Center. They recommended, while the patient was in-house, that she be put on NPH 10 units h.s. and q.a.m. While in the hospital, the patient was able to work with a physical therapist and was able to achieve rehabilitation level 3. Upon discharge, the patient's vital signs were stable. Her heart rate was 78 and her blood pressure was 97/53. She was in sinus rhythm.
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
89,601 | CHIEF COMPLAINT:
PRESENT ILLNESS: Mr. [**Known lastname **] is a 67-year-old male with a past medical history significant for exertional angina dating back approximately five years ago. At that time, he was placed on beta blockers which ultimately resolved his symptoms. However, this past [**Month (only) 956**], he was diagnosed with lung cancer and was treated with surgery and radiation, and had quit smoking at that time. Since then, he gained approximately 40 pounds. Recently he has noted chest pressure and dyspnea on exertion with a limited amount of activity, i.e., mowing the lawn or going for walks, and symptoms always resolve with rest. On [**2189-11-2**], he had a stress echocardiogram where he exercised for 5 minute 58 seconds on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol, reaching 67% of maximal predicted heart rate, and had positive chest pain with modest ST segment depression with biphasic T wave changes noted during the recovery period. Echocardiogram revealed probable exercise-induced ischemia at the inferior base, possibly a small area of ischemia at the apex. At that time, he denied any claudication, no edema, no paroxysmal nocturnal dyspnea, no lightheadedness. He sleeps with two pillows, but attributes this to recent weight gain and need to be somewhat elevated while sleeping. His height was 5'6", weight was 197 pounds. Coronary artery disease risk factors included hypercholesterolemia, previous smoker but quit in [**Month (only) 956**] of this year, positive family history with father having three myocardial infarctions in his 70s, brother with coronary artery bypass graft and died of a myocardial infarction in his 50s.
MEDICAL HISTORY: [**2189-1-8**], diagnosed with lung cancer, treated with XRT and surgery; he has a remote history of ulcers; hyperlipidemia; tobacco.
MEDICATION ON ADMISSION: Aspirin 325 mg by mouth once daily, Pravachol 40 mg by mouth once daily, Norvasc 5 mg by mouth once daily, atenolol 100 mg by mouth once daily, nortriptyline 25 mg by mouth once daily, Imdur 30 mg by mouth once daily, and a multivitamin by mouth once daily.
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: He is married and lives in [**Location 1439**] with his wife. | 0 |
79,700 | CHIEF COMPLAINT: L ureteral stricture
PRESENT ILLNESS: 49yF with history of left ureteral disruption s/p ureteroscopy being managed with left percutaneous nephrostomy tube as well as history of ESBL E Coli UTI presents to ED with four day of increasingly foul-smelling, green urine with left flank pain, low-grade temperatures with chills and nausea. Patient describes symptoms as becoming progressively worse since [**Month (only) **]. Visit to ED in late [**Month (only) **]. She is voiding per urethra without LUTS, hematuria. She denies abdominal pain, emesis or change in bowel habits.
MEDICAL HISTORY: PMH: nephrolithiasis, diabetes, hypertension PSH: 1. Left ureteral stent for stone obstruction, [**3-26**]. 2. Left ureteroscopy with laser lithotripsy, complicated by ureteral disruption and percutaneous nephrostomy tube, [**4-25**]. 3. Antegrade and retrograde attempt at recannulization of ureter, [**5-26**], 4. Second attempt at antegrade and retrograde recannulization, [**6-25**] (short defect seen approximately 0.5 cm). 5. cysto. RPG: total length of ureteral disruption well over 6 to 8 cm. 6. s/p ovarian cyst removal through her lower midline incision
MEDICATION ON ADMISSION:
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: HEENT no abnormalities CV: RRR no MRG RESP: lungs CTA b/l no RRW ABD: obese, soft, NT, ND, BS+ Incision: CDI, staples EXT: no CCE
FAMILY HISTORY: non contributory
SOCIAL HISTORY: non contributory | 0 |
82,164 | CHIEF COMPLAINT: Respiratory distress . Reason for MICU transfer: Critical tracheal stenosis
PRESENT ILLNESS: 39 yo WF with a hx of CAD s/p 5 vessel CABG in [**7-10**] complicated by cardiogenic shock requiring IABP, LV systolic dysfunction (EF 35%), HTN, HLD, DM who presented with to an OSH 3 days ago with dyspnea and was intubated and transferred to the [**Hospital1 18**] for further evaluation. . Her respiratory problems date back to her hospitalization for her CABG on [**2200-7-8**], after which she was intubated for 7 days for cardiogenic shock, successfully extubated and discharged on [**7-19**]. However, she re-presented to an OSH on [**7-21**] with chest pain and dyspnea and was found to have MRSA PNA and was treated with Vanc/Moxi. During that hospitalization, she was also noted to have upper airway stridor and hoarseness [**1-1**] tracheal stenosis found on CT-Chest that was treated with steroids and transferred to [**Hospital1 18**] on [**7-31**]. During that hospitalization, the patient had a rigid bronchoscopy which revealed mucoid concretions that were obstructing the tracheal lumen and given a presumptive diagnosis of tracheitis. Tissue culture grew out corynebactrium however BALs were negative. She was covered empirically with vancomycin, clindamycin, and aztreonam, as well as micafungin for possible fungal infection and Bactrim for PCP prophylaxis given her course of steroids. Post-bronch, her breathing was unlabored with no evidence of inspiratory stridor or hypoxia. CT-chest also demonstrated LAD thought to be secondary to her infection. She was subsequently discharged home on [**2200-8-8**]. . Most recently, she presented to an OSH three days ago with worsening dyspnea was intubated and transferred to [**Hospital1 18**]. Here, she had another rigid bronchoscopy that revealed tracheal stenosis with friable/necrotic tracheal mucosa obstructing ~80% of her tracheal lumen that was subsequently removed. She ultimately underwent tracheostomy and was admitted to the MICU. CT-Chest revealed a small amount of mediastinal air thought to be iatrogenic, LAD which was increased in size from prior, and diffuse ground glass opacities consistent with aspiration. She was started on vanc+cipro on [**8-16**] for recurrent tracheitis and clinda was added on [**8-17**]. She had also been diuresed ~1.5L while in the MICU. Prior to transfer, ID recommended discontinuation of Vanc and Cipro and continuation of IV clindamycin for 10 days. . Prior to transfer, the patient states that she is still short of breath, unable to take deep breaths, but feels better than when she came in. She also describes a periodic cough productive of small amounts of green-yellow sputum. She continues to have pain over both her tracheostomy site and her sternotomy site. She denies any fevers, chills, abdominal pain, or change in her bowel habits.
MEDICAL HISTORY: Anterior NSTEMI s/p 5 vessel CABG [**2200-7-8**] (one note of this actually being a STEMI in the DC paperwork) CHF (EF 35-40% on TTE [**2200-8-4**]) Type 2 Diabetes Mellitus Crohns disease Hypertension Hyperlipidemia Asthma Depression Fibromyalgia S/p ventral hernia repair S/p appendectomy S/p cholecystectomy S/p C-section with tubal ligation
MEDICATION ON ADMISSION: 1. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 2. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 5 days. 6. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain for 6 days. 7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-1**] Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath. 8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. insulin detemir 100 unit/mL Solution Sig: Seventy (70) units Subcutaneous at bedtime. 11. insulin aspart 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous three times a day: Take with meals. 12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours) for 10 days. 14. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 4 days.
ALLERGIES: Penicillins
PHYSICAL EXAM: Admission Physical Exam: General: Intubated and sedate, not arousable to verbal stimuli.
FAMILY HISTORY: No family history of coronary artery disease
SOCIAL HISTORY: Lives with husband in [**Name (NI) **]. - Tobacco: Smokes 2ppd x >14 years. - Alcohol: Social drinker. - Illicits: No drug use. | 0 |
63,261 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 39 year-old gentleman admitted on [**2125-1-19**] to the [**Hospital1 190**] referred from [**Hospital3 29903**]. He is a 39 year-old gentleman with hyperlipidemia and smoking who presented with acute onset of chest pain since five in the morning with radiation to the left arm and nausea. Symptoms resolved spontaneously. He was taken to the Cath Lab at the [**Hospital1 69**] that evening where a stent procedure to the RCA was complicated by guidewire entrapment inside of a stent requiring CT surgery to do a thoracotomy with bypass and excision of the wire. The case was complicated by an episode of coffee ground emesis and a bleed from femoral access site prior to CT surgery. Gastroenterology was consulted and they recommended Protonix and felt it was due to peptic ulcer disease.
MEDICAL HISTORY: 1. Hepatitis B. 2. Hypercholesterolemia. 3. Fatty liver resolved.
MEDICATION ON ADMISSION:
ALLERGIES: He had no known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY: Not significant for coronary artery disease. Please note the patient is only Cantonese speaking and information is second hand.
SOCIAL HISTORY: He smokes one pack per day. He works as a jeweler. He lives at home with his wife. | 0 |
51,897 | CHIEF COMPLAINT: Tx from [**Hospital3 **] with SOB, increased sputum
PRESENT ILLNESS: 75 yo M with h/o COPD, OSA s/p trach, on home oxygen 10-15L via NC/trach, CHF, pulm hypertension, afib on coumadin, who presented to [**Hospital3 **] hospital with 3 days of SOB, thick green sputum production. He also complains of substernal chest pain, worse with inspiration. He denies orthopnea, has intermittent swelling of the lower extremities, denies fever, chills, sick contacts. ON arrival to CCH ER he was satting 93% on 15L, BP 128/78, P 84, RR 22. He was transferred to [**Hospital1 18**] presumably because his pulmonary records are here. On arrival to [**Hospital1 18**] ER, his vitals were T 97, P 86, BP 100/57, 94% NRB. He was given lasix, azitromycin, ceftriaxone, solumedrol and nebs. He was transferred to the [**Hospital Unit Name 153**] given his high o2 requirement. On arrival to [**Hospital Unit Name 153**] he looked well but was satting mid to low 90s on NRB. We placed a trach mask on him to provide some humidified air. His ABG was 7.27/69/56. His trach was changed so we could place him on the ventilator for his hypercarbia and concern for impending hypercarbic resp failure.
MEDICAL HISTORY: 1. Severe COPD. FEV1 1.45 (53% predicted). Followed by Dr. [**Last Name (STitle) 575**] in [**Hospital **] Clinic. On home oxygen via high flow NC during the day (10-15L) and trach mask at night. Home O2 sat reportedly in 87-90% range. 2. OSA, s/p tracheostomy 3. CHF, EF 40-50% [**2159-6-20**], repeat echo [**3-24**] with EF 50% 4. severe pulmonary hypertension PAP 50-55 mmHg ([**6-23**]), repeat echo in [**3-24**] shows pulmonary artery pressure to be higher but was likely underestimated in prior study 5. Chronic renal insufficiency, baseline creat ~1.2-1.3 6. Atrial fibrillation / flutter on coumadin 7. Morbid obesity 8. H/O supraventricular tachycardia; also h/o episodes of bradycardia 9. Chronic RBBB 10. History of atrial myxoma s/p resection [**2148**] 11. Gastroesophageal reflux disease 12. PTSD 13. S/P appendectomy 14. S/P cholecystectomy
MEDICATION ON ADMISSION: 1. Coumadin 6mg qhs 2. Oxycodone prn 3. Captopril 4. Lasix 120mg QD 5. Potassium 6. Phenergan 7. Mag Oxide
ALLERGIES: Beta-Adrenergic Blocking Agents
PHYSICAL EXAM: T 97.8, HR 80-90, BP 100-124/60-80, RR 20's, 85-90% NRB Gen: pleasant male, comfortable, not appearing in resp distress HEENT: JVP difficult to assess, OP clear, trach in place CV: irregular, heart sounds partially obscured by oxygen flow Resp: Crackles at bases bilaterally, decreased air movement diffusely Abd: obese, soft, nt, nd, +bs Ext: 2+ edema in lower legs Neuro: A&Ox3
FAMILY HISTORY: NC
SOCIAL HISTORY: Quit TOB >15 yrs ago (smoked 1.5 ppd x ~40 yrs). Some EtOH with dinner few times per wk. Lives w/wife. | 0 |
80,661 | CHIEF COMPLAINT:
PRESENT ILLNESS: On [**2112-6-5**] the patient had a sudden onset of emesis in the morning with no associated nausea, abdominal pain or change in bowel habits and is passing flatus. She also passed brown stool that day. She has had no signs of fevers or chills, or sick contacts or recent travel. Twenty years ago the patient had a similar episode and by history she was told she had a gallbladder problem, but she never had any treatment given. She presented to the Emergency Department with a fever of 104.4 and mildly tender right upper quadrant with negative [**Doctor Last Name 515**] sign. An ultrasound demonstrated multiple gallbladder stones and a 1.4 cm stone in a 1.5 cm common bile duct. No intrahepatic ductal dilatation or gallbladder wall thickening or pericholecystic fluid. The patient received Levofloxacin and Flagyl and was urgently seen by the ERCP fellow and taken for endoscopic retrograde cholangiopancreatography, which demonstrated some gastritis and severely deformed major papilla and 8 mm common bile duct with no stones and a sphincterotomy was performed with drainage of clear bile. The patient was then admitted to the Medical Service.
MEDICAL HISTORY: 1. Hypertension. 2. Breast cancer status post lumpectomy in [**2103**]. 3. Hypercholesterolemia. 4. Diabetes mellitus type 2. 5. Hypothyroidism status post thyroidectomy. 6. Left cataract surgery, corneal transplant. 7. Pernicious anemia. 8. Stress incontinence. 9. Appendectomy.
MEDICATION ON ADMISSION:
ALLERGIES: Bactrim.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The is a Russian immigrant who taught English. The patient does not use tobacco or alcohol. | 0 |
76,631 | CHIEF COMPLAINT: IPH
PRESENT ILLNESS: 60 yo old male with unknown history found in his car unresponsive. Was brought to OSH and was not following commands, aphasic, and hypertensive at 198/126. CT demonstrated IPH. Patient was given 20 mg of Labetalol and loaded with 1 gram of phosphenytoin and transfered to [**Hospital1 **]. upon arrival here his BP was 160/90. He was given 4 mg of MS and went into bradycardia down to 43 and BP fell to 70/43. Patient was given 0.5 mg of atropine and pressures returned to 131/83. Patient remained saturating 95%.
MEDICAL HISTORY: gout, ETOH
MEDICATION ON ADMISSION: None
ALLERGIES: Morphine Sulfate
PHYSICAL EXAM: On Admission:
FAMILY HISTORY: unknown
SOCIAL HISTORY: ETOH | 0 |
45,518 | CHIEF COMPLAINT: Admitted to OSH w/ mental status changes and found to have large gangrene and cellulitis of L foot
PRESENT ILLNESS: This is a 73 y.o M who lives alone, and does not have a primary care physician because he refused to get medical care. Son notice deterioration in his health few days prior to admission at OSH. Patient was found lethargic, and brought in to OSH ED. He was noted to have a large necrotic/eschar on his L foot with dininished pulses, cellulitic borders and [**3-4**]+ distal edema. Transferred to [**Hospital1 18**] for further management.
MEDICAL HISTORY: Patient is a poor historian. ETOH abuse Rectal mass- not fully worked up Anemia- not worked up
MEDICATION ON ADMISSION: lovenox protonix 2 doses clindamycin
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS:afebrile 98.6-88-18 B/p 124/76 O2 sat 97% room air Gen: alert elderly male in no acute distress wearing a dependands HEENT: no JVD, no carotid bruits, 2+ pulses Lungs: clear to auscultation Heart: RRR, no mumur,gallop or rub ABD: scaffoid, nontender,BSx4, no bruits EXT: rt. foot with thickened toenails,with rt. ist toe duskyness and tip dry gangrene. Lt. [**Last Name (un) 5355**] toes 1,2 dry gangrene with ischemic changes of toe 3,4,5. lateral foot with large area of dry gangrene. Lateral left calf area of dry gangrene. no edema, erythema or drainage. pulses: rt. ra/fem/[**Doctor Last Name **]/dp/pt 2+/2+/2+dopp/dopp mono lt. ra/fem/[**Doctor Last Name **]/dp/pt 2+/2+/2+, Dp absent, pt faintly dopperable, AT dopperable mono Neuro: nonfocal
FAMILY HISTORY: He has a son who has daily contact w/ him and is his healthcare proxy
SOCIAL HISTORY: Widower, who lives alone, on meals on wheels. Known to drink alcohol daily | 0 |
56,694 | CHIEF COMPLAINT: s/p abdominal crush injury, transferred from outside hospital for hemodynamic instability. He was found to have ileal avulsion and a liver laceration.
PRESENT ILLNESS: Mr. [**Known lastname 83592**] is a 32 year old gentleman who was involved in an abdominal crush injury while chopping down a tree. No LOC. He was transferred from [**Hospital3 4298**] after a CT there showed an active mesenteric bleed and hematoma and the patient became hemodynamically unstable.
MEDICAL HISTORY: none
MEDICATION ON ADMISSION: none
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: T 99.2, HR 71, BP 110/50, RR 16, 96%RA GEN - NAD, A&O HEENT - NCAT, EOMI, MMM CVS - RRR PULM - CTAB, no respiratory distress ABD - staples in place, incision healing well, no erythema or drainage, abdomen soft, nontender, nondistended EXTREM - warm, dry, no edema
FAMILY HISTORY: estranged from his family
SOCIAL HISTORY: denies EtOH and recreational drugs | 0 |
66,704 | CHIEF COMPLAINT: Hematochezia
PRESENT ILLNESS: 89 year-old female with history of duodenal bleed presents with painless BRBPR x 2. History obtained from patient and son. She lives at home with VNA and 24 live in aide. The aide noted frank blood in the patient's diaper. The patient/son reported no symptoms during this incident. He had verified this with the patient's aide and visiting nurse. [**First Name (Titles) 20282**] [**Last Name (Titles) 15797**] chest pain, shortness of breath, dizziness, abdominal pain, nausea, vomitting, diarrhea, changes in vision or hearing. In the ED, she was hemodynamically stable. She did report one episode of CP, which resolved spontaneously. EKG unchaned. NGT attempted x 4 without success. No bleeding while in ED.
MEDICAL HISTORY: 1. History of cellulitis 2. Duodenal angioectasia with prior GI bleed 3. Urinary incontinence 4. Osteoporosis 5. Hypertension 6. Iron deficiency anemia 7. Diastolic dysfunction 8. Mitral regurgitation
MEDICATION ON ADMISSION: Pronotix 40 mg PO QD FeSO4 325 mg PO QD Ocuvite Colace 100 mg PO BID Calcium/vitamin D Triamcinolone [**Hospital1 **] Sarna lotion, nystatin ointment Atenolol 25 mg PO QD Tylenol Ditropan XL 10 mg PO QD Fosamax 70 mg PO QSAT Lasix 20 mg PO QD
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Physical examination: VITALS: 98.7 58 122/48 19 98 on RA Gen: Alert, oriented to person, NAD HEENT: OP clear, R pupil post [**Doctor First Name **] Neck: Supple, no LAd Cor: RRR sys murmur Chest: CTAB Abd: s/nt/nd +BS, reducible umbilical hernia Ext: w/wp, +2 DP, mult scars from cellulitis, skin tear L forarm.
FAMILY HISTORY: Non-contributory
SOCIAL HISTORY: Lives in senior independent housing with 24 hour aide. Son is in process of transferring her to [**Hospital 100**] Rehab. Former smoker. No tobacco, EtOH. | 0 |
79,216 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is an 81-year-old female with known coronary artery disease documented in [**2182**] with an ejection fraction of approximately 30-35%, who had been managed medically and was living an active lifestyle. She had been experiencing some chest pain and worsening shortness of breath and orthopnea. On the night prior to admission, the patient had worsening chest pain and presented to the emergency room for evaluation. Upon arrival, she complained of chest pain and the electrocardiogram showed new lateral ST depressions concerning for acute ischemia. Her cardiac enzymes were positive for a CK leak with a troponin of 43. Her chest x-ray was consistent with congestive heart failure. The patient was given sublingual nitroglycerin, morphine, beta blockers and aspirin and was started on a heparin drip. The cardiology service was consulted and the patient was taken for a cardiac catheterization.
MEDICAL HISTORY: The past medical history was significant for coronary artery disease with previous echocardiograms documenting an ejection fraction of 30-35%, hypertension, colon cancer status post partial colectomy, partial deafness and right eye blindness secondary to eyeball rupture.
MEDICATION ON ADMISSION: Her medications at home included aspirin, Lipitor, Zestril, Lopressor, Fosamax, nortriptyline and Imdur.
ALLERGIES: The patient had no known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient lived at home with her husband, who was also very active per her primary care physician. | 0 |
35,265 | CHIEF COMPLAINT: Chest and back pain and lethargy.
PRESENT ILLNESS: The patient is a 54-year-old white female with a long history of labile hypertension, multiple lacunar infarcts who presented to an outside hospital, [**Hospital3 4527**] on [**2137-1-27**] with a complaint of chest pain times one day and back pain times one week which was worse today rated [**9-18**]. Her husband thought she was more sleepy and fatigued than usual. Given her history of stroke, they brought her to the Emergency Room. When she arrived, her systolic blood pressure was in the 70s and she was given multiple liters of normal saline and started on Dopamine with some increase in her systolic blood pressures. She described her pain as dull, occurring intermittently, radiating to her jaw and left arm. She does have a DDD pacemaker so her electrocardiogram was difficult to interpret, however, there was one electrocardiogram done at the outside hospital that had a possibility of anterior ST elevations. There were concern that she was having cardiac ischemia. After the dopamine and intravenous fluids, her blood pressure ultimately rose and she was started on intravenous nitroglycerin for question of cardiac ischemia. She was transferred to [**Hospital6 256**] for potential cardiac catheterization. On arrival to [**Hospital6 256**], her chest and back pain had resolved on the intravenous nitroglycerin. She gave an additional history of nausea, vomiting and diarrhea up to seven stools per day for one week with fevers and chills to 101 and decreased po intake for one week, however, she reports she continued to take all of her blood pressure medication. An electrocardiogram was repeated in our Emergency Room that did not show any significant changes from one done on the previous admission in [**2136-10-10**]. There were no acute ST and T wave changes and she was chest and back pain free. However, given her extreme hypotension and description of severe back pain at the outside hospital, a bedside transesophageal echocardiogram was performed to rule out aortic dissection. She is unable to get MRI secondary to having a pacer and she has a severe allergy to intravenous dye. The transesophageal echocardiogram revealed hyperdynamic left ventricle with normal left ventricular function, no pleural effusion. No obvious wall motion abnormalities and no evidence of aortic dissection. She was therefore admitted to the [**Hospital6 13568**] for rule out myocardial infarction and further evaluation and management of her labile blood pressures and symptoms.
MEDICAL HISTORY: 1. Hypertension since age 13. Has been very labile in the past. She was admitted in [**2136-10-10**] for lacunar infarcts and blood pressure control. She had a past work-up for secondary causes of hypertension which have all been negative. This includes pheochromocytoma, [**Location (un) **] syndrome, hyperaldosteronism, carcinoid syndrome and she has had multiple renal ultrasounds to evaluate for bilateral renal artery stenosis which have been negative per her primary care physician. 2. History of multiple lacunar infarcts since [**2118**]. She usually presents with left-sided symptoms including left facial, arm and leg weakness, dysarthria, dysphasia and clumsiness. She still has several residual deficits from prior infarcts. She has increased left-sided tone with contractures from her previous infarcts. 3. DDD pacemaker implanted for possible complete heart block, although the patient is unsure. 4. Mild asthma. 5. Gout. 6. Cataract in the left eye. 7. She does not have any urinary sensation and urinates on a routine daily scheduled.
MEDICATION ON ADMISSION:
ALLERGIES: To Penicillin, aspirin, Tylenol, Beclovent, Percocet and intravenous dye, which gives her hypotension resulting in a stroke many years ago. Question of allergy to Nitepride.
PHYSICAL EXAM:
FAMILY HISTORY: Multiple family members with hypertension, strokes and renal failure. Her mother died of a brain hemorrhage and had hypertension and renal disease. Her father died of hypertensive stroke.
SOCIAL HISTORY: She lives with her husband and works as a bookkeeper for his contracting company. No tobacco, no alcohol. | 0 |
48,137 | CHIEF COMPLAINT: Esophageal Cancer
PRESENT ILLNESS: The patient is a 64-year-old gentleman who has a very early esophageal cancer as well as Barrett's esophagus. He presents for resection after discussing the option of possible endomucosal resection, which was thought by the interventional gastroenterologist not to be feasible due to scarring from the previous radiofrequency ablation.
MEDICAL HISTORY: Hyperlipidemia DM II- diet controlled GERD with Barretts HGD
MEDICATION ON ADMISSION: Omeprazole 40 mg [**Hospital1 **], MVI, fish oil and flax seed daily
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: VS: T: 96.5 HR: 76 SR BP: 104-119/60 Sats: 95% RA General: 64 year old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR Resp: decreased breath sounds faint bibasilar crackles GI: abdomen soft, non-distended. J-tube site clean intact Extre: warm no edema Incision: right Vats site clean dry intact Neuro: awake, alert oriented
FAMILY HISTORY: Mother- alive 91 Father- DM [**Name (NI) 8962**] sister died of metastatic breast cancer age 62
SOCIAL HISTORY: Married lives with family. Tobacco: 60-90 pack-year quit 15 years ago. ETOH none Retired police officer | 0 |
88,447 | CHIEF COMPLAINT: SSCP after vomiting, new orthopnea
PRESENT ILLNESS: The patient is a 71M with h/o CAD with 2 BMS to LAD and Cx, DM, HTN, gastroparesis who was referred to the ED by his PCP ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) with 3 weeks of worsening SOB, non-exertional CP radiating to the left arm after vomiting, and 4 pillow orthopnea. He has had episodes of vomiting after eating often, but associated SSCP is new. No LLE but pulmonary edema on exam with crackles [**12-30**] of the way up. EKG showed ST depressions in lateral leads V2 - V6 with flipped deep Ts. CP free in ED. Trop positive. Cards was called and cath recommended. In ED got 600 Plavix, heparin gtt, integrillin gtt. No O2 in ED. . Cardiac cath showed left main disease (90% distal) that was not intervened upon and poor LV function (EF 20%) and cardiac surgery was consulted for CABG.
MEDICAL HISTORY: PAST MEDICAL HISTORY: Diabetes, Dyslipidemia, Hypertension Percutaneous coronary intervention, in [**3-30**] showing left main 30% stenosis, patent LAD stents, 30% restenotic circumflex lesion in the distal aspect of the stent, jailed OM1 ostium with 60% stenosis, RCA ostially occluded. -- transient ischemic attack in [**2091**], status post recurrent event, status post cardiac endarterectomy under the care of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2102-12-28**] complicated by slow flow and involving stroke, urgent angiography by Dr. [**First Name (STitle) **] revealing brachiocephalic stenosis 90%, status post angioplasty stenting at that time -- status post stenting of the brachiocephalic artery into the subclavian artery for rescue of the right upper extremity for upper extremity claudication, now with resolution -- history of posterior circulation syndrome, this resolved following subclavian stenting -- peripheral [**First Name (STitle) 1106**] disease status post lower extremity revascularizations by way of atherectomy in [**Month (only) 1096**] and [**Month (only) 359**] of [**2102**], Rutherford-[**Doctor Last Name **] scale is zero -- pseudogout -- gallbladder surgery
MEDICATION ON ADMISSION: aspirin 325mg qd nifedipine 30mg qhs enalapril 20mg qhs chlorthalidone 25mg qam Lipitor 40mg qam metoprolol 25mg [**Hospital1 **] Metformin 850mg [**Hospital1 **] Centrum qhs Folic acid 400mcg qhs Novolin N 36U qam, 18U qpm Novlin R 18U qam, 6U qpm loperimide 2mg prn indomethacin 25mg tid prn
ALLERGIES: Hydrochlorothiazide / Iodine; Iodine Containing / Shellfish
PHYSICAL EXAM: PHYSICAL EXAMINATION: . BP 169/75 HR (reg) 85 RR 20 Temp 97.9 O2Sat 94% 2L 194 lbs . Gen: well developed, well nourished and well groomed. The patient was oriented to person, place and time. The patient's mood and affect were not inappropriate. . HEEN: no xanthalesma, conjunctiva were pink, no pallor or cyanosis of the oral mucosa. . Neck: supple, JVP of 10 cm. The carotid waveform was normal. There was no thyromegaly. . Chest: no chest wall deformities, scoliosis or kyphosis. . Pulm: respirations were not labored and there were no use of accessory muscles. CTAB, normal BS and no adventitial sounds or rubs. . Cor: PMI located in the 5th intercostal space, mid clavicular line. no thrills, lifts or palpable S3 or S4. normal S1S2, no rubs, murmurs, clicks or gallops. . Abd: abdominal aorta was not enlarged by palpation, no hepatosplenomegaly, NT, soft, ND . Ext: no pallor, cyanosis, clubbing or edema. . Skin: no stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: no abdominal, femoral bruits. Carotid bruits b/l . Right: Carotid 2+ Femoral 1+ Popliteal 1+ DP 1+ PT 1+ . Left: Carotid 2+ Femoral 1+ Popliteal 1+ DP 1+ PT 1+
FAMILY HISTORY: His brother had CABG 2 years ago and also smoked. Mother and sister with breast cancer. He has 3 children, no history of breast cancer in them. His son had gynecomastia with onset at age 12, which required surgical excision
SOCIAL HISTORY: Social history is significant for the current tobacco use (~[**12-30**] ppd), he has smoked for about 60 years as much as 3ppd in the past. There is no history of alcohol abuse and he denies illicit substance use. He is retired and previously worked selling men's clothing. He is divorced and lives alone. | 0 |
84,419 | CHIEF COMPLAINT: mitral regurgitation/coronary artery disease
PRESENT ILLNESS: This 73 year old white male has known mitral regurgitation and previously has undergone catheterization to reveal distal right coronary disease. He underwent full mouth extractions recently and is readmitted now for cardiac surgery rescheduled after his need for dental surgery was addressed.
MEDICAL HISTORY: Congestive Heart Failure(Chronic, Systolic) Mitral Regurgitation coronary artery diseasee Hypertension Chronic Atrial Fibrillation Chronic obstructive pulmonary disease Chronic Renal Insufficiency Obesity Dyslipidemia Anxiety History of gastrointestinal bleed s/p colonic polyp removal s/p Left Total Hip replacement s/p Eye Surgery as child
MEDICATION ON ADMISSION: **Warfarin**-2.5mg T,Th,Fri. 5mg Sun/Wed->***last dose [**2118-5-31**] **Lovenox- last dose 5/17 Aspirin 81 qd Co-Enzyme Q10 Lasix 40 [**Hospital1 **] Lopressor 25mg [**Hospital1 **] Omega 3 Fatty Acids Spiriva 18mcg INH daily Spironolactone 25 qd Zocor 40 qhs MVI Advair 250-50 1P [**Hospital1 **] ? Albuterol Nebs qid prn
ALLERGIES: Zestril
PHYSICAL EXAM: admission:
FAMILY HISTORY: non- contributory
SOCIAL HISTORY: Race: Caucasian Last Dental Exam: many yrs ago Lives alone Occupation: retired businessman Tobacco: Quit [**2086**]-started at age 21yo-smoked ~2PPD, 40 pack year history ETOH: Denies | 0 |
64,452 | CHIEF COMPLAINT: morbid obesity
PRESENT ILLNESS: The pt is s/p removal of lap gastic band ,in here for gastric bypass surgery. She underwent the lap band procedure on [**2105-4-22**].In [**2105**] she developed severe epigastric pain and pain at the infusion port site. A CT scan and upper GI series did not reveal an obvious source. However [**Known firstname 11320**] requested removal of theband which was performed on [**2106-8-13**] and her postop course was uneventful. Over the course of 2.5 years [**Known firstname 11320**] has gained significant weight to the point where she now weighs what she did prior to her gastric band surgery in [**2104**]. She expressed wish to have Roux-en-Y gastric bypass at this time to gain control over her escalating gain in weight and improve her quality of health. With the initial weight loss her sleep apnea had improved, has had no flares of asthma, and was much less short of breath with stairs/hills. However some of those symptoms have now returned with her significant weight gain.
MEDICAL HISTORY: Past medical history is significant for obstructive sleep apnea, asthma, dyslipidemia, venous stasis change, irritable bowel syndrome, and cholelithiasis. Her past surgical history is significant for a laparoscopic band, laparoscopic cholecystectomy ([**2103**]), hysterectomy, bilateral lower extremity leg varicose vein stripping, right oophorectomy, hernia repair.
MEDICATION ON ADMISSION: Diazepam 5 mg Tablet po HS Gabapentin 600 mg 1 Tablet(s) po tds
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Vitals:Temp:97.4,Hr:74,BP:116/90,RR:16,Sat 94%RA Gen:A+Ox3 HEENT:PERRL,EOMI Chest:clear,B/L breath sounds N CVS:N S1 S2.No M/R/G Abdomen: soft and non-tender, non-distended with normal bowel sound. Wound:Incissional site C/D/I. Extremities: No edema. B/l DP pulse present. CNS:There were no focal neurological deficits and her gait was normal.
FAMILY HISTORY: Family history is significant for father with lung and prostate cancer. He also had heart disease, diabetes, and obesity. Mother had dyslipidemia and obesity.
SOCIAL HISTORY: Socially, she is a former smoker but quit some years ago. She does not drink excessively or use drugs. | 0 |
7,915 | CHIEF COMPLAINT: bilateral leg weakness and numbness
PRESENT ILLNESS: History and exam obtained with her daughter -in -law (Ms [**First Name8 (NamePattern2) 78403**] [**Name (NI) 78404**]) translating Cambodian. Ms [**Known lastname **] is a 47 year old right handed woman who is primarily Cambodian speaking and has a past medical history significant forneuromyelitis optica (Ab neg) with transverse myelitis andbaseline RIGHT eye blindness and right sided weakness last time admitted in [**Month (only) 1096**] (discharged on 12 / 15/ 08 with a new flare in the context of a UTI w E. Coli: sensitive to quinilones, cephalosporines and AMGs). She has been treated with corticosteroids plus Rituximab (anti CD20 antibody) in the past. She now presents with worsening right sided weakness and numbness plus new LEFT sided weakness and numbness and new urinary/ bowel incontinence. She started with increasing "numbness" in her RIGHT leg and newnumbness in her LEFT leg 48h ago. When enquired, she explains it feels like "pins and needles" around the circumference of her legs form her toes up to her hip in both extremities. In addition, she is experiencing the same sensation up to her umbilicus and in the back (bilaterally). Besides, there is new onset urinary incontinence (starting on 01/ 24 in the evening). She does not feel the need to urinate and does not realize she has urinated till she feels wet. This already happened in her previous flares. Besides, there is new bowel incontinence. Again, she does not feel the need to move her bowels or that she is doing it. Just realizes an accident has happened. She recalls more than 7 events per day, although cannot provide an specific number for th elast 2 days. It is not watery stool, but "loose", in the context of a patient using 4 medications for her constipation, which she has stopped. There was no blood or mucous contents in her stools. There are no sick contacts at home. No nausea or vomiting. No cough or dysuria. She has been complaining of "fever" for the past week. however, when her relatives checked her temperature, it was whithin normal limits. She has been taking Tylenol. She admits having a headache when she feels feverish. It has the same features as her baseline headache. Bifrontal, pressure quality, without aura. Responds to tylenol. There are no muscular spasms ongoing. No Lhermitte either. She refers no phosphene perception. There is pain with ocular movements (bilaterally) in any direction. Importantly, there is no shortness of breath. She was taken to [**Hospital 1121**] Hospital ED. The team at [**Location (un) 12914**] contact[**Name (NI) **] Dr. [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **], whom recommended transfer to [**Hospital1 18**] for admission and further evaluation. She has completed a Rituximab course recently (cannot recall when, probably last week). Never on AZA, not on chronic po corticosteroids. Baseline (same as at discharge on [**2137-11-11**]): she is able to lift her left leg off the bed and wiggle vigorously her ankle and toes. The right leg had minimal movement proximally and slightly increased movement at the toes. She has a T3 level bilaterally, though does have intact sensation in the right leg. She does not have permanent indwelling cathether. She is wheelchair bound. Requires help to bathe and dress up (given hervisual impairment: legally blind in the RIGHT eye, decreased visual acuity in the LEFT eye for which she uses glasses, though apparently she cannot read). She is FC.
MEDICAL HISTORY: 1. Neuromyelitis optica, NMO titer negative 2. HBV core and surface antibody positive, surface antigen negative 3. GERD 4. DM. 5. s/p hysterectomy
MEDICATION ON ADMISSION: Home Meds: NRL/ Psych: 1. Pain management: *Morphine 15 mg Tablet Sustained Release PO Q12H *Oxcarbazepine 150 mg [**Hospital1 **], titrate up to 1-2 tabs [**Hospital1 **] as indicated for squeezing sensation around chest. *Gabapentin 300 mg TID *Amitriptyline 10 mg PO BID 2. Spasticity: *Baclofen 10 mg Tablet Sig: One (1) Tablet PO BID *Perphenazine 2 mg [**Hospital1 **] 3. Insomnia: Zolpidem 5 mg HS
ALLERGIES: Penicillins / Biaxin / Levaquin
PHYSICAL EXAM: Exam on admission: T 98.9F, BP 132/ 72, HR 78, 16 RR, O2Sat 100% RA VC: 3l, NIF 60.
FAMILY HISTORY: NC
SOCIAL HISTORY: Currently living with her husband and daughter ([**Telephone/Fax (1) 78405**]),, a son in-law and three kids. She was born in [**Country **]. Denied EtoH, tobacco or drugs | 0 |
74,808 | CHIEF COMPLAINT: epigastric and chest pain, radiating to the back.
PRESENT ILLNESS: 71 yo female with history of CAD, COPD, HTN, who was initially admitted on [**2136-9-26**] to vascular service with mid upper back pain that radiated to mid-epigastrium raising concern for an aortic dissection. CT showed no dissection and no progression compared with CT at the [**Hospital 4068**] hospital on [**2136-9-25**]. A CT scan revealed a descending aortic ulcer. Vascular surgery recommended medical management and she was then transferred to medicine.
MEDICAL HISTORY: CAD s/p CABG [**2117**], stents [**2128**] and [**2134**] HTN COPD B/L Renal artery stenosis s/p right stent placed [**11-29**]- Last MRA [**8-27**] Anxiety Possible Barretts seen on last egd [**2134**]- but not on bx s/p CCY s/p Appy s/p Oophrectomy renal artery stent placed as above CABG and stent placements as above
MEDICATION ON ADMISSION: Vasotec 40 mg [**Hospital1 **] Cardiazem 240 mg daily Toprol 50 mg daily Loratadine Ativan Advair ASA 325mg daily Niacin 500mg daily Singulair HCTZ 12.5 mg daily
ALLERGIES: Iodine; Iodine Containing / Codeine / Ticlid / Atorvastatin
PHYSICAL EXAM: Exam at the time of transfer to medical floor from the MICU: VS: 97.0 127/91 84 (70-84) 24 95% on 4L NC GEN: Elderly female in no distress, eating lunch, alert, awake, conversant HEENT: PERRL, EOMI, CN II-XII otherwise intact, no palpable cervical LAD, OP moist, no lesions Neck: supple, no LAD, JVP CV: regular, nl S1/S2, [**1-1**] syst murmur PULM: soft bibasilar crackles ABD: soft, nt, nd, NABS. NEURO: A&O x3, answers questions appropriately, no gross motor or sensory deficits EXT: no peripheral edema, warm and well perfused, no clubbing, DP pulses 2+, PT pulses 1+
FAMILY HISTORY: Mother, grandmother died of liver cancer.
SOCIAL HISTORY: Patient has no h/o tabacco. She does not use alcohol. She has 7 children. | 0 |
51,514 | CHIEF COMPLAINT: angina/DOE
PRESENT ILLNESS: 67 yo M with CP and DOE, and +ETT. Echo and cath showed dilated ascending aorta and bicuspid AV.
MEDICAL HISTORY: HTN,AFib,BPH,Tonsillectomy,TURP,CRI(1.8)
MEDICATION ON ADMISSION: amiodarone 200', xocor', flomax, mvi, folate, aspirin
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: NAD HR 76 RR 12 BP 130/82 Lungs CTAB CV RRR Abdomen soft, NT/ND Extrem warm, no edema 1+ dp/pt pulses
FAMILY HISTORY: father with MI at age 59, mother s/p CABG @65
SOCIAL HISTORY: works as a dentist lives with wife 1 etoh/day no tobacco | 0 |
11,240 | CHIEF COMPLAINT: Hemoptysis
PRESENT ILLNESS: 81 year old man with GERD, HTN, who presented on [**4-30**] with hemoptysis. For a more complete HPI please see the NF admission H&P. The pt reported that at 7pm on [**4-29**] he had sudden onset hemoptysis - bright red blood with some clots which he estimated at 2 tbsp. The hemoptysis continued about 4-5 times per hour, and when it did not stop the patient presented to [**Hospital1 18**] ED. The pt denied any prior episodes of hemoptysis, epistaxis or GIB. He endorsed [**Hospital1 **] aspirin for a recent URI. . In the ED, initial VS were: T98.4, HR 112, 141/96, R21, 94% on RA. Nasogastric lavage showed scant red blood thought likely due to swallowing coughed up blood. Cleared after 60 cc. CTA showed RUL spiculated mass. Since the pt's hemoptysis began to slow, and he did not develop hypoxia or an O2 requirement, the pt was admitted to the floor at 2am [**4-30**]. . Initially on the floor the patient appeared comfortable, denied CP, shortness of breath and reported no hemoptysis for [**4-4**] hours. At approximately 7am the pt developed hemoptysis again, and produced 100+cc of bright red blood over the course of the hour. The pt was also noted to be tachycardic in the 120's and was bolused with 1L NS. Blood pressures on the floor were notably elevated in the 180's systolic and the patient's O2 sats remained normal on room air. . Interventional pulmonology was consulted and the pt was taken for urgent rigid bronchoscopy on [**2126-4-30**]. Bronchoscopy showed a large clot in the right bronchus intermedius, but no active bleeding was visualized. A dual-lumen ET tube was placed to occlude blood from R lung from entering L lung, and the patient was transferred to the TSICU for further monitoring. . In the TSICU the pt is intubated and sedated on propofol and paralyzed with rocuronium. Blood pressures had begun to drift down in the OR, and peripheral neosynephrine was at 1mcg/hr. . Review of systems: (Per NF note and brief discussion with pt this am) (+) Per HPI (-) Denied fever, chills, headache, shortness of breath. Denied chest pain or tightness, palpitations, lightheadedness. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. * Denied weight loss, night sweats
MEDICAL HISTORY: - HTN - GERD - BPH - Colon polyp on colonoscopy [**10/2125**]
MEDICATION ON ADMISSION: finasteride 5 mg daily flomax 0.4 mg daily amlodipine ?5 mg daily captopril ?dose TID omeprazole 20 mg QOD multivitamin daily calcium daily recent ASA - 2 tabs daily of unknown strength robitussin prn no other NSAIDs
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Afebrile, BP's 110-120/60, P 50-60, RR 12, 100% on AC 500/12/5/100% General: Intubated and sedated HEENT: Sclera anicteric, MMM, ET tube in place Neck: supple, JVP not elevated, ? anterior cervical LAD. Lungs: Decreased breath sounds at right base, rhonchi present on right side, clear ventilated breath sounds on left CV: Regular rate and rhythm, no murmurs Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Intubated, responds to noxious stimuli Lymph: No supraclavicular, axillary or inguinal LAD
FAMILY HISTORY: Per NF note) One son with psoriasis, other with asthma. Daughter died at age 37 of liver cancer. Mother died at 85 of head and neck cancer and father died in 40s of brain tumor.
SOCIAL HISTORY: (Per NF note) Widowed. Has 2 sons, lives with one of them. Had a daughter as well who passed away. Retired engineer. Travelled during working life around US and various countries ([**Country 4754**], middle east, [**Country 5142**]). Born in [**Location (un) 86**]. No TB contacts. [**Name (NI) **] current smoking history, reports smoking for a short time during WWII only. Father did [**Name2 (NI) **] while he was growing up. No etoh. | 0 |
46,394 | CHIEF COMPLAINT: neck and back pain, found to have severe hyponatremia
PRESENT ILLNESS: Ms [**Known lastname 34298**] is a 86 year old woman presenting for back pain and incidental hyponatremia noted in ED to 113 compared to baseline of near 140. She has a history of type I diabetes, hypertension, hyperlipidemia, coronary artery disease, hypothyroidism, GERD and chronic atrophic gastritis. She currently lives in assisted housing at [**Location (un) 5481**], in the independant living portion of housing. Her presentation begins 3 weeks prior to this ED visit: She went walking with her daughter at this time along the [**Name (NI) **] [**Last Name (NamePattern1) **] and fell while using her walker, sustaining abrasions to her elbows. Thereafter, she developed back pain that progressed over the last two weeks resulting in an evaluation at the [**Location (un) 620**] ER on [**2-28**]. Lumbar x-ray was obtained which did not reveal fracture. She was given tramadol and discharged. No labs were drawn at this point. She returned to her [**Hospital 4382**], where she was transferred to the skilled nursing facility for pain control. Despite this, her pain continued unabated and she presented today to [**Hospital1 18**] ED. Her sodium upon presentation was noted to be 117. Over the past two weeks, her PO intake has been quite poor. Denies vomiting, nausea, or diarrhea. She has been constipated for the last five days with progressive distension of her abdomen. She denied dizziness, syncope or seizure activity. She has had prior admissions for hyponatremia a year ago which was secondary to osmotic diuresis in setting of hyperglycemia which resolved with fluid resuscitation. Review of systems today is also positive for a significant amount of diureses over the past few days despite poor PO intake and hydration. Her last TSH was somewhat supratherapeutic in [**2185**] at 4.9 - she has had thyroid failure for 20-25 years on synthroid. Her last sodium prior to this visit was 139 in [**2187-8-25**]. Today, she is oriented to person, to place, but not to time; she is vaguely able to recount her reason for admission; her daughter states she is quite confused. No new medications. In our emergency department today, she received a CT abdomen / pelvis - with no obvious fracture as source of her back pain. Colon is full of stool with some distension of her colon but no obstruction. She was admitted to the MICU for evaluation and treatment of her hyponatremia. At time of transfer, she had no acute complaints and has the orientation described above.
MEDICAL HISTORY: 1. DM - type I x 50+ years 2. Osteoporosis. 3. Hypertension, hyperlipidemia, and coronary artery disease. - MI at 65yo, medically treated 4. Hypothyroidism, on replacement. 5. Vitamin D deficiency, on replacement. 6. GERD -- endo/mild HH with a mild esophagitis and presbyesophagus with a motility study showing a normal LES but 50% failed contractions [**2186-10-25**]. 7. Chronic atrophic gastritis with intestinal metaplasia -- rule out pernicious anemia. 8. h/o seizure - last in [**2178**] 9. Constipation . Prior Surgical Procedure: 1. Appendectomy. 2. TAH-BSO 3. Endoscopy in the [**2165**] and a colonoscopy, questionable time
MEDICATION ON ADMISSION: 1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 4. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 5. Lantus 100 unit/mL Solution Sig: Eight (8) units Subcutaneous at bedtime. 6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 7. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. senna 8.6 mg Capsule Sig: One (1) Capsule PO at bedtime. 12. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Humalog 100 unit/mL Solution Sig: as per sliding scale units Subcutaneous three times a day. 14. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO once a day. 15. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 6 days.
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: ON ADMISSION: VS: HR 79, BP 146/60, RR 12, 96% RA, temp 98 Gen: Caucasian female, pleasant, but hard of hearing, in no apparent distress; euvolemic in appearance Neck: supple, no lymphadenopathy, no thyromegaly Cardiac: Nl s1/s2 RRR no murmurs appreciable Pulm: clear bilaterally with normoactive breath sounds Abd: soft but has distended abdomen, tympanic, normoactive bowel sounds Ext: no edema noted Discharge exam VSS GEN: Patient lying comfortably in bed nad a+ox3 HEENT: MMM oropharynx clear NECK: supple no thyromegaly CV: rrr no m/r/g RESP: ctab no w/r/r ABD: soft nt nd bs+ EXTR: no le edema good pedal pulses bilaterally DERM: decubitus ulcer noted on back and coccyx neuro: cn 2-12 grossly intact non-focal PSYCH: normal affect and mood
FAMILY HISTORY: NC
SOCIAL HISTORY: Patient lives in assisted care facility at [**Location (un) 5481**] - she has a daytime caretaker [**Name (NI) 636**]. She lost her husband of 62 years 2 years ago. She has three children. Her daughter [**Name (NI) **] [**Last Name (NamePattern1) 4640**] lives in [**Name (NI) 745**] and is her HCP. Pt graduated from college with a degree in social work. She was a homemaker. She used to smoke a little years ago. Denies any Etoh. | 0 |
68,055 | CHIEF COMPLAINT: aortic stenosis
PRESENT ILLNESS: This 87 year old white with known aortic stenosis is pre-op for knee surgery. Preop workup included an echocardiogram which demonstrated critical aortic stenosis and a cardiac catheterization was scheduled. This confirmed severe Aortic stenosis with moderate mitral regurgitation also. She was transferred from [**Hospital1 **] for surgery.
MEDICAL HISTORY: Aortic stenosis hypertension mitral regurgitation degenerative joint disease chronic atrial fibrillation chronic obstructive pulmonary disease h/o right leg deep vein thrombophlebitis chronic venous stasis cahnge right foot s/p right total hip arthroplasty
MEDICATION ON ADMISSION: Diltiazem CD 180', HCTZ 12.5', Advair250/50", Atrovent 2P", MVI, Calcium, Warfarin 2.5', Ultram 50-prn, Methimazole 2.5', Tylenol
ALLERGIES: Fentanyl / Demerol
PHYSICAL EXAM: Admission: T 98.7 Pulse: 81 Resp: O2 sat: 95%-RA B/P Right: 110/76 Left: Height: 4'[**35**]" Weight: 49.5 K/109 lbs
FAMILY HISTORY: non-contributory
SOCIAL HISTORY: Lives with: alone Occupation: retired Tobacco: quit 20 yrs ago ETOH: 2 drinks/day | 0 |
4,170 | CHIEF COMPLAINT: Renal Tumor
PRESENT ILLNESS: 75yF with left kidney mass. Her Ultrasound indicated a moderate sized left kidney mass amenable to possible nephrectomy.
MEDICAL HISTORY: PMH: 1. Congenital nystagmus 2. Asthma (albuterol inhaler PRN) 3. Nasal polyps with chronic rhonitis 4. Hypertension 5. Chronic Anxiety 6. Osteoporosis 7. GERD
MEDICATION ON ADMISSION: Meds on admit: 10mg po oxazepam qd prn flovent 110 2 puffs [**Hospital1 **] FLUTICASONE PROPIONATE 50MCG 2 SPRAYS EACH NOSTRIL DAILY hctz 12.5mg po qd pantoprazole 40mg po qd ventolin 90mcg q4 prn verapamil SR 240mg qd
ALLERGIES: Aspirin / Bactrim / Tenormin / A.C.E Inhibitors / Serevent
PHYSICAL EXAM: No acute distress. Alert and oriented x 3. Regular rate and rhythm no murmurs rubs or gallops. Clear to auscultation no wheezes rales or rhonchi. Soft Nontender, nondistended, bs+ normoactive. No clubbing, cyanosis, edema. Pulses 2+ equal bilaterally.
FAMILY HISTORY: CAD father, mother with depression died at age 37 with CVA. Maternal cousin with leukemia, brother with bladder CA
SOCIAL HISTORY: Born and raised in [**State 350**]. She was a house wife and is now a retired child care worker. She has 3 daughters, one of whom is mentally retarded, and lost a daughter to an illness. She is a widow who lives alone but has family in [**State 2690**]. | 0 |
48,688 | CHIEF COMPLAINT: Status post fall
PRESENT ILLNESS: Patient is a 51 yo male who reported falling at home approximately two weeks ago. The emergency department reports that the patient fell while intoxicated down 11 steps 2 weeks ago and was found with LOC by brother. [**Name (NI) **] was told to come to the emergency department by his employer as he complained of worsening pain on his left elbow. Outside hospital films reveal a displaced L elbow fx and CT head show orbit fx; skull fx, and L IPH.
MEDICAL HISTORY: PMH: diverticulitis PSH: partial colectomy for diverticulitis
MEDICATION ON ADMISSION: Denies
ALLERGIES: Percodan
PHYSICAL EXAM: Afebrile, VSS Exam: Gen: Patient in NAD, Awake, Alert, C collar in place Patient with BL periorbital ecchymosis. EOMI with no signs of entrapment. No blurred vision or loss of visual acuity. Maxillary stable, no blood in nares, no epistaxis or drainage from sinus. Bilateral orbital ecchymosis (racoon eyes). No Battle's sign, no CSF rhinorrhea. Patient is disheveled, poorly [**Last Name (un) 63196**] CTAB RRR soft, NT, ND well healed midline incision rectal good tone guiac neg 2+ DP and PT pulses with 2+ radial pulses
FAMILY HISTORY: NC
SOCIAL HISTORY: +EtOH and TOB and Marijuana | 0 |
98,082 | CHIEF COMPLAINT: chest pain, SOB .
PRESENT ILLNESS: Mr. [**Known lastname 34808**] is a 74 yoM w/ a h/o htn, hypercholesterolemia, PVD, ESRD on HD, AS s/p AVR who is transferred from [**Hospital3 **] for chest pain and SOB. Patient reports being in his usual state of health until 2 weeks ago after having skin resections for skin cancer. The following day, patient went to HD and following HD felt extremely fatigued and generally unwell. Over the next 2 weeks, he has had DOE w/ 1 flight of stairs and half a mile. Prior to 2 weeks ago, he was able to do stairs and walk a couple of miles w/o SOB. He has been spending a significant amount of time in bed due to fatigue and SOB over the last two weeks and also endorses 2 pillow orthopnea which is also new. . Approximately 3 days ago, he developed episodes of chest pain while at rest at work. This pain was associated with pain under his arms as well as SOB but no nausea, diaphoresis, or lightheadedness. The episodes lasted 1-1.5 hours and resolved spontaneously. Over the last 3 days he has had ~ 5 episodes. Then yesterday evening, he was awoken from sleep with 10/10 chest pain again ass. w/ pain under the arms and SOB. His wife called 911 and he was brought to OSH ED. He received 3 SL NTG in transport and by the time of arrival to the ED, his CP had resolved. Patient estimates ~1 hr of chest pain. Per pt's friend, he may have been complaining of chest pain >1 week ago although he did not report to his family. . In the OSH ED, patient was chest pain free. By report, although not available, ECG showed NSR w/ nonspecific ST-TW changes, inferior QWs. CKs were negative but troponins were mildly elevated at 0.16. He was evaluated by Cardiology, started on heparin and NTG gtt for possible unstable angina/ACS. CXR showed moderate CHF and he was dialyzed w/ 2 kgs removed. He was then transferred to [**Hospital1 18**]. . Upon arrival, patient appears comfortable. He denies any further chest pain since his last episode was relieved w/ SL NTG prior to arrival at [**Hospital3 **]. He reports his breathing improved since his dialysis. He is otherwise without complaint. On review of symptoms, he denies any fevers, chills, nightsweats, abdominal pain, diarrhea, constipation, or urinary complaints. As above, he does note DOE and orthopnea. He denies any recent LE swelling, syncope, or presyncope. .
MEDICAL HISTORY: # Aortic Stenosis s/p Aortic Valve Replacement [**2156-1-9**] - (#[**Street Address(2) 65216**]. [**Male First Name (un) 923**] # ESRD [**2-25**] htn on Hemodialysis T/Th/Sat thru L AVF # Hypertension # Hypercholesterolemia # s/p AAA repair in ?[**2150**] @ [**Hospital1 336**] # s/p right aortoiliac bypass # R knee surgery # R aorti iliac bypass # Peripheral Vascular Disease # Anxiety/depression # s/p R quad repair # Benign Prostatic Hypertrophy # s/p L lung biopsy .
MEDICATION ON ADMISSION: asa 325 mg daily atenolol 50 mg daily norvasc 5 mg daily lipitor 10 mg daily renagel .
ALLERGIES: Erythromycin Base
PHYSICAL EXAM: PHYSICAL EXAMINATION: VS: AF, BP 137/65, HR 69, RR 19, O2 100% on NRB Gen: Elderly male in no significant respiratory distress sitting upright on NRB. Oriented x3. Mood, affect appropriate. Pleasant.
FAMILY HISTORY: Denies any family h/o early CAD or other heart problems. .
SOCIAL HISTORY: Lives in [**Location 38640**], MA with his wife. 2 children. Works as a security guard. Former 2 ppd smoker. ~ 96 pk/yr hx. Quit in [**2144**]. Drinks [**1-25**] glasses of wine/day. No h/o heavy EtOH use. . | 0 |
74,141 | CHIEF COMPLAINT: nausea, vomiting, shortness of breath
PRESENT ILLNESS: 34yo M PMHx DM1, ESRD (on HD [**Month/Day/Year **]/Thurs/Sat), severe gastroparesis with recurrent admissions for nausea/vomitting (most recent discharge [**2147-2-17**]), nonischemic cardiomyopathy (EF=30-35%), presenting with nausea, vomiting, and shortness of breath. History was initially obtained from the patient in the emergency department, and subsequently obtained from the patient's girlfriend by the ICU team. . Per ED, the patient reported that 3 days prior to day of admission, he developed nausea and NBNB emesis, consistent with prior episodes of gastroparesis. Symptoms were not initially associated with any fevers/NS/chills, shortnesss of breath, chest pain; beginning 1d prior to admission, he developed worsening pleuritic chest pain, non-exertional, along with shortness of breath and cough. Also reported poorly controlled finger sticks. . Per the patient's girlfriend, the patient has chronic issues with nausea/vomiting from gastroparesis. He was in his usual state of health until Tuesday, when he awoke with shortness of breath prior to dialysis. He felt okay after HD on Tuesday, then developed shortness of breath on Wednesday evening/Thursday morning. He felt better after HD yesterday, but awoke at 5 a.m. today with nausea, vomiting, shortnss of breath. His emesis was profuse and red, but the patient's girlfriend attributes this to red coolaid that he drank last night. No diarrhea. Last BM yesterday per girlfriend. Had mild coughing this morning. No recent travel or sick contacts. Had dental work and was on antibiotics 2-3 weeks ago. The patient's girlfriend is not sure the patient took his usual medications this a.m. but believes he probably did not. No recent med changes per girlfriend. [**Name (NI) **] fever/chills. No syncope. +abdominal pain, diffuse, this a.m. No dysuria. No rash. No myalgia/arthralgia. . On presentation to ED initial vital signs were 99.0 113 225/111 28 89% 3LNC. On exam patient was short of breath, appearing fatigued. He became hypoxic, requiring a non-rebreather. On further history taking, he reported that in setting of vomiting he may have aspirated small amount of vomitus. Labs were significant for WBC 11.8 (N87), Hct 29 (baseline 28), Na 131, K 4.2, glucose 678, Anion Gap 21, VBG 7.47/38, lactate 2.0. CXR significant for pulmonary edema (radiology read), felt to be consistent with pneumonia by ED. Patient was albuterol, ipratropium, NTG, labetalol 10 mg IV x 2, morphine, Zofran, vancomycin 1 gm, cefepime 2 gm. He was given succinylcholine, propofol, fentanyl, and midazolam prior to intubation. A central line and OGT were placed. After intubation, the patient reported to have red frothy secretions from ET tube. Vital signs prior to transfer were T 98.5 P 88, BP 160/91 Sat 100% on AC 500mL 22RR 10peep 100%.
MEDICAL HISTORY: - DM type I since age 19, followed at [**Last Name (un) **]. Complicated by nephropathy, neuropathy, gastroparesis, retinopathy. Multiple prior hospitalizations with DKA, nausea/vomitting [**2-9**] gastroparesis - ESRD on HD T/Th/S via right arm fistula @ [**Location (un) **] [**Location (un) **], dry weight 73kg - Hypertension - Nonischemic cardiomyopathy with EF 30-35% - Anemia: felt to be due to both iron deficiency and advanced CKD - Depression - Pulmonary hypertension - Migraines
MEDICATION ON ADMISSION: - amlodipine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. - aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). - carvedilol 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. - [**Hospital1 40899**] 0.2 mg/24 hr Patch Weekly [**Hospital1 **]: One (1) Patch Weekly Transdermal QSUN (every Sunday). - insulin glargine 100 unit/mL Solution [**Hospital1 **]: Fourteen (14) units Subcutaneous Every morning. - insulin lispro 100 unit/mL Solution [**Hospital1 **]: Sliding Scale units Subcutaneous Before meals and before bed - B complex-vitamin C-folic acid 1 mg Capsule [**Hospital1 **]: One (1) Cap PO DAILY (Daily). - lisinopril 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. - sevelamer carbonate 800 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). - sertraline 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. - hydromorphone 4 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day as needed for pain. - ondansetron 4 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea.
ALLERGIES: Penicillins / Watermelon / Almond Oil / Hydralazine / cefepime
PHYSICAL EXAM: Admission exam: VS: T 98.4 BP 179/98 HR 92 RR 21 Sat 100%/vent Gen: Intubated, sedated. HEENT: Anicteric sclerae. Neck: RIJ in place. Chest: Clear ventilated breath sounds. CV: RRR. Normal s1, s2. No M/G/R. Abd: +BS. Soft. NT/ND. Rectal: Guaiac negative yellowish-brown stool. Ext: WWP. No edema. RUE fistula with good thrill. Neuro: Sedated. PERRL. Moves all extremities.
FAMILY HISTORY: Paternal GF had DM2 but nobody with DM1. Hypertension in a few family members.
SOCIAL HISTORY: -Home: Lives with his GF. Mother lives in the area as well. -Tobacco: trying to quit; has relapsed and smokes 1 pack per week or week and a half -EtOH: previously drank heavily (30-40 drinks/week) but has not used alcohol since [**2144-11-14**] -Illicits: Denies other drugs. | 0 |
19,493 | CHIEF COMPLAINT: black stools, weakness
PRESENT ILLNESS: The patient is a 69 year old femal with history of osteoarthritis who presented with profound fatigue following ~2 weeks of tarry stools. She had no abd pain or increase in stool frequency. There was no nausea/vomiting/diarrhea or constipation. She did have occassional BRPBR but she attributed to hemorrhoids. When she noticed that she could barely walk around her home without getting short of breath, she called EMS to come to the hospital. There were no chest pains, or palpitations. She last took ibuprofen/COX2 for her arthritis several months ago. She does not currently drink alcohol. She takes no medicines regularly except for tylenol. ROS: no cough, chest pain, back pain, dysuria. leg swelling
MEDICAL HISTORY: 1. Osteoarthritis 2. HTN 3. Hyperparathyroidism s/p parathyroid adenoma resection [**4-23**]
MEDICATION ON ADMISSION: 1. HCTZ 25 mg qd 2. Tyelnol arthritis
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS: Tc 98.6, BP 121/53, HR 95-100, RR 20, SaO2 100%/RA General: Pleasant female in NAD, AO x 3. Slightly dyspneic with movement. Able to speak full sentences. HEENT: NC/AT, PERRL, EOMI. +conjunctival pallor. No scleral icterus. MM dry, OP clear Neck: supple, no JVD or LAD Chest: few bibasilar rales, no wheezes CV: RR tachy, s1 s2 normal, no m/g/r Abd: soft, NT/ND, NABS, +guiac positive in ED with dark stool Ext: no c/c/e, good distal pulses b/l Neuro: AO x 3, CN II-XII intact, MS [**5-23**] throughout, sensation grossly intact.
FAMILY HISTORY: NC
SOCIAL HISTORY: Lives at home with her youngest daughter. She has 10 children all of whom live in the [**Location (un) 86**] area. Formerly worked as a travel [**Doctor Last Name 360**], but lost her job after [**9-29**]. Smokes 1 ppd x 29 years, no EtOH or illicits. Prior h/o alcoholism 22 years ago. | 0 |
28,034 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 63-year-old clinical psychologist with a history of renal cell carcinoma who presents with a chief complaint of lower back pain and bilateral left greater than right leg pain. Mrs. [**Known lastname **] was diagnosed with renal cell carcinoma in [**2102-10-28**] and underwent a left radical nephrectomy at that time. Postoperatively, she was treated with radiation therapy to her spine which was completed in [**2103-2-26**]. She has developed increasing lower back pain with left hip and anterior medial thigh pain over the last several months. Pain has progressed and now involves the right buttock and hip. It does not extend into the right leg. She specifically denies any lower extremity motor weakness or bowel or bladder dysfunction.
MEDICAL HISTORY: 1. Rheumatoid arthritis 2. Renal cell carcinoma 3. Gallstone pancreatitis
MEDICATION ON ADMISSION:
ALLERGIES: PENICILLIN WHICH CAUSES A RASH AND SULFA WHICH CAUSES ANAPHYLAXIS.
PHYSICAL EXAM: She measures 5 feet 4 inches tall. She weighs approximately 120 pounds. She has a well healed Chevron incision. Detailed individual muscle testing in the lower extremities reveals full and symmetrical strength, graded 5 out 5 and bilateral iliopsoas, hamstring, quadriceps, dorsiflexors, plantar flexors. Reflexes are grade 2+ to knees and ankles bilaterally. Toes are downgoing bilaterally.
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
3,609 | CHIEF COMPLAINT: Acute renal failure Hepatitis C Cirrhosis, decompensated liver failure
PRESENT ILLNESS: 59 M with h/o hepC cirrhosis, s/p renal and pancreatic transplant for DM, and recent admission for ARF (not thought to be HRS, [**Date range (1) 34961**], admit creat 3.1 and d/c creat 2.3 on [**5-12**]) who presented for routine paracentesis on day of admission, and was found to have elevated creatinine of 3.6. At Day Care Clinic, pt had paracentesis removing 3 L of ascitic fluid which was negative for SBP. Pt stayed hemodynamically stable throughout the procedure with SBP in 90s-100s. Pt received 50 gm of albumin (concentrated) after paracentesis. Pt reports he has not been eating or drinking much fluid due to abdominal distension for the past several days. He reported intermittent nausea and vomiting up food soon after eating. Denied any hematemasis, melena, worsening diarrhea (has bm [**12-15**]/day), hematochezia, decreased urinary stream or urine output (goes 3 times a day). Denied any cough, fevers, but reports chills all the time. Denied sob, chest pain, abdominal pain, n/v, or urinary symptoms. Denied any recent NSAIDS use. Stopped taking ASA recently for easy bruising/bleeding. Has been getting tube feeding at home at night and has been tolerating it well (60cc goal).
MEDICAL HISTORY: 1. Hepatitis C cirrhosis, genotype 1. s/p biopsy [**2-17**] (stage 2-3 fibrosis). HepC VL 965,000 [**2-17**]. +h/o SBP [**4-18**], +h/o encephalopathy, EGD [**2-17**] no varices, +portal gastropathy. no colonoscopy. +recurrent ascites on diuretics. 2. s/p cadaveric renal transplant in [**2107**] for presumed diabetic nephropathy 3. s/p pancreas transplant in [**2108**] now with resolved diabetes 4. HTN 5. Asthma 6. Encephalopathy
MEDICATION ON ADMISSION: 1. Gemfibrozil 600 mg [**Hospital1 **] 2. Hydroxyzine HCl 25 mg QHS 3. Tacrolimus 0.5 mg PO QDAILY at 8 PM 4. Prednisone 5 mg Daily 5. Trimethoprim-Sulfamethoxazole 80-400 mg DAILY (Daily). 7. Pantoprazole 40 mg Tablet PO Q24H 8. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 9. Hexavitamin 1 Tablet PO DAILY 10. Calcium Carbonate 500 mg PO TID 11. Cholecalciferol (Vitamin D3) 400 unit PO DAILY 12. Sodium Bicarbonate 650 mg Two (2) Tablet PO BID 13. Rifaximin 200 mg PO TID 14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 15. Levofloxacin 250 mg Tablet PO Q24H 16. Simethacone 80mg po QID/PRN 17. Ursodiol 600mg [**Hospital1 **]
ALLERGIES: Iodine; Iodine Containing
PHYSICAL EXAM: VS: 98.3 98.3 116/54 88 18 97%RA GEN: NAD, pleasant male. HEENT: PERRLA, EOMI, sclera icteric, OP clear, MM dry, no LAD. left side carotid radiation of murmur. 8cm JVP at 45 degrees. CV: regular, nl s1, s2, 3/6 SEM radiating to carotids and holosystolic murmur at base radiating to axilla, no r/g. PULM: CTA B, no r/r/w. ABD: soft, NT, +distended, + BS, + fluid wave, no HSM. paracentesis dressing in LLQ c/d/i. EXT: warm, 2+ dp/radial pulses BL. [**12-15**]+ edema to mid-calf L>R (not new per pt). NEURO: alert & oriented to place and [**2112-5-11**], CN II-XII grossly intact. + mild L asterixis.
FAMILY HISTORY: Mother deceased MI [**69**], h/o kidney CA, dad alive at 87 yr old. Otherwise NC.
SOCIAL HISTORY: He lives at home with his wife. Ex-[**Name2 (NI) 1818**], quit 15 years ago. He used to work as a cabinet maker in the past. | 0 |
16,595 | CHIEF COMPLAINT: 1. Melanotic stools.
PRESENT ILLNESS: Mrs. [**Known lastname 19730**] is a 41 year-old female with past medical history significant for type I diabetes, end stage renal disease on hemodialysis, hypertension, hyperprolactinemia, history of a GI bleed who presents to the Emergency Department with shortness of breath, abdominal pain and nausea. The patient states that she has had epigastric pain for the past three or four days and that her mother had noted dark / bloody stools which subsequently lead her to bring her daughter to the Emergency Department. The patient states she has been taking two Motrin a day for the past month for chronic leg pain. The patient has a history of upper GI bleed several years ago. She denies any hematemesis, vomiting. She states she has not eaten since the night before admission. In the Emergency Department the patient's blood pressure was 79/44. Her O2 saturation was 100% on room air with a heart rate of 60%, access was obtained in view of a femoral triple lumen catheter. Her blood pressure increased without bolus of fluid or transfusion. Her blood pressure on arrival to the MICU was 100/70 and G tube was placed. Bright red blood was retained which did not clear after 750 cc of flushing with normal saline. The patient continued to remained hemodynamically stable. Her laboratory values were significant for hypokalemia with peaked T waves seen on her EKG. The patient was given sliding scale insulin IV to enhance sodium bicarb along with 2 grams of calcium gluconate. The renal fellow on call was notified and emergent hemodialysis was arranged upon arriving in the medical ICU.
MEDICAL HISTORY: 1. Type I diabetes since the age of 23 years old. She has had several episodes of DKA. 2. End stage renal disease on hemodialysis Tuesday, Thursday and Saturday secondary to diabetes. 3. Diabetes. 4. Hyperprolactinemia. 5. History of upper GI bleed 6. Foot ulcer for which she has had for one month.
MEDICATION ON ADMISSION:
ALLERGIES: Azithromycin leads to gastric upset.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: She lives with her mother. She is a nonsmoker. She occasionally uses alcohol. She has VNA for foot ulcer care. | 0 |
50,980 | CHIEF COMPLAINT: Chest pain
PRESENT ILLNESS: 66 year old male who developed chest pain yesterday with radiation down left arm. CT at outside hospital revealed Type A aortic dissection. Transferred for surgical management.
MEDICAL HISTORY: Hypertension Basal cell carcinoma Depression Hearing loss s/p Appendectomy s/p Vasectomy s/p Kidney cyst removal
MEDICATION ON ADMISSION: Aspirin Chantix HCTZ Labetalol Lisinopril Xalatan Nitro
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Pulse: 70 Resp: 18 O2 sat: 98% 4L NC B/P 131/75
FAMILY HISTORY: non-contributory
SOCIAL HISTORY: Lives: alone, divorced Occupation: Hearing aid specialist Tobacco: current, 1/ppd ETOH: 2 drinks/week | 0 |
93,259 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 44 year old male with a past medical history significant for multiple medical problems including coronary artery disease, status post four vessel coronary artery bypass graft, atrial fibrillation on Coumadin, end stage renal disease on hemodialysis, diabetes mellitus, and left embolic middle cerebral artery cerebrovascular accident, who presents from nursing home with hypotension and bright red blood per rectum. Per nursing home report, the patient had a one day history of dark red blood per rectum. He was incontinence of stool and stool amount was unable to further be quantified. His blood pressure dropped to the 80s systolic and he was also noted to be febrile to 102.0. No abdominal pain, nausea, vomiting or hematemesis was noted. The patient had been noted to have a recent INR of 1.6 to 1.8 with a hematocrit of 25, down from his baseline of 29. Upon arrival in the Emergency Department, the patient was tachycardiac with heart rate in the 120s to 140s with a rhythm of atrial fibrillation. His systolic blood pressure was in the 100s. His hematocrit was 27.5 and his INR was 2.0. Soon after arrival to the Emergency Department he had two episodes of dark red blood per rectum with subsequent drops in his blood pressure to a systolic of 70s to 80s. He received 1 liter of normal saline and 2 units of packed red blood cells. He also received 30 ml of Proplex to reverse his INR, in addition to 10 mg subcutaneous Vitamin K. Proplex was chosen given the patient's anuric end stage renal disease and concern for volume overload. The patient also received Protonix 40 mg intravenously. Following volume resuscitation his blood pressure increased to 110 systolic. He had an nasogastric lavage which showed no evidence of blood or clot. The patient was then admitted to the Medicine Intensive Care Unit for further management.
MEDICAL HISTORY: End stage renal disease on hemodialysis, anuric; diabetes mellitus; diabetic neuropathy; coronary artery disease, status post myocardial infarction; four vessel coronary artery bypass graft in [**2127**]; congestive heart failure with unknown ejection fraction; peripheral vascular disease; dry gangrene; chronic lower extremity edema, status post left middle cerebral artery, stroke with residual right hemiparesis and Wernicke's syndrome; bilateral carotid stenosis, less than 40%, history of Methicillin-resistant Staphylococcus aureus infection in sacrum on Linezolid since [**4-17**]; hyperparathyroidism; calciphylaxis; chronic anemia; decubitus ulcers; status post pneumonia.
MEDICATION ON ADMISSION: Lopressor 100 t.i.d., Aspirin 325 q. day, Coumadin 2.5 q. day, Digoxin .125 q. 72 hours, Lipitor 40 mg q.h.s., Imdur 60 mg q. day, Risperdal .75 q.h.s., 70/30 insulin, 32 units in the morning, 30 units in the evening, Zoloft 25 q.h.s., Colace and Senokot q. day, Verapamil 40 mg q.i.d., Renagel 4000 mg t.i.d., Colchicine .6 q. day, Linezolid 600 b.i.d., started on [**4-17**].
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY: Mom with cerebrovascular accident, Dad with myocardial infarction at age 50.
SOCIAL HISTORY: Nursing home resident, sister guardian, no current tobacco or alcohol use. | 0 |
48,532 | CHIEF COMPLAINT: Altered Mental Status
PRESENT ILLNESS: This a 62 yo M with cirrhosis [**3-12**] NASH, hepatorenal syndrome, and chronic non-healing superinfected RLE wound (VRE and C. [**Month/Day (2) 563**]) in the setting of various foot/malleolar dislocations and fractures followed by multiple debridements, initially admitted for altered mental status, with extended hospital course complicated by UGI bleed who was transferred to the MICU for worsening encephalopathy/AMS on [**2120-4-13**]. . In the MICU, the patient was kept on a NRB with continued respiratory distress. The patient then acutely decompensated and failed a trial of noninvasive ventilation, and was ultimately intubated. The patient had a L IJ hemodialysis line for emergency dialysis. He had multiple rounds of CVVH. He was started on levophed for hypotension. CVVH was stopped an HD was initiated. The patient mental status was treated with lactulose. He also became febrile so zosyn was stopped and meropenem was started for a time. He is currently on daptomycin/meropenem/micafungin. The patient mental status improved and he was successfully extubated. He was also weaned from levophed and was tolerating HD well. He went to the OR for right leg washout on [**2120-4-15**]. He is currently on q3day vac changes. ID followed the patient while in the ICU, and recommended a 6 week course of abx after the last orthopedics intervention. His mental status remained clear and he was hemodynamically stable. He was transferred to the floor.
MEDICAL HISTORY: 1. Cirrhosis likely due to Steatohepatitis, followed by Dr. [**First Name (STitle) 679**]. Last tap [**2120-3-19**]. States he gets tapped q10days. 2. Irritable Bowel Syndrome 3. Type 2 Diabetes Mellitus with extreme insulin resistence 4. Gastroparesis 5. Obesity 6. Hyperlipidemia 7. Rheumatoid Arthritis 8. Depression 9. Chronic Renal Insufficiency baseline Cr 2.6 over the last year [**20**]. Obstructive Sleep Apnea on CPAP 11. HTN 12. ORIF Right ankle
MEDICATION ON ADMISSION: 1. Amlodipine 10 mg 2. BuPROPion (Sustained Release)200 mg [**Hospital1 **] 3. Calcium Carbonate 1000 mg po qd 4. Docusate Sodium 100 mg [**Hospital1 **] 5. Escitalopram Oxalate 10 mg qd 6. FoLIC Acid 1 mg qd 7. Furosemide 80 mg qd 8. HYDROmorphone (Dilaudid) 2 mg q4hrs prnl 4 mg q 4 hrs for severe pain 9. Humulin R U-500 17 units breakfast; 13 units lunch; 15-20 units at dinner; on SS 10. Lactulose 11. Metoprolol Tartrate 25 mg [**2-10**] tab [**Hospital1 **] 12. Pantoprazole 40 mg [**Hospital1 **] 13. Rifaximin 200 mg tid 14. Senna 15. Spironolactone 25 mg [**Hospital1 **] 16. TraMADOL (Ultram) 50 mg qhs 17. Vitamin D 400 u 2 tabs qd 18. fenofibrate 145 mg 1 tablet qd 19. Aranesp 50 mcq/ml q week 20. vancomycin 750 mg IV for 4 weeks. 21. ascorbic acid 500 mg [**Hospital1 **] 22. ampicillin/sulbactam 3 gm q hrs for 4 weeks 23. iron SR 325 mg qd 24. acidophilis 1 cap [**Hospital1 **]
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS: 99.4 105 114/58 20 95% on RA GA: jaundiced M lying in bed, AOx1 (to name only), NAD HEENT: PERRLA. MM dry. no LAD. icteric sclera. no JVD. neck supple. Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: crackles at bases Abd: soft, distended/protuberant with +fluid wave. NT, +BS. no g/rt. liver edge non-palpable. Extremities: hardware supporting RLE cellulitis with wound vac. DPs, PTs 1+ BL.
FAMILY HISTORY: No h/o clotting disorders. Mother died of PNA in 80s, also had thyroid disease. Father died of heart disease in 70's, had cancer (unknown type), tobacco and alcohol abuse. Family h/o T2DM.
SOCIAL HISTORY: Occupation: Has PhD in Psychology-retired Mass DMH psychologist. No tobacco, no ETOH, no other drugs. | 0 |
2,111 | CHIEF COMPLAINT: Elective admission for resection of left sided meningioma
PRESENT ILLNESS: 83 yo F with known left parasaggital meningioma, followed by Dr. [**Last Name (STitle) **], who has had progressive right leg weakness and difficulty walking over the past several months to a year. She lives independently with her husband and it has become increasingly difficult to walk. She is altering her gait and using upper body strenght to walk and climb stairs. Her family notes that she drags her leg when she walks. No pain, numbness or tingling. Work-up of right leg weakness included MRI thoracic and cervical spine that show only mild degenerative changes and chronic T9 compression fx. She was found to have a left sided meningioma and he is she is currently scheduled for elective craniotomy.
MEDICAL HISTORY: HTN, high cholesterol, oral lichen planus, left sided parasaggital meningioma (as above), hypothyroid, Irritable bowel syndrome, GERD, sciatica, aortic/mitral valve insufficiency, recent PNA 3 weeks ago treated as outpatient.
MEDICATION ON ADMISSION: norvasc, atenolol, lipitor, cozaar, levoxyl, MVI, k-dur, prednisone
ALLERGIES: Penicillins / Erythromycin Base
PHYSICAL EXAM: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRLA EOMs Full Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E.
FAMILY HISTORY: NC
SOCIAL HISTORY: lives independently with husband, cooks and cleans | 1 |
91,014 | CHIEF COMPLAINT: abdominal pain w/ nausea and vommiting
PRESENT ILLNESS: 43 year-old woman who was hit by a motor vehicle accident over 6 months ago and, over the past 2 months, has progressive heartburn. For the past couple weeks, she has had intermittent abdominal pain culminating in an episode of severe abdominal pain in the epigastrium associated with nausea and vomiting of nonbilious material. She presented to the emergency room and was found to have a diaphragmatic hernia with spleen and stomach in the left hemi thorax.
MEDICAL HISTORY: Left diaphragmatic hernia,[**3-19**]: MVC with Left ulnar/femur fracture, splenic laceration, Inter cranial hemmorrhage, Left skull fracture
MEDICATION ON ADMISSION: protonix 40', MVI
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: General- middle age female in NAD, slightly anxious HEENT-non-icteric Resp- clear Cor-RRR ABD-soft, BS present, slight tenderness, non-distended, no CVA tenderness Ext- no edema
FAMILY HISTORY: n/c
SOCIAL HISTORY: married, lives w/ [**First Name9 (NamePattern2) 32939**] [**Name (NI) 4628**], MA no etoh, non- smoking social worker | 0 |
59,523 | CHIEF COMPLAINT: Lethargy
PRESENT ILLNESS: 46-year-old female with history of acute alcoholic hepatitis and biopsy-proven cirrhosis complicated by anemia, hepatic encephalopathy, fluid overload, and synthetic dysfunction was brought in by family concerned for lethargy x2 days. It appears that on [**6-17**] her diuretics and lactulose were discontinued for an elevated creatinine of 1.5. Today, pt was BIBA because family was concerned that she has been acting lethargic x 2 days. She does have a history of hepatic encephalopathy and her symptoms were consistent with prior presentations. Of note, her lactulose seems to have been discontinued recently in the setting of diarrhea and creatinine elevation out of concern for further dehydration. She was too lethargic to answer questions appropriately in the [**Last Name (LF) **], [**First Name3 (LF) **] EMS had complained of abdominal pain on the ride over. most of the history was obtained from family. Pt has had many recnet hospitalizations recently at [**Hospital1 18**]: from [**Date range (1) 20228**] (liver failure) and then again [**Date range (3) 20229**] (s/p fall). Her last hospitalization [**Date range (1) 20230**] for worsening hepatic encephalopathy, which had improved since starting lactulose therapy. She was also on rifaximin, lasix 20mg daily and spironolactone 50mg daily
MEDICAL HISTORY: 1. Recent diagnosis of alcoholic hepatitis and cirrhosis as above. 2. Hypertension. 3. Elevated BMI. 4. Cholecystectomy. 5. Anemia (likely thalassemia and anemia of chronic disease) 6. s/p Gastric bypass
MEDICATION ON ADMISSION: . Information was obtained from . 1. FoLIC Acid 1 mg PO DAILY 2. Lactulose 15 mL PO QID 3. Lorazepam 0.5 mg PO BID:PRN anxiety 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours Hold for K > 4.5 7. Sertraline 50 mg PO Q4:PRN pain 8. Rifaximin 550 mg PO BID 9. Spironolactone 50 mg PO DAILY 10. traZODONE 200 mg PO HS:PRN insomnia 11. Thiamine 100 mg PO DAILY
ALLERGIES: mold
PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
FAMILY HISTORY: The patient's father had what was appraently alcoholic cirrhosis. No family history of heart disease, early MI.
SOCIAL HISTORY: Lives with her mother in [**Name (NI) 5110**]. Alcohol excess with last sip of alcohol reportedly 5/[**2142**]. At most, drank 7+ alcoholic beverages a day for at least 10-plus years. Has a daughter, [**Name (NI) 20231**], who is 24 years old and is a good support system. Quit tobacco. | 0 |
95,242 | CHIEF COMPLAINT: angioedema
PRESENT ILLNESS: 43 y/o M with hx of HTN, recently admitted for HTN urgency with headaches as his symptoms, who presents today with angioedema. The day before his presentation, he was in the hospital and started on lisinopril and spironolactone. He had been taking an ACEi from his prior doctor and had been tolerating it well. During his admission, he had a CT head that was normal, a normal stress echo and a high TSH. His levothyroxine dose was increased and his BP meds were changed to spironolactone and lisinopril. He had been feeling fine until he woke up this morning with tight, swollen lips. He has had a sore throat, but no trouble swallowing, controlling his secretions. His tounge doesn't feel different. He has no stridor or wheezes. He has no chest pain. He did have a headache this morning, but it has improved. He has never had an allergic reaction like this before. . In the ED, initial vitals were T 98.2, P 68, BP 158/91, R 18 and 100% on RA. He was treated with solumedrol 125 mg IV x2, famotidine and benadryl. He was placed in observation but his lip swelling did not improve, so he was admitted to the ICU for further monitoring. . On arrival to the ICU, he is feeling well. He thinks his lips are less swollen that before. He does not have SOB, a tight throat, drool or further swelling.
MEDICAL HISTORY: Hypertension Pernicious anemia Hypothyroidism
MEDICATION ON ADMISSION: Lisinopril 20 mg daily Spironolactone 25 mg daily Levothyroxine 100 mcg daily ASA 81 mg daily B12 injection 1000 units q2week
ALLERGIES: Ace Inhibitors
PHYSICAL EXAM: Eyes / Conjunctiva: PERRL
FAMILY HISTORY: Mom with hypertension. There is no family history of premature coronary artery disease or sudden death. No fam hx of allergic rxs.
SOCIAL HISTORY: Originially from [**Country **], denies alcohol, drug and tobacco use. Student at BU in economics. | 0 |
29,941 | CHIEF COMPLAINT: Shortness of breath.
PRESENT ILLNESS: 79 yo M with SOB escalating over the past three weeks. Cath at outside hospital showed LM and 2VD and he was transferred for surgery.
MEDICAL HISTORY: COPD, asthma, CLL, DM, sleep apnea, MR, BPH, Afib, HTN, pulm HTN
MEDICATION ON ADMISSION: dilt 240", lipitor 10, finasteride 5, coumadin 5/2.5, lisinopril 20, HCTZ 25, lanoxin 0.25, metformin 500", claritin 10, albuterol , flovent, spiriva
ALLERGIES: Sulfa (Sulfonamides) / Penicillins
PHYSICAL EXAM: 5'9" 222# HR 68 RR 17 BP 129/56 NAD Left anterior chestwall port-o-cath Lungs CTAB Heart Irregular, 3/6 SEM Abdomen benign Extrem warm, no edema No varicosities
FAMILY HISTORY: mother deceased from MI father with MI 3 brothers with CABG 2 sisters with CABG
SOCIAL HISTORY: lives with wife approx 1 [**Name2 (NI) 5127**]/day denies current tobacco, 35 years of cigar/pipe | 0 |
76,830 | CHIEF COMPLAINT: Lower gastrointestinal bleed.
PRESENT ILLNESS: This is a 56 year old Greek female with a history of recurrent gastrointestinal bleeding, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease and other comorbidities, who presents from her nursing home with maroon stools times ten to fourteen days and bright red blood per rectum for the past two days. For the past ten to fourteen days, she has also had crampy intermittent lower left quadrant pain, nonexertional shortness of breath and moderate fatigue. Falling hematocrit necessitated transfusion of two units of packed red blood cells at [**Hospital6 13846**] Center where she has been living for four months. She denies the following: chest pain, syncope, nausea, vomiting, dysphagia, dysuria or hematuria. She also denies a history of peptic ulcer disease or gastroesophageal reflux disease. She does report swelling and erythema of her legs which has been unchanged for the past six months.
MEDICAL HISTORY: 1. Gastrointestinal bleeds as above. 2. Status post aortic valve replacement with a St. Jude valve in [**2113**]. 3. Congestive heart failure with transthoracic echocardiogram on [**2118-3-4**], showing normal left ventricular systolic function, inability to assess the ejection fraction due to irregular rhythm although an ejection fraction of 40% was shown on [**2117-8-25**]. Right ventricle was dilated with moderately reduced systolic function. Aortic valve prosthesis was well seated, no aortic insufficiency, 2+ mitral regurgitation, 3+ tricuspid regurgitation, pulmonary artery pressure 70 mmHg, mitral valve calcified at the commissures but mobile without stenosis, dilated inferior vena cava suggestive of elevated right heart diastolic pressures. 4. Coronary artery disease. The patient is status post percutaneous transluminal coronary angioplasty in [**2100**]. She is status post multiple myocardial infarctions. Cardiac catheterization on [**2117-8-25**], demonstrated 100% proximal right coronary artery stenosis with diffuse right coronary artery disease, not felt to repairable by angioplasty or bypass. Septal inferior artery with 60% occluded, obtuse marginal 60% occluded and the first diagonal 20% occluded. 5. Hypercholesterolemia. 6. Atrial fibrillation, status post pacemaker placement. 7. History of rheumatic fever. 8. Diabetes mellitus type 2. The patient is now requiring insulin. History of neuropathy and mild nephropathy. 9. Chronic obstructive pulmonary disease. She requires home oxygen at three liters since [**2112**]. 10. Klebsiella urinary tract infection in [**9-10**]. 11. Depression.
MEDICATION ON ADMISSION: 1. Albuterol, ipratropium nebulizers four times a day. 2. Aspirin 81 mg p.o. once daily. 3. Captopril 6.25 mg p.o. three times a day. 4. Digoxin 0.125 mg p.o. once daily. 5. Docusate 100 mg p.o. twice a day. 6. Furosemide 160 mg p.o. twice a day. 7. Gabapentin 100 mg p.o. q.h.s. 8. Metolazone 5 mg p.o. twice a day. 9. Metoprolol 12.5 mg p.o. twice a day. 10. Ocean Spray nasal spray two puffs each naris three times a day. 11. NPH insulin 26 units subcutaneous q.a.m., 6 units subcutaneous q.p.m. 12. Protonix 40 mg p.o. once daily. 13. Simvastatin 10 mg p.o. once daily. 14. Spironolactone 25 mg p.o. once daily. 15. Vitamin C 500 mg p.o. twice a day. 16. Warfarin 5 mg p.o. q.h.s. 17. Zinc Sulfate 220 mg p.o. twice a day.
ALLERGIES: No adverse reactions, no known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY: Mother with type 2 diabetes mellitus.
SOCIAL HISTORY: Two to three pack per day smoker since the age of 14, 70 to 100 pack years total. Quit six years ago. No alcohol use. Had lived at home with husband until four months ago when she moved to [**Hospital6 13846**] Center. | 0 |
96,399 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 55-year-old man with history of hemophilia A, transfusion related HIV, hepatitis B and C, and recent left frontal subdural hematoma in [**Month (only) 547**] of this year who presented to the Emergency Room on the day of admission after having had increasing headache over the prior few days. The headache reportedly began on [**2126-6-7**], although he had been feeling off-sorts over the previous few days. Initially, the headache was mild and generalized and persisted throughout the day prior to admission. When he awoke on the morning of admission, however, the headache was more severe and localized over the left temporal parietal region and accompanied by mild nausea. He thus presented to his Hematologist, Dr. [**First Name (STitle) **], on the day of admission. He was given factor 8 and subsequently had a level of 107, which was as expected. He was then sent to the Emergency Department for a STAT head CT in order to rule out an acute subdural hematoma.
MEDICAL HISTORY: 1. Hemophilia A or factor 8 deficiency treated with prn factor 8 infusions at home. He also has had repeated hemarthroses, status post bilateral total knee replacements and is on chronic opiate therapy for analgesia for the joint pains. 2. Transfusion related HIV. AIDS diagnosed in [**2117**], CD4 count 90 and viral load 8,000 in [**2126-3-31**]. Patient has been off his antiretroviral therapy because of severe side effects for the past several weeks by patient choice. 3. Transfusion related hepatitis B and C infection. 4. Acute left frontal subdural hematoma in [**2126-3-31**] with a history of presentation similar to the current one. 5. History of Achilles lengthening procedure.
MEDICATION ON ADMISSION:
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY: Significant for hemophilia. Brother also died of AIDS.
SOCIAL HISTORY: Lives with wife. Is a former computer analyst. Founded a international nonprofit organization. Denies alcohol, tobacco and prior intravenous drug use. | 0 |
30,750 | CHIEF COMPLAINT: sepsis, aspiration, altered mental status
PRESENT ILLNESS: Patient is an 82 year old portugese speaking male with recent L MCA CVA 2 weeks ago (d/c to [**Hospital1 **] on [**2180-1-25**]), PNA (treated with Unasyn/Zosyn last 2 days), hip fracture, osteomyelitis of left hip, delerium, aphasia who was vomiting x 2 days, shivering, depressed MS, hypoxic to 65, and he was transferred to [**Hospital 8**] Hospital. On arrival to [**Hospital1 8**] vitals were 103.2, 148, 85/41 (all subsequent ones demonstrated HTN), 42, 83% - placed on nonrebreather with little improvement and was found to be tachypneic with labored breathing and was intubated (received versed, lidocaine, rocuronium). Also received cipro 400 mg IV x 1, Vanc 1 g IV x 1, cefepime 2g IV x 1, 2L NS. Noted to have facial movement and with history of left MCA infarct 2 weeks prior patient had CT head which showed hemorrhagic conversion of left MCA infarct. No neurosurgery on call at [**Hospital1 8**] and was therefore transferred for further management. . Upon arrival to [**Hospital1 18**] vitals were 102.3, 129, 129/54, 22, 97% on Ac 500/16/1%/5. Lactate elevated at 6 and code sepsis called. Right IJ sepsis line placed, 3L NS administered, and ativan 1mg given. Transferred to ICU for further management. Patient intubated and unresponsive, unable to obtain further history upon arrival.
MEDICAL HISTORY: # CVA - Presented on [**1-19**] with 2wks MS changes, slurred speech - found to have CVA in left temporal region by CT on [**1-21**] (no TPA). - no paralysis, able to move arms and legs, unable to feed himself, working on getting him up at [**Hospital1 **], follows commands - memory loss/aphagia - nml carotid U/S in [**12-28**] - improved motor to [**5-27**] in UE - intermittent fevers, LP pending with VDRL, HSV, AFB, fungal cx pending at time of transfer to [**Hospital1 **] # Seizures - Developed after recent CVA, controlled with valium and phenytoin # HTN - was on Atenolol, Lisinopril, HCTZ prior to CVA, on hold since # PNA # Sepsis # L hip fracture s/p open reduction/internal fixation in [**2143**] with ongoing drainage - wound + for staph aureus and staph epi in past # Osteomyelitis of left hip [**4-/2179**] (had continuous drainage from hip since [**2143**]'s) # stress MIBI was neg in [**2174**]
MEDICATION ON ADMISSION: Aspirin 325 QD Dilantin 300 PO QD Pravastatin 20 QD Bacitracin oint Dalteparin/Fragmin 5000 units SQ QD Colace Fluoxetine 20 QD MVI Pantoprazole 40 QD Acet prn, Bisacodyl prn, Zofran prn, Compazine prn
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Vitals: 101.4, 122, 112/52, 40, 98% Vent: AC 500/16/0.7/5, PIP 20, ABG 7.31/35/268 (on FiO2 100%) HEENT: PERRL, left ovaloid, unable to assess EOM, anicteric sclera, OP clear Neck: supple, no LAD, no JVD Cardiac: tachy, regular, NL S1 and S2, no MRGs Lungs: CTAB anteriorly with course upper airway sounds Abd: soft, NTND, NABS, no HSM, no rebound or guarding Skin: Erythema overlying left hip, dimples, one of which is draining Ext: warm, 1+ right DP pulse, 2+ left PT pulse, no C/C/E Neuro: sedated, toes equivaqual, not moving . By discharge, patient was extubated, alert, moving all four extremiteis well, speaking occasional words, following commands
FAMILY HISTORY: Mother died of CVA suddenly
SOCIAL HISTORY: Patient was previously fully independent prior to CVA. No ETOH, no tobacco. 2 sons, 2 daughters (one in [**Name (NI) 6257**]). | 0 |
30,827 | CHIEF COMPLAINT: Chest Pain
PRESENT ILLNESS: 57 yo w/ multiple cardiac risk factors who was c/o exertional chest pain (progressively worsening) along with fatigue and occ. shortness of breath. He had an abnormal EKG during ETT. Underwent cardiac cath which revealed severe Aortic Stenosis and clean coronaries. Referred for surgery.
MEDICAL HISTORY: Hypercholesterolemia, Hypertension, Diabetes Mellitus, Degenerative Joint Disease(rt knee)
MEDICATION ON ADMISSION: Zetia 10mg qd, Glucophage 850mg [**Hospital1 **], Univasc 7.5mg qd, Aspirin, Atenolol 25mg qd
ALLERGIES: Lipitor
PHYSICAL EXAM: General: WD/WN male in NAD HEENT: PERRLA, EOMI, NCAT, OP benign Chest: clear bilaterally Heart: RRR with 4/6 systolic murmr Abdomen soft, NT/ND +BS Extremities warm/well-perfused, -edema/varicosities Neuro: A&O x 3, non-focal, MAE
FAMILY HISTORY: Noncontributory
SOCIAL HISTORY: Lives w/ wife and child. Occupation- scaffolding. Occasionally smokes a cigar. | 0 |
59,825 | CHIEF COMPLAINT: Palpitations.
PRESENT ILLNESS: Mrs. [**Known lastname 93688**] is a 53-year-old woman with a history of hypertension, coronary artery [**2180**], status post cath times two at [**Hospital6 **]. Her cath in [**2180**] after her inferior wall myocardial infarction showed 100% RCA occlusion and in [**2188**] which per the patient was [**Last Name **] problem. The patient had been asymptomatic until 1 a.m. on the day prior to admission when she started to experience palpitations and left shoulder pain radiating to her chest. She went to [**First Name (Titles) 4527**] [**Last Name (Titles) 93689**] ventricular tachycardia at a rate of 170 beats per minute with an axis of approximately 120 degrees. She was hemodynamically stable and maintaining well at this time. She was initially bolused with Amio 150 mg IV and then started on an Amio drip without effect on the rhythm. She was then DC cardioverted with 100 joules which converted her to normal sinus rhythm. An EKG after cardioversion revealed that she had inferior ST elevations with reciprocal ST depressions in leads 1 and AVL. The chest pain resolved with conversion to normal sinus rhythm. She was transferred to [**Hospital1 69**] for further management.
MEDICAL HISTORY: 1) Coronary artery disease as above. She had a TEE in 3/99 which showed mild LVH, severe hypokinesis and akinesis of the mid and inferior septum, interventricular septum and inferior posterior walls from base to apex. Her distal septum and anterior apex were hypokinetic to akinetic. Ejection fraction was 35%. She had normal RV function. ETT thallium in [**2184**] was negative. 2) History of CVA. 3) Hypertension.
MEDICATION ON ADMISSION:
ALLERGIES: Contrast dye and Heparin.
PHYSICAL EXAM:
FAMILY HISTORY: Father had an MI at age of 67.
SOCIAL HISTORY: She is a teacher. She is married and has one daughter. She has a 12?????? pack year history of tobacco use. She quit [**Numeric Identifier 93690**]. She occasionally drinks alcohol. | 0 |
29,536 | CHIEF COMPLAINT: abdominal pain, diarrhea, vomiting
PRESENT ILLNESS: 70 yo M PMH HTN,s/p radical prostatectomy, s/p pacemaker who presented to an OSH early this am with severe abdominal pain, diarrhea, nausea and vomiting. Per his wife, symptoms began on [**Name (NI) 766**] evening. Pt was passing multiple loose brown stools at home. Some stools may have been black. He was also vomiting and complaining of severe abd tenderness. She does not believe he had fevers or chills. At the OSH he was hypothermic to 96.6 and hypotensive to 48/15. RR was 24-30. Admission labs were notable for metabolic acidosis, ABG 7.14/32/56/10.9. CEs were elevated. Creatinine also elevated at 2.7. CT ABD showed fluid throughout the colon. Given tender abdomen there was concern for ischemic bowel. Pt was transferred to the ICU where he was started on dopamine and a bicarbonate gtt. He was transferred to [**Hospital1 18**] MICU for additional work-up. . En route pt's MAPs maintained in the 70's on max dose levophed and neosynephrine. . Review of systems: unable to obtain
MEDICAL HISTORY: h/o prostate cancer dysplipidemia BPH s/p pacemaker for syncopal episode htn spinal stenosis, s/p spinal fusion s/p ccy
MEDICATION ON ADMISSION: Fosamax 70mg weekly Detrol 4mg daily Lopid 600mg [**Hospital1 **] Tofranil 10mg daily Home medications: Lipitor 80mg daily Paxil 30mg daily Trazadone 50mg qHS Zetia 10mg daily Flexeril 10mg TID Prilosec 20mg daily Caltrate-VitD Vitamin C ASA 325mg daily Lupron Inj every 3 weeks
ALLERGIES: Celebrex
PHYSICAL EXAM: Tmax: 36.3 ??????C (97.3 ??????F) Tcurrent: 36.3 ??????C (97.3 ??????F) HR: 95 (93 - 99) bpm BP: 110/69(85) {86/63(-16) - 112/78(127)} mmHg RR: 11 (11 - 28) insp/min SpO2: 100%
FAMILY HISTORY: unknown
SOCIAL HISTORY: - Tobacco: quit many years ago - Alcohol: occasional - Illicits: none | 1 |
9,831 | CHIEF COMPLAINT: chest pressure
PRESENT ILLNESS: 81 year old female who was recently admitted [**Date range (2) 31773**] after she presented with chest pain and developed new onset atrial fibrillation. She was started on amiodarone but declined cardioversion, and spontaneously converted back into sinus rhythm prior to discharge. TEE that admission showed severe aortic stenosis, with valve area 0.8-1cm. On [**2128-2-9**], her son called the cardiology office to report that his mother had an episode of atrial fibrillation with rates up to 110-120. She had taken atenololas directed and converted back to sinus later that day. She presented to the ED [**2128-2-13**] with epistaxsis; her INR was 6.7 and she was disharged home with coumadin on hold and returned for cardiac catherization for preoperative evaluation.
MEDICAL HISTORY: Aortic Stenosis Atrial fibrillation Rheumatoid arthritis Hypertension Hypercholesterolemia PMR History of DVT COPD Hyperthyroidism Osteopenia Large ventral hernia Hearing loss C-Section x 3 Ventral hernia repair x 2
MEDICATION ON ADMISSION: AMIODARONE - 200 mg Tablet - 2 Tablet(s) by mouth DAILY (Daily) BUPROPION HCL [BUDEPRION SR] - 150 mg Tablet Extended Release - 1 Tablet(s) by mouth once a day for 3 days and then twice a day there after HYDROXYCHLOROQUINE [PLAQUENIL] - 200 mg Tablet - 1 (One) Tablet(s) by mouth twice a day PRAVASTATIN [PRAVACHOL] - 20 mg Tablet - 1 Tablet(s) by mouth once a day WARFARIN - 2.5 mg Tablet - 1 Tablet(s) by mouth Once Daily at 4 PM ASPIRIN - (OTC) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth once a day CALCARB 600 - 600 mg (1,500 mg) Tablet - 1 (One) Tablet(s) by mouth twice a day ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 1,000 unit Tablet - 1 Tablet(s) by mouth daily MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - Tablet - 1 (One) Tablet(s) by mouth daily OMEGA-3 FATTY ACIDS [FISH OIL] - (OTC) - 1,000 mg Capsule - once a day
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Pulse: AF 98 Resp: 20 O2 sat: 96% B/P Right: 122/72 Left: 141/71 Height: Weight:
FAMILY HISTORY: Mother died of a ruptured AAA at age 70. Father died of leukemia. No family history of premature coronary artery disease, unexplained heart failure, or sudden death.
SOCIAL HISTORY: Lives with: Husband Occupation: Retired Tobacco:+Tobacco abuse - 1 pack per day since [**2062**] ETOH: no history of drug or alcohol abuse | 0 |
45,883 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 60-year-old man with a history of chest pain since 7/[**2188**]. The patient had a cardiac catheterization, which showed a high-grade LAD lesion.
MEDICAL HISTORY: 1. Abdominal aortic aneurysm approximately 2.9 cm. 2. Hypertension. 3. Gastroesophageal reflux disease. 4. Hypercholesterolemia.
MEDICATION ON ADMISSION:
ALLERGIES: The patient is allergic to AMOXICILLIN, which gives him a rash.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
65,071 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 45-year-old woman who presents for operation of bilateral total mastectomies with immediate breast reconstruction using autologous tissue, in essence free TRAM flap.
MEDICAL HISTORY: The patient's past medical history is consistent with intraductal carcinoma diagnosed by open surgical biopsy on [**2176-8-6**]. Patient had a 1.5 cm grade 2 lesion. Patient has an ER/PR positive tumor that was HER- 2/neu negative. There were 0/9 nodes involved. Patient received dose-dense chemotherapy x4. The patient's past medical history is consistent with asthma, 3 Staph. infections.
MEDICATION ON ADMISSION:
ALLERGIES: Patient is allergic to CT scan dye, possibly latex, and possibly tape.
PHYSICAL EXAM:
FAMILY HISTORY: Is consistent with lung cancer.
SOCIAL HISTORY: The patient is married. She is a kindergarten teacher. She does not smoke cigarettes. She drinks alcohol rarely. | 0 |
36,021 | CHIEF COMPLAINT: Right cerebellar hemorrhage
PRESENT ILLNESS: This is a 73 year old man with hypertension and vascular disease transferred from [**Hospital3 417**] Hospital with reported cerebellar hemorrhage. He reportedly was brought to the OSH after developing nausea, vomiting, and diaphoresis at his apartment complex. He arrived complaining of a [**10-25**] headache; the nursing notes says he was awake and speaking and denied CP/SOB on arrival. He was markedly hypertensive on arrival -- BP was recorded initially as 232/132 (VS otherwise unremarkable). CBC and coags were normal (INR 0.9 and no known h/o A/C); BMP was pending. ECG remarkable for obvious LVH (voltage criteria) and ?RBBB (RSR' in III), with NSR. He was given Zofran and labetalol, and when his systolics remained elevated in the 200s, he was started on a nitroprusside drip. He was taken for NCHCT, which showed a 3cm Right cerebellar hemorrhage. At some point during this initial evaluation, he became acutely non-responsive, so he was intubated (induced with etomodate and succinylcholine, also fentanyl) and Med-Flighted here to [**Hospital1 18**]. He was continued on the Nipride gtt en route, and paralyzed for transport using rocuronium and propofol gtt. He arrived here around 21:30 with BP 267/131, down to 168/96 with increased nitroprusside gtt rate. He was flaccid (paralyzed). The ED resident informed me that someone had commented on "asymmetric pupils" at some point, but the [**Location (un) **] personell said that his pupils were 2mm and equal the entire trip (they were this size of smaller, non-reactive, on my arrival to the ED a few minutes after his arrival).
MEDICAL HISTORY: 1. Hypertension 2. Renal artery stenosis 3. AAA endovascular repair c/b R ext iliac pseudoaneurysm, also s/p repair [**2195**] 4. Peripheral vascular disease 5. Nephrolithiasis 6. Hyperlipidemia 7. COPD
MEDICATION ON ADMISSION: 1. Plavix 2. simvastatin 3. amlodipine 4. labetatlol 5. lisinopril 6. Cardura (doxazosin) 7. Percocet 8. Ambien 9. Atrovent 10. Advair 11. Miralax 12. colace 13. vitamin C
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: On admission: Mental Status: Sedated / non-responsive. Does not blink or track. Later, as paralytic lifted, he grimaced inconsistently to noxious stimulation and spontaneously moved his Right shoulder and both legs.
FAMILY HISTORY: non-contributory
SOCIAL HISTORY: Lives alone, ex wife lives in U.S. but the rest of extended family resides in [**Country 1684**]. He is primarily arabic speaking, but understands some English. no tobacco. | 0 |
37,200 | CHIEF COMPLAINT: Ascending aortic aneurysm, bicuspid aortic valve
PRESENT ILLNESS: This 59 year old male with a known ascending aneruysm for at least 7 years, followed by serial echocardiograms. His last echo revealed a 5cm dilated root with a probable bicuspid valve and moderate aortic insufficiency. He had a negative stress echo and catheterization revealed no significant coronary disease. He was admitted for elective surgery.
MEDICAL HISTORY: thoracic ascending aneurysm depression vertigo paroxysmal atrial fibrillation
MEDICATION ON ADMISSION: Medications - Prescription BUPROPION HCL [WELLBUTRIN SR] - (Prescribed by Other Provider) - 150 mg Tablet Sustained Release - 1 Tablet(s) by mouth once a day ESCITALOPRAM [LEXAPRO] - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: HR 54 BP 122/75 RR 18 SAT 99% Physical Exam- General: WDWN in NAD Cardiac: RRR with Quiet [**12-16**] diastolic murmur Chest: Lungs clear bilateral [X] Abdomen: Soft [X] Nontender [X] Nondistended [X] Extremities: Warm [X] Well perfused [X] Edema: None
FAMILY HISTORY: father had aneurysm sx in his 80s(? type)
SOCIAL HISTORY: self employed/actor 20pk year history, stopped [**2166**] bottle of wine /week demntal exam <6 months | 0 |
40,140 | CHIEF COMPLAINT: Liver Mass 9cm
PRESENT ILLNESS: The patient is a 79-year- old male with a h/o alcoholic cirrhosis who was noted to have abnormal liver function tests and an ultrasound demonstrated a 14 x 11 x 10 cm mass in the right lobe occupying segment 6, 7 , 8 consistent with hepatocellular carcinoma. He has had a prior cholecystectomy. A CT scan of the chest and abdomen demonstrated no evidence of pulmonary metastases. The abdominal CT demonstrated a mass occupying segment 6, 7 and 8 measuring 13 x 10.4 cm. There was no involvement of the medial segment of the left lateral segment. The liver appeared to be cirrhotic. The spleen was not enlarged and there was no evidence of portal hypertension. At time of operation, he had a large mass occupying segment 6, 7 and 8 as noted on preoperative CT scan. IUS demonstrated the mass was approx 8 mm from the middle hepatic vein. There was no tumor in the left lobe of the liver. Therefore, Right hepatic lobectomy was performed on [**2189-6-25**].
MEDICAL HISTORY: PMH: HTN, DMt2, DJD, EtOH-induced cirrhosis, fatty liver
MEDICATION ON ADMISSION: pioglitazone 15', nifedipine CR 30', metoprolol 25', metformin 500", vit D2 50K qweek, Lidocaine patch
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: [**2189-6-30**] T 34.0 C BP 79/45 HR 76 RR 24 O2Sat 99% CMV FiO2 80% Gen: Intubated and currently undergoing cooling protocol including EEG. HEENT: Significant scleral edema bilaterally. CV: RRR, no murmurs/gallops/rubs Lung: Clear anteriorly Abd: Well healing scar over the liver - distended but soft. Ext: 2+ edema
FAMILY HISTORY: non-contributory
SOCIAL HISTORY: SH: Lives at home - retired farmer and originally from [**Country 651**]. Hx of EtOH abuse. | 1 |
85,319 | CHIEF COMPLAINT: lethargy
PRESENT ILLNESS: 44-year-old female with collagenous colitis/Crohn's disease presented to ER with fatigue and fever to 101.7 F at home after having had her Hickman (X 18 hrs) repaired the previous day. In the ED, temp 103 F, bp 142/69; bp dropped to 96/35. She received vanco/Cefipime for presumed lung infection and 2L NS. She was admitted to the [**Hospital Unit Name 153**], covered with vanco/cefapime until cx grew coag negative staph, switched to vanco. Volume resuscitated with stabilization of bp in 110s. ICU course also notable for d/c coumadin (had completed 6 mos course for prior PE), hyponatremia (resolving with fluid resuscitation), anemia (HCT dropped to 19.8) for which she received 1unit PRBC, and facial/neck swelling (chronic in the setting of venous stenosis from multiple prior line placements. IR and surgery consulted, goal is to preserve Hickman. Currently, the patient reports generalized myalgias, occasional lightheadedness. She denies fevers/chills . ROS: No weight loss. (+) fatigue/malaise. No chills, night sweats, loss of vision. (+) dry mouth. No sinus pain, sore throat, chest pain, palpitations. (+) chronic LE edema and DOE. No current shortness of breath or hemptoysis. (+) dry cough this a.m. No nausea, vomiting. (+) chronic RUQ/RLQ abdominal pain, unchanged from baseline. (+) diarrhea, [**6-2**] BM/day, at baseline, no melena or hematochezia. No bleeding, lymphadenopathy, dysuria, hematuria, increased urinary frequency/urgency, rash. (+) loss of energy. (+0 myalgias/arthralgias. No numbness/tingling, headache. (+) chronic LBP, no change from baseline.
MEDICAL HISTORY: 1) Crohn's disease (dx [**2122**], on MTX/Remicaide, baseline [**11-7**] BM's per day), s/p colectomy [**1-25**], reanastamosis (ileo-rectal) [**6-25**], h/o collagenous colitis 2) Crohn's arthropathy (seronegative) 3) GERD 4) Raynaud's 5) Depression/Anxiety 6) Migraine HA's 7) Iron Def Anemia 8) MSSA line infxn [**8-27**] 9) Burkholderia bacteremia [**9-27**] and [**10-27**] 10) Chronic Hickman Catheter for IVF 11) SVC syndrome, Left IJ and Left Subclavian stenosis s/p angioplasty in [**4-28**] 12) hx of left exudative pleural effusion of unclear etiology h/o VATS~[**2123**] - for left exudative pleural effusion around time of #7 13) hx of left pneumothorax due to porta-cath placement 14)left knee arthroscopy 15)Schatzki's ring-noted on EGD 16) h/o post menopausal vaginal bleeding 17) oral hsv
MEDICATION ON ADMISSION: 1. Advair one puff b.i.d. 2. Albuterol p.r.n. 3. Pentasa 1 gm t.i.d. 4. Klonopin 1 mg q.i.d. 5. Protonix 40 mg b.i.d. 6. Amitriptyline 50 mg q.h.s. 7. Methadone 10 mcg/mL, 3 mL or 30 mg q.i.d. 8. Dilaudid 8 mg one to two tablets every four hours p.r.n. pain. 9. Weekly methotrexate (q [**Name Initial (PRE) 766**]). 10. Folate supplements. 11. Niferex 150 twice a day. 12. Coumadin 7.5 mg 4x/wk, 5 mg 3x/wk. .
ALLERGIES: Bactrim / Sulfonamides / Morphine / Shellfish
PHYSICAL EXAM: PE: Tc 98.5, pc 91, bpc 96/64, pc 91, resp 16, 96% RA Gen: chronically-ill appearing elderly female, A&OX3, NAD HEENT: anicteric, pale conjunctiva, OMM dry, OP clear, neck supple, no LAD. (+) generalized neck swelling w/o cords palpated Cardiac: RRR, II/VI SM at LSB Pulm: CTA bilaterally Chest: Hickman catheter with minimal erythema at opening, non-tender Abd: NABS, moderately distended, tympanitic, mod RLQ/LLQ tenderness without rebound or guarding Ext: trace LE edema at ankles bilaterally, warm, 2+ DP bilaterally Neuro: CN II-XII grossly intact and symmetric bilaterally, [**5-28**] strength throughout with encouragement, sensation intact to light touch proximally and distally in upper and lower extremities bilaterally.
FAMILY HISTORY: Father has polycythemia, mother has melanoma.
SOCIAL HISTORY: The pt lives in [**Location 246**] with her husband and two children, She does not work, She smokes 0.5-1ppd x 20 yrs, She drinks [**1-26**] beers/day | 0 |
54,945 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 65-year-old who presented to [**Hospital6 256**] Emergency Department with coffee ground emesis times three the night prior to admission. The patient reported a two week history of right lower quadrant and left lower quadrant abdominal pain. The pain was a constant, colicky pain that kept the patient up at night and the pain could not be relieved by either position or medication. The patient one episode of melena in the Emergency Department. He also denied any recent change in bowel habits, recent nausea, hematuria, or dysuria. Of note was that the history was limited due to the patient being on a tracheostomy tube with limited verbal responses.
MEDICAL HISTORY: The previous medical history is significant for coronary artery disease status post myocardial infarction in [**2199-5-21**], left ventricular ejection fraction was 60% with pulmonary hypertension; atrial fibrillation; chronic obstructive pulmonary disease, steroid and oxygen dependent; multiple pneumonias, Methicillin resistant Staphylococcus aureus, fluoroquinolone resistant Klebsiella, and Pseudomonas; status post cerebrovascular accident with left hemiparesis secondary to right cerebral CVA; left iliopsoas bleed on Heparin; abdominal aortic aneurysm, 5 cm and stable; multiple GI bleeds; gastroesophageal reflux disease; diverticulosis; history of C. difficile colitis; facial trauma with multiple fractures; Zenker's diverticulum; cataracts, status post right eye cataract surgery; status post multiple falls.
MEDICATION ON ADMISSION: ASA 81 mg q. day, Heparin 5000 units subq. b.i.d., Verapamil 40 mg q. 8 hours, Isordil 10 mg t.i.d., Digoxin 0.125 mg q. day, Albuterol nebulizers q. 4 hours, Atrovent nebulizers q. 4 hours, Prednisone 7.5 mg q. day, Flovent metered dose inhaler 220 mcg 2 puffs b.i.d., Combivent, Celexa 40 mg q. day, Ativan 0.5 mg q.h.s., Tums one tablet q. 8 hours, Dulcolax suppositories, Lactulose, and fiber source via G-tube feeds.
ALLERGIES: The patient is allergic to IV contrast dye. He is also allergic to strawberries.
PHYSICAL EXAM:
FAMILY HISTORY: The patient's mother had coronary artery disease.
SOCIAL HISTORY: The patient lives alone in the [**Hospital 2670**] Nursing Home. | 0 |
38,291 | CHIEF COMPLAINT: New diagnosis ALL
PRESENT ILLNESS: HPI: 51M with HTN, CAD s/p stenting [**2123**], HTN who presented with shortness of breath and new leukocytosis to 199k with 88% blasts. He was in his USOH until 2weeks ago when he began to develop increased DOE and worsening exercise tolerance with occassional chest pressure. He continued to work and today he developed near syncopal symptoms while raking at work. EMS was called and he was taken to [**Hospital1 34**] where he was found to have new WBC to 199k, HCT 28.5, PLT 33k with reported 2% polys and 85% blasts. Fibrinogen was 354, INR 1.4, Cr 1.4. Cardiac biomarkers were negative and his EKG was unchanged from prior. He was seen by Dr. [**First Name8 (NamePattern2) 2855**] [**Last Name (NamePattern1) **] from [**Doctor Last Name **] hematology and started in hydroxyurea 2gm and allopurinol. He was transferred to [**Hospital1 18**] for further management. . In the ED inital vitals were, 98.1 139/79 62 98 RA. He had a pheresis line and picc placed. On admission, he was fatigued but otherwise well. No SOB/DOE or chest pressure at rest. No HA, N/V or dizziness. He denies easy bruising or bleeding and specifically denies dark tarry stools, gum bleeding, hematuria. No fevers, chills or night sweats. Sent to IR for pheresis catheter and PICC placement. . Patient was transferred to the [**Hospital Unit Name 153**] overnight where he received high volume IVFs, plasmapheresis, rasburicase 6mg IV for a uric acid of 11 and 1 unit of PRBCs for a hct of 21.4. AM labs showed Hct 23.1, platelet count of 18, WBC 88.5, K+ 3.7, Ca+ 8.2, Phos 4.4, uric acid 4.4, BUN 18, Cr 0.8. . This morning in the [**Hospital Unit Name 153**], patient had a bone marrow biopsy and a TTE showing an EF>55%. He received hydroxyurea 3000mg PO, dexamethasone 20mg PO, 1 unit of platelets. Patient received a total of 3L of fluid going at 200ml/hr. Repeat plts 43, hct 25.1, WBC 109.7, uric acid 3.2. . On transfer to the floor, the patient is stable. VS are T 98.6, BP 120/60, HR 52, RR 20, Satting 97% RA. No complaints.
MEDICAL HISTORY: 1. NIDDM2 on Metformin/Glyburide 2. HTN 3. Hyperlipidemia 4. Hypothyroidism 5. Cervical DJD/OA 6. CAD s/p stenting x1 in [**2123**] by Dr. [**First Name4 (NamePattern1) **] [**Known firstname 8467**]. The patient had followed with him but not in the past several years. The patient's last exercise treadmill test was in [**2127**] and it was non-diagnostic. 7. S/P CCK in [**2127**] 8. Psoriasis controlled with topicals in past, had tried PUVA in past several years ago
MEDICATION ON ADMISSION: Metformin, 1000 g in the morning and 500 mg in the evening glyburide 5 mg b.i.d. simvastatin 20 mg daily enteric-coated aspirin 325 mg daily lisinopril 10 mg daily levothyroxine 0.1 mg one tablet MTWTh, 2 tablets FSaSu
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: ADMISSION EXAM: GEN: well appearing white male HEENT: Pupils equal round and reactive, extraocular movements intact, oropharynx clear w/o lesions or petechiae, good dentition 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: obese, soft, non-tender, non-distended, +Bowel sounds, no fluid wave or bulging flanks, no CVAT, no hepatosplenomgaly LYMPH: no cervical, axillary or inguinal LAD EXT: warm, well perfused, no cyanosis/clubbing/edema, no open lesions SKIN: multiple large psoriatic plaques on trunk as well as confluent on much of his bilateral lower extremities, no evidence of superficial infection. NEURO: AOx3, CN2-12 intact, 5/5 strength in all extremities, grossly normal sensation, gait not assessed. LINES: PICC line and pheresis line are c/d/i without bleeding or drainage
FAMILY HISTORY: No known hematologic malignancies, +HTN
SOCIAL HISTORY: Living/Support: He is married and lives with his wife, they have 2 children ages 19 (daughter in nursing school) and son 14 Work/Income: He runs the park/rec dept in [**Last Name (un) 33487**], MA and works part time at [**Company **]. EtOH: Very rare Tobacco: Never Illicits: denies, no h/o IVDU Diet/Exercise: No regular exercise, tries to follow cardiac/diabetic diet Hobbies: Family Travel: NONE Pets: 1 cat | 0 |
9,620 | CHIEF COMPLAINT: shortness of breath, increasing oxygen requirement
PRESENT ILLNESS: 67 y/o female with metastatic breast ca (mets to liver, lung, and possibly cavernus sinus) on ongoing weekly paclitaxel, presented with persistent fevers. On [**2104-9-16**] patient began her cycle 2 day 1 of paclitaxel. On that day she was found to have a fever of 100.9. Her only symptom was generalized achiness. At that time CXR was negative, as were blood cultures. Her urinalysis showed 6 WBCs and few bacteria. She was treated empirically with ciprofloxacin for a possible UTI x 1 week. . Fevers continued with development of URI symptoms, myalgias, non-productive cough. She was admitted to [**Hospital1 18**] on [**9-24**]. CXR on [**9-24**] showed no acute cardiopulmonary process. CXR on [**9-25**] showed mild asymmetry in the upper zones with some suggested increased opacification on the right. . Of note, her WBC has trended down to 1.6 in setting of recent chemotherapy and reaching nadir. Vancomycin, Cefepime, and Azithromycin were started on [**2104-9-25**]. . On the floor, patient triggered twice for increased respiratory rate into the high 20s and low 30s. Her oxygen requirement has risen from 98% on 2L NC to 88-90% on [**4-17**] L NC overnight. Her ABG was 7.43/40/62 on 5L NC. CTA is read as atypical infiltrate versus diffuse lymphangitic carcinomatosis resulting in congestion of the lung parenchyma. Oseltamivir 75 mg PO/NG [**Hospital1 **] was added on [**9-26**], ID was consulted, and ICU admission was requested for increasing oxygen requirement and request for bronchoscopy with biopsy - question is whether this pulmonary process is indeed lymphomatous spread or simply atypical infection. . Of note, patient has been on intermittent decadron doses since cyperknife treatment (last dose 5 days ago). . Prior to transfer, patient was hemodynamically stable. O2 reported as 80% on 4L NC and 90% on 6L NC. . On arrival to the ICU the patient reported that she was working somewhat more than usual to breath. She denied pain anywhere or any other complaints.
MEDICAL HISTORY: # Metastatic breast cancer: - [**2098**]: a mass was found in her left breast on mammogram - [**2099-4-23**]: lumpectomy. Pathology showed invasive ductal carcinoma, ER positive but Her2 negative. - [**Date range (1) 104395**]: received chest irradiation followed by adjuvant endocrine therapy on protocol MA27 with exemestine. She continued on exemestine until [**2102-3-17**] when a chest X-ray showed a 4 mm mass in her left lung and biopsy by Dr. [**First Name (STitle) **] [**Doctor Last Name **] showed metastatic breast carcinoma. - [**Date range (2) 104396**]: received capecitabine - [**8-/2103**]: chemotherapy was switched to liposomal doxorubicin because of progressive lung metastases. She continued on liposomal doxorubicin until she again had progressive disease and was started on paclitaxel. - [**2104-8-5**]: PET showed FDG-avid disease in her lungs and possbily the liver. - early [**2104-7-13**]: she experienced increased, but mild, headache frequency. She experienced blurry vision in OS that lasted for seconds upon awakening in a.m. MRI showed Meckel's cave enhancing mass. This was felt to be possible brain met vs. unresectable meningioma. She was treated with CyberKnife which she completed on [**2104-8-29**]. She was on dexamethasone during her cyberknife treatments. . OTHER MEDICAL HISTORY: Hypertension Hypercholesterolemia TAH-BSO for fibroids.
MEDICATION ON ADMISSION: atenolol 50 mg daily chlorhexidine mouthwash ciprofloxacin 500 mg [**Hospital1 **] esomeprazole 40 mg [**Hospital1 **] ibandronate 150 mg monthly levothyroxine 75 mcg daily lisinopril 5 mg daily lorazepam 0.5-1 mg q6h prn nausea, insomnia simvastatin 20 mg daily aspirin 81 mg daily calcium-vitamin D3 630 mg-400 units daily cholecalciferol 1000 units daily MVI omega-3 fatty acids
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: GEN: Alert in NAD HEENT: EOMI, PERRL, neck supple, MMM, no thrush/exudate LUNG: Fine right sided crackles, no wheezes or rhonchi CV: RRR, S1+S2, no M/R/G ABD: +BS, NT/ND EXT: no edema, no rash, 2+ pedal pulses NEURO: CN II-XII without focal deficit
FAMILY HISTORY: Her mother has hypertension and hypercholesterolemia. Her father died at age 81 from pancreatic cancer. Brothers have hypertension and hypercholesterolemia. Daughter had [**Name2 (NI) 500**] allograft after resection of a right radius giant cell tumor.
SOCIAL HISTORY: Retired. Smoked less than 1 pack of cigarettes per day for 10 years before quitting in [**2077**]. Zero to 3 alcoholic drinks per week. No illicit drugs | 0 |
98,537 | CHIEF COMPLAINT: Dyspnea
PRESENT ILLNESS: 85F with critical Aortic Stenosis, diastolic Heart Failure, and Coronary Artery Disease who presented with dyspnea since [**2-25**]. She had been symptomatic from her aortic stenosis with dyspnea at rest, worse with exertion for the past several months. She also experiences angina with any exertion and had 1 syncopal episode 2 months ago in setting of NTG use. Pt developed shortness of breath last night, similar to her usual dyspnea, worsened overnight. In am she called EMS who found her to be tachypneic to the 30s, with 02 sats in the 70s. She was placed on a NRB with increase in 02 to 90s, BP was initally elevated to systolic 180. She was noted to have crackles throughout her lung fields on exam and was given 60mg IV lasix as well as a NTG tab in the field. On arrival her VS 97.7 65 135/52 100% (bipap) crackles were persistently appreciated and she was placed on BiPAP. She was given 1 full dose ASA. Had a CXR which showed low lung volumes, b/l effusions and pulmonary edema. ECG showed no change from prior. Labs notable for negative cardiac enzymes, normal CBC and renal function, normal electrolytes, lactate 2.7. On BiPAP her RR decreased to 18, BP stabilized at 90-110s. UOP >700cc. At time of transfer her VS: Afebrile 63 96/45 19 97% 40% Fi02 on [**5-20**].
MEDICAL HISTORY: Coronary Artery Disease, totally occluded RCA Severe calcific AS Diet controlled diabetes Hypertension Dyslipidemia Nonalcoholic steatohepatitis GERD diastolic and systolic dysfunction cholelithiasis umbilical/ventral hernia s/p b/l cateract surgery
MEDICATION ON ADMISSION: Aspirin 162 mg daily, Diltiazem 240 mg daily, Aricept 10 mg daily, Toprol 25 mg daily, Lipitor 10 mg daily, Enalapril 2.5 mg daily, Effexor 75 mg daily, Clonazepam 0.5 mg p.r.n, Prilosec 40 mg daily, russian herbal drops for chest pain
ALLERGIES: Pneumovax 23
PHYSICAL EXAM: VS: 98.4 67 122/66 17 96% 4L NC GENERAL: Elderly woman, NAD. Resting comfortably on NC. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. MMM. NECK: Supple with JVP of 12cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Regular rate and rhythm. 2/6 systolic murmur, loudest over right upper sternal border. No S2. + intermittent S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Minimal bibasilar crackles. ABDOMEN: Soft, NTND. No HSM or tenderness. + ventral hernia. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right:DP 2+ PT 2+ Left: DP 2+ PT 2+
FAMILY HISTORY: No family history of early MI, otherwise non-contributory.
SOCIAL HISTORY: She denies history of tobacco and alcohol. She currently lives alone, is widowed. Her sister lives in the same building. Her graddaughter lives close by, is HCP | 0 |
63,557 | CHIEF COMPLAINT: Fever, chills
PRESENT ILLNESS: 48yoM with intrahepatic cholangiocarcinoma s/p right hepatic lobectomy, common bile duct excision, cholecystectomy, portal lymph node dissection, Roux-en-Y hepaticojejunostomy to left hepatic duct on [**2199-6-21**], admitted with fever to 103 and chills since yesterday. He has a PTC and JP drain in place Patient states his appetite has been okay, had one episode of vomiting yesterday, denies diarrhea, nausea. Denies chest pain, shortness of breath, cough. Denies abdominal pain, but states he has had bilateral flank pain. PTC drain output was almost to zero, JP drain still had some output, but has increased to about 20cc daily. Nature of drainage has not changed in color, is not cloudy and does not have a foul smell. Has been on Augmentin since discharge on [**7-12**] when drains were repositioned.
MEDICAL HISTORY: Klatskins tumor, [**2189**] VATS for lung bulla, HTN, hypercholesterolemia, allergies, T&A, L inguinal hernia repair as child
MEDICATION ON ADMISSION: Prilosec 20 daily, Paxil 20 daily, [**Doctor First Name **] 180 daily, Augmentin 875/125 [**Hospital1 **]
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Gen: NAD, A&Ox3 CV: RRR, no m/g/r Lungs: CTAB, no increased work of breathing Abd: soft, [**Name (NI) **], ND, PTC (segment IV) in place - with bilious fluid in bag. PTC (segment II/III) in place - capped JP in place - with bilious/serous fluid in bulb. Insertion points of all 3 drains clean and dry. Ext: no C/C/E
FAMILY HISTORY: mother:alive with breast cancer dx in [**2172**] father alive with acute lymphocytic leukemia and had a valve replacement in [**2165**]. brother in good health.
SOCIAL HISTORY: He is married and has two children, ages 21 and 18. He is the vice president of a company. He stopped drinking all alcohol on [**5-4**] | 0 |
12,435 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 73 year old female who was otherwise healthy who started complaining of numbness and weakness of the right arm and leg. It lasted about two weeks. It was discovered that she had a left middle cerebral artery aneurysm and was admitted status post the coiling of the left middle cerebral artery aneurysm on [**2160-6-18**]. She was admitted to the trauma sick unit post coiling. During the procedure it was noted that a small non- occlusive thrombus had formed on an M2 division at its origin near the coil mass and this was treated with intravenous Integrilin with resolution. There were no post- operative neurological deficits noted.
MEDICAL HISTORY: Coronary artery disease.
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
38,879 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is an 87-year-old male status post left radical nephrectomy for renal oncocytoma, who presented on [**3-22**] for outpatient follow-up CT scan of his head status post motor vehicle accident. The patient was found at that time to have a left subdural hematoma and was transported to the emergency room for work-up. Subsequent to the patient's initial admission and evaluation by the neurosurgery team the patient was noted to have increasing nausea and vomiting as well as abdominal distention. CT scan of the abdomen and pelvis was obtained at the time which demonstrated a high-grade small bowel obstruction with a transition point near the previous surgical site for his left nephrectomy for renal oncocytoma.
MEDICAL HISTORY:
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
9,401 | CHIEF COMPLAINT: Shortness of breath and Diaphoresis
PRESENT ILLNESS: 47 yo F with h/o cardiomyapathy, schizoaffective disorder, bipolar disorder, hypertension who was brought in by ambulance. She complained of 2 hours of SOB and diaphoresis. EMS gave her nitro Slx3, lasix and ASA. She had rales [**1-27**] way up, satting 80's on NRB, and hypotensive initially. VS were 74/42, HR 134, T 101.8, RR 40. ECG showed sinus tachycardia, vent bigeminy, STE in V1-V4, STD with TWI in v5-v6. She was intubated in the ED. Tox screen was negative. Labs notable for slightly elevated WBC 11., HCO3 20, creat 1.4 (bl 1.1), CK 172, MB 4, Trop 0.02, lact 5.6. After intubation she became hypertensive with SBP>200. She was given ASA, started on nitro gtt and BPs were in 170's/90's. She was guaiac positive.
MEDICAL HISTORY: . Hypertension, poorly controlled. 2. Hypertrophic cardiomyopathy. 3. Left heart failure with a BNP of 4900 and EF of 50%. 4. Diabetes mellitus, type 2 uncontrolled with an A1c of 8.1. 5. Morbid obesity. 6. Iron deficiency anemia. 7. Epigastric pain, now resolved. 8. Schizo-affective disorder 9. CKD
MEDICATION ON ADMISSION: Nifedipine 60 mg tablets sustained release once a day Aspirin 81 mg once a day Lasix 20 mg once a day Lisinopril 10 mg once a day Glyburide 5 mg once a day Ferrous sulfate 325 mg twice a day Colace 100 mg twice a day Geodon 100 mg [**Hospital1 **] (80 QAM, 20 QHS) Depakote 500 mg [**Hospital1 **] Haldol 100 mg IM Q3 weeks
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: 101.8, 88, 175/96, 25 on vent AC 500x18, PEEP 5, 100% GENL: sedated, obese, unkempt HEENT: JVP unable to be assessed given body habitus CV: RRR no MRG Lungs: Rales [**1-27**] way up Abd: obese, soft, nontender, +BS Ext: no edema, 2+ pedal pulses
FAMILY HISTORY: no early cardiac deaths, diabetes mellitus, or hyperlipidemia
SOCIAL HISTORY: smokes free tobacco, drinks occasionally, remote marijuana use. Lives in group living arrangement. | 0 |
69,507 | CHIEF COMPLAINT: Presented to OSH with c/o SOB x several days
PRESENT ILLNESS: This is an 80 yo female who presented to OSH [**3-20**] with compliants of shortness of breath. Treated for CHF with diuresis and CPAP and heart rate controlled with beta blockers. At OSH, cath revealed severe aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.3-0.4 cm2, with echo confirming this and showing an EF of 50%. She was transferred to the [**Hospital1 18**] for eval for AVR.
MEDICAL HISTORY: Diabetes type 2 Hypothyroidism Hypertension Hyperlipidimia Anemia/ GIB Atrial fibrillation Inflammatory breast CA s/p XRT/chemo Hypertrophic cardiomyopathy Bilateral knee replacement Chronic obstructive pulmonary disease
MEDICATION ON ADMISSION: Metformin, Avandia, Hyzaar, Aricept, Arimidex, Lipitor, Coumadin, Digoxin, Atenolol, Aspirin, Levoxyl, Potassium chloride, Niferex, Protonix.
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: Lives alone in [**Hospital3 **]. Denies history of ETOH or tobacco use. | 0 |
96,852 | CHIEF COMPLAINT: headache, hypertension
PRESENT ILLNESS: 77F former smoker with HTN, thyroid nodule, and anxiety presents with headache. She came to the emergency room because she had a headache and thought her BP must be elevated. She does not have a h/o headaches and the last time she had a headache, her BP was elevated so she felt it must be the case this time. Denies vision changes, lightheadedness or chest pain. No numbness/tingling except for some stiff/tingling left fingers this afternoon after waking from a nap, but it quickly resolved. . In the ED, initial vitals were remarkable for SaO2 of 90% RA. Pt denies SOB. HA resolved with sublingual nitroglycerin given by EMS. HTN treated in ED with total of 15mg lopressor IV. Ambulatory SaO2 was 90% RA. CXR (done b/c low O2 sat) showed new large R pleural effusion, with possible air bronchograms (see read below). Pt given levofloxacin and admitted for w/u of new pleural effusion. Vitals on transfer vs temp 98 HR 67 BP 184/80 RR 22 O2sat 96%RA. . On the floor, pt's headache had resolved. She states she has never been aware of SOB. She states she is unable to do as much as she could about a year ago but is still able to perform many of her household chores by herself. She lives on the [**Location (un) 17879**] and is able to climb the steps (approx 20) in [**12-25**] min, only getting SOB if she climbs too fast or walks too quickly to the bathroom. She does not know if she has dyspnea with exertion as she does not exercise much. For the past week, she has noted that she has some orthopnea and needs to sleep with 2-3 pillows which helps. Mild exertional dyspnea was noted by her PCP in [**2125-6-22**]. . Of note, pt has had significant anxiety for the past year due to loss of her husband and workup of her thyroid nodule. She becomes SOB and has palpitations when anxious and is unable to provide clear history about her breathing when she feels calm. Also, Pt states her weight [**2125-7-23**] was 163 lbs. She cut out sugar and salt from her diet due to DM and CRI and weight decreased to 121 lbs(not exactly intentional, but did decrease with diet). Weights not recorded in OMR to correlate. . BP on the floor was 210/114, possibly due to anxiety. Pt given lorazepam 0.5mg x1 and BP rechecked in both arms 30 min later. Still 190/92 R arm and 240/100 L arm. Pt remained asymptomatic although she was very uncomfortable when cuff inflated. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats. Denied cough. Denied chest pain or tightness. Denied nausea, vomiting, diarrhea. Occassional constipation, chronic for her. Last BM was yesterday and appeared normal. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias.
MEDICAL HISTORY: -Thyroid nodule (most recent FNA [**2126-7-3**] - insufficient material) -Anxiety -Type 2 diabetes - used to be on metformin and actos, but DM improved when she lost weight -Hyperlipidemia - h/o rhabdomyolysis with statin (hospitalized in ICU) -Hypertension - metoprolol most recently increased to 75mg daily on [**2126-7-15**]; -Right subclavian stenosis with 52 mm systolic blood pressure gradient. -Chronic kidney disease, last Cr 2.8 on [**2126-7-15**] - seen by nephrology, attributed to hypertension and diabetes -Bilateral less than 40% ICA stenosis.
MEDICATION ON ADMISSION: Medications - Prescription (confirmed with patient's home list) AMLODIPINE - 10 mg daily ISOSORBIDE MONONITRATE ER - 30mg daily LORAZEPAM - 0.5 mg daily METOPROLOL SUCCINATE - 75 mg Tablet Sustained Release daily ONDANSETRON HCL - 4 mg q8h: PRN nausea SERTRALINE - 50mg daily (pt takes in evening) ASPIRIN - 325mg daily CALCIUM CARBONATE 500 mg- 2 tabs [**Hospital1 **] (Pt taking Ca but does not have dose with her) Vitamin D - 1600 IU daily (400mg QID) FERROUS SULFATE - 65mg daily (elemental) - ordered as Ferrous Sulfate 325mg daily on admission MULTIVITAMINS
ALLERGIES: Penicillins / Lasix
PHYSICAL EXAM: Physical Exam on admission [**2126-7-23**]: Afebrile BP: 190/92 (R arm), 240/100 (L arm) P:72 R:20-24 O2: 94% 2L (90% RA) General: Pleasant, alert, oriented, appears anxious HEENT: Sclera anicteric, MMM, oropharynx clear Neck: visible and palpable L nodule at L base of thyroid, supple, no LAD Lungs: Bronchial breath sounds on R, Basilar rales on L, dullness to percussion approx [**11-24**] way up on R, dullness [**11-25**] way up on L. CV: RRR, normal S1 + S2, 1/6 systolic murmur at RUSB and LUSB, no rubs or gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: warm, well perfused, 2+ DP pulses, trace nonpitting edema of L leg (chronic per pt); no edema of R leg . Physical exam on discharge [**2126-8-3**]: Vitals: 97.2 BP: 179/73 P:68 O2: 97% RA General: Pleasant, AOx3 HEENT: PERRL, sclera anicteric, MMM, oropharynx clear Neck: visible and palpable L nodule at L base of thyroid, supple, no LAD Lungs: bibasilar crackles, no wheezes or ronchi CV: RRR, normal S1 + S2, 2/6 systolic murmur at RUSB and LUSB radiating to carotids and L axilla, no rubs or gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: warm, well perfused, 2+ DP pulses, trace nonpitting edema of L leg (chronic per pt); no edema of R leg Skin: large erythematous patch on lower abdomen and thighs, no increased warmth, swelling or tenderness, dry skin Neuro: CN II-XII intact, [**3-26**] strenth UE and LE b/l, able to follow simple commands, no dysarthria
FAMILY HISTORY: non-contributory
SOCIAL HISTORY: Widowed, Lives alone, daughter and son-in-law live downstairs and help her carry things upstairs. Pt able to do her own laundry, dishes, some other household chores but does get more tired than before. Quit smoking 40y ago, no EtOH, no drugs, no current sexual relationship. . Note: Daughter with Asperger's syndrome; Per pt's son: Pt feels her daughter and son-in-law can take care of her but daughter sometimes has difficulty taking care of herself. | 0 |
43,371 | CHIEF COMPLAINT: bradycardia
PRESENT ILLNESS: 78 W with pmhx of CAD s/p CABG, HTN, afib s/p pacer in [**2158**], hyperlipidemia, DM, hypothyroidism, CVA presents with asymptomatic bradycardia. She was taking her blood pressure with a home monitor and noted a low heart rate. She noted an episode of lightheadness, which resolved spontaneously. She otherwise was asymptomatic, denied SOB, cp, n/v, diarrhea, constipation. . Pacer followed at OSH, and denies malfunction, checked in [**Month (only) **] by phone, and was without malfunction. . In ED VS 97.8 164/44 39 222 100% 3L. She was evaluated by EP and found to have a nonfunctioning pacemaker, was given 2.5 mg Vit K PO. Temp wire was held as not indicated, patient being asymptomatic. . 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: 1. CABG x4: LIMA to the LAD, saphenous vein graft to left circ, saphenous vein graft to PDA, and question saphenous vein graft to RCA. 2. Diabetes. 3. Hypercholesterolemia. 4. Hypertension. 5. Hypothyroid. 6. Atrial fibrillation. 7. History of cerebrovascular accident. 8. S/p Dual Chamber [**Company 1543**] Cardiac Risk Factors: + Diabetes, + Dyslipidemia, + Hypertension . Cardiac History: CABG, anatomy as follows: LIMA to the LAD, saphenous vein graft to left circ, saphenous vein graft to PDA, and question saphenous vein graft to RCA
MEDICATION ON ADMISSION: Lasix 80mg Daily Cartia 240mg Daily Glipizide 2+[**2-27**] HCTZ 12mg Daily Metoprolol 50mg [**Hospital1 **] Lipitor 20mg Daily Levothyroxine 75mcg Warfarin 3mg Daily Aspirin 81mg Daily Metoformin 500mg Daily Amiodarone 200mg Daily NTG
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS: T97.9 , BP 151/52 , HR 39 , RR 16, 99 O2 % on 2L Gen: WDWN female, NAD, AAOx3, pleasant, HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of cm 10 cm CV: Bradycardic, regular normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Mild crackles at bases
FAMILY HISTORY: n/c
SOCIAL HISTORY: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. | 0 |
45,781 | CHIEF COMPLAINT: Hemoptysis
PRESENT ILLNESS: HPI: 79 yo M w/ hx vascular dementia, aphasia w/ G-tube for [**Last Name (un) **] aspiration, chronic foley transferred from NH for BRB in mouth. Pt then had another episode of "large amount" ~ [**11-26**] cup of bright red blood total of both times of hemoptysis in the ED after arrival. . In ED s/p G-tube lavage w/ old clot, easily cleared. S/p levofloxacin, flagyl, 2L IV NS, protonix. In ED discussion w/ pt's wife and [**Name (NI) **] [**Last Name (NamePattern1) **], MD and wife wants "everything done." Pt full code status confirmed. .
MEDICAL HISTORY: Renal/GU: 1. Nephrolithiasis/Uretolithiasis/Urosepsis a.Proteus urosepsis secondary to obstructing uretal stone, relieved by percutaneous nephrostomy tube, complicated by perinephric hematoma. Hospitalized [**2141-3-29**] x14d. b.Hematuria from nephrostomy secondary to renal stone. Hospitalized [**2141-4-16**] x5d. c.Tube dislodged [**2141-5-25**] and was replaced d.Klebsiella urosepsis secondary to uretrolithiasis. Hospitalized [**2141-8-7**] x2d e.Uretal stone was passed during hospitalization [**2141-8-7**]. f. Percutaneous nephrostomy tube removed CV: 1.Hypertension. 2.Descending thoracic aortic aneurysm. GI: 1.G tube placement 2.Dysphagia secondary to CVA, plus aspiration pneumonia status/precautions 3.Cholelithiasis 4. History of elevated liver function tests. PULM: 1.Aspiration pneumonia. Hospitalized [**6-/2136**] MSK: 1.S/p Proteus abscess. Hospitalized [**7-27**]. Status post incision and drainage. Neuro/Psych: 1.Cerebrovascular accident leading to dementia and aphasia. Nonverbal. 2.Depression 3.Atypical Psychosis FEN: 1.H/o of hypernatremia
MEDICATION ON ADMISSION: MEDS: famotidine 20mg po q24h hctz 12.5mg po q24h lisinopril 20mg po q24h zoloft 50mg po q24h albuterol prn tylenol prn ipratropium prn Bactrim DS 1 tab po q12h x 3 days d1 = [**2142-1-12**] augmentin 500mg po q8h x 10days [**2142-1-31**] for UTI
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: PE: Tm 101.8, Tc 98 HR 89 (100-115) BP 112/55 (100-133/60-80's) 21 (18-24) 100% 2L NC Gen: Thin cauc M lying in stretcher in NAD, missing 2 front teeth, not cooperative w/ exam, nonverbal. HEENT: anicteric with dried blood at corners of mouth Heart: RR, S1, S2, no m/r/g no AI murmus Lungs: no rales, no crackles, no wheezing ABd: G tube in place dressing c/d/i, mildly Distended, NT, no masses Ext: no edema GU: chronic indwelling foley in place, clear yellow urine in bag
FAMILY HISTORY: N/C
SOCIAL HISTORY: The patient is not verbal. He lives at [**Hospital3 2558**]. His family is involved in his care. | 0 |
94,803 | CHIEF COMPLAINT: Lower GI bleed
PRESENT ILLNESS: 67M with COPD, CHF (EF 25%), Chronic Kidney Disease Stage IV, h/o HCC and EtOH cirrhosis s/p OLT [**2104-8-22**] now transferred from [**Hospital3 **] Hospital with a lower GI bleed. He initially presented to [**Hospital **] hosp with lethargy, change in mental status and black stools as well as diarrhea with bright red blood. Pt also reported non-bloody bilious emesis prior to admission. Pt admitted to [**Hospital **] hosp on [**2107-1-5**] with a Hct of 10%. A tagged RBC scan [**1-5**] showed increased activity in the left mid abdomen which conformed to a loop of bowel and demonstrated a transit over time c/w an acute GI bleed in the descending colon. He was admitted to the ICU and transfused 5 units of PRBC with a Hct rise from 10% to 31% this morning [**1-6**]. The pt was then tansferred here to [**Hospital1 18**] for futher management. Pt had a peak troponin I of 0.12 which decreased to 0.11 at the time of transfer.
MEDICAL HISTORY: liver transplant ([**2104-8-22**]) EtOH cirrhosis HCC anemia essential thrombocytosis prior complications of ascites malnutrition portal [**Month/Day/Year **] with grade 2 esophageal varices h/o duodenitis [**7-18**] grade 1 rectal varices grade 2 esoph varices and gastritis by EGD [**3-/2106**] CAD: ([**2104-7-1**] coronary angiography -inferolateral akinesis & substantial lateral hypokinesis. 50% LAD lesion. Circ occluded distally. RCA 40% stenosis) CHF: ECHO [**9-19**], EF 25% failure to thrive s/p PEG
MEDICATION ON ADMISSION: Procrit 20,000 Units SC Qweek, Peptamen TF 240ml 1 can TID with 30ml H20 before and 60ml H20 after each can, Lasix 160 QDay, Zaroxolyn 5pm PO QAM prior to lasix, Imdur 30, Norvasc 5, Rapamune 2, Coreg 25 [**Hospital1 **], Dualcitra liquid 30ml [**Hospital1 **], Creon 2 tab TID c meals, Testosterone TD 2.5mg daily, Zocor 10, Calcitriol 0.25, Remeron 15, Prednisone 5, Pepcid 20
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Temp 97.9, HR 73, BP 133/91, RR 18, O2 Sat 100RA Gen: Cachectic male, alert and oriented, appropriate and conversive HEENT: No sceral icterus, EOMI, MMM CV: RRR, No R/G/M RESP: Lungs CTAB ABD: Soft, NT, ND, Well healed OLT surgical incisions, PEG clamped, flushed with 100cc H2O with clear return on aspiration Ext: Malnurished, extremely thin extremities, no peripheral edema, feet WWP Rectal: External hemorrhoids, no blood in rectal vault, Guaiac +
FAMILY HISTORY: Non contributory
SOCIAL HISTORY: The patient owns business in [**Hospital3 **]: a clothing store and a limousine business. Recently he started working from home due to his poor health. He lives with his wife, who is very supportive. He smokes. No drugs. Stopped EtOH in 6/[**2103**]. | 0 |
14,515 | CHIEF COMPLAINT: acute on chronic renal failure
PRESENT ILLNESS: 73 yr old patient with chronic CHF r/t non ischemic dilated cardiomyopathy, EF 20%, CRF from h/o renal cell carcinoma, mono-clonal gamopathy, htn, no acute indication for HD.has an AICD for primary prevention. She is transferred from [**Hospital1 882**] for management of acute on chronic renal faillure. . In [**Month (only) **] was admitted to [**Hospital1 **] for back pain and incidentally found to have gallbladder stones. On that admission she was treated with vand and unasyn followed by Augmentin for a total of a 10 day course end [**2128-3-2**] for GB PPX and UTI. She was discharged to rehab. . She then was re-presented to [**Hospital1 **] with nausea, vomiting x6 episodes NBNB and diarhea, and renal failure thought to be secondary to dehydration. ERCP was planned at [**Hospital1 112**]; however, this was cancelled secondary to renal failure. She was transferred to [**Hospital1 18**] for further management. Of note her Creatinine on admission was 3.5 and is now up to 4.5 (baseline 2.5-3.0). Given her history the initial though was that she was dry and they gave her 750cc NS, however her creatinine went up. Thinking she was suffering from poor forward flow in the setting of her volume overload she was restarted on her torsemide with worsening of her renal function. The patient has never been dialyzed and has no acute indication. . She was transferred to the [**Hospital1 **] for further management, though why cardiology is unclear. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope.
MEDICAL HISTORY: DM (last A1c 7.6) Renal cell carcinoma s/p nephrectomy [**2119**] MGUS vs Myeloma CRI (baseline 2.5 --> 4.49) Pacemaker Gout Right nephrectomy Pyleonephritis Hyperlipidemia Ischemic Cardiomyopathy (EF 20 %) Hypertension Osteoporosis Chronic back pain (on fentanyl) h/o pyelo c/b urosepsis
MEDICATION ON ADMISSION: Tylenol 650mg q6h Amiodarone 200mg [**Hospital1 **] Aspirin 81 daily Coreg 6.25 [**Hospital1 **] Colace Fenatanyl 25 ucg q72H Apresoline 25mg TID Dilaudid .5mg q4h prn pain Lantus 10 units qHS HSS Lidoderm patch Maalox liquid 30ml q4h prn omeprazole 20mg daily Senna 2 tabs [**Hospital1 **] Demadex 80mg [**Hospital1 **]
ALLERGIES: Captopril / Sulfa (Sulfonamide Antibiotics) / Simvastatin / Neurontin / IV Dye, Iodine Containing
PHYSICAL EXAM: VS: T=97.5 BP=103/62 HR=59 RR=18 O2 sat=91%RA GENERAL: WDWN W 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: No cardiovascular history
SOCIAL HISTORY: No tobacco, alcohol, or drugs. She is married and lives with family. | 0 |
36,444 | CHIEF COMPLAINT: Dyspnea
PRESENT ILLNESS: 58 yo male with HIV (CD4 463, VL undetectable on [**2120-3-1**]), HCV c/b stage II cirrhosis, COPD GOLD stage II, chronic pain and spinal stenosis on [**Date Range **]/narcotics who presents with dyspnea. Patient reports acute shortness of breath at rest and with exertion for the past 2 days. He reports associated pleuritic chest pain on the right side. SOB is not positional. He reports recent fever to 102, fatigue, cough, muscle aches for the past 2 days. He denies sick contacts. [**Name (NI) **] denies recent travel or increased immobility. Patient tried inhalers at home which did not improve his symptoms. Patient reports orthopnea for the past several months, but denies chest pain, PND or lower extremity edema. Prior to this he was his usual state of health. He takes his HIV medications regularly. . On presentation to ED VS 97.3, 124/73, 52, 22, 99% RA. O2 sat ranging 96-100 on RA to 2 L. Pt afebrile. Patient given pentamidine, morphine 8 mg, ativan 2 mg, magnesium sulfate, duconeb, dexamethasone 10 mg IV, NS 500cc, Atovaquone, Zofran, Phenergan. Admitted to the ICU for close monitoring. . Of note, patient recently had admission [**Date range (1) 46889**] due to abscess following cat scratch and discharged on augmentin and doxycycline for 10 days total (history 10 days total).
MEDICAL HISTORY: *HIV/AIDS x 20 years with (CD4 463, VL undetectable on [**2120-3-1**]) - dx [**2094**]; IVDU or heterosexual contact (known HIV+) - CD4 nadir 12 ([**2097**]) - OI/OM: Pneumocystis pneumonia, [**2102**] Thrush, intermittent *Hepatitis B: positive core antibody, cleared infection *Hepatitis C: stage three fibrosis in [**2-/2119**] *History of MSSA and Strep Milleri abscesses *COPD COPD Gold Stage 2. [**8-4**] PFTs: FEV1/FVC 57, FEV1 = 57% predicted *H/o nephrolithiasis leading to several admissions for abdominal pain *S/p MVA with residual neck/back pain, numbness in fingers *Spinal Stenosis with chronic back pain and peripheral neuropathy *Depression *S/p celiac trunk patch angioplasty and division of median arcuate ligament syndrome in [**2114**] *Bilateral Hydroceles and Uroceles *Gastritis (EGD in [**3-/2118**]) *History of EtOH abuse, IVDU 20 y.a. including heroin and cocaine abuse *BPH *Macrocytic anemia *Cataract
MEDICATION ON ADMISSION: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath, wheeze. 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath, wheeze. 3. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 7. lamivudine-zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. [**Hospital1 **] 10 mg Tablet Sig: One [**Age over 90 1230**]y Five (155) mg PO DAILY (Daily). 9. promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 10. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 13. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO three to four times a day as needed for pain. 16. OxyContin 40 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO four times a day as needed for pain.
ALLERGIES: Bactrim / Prednisone / Codeine / Iodine
PHYSICAL EXAM: Tmax: 36.1 ??????C (96.9 ??????F) Tcurrent: 36.1 ??????C (96.9 ??????F) HR: 51 (51 - 66) bpm BP: 140/86(96) {137/79(91) - 161/102(115)} mmHg RR: 16 (14 - 18) insp/min SpO2: 98% Heart rhythm: SB (Sinus Bradycardia)
FAMILY HISTORY: Father: brain aneurysm; Mother: lung cancer; Brother: [**Name (NI) 2320**]; Brother: died of drug overdose
SOCIAL HISTORY: Smokes ~1ppd for >20 yrs, quit 4 months ago. Denies current EtOH. Former illicit drug use (IVDU cocaine last in [**2105**]). Currently lives alone in [**Hospital1 392**]. Widowed after wife passed away in [**2118**] s/p liver transplant. History of incarceration from [**2106**]-[**2112**] (per pt, due to gambling but per OMR, due to armed invasion/assault). Former corrections officer currently on disability secondary to back pain. 2 children who live with their mother (his ex-wife). | 0 |
71,286 | CHIEF COMPLAINT: shortness of breath
PRESENT ILLNESS: 45 yo woman with severe Asthma and COPD with FEV1 of 0.24 being evaluated for possible lung transplant comes in after 2 days of fevers to 102, cough, congestion, unable to bring up sputum and shortness of breath. She tried increasing frequency of her home nebs, spoke with her PCP and was started on erythromycin and mucinex. As she was still short of breath, she came in to the ED for evaluation via EMS. She denies any sick contacts and has been compliant with med regimen. she denies any other symptoms. . In ED started on continuous nebs with heliox and improvement in respiratory distress, but still tachypnic and working to breathe. Received solumedrol, 125mg IV, levoquin 500mg once, Magnesium 2gm and continuous neb as above.
MEDICAL HISTORY: 1. COPD, PFTs in [**1-17**] with FEV1 0.24(10%), FVC 1.25(41%) and FVC/FEV1 28%- on Home O2 at 2L NC, on chronic steroids, hx of prolonged intubation requiring trach for resp failure in [**1-15**], last flare [**11-16**] 2. Hypertension 3. Anxiety 4. Leukocytosis of unknown etiology with negative BMBx. 5. Osteoporosis- on fosamax 6. Shoulder pain 7. History of positive PPD s/p 6mos of isoniazid 8. Mitral valve prolapse
MEDICATION ON ADMISSION: Albuterol/Atrovent nebs Flovent Serevent Singulair Tiotropium Captoril Fosomax Efffexor Neurontin Seroqul Protonix Oxybutinin Klonopin
ALLERGIES: Compazine
PHYSICAL EXAM: VS:101.2 axillary, 144 123/79 28 97%2LNC GEN aao, tachypneic in mod resp distress, able to answer in short word phrases with increased work of breathing HEENT PERRL, dryMM, + trach scar CHEST diffuse wheezes bilaterally, no crackles CV RRR, tachycardic Abd soft, NT/ND, +BS EXT no edema
FAMILY HISTORY: NC
SOCIAL HISTORY: +smoker, has young son and involved mother | 0 |
69,976 | CHIEF COMPLAINT: Jaundice
PRESENT ILLNESS: This is a 58-year-old woman with a history of hyperlipidemia, known fatty liver, and history of anxiety presenting with jaundice. History is obtained from her and her son, [**Name (NI) 916**]. [**Name2 (NI) **] son states that for the past three months she has been unwell. She has had significant social stressors including divorce from a 30-year marriage and failure of her business. Her husband left her within the past several months. Her son has been visiting and states he has found her in bed covered in her own feces and she has been deeply depressed. He had tried to persuade her to seek care but she had been reluctant. She had also been weak and falling at home and he once found her with what he described as a black eye. She denied concern for abuse stating that she lived alone. She has a history of heavy alcohol use, up to a bottle of vodka or a large bottle of wine daily. She admits to her most recent alcohol use being [**Holiday **]. Her son confirms this history and adds that she may have been drinking until [**11-30**] (her birthday), but it was on that day that he noticed the jaundice and physically removed all alcohol from the house. She has been taking ativan and ambien regularly despute being lost to regular medical care since [**2099**]. She admits to taking the ambien but it is nto clear how regulary she has been taking the ativan. Her son states that he placed ativan by her bed to see if she took it while he was gone and she did not. Her urine tox is negative for benzos. . She denies fevers, chills, hematemesis, hematochezia, abdominal pain, chest pain and shortness of breath. She states about a week ago her stool did look darker to her. . In the ED, initial vitals were 99.2 62 100/63 18 100%. A diagnostic paracentesis was negative for SBP. A cxr was negative. DRE in ED revealed stool that was OB negative. . On transfer: Temperature 97.9. Pulse 68. Respiratory Rate 16. Blood Pressure 113/53. Rhythm Normal Sinus Rhythm. O2 Saturation 100. O2 Flow ra. Pain Level 0.
MEDICAL HISTORY: 1. HTN 2. Anxiety 3. Fatty liver with abnormal LFTs 4. Hyperlipidemia, last check [**2099**] and was 338 total 5. Bipolar disorder diagnosed [**2103**] 6. Alcohol dependence
MEDICATION ON ADMISSION: LORAZEPAM 0.5MG TABLETS TAKE ONE-HALF TO ONE TABLET BY MOUTH THREE TIMES DAILY AS NEEDED atenolol 100 mg Tab one Tablet(s) by mouth once a day ZOLPIDEM 10MG TABLETS TAKE [**12-31**] TO 1 TABLET BY MOUTH EVERY NIGHT AT BEDTIME AS NEEDED
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Admission Physical Exam: VS: 98.5 102/49 71 20 (by my count 32) 99% RA Weight 152 lbs GENERAL: NAD, anxious appearing, diffusely jaundiced HEENT: Sclera icteric. PERRL, EOMI. mildly dry MM, OP clear. Palate jaundiced. NECK: Supple, no LAD CARDIAC: RRR, nl S1 S2, no MRG LUNGS: CTAB, no rales wheezes or rhonchi ABDOMEN: soft, non-tender, mildly distended. Cannot palpate liver edge. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 1+ LE edema SKIN: macular erythematous rash diffusely, most prominent on upper extremeties with elbow sparing. frank jaundice. NEURO: alert, oriented x 3, slight asterixis, CN II-XII tested and intact, strength 5/5 throughout, gait normal . Discharge PE: VS: 98.9 132/62 72 100%RA GENERAL: NAD HEENT: Sclera icteric. NG tube in place. CARDIAC: RRR, nl S1 S2, no MRG LUNGS: CTAB, no rales wheezes or rhonchi ABDOMEN: soft, non-tender, mildly distended. Cannot palpate liver edge. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 1+ LE edema NEURO: alert, oriented x 3, no asterixis
FAMILY HISTORY: Mother died of CHF, also had breast cancer. Father died of MI. HTN in sister, brother and father. DM in PGM (late in life). MGM and mother had breast cancer. No ovarian cancer. MGF had EtOH liver disease of some kind.
SOCIAL HISTORY: recent divorce. used to be antiques dealer until recently -Tobacco history: None -ETOH: prior heavy use. last use [**Holiday **] or [**11-30**] -Illicit drugs: None | 0 |
92,424 | CHIEF COMPLAINT: HEADACHE
PRESENT ILLNESS: HPI: 46M with mild HA x 2 days. Headache became severe with near fainting at 3 hours prior to presentation. Initially went to [**Hospital6 3105**] and CT showed large SAH. At OSH pt had near syncopal episode with vomiting. Pt also reported neck/back pain that was worse with movement. No history of trauma. Denies fevers, chills, change in vision, diarrhea, chest pain, or SOB. Pt transferred to [**Hospital1 18**] for further management.
MEDICAL HISTORY: Hep C splenectomy Spine surgery - 6 screws
MEDICATION ON ADMISSION: Medications prior to admission: Methadone 115mg/daily
ALLERGIES: Hydralazine
PHYSICAL EXAM: PHYSICAL EXAM: O: T: 99.2 BP: 134/77 HR: 94 R: 16 97% 3LNC O2Sats Gen: mild grimace, NAD. HEENT: Pupils: B 2mm with minimal reactivity EOMI Neck: Pain with passive or active ROM Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors.
FAMILY HISTORY: NC
SOCIAL HISTORY: Social Hx: Lives in [**Hospital1 487**], h/o IVDU quit 20+ years ago, 1/4pack cigs/day, social ETOH Spanish is primary language Family involved in care/decision making. | 0 |
7,725 | CHIEF COMPLAINT: Chest pain.
PRESENT ILLNESS: This is a 71-year-old man who over the past several months has had several episodes of exercise angina. He had a positive stress test and then underwent cardiac catheterization which revealed 60% left main, 60% LAD, 50% OM2 and occluded RCA and mild left ventricular dysfunction.
MEDICAL HISTORY: Diabetes mellitus, bilateral mastoidectomies.
MEDICATION ON ADMISSION: Glipizide 5 mg daily, aspirin 81 mg daily, Lorazepam 15 mg daily, multivitamin.
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY: No CAD.
SOCIAL HISTORY: Married with 3 children. | 0 |
55,195 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 50 year old man with a past medical history significant for coronary artery disease, status post myocardial infarction as well as a minimally invasive coronary artery bypass grafting with the left internal mammary artery to the left anterior descending by Dr. [**Last Name (STitle) 1537**] in [**2159**].
MEDICAL HISTORY: Past medical history is also significant for diabetes mellitus and hyperlipidemia.
MEDICATION ON ADMISSION: The patient was on no medications at the date of admission.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient has no known history of tobacco or alcohol use or abuse. | 0 |
6,333 | CHIEF COMPLAINT: Chest pain and alcohol withdrawal
PRESENT ILLNESS: 47 yo M with ETOH abuse c/b dilated cardiomyopathy (EF 49% 9/07), HCV, h/o lung aspergillosis c/b cavitary lesion who p/w etoh withdrawal and chronic reproducible chest pain. He currently drinks [**1-3**] gallon of vodka daily, his last drink was evening of [**2102-1-13**]. He reports that after his recent d/c from the hospital on [**1-6**], he attempted to make multiple follow up appointments with MDs and detox, but "did not hear back"; he became frustrated and again began drinking [**1-3**] gallon of vodka/day. He reports he has also been having chest pain which is chronic in nature which he reports gets worse when he's drinking significant amounts. He reports it "hurts every time my heart pumps". He denies CP with deep inspiration and denies SOB. He has had no cough or hemoptysis. He reports since being in the ED, he feels increasingly tremulous and anxious and is hypertensive "because he's withdrawing." He denies hallucinations. In the ED, initial vitals were 97.3 98 [**Telephone/Fax (2) 23538**]% on 2L NC. Urine tox was positive for benzos and cocaine; serum EtOH level was 249. ECG reportedly with "NSST depressions and J pt elevations". CEs were negative x2 sets. CXR was performed which showed stable radiographic appearance of known cavitary lesions in both lung apices with no new process identified. Plan was initially for d/c from ED given negative CEs, however patient began to withdraw in ED with sx of tremulousness, anxiety, hypertension. He received thiamine, folic acid, MVI. He received a total of 40mg diazepam (30mg IV, 10mg PO). He was hypertensive to the 170s-230s systolic and received his home dose lisinopril and IV hydralazine x2. His home dose beta blocker was held given urine tox positive for cocaine. Of note, he has had multiple past admissions for CP and EtOH withdrawal, most recently from [**Date range (1) 23539**] at which time he required large amounts of benzos for safe detox. He was discharged home with plans to be admitted to inpatient substance abuse program at [**Hospital1 882**], however he did not do this. He is now being admitted to the ICU for EtOH withdrawal for q30min-1h CIWA.
MEDICAL HISTORY: Past Medical History: - EtOH abuse - h/o withdrawl seizures - Alcoholic Dilated Cardiomyopathy (EF 25%) - cocaine abuse (last use ~ 3 weeks ago) - hypothyroidism - h/o head and neck cancer s/p resection and radiation in [**2093**] - bilateral cavitary lung lesions; bx demonstrated Aspergillous fumigatus and [**Female First Name (un) 564**] albicans [**2-/2102**] - h/o C. diff colitis - h/o IVDA per OSH records (pt denies)
MEDICATION ON ADMISSION: Aspirin 81 mg PO DAILY Levothyroxine 75 mcg PO DAILY Buspirone 10 mg PO BID Toprol XL 150 mg Tablet PO once a day Lisinopril 30 mg PO DAILY Trazodone 50 mg PO HS Olanzapine 5 mg PO HS B-complex with vitamin C Hexavitamin Folic acid 1mg PO daily Thiamine 100mg PO daily
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS: Temp: 97.5 BP: 185/119 HR:102 RR:19 O2sat 97%RA GEN: Appears mildly tremulous, moderate distress [**Month/Day (2) 4459**]: PERRL, EOMI, anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules, left anterior neck with soft tissue defect s/p surgery for head and neck cancer RESP: CTA b/l CV: rrr, soft II/VI systolic murmur at RUSB ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice, wound mid low back healing without erythema, induration, warmth, fluctuance NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. 2+DTRs-patellar and biceps.
FAMILY HISTORY: Mother with CAD. Sister with h/o CVA.
SOCIAL HISTORY: Smokes < [**1-3**] ppd recently; prior to that he smoked 1 ppd x30 years. Heavy EtOH use (usually >1 gallon vodka per day). Sober x10 years up until ~2 years ago; more recently, reports several months of sobriety. +Cocaine abuse; last use several wks ago. He denies IVDA. Sexually active with his girlfriend. | 0 |
5,371 | CHIEF COMPLAINT: respiratory distress and weakness
PRESENT ILLNESS: This 86 year old man with h/o Afib(on warfarin), CHF, CAD(s/p AMI '[**33**]), and PVD, developed a fever 1 wk prior to admission, and since his primary physician had relocated, he opted to treat himself with amoxicillin 1000 mg tid, using pills that he kept for dental procedures. His fever resolved, but he developed myalgias and arthralgias as well as increasing dyspnea. He presented to the ED and an echocardiogram on [**6-10**] revealed a large pericardial effusion, EF-30%, most of fluid in posterior. region. Tamponade physiology. Pulsus 22-25. Pt. went to OR for pericardial window, approx. 1 liter of blood tinged fluid was drained(gram stain neg./prelim. cx neg for malignant cells). Pt was extubated on [**6-12**], without incident.
MEDICAL HISTORY: Afib(on warfarin) CHF CAD(s/p AMI '[**33**]) PVD Pulm. HTN asthma gout CEA('[**36**]) CVA('[**35**]) hypothyroidism
MEDICATION ON ADMISSION: Lactulose 30 ml PO Q8H:PRN Metoprolol 50 mg PO BID hold for SBP<100, HR<55 Morphine Sulfate 1-5 mg IV Q4-6H:PRN Acetaminophen 325-650 mg PO Q4-6H:PRN Multivitamins 1 CAP PO QD Allopurinol 100 mg PO QOD Pyridoxine HCl 50 mg PO QD Albuterol-Ipratropium [**12-20**] PUFF IH Q6H Senna 1 TAB PO BID Bisacodyl 10 mg PO QD:PRN Calcium Carbonate 500 mg PO TID Docusate Sodium 100 mg PO BID Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
ALLERGIES: Sulfonamides / Ticlid / Persantine / Aspirin / Benadryl / Xylocaine / Prevacid
PHYSICAL EXAM: T: 97.2 HR: 77 (A Fib) RR: 22 BP: 110/47 O2sat: 99 4L NC Gen: in NAD. HEENT: PERRL, neck supple Lungs: diffuse crackles, few wheezes in B middle to lower lobes Chest: CT in place with dry dressing. Heart irregular rhythm. No murmurs Abd: +mass R middle to lower quadrant. Soft, non-tender. +BS Ext: 1+ edema to mid-calf. Ecchymoses, varicose veins B Neuro: A&Ox3. Non-focal
FAMILY HISTORY:
SOCIAL HISTORY: no tobacco or EtOH Lives with wife, a receptionist Retired pharmacist | 0 |
54,513 | CHIEF COMPLAINT: shortness of breath and edema
PRESENT ILLNESS: Pt is a 51 y/o F call-out from MICU after admission for likely TTP. Please see excellent MSIII note for full details, but briefly, pt had been in USOH being treated for foot cellulitis X 2weeks with Keflex. After 10 days Keflex, she began to note full body non-raised rash, petechiae over arms, and larger confluences on her legs. Keflex d/c'd, given Benadryl, and started on doxycycline, which she said made her feel sick. Pt noted increased fatigued, [**Location (un) **] over her baseline, increasing SOB with exertion. . In the ED, initial laboratories remarkable for anemia with a hct of 25.7 and thrombocytopenia 85,000. BUN/Cr 83/10. She was afebrile but hypertensive. Heme/onc and renal consulted. RBCs and RBC casts in urine. Smear positive for schistocytes. Plasmapheresis initiated for presumed TTP. She was given nitro paste, tylenol, solumedrol 500mg IV x1, and labetalol 400mg po x1. A R IJ pheresis catheter was placed. . In MICU, improvement in thrombocytopenia and elevated LDH s/p pheresis and HD X3. She was hemodynamically stable and called out to floor. Pt still oliguric. . On floor, she has no complaints exceot some mild fatigue on exertion; however, she reports feeling better with improved breathing and able to lie flat without SOB/orthopnea. She denies any pain. ROS negative for recent diarrhea, no viral URIs, no icterus or changes in the color of her skin or urine. Denies dysuria, chest pain, confusion, fevers, or ataxia.
MEDICAL HISTORY: None
MEDICATION ON ADMISSION: occasional Motrin or Tylenol recently on Keflex and doxy
ALLERGIES: Keflex / Cephalosporins
PHYSICAL EXAM: VS: 99.3 185/110 86 20 93 % RA Gen: well appearing, NAD HEENT: faint scleral icterus, PERRL, EOMI, OP clear NECK: RIJ in place, nl LAD CV: RRR, nl S1/S2, 2/6 SEM (flow murmur) Pulm: bibasilar crackles at bases bilaterally Abd: soft, NT/ND, +BS, no masses Ext: trace pitting edema, warm, good pulses Neuro: alert and oriented, appropriate Skin: Irregular 1cm left upper back lesion nontender, raised, pink (known to pt). Numerous small papules over entire back; non-pruritic
FAMILY HISTORY: no known clotting d/o, no PE or DVT; M with + miscarriage
SOCIAL HISTORY: Lives with husband and 2 of her 3 children. Denies tobacco, drinks occasional social EtOH, and denies IVDU. Is [**Name8 (MD) **] RN in day surgery. | 0 |
11,784 | CHIEF COMPLAINT: Increase fatigue/Chest tightness w/ activity
PRESENT ILLNESS: 65 y/o active male with h/o HTN and DM c/o increase fatigue and chest tightness w/ activity. Had +ETT followed by cath which revealed severe 3 vessel disease.
MEDICAL HISTORY: Hypertension Diabetes Mellitus s/p Back surgery [**2174**] s/p L Hand tendon repair s/p R. Thunb repair s/p Cervical Laminectomy s/p Varicocele repair
MEDICATION ON ADMISSION: 1. Atenolol 25mg [**Hospital1 **] 2. Accupril 20mg qd 3. Zantazc 150mg qd 4. Metformin 1000mg [**Hospital1 **] 5. Diltiazem 240mg qd 6. Glipizide 10mg [**Hospital1 **] 7. ASA 325mg qd 8. Humulin NPH 60 units at hs 9. MVI 10 Ibuprofen prn
ALLERGIES: No Drug Allergy Information on File
PHYSICAL EXAM: Vitals: 80 20 160/80 6'1" 270 General: Well-appearing 65 y/o male in NAD Skin: Unremarkable, -lesions HEENT: EOMI, PERRLA, NC/AT Neck: Supple, FROM, -JVD Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/NT +BS Ext: Warm, well-perfused, trace edema, -varicosities Neuro: A&Ox3, CN2-12 intact, non-focal
FAMILY HISTORY: Non-contributory
SOCIAL HISTORY: Lives with wife. [**Name (NI) **]. Quit smoking 25 yrs ago. Doesn't drink. | 0 |
27,112 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 41 year-old woman with advanced aid CD4 count less then 30 admitted on [**11-21**] with fever for the past few weeks and intractable developed fever and cough with a question of right lower lobe pneumonia and was started on Levofloxacin. She was also started on oral Fluconazole for thrush. Her Levofloxacin was changed to Augmentin as the patient continued to spike fevers through the Levofloxacin. The patient developed night sweats as well as inguinal pain. She was admitted on [**11-21**] for evaluation of fever, night sweats and evaluation of vomiting On admission the patient's O2 sat was 92%. The chest x-ray was read as diffuse interstitial infiltrates with bibasilar air space opacities and small pleural effusions compatible with PCP. [**Name10 (NameIs) **] scan on [**11-22**] of the abdomen and chest showed chronic lung changes manifested as interstitial thickening with several punctate cystic lesions and increased consolidation in the right upper and lower lobes with a moderate right sided pleural effusion. Pericholecystic fluid was seen as well as extensive lymphadenopathy in the inguinal region, thorax and supraclavicular and axillary regions. Over the past two days the patient has had increasing fevers, increasing oxygen requirements and dyspnea. The patient was started on Bactrim on [**11-22**] as well as Prednisone for presumed PCP. [**Last Name (NamePattern4) **] [**11-24**] chest x-ray repeated showed a combined alveolar interstitial pattern, which has progressed since [**11-22**]. The patient's antibiotics were broadened to include Azithromycin and Ceftriaxone. The [**Hospital Unit Name 153**] moonlighter was called to see the patient at 10:00 p.m. with progressive dyspnea and O2 requirements necessitating 100% nonrebreather. The patient agreed to intubation and was taken directly to the [**Hospital Unit Name 153**] for intubation. The patient at that time denied abdominal pain, chest pain and had been compliant with her PCP [**Name Initial (PRE) 1102**].
MEDICAL HISTORY: HIV since [**2102**], systolic murmur, negative PPD, but anergic pneumonia as described. Zoster in a VI nerve distribution with post herpetic neuralgia, high grade cervical dysplasia status post cryotherapy, anxiety, depression, left sided oophorectomy, microbacterium in sputum in [**2111**], migraines and herpes.
MEDICATION ON ADMISSION: Bactrim, Darvon, Fluconazole, Coletra, Imivudene, Stavudene, Lotrisone, Mycelex and Remeron.
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY: Mother with emphysema. Father with lung cancer.
SOCIAL HISTORY: Heterosexual. She obtained HIV through intercourse with an intravenous drug abuser. Positive tobacco use. Rare ethanol use. G6 P6. | 1 |
48,218 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 44 year old male with past medical history of polysubstance abuse who was an unrestrained passenger in a high speed motor vehicle collision who was transferred from an outside hospital. The accident was a car versus a tree with severe front end damage. Initially complained of difficulty breathing and chest discomfort. Hemodynamically stable on presentation. He was intubated for combativeness. Tox screen was positive for benzos, cocaine and opiates. He was hemodynamically stable with hematocrit of 43.
MEDICAL HISTORY: Polysubstance abuse. Hep B. Hep C. Left tib/fib fracture.
MEDICATION ON ADMISSION:
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
17,554 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 22 year-old male who began having abdominal pain, nausea, vomiting and high fever in [**2192-10-13**]. He was seen at a community hospital near [**Location (un) 52794**]and underwent a CT scan of the abdomen that apparently was interpreted as gas collecting in the left lower lobe of the liver. An MRCP demonstrated dilated peripheral hepatic ducts with a possible stricture. An endoscopic retrograde cholangiopancreatography showed normal common bile duct and distal hepatic ducts. The peripheral ducts were not filled in the area of the CT and MRCP abnormality. He was treated with intravenous antibiotics for cholangitis and his fever resolved. He was discharged on Ciprofloxacin 500 mg po b.i.d. and he was seen by Dr. [**First Name (STitle) **] [**Name (STitle) 8551**] on [**2192-11-27**] and underwent a CT scan of the abdomen on [**12-8**]. This was read as showing persistent pneumobilia on the left lobe of the liver that was unchanged from [**Month (only) **]. No abscess was seen. The peripheral left hepatic bile ducts were dilated and no other abnormalities were found. He denies any history of jaundice, but he does have a long standing history of intermittent gastrointestinal distress. He has lost 25 pounds during this illness secondary to anorexia. He denies any history of diarrhea or constipation. He underwent an endoscopic retrograde cholangiopancreatography at [**Hospital1 190**] on [**12-25**] that demonstrated common bile duct, common hepatic duct, cystic duct and gallbladder were normal. The distal pancreatic duct was filled with contrast and well visualized. There were no abnormalities. He had an area of stricture in the left hepatic duct with proximal marked dilatation consistent with primary sclerosing cholangitis, focal Caroli's disease or cholangiocarcinoma. He is now referred for consideration of left hepatic lobectomy.
MEDICAL HISTORY: Stomach pain since [**2173**].
MEDICATION ON ADMISSION:
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY: Mother ahs heart disease. There is no family history of liver disease.
SOCIAL HISTORY: He has one or two social alcoholic beverages per month. He smokes five cigarettes per day. He has no history of intravenous drug use, marijuana use, blood transfusions, hepatitis or piercing. He has a college education and is a graduate student at [**Location (un) 35240**] [**Location (un) **]. He is single and has no children. | 0 |
28,224 | CHIEF COMPLAINT: back pain
PRESENT ILLNESS: The patient is a 72 year-old female who presented to the B.I. [**Hospital1 **] emergency room, transferred from an outside hospital with a diagnosis of a ruptured leaking aneurysm. The patient remained hemodynamically stable and upon arrival underwent a CT angiogram of the abdomen and pelvis which confirmed the suitability of the aortic aneurysm for endovascular repair. Therefore, the patient was brought up to the Endo suite for immediate endovascular repair.
MEDICAL HISTORY: [**Last Name (un) 1724**]: lasix 40 [**Last Name (LF) **], [**First Name3 (LF) **] 81', advair, singulair, albuterol, protonix 40', isordil 30', cardia xt 180', simvastatin 20', klor-con
MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: lasix 40 [**Last Name (LF) **], [**First Name3 (LF) **] 81', advair, singulair, albuterol, protonix 40', isordil 30', cardia xt 180', simvastatin 20', klor-con
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: a/o nad cta rrr abd - benign DP palp bilat
FAMILY HISTORY: not known
SOCIAL HISTORY: not known | 0 |
69,585 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 61-year-old white male dermatologist with history of chest pain since [**2156**]. He had a positive exercise treadmill test that ultimately prompted him to undergo a percutaneous angioplasty with stent in [**2164-4-11**]. In [**2164-9-11**] he was ultimately restented and then in [**2165-6-11**] underwent iridium with stenting. He had recurrence of chest pain in [**Month (only) 216**] and went back to the cath lab ultimately in [**2165-12-12**] showing 100% left circumflex disease stenosis, oblique marginal I 100%, oblique marginal II 100% and right coronary artery 90% stenosed.
MEDICAL HISTORY: Hypertension, periodic movements of sleep, hypercholesterolemia, tophaceous gout, aphthous stomatitis, GERD as well as acoustic neuroma in the left ear 15 years ago.
MEDICATION ON ADMISSION: Medications on admission included atenolol 50 mg p.o. in the morning and 100 mg p.o. q.h.s., Accupril, Lipitor, allopurinol, colchicine, ranitidine, aspirin.
ALLERGIES: Benzoin.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
65,715 | CHIEF COMPLAINT: CSF Rhinorrhea
PRESENT ILLNESS: 53M with a recent discharge from the neurosurgical service on [**2181-11-16**]. Underwent R temp craniotomy for metastatic adenocarcinoma on [**2181-10-5**] followed by XRT 10 sessions finishing mid [**Month (only) **]. Presented to [**Hospital1 18**] [**2181-11-7**] with post nasal salty drainage and clear drainage from nose; admitted with lumbar drain placement for 1wk, was removed and had no nasal drainage. Discharged [**2181-11-16**] and called back on [**11-18**] am stating salty drainage from previous night back of throat and this morning several episodes "gushes of clear fluid" out his right nare. He also complains of left calf pain beginning yesterday that is exquisitly tender. Pt has only mild headache. Pt denies fever, chills, weakness, neuro changes.
MEDICAL HISTORY: Lung CA - s/p L Lower Lung Lobe resection [**2180**] [**2181-10-5**] - s/p Right craniotomy for resection of mass
MEDICATION ON ADMISSION: Simvastatin 40 mg Tablet PO DAILY Levetiracetam 500 mg 2 Tablets PO BID Docusate Sodium 100 mg Tablet PO BID Hydromorphone 2 mg Tablet PO Q4H PRN
ALLERGIES: Penicillins
PHYSICAL EXAM: Upon Admission: PHYSICAL EXAM: O: T:98 BP:118/ 66 HR: 76 R16 O2Sats 95RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils:3->2 EOMs full Neck: Supple.
FAMILY HISTORY:
SOCIAL HISTORY: Social Hx: married, 50pk yr tobacco hx, occas EtOH | 0 |
76,746 | CHIEF COMPLAINT: Acute Renal Failure, Urinary Obstruction, Coagulopathy, Atrial Fibrillation with Rapid Ventricular Response
PRESENT ILLNESS: Mr. [**Known lastname 10528**] is an 81 year old Male with atrial fibrillation on coumadin, benign hypertension, who presents with 4 days of constipation and abdominal pain. He describes the abdominal pain as diffuse, mild, [**2180-4-13**]. Also has noted that his urine has been "backed up" for the past few days. Denies fever, chills, chest pain, SOB. He does have a cough productive of dark, thick sputum but this is chronic for years and unchanged. Denies dysuria. He did have some difficulty with constipation a couple weeks ago but that resolved more quickly. Usually, his stools are regular.
MEDICAL HISTORY: Benign Hypertension Paroxsysmal Atrial fibrillation on coumadin s/p Bilateral cataract removal Surgical resection for unknown Head & Neck cancer, requiring removal of Right jugular vein, right and left submandibular nodes and all of his mandibular teeth and subsequent radiation
MEDICATION ON ADMISSION: (Per chart, pt only mentioned 2 meds) Metoprolol 12.5mg PO BID Lisinopril 10mg PO daily HCTZ 25mg PO daily Protonix 40mg PO daily Coumadin 6mg PO daily
ALLERGIES: Penicillins
PHYSICAL EXAM: Admission Physical Exam: Vitals: T: 99.3, BP: 148/83, P: 134, R: 22, O2: 96% 4L General: Alert, oriented, pleasant elderly male in no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, edentulous Neck: supple, JVP elevated to ear lobe, no LAD, markedly contracted skin with radiation telangectasias Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mild RUQ tenderness, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 1+ distal pulses, trace ankle edema
FAMILY HISTORY: Non-contributory
SOCIAL HISTORY: Lives with his wife. Retired, formerly worked for Eastern Airline in the cargo, mail, and freight department. Smoked 3ppd x 30+ years, quit in [**2151**]. Quit EtOH in [**2151**]. No illicit drug use. | 0 |
84,117 | CHIEF COMPLAINT: aphasia
PRESENT ILLNESS: [**Known firstname **] [**Known lastname 18825**] is a 50 year old RH woman assessed in the past for atrial flutter at the [**Hospital **] clinic in [**Location (un) 620**] in [**2191**] by Dr. [**Last Name (STitle) **]. A holter study in 03 / 03 showed three recordings with runs of Atrial fibrillation. After that evaluation, she did not return to this clinic and remained most of the time symptoms-free. However, a year ago she started with episodes of palpitations accompanied occasionally by chest pressure. It is centrothoracic, non-radiated, not associated to n-v, lightheadedness or any other symptoms. Initially she associated it with exercise,though eventually it happened at rest. The pressure would last for 15 minutes sometimes, whereas the palpitations would occasionally last for 2 hours. She had never had any focal weakness, numbness, diplopia, dysarthria, dysphagia or any other neurological symptoms. She denies talking any pills to lose weight, or drugs, or thyroid hormone. She has no asthenia/ anorexia. There was no special diets, or evidence of CHF by history. Finally, she is not pregnant. There is no weight loss, no diarrhea or aother hyperthyroidism data. She does not abuse alcohol. Today she started feeling clumsy at 11:00 am. She could not properly close the zip in a coat. Then she tried to talk to her husband and found she could not produce words. She could understand him, but not convey words. The episode lasted for 5 minutes. She relates no weakness or numbness. No other accompanying symptoms. At 11:30 am she felt unable to speak again. This time for a few seconds. She canot actually clarify if the event was real or she was anxious. They decided to visit the [**Location (un) 620**] ED. Once there, she had another event at 2:00 pm. She was running HR 130 AF and received lopressor 5 mg iv. Then she received a CT Head scan: normal. Subsequently received ASA 325 and heparin drip (bolus of 3500 units) and was sent to [**Hospital1 18**] ED. She has an appointment with Dr. [**Last Name (STitle) **] (cardiology) in 2 weeks.
MEDICAL HISTORY: Atrial flutter diagnosed three years ago with runs of atrial fibrillation.
MEDICATION ON ADMISSION: Medications: Minocin 100 qd MVA Vit D and calcium carbonate (unknown dose): 2qwk Omega 3 oil.
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Physical Examination: VS:99.1F, 122/ 64, 70-90 bpm, RR12, 100% in RA. Gen: Lying in bed, NAD. HEENT: NC/AT, moist oral mucosa. Neck: supple, no carotid or vertebral bruit. No meningysmus. No goiter or nodules at palpation, no bruits. Back: No point tenderness or erythema CV: tachycardic, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: Soft, nontender, non-distended. No masses or megalies. Percussion within normal limits. +BS. Ext: no edema, no DVT data. Pulses ++ and symmetric.
FAMILY HISTORY: Family history: grandmother with MI and stroke at age 63.
SOCIAL HISTORY: Social history - she is a mother of three kids, works in a dermatologist office. She does not smoke and consumes 2 glasses of wine per night. Denies drugs | 0 |
58,221 | CHIEF COMPLAINT: worsening shortness of breath, arm pain with exertion
PRESENT ILLNESS: Patient is an 81yo caucasian female with pmhx CAD, RV dysfunction, EF 35%, CVA, DM, CKD, PVD, and known aortic stenosis now symptomatic with recent hospitalization for acute on chronic CHF requiring aggressive diuresis. Echo at the time revealed [**Location (un) 109**] 0.8 cm2. She reports episodes of dizziness and fatigue, loss of balance when going from sitting to standing position, ability to go up only 2 stairs before stopping due to SOB, near syncopal episodes with stair climbing, and ability to walk only 20 feet before needing to stop. During clinical visit, witnessed onset of RUE arm pain with 5 meter walk test. She is being referred for aortic valve treatment options.
MEDICAL HISTORY: - Aortic stenosis s/p AVR - Heart Failure(Diastolic, chronic) - Hypercarbic Respiratory Failure - Atrial Fibrillation - Right Ventricular dysfunction - Pulmonary hypertension - Obstructive Sleep Apnea - uremia - Coronary artery disease s/p CABG x2 - Acute Renal Failure
MEDICATION ON ADMISSION: ATORVASTATIN 80 mg daily, CITALOPRAM 40 mg daily, ERGOCALCIFEROL (VITAMIN D2) [DRISDOL] 50,000 unit Capsule weekly, FUROSEMIDE 80 mg [**Hospital1 **], GLIPIZIDE 5 mg [**Hospital1 **], HYDROCODONE-ACETAMINOPHEN 5 mg-500 mg Tablet PRN Q8 hours PRN, METFORMIN 1,000 mg [**Hospital1 **], METOPROLOL SUCCINATE 150 mg daily, ZOLPIDEM 10 mg daily, ASPIRIN 81 mg daily, CYANOCOBALAMIN (VITAMIN B-12) 1000 mcg
ALLERGIES: Nitrofurantoin / Phenazopyridine / Sulfa(Sulfonamide Antibiotics) / Percocet / Penicillin V
PHYSICAL EXAM: Pulse: 63 B/P: Right 127/39 Left 129/48 Resp: 18 O2 Sat: 94% (RA) Temp: 97.6 Height: 62 inches Weight: 165 lbs General: alert pleasant elderly female in NAD while seated in wheelchair. Skin: color pink, skin warm and dry, no lesions/decubiti, turgor fair. HEENT: normocephalic, anicteric, conjunctiva pink. Neck: neck supple, trachea midline, carotid bruit vs. murmer Chest: no obvious defomitities/scarring. LS essentially CTA. Heart: murmer RSB radiating to neck. Abdomen: soft, NT, ND, (+)BS x 4 quadrants Extremities: no obvious deformities, 2+ pedal edema bilaterally. Neuro: alert, pleasant, gross FROM Pulses: palpable peripheral pulses.
FAMILY HISTORY: - mother deceased age 76, lung cancer - father deceased age 39, "gassed" in the war - 2 brothers deceased in their 80's, DM,CAD - sister deceased age 86, throat cancer - 2 daughters alive and well.
SOCIAL HISTORY: lives in ranch style home, 2 steps to enter, uses three prong cane and walker as needed. Last Dental Exam: Dr. [**First Name (STitle) **] ([**Location (un) **], NH) Lives with: husband Occupation: retired (worked at Sears) Tobacco: [**1-20**] ppd age 17-40, quit 40 years ago ETOH: 1/week | 0 |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.