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87,200 | CHIEF COMPLAINT: Severe aortic stenosis.
PRESENT ILLNESS: Mr. [**Known lastname 30380**] is a 56 year old male who reports that he was diagnosed with aortic stenosis approximately three years ago. Over the years, he states that he had noticed progressive dyspnea on exertion. Currently he finds that he becomes short of breath after climbing just one flight of stairs. The previous summer, he experienced two syncopal episodes which both took place in very hot weather while he was doing strenuous work. He states that prior to these episodes he was very short of breath because of the amount of exertion he was involved in. He states that he lost consciousness for several minutes during those episodes. His most recent echocardiogram was in [**2154-8-8**], which showed an ejection fraction of approximately 60 to 70% and a mildly dilated left atrium. The right atrium and aortic root were also mildly dilated. The aortic valve was bicuspid with severely thickened and deformed leaflets, and there was moderate aortic stenosis with a peak gradient of 82 millimeters of mercury and a mean gradient of 52 millimeters of mercury. The estimated valve area at this time was 0.9 centimeters. There was also trace evidence of aortic insufficiency. The patient denied any history of angina or other symptoms of coronary artery disease. He denied claudication, orthopnea, paroxysmal nocturnal dyspnea, and lightheadedness. He did state that he did have occasional lower extremity edema at the end of the day.
MEDICAL HISTORY: 1. Hypertension for 20 years. 2. Obesity. 3. Sleep apnea on CPAP at night. 4. Severe knee and elbow pain due to prior history of playing football. 5. Elevated baseline creatinine due to many years of ibuprofen overuse.
MEDICATION ON ADMISSION: 1. Aspirin 81 mg q. day. 2. Cardia 300 mg once a day. 3. Amiloride/HCTZ 5/50 mg q. day. 4. Lisinopril 20 mg q. day. 5. Ibuprofen 800 mg twice per day.
ALLERGIES: The patient has no known drug allergies but is allergic to shellfish and dye.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient is married and works as a sales manager. He has a history of tobacco use which he quit 11 years ago. He occasionally consumes alcohol in social settings. | 0 |
47,662 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 21-year-old female, status post a fall while intoxicated from a fire escape, who landed on her head with positive loss of consciousness. The patient was unresponsive, but per Emergency Medical Service was moving all extremities. The patient was intubated, collared, and brought to the Emergency Department. The patient had stable vital signs en route. In the Emergency Department, she was moving all extremities in the trauma bay but not following commands. She had received Fentanyl, succinylcholine, and vecuronium for the intubation.
MEDICAL HISTORY: None.
MEDICATION ON ADMISSION: None.
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The use of alcohol. No other social history known. | 0 |
25,696 | CHIEF COMPLAINT: dyspnea
PRESENT ILLNESS: 65 yo F with hx of COPD, non small cell lung cancer s/p chemo and radiation in [**2175**], OSA who presents with dyspnea. Patient reports gradual worsening dyspnea over the last week. She saw her PCP and was started on Zpack and steroid burst however she continued to feel badly. She reports productive cough. Denies fever. At baseline able to walk a few blocks but recently only able to walk 10 feet from her bed to her bathroom. Denies lower extremity swelling. . In the ED, initial vital signs were 99.2 96 140/69 24 83%. Exam was significant for diffuse rhonchi. Labs significant for WBC of 16.2 with 92% neutrophils. CXR revealed multilobar pneumonia and was given a dose of levofloxacin and methylprednisolone 125 mg x1. She was treated with nebs x 3. She was placed on 4L nasal cannula with sats around 90%. She was subsequently admitted to the MICU for further care. . On arrival to the MICU, patient felt improved. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes.
MEDICAL HISTORY: - Stage IIIb lung cancer diagnosed 3 years ago now s/p chemo & XRT - Asthma/COPD - [**Doctor Last Name 933**] disease s/p RAI - GERD s/p Nissen fundoplication - Hypertension - Sinusitis - Depression - Anal fissure - Tonsillectomy - Hemorrhoidectomy - Pilonidal cyst excision - Ear plastic surgery - Appendectomy
MEDICATION ON ADMISSION: 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Xopenex Inhalation 6. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a day. (takes 2 tabs on sunday) 7. mom[**Name (NI) 6474**] 50 mcg/Actuation Spray, Non-Aerosol Sig: [**11-29**] Nasal once a day. 8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 9. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: as directed Inhalation as directed. 11. trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 14. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) 15. Januvia 50 mg qd 16. Diovan 80 mg qd 17 levemir 38 units qpm
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Physical Exam on Admission:
FAMILY HISTORY: - Mother: HTN, TTP, goiter - Father: [**Name (NI) 3495**] disease, CVA, lung cancer - Sister: MS - Brother: Psychiatric illness
SOCIAL HISTORY: - 30 pack year smoker, quit in [**2157**] - No EtOH use - No exposure to radiation or asbestos - She is single and lives alone, she works as an inspector for [**Company 80094**] | 0 |
42,294 | CHIEF COMPLAINT:
PRESENT ILLNESS: Short gut syndrome, chronically occluded superior vena cava, right brachiocephalic vein and right jugular vein, occlusion of the inferior vena cava and both common iliac veins, TPN dependent. polyposis, she had resection of her colon at age 20 and now has a high output ileostomy. She is dependent on TPN although she can take small amounts of oral food. Over the years, she has chronically occluded both internal jugular veins, both subclavian veins and the upper segment of the superior vena cava. She came in [**2138-7-26**], to our attention when she had developed Staphylococcus aureus sepsis At this time, we removed a tunneled femoral catheter which had been tunneled from the right groin into the left upper chest and placed temporary access. After clearing of the infection, we were attempting to recanalize the occluded central veins but were unsuccessful, even with a sharp recanalization technique. On [**2138-12-9**], I then decided to place a new tunneled right femoral 7French double lumen Hickman catheter with tip at the level of L1 and the exit site over the lateral thigh. The patient came to see on [**2139-9-7**], in clinic with the chief complaint of line dysfunction. She had noticed some sluggishness of return during TPN infusions and then had stopped TPN and only placed hydration. She brought a venogram from [**2139-8-26**], which demonstrated that the tip of the catheter had pulled back into the distal inferior vena cava. There was some high grade narrowing in both common iliac veins which were still patent at this time. The inferior vena cava was not filled and there were paralumbar collaterals. On [**2139-9-11**], she was admitted to St. [**Hospital 107**] Medical Center in [**Hospital1 189**], [**State 350**] for line sepsis, generalized weakness, near syncope and low grade fever. She came to the [**Hospital1 69**] on [**2139-9-15**]. She presented in a severely debilitated status. Her blood pressure was 96/54, with a pulse rate of 123, temperature 100, and oxygen saturation 99%. The catheter over the right thigh had pulled back with the calf being outside of the skin. There was some swelling and induration over the right thigh extending to the level of the knee which was suggestive of deep venous thrombosis but additional superinfection and cellulitis could not be ruled out. The lungs were clear. The abdomen was soft. There was an intact left lower quadrant ileostomy. The heart rate was regular and considering the rate, murmurs could not be elicited. To assess her semi-obtunded status, blood was drawn which revealed a severe hypomagnesemia with a level of 0.7 and a hematocrit of 26.6. She received an infusion of Magnesium. Because of an antibody to the blood, blood was ordered but couldn't be transfused before the start of the procedure. To reduce further risks of sepsis due to the line, we proceeded with recanalization of the inferior vena cava. Because of the patient's low pain threshold, all procedures had to be performed under MAC anesthesia. I removed the tunneled right femoral line and replaced it with a 7French bright tip sheath. I also gained access through the left femoral vein. It was possible to recanalize both iliac veins and the chronically occluded inferior vena cava. Infusion catheters were placed and TPA was infused for the remainder of the day and of the night. On [**2139-9-16**], the patient returned to the angiography suite in the morning. Some interval lysis had occurred. The TPA infusion was continued until the afternoon. In the meantime, she had been transfused with two units of packed red blood cells and her hematocrit had reached 30.0. In the afternoon, I was able to dilate the occluded inferior vena cava and place kissing stents in the chronic occlusion channels of the inferior vena cava. Stents were also extended into both common iliac veins and the adjacent segments of the external iliac veins. The patient was heparinized overnight. The next morning a follow-up was done which demonstrated that the left sided system was still open. On the right side, a separation between the caval and the iliac stent had occurred and the inferior stent had moved slightly laterally. The main goal for this day's procedure was to give the patient also a superior vena cava access since it became clear that she would be having recurrent infections in the long run. The main treatment goal was to provide for the future three access sites: one for a tunneled line, one for a temporary line should the permanent one become infected and needs pulling, and a 3rd for a new tunneled line, considering this patient is life- long tpn. She was controlled with Vancomycin. Her levels on the one gram per day regimen was what she came from the outside revealed a Vancomycin random level of 40. With input from infectious diseases consult over the next days, appropriate Vancomycin regimen was obtained. On [**2139-9-17**], I then undertook sharp recanalization of the superior vena cava through a right internal jugular approach by placing a snare into the superior vena cava as a target. It was possible to recanalize the internal jugular, brachiocephalic, and superior vena cava with stents and place a temporary double lumen catheter. In the same session, I also repaired the separated caval stent by placing of an additional briding stent. By the next morning, the patient remained heparinized. She had some oozing around the right neck exit site. I had removed the femoral access on the evening before to reduce the overall risk of infection. We had obtained cultures from the tip of the previously indwelling tunneled catheter and blood cultures were obtained. There was no growth to date. A regimen with one gram Vancomycin every eighteen hours was then achieved with appropriate trough levels. Ultimately, the right internal jugular line was exchanged for a tunneled 7French double lumen Angiodynamics catheter of 57 centimeter length. The tip was placed into the superior vena cava. In the following course, the patient had only low grade temperature to 100, however, no spikes. She was transferred to the [**Hospital1 **] from the Intensive Care Unit on [**2139-9-22**]. On [**2139-9-22**], she still had some swelling of her neck and both arms which may have been related to fluid therapy. An ultrasound on [**2139-9-13**], demonstrated that the internal jugular vein and superior vena cava were patent compatible with a successful recanalization. On [**2139-9-23**], the swelling had been much reduced so that now there also was a satisfying clinic result, and on [**9-24**] facies and arms were normal. We had attempted to Coumadinize her since she had been on Coumadin on the outside. However, because of the unreliable gastrointestinal absorption, we decided to add instead greater amounts of Heparin to her TPN and her daily infusion regimen. Of note, her hematocrit drifted again down to 23.0% on [**2139-9-22**]. This included a blood loss of about 250 cc for all the surgical interventions. We therefore transfused her again with two units of packed red blood cells. From an infectious disease point, she never expressed open sepsis. We will keep her on Vancomycin until [**2139-9-24**]. She developed an oral herpes which was treated for five days with Acyclovir. The TPN is to be reinstituted with a nightly infusion. With hematology consult we recommend to add folate and B12. B12 may not be stable in TPN, so she may need addional injections. We drew folate and B12 levels today. results are pending. adapted the composition to address the recurrent. Heparin in the TPN infusion bag should be increased to 8000 U per day. The daily 1 L infusion of D5-/2NS should be supplemented with 5000 U heparin to be infused over the day. Additional fluid should not contain heparin if need for hydration in presence of a high out put ileostomy. We also obtained hematology consultation to address the issue of recurrent bouts of anemia which the patient also had at home. This resulted in the B12 and folate additon recommendation. We also drew today Ferritin, folate, B12 and reticulocyte counts. Dr. [**Last Name (STitle) 3060**] will follow up with outpatient consult. Recommend also bone density study because of prior hysterectomy and heparin use as well as genetic cousneling because of [**Doctor First Name **] familial inbcidence of cancer to assess for Li-Frameni BRCA. On discharge, the patient is stable. She has no signs of acute infection.
MEDICAL HISTORY:
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
42,049 | CHIEF COMPLAINT: Increased chest pain and shortness of breath.
PRESENT ILLNESS: The patient is a 68-year-old gentleman with a known history of coronary artery disease and recent onset of atrial fibrillation. The patient complained of increased symptoms of dyspnea and angina. He underwent cardiac catheterization, which revealed three-vessel disease. He is now admitted for coronary artery bypass graft.
MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction 2. Recent onset atrial fibrillation in the past eight weeks. 3. Tuberculosis. The patient was hospitalized for two months in the [**2095**]. 4. Hypertension. 5. Noninsulin dependent diabetes mellitus. 6. Gastroesophageal reflux disease. 7. Prostate carcinoma status post XRT and brachytherapy. 8. CVA times three in [**2098**], [**2108**], and [**2111**]. 9. Hypercholesterolemia.
MEDICATION ON ADMISSION: 1. Plavix discontinued [**4-11**]. 2. Detrol 2 mg b.i.d. 3. Atenolol 75 mg in the AM; 50 mg q.PM. 4. Glyburide 3 mg b.i.d. 5. Lipitor 10 mg h.s. 6. Amitriptyline 10 mg q.d. 7. Zestril 30 mg q.a.m. and 10 mg q.p.m.
ALLERGIES: The patient is allergic to ASPIRIN, WHICH CAUSES INCREASED FACIAL SWELLING AND INCREASED SHORTNESS OF BREATH.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
81,046 | CHIEF COMPLAINT: Chest pain
PRESENT ILLNESS: 64 y/o male with h/o CAD (s/p 5VCABG [**2176**]), HTN, and hyperlipidemia who presented with acute onset of CP. Patient states that recently he has noticed increasing exertional CP (chest pressure) over the past year. Today, around 1pm, he developed non-exertional [**10-9**] SSCP associated with SOB and diaphoresis. Pt was taken to OSH. EKG showed STE in V2, V3, aVf and STD in V1, aVL. Pt was med-flighted to [**Hospital1 18**] for cath. . In the cath lab, he was found to have occluded SVG to D1 and RCA; patent LIMA to LAD, SVG to OM1; severe 3VD. 90% stenosed RCA was stented with 2 overlapping drug eluting stents. Mildly elevated R and L sided pressure. Normal CO/CI. . The patient was transferred to the CCU post-cath for further monitoring and managment. In the CCU, pt was asymptomatic without any CP, SOB, diaphoresis, nausea, or pain.
MEDICAL HISTORY: CAD (s/p 5VCABG [**2177-12-12**]) HTN Hyperlipidemia
MEDICATION ON ADMISSION: Aspirin 81 mg daily Atenolol 25 mg daily Atorvastatin 40 mg daily
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS: T97.2 P77 BP 141/70 RR 19 99%2L Gen: well-appearing, pleasant Neck: JVP 6cm, no carotid bruits CVS: distant HS, no m/g/r Lungs: CTAB anteriorly Abd: soft, NT, ND, +BS Ext: no edema Groin: A and V sheaths in place.
FAMILY HISTORY: Father died of stroke in 70s. Sister with rheumatic fever.
SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] denies tobacco, EtOH, or IVDU. He is currently unemployed. | 0 |
35,155 | CHIEF COMPLAINT: large IPH
PRESENT ILLNESS: The patient is a 70 year old man with a h/o prior stroke now presenting with a large IPH. The patient is unable to give a history so details are taken from his medical record. He was in his usual state of health until right after dinner, he arose from the table and then collapsed to the ground. He was "out of it" for about a minute. When he came to, he was agitated and confused. EMS was called and he was taken to Caritas [**Hospital 39167**]. A head CT there revealed a small amount of right parietal subarachnoid blood. During his stay there, he also vomited and was intubated for aspiration protection. He was transferred to [**Hospital1 18**] for further care.
MEDICAL HISTORY: -atrial fibrillation -CAD s/p CABG -h/o rectal polyps -h/o old left parietal stroke -h/o sleep apnea
MEDICATION ON ADMISSION: ASA Simvastatin Amiodarone 200 Clopidogrel 75 Furosemide Ramipril
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Vitals: 98.6 155/88 88 16 General: older man, intubated Upon admission: Neck: supple Lungs: clear to auscultation CV: irregular rhythm Abdomen: non-tender, non-distended, bowel sounds present Ext: warm, no edema
FAMILY HISTORY: unknown
SOCIAL HISTORY: -lives with wife -no tobacco or alcohol use | 0 |
66,993 | CHIEF COMPLAINT: unwitnessed fall at home/[**Hospital3 **] facility, rapid heart rate
PRESENT ILLNESS: Mrs. [**Known lastname 10528**] is a [**Age over 90 **]-year-old female with PMH significant for atrial fibrillation,HTN, breast cancer (s/p mastectomy [**2049**]), hypothyroidism, who was originally admitted on [**11-28**] following an unwitnessed fall at home. Prior to ED arrival the patient had been evaluated by her PCP at her [**Hospital3 **] facility for left shoulder pain which was felt to be due to an effusion. According to patient she went into her bathroom, remembers sitting on the toilet, then she fell to the floor. She did not recall feeling lightheaded or dizzy. She denied any palpitations, chest pain, or acute onset of shortness of breath. She did not believe that she lost consciousness and could recall details of her entire fall. Patient believes she was on the floor for a few hours because she found it very difficult to pull herself up. She reported that she thought she may have hit her head and left shoulder. . In the ED her initial vitals were T 98F, HR 156, BP 160/80, RR 22, and O2 sat 95% on RA. She was found to be in rapid atrial fibrillation to the 150's and was started on a diltiazem drip with initial good effect. She received a dose of ciprofloxacin for a positive UA in the setting of a leukocytosis to 19. CT of the head and neck were negative for any fractures, and no intracranial bleeds were noted. Bilateral shoulder x-rays were negative for fractures or dislocations. . At time of arrival to the medical floor patient's rate was down to the 60's-70's. She denied any palpitations, CP or SOB. Her main complaint was left sided shoulder pain, which had been chronic for some time. She denied any recent illnesses including URI symptoms, urinary symptoms, diarrhea, nausea or vomiting. She reported poor appetite for a few days. . . On the medical floor, she subsequently had multiple triggers for atrial fibrillation with RVR. Blood cultures from admission grew GPC so she was started on Vancomycin on [**11-29**]. Due to complaints of left shoulder pain, she then underwent arthrocentesis of the left shoulder. Culture of the joint fluid ultimately yielded MSSA, as did multiple blood cultures ([**2-24**] from [**11-28**], [**12-29**] from [**11-29**], and [**12-25**] from [**11-30**]). She was seen by the cardiology service who recommended changing her from diltiazem for metoprolol. . Of note, her fluid balance remained positive throughout the beginning of her hospital course, and her weight increased from 68->73kg. Due to concern over ARF, she received IVFs and she then developed fluid overload, pulmonary edema and hypoxia which required transfer to the MICU for stabilization. Her MICU course was complicated by AFib/Flutter with RVR occasionally requiring IV nodal agents. She was aggressively diuresed in the MICU with IV furosemide and at time of transfer, her shortness of breath had abated and her oxygen saturation level was much improved to 96% on 5L NC. . Once she stabilized she was transferred to [**Hospital1 1516**]/Cardiology service for ongoing management and continued on Diltiazem drip for rate control. At time she transferred out of MICU, she was receiving Diltiazem Extended-Release 300 mg PO daily and Metoprolol Tartrate 25 mg PO TID, with additional IV agents as needed. The patient's bacteremia was felt to be related to an underlying endocarditis. Echocardiogram on [**2102-11-30**] showed EF of 70%, mild AS, and at least moderate 2+ mitral regurgitation. No comparisons existed in our system. Patient was also complaining of diffuse generalized abdominal pain that had been present for 2 days near the end of her MICU course prior to transfer to cardiology service. The patient had not had a bowel movement in about 4 days. Surgical service was called due to preliminary read on abdominal CT which showed SBO and incarcerated right inguinal hernia which was reported to be at transition point near terminal ileum. Surgery consult called and evaluation on the floor found that hernia was reducible. Primary team placed NGT for ease of her abdominal pain and distension from SBO/ileus. Surgical options were limited due to multiple co-morbidities, especially her bacteremia, suspected endocarditis, unstable atrial fibrillation with RVR and her ongoing dyspneic episodes. This prompted multiple discussions with patient and family surrounding goals of care during the last days of her hospital course. The palliative care service had been following the case and had multiple patient/family meetings. She pulled her NGT out on two occasions and her mentation was less clear toward the end of her hospital course. She was given low doses of morphine, Tylenol, and anti-emetics for SBO-related abdominal pain control. Ultimately, the patient's family (HCP/son) asked for no additional invasive measures, especially surgery. Code status was changed to DNR/DNI, and she was soon made comfort measures only per family's wishes. Sadly, she passed away soon thereafter on the morning of [**2102-12-8**].
MEDICAL HISTORY: -Breast Cancer, s/p L mastectomy in [**2049**] -Atrial Fibrillation, rate controlled on metoprolol, unclear if on coumadin -Hypothyroidism -Hypertension -? RA -HTN -h/o falls -OA, DJD hips/knees -uterine prolapse
MEDICATION ON ADMISSION: Home Meds: -Amlodipine 10 mg daily -ASA 81 mg daily -Lisinopril 40 mg daily -Metoprolol Succinate 50 mg daily -Zofran 4 mg Q6-8hrs:PRN ................................. MEDICATIONS ON TRANSFER from MICU to [**Hospital1 1516**]/Cardiology floor on [**2102-12-7**]: APAP ASA 81MG CAPTOPRIL 6.25MG TID DILTIAZEM 300MG XR DAILY DOCUSATE 100MG PO BID SENNA 1 TAB PO BID HEPARIN SC IPRATROPIUM NEBULIZER LACTULOSE 30MG PO TID LEVOTHYROXINE 100MCG DAILY METOPROLOL TARTRATE 50MG TID MILK OF MAGNESIA NAFCILLIN 2G IV Q6H, DAY 1=[**12-7**] OMEPRAZOLE 40MG DAILY ONDANSETRON 4MG IV Q8H COMPAZINE 10MG IV Q6H PRN
ALLERGIES: Sedatives, Barbiturate, Classifier
PHYSICAL EXAM: Initial Admission Exam: Vitals 98.5F, HR 144, BP 141/86, RR 19, O2 Sat 92% on 5L General Thin elderly woman moaning HEENT Sclera anicteric, conjunctiva pale, dry MM Neck +JVD Pulm Lungs with occasional wheeze bilaterally (exam limited by patient pain on movement) CV Tachycardic irregular S1 S2 soft systolic murmur at apex Abd Soft nontender +bowel sounds Extrem Warm 2+ distal pulses 2+ bilateral LE edema. L shoulder very tender to light touch. Neuro Alert and awake, oriented x3 and attention intake. Moving all extremities. Derm No peripheral stigmata of endocarditis . . Exam on transfer out of MICU to the [**Hospital1 1516**] Cardiology service: HR 130s, BP 118/72, O2Sat 95% on 6L NRB, RR 28, afebrile GEN: Pallid, frail appearing female with slight nasal flaring but no accessory muscle use, no complaints of pain HEENT: NC/AT, EOMI, PERRLA NECK: JVP at 8-9cm, supple COR: Irregular rhythm, rapid rate. S1 and S2 appreciated, loud S2 and 3/6 systolic flow murmur at sternal border, no rubs, 2+ carotids B/L PULM: coarse breath sounds over anterior lungs/upper posterior fields and decreased lung sounds at bases bilaterally. She has large left breast mastectomy scar and a small scabbed over sore over left chest about size of a quarter, rounded. No active bleeding or discharge at site. ABD: Diffuse distension, soft, +extreme tenderness at RLQ and mild tenderness over umbilical area, + rebound tenderness, reducible right inguinal hernia noted. EXT: Pitting edema of lower extremities bilaterally
FAMILY HISTORY: non-contributory
SOCIAL HISTORY: Lived at Foley Senior House/[**Hospital3 400**] Center. Used to live in [**First Name8 (NamePattern2) 42531**] [**Last Name (NamePattern1) 3908**] and worked as administrative assistant. She enjoys painting. She has nursing assistance at facility to help with her medications. Smoked cigarettes for 20-30 years and quit 50 years ago. Denies any ETOH use. No prior drug use history. She is wheelchair bound due to multiple prior falls. | 1 |
16,552 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 53-year-old woman with a history of diabetes, chronic hypertension, and congestive heart failure, who presented originally with postmenopausal bleeding x1 episode. An ultrasound done as an outpatient showed an endometrial stripe of 12 mm and normal ovaries. The decision was made to do a D and C to rule out malignancy.
MEDICAL HISTORY: Significant for coronary artery disease, CHF with a ejection fraction of 55% on a [**2192-3-28**] echo, insulin dependent diabetes, atypical chest pain with a negative work up and a negative MIBI on [**2192-3-28**], asthma, sleep apnea, anemia, lower extremity edema, GERD, and a PE in [**2188-9-28**] requiring 12 months of Coumadin anticoagulation, obesity, hypercholesterolemia, migraines, colon polyps, depression, hypercholesterolemia.
MEDICATION ON ADMISSION: Singulair 10mg QD Prilosec 20mg QD Renagel 800mg TID, w/meals Humulin Seroquel 25qhs Verapamil 240 QD Albuterol Buproprion Aranesp Lisinopril 20 QD Effexor Lasix 40mg QD Advair
ALLERGIES: Codeine, aspirin, Augmentin, Trazodone, ibuprofen, Atrovent, Reglan, Ampicillin, and Lipitor.
PHYSICAL EXAM:
FAMILY HISTORY: Significant for heart disease, diabetes, and colon cancer.
SOCIAL HISTORY: She lives alone and ambulates independently. She denies any type of alcohol or drug use. | 0 |
76,811 | CHIEF COMPLAINT: shortness of breath
PRESENT ILLNESS: 79 year old male with moderate to severe aortic regurgitation with associated fatigue, dyspnea and neck pain was admitted preoperatively for an Aortic Valve Replacement on [**2182-5-9**]. He was placed on heparin drip for Coumadin washout for paroxysmal Atrial Fibrillation. Initial labs were drawn and revealed neutropenia and an elevated creatnine from baseline. Based on Mr.[**Known lastname 101329**] history of renal transplant, the Renal Transplant Service was consulted. His medications were reviewed and recommendations were made. His Cyclosporine and prednisone were continued. Azathioprine and Colchicine were discontinued per renal. Labs were monitored. His Creatnine drifted down to 1.5 and WBC ct=1.5 on [**5-14**]. The decision was made to rescreen Mr.[**Known lastname 57554**] for rehab with postponement of his AVR until his lab values trend towards normalizing. He returns to [**Hospital1 18**] today for heparin bridge preop AVR/? Asc.Ao.Replacement with normalizing lab values.
MEDICAL HISTORY: 1. Moderate-to-severe aortic insufficiency with dilating LV, currently be evaluated for valve replacement by cardiac surgery. 2. Recent cardiac catheterization showing no obstructive coronary artery disease, however, found to have elevated filling pressures, requiring diuresis. 3. Hypertension. 4. Kidney transplant in [**2155**] due to PCKD, the baseline creatinine approximately 1.6. 5. Hyperlipidemia. 6. Peripheral neuropathy. 7. Diverticulitis. 8. Pseudogout. 9. Osteoporosis. 10. Atrial fibrillation, currently on Coumadin for thromboembolic prophylaxis.
MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Alendronate Sodium 70 mg PO QSUN 2. Benzonatate 100 mg PO TID:PRN cough 3. CycloSPORINE (Sandimmune) 100 mg PO DAILY 4. Diltiazem Extended-Release 120 mg PO DAILY 5. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **] 6. Hydrochlorothiazide 12.5 mg PO DAILY 7. Lovastatin *NF* 20 mg Oral daily 8. Metoprolol Tartrate 75 mg PO TID 9. Furosemide 40 mg PO BID 10. Fluticasone-Salmeterol Diskus (100/50) 2 INH IH [**Hospital1 **] 11. PredniSONE 5 mg PO DAILY 12. Warfarin 2.5-3.75 mg PO DAILY 13. Aspirin EC 81 mg PO DAILY 14. Guaifenesin [**4-25**] mL PO Q6H:PRN cough 15. Multivitamins 1 TAB PO DAILY
ALLERGIES: Penicillins / Cephalosporins / ciprofloxacin
PHYSICAL EXAM: Admission Physical Exam 97.6 131/60 64AFib 18 100%RA General: NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM []Limitied ROM Chest: Lungs clear bilaterally []crackles right base, o/w clear Heart: RRR [x] Irregular [] Murmur [x] grade _2/6 syst__ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds [x] Extremities: Warm [x], well-perfused [x] Edema []+2 lower ext edema _____ Varicosities: None [x] Neuro: Grossly intact [x]
FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory.
SOCIAL HISTORY: Patient previously worked as an engineer for channel 5. He currently lives in a house himself. His wife passed away 9 years ago. Prior history of 3 ppd X 20 years, quitting 34 years ago. Occasional ETOH (few beers per week). No illicits. His daughters ([**Name2 (NI) **] (daughter) - ([**Telephone/Fax (1) 101330**], [**Female First Name (un) **] (daughter) [**0-0-**]) are very involved. | 0 |
56,472 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 41 year-old white female with a history of presenting with seizures in the fall of [**2131**], which led to a workup and an MRI, which showed an AVM of the right temporal region. She was admitted at that time for diagnostic angiogram, which confirmed the presence readmitted now for further angiographic embolization treatment of the AVM.
MEDICAL HISTORY: Otherwise unremarkable.
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: She is a nonsmoker with a positive alcohol intake history. | 0 |
50,081 | CHIEF COMPLAINT: resp distress, somnolence
PRESENT ILLNESS: This is a 44 y/o female with CAD s/p multiple stents, s/p CABG at age 34, who was recently at [**Hospital1 18**] from [**Date range (1) 13514**] for hypoxic respiratory failure requiring intubation and ARF thought to be [**3-13**] rhabdo and hypovolemia, who now p/w hypoxia, lethargy, and acute renal failure. Per report, she was found by her sister to be unresponsive today at home, and per son who saw her this morning, thought she was just "sleeping" but difficult to arouse. Her sister last talked to the patient yesterday evening around 6pm. Per history, pt was c/o of worsening back pain. It is unknown how long patient was down. [**Name (NI) 1094**] sister called EMS and pt was brought into the ED. Pt was noted by EMS to be cyanotic and no O2 sats were obtainable. . In the ED, VS were Tc 98.8, BP 138/77, HR 100, RR 28, SaO2 100%/NRB, AO x 1. Labs were significant for an ABG 7.01/77/113 on a NRB, K of 8.0 initially, Cr of 6.0. Phos was also markedly elevated at 16.7. She was given a dose of narcan and awoke marginally, but was still somnolent. For hyperkalemia, she was given 1 amp calcium gluconate, insulin 10 units IV, 1 amp of D50, 60 mg of kayexalate, and 1 amp of bicarb. She was afebrile, but given an elevated WBC of 19, was pan-cultured and given one dose of Levofloxacin. During her course, her SBP's dropped to the 60's-70's systolic and she was given a total of 5 L NS with response of SBPs to 110's. She was also started on a bicarb gtt given the metabolic acidosis. She was tried on BiPAP initially for a hypercapnia, however patient did not tolerate and was subsequently intubated. Post-intubation, she was hypotensive to 70's and was started on dopamine transiently, now weaned off. She is currently receiving her 6th L of NS, with 7th L hanging. Continues on bicarb gtt. Serum tox was negative, urine tox not obtainable at that time as pt was anuric in ED. . From the ED, she was transferred to the MICU for respiratory failure and ARF. Pt is currently sedated and intubated.
MEDICAL HISTORY: Stent of RCA graft ([**4-12**], [**6-12**], 5 overlapping stents RCA to PDA in [**10-13**]), OM1 DES in [**11-12**]) CHF (EF 30-40%, 2+MR, 2+ TR in [**7-13**]) HTN Hypercholesterolemia Obesity GERD Depression PVD Hypothyroidism DM II
MEDICATION ON ADMISSION: 1. Atorvastatin 80 mg qd 2. Toprol XL 50 mg qd 3. Lisinopril 5 mg qd 4. Clopidogrel 75 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Aspirin 325 mg PO DAILY 7. Furosemide 80 mg qd 8. Citalopram 40 mg qd 9. Glyburide 5 mg [**Hospital1 **] 10. Synthroid 50 mcg qd 11. Percocet 2 tabs q4 hrs 12. Folic acid 1 mg qd 13. Morphine sulfate 60 mg tid 14. Prilosec 15. Trazadone 300 mg qhs 16. Albuterol prn 17. Cytomel 5 mg qd 18. Compazine 5 mg prn
ALLERGIES: Succinylcholine / Penicillins / Sulfa (Sulfonamides)
PHYSICAL EXAM: VS: Tc 98.1, BP 101/58, HR 84, RR 24 on AC 550 x 24, FiO2 100%, PEEP 5, SaO2 97% General: Sedated and intubated. HEENT: NC/AT, pupils pinpoint and minimally reactive, MM dry, OP clear Neck: supple, difficult to appreciate JVD Chest: diffusely rhonchorous and wheezy anteriorly CV: RRR, s1 s2 normal, 2/6 SEM Abd: obese, mild distension, hyperactive BS, soft, NT Ext: no c/c/e, w/w/p, faint distal pulses Neuro: sedated
FAMILY HISTORY: as per patient there are 7 generations of women on her mother's side who have all died at a young age of heart disease. Mother - died of MI at age 50 Grandmother - died with ASD Father - DM, EtOH abuse, no CVD Grandfather - DM 2 brothers - one died of fat embolus at age 18 and another died recently of opiod overdose.
SOCIAL HISTORY: Pt lives with husband, mother-in-law and along with two kids. Pt smoked 2ppd x30years and drinks 3 drinks/mo- quit 2 months ago but still smokes occasionally-one or two cigarettes per day. Pt denies any illicit drug use. | 0 |
93,567 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 58 year old gentleman with a prior history of coronary artery disease status post myocardial infarction times four, who was initially seen in an outside Emergency Room the day prior to admission with complaint of pre-syncope and was sent home. He represented to [**Hospital3 **] Emergency Room with crushing substernal chest pain. At the outside hospital he had evidence of an inferior myocardial infarction with ST elevations in leads II, III and F. He was treated with 100 mg bolus of TPA and initially had symptom improvement, however, soon afterwards, his ST elevations returned and the patient became hypotensive to pressure of 50 systolic. At [**Hospital3 6592**] he was placed on Dopamine gtt, intubated, given an Integrilin 50.5 ml bolus 11 ml per hour afterwards and transferred to [**Hospital1 69**] for a catheterization. Presenting to the catheterization laboratory, catheterization revealed a very small right coronary artery with good collaterals to left anterior descending, chronically occluded left anterior descending and evidence of circumflex disease. The patient underwent angioplasty of his left circumflex artery which he tolerated well, although he did have ST elevations during the procedure, they resolved after angioplasty. The patient did have profuse bleeding from his right groin site and his oropharynx during the procedure. The patient's INR and PTT were checked and found to be 9.0 and 89 respectively, which was an elevation of an INR of 1.03 and PTT of 26.8 at the outside hospital. It should be noted that the patient was not on Coumadin and no heparin was given.
MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction times four by outside hospital report. 2. Chronic obstructive pulmonary disease on home O2 with a baseline O2 requirement of 3 liters. 3. Hypertension. 4. Alcohol abuse.
MEDICATION ON ADMISSION:
ALLERGIES: The patient had no known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: Significant for tobacco use although the patient did quit four years ago. No prior drug use. Significant alcohol use/abuse. | 0 |
33,033 | CHIEF COMPLAINT: pea arrest
PRESENT ILLNESS: 23 y.o. Male w/ h.o. Benzo and Heroin [**Hospital **] transferred from [**Hospital 21242**] hospital after being found down in PEA arrest likely [**1-20**] Heroin OD. . Per ED signout pt was found by passer by this AM unconcious, EMS was called and found him in PEA arrest, they coded him in the field for 20 minutes which included 3 rounds of Epinephrine, Atropine, 8 of Narcan. Pt was taken to Widden ED where he coded again and reecived 2 rounds of medications. He was found to be in V. fib and received 1 shock, he was then noted to be irregular WCT thought to be A. fib with aberrancy. He was ?intubated at Widden with an ABG notable for acidosis. He was then placed on Artic Sun and transferred to [**Hospital1 18**] ED. In the ED he was noted to be sinus tach, overbreathing the vent. Unclear but EMS thought pt did have somewhat of a gag at Widden. In the ED he had an A-line placed, has 2PIVs. . In discussion with the family it is unclear if this was an attempt on his life versus taking an excessive amount of heroin. Per grandmother pt usually is someone who takes substances in excess. Per grandmother pt has also been very depressed, 2 weeks he overdosed at his grandmother's house though it is not clear if this was an attempt. His girlfriend apparently overdosed last week. Pt was interested in sobriety from his heroin habit and was being seen at Connections where his urine was negative for heroin last week. . On the floor, he was noted to be on a cooling blanket, sinus tachycardia to 110s and BP 120s on Levophed. Pt already intubated with RR 14 which was increased to 20, PEEP 5, FiO2 50%. . Review of systems: Unable to obtain. .
MEDICAL HISTORY: Past Medical History: (Per ED and family member) h.o. Heroin overdose Heroin/Benzo abuse Bipolar disorder Depression .
MEDICATION ON ADMISSION: Depakote ER 500mg daily
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Vitals: T:96.3, BP:11 P: R: 18 O2: General: Caucasian Male intubated in NARD. HEENT: Pupils fixed and dialted (received Atropine in the field), Sclera anicteric, MMM Neck: supple, JVP not elevated, no LAD Lungs: Coarse BS noted bilaterally. CV: S1, S2, distant when compared to course breath sounds. Tachycardic, no murmurs, gallops or rubs Abdomen: Soft, non-distended, bowel sounds present Ext: Cool to touch on cooling blanket. No edema noted.
FAMILY HISTORY: noncontributory
SOCIAL HISTORY: Pt has history of drug abuse per family members, recently overdosed on Heroin 2 weeks ago. Was attending ?detox at Connections with clean urine test 1 week ago. Girlfriend also overdosed a week ago. | 1 |
30,546 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 66-year-old male with a history of a cerebrovascular accident with residual right-sided weakness who presented after having severe acute onset of headache the night before admission. The patient's wife stated he had no trauma or precipitating factors. The patient vomited three times overnight. Denied any fever, chills, nausea, chest pain, shortness of breath or visual changes. The patient awoke this morning with increased right leg weakness and continuous headache and now new onset of neck pain notably with flexing. The patient currently states that he only has a headache.
MEDICAL HISTORY: Hypertension. Hypercholesterolemia. Cerebrovascular accident in [**2112**].
MEDICATION ON ADMISSION:
ALLERGIES: No known allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
28,997 | CHIEF COMPLAINT: Chest discomfort
PRESENT ILLNESS: 54 y/o male who has been experiencing chest and epigastric pain for approximately the last month. Recently underwent inguinal hernia repair and several days after surgery began experiencing worsening chest pain radiating to shoulders. Patient went to PCP and eventually [**Name9 (PRE) **] and was ruled in for a myocardial infarction. Had cath during admission which revealed severe three vessel coronary artery disease. Post-cath he suffered a CVA, but with no current residual. He now present for surgical revascularization.
MEDICAL HISTORY: Cornary Artery Disease s/p Myocardial Infartion [**1-6**], Stroke [**1-6**], Hypertension, Hyperlipidemia, Pneumonia [**1-6**], s/p bilateral hernia repairs
MEDICATION ON ADMISSION: Imdur 30mg qd, Lisinopril 5mg qd, Lopressor 150mg [**Hospital1 **], Zocor 20mg qd, Nitro prn, Plaivx 75mg qd (unsure when pt. stopped)
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS: 72 12 132/80 5'9" 175# Gen: WDWN male in NAD Skin: W/D intact HEENT: EOMI, PERRL, NCAT Neck: Supple, FROM -JVD, -carotid bruit Chest: Mostly CTA with slight decrease at left base with ronchi Heart: RRR -c/r/m/g Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, -edema, superficial varicosities. Neuro: A&O x 3, MAE, non-focal
FAMILY HISTORY: NC
SOCIAL HISTORY: Quit smoking several weeks ago after 1/2ppd x 15-20yrs. Occ. ETOH. | 0 |
17,694 | CHIEF COMPLAINT: septic shock
PRESENT ILLNESS: HPI: 47 y.o. man with ESRD on HD, Hep C/ETOH cirrhosis, Asthma, recently discharged [**2175-12-19**] after being treated for enterobacter pneumonia with hypoxic resp distress, which was complicated by allergic rxn to certain HD filters, who was found on the floor by his wife on the evening of [**1-2**]. He was arousable and responsive, so she did not move him. On the AM of [**1-3**], the patient's wife again tried to arouse him from the floor, but this time, he could not be aroused. She called 911 and he was admitted to [**Hospital3 2568**] ICU. . At [**Hospital3 2568**], He was hypotensive (60/30) and started on levophed, dopamine, and vasopressin to maintain his BP. He also was hypoglycemic and received D50. Blood cultures (1/2 bottles on [**1-3**], then 2/4 bottles on [**1-4**]) grew GPC in pairs and chains. He also had a paracentesis which was consistent with SBP based on WBC but did not grow any bacteria. He was started on Vanco/Zosyn, which was changed to Dapto/zosyn out of concern for VRE, but then . He has a tunnelled HD line which was a potential source but it was felt that SBP was the more likely source. His INR was initially 11, which came down to 5 after FFP. B/c of the coagulopathy, it was felt unsafe to take out the HD catheter. He had a left IJ line placed.
MEDICAL HISTORY: - Cirrhosis [**2-17**] untreated HCV, alcohol abuse, not on transplant list - Esophageal varices s/p [**12-20**] banding - h/o SBP - ESRD on HD T/Th/Sat (from ATN, HRS) - Anemia of chronic disease - Asthma - Depression - Schizotypal personality disorder - Left LE abscess in [**9-/2175**] at [**Hospital3 2568**], growing enterobacter
MEDICATION ON ADMISSION: 1. Rifaximin 400 mg PO TID 2. Nadolol 20 mg PO Daily 3. Lactulose 60 ML PO qid 4. B Complex-Vitamin C-Folic Acid - 1 cap daily 5. Thiamine 100 mg po daily 6. Folic Acid 1 mg po daily 7. Sevelamer 1600 mg PO TID W/MEALS 8. Protonix 40mg daily 9. Fluticasone-Salmeterol 250-50 1 puff [**Hospital1 **] 10. Albuterol 1 puff Q6H 11. Atrovent 1 puff Q4H 12. Dilaudid 1mg PO q6H prn 13. Sucralfate 1gm po QID . Meds on transfer: 1. Zosyn 2.25gm Q8H 2. Lactulose QID 3. Insulin sliding scale 4. Levophed gtt 5. Vasopressin gtt
ALLERGIES: Vitamin K
PHYSICAL EXAM: VS: T 96.1 BP 75/61, HR 87, R 25, 100% 2L Gen: no apparent distress HEENT: icteric sclerae, dry MMM, Neck: no JVD Lungs: bibasilar crackles Heart: RRR nl S1S2, no m/r/g Abd: +BS, mod distention, soft, mild TTP diffusely. No rebound or guarding. Ext: 2+ dependent edema up to thighs and sacrum Neuro: AAO x 3, conversant. strength 5/5, + asterixis
FAMILY HISTORY: - No history of liver disease. - Maternal aunt with DM
SOCIAL HISTORY: - Personal: Lives with wife. - Substance abuse: Denies current tobacco, ETOH, or drug use. Per [**Hospital3 2568**], he may not be reliable and his wife is not certain since he is alone much of the day. - Heavy ETOH use in past, prior IV drug use in [**2148**], but last reportedly [**4-21**]. Former smoker. | 1 |
89,725 | CHIEF COMPLAINT: Hydrocephalus
PRESENT ILLNESS: 39 y/o female transferred with recent admission s/p being hit by a car (she was pedestrian). She was GCS of 6 at scene with multiple attempts of intubation in route to [**Location (un) 8641**]. When in ED at [**Location (un) 8641**], intubation was successful. CT of head showed large R SDH, IPH, and frontal skull fracture. CT of c-spine and torso were also done with no abnormal findings. She was transferred to [**Hospital1 18**] by ambulance for further neurosurgical workup. She was admitted to neurosurgical service and taken emergently to OR for R craniectomy, with L frontal lobectomy and partial temporal lobectomy and and external ventricular drain placement. Exam improved to withdrawal and some localization to pain, a peg was placed on [**7-19**]. Patient had respiratory complications requiring SICU readmission, with possible hosp-associated PNA -> cultures grew out ACINETOBACTER and STENOTROPHOMONAS and abx were tailored to those organisms. The patient was weaned to trach mask. The patient was discharged to rehab.At rehab there was concern for edema over the site of the craniectomy and the patient was sent for a head CT which showed significant hydrocephalus. Per transfer note patient has been afebrile with negative blood cultures She was transferred to [**Hospital1 18**] for further eval.
MEDICAL HISTORY: unknown
MEDICATION ON ADMISSION: Amantadine 100mg TID, Artificial Tears gtt both eye TID, Bacitracin ointment to scalp wound [**Hospital1 **], Colace 300mg [**Hospital1 **], Methadone 5mg q12h, Metoprolol 25mg [**Hospital1 **], Ranitidine 10mg [**Hospital1 **], Senna Syrup 10mg (2 tabs) q12h, Tylenol 650mg q4h pRN Albuterol NEB q6h PRN, Dulcolax 10mg PR PRN, Milk of Mag 30mg QD PRN Nystatin 100,000U swish and spit PRN
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Exam on Admission: T:99.0 BP: 118/90 HR:81 R:16 98% O2Sats Gen: Patient lying in bed, pulsations on her R scalp at craniectomy site, opens eyes to nox stim. During EVD placement patient open HEENT: Removal of R ant skull, craniectomy scar healing. Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+, Peg in place Extrem: Patient with severely contracted, plantar flexed feet.
FAMILY HISTORY: unknown
SOCIAL HISTORY: unknown | 0 |
78,556 | CHIEF COMPLAINT: headache
PRESENT ILLNESS: 30 yo M with a history of a growth hormone secreting pituitary macroadenoma s/p resection in [**2195**], hypothyroidism, diabetes, and adrenal insufficiency, who presents with intermittent blurry vision and headache since yesterday. Pt notes headache localized to the top of the head and behind the eyes more pronounced on the left. Pain incrased with eye movement particularly with left lateral gaze. Denies loss of vision or visiual deficits however notes general blurriness to vision. He denies any stiff neck, recent trauma,increased weakness of extremitites, new neurologic symptoms including new weakness/numbness, nausea, fevers/chills, cough. Denies any changes to speech, memory, gait. . He presented to OSH, where head CT was consistent with stable 1.7 X1.5 cm hyperdense sellar and suprasellar mass present . He was transferred to [**Hospital1 18**] for neurosurgery evaluation. . In the ED initial vital signs were 97.7 74 128/86 12 98% 3L. Neurosurgery was consulted who recommended MRI with and without contrast. The patient was given 1mg IV dilaudid. MRI performed and patient transferred to the floor. . Review of Systems: (+) Per HPI (-) Review of Systems: GEN: No fever, chills, night sweats, recent weight loss or gain. HEENT: No headache, sinus tenderness, rhinorrhea or congestion. CV: No chest pain or tightness, palpitations. PULM: No cough, shortness of breath, or wheezing. GI: No diarrhea, constipation or abdominal pain. No recent change in bowel habits, no hematochezia or melena. GUI: No dysuria or change in bladder habits. MSK: No arthritis, arthralgias, or myalgias. DERM: No rashes or skin breakdown. NEURO: No numbness/tingling in extremities. PSYCH: No feelings of depression or anxiety. All other review of systems negative.
MEDICAL HISTORY: 1. panhypopituitarism secondary to growth hormone secreting macroadenoma. 2. Diabetes mellitus with hemoglobin A1c of 17. 3. History of sleep apnea, diagnosed recently. 4. History bacteremia with coag-negative staphylococcus, resistant to oxacillin. 5. Adrenal insufficiency. 6. Hypothyroidism. 7. Diabetes insipidus. 8. Growth hormone-secreting pituitary macroadenoma status post resection. 9. Acromegaly. 10. Superficial septic thrombophlebitis with bacteremia. 11. He has had some history of vaccination as in childhood with right arm deformity. 12. CRANIOTOMY with resection of pituitary macroadenoma, [**2196-10-28**] 13. chronic left MCA territory infarct
MEDICATION ON ADMISSION: Metoprolol 100mg [**Hospital1 **] Metformin 1000mg qAM, 1500mg qPM Lisinopril 10mg daily Hydrocortisone 20mg qAM, 10mg q4pm Levothyroxine 75mcg 1 tab daily Amlodipine 10mg 1 tab daily Famotidine 20mg [**Hospital1 **] Glipizide 10mg [**Hospital1 **] Pioglitazone 13mg daily Desmopressin 0.1mg TID Insulin Humulin Sliding scale Omeprazole 20mg daily Insulin NPH (30u qAM, 25u qPM)
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: On admission: VS: 130/100, 76, 18, 99%3L GEN: AOx3, NAD HEENT: PERRLA. MMM. Macroglossia. no LAD. no JVD. neck supple. No cervical, supraclavicular, or axillary LAD Cards: RR S1/S2 normal. no murmurs/gallops/rubs. Pulm: No dullness to percussion, CTAB no crackles or wheezes Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**] sign Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes or bruising Neuro: CNs II-XII intact. 5/5 strength in L extremities. DTRs 2+ BL in patella/biceps. sensation intact to LT, cerebellar fxn intact to rapid alternating movements. gait WNL. Right arm is held flexed at elbow and wrist.Right UE [**4-3**] compared to LUE [**5-3**]. [**Month/Day (1) 12588**] fields grossly intact. Pain with eye movement to the left lateral side.
FAMILY HISTORY: Patient is unaware of any history of diabetes or other endocrinopathies.
SOCIAL HISTORY: He is an illegal immigrant from [**Country 6257**] who has lived in [**Location (un) 29158**] for the past eight years. He does not currently work. He does not drink alcohol. He used to smoke one pack per day of cigarettes, but has not smoked since his hospitalization. He drinks mostly decaf coffee, and reports no illicit drug use. | 0 |
66,080 | CHIEF COMPLAINT:
PRESENT ILLNESS: Mrs. [**Known lastname 105134**] is a [**Age over 90 **]-year-old woman with a significant history of coronary artery disease, status post myocardial infarction times three, congestive heart failure (last echo with an ejection fraction of 40%) Paroxysmal atrial fibrillation with a rapid response, presented with chest pain and a rapid rate, and respiratory decompensation. She was emergently intubated, had admitted from the emergency department to [**Hospital1 190**] CCU. The patient was noted to have ST elevations with her rapid rate which cleared when her rate was adequately controlled with beta-blockers. However, later that evening she developed sinus bradycardia. This is a known response in the patient to administration of beta-blockers. In the CCU she was diuresed with resolution of respiratory distress, CKMB fraction was positive but Troponin I was negative. She was initially started on Heparin but this was stopped due to the feeling that she was likely not suffering infarction. She was called out to the floor in stable condition.
MEDICAL HISTORY: 1. Coronary artery disease. Status post myocardial infarction times three. 2. Congestive heart failure. Echo [**5-/2171**] with an EF of 40 to 45% 3. Hypertension. 4. Glaucoma. 5. Depression. 6. Paroxysmal atrial fibrillation/flutter. 7. Chronic renal insufficiency. 8. Hypothyroidism. 9. Early dementia. 10. CLL. 11. Asthma.
MEDICATION ON ADMISSION: 1. Levoxyl 100 mcg p.o. q day. 2. Cefrolucas 20 mg p.o. b.i.d. 3. Isordil 40 mg p.o. three times a day. 4. Zestril 10 mg p.o. q day. 5. Aspirin 81 mg p.o. q day. 6. Colace 100 mg p.o. b.i.d. 7. Senokot. 8. [**Doctor First Name **] 60 mg p.o. q day. 9. Azapt drops to each eye. 10. Serevent two puffs b.i.d. 11. Lasix 10 mg p.o. q day. 12. Flexeril 20 mg p.o. q day. 13. Zyprexa 2.5 mg q h.s. 14. Asthmacort two puffs p.o. twice a day. 15. Lactulose p.r.n.
ALLERGIES: Penicillin and Codeine.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: Lives in [**Hospital3 **]. Primary care physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. | 0 |
2,298 | CHIEF COMPLAINT: Cholangitis
PRESENT ILLNESS: 49F transferred from [**Hospital3 **] Hospital after admission and discharge for ERCP and stent placement 4 days ago for cholelithiasis. Worsening jaundice, nausea, and vomiting x 24 hours.
MEDICAL HISTORY: hypothyroid and MR
MEDICATION ON ADMISSION: abilify, aricept, levothyroxine, enulose, prilosec, primidone, loratidine, vit c, vit d, klonopin, claritin, colace, lactulose (doses not given in transfer)
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Upon presentation to [**Hospital1 18**]: 98.0 102 136/115 18 86 intubated jaundiced scleral icterus CTAB RRR epigastric and ruq tenderness no overt peritoneal signs abd distended dark urine
FAMILY HISTORY: Noncontributory
SOCIAL HISTORY: lives at group home | 0 |
22,221 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 76 year-old white female with a past medical history of diabetes mellitus type 2, hypertension, hypercholesterolemia who presented from an outside hospital for evaluation, and possible coronary catheterization and EP study. The patient has had a history of multiple syncopal episodes and mechanical falls over the last few months resulting in multiple Emergency Department visits. Her last admission to the outside hospital was several days to prior to this admission. She was admitted for syncope. At that time she had sudden dizziness and lightheadedness. This was sometimes brought on by standing up. She denies any associated chest pain, shortness of breath, diaphoresis, palpitations, orthopnea, paroxysmal nocturnal dyspnea. She presented again to [**Hospital 1474**] Hospital on the day of admission around noon complaining of episode of syncope at her rehabilitation program. This was possibly associated with seizure activity, although no bystander accounts were available. Upon arrival to the outside hospital, her vital signs were temperature 98.8, pulse 42, blood pressure 132/56, respiratory rate 14, oxygen saturation 96% on room air. In the Emergency Department she had witnessed ventricular tachycardia with positive loss of consciousness and seizure activity. A precordial thump reverted the patient to sinus bradycardia. The ventricular tachycardia then recurred and precordial thump delivered again with reversion to sinus bradycardia. She received two runs of potassium at 10 milliequivalents along with 40 milliequivalents or oral potassium. Lidocaine drip was started at 1 mg per hour. No future episodes of ventricular tachycardia were noted. The patient was also noted to have long pauses on telemetry associated with dizziness. She was transferred to the Coronary Care Unit at the outside hospital where she was started on heparin 1200 units per hour without bolus, and lidocaine drip with increase at 2 mg per hour. The patient was then transferred there that day to [**Hospital1 1444**] for possible coronary catheterization and EP study. On arrival here the patient was confused with poor recollection of the days events. She denies chest pain, shortness of breath, dizziness, lightheadedness.
MEDICAL HISTORY: 1. Diabetes mellitus for two years, controlled with oral medication and regular insulin sliding scale. 2. Hypertension. 3. Hypercholesterolemia. 4. Hypothyroidism.
MEDICATION ON ADMISSION:
ALLERGIES: The patient reports allergies to sulfa drugs resulting in rash.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient is widowed. She lives alone, across the street from her son. She is a Jehovah's witness and does not consent to any blood products during admission. For the past one week she has been enrolled in a rehabilitation program after her last hospital admission for syncope. Upon discussion with relatives, it is noted that the patient sometimes has trouble with medication dosages and relatives feel that she may often mix up her medications. | 0 |
38,161 | CHIEF COMPLAINT: Dyspnea
PRESENT ILLNESS: Mr [**Known lastname 19017**] is a 66 year-old man with a PMHx of stage 4 COPD (FEV1 0.65L;FEV1/FVC 37% predicted in [**4-14**]) on 4L home o2 with numerous hospitalizations for COPD exacerbations and intubation, hypertension, coronary artery disease, GERD who presents with SOB and CP. He is admitted to the ICU for management of dyspnea and hypotension. . He was in his USOH until a few days ago when he started feeling worsening SOB compared to his baseline, in the setting of running out of his inhalers. At baseline, he has SOB with minimal activity. This morning, he was again feeling short of [**Date Range 1440**] while sitting in his bed and used his inhalers. Usually, they improve his symptoms, but they did not this morning. He also began experiencing acute on chronic chest pain, with paroxyms of left sided chest pressure worsened with activity. He then called EMS. Of note, he has a history of chest pressure in association with shortness of [**Date Range 1440**]. . In the ED, his initial VS were 99.3 BP 110/45, HR 95, RR 22 O2sat 94% on room air. He was given Combivent nebs, SoluMedrol 125 mg IV x1, vancomycin, and zosyn. He reported improvement of his SOB with nebs. He also had a SBP drop to the 80s while sleeping and responded to 2L of NS bolus. He was then admitted to the MICU for further management of dyspnea and hypotension. . Recent history is notable for the absence of cough, fevers, chills, and sick contacts. [**Name (NI) **] denies nausea, vomiting, or diuresis in association with his CP, but does note a pleuritic quality. He does state that he has had decreased oral intake over the last few days.
MEDICAL HISTORY: # Severe COPD on 4 L O2 at home w/ BiPAP qhs - s/p multiple admissions and intubations for flares - [**4-/2107**]: FEV1 0.65L;FEV1/FVC 37% predicted in [**4-14**] # h/o chronic indwelling urethral catheter - has been out for >1 yr - has a h/o VRE UTI # hx of MRSA # CAD s/p NSTEMI ([**2101**]) - [**4-10**] with NL cath - TTE with preserved biventricular function in [**2103**] - uses ntg ~1x/week # Steroid induced hyperglycemia # Hypertension # Hyperlipidemia # Chronic low back pain L1-2 laminectomy from accident at work # Left shoulder pain for several months # Cataracts bilaterally - s/p surgery for both # GERD # BPH # Hx of resistant Pseduomonas PNA infxn
MEDICATION ON ADMISSION: Home Meds (per last d/c summary) 1. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO once a day for 2 days. 11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) tablet PO 3X/WEEK (MO,WE,FR). 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 14. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) 15. Prednisone 10 mg Tablet Sig: Take Six (6) tablets from [**Date range (1) 19036**], take five tablet from [**Date range (1) 3563**], take 4 tablets from [**Date range (1) 19037**], take three (3) tablets from [**Date range (1) 19038**], then take your normal 20mg per day from then on Tablets PO once a day. 16. Vitamin D-3 400 unit Tablet Sig: Two (2) Tablet PO once a day. 17. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) INH Inhalation once a day. 18. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) application Topical three times a day as needed. 19. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for nebulization Sig: One (1) Neb Inhalation every six (6) hours as needed for sob/wheeze.
ALLERGIES: Levaquin
PHYSICAL EXAM: Per Admitting Resident:
FAMILY HISTORY: Mother w/ asthma, Alzheimer's disease. Father w/ [**Name2 (NI) 499**] cancer.
SOCIAL HISTORY: Retired [**Company **] mechanic. Exposed to a lot of spray paint. Married with six children. Lives at home in [**Location (un) 686**] with wife. [**Name (NI) **]-son was recently removed from the house per home services given his selling drugs and guns in the house. The patient reports feeling safe currently at home. Minimally active at baseline, walks to kitchen and bathroom, but spends most of day in bed. Substances: 20 p-y smoking, quit 25 years ago. Occassional EtOH. Quit marijuana 3 years ago. Denies IVDA. | 0 |
53,063 | CHIEF COMPLAINT: CC:[**CC Contact Info 61604**] Major Surgical or Invasive Procedure: none
PRESENT ILLNESS: HPI: 37YO man with long hx of alcohol abuse, with frequent ED visits/hospitalizations for same was brought to the ED today after being found by EMS sleeping on street. He reports drinking [**2-8**] pints of vodka daily. He eats very little. He also drinks listerine each night. He reports frequent falls (recent scalp lac w/ staples; abrasion over face). His ETOH level was 434 at 10:00 AM. He was given Ativan 2 mg at 6:30 in the ED for CIWA =13; then given Ativan 2 mg at 6:30pm for CIWA = 23. He was admitted to the floor for EtOH withdrawal. . On arrival to the floor, the patient was given Valium 10 mg PO and 10 mg IV over 40 minutes without improvement in his CIWA. He is transferred to the ICU for further management. . Of note, previous admission in [**Month (only) 205**] for ETOH withdrawal pt required 20mg PO valium q15min, then left AMA. . Pt not cooperative for further ROS. .
MEDICAL HISTORY: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures
MEDICATION ON ADMISSION: None
ALLERGIES: Penicillins
PHYSICAL EXAM: Vitals: 99.3, 110/64, 115, 18, 99% RA GEN: diaphoretic, sitting in bed, anxious HEENT:hematoma on R occipital area where staples removed last week. scabb on bridge of nose and R temple. PERRLA 5mm->2mm, EOMI, throat non-erythematous, poor dentition, MMM Lungs: clear CV: tachy, rrr Abd: + bs soft, limited exam, no focal tenderness ext: + tremor, no c/c/e
FAMILY HISTORY: Possible OCD in his father.
SOCIAL HISTORY: Currently reports drinking "at least" a lint of vodka each morning and listerine each evening. He has a history of polysubstance abuse: EtOH, heroin, IVDU, benzo, h/o alcohol withdrawal seizures and DT's, h/o section 35. h/o incarceration for possession, estranged from family, never married, no children, homeless | 0 |
39,951 | CHIEF COMPLAINT: Transferred for Intracranial hemorrhage
PRESENT ILLNESS: 79 year-old man with a history of hypertension, dyslipidemia, TIAs s/p carotid endarterectomy, coronary artery disease s/p myocardial infarction and CABG, v-fib arrest in [**2152**] s/p pacemaker placement, and on Aspirin and Plavix who presents as a transfer from [**Hospital **] Hospital for management of intracranial hemorrhage. The patient was reportedly "confused" at breakfast this morning. Later, he was sitting and watching television; he had difficulty getting up from a seated position at ~11:30 am. By 1 pm, he apparently had further difficulty standing up, and emergency services were notified. He was reportedly observed to have a right facial droop and was "listing to the right" by one report. He was taken to [**Hospital **] Hospital where he was a bit drowsy, though GCS was reported as 14. His initial vitals at 3 pm included a blood pressure 190/102, pulse 100, and SaO2 99. Blood pressures rose to as high as 230s/140s range. CBC reportedly showed a thrombocytopenia. Chemistry, and urinalysis were unremarkable; INR was 1.1. EKG was ventricular-paced (rate 100), and chest x-ray clear. CT head will showed a left thalamic bleed (4 x 3 cm), with third ventricular extension. Mild prominence of the lateral and third ventricles was noted. There was 7 mm of left-to-right shift. The patient was started on Nipride to control blood pressure. He was given Zofran and two units of platelets. The patient was med-flighted to [**Hospital1 18**] for further management. En route, the patient was loaded with 1 gram of phenytoin. The patient reportedly "lost his airway" upon landing on the roof, and was intubated on the spot.
MEDICAL HISTORY: -Hypertension -Dyslipidemia -TIAs s/p bilateral carotid endarterectomy (years apart) -Coronary artery disease s/p myocardial infarction and CABG -V-fib arrest in [**2152**] s/p pacemaker placement -Anxiety -An abdominal aortic aneurysm is noted on transfer paperwork
MEDICATION ON ADMISSION: -Plavix 75 mg daily -Aspirin 81 mg daily -Zocor 40 mg daily -Toprol XL 100 mg daily -Lasix 20 mg daily -Folate 1 mg daily -Ferrous sulfate 325 mg daily -Ranitidine 150 mg daily -Ativan 0.5 mg q 4 hours prn anxiety -Tylenol 650 mg q 4 hours prn pain -Trazodone 50 mg qhs prn sleep -Nitro 0.3 mg prn chest pain -Chlorpheniramine 0.4 mg q 4-6 hours prn allergy -Desonide prn -Nasonex prn -Spiriva prn
ALLERGIES: Erythromycin Base / Methyldopa
PHYSICAL EXAM: Vitals: T 99.6 F BP 155/63 P 75 RR 14 SaO2 100 on ventilator General: sedated HEENT: NC/AT, sclerae anicteric, orally intubated Neck: supple, no nuchal rigidity, no bruits Lungs: clear, ventilated breath sounds CV: regular rate and rhythm, no MMRG Abdomen: soft, non-tender, non-distended Ext: cool feet, no edema, pedal pulses appreciated Skin: no rashes
FAMILY HISTORY: Coronary artery disease by prior report, otherwise unknown
SOCIAL HISTORY: By report, was previously a cigar smoker and drank alcohol "earlier in life." Otherwise unknown at this time. | 1 |
3,567 | CHIEF COMPLAINT: [**First Name3 (LF) 10964**] overdose Pyelonephritis C.difficle colitis
PRESENT ILLNESS: Patient is a 43 year-old female with a complicated history of multiple sclerosis with a resultant neurogenic bladder and chronic pyelonephritis, who was transferred from an OSH for a liver transplant consult s/p [**First Name3 (LF) 10964**] overdose. She has been taking large amounts of [**First Name3 (LF) 10964**] (3.5-5gm/day) for the last two years to help alleviate her chronic abdominal pain and flank pain from pyelonephritis. She was in her usual state of health, until approximately three weeks ago, when she presented to an OSH with abdominal pain, flank pain, vomiting, hypoglycemia, high wbc count, and dysphagia. Six days prior to admission at [**Hospital1 18**], after spending two weeks at the OSH, she returned home with the diagnosis of viral enteritis. Upon returning home, she developed severe right upper quadrant pain at rest that was rated a [**11-22**]. The pain was of similar quality to her previous pain at the OSH, constant, sharp, non-radiating, and increasing with palpation. She experienced N/V (no blood) and a decreased appetite, but denied any shortness of breath, chest pain, bright red blood per rectum, or melena. To alleviate her abdominal pain, she increased her pain medication to 10 tabs of [**Month/Year (2) 10964**] (5 gm/day) and Percocet 2 tabs q3hr (16tab x .325 = 5.2gm). Two days prior to admission, she took an additional 10 tablets of Darvoset. Her boyfriend found her unresponsive at home, and took her to the OSH. . At the OSH, patient??????s vital signs were temp 97, heart rate 74, blood pressure 98/52, respiratory rate 15, and O2 sat 96% RA. She was noted to be lethargic with slurred speech. Her serum acetominophen level, measured approximately 6 hours after overdose, was found to be 220mg/ml. There was no clear time of last ingestion. She was started on acetylcysteine. For her blood sugar of 21, she was given D50W. A nasogastric tube was placed, which yielded heme positive coffee grounds followed by bilious material. She was guaiac positive. A KUB showed increased stool without obstruction. . Labs at OSH included: WBC 14.8 HCT 43, plt 226. NA 145, K 3.8, Cl 112, HCO3 19, BUN 26, CR 1.0. Glucose 21. AST 1394 ALT 2995 LDH 4039 Ammonia 16. Urine toxicology screen was positive for Benzo, THC, Prophoxypteme . One day prior to admission, the patient was transferred to the [**Hospital1 18**] for a liver transplant consult. Her vital signs were stable. In the [**Hospital1 18**] ED, she was given acetylcysteine @ 3.2 gm q4h IV, D5W @75cc/hr, and then switched to D10W for a finger stick blood glucose in the 50s. For her N/V, she was given ativan 2mg IV and anzemet 12.5mg. Her abdominal pain was treated with dilaudid 0.5 mg IV. . In the MICU, acetylcysteine was continued at @ 3.2 gm q4h IV, ativan was continued at 1mg IV q4hours for nausea, and dilaudid was given 0.5mg IV q3hours for abdominal pain. She was maintained on D5NS 100cc/hr. During this time, she became febrile to 101.2. Urine cultures grew E.coli, and she was started on Ceftriaxone. . After 24 hours of observation in the MICU, she was transferred to medicine. At the time of the interview, the patient complained of RUQ and RLQ pain [**11-22**] which was dulled to an [**9-22**] with dilaudid. In addition, she reported left flank pain that developed one day prior to admission. She reports constipation, +N/V, and a decreased appetite.
MEDICAL HISTORY: 1. Chronic pyelonephritis. S/p right nephrectomy in [**2097**]. 2. Recurrent UTIs, up to 12 over the last 12 months. Similar microbiology patterns with resistance to many antibiotics, but sensitive to cefotetan. 3. Multiple sclerosis leading to a neurogenic bladder. Patient had a chronic suprapubic catheter in place, which was removed due to the multiple UTIs. Currently, patient self-catheterizes bladder. 4. Pituitary adenoma resected in [**2103**]. 5. Cholecystectomy. Date unknown. 6. Bowel resection secondary to obstruction. Date unknown. 7. Anxiety and depression. Patient is seen by a psychiatrist once a month.
MEDICATION ON ADMISSION: At home: MVI I tab daily Clonazepam (Klonopin) (dose unknown) Venlafaxine (Effexor) (dose unknown) Docusate (Colace) (dose unknown) Folate (dose unknown) Fentanyl patch 100mcg/hour Acetominophen ([**Name10 (NameIs) 10964**]) 500mg PO q4-6hours Percocet 2 tabs q3hr . Meds on transfer Hydromorphone (Dilaudid) 0.5-1 mg IV Q3-4H:PRN Ipratropium Bromide (Atrovent) MDI 2 PUFF IH Q4-6H:PRN Acetylcysteine 20% 3200 mg IV Q4H Lorazepam (Ativan) 0.5-2 mg PO/IV Q4H:PRN Albuterol [**2-14**] PUFF IH Q6H:PRN Nicotine 14 mg TD DAILY Bisacodyl (Dulcolax) 10 mg PO/PR DAILY:PRN Pantoprazole (Protonix) 40 mg IV Q24H Ceftriaxone (Rocephin) 1 gm IV Q24H Dolasetron Mesylate (Anzemet)25 mg IV Q8H:PRN
ALLERGIES: Compazine / Reglan / Sulfa (Sulfonamides) / Morphine / Tetracycline / Seroquel
PHYSICAL EXAM: Vitals: Tm 100.8, HR 66, BP 120/66, RR 12, O2 sat 100RA Gen: Thin, frail woman lying in bed uncomfortable and in pain. HEENT:Head: NC/AT Eyes: PERRL 3.5mm-> 3mm sluggish response. EOMI, No scleral icterus. Ears: Hears finger rub at 3 inches. Nose: septum midline, intact. Membranes normal; no polyps, discharge, sinus tenderness Mouth: lips and membranes unremarkable. Moist. Top dentures. Tonsils present. Neck: full ROM. Thyroid palpable. Trachea midline. Nodes: no palpable cervical, supraclavicular adenopathy. CV: No JVD. RRR, normal S1/S2, no M/R/G. No carotids bruits Resp: Thorax symmetrical; no increased AP diameter or use of accessory muscles. Normal to percussion. CTAB, no rales, wheezing. Abd: Scaphoid +BS in all four quadrants, no aortic bruits. Soft, nondistended. Liver percusses 8cm in midclavicular line; 3cm below 12th rib. + right upper and lower quadrant abdominal tenderness. Liver tip is not palpable (area was too painful for deep palpation), + rebounding, minimal guarding. + left CVA tenderness. No hepatosplenomegaly or masses. Ext: No clubbing/cyanosis/edema. Cool and dry. 2+ tibialis anterior, posterior pedis, and radial pulses bilaterally Rect: Guaiac positive Skin: Right port-a-cath in place for approximately 1 month.
FAMILY HISTORY: Mother has Type 2 Diabetes Mellitus. Aunt (on mother??????s side) had pancreatic cancer. Father is healthy. No family history of heart disease
SOCIAL HISTORY: Patient was living with her 12 year-old daughter, who is now staying with her ex-husband during this hospitalization. Patient??????s boyfriend, [**Name (NI) **], is her main source of support. Her father lives in the area and her mother, who is currently in [**Name (NI) 108**] for the winter with her step-father, are also extremely supportive. She used to work as a telephone operator, but stopped after her diagnosis with a pituitary adenoma. She has a 19 pack-year smoking history, and denies any alcohol or recreational/IV drug use. | 0 |
65,667 | CHIEF COMPLAINT: Dyspnea on exertion
PRESENT ILLNESS: 88 year old male with known aortic stenosis complaining of increased dyspnea on exertion. He states he is requiring oxygen at night due to shortness of breath.Further cardiac workup revealed no coronary disease, severe Aortic Stenosis. Cardiac surgery was donsulted for surgical correction.
MEDICAL HISTORY: CHF CAD s/p MI [**2077**], 96, s/p PTCA without stenting afib AS TIA HTN HL h/o bradycardia on BB ? Stage III CKD ? Asbestosis
MEDICATION ON ADMISSION: FUROSEMIDE - (Prescribed by Other Provider) - 40 mg [**Location (un) 8426**] - 1 [**Location (un) 8426**](s) by mouth DAILY (Daily) HYDRALAZINE - (Prescribed by Other Provider) - 50 mg [**Location (un) 8426**] - 1 [**Location (un) 8426**](s) by mouth four times a day Hold for SBP less than 100/ heart rate less than 50 METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg [**Location (un) 8426**] - 0.5 (One half) [**Location (un) 8426**](s) by mouth twice a day NITROGLYCERIN - (Prescribed by Other Provider) - 0.2 mg/hour Patch 24 hr - Apply 1 patch topically daily OXYBUTYNIN CHLORIDE - (Prescribed by Other Provider) - 5 mg [**Location (un) 8426**] - 1 [**Location (un) 8426**](s) by mouth twice a day OXYCODONE - (Prescribed by Other Provider) - 5 mg Capsule - 1 to 2 [**Location (un) 8426**] by mouth every 4 hours as needed for as needed for pain RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg [**Location (un) 8426**] - 1 [**Location (un) 8426**](s) by mouth twice a day TRAZODONE - (Prescribed by Other Provider) - 50 mg [**Location (un) 8426**] - 0.5 (One half) [**Location (un) 8426**](s) by mouth HS (at bedtime) as needed for insomnia VERAPAMIL - (Prescribed by Other Provider) - 120 mg [**Location (un) 8426**] Sustained Release - 1 [**Location (un) 8426**](s) by mouth every twenty-four(24) hours WARFARIN - (Prescribed by Other Provider) - 2 mg [**Location (un) 8426**] - 3 [**Location (un) 8426**](s) by mouth once a day on Sat, & Sun Medications - OTC ACETAMINOPHEN - (Prescribed by Other Provider) - 325 mg [**Location (un) 8426**] - 2 [**Location (un) 8426**](s) by mouth three times a day ASPIRIN - (Prescribed by Other Provider) - 81 mg [**Location (un) 8426**], Chewable - 1 [**Location (un) 8426**](s) by mouth DAILY (Daily) SENNOSIDES-DOCUSATE SODIUM [SENNA-S] - (Prescribed by Other Provider) - 8.6 mg-50 mg [**Location (un) 8426**] - 1 [**Location (un) 8426**](s) by mouth twice a day as needed
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Pulse:82 Resp:13 O2 sat: 97/RA B/P Right:154/80 Left:160/72 Height:5'7" Weight:182 lbs
FAMILY HISTORY: Mother and father with "heart problems"
SOCIAL HISTORY: SHx - resides in [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 731**] Rest Home in [**Location (un) 1157**] [**Telephone/Fax (1) 42303**]. He is widowed x1 yr. Has 3 grown children to assist with discharge needs. Daughter [**First Name4 (NamePattern1) 2411**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 42304**] | 0 |
28,163 | CHIEF COMPLAINT: bleeding hepatic mass
PRESENT ILLNESS: Mr. [**Known lastname 1637**] is a 29 year old man, previously in good health, who reported being in usual state of health until approximately 2pm the afternoon prior to presentation. He stated that the pain was sudden in onsent and confined to his RUQ. He denied any reecnt trauma to the affected area. Per report, Mr. [**Known lastname 34143**] pain worsened over the ensuing night, prompting him to take one Percocet without much alleviation of his symptoms. He subsequently presented to LGH, where a CT abdomen was performed and demonstrated a large mass located within segment 7 of his liver. The mass was noted to be associated with a significant amount of intraabdominal fluid/blood. Given this finding, he was transferred to [**Hospital1 18**] for further care. On initial evaluation, Mr. [**Known lastname 1637**] was noted to be tachycardic to 115 and hypotensive to SBP of 85, with modest improvement s/p administration of 1L crystalloid.
MEDICAL HISTORY: ARF s/p ingestion of nautral diuretic product
MEDICATION ON ADMISSION: none
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: On Discharge: VS: 100.2 87 139/98 18 96RA Gen: walking around room, appears comfortable CV: RRR, no m/r/g, nml s1/s2 Resp: CTAB Abd: soft, remains distended, normoactive bowel sounds, minimally tender to palpation RUQ, no rebound/guarding, no ecchymoses Ext: no c/c/e, alle extremities wwp
FAMILY HISTORY: No family history of liver disease/cancer/masses
SOCIAL HISTORY: Bodybuilder. In school. Denies T/E/D. | 0 |
65,906 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is an 18-year-old gravida 1, para 0-1-0-1, with type 1 diabetes transferred from [**Hospital 1474**] Hospital on [**2140-12-25**], after being delivered at 36 weeks gestational with a question of preeclampsia versus eclampsia. The patient had a seizure in the setting of hypoglycemia. Glucagon was administered and the reported blood glucose was 78. She had some gastrointestinal symptoms and poor p.o. intake for two to three days. She was taken to the Operating Room at [**Hospital1 1474**] for an uneventful cesarean section. The patient underwent a primary low transverse cesarean section and delivered a baby weighing 6 pounds, 2 ounces, with Apgars of 8 and 9 at one and five minutes respectively. After delivery the glucose was noted to be 330 with plus ketones. Glucose was corrected with subcutaneous Humalog. Magnesium was then started for preeclampsia and eclampsia. The patient then developed some respirations symptoms and an increased AA gradient. CT angiogram was performed which ruled out pulmonary embolus. The patient also developed a cough with greenish sputum, was therefore started on empiric cefoxitin and Zithromax for possible aspiration pneumonia. Due to the question of aspiration pneumonia versus peri-partum cardiomyopathy, the patient was transferred to [**Hospital1 188**] at that point. She was treated with intravenous steroids (IV Solu-Medrol), prior to transfer. The patient was also noted to have increased blood pressures ranging from 150-160s over 80-100. She was placed on magnesium two grams an hour at [**Hospital 1474**] Hospital for 24 hours.
MEDICAL HISTORY: 1. Insulin-dependent diabetes mellitus times five years, with no evidence of retinopathy or neuropathy or macrovascular disease. Last hemoglobin A1C was 6.4%. The patient does have a history of abnormal microalbuminuria. 2. Depression. 3. Smoking history one pack per day.
MEDICATION ON ADMISSION: 1. Humalog NPH insulin. 2. Zithromax at 250 mg p.o. q. day. 3. Multivitamin. 4. Protonix 40 mg p.o. q. day. 5. Hydralazine 10 mg times one intravenous push.
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient smoked a half a pack per day prior to pregnancy. | 0 |
73,910 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is one of several [**Hospital3 **] Hospital admissions for this elderly male. The history of this admission goes back to a previous admission in [**2188-9-14**] when the patient was admitted for repair of an incarcerated paraileostomal hernia in the setting of a prior hernia repair. This operation itself followed a panproctocolectomy for Crohn's disease. Following that operation, the patient appeared to be doing well and was, however, readmitted to the hospital on [**2188-10-13**] until [**2188-10-21**] with what appeared to be left upper quadrant pain and a hematoma but there was nothing that appeared to warrant surgery. He was consequently discharged home on [**2188-10-21**] but then readmitted on [**2188-10-27**] which is the date of this admission. The reason for this readmission was that the patient continued to have developed temperatures and a high white cell count while an outpatient and developed increasing left upper quadrant pain. On this occasion, he was readmitted and CAT scanned and a fluid collection which was not evident on the previous admission was drained. He was then admitted to the floor for further follow-up.
MEDICAL HISTORY: Status post panproctocolectomy for Crohn's disease.
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 1 |
74,740 | CHIEF COMPLAINT: Abdominal aortic aneurysm.
PRESENT ILLNESS: The patient was referred to Dr. [**Last Name (STitle) 1391**] for evaluation of abdominal aortic aneurysm. She now is admitted for elective open abdominal aortic repair with ventral herniorrhaphy. Initial findings of the aneurysm was on a x-ray for workup for a UTI.
MEDICAL HISTORY: Includes rheumatoid arthritis, prednisone dependent and on methotrexate; ischemic heart disease with a myocardial infarction in [**2155**], stress test done on [**2159-11-18**] was without ischemic changes, no perfusion deficits, ejection fraction was 72% with no wall motion abnormalities; also history of GERD; history of urinary tract infections, treated; history of skin cancer; history of MRSA infections; history of UTI sepsis with hypotension.
MEDICATION ON ADMISSION: Aspirin 81 mg daily, atenolol 50 mg daily, Atrovent puffer 2 daily, Colace 100 mg daily, folic acid 1 mg daily, Lipitor 20 mg daily, lorazepam 0.5 mg [**12-31**] tablet daily, prednisone 5 mg in the morning and 2 mg in the evening, Protonix 40 mg daily. Other medications include Actonel 35 mg daily, methotrexate 2.5 mg 6 tablets q. Friday, multivitamins, vitamin D and oyster calcium.
ALLERGIES: A history of multiple drug allergies; which include DEMEROL causing nausea and vomiting; LOPRESSOR causing hypotension; PENICILLIN manifestation no documented; all "[**Last Name (un) **] DRUGS like i.e., NOVOCAINE/LIDOCAINE."
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
27,473 | CHIEF COMPLAINT: Squeezing chest pain and dizziness.
PRESENT ILLNESS: Patient is a 60-year-old man with history of coronary artery disease status post MI in [**2165**], RCA stent in [**2170**] for a 90% mid stenosis of the RCA who was admitted on [**6-3**] for chest pain. Dobutamine MIBI at that time revealed a partially reversible inferior defect without any EKG changes or symptoms during the exam. The ejection fraction at that time was 60%. No intervention was done as patient refused and he was managed medically. From that time he has been in his usual state of health until presenting today with a sudden squeezing sensation in his chest starting approximately 2 PM on the day of admission which was relieved with sublingual Nitroglycerin. The patient returned approximately six hours later at which time he took another Nitroglycerin tablet and called EMS to bring him to the Emergency Department. The chest pain was associated with nausea, diaphoresis and dizziness. He also had worsening shortness of breath at the time. The pain did not radiate anywhere. In the Emergency Department, he was given Atrovent nebulizers, oxygen and sublingual Nitroglycerin times two. He was started on a heparin drip. Shortly thereafter he was found to be in sinus bradycardia with a rate in the 30s with stable blood pressure and worsening O2 saturation to the 70s. He was placed on a nonrebreather mask and given 0.5 mg of Atropine with good response. He was diuresed with Lasix for symptoms of heart failure. He was then admitted to the Coronary Care Unit for further management.
MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction in [**2165**] and RCA stent in [**2170**]. 2. Hypertension. 3. Severe chronic obstructive pulmonary disease on home O2. 4. Gastritis. 5. Gastroesophageal reflux disease. 6. Right eye blindness secondary to trauma.
MEDICATION ON ADMISSION: 1. Atenolol 50 mg q. day. 2. Lisinopril 5 mg q. day. 3. Aspirin 325 mg q. day. 4. Isosorbide Dinitrate 10 mg t.i.d. 5. Combivent inhaler. 6. Sublingual Nitroglycerin p.r.n. 7. Home O2.
ALLERGIES: 1. Lipitor. 2. Imdur. Both of which cause rash and hives.
PHYSICAL EXAM:
FAMILY HISTORY: Father died in his 60s of heart disease.
SOCIAL HISTORY: Patient is a former pilot. He has a 40 pack year smoking history. He quit two years ago. Denies any alcohol or drug use. He is a widower. | 0 |
68,276 | CHIEF COMPLAINT: Asymptomatic with coronary artery disease
PRESENT ILLNESS: 61 y/o female whi underwent stress test and was found to have ST depressions. Referred for cath which revealed severe coronary disease. Then referred for surgical revascularization
MEDICAL HISTORY: Dibates Mellitus, Hypertension, Hypercholesterolemia, Hyperkalemia, Uterine Cancer s/p XRT/TAH/BSO
MEDICATION ON ADMISSION: Lantus 38 units qd, Atenolol 100mg [**Hospital1 **], Crestor 20mg qd, Adalat 60mg qd, Metformin 850mg [**Hospital1 **], Aspiring 325mg qd, Fosamax 35mg wkly, Sodium Polyspyrene, MVI
ALLERGIES: Penicillins / Percocet
PHYSICAL EXAM: VS: 86 15 156/68 5' 158# General: NAD Skin: Unremarkable HEENT: EOMI, PERRL, OP benign Neck: Supple, FROM, -JVD, -carotid bruits Chest: CTAB -w/r/r Heart: RRR, +S1S2, -c/r/m/g Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, -edema, superficial varicosities Neuro: MAE, Non-focal, A&O x 3
FAMILY HISTORY: Brother had CABG in 40's
SOCIAL HISTORY: Denies tobacco or ETOH use. Lives alone. | 0 |
35,978 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 58 year-old right handed man who was working as an industrial floor cleaner in the [**Doctor Last Name **] hours in the morning on [**12-16**] when he slipped on the floor, fell backwards and hit his head. He did no lose consciousness, but was in a significant amount of pain. Thus he sought medical attention.
MEDICAL HISTORY: Aortic valve replacement in [**2147**].
MEDICATION ON ADMISSION:
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
57,563 | CHIEF COMPLAINT: unresponsive
PRESENT ILLNESS: Ms. [**Known lastname 22571**] is a 53 year old female with type I DM with insulin pump HL, hypothyroid, dyslipidemia, hx of tracheostomy after MVC, psychiatric disorder who was found unresponsive on her couch today. Per EMS report, she was noted to have rectal temp of 90.7. Blood glucose was read as "high". She was reported to have two days of vomiting. Her insulin pump was noted to be shut off. She was subsequently taken to [**Hospital3 **] where her exam was notable for arousle to pain with eyes deviated to right, BP of 99/57 and pulse of 87. ABG with PH of 6.87, UA normal except for ketones, glucose of 949, HCO3 < 5, troponin of 0.392 and WBC of 37.9. She was started on insulin gtt, 2 amps of bicarb and cefepime/vancomycin. MD notes from OSH notes he turned off the pump, prior to sending to [**Hospital1 18**]. Sedation shut off in transit by [**Location (un) **], noted to not have response. At [**Hospital1 18**] ED, initial vitals were 95.0. She was started on fentanyl/versed gtt/insulin 7 units. Labs notable for ABG of 7.11/40/456 on 500 X 15 FiO2 of 100%, 5 PEEP; lactate of 4.5, HCO3 of 10, lipase of 696 and glucose of 686. She got 4L at OSH. 500 cc here at ED. She was subsequently admitted to MICU for further evaluation and management. On arrival to the MICU, she was intubated and sedated. Her ex-husband confirmed that she started having nausea and vomiting for past two days with increasing confusion. He does not report her having any sick contacts except hospital visit two weeks ago for his pulmonary edema admission. She has not eaten out though she regularly goes to casino but no alcohol intake. He reports she has not had chest pain, shortness of breath, fever or chills. He reports she has not endorsed SI to him.
MEDICAL HISTORY: IDDM Osteoperosis Fibromyalgia Anxiety Depression Bipolar Disorder s/p MVA [**4-2**] w/ multiple face/pelvic/spine fx -intubated x1 month, s/p trach Hypothyroidism Hyperlipidemia
MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Rosuvastatin Calcium 40 mg PO DAILY 2. Ezetimibe 10 mg PO DAILY 3. LaMOTrigine 75 mg PO QHS 4. Aripiprazole 5 mg PO QHS 5. Duloxetine 120 mg PO DAILY 6. Pregabalin 100 mg PO TID 7. Quetiapine Fumarate 100 mg PO QHS 8. Levothyroxine Sodium 125 mcg PO DAILY 9. Nicotine Patch 14 mg TD DAILY 10. Tiotropium Bromide 1 CAP IH DAILY 11. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 12. Alendronate Sodium 70 mg PO 1X/WEEK (MO) 13. Estring *NF* (estradiol) 2 mg Vaginal q3months 14. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain 15. Aspirin 81 mg PO DAILY 16. Calcium 600 with Vitamin D3 *NF* (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit Oral [**Hospital1 **] 17. Omeprazole 40 mg PO DAILY 18. Insulin Pump SC (Self Administering Medication)Insulin Aspart (Novolog) (non-formulary) Basal rate minimum: 1.3 units/hr Basal rate maximum: 1.3 units/hr Target glucose: 80-180 Fingersticks: QAC and HS
ALLERGIES: Imitrex / Iodine-Iodine Containing
PHYSICAL EXAM: Admission Exam General: Intubated. Sedated. HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Not assessed Discharge Exam VS: T: 97.4 BP: 129/47 P: 85 R: 16 18 O2: 98% on RA Gen: NAD, AAOx3 HEENT: EOMI, MMM CV: RRR, normal S1/S2, no m/r/g Lungs: CTAB, no wheezes, rhonchi or rales Abdomen: soft, non-tender, non-distended Ext: 2+ radial and DP pulses Neuro: Motor and sensory grossly intact in upper and lower extremeties, bilaterally
FAMILY HISTORY: Father had lung cancer with a history of smoking, as well a coronary artery disease. No known family exposure to TB.
SOCIAL HISTORY: The patient reports that she quit smoking since [**2137-3-26**]. 20 pack year smoking history. She does not drink any alcohol. | 0 |
34,661 | CHIEF COMPLAINT: respiratory failure, fevers, delerium & inability to wean from vent
PRESENT ILLNESS: Mr. [**Known lastname 10010**] was admitted on [**8-2**] to [**Hospital6 12736**] after presenting on [**8-2**] with hypotension, fevers, and acute renal failure likely thought to be due to urosepsis. He was treated with zosyn/cipro, but Urine culture was negative and he responded to fluids. He did not require pressors. His antibiotics were tailored to zosyn alone. He remained predominantly on AC and was transferred due to inability to wean from vent and concern for trach leak and TBM. . Of note, he has been in and out of hospitals since [**Month (only) 116**]. He initially presented to [**Hospital1 1774**] on [**5-22**] with back pain, sciatica, and parasthesias. He was found to have ARF (Cr 9.0), and hyperkalemia (K 7.5). His renal failure was thought to be due to NSAID use and he was urgently dialized for hyperkalemia. He was intuabed for repiratory failure secondary to pneumonia and airway protection for AMS. He ultimately developed ARDS and was ultimately trached and PEGed. He was treated for PNA with cefepime, vanco, impienem and daptomycin but had persistent fevers and delerium. He was anticoagulated for a RIJ line associated thrombus. He underwent an FUO workup which included a PET scan which showed increased marrow and splenic uptake. He ultimately improved and was weaned to PS throughout most of the day and then sent to [**Hospital1 **] on [**7-7**]. . He was at [**Hospital1 **] for another month. He continued to have fevers and altered mental status which worsened over the past few days. He developed diarrhea and so tube feeds were held for several days. He was then sent to CHA for fevers and hypotension. . Upon arrival to MICU, unable to obtain further history as patient is altered, portugese speaking only, and is not accompanied by family.
MEDICAL HISTORY: Diabetes Mellitus Obstructive sleep apnea Chronic Kidney disease (baseline Cr reportedly 2-2.5 - diabetic and hypertensive nephrophathy) Morbid Obesity Gout
MEDICATION ON ADMISSION: Transfer Medications: Tylenol PRN Albuterol inh prn Combivent PRN Calcium carbonate 1250 mg/5 ml TID Diltiazem 60 mg [**Hospital1 **] Morhpine 30 mg PO q 6 hours Nysttin topical to inguinal folds prn Zosyn 2.25 IV q 6 hours day 4 Prevacid 30 mg daily Vitmain D 800 mg daily
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS: HR 95, BP 153/59, RR 21, 97% on PS 5/5 50% Gen: trached HEENT: PERRL, trach present CV: difficult to auscultate due to coarse breath sounds Pulm: coarse breath sounds diffusely Abd: obese, soft, NT, + g-tube Ext: no periphearl edema
FAMILY HISTORY: Mother had heart and kidney and died at 89 from renal failure.
SOCIAL HISTORY: Married, lives with wife and 24 year old sone. Previously worked as a butcher, but now on disability [**2-15**] choric back pain/sciatica. | 0 |
26,791 | CHIEF COMPLAINT: Low back pain and inability to care for himself, fungating tumor growing from enterocutaneous fistula
PRESENT ILLNESS: Patient is 55 yo male with h/o Crohn's disease and hypercoagulable condition s/p multiple amputations as a complication of this who presents for increasing low back pain and failure to care for himself at home. Pt was recently admitted to [**Hospital1 2177**] for [**Hospital1 **] and found to have line sepsis and new dx of stage IV mucinous adenocarcinoma from fungating mass originating from enterocutaneous fistula. (Admitted to [**Hospital1 2177**] from [**9-10**]) His tunnel line was replaced at [**Hospital1 2177**] on the contralateral side after removing the previous line. The patient also had multiple episodes of anemia characterized by a HCT drop from 24-25. Abdominal CT scan negative for bleeding. He required 4 units PRBCs but a source of the bleeding was never found. Patient was d/c'd 2 days ago with intent of presenting to [**Hospital1 18**]. Patient went home instead to care for himself and was unable to do this with increased ostomy output and increasing low back pain.
MEDICAL HISTORY: 1.Crohn??????s disease: diagnosed at age 21, followed by Dr. [**Last Name (STitle) 1940**]. Has involvement of his mouth, proximal small bowel, ampulla of Vater and biliary system. Had small bowel resection and cholecystectomy at same surgery in past. Treated with Remicade in late [**2133**], though course was stopped due to burning pain in his legs and joint pains. Has also had 6-MP therapy (as above) and did not respond to budesonide (Entocort). Currently treated with pentasa and intermittent prednisone. Most recent steroid course completed 1 month ago. 2.Antiphospholipid antibody syndrome: Diagnosed with hypercoagulable state at age 29. In the past has been told that he also had antithrombin III deficiency. Per Dr. [**Last Name (STitle) 410**]??????s notes, he did not have antithrombin III deficiency in [**2125**], but had high levels of anticardiolipin IgG antibody (normal IgM) and positive lupus anticoagulant at that time. Repeat tests in [**2130**] revealed very high levels of both IgG and IgM anticardiolipin antibody. On chronic anticoagulation with coumadin, INR goal 3.0-4.0. 3.[**Doctor Last Name **]??????s syndrome: known to have mild case per Dr. [**Last Name (STitle) 1940**]??????s notes. 4.Pulmonary embolism: History of at least 2 PE??????s in distant past, had IVC filter placed. 5.L AKA and R BKA: s/p multiple bilateral amputations secondary to clotting, status post right below-knee amputation in [**5-/2114**], s/p revision in 09/84, s/p left above-knee amputation in 05/95, s/p revision in 05/[**2132**]. 6. Small bowel resection and cholecystectomy: as above. 7. Reversible pancytopenia of unclear etiology. 8. Iron deficiency anemia. 9. Lactose intolerance. 10. Osteoarthritis. 11. Status post vascular bypass surgery of his right groin.
MEDICATION ON ADMISSION: Lovenox 60 mg Dilaudid 2 mg 1-2 tabs Folic acid 1 mg Pantoprazole 40 mg qd Hydroxycholoroquine 200 mg [**Hospital1 **] and 100 mg [**Hospital1 **] Vitamin D [**Numeric Identifier 1871**] IU q T/T/S Iron sulfate 325 mg Prednisone 15 mg qd Calcium - vitammin 500-125 mg tid Humira 40 mg /0.8 l SQ each saturday' Forte injection 20 mcg qd Mesalamine cr cap [**2130**] mg [**Hospital1 **]
ALLERGIES: Plasma Expander Classifier / Valium / Mercaptopurine / Remicade / Shellfish Derived
PHYSICAL EXAM: VS: 98.6, 124/78, 18, 96% on RA GENERAL: Thin male who looks his stated age Nourishment: At risk Grooming: Good Mentation: Alert, conversant, completely up to date about his medical diagnoses. Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Respiratory: Lungs CTA bilaterally without R/R/W Cardiovascular: RRR, nl. S1S2, no M/R/G noted Gastrointestinal: Large polypoid fungating abdominal wall mass and enterocutaneous fistula. Genitourinary: wnl. Skin: Stage II sacral decubitus ulcer. Extremities: 2+ radial, DP and PT pulses b/l. 2+ edema of UEs b/l. Lymphatics/Heme/Immun: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. Psychiatric: WNL - remarkably after all that he has been through. . At Discharge: Vitals:__________ GEN: A/Ox3, somnolent/withdrawn on occasion. Depressed. CV: RRR, no M/R/G. Face/Upper extremities: Moderate Edema, + radial & brachial pulses. + cap refill. R & L arm broken skin weeping serous fluid. Neck: distended, edematous, +JVD RESP: RR-20-24, SOB/DOE, occasional wheeze. ABD: +BS, +flatus, +BM-liquid, brown stool, ND, appropriately TTP, central incision with vacuum dressing appliance-wound bed: Beefy red granulation tissue, close to skin level, fistula LLQ lateral wound bed wall. Lower Extrem: Mild edema. B/L LE amputee. Skin: generalized maculo-papular rash Upper extremities, trunk, back. Coccyx stage II ulcer, pink tissue, blanching. Duoderm applied.
FAMILY HISTORY: His mother had hypercoagulability and was on Coumadin as well. She also had lung cancer. His father was an alcoholic, he had [**Name (NI) 4522**] disease, and he died secondary to cirrhosis.
SOCIAL HISTORY: The patient does not smoke or drink alcohol. He was using recreational drugs including marijuana in the 60s but not recently. He denies ever using intravenous drugs. He is single and has no children. He has been on disability since [**2108**]. Lives in subsidized housing. HCP = niece [**Name (NI) **] Di [**Name (NI) 25912**] [**Telephone/Fax (1) 25913**]/[**Numeric Identifier 25914**] | 0 |
33,938 | CHIEF COMPLAINT: DKA
PRESENT ILLNESS: 39 y/o female with T1DM who presents with weakness and was found to be hyperglycemic. Pt reports that she had been feeling weak over the past 1-2 days and did not take her insulin for two days. Denies F/C. Denies CP or SOB. Denies urinary or bowel symptoms. Does admit to N/V. Denies hematemesis, melena, or hematochezia. Admits to mild URI symptoms over the past 2 days. In the ED, vitals upon presentation were T 98.6 HR 123 BP 132/69 RR 19 99%RA. Laboratory testing revealed DKA and she was given a bolus of 10 units of regular insulin and started on an insulin gtt. She was also aggressively fluid resuscitated with IVF, a total of 4L NS. Her FSBG improved to ~240 and she was started on D51/2NS. Her symptoms improved dramaticallly. She was also given potassium and zofran. CXR was WNL. She was admitted to the ICU for further care.
MEDICAL HISTORY: Type I Diabetes Mellitus with mild retinopathy, las A1C 10%
MEDICATION ON ADMISSION: Zocor 40 mg daily Novalog Insulin Levemir Insulin Flonase PRN Aspirin 81 mg daily (although probably only takes 1-2x a week because she forgets to take it)
ALLERGIES: Shellfish
PHYSICAL EXAM: On Presentation: VSS GEN: NAD. HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear. NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline. COR: RRR, no M/G/R, normal S1 S2, radial pulses +2. PULM: Lungs CTAB, no W/R/R. ABD: Soft, NT, ND, +BS, no HSM, no masses. EXT: No C/C/E, no palpable cords. NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses
FAMILY HISTORY: Grandmother had diabetes and leukemia. Mother has benign breast disease. Son recently diagnosed with DM type I.
SOCIAL HISTORY: Former tobacco, quit 9 years ago. Rare EtOH. No IVDU, lives with two children. ETOH socially. Works at [**Hospital3 328**] as practive manager. | 0 |
42,635 | CHIEF COMPLAINT: s/p Motorcycle crash
PRESENT ILLNESS: 35 yo female who was on a motorcycle (helmeted) 2 days ago, sustained a fall with no reported LOC resulting in left tib/fib fracture, left scapular neck fracture, Grade [**4-9**] splenic laceration and multiple rib fractures. She was tranported to [**Hospital1 18**] for further care.
MEDICAL HISTORY: Denies
MEDICATION ON ADMISSION: None
ALLERGIES: Penicillins
PHYSICAL EXAM:
FAMILY HISTORY: Noncontributory
SOCIAL HISTORY: | 0 |
73,967 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 66-year-old male transferred from [**Hospital 1474**] Hospital after ruling in for a non-Q wave myocardial infarction. He presented on [**2173-4-13**] when he developed significant shortness of breath at rest as well as a pressure-like chest pain. He had nausea but no vomiting or diaphoresis. EMS was called and reported an O2 saturation of 86% and ST elevation in leads 2 and 4. At the [**Hospital1 1474**] emergency room the patient was noted to be in congestive heart failure. He was treated with Lasix and O2. The patient was admitted to [**Hospital1 1474**] where further work-up revealed increased BUN and creatinine of 6.6, creatinine clearance calculated at 11. Renal ultrasound was reported as normal. Echocardiogram reported an ejection fraction of 15-20% down from 60% in [**9-14**], severe diffuse left ventricular hypokinesis and akinesis noted, one episode of supraventricular tachycardia to the 160s only symptomatic with palpitations. The patient was treated with Lopressor. Also hematocrit on admission was 26. The patient was transfused several units of packed red blood cells. He was transferred to [**Hospital1 69**] for catheterization which showed severe two-vessel disease including left main.
MEDICAL HISTORY: 1. Prostate cancer 12-13 years. 2. Diabetes mellitus x 10 years, insulin x 5 years. 3. Chronic renal failure. 4. Transient ischemic attack. 5. Right carotid stent. 6. Hypercholesterolemia. 7. Hypertension.
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient quit smoking cigarettes three years ago, smoked one pack per day x 30 years. | 0 |
78,955 | CHIEF COMPLAINT: Nausea/vomiting and abdominal pain
PRESENT ILLNESS: The patient is a 39 year old male who complained of having "the flu" for several days with cough, chest pain, malaise. One day prior to presentation, he had severe nausea and vomiting as well as right flank pain. The pain was constant, and localized to the right flank. No fever or chills. No prior episodes. He reports flatus and green bowel movements. He denied any blood, melena, dysuria.
MEDICAL HISTORY: His past medical history is significant for a history of alcohol abuse.
MEDICATION ON ADMISSION: None
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: The patient's exam on admission was Temp 99.9, HR 98, BP 165/85, RR 18, SaO2 97% room air Tired, shaky Bilateral basilar crackles Regular rate and rhythm Hyperactive bowel sounds, palpable liver to umbilicus, firm, moderately tender, nondistended, no rebound or guarding, no [**Doctor Last Name 515**] sign Rectal tone normal, no mass, Guiac positive Extremities warm and well-perfused without edema
FAMILY HISTORY: His father and mother both died of cancer.
SOCIAL HISTORY: He has not had any alcohol for the 2 weeks prior to admission. He quit smoking one year ago. He works as a painter and carpenter. | 0 |
43,028 | CHIEF COMPLAINT: s/p Assault
PRESENT ILLNESS: 28 y/o M transferred from [**Hospital 8125**] Hospital after reportedly assualted where he was kicked and punched multiple times to his head and torso; no reported LOC. Transferred to [**Hospital1 18**] with stable with left rib fractures and mutliple splenic lacerations.
MEDICAL HISTORY: Depression
MEDICATION ON ADMISSION: Celexa
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM:
FAMILY HISTORY: Noncontributory
SOCIAL HISTORY: | 0 |
39,748 | CHIEF COMPLAINT: Anemia.
PRESENT ILLNESS: 71 year old [**First Name3 (LF) 8230**] speaking gentleman with past medical history of hypertension, right sided MCA CVA with left sided residual hemiparesis and speech deficit, s/p resection of colocutaneous fistula, transverse [**First Name3 (LF) 499**] resection and resection of gastrocolic fistula at [**Hospital1 3278**] who was recently admitted to [**Hospital1 18**] from [**2150-2-9**] to [**2150-3-6**] for AAA repair and readmitted shortly thereafter with hypernatremia from [**3-10**] to [**3-12**]. He presented with a low HCT. . SUMMARY OF HIS RECENT COURSE: The patient was admitted to [**Hospital1 3278**] in [**1-/2150**] and found to have his G-J tube eroded into his transverse [**Year (4 digits) 499**] through gastrocolic fistula. This was repaired, as well as a colocutaneous fistula. He was sent home but then presented to [**Hospital1 18**] several days later in late [**1-/2150**], was unstable so intubated and taken emergently for AAA repair. He stayed here for a month post op ([**Date range (1) 90361**]) with a complicated course afterwards including a MRSA PNA treated with 14 days of IV vanco, [**Last Name (un) **], acute blood loss anemia requiring PRBC's, hypernatremia, diarrhea with three negative Cdiff's, and new afib. He was readmitted from [**Date range (1) 90362**] for atrial fibrillation. He was noted at a point in between to have a Hct drop, so he was sent in for blood transfusion on [**3-21**] then sent back to rehab. On [**3-25**] he had a G-J tube exchange. He then came to ED in mid [**4-4**] with Hct drop from 30's to 17 and found on CT to have a very large pelvic hematoma. Of note, he may have been abandoned by his family. There are several SW notes to this effect. . He was sent to our ED referred to ED from HCT fall from 29->17. In our ED, he got 2u pRBC, last one at 10:30. Large bore access with 14g and 16g. His only complaint was pain in left leg. EKG: old RBBB, rate 100. Guaic + brown, gellatinous stool. Vascular saw him and recommended CTA that revealed a "14 x 7 cm hetereogeneous hyperdense collection concerning for acute hematoma." Surgery saw him and recommended medicine admission.
MEDICAL HISTORY: Right MCA CVA with residual left hemiplegia in [**2147**] negative Hypertension History of hypernatremia AAA s/p retroperitoneal repair in [**1-/2150**] Large pelvic hematoma in intramural right sigmoid [**Year (4 digits) 499**] with endoluminal extension and bleeding per rectum in [**3-/2150**] . PAST SURGICAL HISTORY: Ex lap for fecal drainage around PEG site: resection of colocutaneous and gastrocolic fistulas ([**Hospital 3278**] Medical Center [**1-30**] - [**2-6**]).
MEDICATION ON ADMISSION: Aspirin 325 Lansoprazole 30 Metop 12.5 [**Hospital1 **] Ipratropium q6 Lidoderm patch fibersource tubefeeds which he tolerates well at goal rate of 65 cc/hr with 1-2 loose BM a day
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Upon admission: General: Cachetic male in no acute distress. Sleeping but easily awoken. HEENT: NC/NT/Anicteric. Temporal wasting. Dry mucous membranes. Very poor dentition. Neck: Supple, JVP @ 8 cm. No thyromegaly, Firm submandibular left sided 1x1cm lesion. Lungs: Rhonchorous at the bases, upper airway sounds. CV: Tachy rate and rhythm. No murmurs or gallops appreciated. Abdomen: Soft, nontender and nondistended. Hyperactive bowel sounds. G-tube in place without erythema around it. Suture intact with no drainage or erythema around the site of AAA repair. GU: Foley in place Rectal Tube in place. Ext: No edema. No rash. wwp, DP 2+ bilaterally. Left arm and leg contractures. Neuro: CN 2-12 intact (PERRLA. EOMI. No facial droop. Midline tongue protusion). Language intact. L arm internally rotate and forearm externally rotated similar to left leg which is internally rotated which is consistent with prior CVA. Increase tone on left UE and LE. [**3-17**] motor strength on right UE and LE. . At discharge: V/S: 97.2 149/90 83 24 97% on RA I/O: [**Telephone/Fax (1) 90363**]/1000+50 maroon tinged stool gen: thin cachetic male awake and alert in NAD HEENT: temporal wasting, sclera anicteric, MMM without lesions Neck: supple, submandibular firm nodule CV: RRR, no m/r/g Resp: bibasilar rhochi to mid lung fields Abd: +BS, soft, nondistended, nontender, soft non pulsatile RLQ mass Ext: wwp, no LE edema, DP 2+ bilaterally, left arm and leg contractures
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Mandarin speaking only. Sister [**Name (NI) 17470**] and nephew [**Name (NI) **] are HCP. [**Name (NI) **] has been living at [**Hospital3 2558**]. His family has not been guardianship as they were very difficult to get in touch with, concerns of abandonment. | 0 |
58,989 | CHIEF COMPLAINT: abdominal pain, ischemic colitis
PRESENT ILLNESS: The patient, a lovely, active, 67-year-young hypertensive former heavy cigarette smoking lady with emphysema, moderately-severe obstructive chronic pulmonary disease with recurrent pneumonias, presenting to Vascular Surgery (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43078**]) with 3 weeks with atheroembolization, clearly tender purple toes, and to have a 4.2-cm intact infrarenal aneurysm, likely with shaggy thrombus by CTA. After medical optimization, cardiac and pulmonary optimization by Dr. [**Last Name (STitle) 88034**] and Dr. [**Last Name (STitle) 88035**], and after a full discussion of the risks, benefits, and alternatives including aortobifemoral bypass and transfemoral stent graft repair, the patient and her family desire definitive repair, accepting nonpulmonary complications, specifically higher in her case.
MEDICAL HISTORY: PMH: left thalamic ICH [**10-16**], HTN, COPD, thyroid disease, CAD, type 2 diabetes mellitus, previous smoker
MEDICATION ON ADMISSION: Cozaar 100 mg PO daily , Lopressor 25mg PO BID HCTZ 12.5mg PO daily Xanax 0.25 mg PO prn Home oxygen 2.5 L at night, and sometimes during the day Symbicort [**Hospital1 **], ProAir prn
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Physical exam on [**4-2**] by Transplant/Hepatobiliary Consult: VS: 99.9 99.6 87-92 150's/60's 17 99% 2L I/O's: 2230/780 BMx2 CVP 7-9 UOP: 100 cc last hr Gen: AOx1-2, lethargic CVS: RRR Pulm: increased work or breathing Abd: Distended, TTP throughout + rebound +voluntary guarding. Peritonitis LE: No LLE, warm well perfused
FAMILY HISTORY: Father died age [**Age over 90 **] w/complications of Alzheimer's. Mother is aged 96 w/mild memory issues and is retired RN.
SOCIAL HISTORY: Substance use history: per family, h/o EtOH > 20 years ago, now occasionally has one glass of wine during special occasions. Per OMR, h/o 40 pack-years tobacco, quit [**2169**]. No other substances. | 0 |
15,665 | CHIEF COMPLAINT: shortness of breath
PRESENT ILLNESS: 68 y/o F with no medical care x years, who called EMS tonight c/o shortness of breath. Upon their arrival, she was found to be agonal breathing, foaming at the nose/mouth, and an oxygen saturation of 80%. (Per report from ED resident, as there are no EMS records available.) She was intubated by EMS and brought to [**Hospital3 3583**]. At [**Hospital1 46**], she was hemodynamically stable (sbp 120s-140s, pulse 100s). She was given versed 2 mg, narcan 2 mg, morphine 4 mg, and ativan 1 mg. Per our ED resident, she was also given lasix 40 mg and had 800 cc UOP at [**Hospital1 46**] but this is not in their records. She had an EKG that demonstrated a LBBB, and so she was Medflighted to [**Hospital1 **] for possible cardiac intervention. She also received vecuronium at some point. . In our ED, her vitals were: 99.4, 115/75, 113. Her inital vent settings were not recorded, but her oxygen saturation was between 94 and 98% on 100% FiO2. She required a PEEP of 15. She was noted to have a UTI on her UA and was given vanco, levofloxacin, and flagyl. She was also given sedation with versed. She had a bedside echo by the ED resident which reportedly showed a hyperdynamic state. . Upon discussion with her daughter, she reports that the pt is a [**Doctor First Name **] Scientist and has not seen a doctor for over 20 years secondary to her religious preferences. Her daughter states the pt has been more short of breath lately and has been complaining of weakness and dizziness, as well as insomnia. This has been going on for a matter of months. Did not complain of chest pain, nausea, vomiting, abd pain per daughter. [**Name (NI) **] daughter saw her yesterday [**2141-2-7**] and noted that her mom was able to get around the house, etc.
MEDICAL HISTORY: unknown as pt has not seen physician in over 20 years. Per daughter, she shattered her patella a few years ago and refused surgical intervention at that time.
MEDICATION ON ADMISSION: None
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: T: 98.0 BP: 109/59 P: 86 AC 600x22 (23) FiO2 0.7 Peep 15 O2 sat 100% Gen: intubated/sedated but opens eyes to voice, follows commands in all four extremities HEENT: pupils 2 mm and nonreactive bilaterally, dried blood on face Neck: JVD difficult to visualize Lungs: inspiratory crackles at left base, good air movement, no wheezing CV: tachycardic, distant heart sounds, no murmur Abd: soft, nontender, nondistended, +bs. + Vaginal prolapse with some skin breakdown. Ext: trace to 1+ pitting lower extremity edema bilaterally to knees
FAMILY HISTORY: noncontributory per daughter
SOCIAL HISTORY: Lives by herself. Works as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Science Practitioner. Used to smoke tobacco, daughter unsure how much, quit 20 years ago. No EtOH use. Divorced. | 0 |
79,754 | CHIEF COMPLAINT: Shortness of breath, cough, and fever.
PRESENT ILLNESS: The patient is a 67 -year-old Russian speaking female with a past medical history significant for diabetes type II, congestive heart failure of unknown etiology, and hypertension. The patient presents with a three day history of progressively worsening shortness of breath and dyspnea on exertion, wheezing, nonproductive cough, and fever to 102 F on the day prior to admission. Per patient's husband, she denies any nausea or vomiting, chills at night, night sweats, or chest pain. She denies diarrhea. She has been constipated. The patient does have paroxysmal nocturnal dyspnea and two pillow orthopnea. The patient denies dysuria. Fingersticks at home have been running approximately 200 to 270's. The patient denies any sick contacts. On the morning of presentation, the patient was noted to be more lethargic by her husband. [**Name (NI) **] report, her oxygen saturation upon arrival of the EMS, was in the 80's. The patient was placed on 100% nonrebreather and arrived at [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] where she was noted to be wheezing on examination. She was given Albuterol and Atrovent nebulizers with improvement of her oxygen saturation from 90% to 94%, also on 100% nonrebreather. She was also administered 40 mg of IV Lasix times two with diuresis of approximately one liter. The patient denied any chest pain throughout her entire presentation.
MEDICAL HISTORY: 1. Type II diabetes mellitus. 2. Morbid obesity. 3. Hypertension. 4. Congestive heart failure of unclear etiology with normal [**Name (NI) 20679**] systolic function. Question of left ventricular hypertrophy on prior echocardiogram. 5. Stasis dermatitis in bilateral lower extremities. 6. No history of coronary artery disease. 7. Restrictive lung disease, believed to be secondary to morbid obesity. The patient does have a home O2 requirement of approximately 2.0 to 2.5 liters during the day time. 8. Presumptive obstructive sleep apnea.
MEDICATION ON ADMISSION:
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY: Negative for cancers. Paternal grandmother with diabetes mellitus and maternal aunt with coronary artery disease.
SOCIAL HISTORY: The patient denies any tobacco use. She lives with her husband, no alcohol use. She is gravida II, para II. | 0 |
87,047 | CHIEF COMPLAINT: Transfer for liver abscess.
PRESENT ILLNESS: Pt is a 82 yo m with a fall in [**Month (only) **] c/b by long hospital course and pna now vent dependent, who presents with leukocytosis and ?liver abscess. Per report pt had a percutaneous drain but has hx of ccy. . Had recent MRSA in sputum and was treated with IV vanco which was DC's given increasing Cr. Baseline creatinine is 0.7. WBC increasing, picc line pulled. Cath tip cx negative. C-diff, and urine cx negative. CXR with no evidenc of pneumonia. U/S with abnormaility on liver with CT confirmation. BP 94/55 afebrile, with a decreased urine output 200 cc/ 8 hr. 2 stage II located on sacrum. Patient was then sent to the [**Hospital1 **] for further evaluation. . Labs in the ED were significant for wbc 17.8, alt 69, ast 59, nl tbili, inr 6.7-- got vit K, and creat 2.6. . OSH ct scan was reviewed by surgery which showed ? liver abscess. BP's were in the 80's systolic. Pt got 4L IV NS, levo/amp/flagyl, u/o 400 in 2hrs in ED.
MEDICAL HISTORY: CAD (MI [**56**]), A fib, CHF, HTN, s/p fall with c-spine fracture [**3-14**], recent respiratory failure s/p tracheostomy, acalculous cholecystitis requiring percutaneous drainage per report but history of CCY, gout
MEDICATION ON ADMISSION: (on transfer) 1. Meropenem 500 mg IV Q12H 2. Albuterol 6 PUFF IH Q4H 3. Calcium Carbonate 500 mg PO BID 4. Nephrocaps 1 CAP PO DAILY 5. Famotidine 20 mg PO DAILY 6. Insulin SC Sliding Scale 7. Vancomycin 1000 mg IV Q48H 8. Ipratropium Bromide MDI 6 PUFF IH Q4H Allergies: Iodine, shellfish
ALLERGIES: Iodine
PHYSICAL EXAM: Vitals: BP 143/53, HR 85, R 31 Gen: trach Pt. minimally responsive, opens eyes, does not follow commands CV: irregularly irregular, no M/R/G Lungs- clear anteriorly, course breath sounds Abdomen- soft, non tender, distend, + BS, no guarding or rebound PEG tube in place. 2 decub ulcers stage 2 on sacrum. Rectal: no masses, brown stool in vault Ext: edematous
FAMILY HISTORY: Unknown.
SOCIAL HISTORY: Worked in a legal firm, quit smoking 25 years ago. Does not drink alcohol. | 0 |
1,280 | CHIEF COMPLAINT: Dyspnea
PRESENT ILLNESS: 46-yo-man w/ active cocaine use presents w/ LE edema. 10 days ago, he developed b/l LE edema that has gotten progressively worse until now. Three days ago, he developed dyspnea on exertion when climbing stairs, assoc w/ 2-pillow orthopnea and PND. He denies any recent chest pain, palpitations, headache, confusion, weakness, numbness, abd pain, or hematuria. No recent viral syndromes or URIs. He does admit to cocaine use last night. Today, his wife convinced him to present to the ED for evaluation. . In the ED, his BP was 230/170. BNP was elevated at 7500. CXR revealed evidence of cardiomegaly and pulm edema. He was treated w/ ASA 325 mg, lasix 10 mg IV, and hydralazine 10 mg IV x 2. He responded well to lasix w/ good UOP, but diastolic BP remained elevated at 170, prompting initiation of nitroprusside gtt. He is now admitted to the CCU for further care.
MEDICAL HISTORY: none
MEDICATION ON ADMISSION: none
ALLERGIES: Penicillins
PHYSICAL EXAM: VS: T , BP 181/122, HR 84, RR 12, O2 98% 2L/m Gen: lying flat in bed, pleasant and conversational, NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear w/ MMM. Neck: Supple with JVP of 8 cm. CV: reg s1, loud s2, + 2/6 systolic murmur radiating to axilla, no s3/s4/r Pulm: CTA b/l w/ no crackles or wheezing Abd: obese, +BS, soft, NTND. Ext: warm, 2+ DP b/l, 2+ pitting edema to knees b/l Neuro: a/o x 3, CN 2-12 intact
FAMILY HISTORY: There is no family history of premature coronary artery disease or sudden death.
SOCIAL HISTORY: significant for current tobacco use. Drinks 3-4 beers a few times weekly, no h/o withdrawal symptoms, seizures or DTs. Snorts cocaine 1-2 times monthly. Never injected drugs. | 0 |
43,484 | CHIEF COMPLAINT: Left empyema Fevers
PRESENT ILLNESS: 60-year-old gentleman who recently underwent a left upper lobectomy for primary lung cancer ([**2146-9-5**]). He subsequently developed a staph aureus left empyema postoperatively requiring re-exploration and drainage. He was recovering from that when he again developed fevers to 103. Repeat imaging demonstrated residual pockets within the chest space. He was transferred to the [**Hospital1 69**] on [**2146-9-17**] for further care and evaluation.
MEDICAL HISTORY: Primary lung cancer Diabetes Bronchitis/COPD Arthritis Hemorrhoids Cholelithiasis Pilonidal cyst Pelvic fracture secondary to MVA s/p repair [**2140**] L4-L5 disc disease Sinusitis Hepatomegaly
MEDICATION ON ADMISSION: Meropenem Vancomycin Pantoprazole Insulin Tylenol
ALLERGIES: Penicillins / Iodine
PHYSICAL EXAM: On admission, the patient's vital signs were as follows:
FAMILY HISTORY: Mother with pancreatic cancer
SOCIAL HISTORY: | 0 |
90,856 | CHIEF COMPLAINT: s/p fall, change in mental status, Headache, syncopal
PRESENT ILLNESS: 55 y/o female on coumadin for A-fib s/p fall x 2 days ago presents to OSH hospital after syncopal episode. Went to OSH 2 days ago for headache, head CT was negative and was sent home. Presented to PCP today for change in mental status and headache. While at PCP's office, syncopized and was transferred to [**Hospital3 **]. INR was 5.2, one unit of FFP administered and head CT showed R SDH with mid line shift. Her mental status began to decline so she was then intubated for airway safety and transferred to [**Hospital1 18**] for further neurosurgical workup. Patient received 10mg of Vitamin K and profiline in emergency department.
MEDICAL HISTORY: 1. HCV (genotype IIB) cirrhosis s/p pegylated interferon and ribavirin with clearance of hepatitis virus in [**2101**], c/b portal hypertension, ascites, and variceal bleed 2. Fibromyalgia 3. Granuloma annulare 4. Hypothyroidism 5. Disc disease in the cervical and lumbar spine 6. B12 and iron deficiencies
MEDICATION ON ADMISSION: B12 INJECTION - im monthly CLONAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth prn CLOTRIMAZOLE [MYCELEX] - 10 mg Troche - dissolve one in mouth five times a day Do not drink or eat for 15 minutes after taking FUROSEMIDE - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a day LACTULOSE - (Prescribed by Other Provider) - 10 gram/15 mL Solution - 30cc Solution(s) by mouth three times a day as needed for constipation LEVOTHYROXINE [LEVOXYL] - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 125 mcg Tablet - 1 Tablet(s) by mouth once a day LIPASE-PROTEASE-AMYLASE [CREON 10] - (Prescribed by Other Provider) - 249 mg (33,200 unit-[**Unit Number **],000 unit-[**Unit Number **],500 unit) Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth prn before or after meals NADOLOL - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day OXYCODONE - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth prn SPIRONOLACTONE [ALDACTONE] - 50 mg Tablet - one Tablet(s) by mouth daily WARFARIN - 5 mg Tablet - 1 Tablet(s) by mouth once a day start 5 today and check INR tomorrow ZOLPIDEM - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth QHS prn Medications - OTC ACETAMINOPHEN [TYLENOL EXTRA STRENGTH] - (OTC) - 500 mg Tablet - 1 Tablet(s) by mouth prn CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - (OTC) - 400 unit Capsule - 1 Capsule(s) by mouth once daily MULTIVITAMIN - (OTC) - Tablet - 1 (One) Tablet(s) by mouth once a day OMEGA-3 FATTY ACIDS - (OTC) - 1,000 mg Capsule - 1 (One) Capsule(s) by mouth once a day PROBIOTIC - (OTC) - Dosage uncertain
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: On Admission: T: unable to obtain BP:119/77 HR: 84 R :15 O2Sats: 100% on CMV Gen: Patient off sedation for exam, intubated, following commands HEENT: Bilateral orbital edema, normocephalic Pupils: R 6-5mm, L 5-4mm EOMs: intact
FAMILY HISTORY: Her brother has a history of polio and [**Name (NI) 4278**] disease who is deceassed. Her father had a history of breast carcinoma and her mother has [**Name (NI) 2481**] disease. She has one brother who has Hep (uncertain on type), and her mother also had hepatitis
SOCIAL HISTORY: Currently on disability. she lives with her sister. She never married and does not have any children. No tobacco,ETOH or IVDU. Unclear etiology of Hep C- believes it may have been [**2-10**] surgery w/blood transfusion as a child. | 0 |
47,547 | CHIEF COMPLAINT: Dyspnea on exertion
PRESENT ILLNESS: This is a 32-year-old patient who has had a prior homograft replacement of the aortic root for aortic stenosis, presented at this time with severe aortic stenosis confirmed by echo with symptoms. He was electively admitted for redo sternotomy and replacement of the aortic valve and possibly root replacement.
MEDICAL HISTORY: - s/p homograft AVR in [**2146**] - h/o atrial flutter, status post cardioversion - h/o subarachnoid bleed in the right parietal temporal region secondary to Lovenox; w/u in progress for platelet dysfunction - s/p appendectomy in [**2140**] - hernia repair in [**2156**]
MEDICATION ON ADMISSION: Lopressor 25 mg daily Multivitamin aldactazide 25 mg/ 25 mg daily
ALLERGIES: Penicillins / Erythromycin Base
PHYSICAL EXAM: 98.7, 101/60, 81, 22, 97/RA, 128.3 KG Gen: comfortable, no distress HEENT: no LAD, MMM, PERLA, no OP lesions Neck: thick, no JVD appreciable Heart: S1/S2, RRR, 3/6 SEM best heard at RUSB Abd: obese, soft/NT EXT: no edema, 2+ pulses Neuro: AOx3, no focal deficits
FAMILY HISTORY: -mother with diabetes -father is healthy -no strokes in family -no h/o premature CAD/sudden cardiac death
SOCIAL HISTORY: He is married, with three children. Owns a restaurant in [**Location (un) 246**], cooks there. Social ETOH, quit smoking several months ago, previous pack per day for 12-years. | 0 |
53,417 | CHIEF COMPLAINT: s/p Gunshot wound RLQ/Right groin
PRESENT ILLNESS: Mr. [**Name13 (STitle) 77892**] is a 32 year old male who was by report found unresponsive in a park with a gunshot wound to the RLQ. He was taken to an area hospital where he was found to have right iliac vein and right external iliac artery transection. He underwent an exploratory laparotomy, repair of right external iliac artery with a Gortex jump graft and ligation of the right iliac vein. He received a total of 14 units of PRBC, 4 units FFP and 15 units platelets. He was stabilized there and transferred to [**Hospital1 18**] ED for further care.
MEDICAL HISTORY: Denies
MEDICATION ON ADMISSION: None
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Upon admission: NAD RRR CTAB Abd: soft NT/minimally distended midline abdominal incision C/D/I RLQ incision with small area of open wound at bullet entrance Extr: RLE sensation and motor intact, mild foot drop vacs to medial and lateral fasciotomy sites
FAMILY HISTORY: Noncontributory
SOCIAL HISTORY: +EtOH on weekends, denies tobacco or recreational drug use | 0 |
84,658 | CHIEF COMPLAINT: chest pain
PRESENT ILLNESS: Mr. [**Known lastname **] is a 62 year old man with diabetes on insulin pump and hypertension, admitted on [**6-17**] to outside hospital with [**Hospital 39700**] transferred to [**Hospital1 18**] for cardiac catheterization. He notes that chest pain started last Friday [**6-12**] around 8pm, was sharp and very severe [**10-25**] and lasted until 3am, about 7 hours. He thought it might have been from indigestion. On Saturday night the pain returned, peaked at 7/10 and resolved after an hour. Patient was in DC with his wife and a couple of friends at the time who noted that his speech was slurred and he was a little off balance for a couple of days. He states that the pain was associated with Left arm tingling and diaphoresis. He had a couple more smaller episodes of chest pain in the next couple days as well and returned to town on Wednesday. Patient's chest pain symptoms initially began about 1-2 months ago but very mild, so he ignored them.
MEDICAL HISTORY: PAST MEDICAL HISTORY: Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension . Other Past History: - IDDM (type 2?) on insulin pump - HTN - Hyperlipidemia - Retinopathy of the L eye - (followed by Dr. [**Last Name (STitle) 39701**] of [**Doctor Last Name 9243**] Retina Associates, [**Location (un) 86**]) - history of H.pylori - S/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4675**] cyst rupture - Previous diagnosis of Reflex Sympathetic Dystrophy of the R foot, s/p spinal cord stimulator device placement in [**2167**] - R foot penetrating traumatic injury - [**2152**] - H/o recurrent R foot cellulitis and possible osteomyelitis (further details as noted in HPI) - s/p Multiple right foot surgeries - Hx of abdominal neurostimualtor
MEDICATION ON ADMISSION: lipitor 80mg [**Hospital1 **] insulin pump - novolog 1.5u/hr daytime, 1.7u/hr night metformin 500mg [**Hospital1 **] HCTZ 50mg daily valsartan 80mg daily amytriptyline 150mg QHS MVI aspirin 325mg daily
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: ON ADMISSION VS - 97.6 164/85 86 18 100%2L Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. PERRL, EOMI. Neck: +Left sided carotid bruit CV: Reg Rhythm, Normal rate, +soft systolic murmur. Chest: Resp unlabored, no accessory muscle use. CTAB anteriorly and laterally. Abd: Soft, nontender, obese, subutaneous insulin pump right side
FAMILY HISTORY: There is no family history of premature coronary artery disease or sudden death. No family history of diabetes.
SOCIAL HISTORY: Married, children. Currently disabled due to R foot injury, not working. No smoking, no alcohol use. No history of illicit drug use. Used to work as foreman. | 0 |
58,188 | CHIEF COMPLAINT: Confusion.
PRESENT ILLNESS: A 50-year-old female with a history of insulin dependent diabetes, depression, hypertension, and Crohn's disease, who was apparently in her usual state of health up until one day prior to admission when her husband returned and found her to be covered in feces, agitated, confused, and acutely changed in mental status. Per her husband, there has been no history of suicidal ideation, fever or chills. No history of bizarre behavior, rashes, nausea, or vomiting. Of note, she works as a nurse. She was brought to [**Hospital3 7571**]Hospital with vital signs at the time: Temperature 99.3, blood pressure 128/69, heart rate of 103, breathing at 18, 99% on room air, and required four-point restraints, and was electively intubated for airway protection. A lumbar puncture was performed at the outside hospital which revealed a white count of 500, white cells with [**Pager number **]% lymphocytes. A subsequent tox screen was negative. She was empirically treated with Rocephin, Solu-Cortef, charcoal, Vancomycin, acyclovir, and was directly transferred to the [**Hospital1 188**] Intensive Care Unit.
MEDICAL HISTORY: 1. Insulin dependent diabetes. 2. Crohn's disease. 3. Hypertension. 4. Depression. 5. Sciatica. 6. Chronic back pain.
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY: Mother with [**Name (NI) 2481**] and father with coronary artery disease.
SOCIAL HISTORY: She works as a nurse. She has a remote tobacco history, quit four years ago. Occasional alcohol use, denies IV drugs. She is married and works as a nurse manager at a nursing home. She denies any travel. She has pet rabbits which bite her occasionally. | 0 |
17,957 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is an 18 year old with a history of a skiing accident and weakness of the right lower extremity on [**2152-11-15**], transferred from [**Hospital **] [**Hospital3 26522**] Center. He fell while skiing on moguls on [**11-15**], with epistaxis times two and loss of consciousness and generalized tonic/clonic seizure at the site. The patient regained consciousness spontaneously and was placed on backboard and spine precautions and transferred to [**Hospital **] [**Hospital3 26522**] Center. In the Emergency Room, the patient was not able to move his right leg and was found to have a weakness in the right lower extremity and complained of pain in the back and right side of the abdomen and flank area. His motor strength, his hip flexors were 2 plus on the right, 4 on the left. Knee extension was 3 on the right and 4 on the left. Knee flexion was 3 plus on the right and 4 on the left. [**Last Name (un) **] was 2 plus on the right and 5 on the left. Plantar flexion was 4 on the right and 5 on the left, and dorsiflexion was 3 on the right and 5 on the left. He had intact sensory examination and positive bulbocavernosus and intact spinal sphincter tone. He was found to have a T9 burst fracture and he was put in the steroid protocol with log-rolling precautions. He had an MRI of the spine and had a TLSO brace fitted and he was transferred to [**Hospital1 69**] on [**2151-11-21**], for further management.
MEDICAL HISTORY: He has a negative past medical history and negative past surgical history.
MEDICATION ON ADMISSION:
ALLERGIES: No known allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
26,881 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 72-year-old Philippino male admitted for a worsening of his Parkinson's disease. Family noticed an acute worsening of his symptoms on [**10-10**]. Patient's family had discontinued his Sinemet prior to him presenting in the Emergency Room. Patient was admitted to the Neurology Service to rule out an acute stroke versus exacerbation of Parkinson's disease. Patient was found to have new left arm and leg weakness on admission. Patient had a CAT scan of the head done on [**10-28**] secondary to his not being able to tolerate MRI. Patient was found to have a massive right frontotemporal parietal subdural hemorrhage with fluid level and midline shift and neurosurgery was consulted at that time. The right subdural hemorrhage was subacute in appearance on head CT. Patient was monitored for immediate bedside drainage of subdural hemorrhage in the Intensive Care Unit and aspirin and subcutaneous heparin were discontinued at that time. On [**10-28**], a bedside right subdural drain was placed with good flow of subacute appearing subdural fluid at that time. Status post procedure, the patient was sleepy, had received sedation for the procedure, but was able to follow commands times four and was moving all extremities well. On [**10-30**], the patient was alert and oriented to person and place. EOM were full. Patient was able to wiggle his toes. A repeat head CT was performed that showed that the right frontal drain was in the epidural space. There still was a significant amount of subdural component. On the repeat head CT, the drain was readjusted, therefore, on [**10-30**], and again, good flow of hygroma subdural fluid was obtained secondary to readjustment of the drain. On [**10-31**], patient was doing well. No dyskinesia were noted. There was a minimal left pronator drift. Speech was clearer. Subdural drain had drained about 50 cc. CAT scan was rechecked at this time. Subdural fluid seized to drain on [**10-31**]. Repeat CAT scan was stable. Drain was discontinued at that time. Patient continues to neurologically improve and was transferred to the floor on [**11-1**]. Patient still had some persistent mild left leg weakness. Patient's Sinemet was adjusted by Neurology on [**11-1**]. Patient was out of bed with Physical Therapy. Patient was discharged to [**Hospital3 **] on [**11-2**]. At time of discharge, patient was neurologically stable. Patient was discharged on the following medications:
MEDICAL HISTORY:
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
7,765 | CHIEF COMPLAINT: AAA
PRESENT ILLNESS: Pt with a known AAA was evaluated and found to be a good candidate for EVAR. After discussion with the patient and his family, arrangements were made for the patient to be admitted for elective EVAR.
MEDICAL HISTORY: 1. Throat cancer status post chemo/XRT without recurrence. 2. Prostate cancer status post seed, brachytherapy. 3. AAA 4. difficult airway due to previous RT/chemo 5. dysphagia
MEDICATION ON ADMISSION: aspirin 81mg daily
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Gen: WDWN male in NAD, alert and oriented CV: RRR Lungs: CTA bilat ABD: soft no m/t/o Extremities: Warm, well perfused with palpable distal pulses
FAMILY HISTORY: no known aneurysms
SOCIAL HISTORY: lives alone, denies tobacco/etoh use, independent in adl's, strong family support from 2 nieces | 0 |
55,123 | CHIEF COMPLAINT: Respiratory failure
PRESENT ILLNESS: 73 yoF w/ h/o HTN, hyperchol, and prior TIAS initially presented to ED [**2182-3-6**] following episode of sudden onset transient slurred speech and paresthesias of lip (sbp at home 190s). In [**Name (NI) **], pt evaluated by neuro, had MRI (-) for acute stroke. [**2182-3-7**] a.m., pt had episode of N/V followed by tachypnea and increased work of breathing. Received lasix 40 mg IV X 1, nitro gtt and was placed on BiPAP for suspected CHF. However, sbp decreased to 60s (no improvement following d/c of nitro gtt). She was intubated, started on levophed and gtt. CTA (-) for PE, showing diffuse ground glass opacities and bibasilar opacities (c/w pulmonary edema and aspiration). Pt then sucessfully extubated. Transferred to the floor [**3-11**] and doing well at this time
MEDICAL HISTORY: 1) HTN 2) Hypercholesterolemia 3) h/o pancreatitis 4) lumbar radiculopathy s/p laminectomy 5) s/p bilateral hip replacements 6) h/o aspiration PNA
MEDICATION ON ADMISSION: 1. Lipitor 20 mg daily 2. HCTZ 12.5 mg daily 3. Toprol 75 mg daily
ALLERGIES: Sulfonamides / Iodine
PHYSICAL EXAM: On transfer from MICU to floor. 97.1 135/64 66 15 97% 4L NC Gen- Awake. Pleasant. Alert. NAD. HEENT: PERRL. EOMI. MMM. Cardiac- RRR. S1 S2. No murmers. Pulm- Faint crackles at right base. Abdomen- Soft. NT. ND. Positive bowel sounds. Extremitis- 1+ bilateral LE edema.
FAMILY HISTORY: NA
SOCIAL HISTORY: No tobacco or ETOH use. Mother of 8 children. Very involved family. | 0 |
36,801 | CHIEF COMPLAINT: Chest pain
PRESENT ILLNESS: Ms. [**Known lastname **] is an 81 year-old woman a history of bronchiectasis, dementia, presumed microaspiration and recurrent aspiration pneumonia, s/p recent discharge on [**2117-1-28**] for pneumonia being treated with vanc/zosyn (to complete on [**2117-2-3**]), who presented yesterday for management of chest pain and is transferred to the MICU for afib with RVR and hypotension. . She was feeling well until [**2117-2-1**] when she developed substernal CP that was not associated with diaphoresis, nausea, or vomiting. EKG in the ED was negative and she ruled out MI. CXR suggested new retrocardiac infiltrate versus atelectasis. On the floor, she entered afib with RVR 120-140s (new diagnosis) at 2 a.m. and SBP dropped from 90s to 70s after a dilt 5 mg IV push. She was asymptomatic. A bolus of 500cc was started with SBP improvement to 80s, ASA 325 given, and MICU was consulted for transfer because of increased nursing requirements. . In the MICU the patient's SBP in 90s to 100s with pediatric cuff and the pressors that were temporarily started were stopped. A bronchoscopy was performed that showed evidence of aspiration and cultures were sent. Swabed for flu and negative. A TEE was done that showed hyperdynamic LV.
MEDICAL HISTORY: - bronchiectasis - felt [**3-2**] recurrent microaspiration, was due for video swallow at rehab facility [**12-7**] - Dementia - Neuropathy - Osteoporosis - Chronic venous stasis ulcer - Gallbladder polyp seen on u/s - needed follow up in [**8-6**] - presumed recurrent aspiration pneumonia - Chronic Venous Stasis Ulcer - h/o AFB positive - MYCOBACTERIUM CHELONAE
MEDICATION ON ADMISSION: Alendronate 70 mg PO QTHUR Donepezil 10 mg PO qhs Aspirin 81 mg qday Gabapentin 600 mg PO bid Lidocaine 5 % Patch\ Memantine 10 mg PO BID Acetaminophen 325 mg 1-2 Tablets PO Q6H prn Calcium 500 + D (D3) 500-125 mg-unit PO twice a day Guaifenesin 100 mg/5 mL 10 ml PO Q6H Albuterol nebs q6h Ipratropium q6h Piperacillin-Tazobactam 2.25 gram IV Q6H Vancomycin 1 gm IV Q 24H Albuterol inh prn
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS: T 96.8 HR 64 BP 122/75 RR 20 Sats 91% RA GEN:The patient is in no distress and appears comfortable CHEST: decreased lung sounds at bases, no wheeze, no rhonci CARDIAC: Regular rhythm; no murmurs, rubs, or gallops. ABDOMEN: No apparent scars. Non-distended, and soft without tenderness EXTREMITIES: no peripheral edema, warm NEUROLOGIC: 5/5 strength x 4, grossly oriented
FAMILY HISTORY: The pt's mother died of an enlarged heart, and her father died of pneumonia (age 40-50). She has a deceased brother and sister, from unknown causes. She does have a living sister on [**Hospital3 **]. She never had any children.
SOCIAL HISTORY: The pt previously worked as a graphic designer and a painter with watercolors. She is a never smoker. She drinks 3oz of wine with dinner, less than daily. She denies any recreational drug use. She denies any known exposure to asbestos or tuberculosis. [**Name (NI) 105966**] sister has moved here to help her. | 0 |
95,485 | CHIEF COMPLAINT: back pain
PRESENT ILLNESS: 88F with hx of CAD s/p MI and CABG [**2110**], breast CA in [**2101**] s/p XRT, chemo and LND, osteoporosis, afib s/p pacemaker, and hemorrhagic stroke (not confirmed)with [**Last Name (un) 19171**] back pain presenting with back pain to ED who became hypoxic after CTA. Pt woke up this morning with severe back pain and was also having diarrhea at that time. Pt is presently on Azithro for PNA, coughing with minimal phlegm. She has a history of back pain that began about 1 yr ago, is intermittent, and has recently been causing her more pain.
MEDICAL HISTORY: Coronary artery disease s/p 3 vessel CABG Sinus note dysfunction s/p dual-chamber pacemaker Atrial fibrillation Possible subdural hematoma vs hemorrhagic stroke (not confirmed) Breast cancer s/p chemoradiation and axillary node dissection Chronic kidney disease stage III Fibromyalgia Cholecysectomy Tonsilectomy Total left hip arthroplasty
MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete. Information was obtained from Pharmacy. 1. Acetaminophen 650 mg PO TID 2. Aspirin 325 mg PO DAILY 3. Atorvastatin 10 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Nadolol 40 mg PO DAILY 6. Ranitidine 150 mg PO DAILY 7. Furosemide 10 mg PO DAILY 8. cranberry extract *NF* 0 mg ORAL DAILY 9. Os-Cal 500 + D *NF* (calcium carbonate-vitamin D3) 500mg (1,250mg) -600 unit Oral daily 10. TraMADOL (Ultram) 25 mg PO Q6H:PRN back pain 11. Digoxin 0.0625 mg PO EVERY OTHER DAY 12. estradiol *NF* 0.01 % (0.1 mg/g) Vaginal daily 13. Lidocaine 5% Patch 1 PTCH TD DAILY back pain Patient can refuse if she does not have pain. 14. Acidophilus Probiotic *NF* (acidophilus-pectin, citrus) 100 million-10 cell-mg Oral Daily
ALLERGIES: morphine / Protamine / Augmentin / Bactrim DS / Levofloxacin
PHYSICAL EXAM: Admission Exam: VS 97.5, 136/57, 73, 11, 93-100% on 3L NC General: AAOx person, place, month, and year. tangential thought process requiring frequent redirection. cachectic HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: irreg irreg rhythm, no m/r/g, pacer prominently visible in subcutaneous tissue on right anterior chest wall Lungs: diffuse crackles bilat, worse in lung bases, no wheezes or rhonchi Abdomen: soft, palpable firm bladder, TTP mildly diffusely, NABS
FAMILY HISTORY: Father-lung cancer (died, age 85) [**Name (NI) 90825**] [**Name (NI) 90826**]
SOCIAL HISTORY: Lives at [**Hospital3 **] center ([**Hospital3 **]). Previously lived in [**Doctor First Name 5256**], and recieved all of her medical care at Duke. Denies alcohol and tobacco use. Son [**Doctor First Name 401**] lives in town with his family | 0 |
20,678 | CHIEF COMPLAINT: Abdominal & back pain, nausea and vomiting
PRESENT ILLNESS: 73 year-old female with 1 month h/o RUQ pain presented to [**Hospital3 24768**] on [**2113-9-21**] with increased RUQ pain, nausea, vomiting, back pain, and temperature of 101.0 degrees F. She was being evaluated for ascending cholangitis, when she had an episode of desaturation to 80s on room air, with observed circum-oral cyanosis, yet immediate return to the 90s when placed on oxygen, 2L via nasal cannula. A D-dimer was sent and returned high (>1000) and she was empirically placed on heparin gtt for presumed pulmonary embolus. She was given gentamicin 80mg, levaquin 500mg and flagyl 500mg x 2. A CT scan abdomen / pelvis without contrast revealed abnormal hypodensity in right lobe of liver (2.5cm in diameter), colonic diverticulosis, and mild thinning of wall of colon in LLQ. No intrahepatic or extrahepatic biliary ductal dilatation. Labs were as follows: WBC 21.7, D-dimer 1050, T.bili 1.6, D.bili 0.8, AP 164, AST 52, ALT 44, Alb 2.2, Trop I 0.11, BUN 34, Cr 1.8. At this point, a decision was made to transfer to [**Hospital1 18**] for further evaluation. She was enroute to [**Hospital1 18**] in the evening on [**2113-9-22**] when she became hypotensive (SBP 70s) and reported pleuritic chest pain. She was subsequently diverted to [**Hospital **] Hospital. In [**Location (un) 75093**] emergency department, she was resuscitated with fluid and given demerol with improvement in blood pressure and pain. Once stabilized, she was transported to [**Hospital1 18**] and admitted to the SICU for further evaluation and management.
MEDICAL HISTORY: PMH: Anxiety Diabetes Mellitus on Glyburide 10mg twice daily GERD on Nexium 40mg daily Depression on Zoloft 50mg daily Hypertension Gastritis H/o paroxysmal A-fib controlled with lopressor Parkinson's Hypothyroidism Rheumatoid Arthritis Fibromyalgia Hyperlipidemia H/o RLE DVT s/p knee replacement COPD Chronic back pain Diverticulitis IBS Esophageal strictures Hiatal hernia . PSH: Cholecystectomy ([**2109**]) TAH-BSO ([**2077**]) Rotator cuff surgery Bilateral knee replacements([**2104**]/[**2111**])
MEDICATION ON ADMISSION: Metoprolol 50mg po BID Glyburide 10mg po BID Enalapril 80mg every am Zoloft 50', HCTZ 25', Nexium 40', Darvocet prn, Carafrate 1 tablet po four times daily Sinemet 10/100 po twice daily Vitamin E 800mg po daily Colace 100mg po twice daily Lethicin 1325 po daily
ALLERGIES: Penicillins / Morphine / Biaxin / Sulfa (Sulfonamides) / Ciprofloxacin / Aspirin
PHYSICAL EXAM: T 98.2 HR 72 BP 142/83 RR 16 O2 sat 97% on 2L Nc Gen: awake, alert, uncomfortable secondary to pain, pale HEENT: PERRL, EOMI, mucous membranes moist, oropharynx - clear CV: regular rate and rhythm Pulm: CTA, bilaterally. No wheezing, rales, crackles. Chest: Tenderness on palpation of the chest wall and rib cage, bilaterally. Increased pain with deep inspiration. Abd: soft, non-tender on palpation, obese, positive bowel sounds Ext: warm, well-perfused. no edema Neuro: no focal deficits
FAMILY HISTORY: Unremarkable
SOCIAL HISTORY: The patient lives with her daughter. [**Name (NI) **] husband is deceased. She does not smoke, drink, or use recreational drugs. | 0 |
42,840 | CHIEF COMPLAINT: shortness of breath, fevers, hypoxia, hemoptysis
PRESENT ILLNESS: Briefly this is a 41 y.o. Male with h.o. OSA on BiPAP, HTN, and asthma who initially presented with 3 day h.o. increased SOB, diaphoresis, fevers. Transferred to the ICU for hypoxia and hemoptysis with Hct drop. . Day prior to admission noted a cough productive of clear phlegm. He also noted some watery [**First Name3 (LF) **] with cough. Per prior H&P he had similar episode 7 years ago after shooting cocaine. He denies any recent drug use. On admission he was noted to have a leukocytosis of 16.3. CXR showed no PNA however no retrocardiac opacity was able to be ruled out per medicine team. He was sent for influenza swabs which were negative. He also was started on Levofloxacin for presumed CAP. . On review of OMR it appears his nasal swab for viral was negative, [**First Name3 (LF) **] cultures x 2 were negative and pending. A sputum culture was attempted but was unfortunately contaminated. Since admission pt has been saturating in the mid 90s on 3L n.c., subsequently pt triggered for hemoptysis and hypoxia. He had an episode of hemoptysis x 1 and desaturated to the low 80s. He was transitioned to shovel mask 10L and his saturation improved to the low 90s even with continuous nebulizers. Pt underwent ABG which showed pH 7.43, pH2 60, pCO2 42. CTA was also obtained which was notable for pneumonia versus hemorrhage. . Pt was transferred to ICU for closer monitoring and consideration for possible Non-invasive versus intubation for possible bronchoscopy. He is subsequently being transferred to the floor on [**2-5**] L NC, with saturations in the mid to high 90s, on levofloxacin.
MEDICAL HISTORY: HTN Pulmonary HTN likely [**1-5**] OSA Depression asthma- asymptomatic x4 years, used to use albuterol inhaler. bipolar (no medications for 6 months) obesity OSA on BiPAP s/p ex lap for gun shot wound
MEDICATION ON ADMISSION: Atenolol 150 mg daily Bupropion 75 mg [**Hospital1 **] Citalopram 10 mg daily Clonidine 0.1 mg patch weekly Furosemide 40 mg daily Lisinopril 40 mg daily Nifedipine Extended Release 180 mg daily KCl 30 mEq Sustained release daily Simvastatin 80 mg daily Trazodone 25 mg qhs
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Exam during MICU: VS - 97.9, 96.5, 149-152/94-100, 78-85, 20, 96 FM General: African American Male lying down in bed with shovel mask, slightly tachypneic HEENT: MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Crackles noted in b/l upper lobes, absent BS noted within the LLL and diminished sounds noted in the RLL. CV: Distant S1, S2, no m/g/r, RRR Abdomen: Soft, NT, ND, +BS x 4, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
FAMILY HISTORY: Mother - CHF, asthma Sister - asthma GF - DM
SOCIAL HISTORY: denies tobacco. History of EtOH (6 pack once a week x10 year) and heroin abuse , clean for 7 years. Did a 5 year prison sentence until [**2159**]. | 0 |
27,531 | CHIEF COMPLAINT: shortness of breath
PRESENT ILLNESS: Mr. [**Known lastname 1537**] is a 56 year old man who was discharged on [**8-6**] after plasmapheresis x 5 for [**First Name9 (NamePattern2) 7816**] [**Location (un) **] Syndrome complicated by ileus. He was recovering at [**Hospital **] rehab when he woke on day of admission ([**8-19**]) with dyspnea. Vital signs were obtained and he was found to be sating 82% on 4L NC. He improved to 90% on ventimask. Patient was sent to ED at [**Hospital1 **] on [**2195-8-19**] and went to MICU overnight prior to transfer to medicine due to respiratory improvement. Patient says he has had SOB for 6 days, when he developed SOB at rest and while lying down. Patient has not ambulated since discharge secondary to weakness in LE from GB. He says he has difficulty eating secondary to reflux, coughing, and choking on food, and difficulty swallowing. His SOB worsened through the day of admission. CXR on [**2195-8-17**] at [**Hospital1 **] revealed infiltrates in the lower lobes in addition to the RML. He was treated with levofloxacin and Timentin at [**Hospital1 **]. He also developed a cough productive of yellowish sputum. He complains of reflux that worsens his dyspnea. The CXR at [**Hospital1 **] was also thought to be consistent with CHF so he was diuresed with 80 mg IV lasix resulting with a UOP of 850 cc at [**Hospital1 **]. Patient was receiving standing dose of 80 mg po qd lasix at [**Hospital1 **]. A WBC count was obtained and was elevated at 10.9 on day of admission to MICU. Bilateral LENIs were obtained that were negative for DVT. An EKG was obtained that showed fist degree AV block, and nonspecific ST changes. BNP 2 days prior to admission was high at 140 (upper limit of normal is 99). On the day of admission, an ABG was obtained that showed 7.46/47/117. . As the patient had abdominal pain, an ultrasound was obtained on [**8-17**] which showed normal gallbladder, kidneys, common hepatic duct, pancreas, and spleen. It was remarkable for a mild right sided hydronephrosis and bilateral renal cysts. KUB was negative for obstruction. A day prior to admission, his lipase was found to be elevated at 107 but his amylase was normal. . In the ED, he was given vanco and flagyl. Prior to this, he received levofloxacin.
MEDICAL HISTORY: 1. Cystinuria, on penicillamine for 25 years 2. HTN 3. Remote afib, has had none for 15-20 yrs 4. CHF, diastolic, thought secondary to penicillamine 5. Primary pulmonary HTN 6. Chronic renal insufficiency, baseline Cr 1.9-2.2 7. Gout 8. Multiple renal cysts 9. h/o pancreatic mass 10. Chronic gastritis, GERD 11. Anemia 12. h/o elevated PSA, prostae bx negative [**2192**] 13. Cutis laxa secondary to penicillamine 14. Restless legs syndrome
MEDICATION ON ADMISSION: 1. Allopurinol 300 mg QD. 2. Amlodipine 2.5 mg QD. 3. Folic Acid 1 mg PO BID. 4. Pramipexole 0.25 mg QD. 5. Aspirin 325 mg QD. 6. Acetaminophen 325 mg PRN 7. Spironolactone 25 mg QD 8. Omeprazole 20 mg QD 9. Sodium Citrate-Citric Acid 500-334 mg/5 mL 15 ML PO QID PRN. 10. Furosemide 120 mg PO QPM 11. Zolpidem Tartrate 10 mg HS PRN 12. Clonazepam 0.5 mg PO Q8H 13. Heparin SQ TID 14. Docusate Sodium 100 [**Hospital1 **] 15. Phenol-Phenolate Sodium 1.4 % Mouthwash PRN 16. Morphine 15 mg Tablet Sustained Release QPM 17. Gabapentin 300 mg [**Hospital1 **] 6 pm 10 pm. 18. Captopril 50 mg TID 19. Morphine 2 mg Injection Q4H PRN 20. Senna 8.6 mg PRN. 21. Dulcolax 10 mg PRN Levofloxacin (started [**8-17**]) Timentin (started [**8-17**])
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: PE: Tm 98.4 Tc 97.2 HR 79 BP 115/64 RR 16 O2 95% on 4 L NC Gen: pleasant and cooperative, sitting up conversant, nasal cannula in place HEENT: MMM NCAT, hoarse voice (chronic), throat-MMW, no erythema, exudates Neck: no LAD supple, thyroid enlarged Cor: RRR no murmurs Pulm: dull at right base with crackles BL in lower lobes and RML Back: no costovertebral tenderness Abd: distended but no guarding, no tenderness, + BS Ext: [**Name (NI) 63284**], DP, PT 2+ bilaterally, strength ankle flexors and extensors [**4-2**] bilaterally, upper and lower extremities [**4-2**] bilaterally; 1+ patellar reflexes BL, 2+ biceps reflexes BL, reflexes in achilles BL not able to obtain Neuro: CN II-XII intact. Ambulation not tested as patient says he can't walk Derm: skin at neck and axilla with thick consistency and hyperpigmented macules consistent with penicillamine rectal: guiac negative
FAMILY HISTORY: Maternal aunt with DM, stroke in 70s, PGM with DM. No cystinuria.
SOCIAL HISTORY: Lives with fiancee, works as software engineer. No tobacco, [**1-1**] drinks (glass wine) with dinner/week, no other drugs. | 0 |
52,937 | CHIEF COMPLAINT: Nausea, Vomiting
PRESENT ILLNESS: Mr. [**Known lastname 101121**] is a 76 year old male with h/o pancreatic cancer (dx [**2113-1-2**]) s/p Whipple procedure in [**12-28**] found to be metastatic on CT in [**6-27**], COPD, and HTN who presented to the ED early yesterday a.m. N/V and abdominal pain. He had been admitted on [**8-1**] to the medicine service for decreased PO intake, felt to be multifactorial. He was then readmitted from [**Date range (1) 6106**] to the surgery service for partial SBO that appeared to resolve. Of note, his anion gap during that admission was elevated to 19, and 15 on discharge. He was tolerating small amounts of PO on discharge. He says that he still had abdominal pain on discharge, but over the last day he also developed nausea and vomitted 3 times, prompting his return to the ED. His vomitus is non-bloody, non-bilious, with food particles. His last bowel movement was 2 days ago while inpatient. He denies any melena or hematochezia. No fevers, chills, SOB, cough, urinary frequency or dysuria. . He has had decreased appetite with occasional N/V for the last month or so, and per report, has had a 40 pound weight loss since [**12-28**]. He has intermittent band-like abdominal pain and takes dilaudid/percocet PRN. . In the ED the patient appeared comfortable, with a mildly tender abdomen. VS were 96.3, 94, 122/74, RR 16, 97% RA. A KUB showed dilated small bowel loops improved since last KUB. Surgery did not feel the patient had a surgical abdomen. His labs were notable for an HCO3 of 18, with a gap of 20, a glucose of 286, and a WBC count of 23 which is actually lower than usual. A UA showed ketonuria and glucosuria. He was given 5 U SQ regular insulin and admitted to the medicine floor. On the floor he received 2x 10U of insulin. His AG increased to 21, with a glucose of 300, and he was transferred to the [**Hospital Unit Name 153**].
MEDICAL HISTORY: 1. Intraductal papillary mucinous tumor and cholangitis -pT3N1 pancreatic adeno-squamous carcinoma (stage IIb) 2. S/P Whipple (cholecystectomy, pancreatotomy, splenectomy, hepatojejunostomy and duodenojejunostomy) in [**12-28**]. 3. Colon Ca - stage III s/p L hemicolectomy in 98, s/p chemo with 5FU, leucovorin. 4. COPD 5. HTN 6. Asthma 7. Gout 8. s/p Appendectomy 9. thrombocytosis of unclear etiology since [**2106**] 10. leukocytosis of unclear etiology since [**2103**] 11. depression 12. Diabetes (recent episodes of hypoglycemia per OMR)
MEDICATION ON ADMISSION: Prednisone 5 mg daily Lipitor 10 mg daily Zoloft 100 mg p.o. q.a.m. Protonix 40 mg p.o. daily Flomax 0.4 mg p.o. nightly Percocet 5/325 mg 1-2 tablets p.o. q.4-6h. for pain Dexamethasone 10 mg p.o. q.6-8h. p.r.n. nausea. Lipram(pancreatic enzymes) CR20 Insulin Lantus 12 Q AM/ humalog scale
ALLERGIES: Aspirin / Bactrim Ds
PHYSICAL EXAM: Vitals: 126/57, HR 75, RR 18, 100% RA GEN: Cachectic male appearing comfortable but tired, resting in bed with knees tucked toward chest. HEENT: Anicteric sclerae, dry mucous membranes. Chest: Rales at R base, otherwise diffusely decreased air movement. Cor: RR, normal rate, no m/r/g. Abdomen: Hyperactive bowel sounds. Soft, scaphoid. Tender to palpation diffusely but most pronounced in RLQ. No guarding or rebound. Horizontal scar extending across epigastrium. Ext: Atrophic. No c/c/e. Neuro: A&O x 3.
FAMILY HISTORY: Non-contributory .
SOCIAL HISTORY: Originally from [**Country 532**]. He lives at home with his wife. Ambulates with a cane. | 1 |
45,784 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 36 year old Caucasian male with no past medical history who presents with a one week history of subjective fevers, chills, and aching bones. The patient was in his usual state of health until approximately ten days prior to admission when he had several alcoholic drinks and lost consciousness. One and a half days later the patient developed a sudden onset of chills and rigors and noted that he had to turn the heat up in his apartment to stay warm. The patient subsequently developed arthralgias/myalgias with bony aches and pains. The patient then developed a cough he describes as dry, productive of red bloody mucous. The patient also endorses an episode of emesis, nonbloody as well as nonbloody diarrhea with abdominal pain. The patient saw his primary care physician the following day and was diagnosed with a viral syndrome and prescribed relaxants for right-sided back pain. The patient continued to have fevers, chills and a slight dry cough but on the day prior to admission felt short of breath and called his primary care physician. [**Name10 (NameIs) **] primary care physician encouraged the patient to present to the Emergency Room.
MEDICAL HISTORY: None.
MEDICATION ON ADMISSION:
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient smoked one to three packs per day for 20 years, but quit three years ago. He currently smokes two cigars per day. The patient drinks 12 beers per week, at least one per day. The patient is originally from [**Location (un) 311**] and came to the United States three years ago. He is currently in a monogamous relationship with his girlfriend and denies any history of illicit drug use or male sexual partners. | 0 |
7,821 | CHIEF COMPLAINT: Internal carotid artery stenosis.
PRESENT ILLNESS: This is a 76-year-old female with multiple medical problems including coronary artery disease, peripheral vascular disease, hypertension, insulin-dependent diabetes mellitus, hypercholesterolemia (with critical stenosis of the of the right internal carotid artery of 80% to 99%) who was admitted for stenting and for angiography. A preoperative computerized axial tomography of the head on [**2196-4-19**] was negative for any major vascular and territorial infarction but was positive for heavy atherosclerotic calcifications within the cavernous portions of the internal carotid arteries. A subclavian angiography, as well as carotid and cerebral angiography, showed proximal left subclavian disease, hypoplastic left vertebral artery, tortuous right brachiocephalic artery with a full 360-degree loop in the common carotid artery and right subclavian artery. There was an 80% calcified lesion at the origin of the internal carotid artery and a tortuous right common carotid artery. Due to the tortuosity of her vessels, angioplasty and stent of the right internal carotid artery was unsuccessful. Of note, a small type A dissection of the proximal carotid artery from the sheath position occurred during the procedure. The patient was admitted to the Coronary Care Unit for observation after the procedure.
MEDICAL HISTORY: 1. Hypertension. 2. Insulin-dependent diabetes mellitus. 3. Hypercholesterolemia. 4. Right shoulder surgery. 5. Hysterectomy. 6. Bilateral vein stripping and ligation. 7. Right femoral artery pseudoaneurysm repair. 8. Coronary artery disease with an inferior myocardial infarction in [**2183**] and a non-Q-wave myocardial infarction in [**2192**]. In [**2193-12-23**], coronary artery bypass graft times two with left internal mammary artery to left anterior descending artery and right internal mammary artery to first obtuse marginal. She was admitted most recently in [**2195-10-23**] for chest pain. A catheterization at that time showed patent grafts. 9. Class III congestive heart failure with biventricular pacemaker and an ejection fraction of 20%. 10. Gastrointestinal bleed with urgent colectomy in [**2194-9-22**]. 11. Chronic anemia. 12. Chronic renal insufficiency (with a baseline creatinine of 1.3 to 2). 13. Peripheral neuropathy. 14. Peripheral vascular disease and claudication. 15. Neurogenic bladder.
MEDICATION ON ADMISSION:
ALLERGIES: She has no known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY: No family history of coronary artery disease.
SOCIAL HISTORY: She denies any tobacco history. She has occasional alcohol. She lives with her husband and her daughter. She has occasional [**Hospital6 407**] services. | 0 |
71,510 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 52 year old female with a history of congestive heart failure, diabetes mellitus, hypertension, atrial fibrillation, obesity and peripheral vascular disease on Coumadin who presents with bright red blood per rectum since about midnight on the day prior to admission. The patient experienced periumbilical abdominal pain followed by watery non-bloody diarrhea all afternoon. The patient was recently admitted to the [**Hospital Unit Name 196**] Service from [**1-4**] until [**1-16**] with congestive heart failure and a non-ST elevation myocardial infarction and new onset of rapid atrial fibrillation where she was treated with a Diltiazem drip. The patient was started on Coumadin at that time. The patient had an elevated creatinine during that admission which was thought to be secondary to over diuresis, so her Lasix dose was decreased. Since the day prior to admission, the patient denies any chest pain, palpitations or shortness of breath, but does report some lightheadedness. The patient also reports nausea and vomiting with two episodes of non-bloody emesis with food particles. The patient does report having bloody stools greater than ten years ago when she was drinking heavily, but that had never been worked up. She denies a colonoscopy or esophagogastroduodenoscopy in the past. The patient takes Daypro chronically. The patient is still with some abdominal pain and bright red blood per rectum. Her nasogastric lavage was negative.
MEDICAL HISTORY: 1. Congestive heart failure with an echocardiogram in [**2169-12-13**], with one plus mitral regurgitation, two plus tricuspid regurgitation, normal wall motion and ejection fraction. 2. Diabetes mellitus. 3. Hypertension. 4. Cerebrovascular accident with seizure disorder. 5. Morbid obesity. 6. Peripheral vascular disease status post left femoral to popliteal bypass in [**2164**]. 7. Hypercholesterolemia. 8. Atonic bladder. 9. Right total knee replacement in [**2163**]. 10. History of Methicillin resistant Staphylococcus aureus in her left knee. 11. Major depression. 12. History of atrial fibrillation in [**2169-12-13**]. 13. Coronary artery disease status post non-ST elevation myocardial infarction in [**2169-12-13**] with a cast at that time showing a 50% ostial lesion with no intervention done. 14. Chronic renal insufficiency with a creatinine of between 1.2 and 1.5. 15. Osteoarthritis.
MEDICATION ON ADMISSION: 1. Albuterol Multiple dose inhaler. 2. Protonix 40 mg p.o. q. day. 3. Risperidone 2 mg p.o. twice a day. 4. Zoloft 10 mg p.o. twice a day. 5. Metoprolol 200 mg p.o. twice a day. 6. Lisinopril 20 mg p.o. q. day. 7. Doxepin 10 mg p.o. twice a day. 8. Aspirin 325 mg p.o. q. day. 9. Iron sulfate 225 mg p.o. q. day. 10. Sublingual Nitroglycerin as needed. 11. Senna as needed. 12. Colace. 13. Lasix 80 mg p.o. twice a day. 14. Coumadin 10 mg p.o. q. h.s. 15. Insulin 70/30, 70 units at breakfast and 25 units at night. 16. Daypro one tablet p.o. q. day.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY: Diabetes mellitus.
SOCIAL HISTORY: The patient lives alone. She has a tobacco history of 30 pack year, half pack per day. No alcohol, but has a past history of alcohol abuse. She has Visiting Nurses Association services. | 0 |
38,181 | CHIEF COMPLAINT: Orthostatic hypotension/weakness/aplastic anemia.
PRESENT ILLNESS: A 66-year-old female with history of aplastic anemia admitted to the [**Hospital1 18**] on [**2196-1-29**] with pancytopenia. She has idiopathic aplastic anemia. The patient now presents with orthostatic hypotension and generalized weakness. During her last hospitalization, the patient was treated with antithymocyte globulin and then with csa , Neoral, and was discharged to home. All her hepatitis serologies were negative. Since her discharge, the patient has been feeling weak. Also she has been feeling dizzy, short of breath, and too tired to perform any activities. She has had very low energy. She denies cough, but has had low-grade temperatures. The patient denied diarrhea, constipation, hematuria, dysuria, and hematochezia. She has had persistent mouth pain. On the morning of the day of admission, the patient woke up with a rash on both arms. She was seen in clinic and her blood pressure was found to be 76/48, and she was dizzy when standing. She was treated with IV fluids with good response in her blood pressure. The patient stated that she had decreased p.o. intake secondary to mouth sores.
MEDICAL HISTORY: 1. Aplastic anemia diagnosed in [**2196-1-11**], as per history of present illness. 2. Supraventricular tachycardia. 3. Panic disorder. 4. GERD. 5. Osteoporosis. 6. History of rheumatic fever. 7. Status post tubal ligation.
MEDICATION ON ADMISSION:
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient lives with her husband. She has never smoked. She reports rare alcohol use. There is no history of drug abuse or illicit drug use. She was working in an office without exposure to any chemicals. | 0 |
72,034 | CHIEF COMPLAINT: Airway edema
PRESENT ILLNESS: This is a 24 year old female with PMH of metastatic breast cancer to lungs, liver, and bone complicated by multiple vertebral fractures, currently on palliative chemotherapy and XRT for about 1 month, who presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital for further evaluation of 1 week of persistent nausea and vomiting and was transferred to [**Hospital1 18**] for concern of airway edema seen on imaging. She originally presented to the OSH with 1 week of N/V with her last chemotherapy being administered on [**6-10**]. Her potassium was 3.1 which was repleted and she was given zofran, dilaudid, IVFs, and was sent home. Later that same day she represented to the OSH with inability to swallow her saliva. At that point, her temperature was 100.3 and a CT scan of her neck was performed. She was noted to have abnormal thickening and edema of the aryepiglottic folds, right greater than left, as well as nonspecific circumferential edema at the pharyngeoesophageal junction on a CT scan of her neck at the OSH. No abscess was noted on imaging. She was given solumedrol, dilaudid, ativan, Tylenol, and clindamycin at the OSH prior to being transferred to the ED here at [**Hospital1 18**] for further evaluation. . In the ED, initial VS were: T=96.2, HR=80, BP=90/60, RR=22, and POx=96% RA. She was not noted to be in any respiratory distress and did not have any stridor. ENT was called to evaluate her airway at which point it was noted that the patient has had a several day history of progressive globus, dysphagia, and odynophagia. She also reported airway discomfort at night. During her initial wave of palliative radiation to cervical/thoracic spine, she also developed similar symptoms which resolved on steroid therapy that was subsequently stopped about 3 weeks ago. She did report developing some rashes which she attributed to the steroid administration. She was given ceftriaxone and it was recommended that she receive IV Decadron 10mg every 8 hours for 24 hours and be admitted to the MICU for airway observation. A 22g and 18g peripheral IV were placed. Prior to transfer to the ICU her vitals were T=97, HR=63, BP=93/68, RR=14, and POx=97% RA. . On the floor, her initial vitals were T97 BP114/87 RR12 P92 sat97RA. She is comfortable. She has no audible stridor. She denies difficulty breathing, coughing, shortness of breath. She otherwise notes diffuse abdominal soreness, but no N/V. She mentions a recent episode of oral thrush several weeks ago. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias.
MEDICAL HISTORY: -Metastatic breast cancer to lungs, liver, and bone complicated by multiple vertebral fractures, currently on palliative chemotherapy and XRT for about 1 month
MEDICATION ON ADMISSION: -Methadone 5mg [**Hospital1 **] -Dilaudid 2-4mg [**Hospital1 **] -Ativan 0.25mg QID -Vitamin D 500units daily -Calcium 600mg daily -restoril 15mg QHS -nystatin -zofran 4mg q6hr
ALLERGIES: Diphenhydramine / pseudoephedrine / Latex / Dexamethasone
PHYSICAL EXAM: Vitals: T97 BP114/87 RR12 P92 sat97RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear. No pharyngeal edema or massesnoted. Neck: supple, JVP not elevated, no LAD. No stridor. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, sore to palpation diffusely, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
FAMILY HISTORY: Mother with SLE, raynauds. Mother's side with "autoimmune diseases." No cancer history
SOCIAL HISTORY: Lives at home with mother in [**Name (NI) **] | 0 |
73,679 | CHIEF COMPLAINT: DOE, lightheadedness
PRESENT ILLNESS: This is a 83 year-old female with a h/o ischemic colitis, MGUS, HTN, AS who presents with SOB, lightheaded, found to have Hct of 19 down from 26. She developed a transfusion reaction vs flash pulmonary edema in the ED and was admitted to MICU for further monitoring. She was briefly on Bipap and her dyspnea/hypoxia resolved. She was diursed 1.2 L (but her breathing improved prior to this). Her hct has been stable after 2U pRBCs. Please see below for more details of her presentation and course. Ms. [**Known lastname **] feels well currently, no dyspnea, orthopnea, PND, fevers, chills, cough, LE swelling. . Pt recently had an episode of nonbloody vomiting, felt also more tired, lightheaded and had DOE. Denied any CP, syncope, diaphoresis. She is being closely followed by her PCP, [**Name10 (NameIs) **] found to have worsened anemia with Hct from baseline of 30s down to 24 on [**2126-5-6**]. Her valsartan was held and her PPI was increased to [**Hospital1 **]. She underwent EGD on [**2126-5-8**]. EGD was unremarkable but pt had a granulomatous mass on colonoscopy in [**9-/2125**] which was initially suspicious for plasma cell neoplasm and led eventually to the diagnosis of MGUS (per last Heme/Onc note from [**2126-3-27**]). Of note, she has known ischemic colitis with LGIB in [**2121**] and [**7-/2125**], treated conservatively. . On day of admission, she was more lightheaded, became diaphoretic while trying to have a BM in the bathroom. Her relatives called 911 and she was brought to the ED. . In the ED, her VS were T97.1, 84, 116/50, 12, 99%RA. She was guaiac positive but takes iron. An EKG was unremarkable. CXR with no acute process. Labs notable for Hct of 19 down from 26 just three days ago. Pt was given 2L IVF and was ordered for 2U PRBC. However, after 60cc of blood, she developed facial redness, diaphoresis, was cool and pale, and was sob with diffuse crackles on exam. She says that she was not at all dyspneic until getting blood. Her BP went down to 83/41 transiently. RR up to high 30s and tachy to 122. She was given IV benadryl, solumderol, and zantac. Repeat CXR showed fluid overload. She was started on BiPAP with improvement of symptoms. She was weaned to NC (satting 100% on 3L) but her admission bed was changed to ICU for closer monitoring. . On arrival in the MICU, she was less SOB, satting well on 2.5L NC. In the MICU she was briefly on BIPAP, SOB resolved with before diuresis. She recieved 2U pRBCs without event, but was diuresed 1.2L with 10mg IV lasix. Transfusion medicine feels that she did not have a blood reaction, but likely flash pulmonary edema. . ROS: The patient denies any fevers, chills, nightsweats, abdominal pain, chest pain, or lower extremity edema. She c/o occasional urinary frequency, dysuria, and constipation.
MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Moderate aortic stenosis. Last echo in [**2122**] with AoVA 0.8-1.19cm2 4. Gout. 5. Ischemic colitis with LGIB in [**2121**] and [**7-/2125**], treated conservatively. 6. Diverticulosis. 7. MGUS (Oncologist Dr. [**Last Name (STitle) 410**]
MEDICATION ON ADMISSION: 1. Atenolol 25 mg once a day. 2. Protonix 40 mg [**Hospital1 **]. 3. Simvastatin 20 daily. 4. Allopurinol 300 daily. 5. Psyllium daily 6. Iron 160 [**Hospital1 **]. 7. (Valsartan 160 daily held for last few days by PCP)
ALLERGIES: Lisinopril
PHYSICAL EXAM: Vitals: T: 97.6 BP: 100/43 HR: 81 RR: 20 O2Sat: 99% on RA. -1.2L
FAMILY HISTORY:
SOCIAL HISTORY: Used to drink one cocktail drink a day. Denies any tobacco use. Lives at home with sister. Is functional, does all ADLs herself. Not married. | 0 |
53,717 | CHIEF COMPLAINT: melena
PRESENT ILLNESS: Mrs [**Known lastname 1968**] is a 66 yo woman with ESRD on HD, c/b calciphylaxis, afib on [**Known lastname **], who c/o generalized weakness x2-3 wks now presents with tarry stools and hypotension. Pt states that she had a large, black, tarry BM this morning, then went to [**Known lastname 2286**] today and was feeling weaker than usual, requiring help with ambulating. She was hypotensive and INR was found to be elevated to 19, therefore she was referred to the ED for further evaluation. Pt [**Known lastname **] other symptoms including fever, however does state that she has had watery diarrhea 4x/day for the last several days, also c/o decreased appetite. She has also been feeling lightheaded. She [**Known lastname **] changes in her diet recently and does not think that she could have accidentally overdosed on her [**Known lastname **]. . In the ED, initial vitals were: 97.5 104 80/23 18 100% 4L (baseline 3L), however sbps range from 70-90s at baseline and the pt was mentating well. Exam was notable for melanotic, guiac + stool, gastric lavage showed no evidence of bleeding. Labs were notable for a crit of 20.2, INR was 19.2. She was given pantoprazole, dilaudid, 2U PRBCs, 2 U FFP, 2 U fluids. 2 18 gauge periph IVs were placed. Chest xray was without effusion or consolidation, L-sided [**Known lastname 2286**] line in place. She was seen by renal and GI in the ED who will continue to follow on the floor. . On the floor, pt is alert, oriented, c/o pain in legs, otherwise asmptomatic. . ROS: (+) Per HPI, also c/o chest congestion, worse DOE for the last [**3-1**] wks, pt only able to ambulate a few feet before becoming SOB. She had one epidode of vomiting after taking meds last night. (-) [**Month/Day (3) 4273**] fever, chills, night sweats, recent weight loss or gain. [**Month/Day (3) 4273**] headache, sinus tenderness, rhinorrhea. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias.
MEDICAL HISTORY: Cardiac: 1. CAD s/p Taxus stent to mid RCA in [**2101**], 2 Cypher stents to mid LAD and proximal RCA in [**2102**]; 2 Taxus stents to mid and distal LAD (99% in-stent restenosis of mid LAD stent); NSTEMI in [**7-31**] 2. CHF, EF 50-55% on echo in [**7-/2105**] Systolic and diastolic heart failure with mild mitral regurgitation and tricuspid regurgitation. 3. PVD s/p bilateral fem-[**Doctor Last Name **] in [**2093**] (right), [**2100**] (left) 4. Hypertension 5. Atrial fibrillation noted on admission in [**9-1**] 6. Dyslipidemia 7. Syncope/Presyncopal episodes - This was evaluated as an inpaitent in [**9-1**] and as an opt with a KOH. No etiology has been found as of yet. One thought was that these episodes are her falling asleep since she has a h/o of OSA. She has had no tele changes in the past when she has had these episodes.
MEDICATION ON ADMISSION: HYDROmorphone (Dilaudid) 4 mg PO/NG Q6H:PRN pain Ipratropium Bromide Neb 1 NEB IH Q6H Albuterol 0.083% Neb Soln 1 NEB IH Q6H Allopurinol 100 mg PO/NG DAILY Insulin SC (per Insulin Flowsheet) Levothyroxine Sodium 175 mcg PO/NG DAILY Acetaminophen 1000 mg PO/NG Q8H Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **] Calcitriol 0.25 mcg PO DAILY Neomycin-Polymyxin-Bacitracin 1 Appl TP Doxercalciferol 7 mcg IV ONCE Duration: 1 Doses Order date: [**8-3**] Nephrocaps 1 CAP PO DAILY Omeprazole 20 mg PO BID Paroxetine 40 mg PO/NG DAILY Fluticasone Propionate NASAL 2 SPRY NU Polyethylene Glycol 17 g PO/NG DAILY:PRN Gabapentin 300 mg PO/NG QAM Gabapentin 600 mg PO/NG HS Simvastatin 40 mg PO/NG DAILY Sodium Chloride Nasal [**1-29**] SPRY NU TID:PRN dryness TraMADOL (Ultram) 50 mg PO Q4H:PRN pain sevelamer CARBONATE 800 mg PO TID W/MEALS Order date: [**8-3**] @ 0013
ALLERGIES: Mevacor / Bactrim / Dilantin Kapseal / Naprosyn / Clindamycin / Percocet / Quinine / Levofloxacin / Penicillins / Vicodin / latex gloves / Morphine / optiflux
PHYSICAL EXAM: On Admission: VS: Temp:97 BP: 109/45 HR:99 RR:12 O2sat 100% on RA GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, JVP not visualized CV: tachycardic, irregular, S1 and S2 wnl, no m/r/g RESP: End expiratory wheezes throughout, otherwise CTA BREASTS: large, nodules underlying errythematous patches, ttp ABD: obese, nd, +b/s, soft, nt, no masses or hepatosplenomegaly. Surgical scar on right side. EXT: 1+ edema bilaterally. Incision on R leg with stiches in place, mild surrounding errythema, ttp around lesion and in LE bilaterally, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] throughout to light touch. SKIN: as above NEURO: AAOx3. Cn II-XII intact. Moves all extremities freely
FAMILY HISTORY: Per discharge summary: Sister: CAD s/p cath with 4 stents MI, DM, Brother: CAD s/p CABG x 4, MI, DM, ther: died at age 79 of an MI, multiple prior, DM, Father: [**Name (NI) 96395**] MI at 60. She also has several family members with PVD.
SOCIAL HISTORY: Lives on the [**Location (un) 448**] of a 3 family house with [**Age over 90 **] year old aunt and multiple cousins in Mission [**Doctor Last Name **]. Walks with walker. Quit smoking in [**2102**], smoked 2.5ppd x 40 years (100py history). Infrequent EtOH use (1drink/6 months), [**Year (4 digits) **] other drug use. Retired from electronics plant. | 0 |
41,708 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is an 80 year-old male nursing home resident with a past medical history significant for Parkinson's disease, aspiration pneumonia, MRSA colonization, acute renal failure, J tube placement who was found unresponsive at [**Hospital3 2558**] at 12:15 p.m. on [**2154-1-5**]. He was noted to be asystolic without a pulse at the time per the nursing home attendants. CPR was begun. EMS was begun. Upon arrival EMS noted the patient to be in pulseless electrical activity. He was electively intubated in the field and was given epinephrine down the ET tube times two plus Atropine times one. The patient was then brought to [**Hospital1 69**] Emergency Department where he was noted to still be in pulseless electrical activity. That briefly turned into asystole. He was given more epinephrine and atropine via the intravenous, sodium bicarb and calcium gluconate. The patient reestablished perfusion blood pressure with high dose Dopamine. He was unresponsive to verbal stimuli. His pupils were dilated and fixed in the Emergency Department. The patient was then transferred to the Medical Intensive Care Unit for further care.
MEDICAL HISTORY: 1. Parkinson's disease. 2. Mild dementia. 3. MRSA pneumonia. 4. Orthostatic hypotension. 5. J tube. 6. Acute renal failure.
MEDICATION ON ADMISSION:
ALLERGIES: No known drug allergies.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: He is a nursing home resident. He lives at [**Hospital3 2558**]. | 1 |
55,532 | CHIEF COMPLAINT:
PRESENT ILLNESS: This is a 73-year-old Russian-speaking man with a history of hypertension and diabetes. He had an old stroke as well, and presents with several days of increasing weakness in his right side. At baseline, he is able to ambulate despite an old left-sided hemiparesis. He was unable to give a history because he is Russian-speaking, but his wife clearly says that his hemiparesis has worsened. Also he has been shaking in the left arm and leg for at least the day prior to admission as well. Three weeks ago, he fell and hit his head. Apparently the CT scan at the time was normal, according to the family. No chest pain, shortness of breath or fever or diarrhea. When he was seen in the Emergency Department, he was clearly shaking his left arm rhythmically, consistent with an appearance of a focal motor seizure. He was given 1.5 mg of Ativan and started on an oral Dilantin load, for which the patient stopped seizing. However, after 20 minutes of rest, seizures started again. At that point, intravenous Dilantin was loaded an Ativan was given again, with a halting of the seizure activity.
MEDICAL HISTORY: He has a history of a gastrointestinal bleed from question of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear, he has Type II diabetes controlled with oral agents, he is hypertensive, runs in the 150s with left ventricular hypertrophy, has chronic renal insufficiency. Cardiac-wise, he has normal left ventricular function with hypertrophy.
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY: Unknown.
SOCIAL HISTORY: He worked as a tailor. It is not known whether he has ever smoked, and it is unknown whether he drank. | 0 |
26,566 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 48-year-old woman with a past medical history of HIV and hepatitis C who is having problems with nausea and vomiting. Workup included a head CT which showed three aneurysms. The patient was admitted for coiling of these aneurysms.
MEDICAL HISTORY:
MEDICATION ON ADMISSION: 1. Zantac 150 two times a day. 2. Celexa 60 every day. 3. Albuterol inhaler. 4. Zofran as needed.
ALLERGIES: Penicillin and Augmentin.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
21,647 | CHIEF COMPLAINT: Lightheadedness, nausea, progressive anemia, and melena.
PRESENT ILLNESS: Pt is a 49yo woman with h/o severe GERD, h/o morbid obesity s/p Roux-en-Y gastric bypass [**11/2161**], iron-deficiency anemia, presenting with lightheadedness, nausea, progressive anemia, and melena. Pt noted onset of heartburn towards the end of [**11/2162**], with epigastric discomfort and heartburn after eating. This was different from her prior GERD, which manifested more as reflux and throat burning. Diet adjustment was advised, including Stage III diet and avoiding nuts, and she was started on Pepcid AC. With these changes she felt significantly better almost immediately. She was doing well until Saturday [**1-15**], when she developed new dizziness. She has had occasional episodes of dizziness over the last year, but they were always transient and resolved quickly, but yesterday her dizziness persistent and she began to feel more faint and nausous. She found her BP to be lower than usual (SBP 90s), so she went to [**Hospital1 34**] where she was found to be orthostatic and Guaiac positive on rectal exam. Hct returned at 23 (most recent values here >30), so she was started on IV fluids and a PPI gtt and transferred to [**Hospital1 18**]. She does recall a black tarry stool on Friday [**1-14**], but didn't think much of it. She denies any recent abdominal pain, emesis or hematemesis, diarrhea, constipaion, or BRBPR. She did not have any associated chest pain or dyspnea, but did have palpitations. She denies any recent aspirin or NSAID use, or any significant EtOH intake. She was recently on an unknown antibiotic for a dental infection, and has been on Pepcid AC for her heartburn and epigastric discomfort.
MEDICAL HISTORY: 1. Depression and anxiety On medications Resolved 2. Hypertension No medications required currently 3. Type 2 diabetes mellitus- Resolved 4. Hyperlipidemia with delineated triglycerides- resolved 5. Obstructive sleep apnea requiring BiPAP- No symptoms 6. Severe gastroesophageal reflux-Resolved 7. Fatty liver. 8. Iron deficiency anemia. 9. Stress urinary incontinence- No recent episodes 10. Low back pain.
MEDICATION ON ADMISSION: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO once a day. 3. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2) Tablet PO three times a day. 4. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 5. Iron High Potency 240 mg (27 mg Iron) Tablet Sig: Two (2) Tablet PO once a day. 6. multivitamin Tablet, Chewable Sig: Two (2) Tablet, Chewable PO once a day.
ALLERGIES: Penicillins / Codeine Phos/Acetaminophen
PHYSICAL EXAM: VS: Afebrile, VSS General: WA woman in NAD, comfortable, appropriate HEENT: NC/AT, PERRL/EOMI, sclerae anicteric, + conjunctival pallor, MMM, OP clear Neck: supple, no LAD Lungs: CTA bilat, no r/rh/wh Heart: RRR, nl S1-S2, no MRG Abdomen: +BS, soft/NT/ND, no palpable HSM Extrem: WWP, no c/c/e Skin: no rash or lesions Neuro: A&Ox3, intact and non-focal
FAMILY HISTORY: Stroke, obesity, hyperlipidemia.
SOCIAL HISTORY: Former smoker, quit many years ago. Does not drink excessively or use drugs. Homemaker, marries, lives with husband. [**Name (NI) **] two sons. | 0 |
3,358 | CHIEF COMPLAINT: blurry vision on the left visula field.
PRESENT ILLNESS: 73 year-old righ handed male who has noiced blurry vision on the left visual field while doing his crossword puzzle and playing golf.His visual problem got worse over time MRI -/+ gadolinium in [**Hospital1 756**] and [**Hospital 63531**] Hospital [**2125-7-21**] showed an enhancing mass in the optic chiasm and the right optic nerve. There was a spot of enhancement as well as T2 and FL IR hyoerdensities in the left cereberal peduncleand left insula.[**Doctor First Name **] any headcahe, nausa, vomiting, seizure or fall. Patient was placed on a dexamethasone without any imporovement on his vision. Patient refeered to Dr [**Last Name (STitle) **] by Dr [**Last Name (STitle) 724**] for surgical evaluation. After long discussion with patient benefits, risk of surgery by Dr [**Last Name (STitle) **] patient and family decided to have an elective surgery.
MEDICAL HISTORY: HTN Hyperlipidemia.
MEDICATION ON ADMISSION:
ALLERGIES: Horse/Equine Product Derivatives
PHYSICAL EXAM: Vital signs: 97.3 76 16 195/58 98% RA preo holding area. GEN: elderly man NAD, [**Doctor Last Name **]=[**Doctor First Name **] in strecther. SKIN:good turgor tonus, no ecchymosis. HEENT: neck supple, no coratid bruits, sclera unicteric/no hemorrhage. CVS: RRR, S1/S2, No M/G/R. CHEST: CTA A/P bilat. ABD: soft, nontender, nondistended, bowel sounds present. EXT: no edema, no clubbing, PP+/bilat. NEURO: alert, awake, orientedx3. Language fluent with good comprehension. CN: pupils are equal reactive to light, 4 mm to 2 mm bilaterally. There is no afferent pupillary defect. Extraocular movements are full. Visual field examination shows a left hemianopsia in OS and a left upper quadrantaposia in OD. Funduscopic examination reveals sharp disks margins bilaterally, but his right optic nerve is a slightly pale. His face is symmetric. Facial sensation is intact bilaterally. His hearing is intact bilaterally. His tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: He does not have a drift. His muscle strengths are [**4-26**] at all muscle groups. His muscle tone is normal. His reflexes are 0-1 bilaterally. His ankle jerks are absent. Sensory examination is intact. Coordination examination does not reveal dysmetria. His gait is normal. He does not have a Romberg.
FAMILY HISTORY: Strong family hsitory of esophageal CA.(grandmother, sister, first cousin w/ esophageal CA).
SOCIAL HISTORY: lives with wife, fully independent with [**Name (NI) 5669**] at home prior to surgery. Tobacco: 1PPDx20 years.Quit in [**2090**]. ETOH:occ | 0 |
32,663 | CHIEF COMPLAINT: anemia and acute renal failure
PRESENT ILLNESS: [**Age over 90 **] year-old female with hypertension admitted [**2138-8-25**] with acute renal failure secondary to hydralazine-induced glomerulonephritis (p-ANCA positive). Patient was initially nonresponsive to steroids, plasma exchange, and was started on hemodialysis on [**2138-9-9**]. She received her second HD treatment on [**2138-9-11**]. During both treatments L IVF was removed. Both renal and rheumatology have followed patient to date. Cyclophosphamide was considered, but not started given concern for toxicity due to age. . Overnight, patient developed oxygen requirement, initially hypoxic to 90% on room air at rest, 85% with ambulation. Oxygen delivery was increased progressively from 3L to 6L nasal cannula. She appeared volume overloaded on exam and CXR. She was given Lasix 40mg IV x2 with minimal urine output. Nebulizers were tried with minimal relief. Renal was called re: urgent dialysis, which was not possible. Additionally, given rapid progression of hypoxia, renal suspected etiology other than volume overload alone. Of note, patient also with hemoptysis this morning on multiple occasions - largest approximately 1 teaspoon bright red blood. Given progressive hypoxia and increased work of breathing, patient is transferred to [**Hospital Unit Name 153**] for further management. . Hospital course also complicated by lower GI bleed, anemia, coagulopathy, UTI. On [**2138-9-10**], patient developed LGIB in context of constipation and straining for bowel movement. GI was consulted. Based on recent colonoscopy, transient diverticular bleed was suspected. Ischemic colitis was also considered given underlying vasculitis. Patient also with chronic anemia. She has required 2 pRBC transfusions during this hospital course. Patient also with uncomplicated UTI treated with ciprofloxacin PO x3 days on admission. . On arrival to [**Hospital Unit Name 153**], was with O2 saturation 100% on 100% O2 shovel mask. She complained of shortness of breath, fatigue. She was urgently intubated given respiratory distress.
MEDICAL HISTORY: Hepatitis B secondary to transfusion ([**2078**]) Hypercholestremia Hypertension Carotid stenosis s/p endartarectomy Arthritis, s/p right THR ([**2130**]) Gastritis Prolapsed bladder s/p bladder suspension Breast cyst
MEDICATION ON ADMISSION: Medications at home: (taken from admission H&P) Valsartan 320mg PO daily ASA 81mg PO daily Hydralazine 100mg PO TID HCTZ 25mg PO daily Simvastatin 20mg PO daily Metoprolol 25mg PO BID Citalopram 10mg PO daily (started [**2138-8-25**]) ferrous sulfate 325mg (65mg iron) tab just d/c'ed recently by pcp
ALLERGIES: Sulfonamides / Macrodantin / Codeine / Norvasc / Hydralazine / Heparin Agents
PHYSICAL EXAM: On admission [**2138-8-26**]: Pt is at baseline per daughter who is with pt Pt is awake and responds appropriately. Able to tell me it is [**2138**] but unable to correctly tell me month or date or identify name of president. 97.8 197/77 78 14 99%RA CV-RRR lungs - CTA bilat abd - soft, nt, nD, no guarding ext - no c/c/e . On admission to [**Hospital Unit Name 153**] (prior to intubation) [**2138-9-12**]: 96.8, 95, 169/112, 20, 91% shovel mask 100% General: Labored respirations with use of accessory muscles HEENT: Sclera anicteric, dry blood at mucous membranes and in mouth, no site of active bleeding Neck: Supple, JVP difficult to assess given accessory muscle use Lungs: Rhoncherous throughout with crackles to midlung fields bilaterally; no wheezes; decreased breath sounds at bases bilaterally CV: Heart sounds hindered by rhonchi; regular, no murmurs appreciated Abdomen: Distended; hypoactive bowel sounds; nontender GU: No Foley Ext: Warm, well-perfused; 2+ radial and DP pulses; 1+ lower extremity edema to knees bilaterally
FAMILY HISTORY: unknown
SOCIAL HISTORY: Lives in apartment above daughter's home. Well-supported by family. Active prior to admission - capable in all ADLs. Per daughter, no tobacco, alcohol, or illicit drug use. Formerly worked at [**Company 3004**]. | 1 |
8,184 | CHIEF COMPLAINT: Hematemesis.
PRESENT ILLNESS: 30 y/o M with PMHx of Anxiety and substance abuse who presented to [**Hospital3 4107**] c/o multiple episodes of hematemesis and coffee-ground emesis that began 12hrs prior to presentation. He reports decreased appetite on Sat with some Etoh consumption and cocaine use. On sat evening, he had one episode of dark purple emesis that he attributed to grapes that he had eaten early in the day. Of note, he also reported dark black stool that began recently and he has been taking [**11-30**] Aspirin up to three times/day for headache this week. On Sunday morning, he had 12 episodes of emesis, both coffee grounds and later bright red blood in his emesis. He had palpitations and was concerned about the bleeding so he presented to [**Hospital3 **] ER for evaluation. He was notably tachycardic in 130s, normotensive and had one witnessed episode of bloody emesis. Hct was 45 and pt was transfused 1u of prbcs for hct 45 prior to transfer to [**Hospital1 18**] ER. . In the ED, initial vs were: T 97 HR 130 BP 119/63 RR 18 Sats 97% RA. Gi was consulted and recommended starting a PPI & octreotide gtt. Pt was c/o mild abdominal pain with mild transaminitis and Tbili 1.7. He received 4L NS IVF and tylenol 1 gram po with some HR response. . On arrival to the MICU, pt was comfortable lying in bed. He is denying abd pain, nausea, lightheadedness, palpitations or chest pain.
MEDICAL HISTORY: ETOH abuse with h/o withdrawal (?seizure) Polysubstance abuse Anxiety d/o with panic attacks
MEDICATION ON ADMISSION: Xanax prn ASA prn
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
FAMILY HISTORY: Non-contributory.
SOCIAL HISTORY: Pt lives with his fiance and has a history of ETOH abuse, including withdrawl and possible seizure. He reports remote IVDU and occaisional cocaine abuse. | 0 |
70,225 | CHIEF COMPLAINT: distended abdomen
PRESENT ILLNESS: Mr. [**Known lastname **] is a 59 M with NASH-cirrhosis complicated by ascites and edema who is currently listed on the transplant list with a MELD of 18, who is being directly admitted from clinic with weight gain/refractory ascites, and periumbilical redness, and a possible ventral hernia. . He has struggled with ascites and weight gain, though was recently aggressively diuresed (lasix 40, spironolactone 200mg) 26 pounds to a dry weight of 223, though was afflicted by leg cramps, [**Last Name (un) **] with creatinine to 1.7 from 1.0, and mild hyponatremia to 132. Diuretics were held for about a week, and when followup labs showed some improvement (Cr 1.4) he resumed spironolactone 100mg and lasix 40mg daily. He unfortunately gained about 7 pounds during that week, weighing in at 253 from 246 at his scheduled followup appointment today with the liver clinic. He has been taking his diuretics as prescribed and is making urine. He denies any salt indiscretions though had 2 slices of pizza over the weekend, which is an occasional indulgence. . He developed a slight redness over his periumbilical area four days ago that is not painful, warm, or pruritic. He relates it to recently starting rifaximin for slight asterixis seen on recent exam. It has spread slowly. He blames symptoms of fatigue and weakness on this medication. . On ROS, he denies, headaches, fevers, chills, nausea, vomiting, BRBPR, diarrhea, melena, abdominal pain, chest pain, shortness of breath, or coughing. No dysuria or hematuria. .
MEDICAL HISTORY: -Type 2 diabetes. -Hypercholesterolemia. -[**Doctor Last Name 9376**] disease. -L5/S1 discectomy in [**2095**] and [**2098**]. -NASH cirrhosis, listed for transplant
MEDICATION ON ADMISSION: FUROSEMIDE - (Dose adjustment - no new Rx) - 40 mg Tablet - 1.5 Tablet(s) by mouth once a day LIRAGLUTIDE [VICTOZA] - (Prescribed by Other Provider) - 0.6 mg/0.1 mL (18 mg/3 mL) Pen Injector - inject 1.2 mg once daily METFORMIN - (Prescribed by Other Provider) - 1,000 mg Tablet - 1 Tablet(s) by mouth twice a day RIFAXIMIN [XIFAXAN] - 550 mg Tablet - 1 Tablet(s) by mouth twice a day SPIRONOLACTONE - (Dose adjustment - no new Rx) - 100 mg Tablet - 1 Tablet(s) by mouth a day . Medications - OTC CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) - 2,000 unit Capsule - 1 Capsule(s) by mouth once a day MAGNESIUM OXIDE - 400 mg Capsule - 1 Capsule(s) by mouth twice a day
ALLERGIES: Penicillins
PHYSICAL EXAM: Physical Exam on Admission: VS: T98.0 BP117/66 P80 RR18 Sat100RA GENERAL: Well appearing male in no acute distress HEENT: Sclera ANicteric. PERRL, EOMI. CARDIAC: RRR, S1 S2 clear and of good quality without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Distended but Soft, non-tender to palpation. Dullness to percussion over dependent areas but tympanic anteriorly. faintly demarcated area of erythema but no induration over the periumbilical area, marked with pen. EXTREMITIES: 2+ [**Location (un) **] bilaterally to knees. NEURO: AAOx3, CN 2-12 intact bilaterally
FAMILY HISTORY: Remarkable for [**Doctor Last Name 9376**] disease and coronary artery disease. No history of liver disease or liver cancer.
SOCIAL HISTORY: The patient lives in [**Hospital1 392**], [**State 350**] with his wife. [**Name (NI) **] has three daughters who are in good health. He works as an electrical engineer. Denies tobacco, ethanol, or IV drug use. | 1 |
79,474 | CHIEF COMPLAINT: The patient is a 78-year-old male with a history of coronary artery disease and is status post coronary artery bypass graft times two with a porcine mitral valve replacement and congestive heart failure, with an ejection fraction of less than 20%.
PRESENT ILLNESS: The patient had been in his usual state of health at home until two weeks prior to admission. At that time, the patient began noticing increased shortness of breath and dyspnea on exertion. Typically, he was able to walk half a mile without any problems. [**Name (NI) **] also states that he had a 3-pound weight gain over that period of time. During the week prior to admission the patient had his Lasix dose doubled to 40 mg once a day. He had some laboratory work drawn on [**Hospital3 4298**] which showed an increase of his creatinine to 3 from a baseline of 2.3 to 2.5. The patient was subsequently seen in the Congestive Heart Failure Clinic by Dr. [**Last Name (STitle) **] where he was noted to be in worse condition compared to his previous office visit in [**2122-7-26**]. The patient has also had previous admissions for congestive heart failure requiring milrinone to aid in his diuresis. His most recent admission was in [**2122-3-26**].
MEDICAL HISTORY: 1. Coronary artery disease; the patient is status post coronary artery bypass graft in [**2102**] and a redo coronary artery bypass graft in [**2121-3-26**]. The patient has also undergone a cardiac catheterization and stenting of his vein graft to his left anterior descending artery in [**2122-1-26**]. 2. [**State 531**] Heart Association class III congestive heart failure. The patient was found on echocardiogram to have an ejection fraction of less than 20%. 3. Mitral valve replacement with a porcine mitral valve. 4. DDD pacemaker for complete heart block following his redo coronary artery bypass graft. 5. Hypercholesterolemia. 6. History of atrial fibrillation, post redo coronary artery bypass graft that was initially treated with Coumadin but subsequently discontinued secondary to hemoptysis in [**2121-7-26**]. 7. Chronic renal insufficiency.
MEDICATION ON ADMISSION: 1. Amiodarone 100 mg p.o. q.d. 2. Carvedilol 3.125 mg p.o. b.i.d. 3. Losartan 25 mg p.o. q.d. 4. Digoxin 0.125 mg on Monday and Thursday. 5. Erythropoietin 10,000 units every week on Wednesday. 6. Lipitor 10 mg p.o. every Monday, Wednesday and Friday. 7. Lasix 40 mg p.o. q.d. 8. Prilosec 20 mg p.o. q.d. 9. Vitamin E. 10. Flonase.
ALLERGIES: PENICILLIN, DOXYCYCLINE.
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: The patient is a retired architect and denies a smoking or alcohol history. | 0 |
530 | CHIEF COMPLAINT: seizure and hematemesis
PRESENT ILLNESS: 47 L handed male with PMH sig for transverse myelitis dx [**12-8**] undergoing tx with 6mo of steroids presents from OSH with hematemesis, gastric ulcer with visible vessel s/p EGD and cauterization here on [**2-14**]. In [**2123-11-3**], he started developing severe lower back pain with weakness in his legs and numbness in his hands. He had been diagnosed by his PCP as having back arthritis. He was progressively getting worse and one day he fell and could not stand up. His symptoms did not improve and he presented to [**Hospital1 2025**] on [**2123-11-18**] with worsened hand/LE weakness 1/5 strength, hyperreflexia. Full spine MRI at [**Hospital1 2025**] revealed questionable mass and intramedullary T2 hyperintense from C2-L2 with cord expansion and patchy enhancement. Further workup for malignancies included negative abd/chest CT and brain MRI. CSF analysis revealed WBC 8 [L 97% M 3%], glucose 85, protein 38. [**Doctor First Name **], RF, HSV; mycoplasma PCR, VRDL pending; Gram stain, cx showed NG. He was started on solu-medrol 1g IV daily x5d with considerable improvement of LE strength. Repeat MRI showed diminished T2 hyperintesities. He was discharged to home on [**2123-11-27**] and arranged for solu-medrol taper. He was also started on balcofen for spasticity, and told to f/u as outpatient in [**Hospital 878**] clinic. Shortly after d/c of steroids, symptoms relapsed. Presented here [**12-6**] with bacteremia, septic right knee and weakness. At that time pt was found to have a septic joint and gout which was treated appropriately with antibiotics and NSAIDs. He was later transfered to the neurology service for w/u of his weakness. An MRI of the head was normal, but MRIs of the spine revealed edema and enhancement C3-C6 suggestive for lymphoma vs sarcoid vs myelitis. A chest CT revealed pulmonary nodules. A biopsy of the nodules were performed, which showed only lung parenchyma, however it is uncertain that the nodules were truly biopsied. An LP revealed increased protein, though tap was traumatic and many RBCs were present. CSF viral studies-->+VZV, -EBV, and -HSV PCR. ACE normal. He was started on a second course of high dose steroids 1gm soulmedrol x5days to be followed by a 6 month course of PO steroids. Pt was d/c'd home on [**12-30**] with improving exam. Pt had been doing well at home with PT/OT until [**2124-2-8**], when pt's wife noticed pt undergo a possible seizure followed by coffee ground emesis. The pt's body stiffened. He then began having a rhythmic shaking of the LUE for about 30 seconds. Pt was then unresponsive for 5-10 minutes, after which he had coffee ground emesis. He was taken to OSH, where an EGD showed a gastric ulcer with a visible vessel and a Hct was 26. Pt was treated with H2 blocker and d/c'd home on [**2-13**]. The following day, pt developed a second episode, which per the wife, was exactly like the first, and was followed by a large amount of hematemesis. Pt taken to OSH and then transferred to [**Hospital1 18**], where a HCT on admission was 24.3. He was admitted to the MICU for UGIB.
MEDICAL HISTORY: HTN gout hypercholesterolemia asthma C4-C6 spinal stenosis (recent dx) eczema
MEDICATION ON ADMISSION: theophylline 200mg po bid beclovent 5qid prednisone 60mg po q24h allopurinol 300mg po qd zocor 40mg po qd enalapril 20mg po qd pepcid 20mg po bid bactrim 1tab po bid iron PO supplement
ALLERGIES: Penicillins / Peanut / Egg
PHYSICAL EXAM: Vitals: 97.3 110-138/70-90 HR68-90 RR16-18 O2 Sat 95-100%. Gen: sitting in chair, NAD. HEENT: supple neck Pulmonary: CTA bilaterally Cardiovascular: RRR, S1/S2 no murmur Abd: +BS, soft NT/ND Ext: no edema
FAMILY HISTORY: non-contributory no history of neurologic or CT disease
SOCIAL HISTORY: non-smoker Former EtOH user [**2-4**] drinks per night no h/o IVDU married x 8yrs works as computer analyst | 0 |
13,880 | CHIEF COMPLAINT: found down, xferred to OSH, then to [**Hospital1 18**]
PRESENT ILLNESS: Mr. [**Known lastname 16490**] is a 69 yo with IDDM, PVD, CVA [**2138**] (no residual deficits), ESRD [**1-9**] ([**3-12**]) DM, not on HD, with a h/o of multiple episodes of hypoglycemia taken emergently to OSH after this wife found him unresponsive in bed, surrounded by empty coke cans. Blood glucose was 6. [**Name (NI) 1094**] wife states that the patient has not been feeling well for the last couple of days prior to event, having increased [**Last Name (LF) **], [**First Name3 (LF) 1658**] colored, foul smelling diarrhea. Pt denieed fevers, chills, abdominal pain, but has not been eating well. Wife reports more incontinence. Patient has had DM for decades and is on NPH and regular insulin followed by [**Last Name (un) **]. Worsening renal fx reportely over the past year, with multiple discussions with his nephrologist, Dr. [**First Name (STitle) 805**] about initiation of HD. Yesterday AM, the patient was more confused, reportedly, then was found unresponsive by his wife. with a BG of 6. Pt was given 1 amp of dextrose in the field. The patient reportedly did not fall, and did not complain of any CP, SOB, dizziness, lightheadedness or diaphoresis. He does not remember feeling shaky before the episode. . Pt was taken to OSH emergently, was intubated in the field. Prior to intubation, the patient apparently vomited and aspirated a large amount of particulate matter (witnessed by paramedics). Particulate matter was aspirated from his ETT. When brought to the ED, the patient was not responding to any commands. Head CT was done at OSH was reportedly negative, showing an old infarct, but no acute process. Blood sugar was reportedly in the 20s. Laboratory studies revealed an non-AG metabolic acidosis, renal insufficiency but normal lactate levels. Per OSH records, the patient had a transient episode of hypotension of unkown etioology, but rebounded back quickly with 500ccs bolus. Per the patient's wife, the patient did administer his NPH this AM. Patient with h/o DM and found unresponsive with significant hypoglycemia. Intubated for airway protection but not waking up (Etomidate, Ativan given). Exam shows brainstem function (gag) but not much else. Paitent HD stable, on vent. To come TO [**Hospital1 18**] tonight to MICU green as patient is usually cared for at [**Hospital1 18**] for DM and renal failure. . Prior to xfer from OSH, received a call from [**Name8 (MD) 16491**] MD reporting that the patient was becoming more awake, following commands. Pt unlikely able to protect airway, so kept intubated and xferred to [**Hospital1 18**]. In the MICU, he became more awake, but continued to have problems with aspiration. CXR noted bilateral effusions and infiltrates c/w aspiration PNA.
MEDICAL HISTORY: 1. Ischemic colitis [**2-8**], s/p ex lap and rigid sigmoidoscopy without evidence of ischemic bowel. 2. PVD: s/p right popliteal to dorsalis pedis bypass and left femoral-popliteal and popliteal-anterior tibial bypass, R CEA, and right SFA stent. 3. Type I Diabetes mellitus - brittle diabetic; episodes of severe hypoglycemia and DKA 4. Status post CVA >10 yrs ago. 5. History of CHF with preserved EF 6. COPD- no PFTs in system 7. Hypertension 8. Glaucoma 9. CKD-baseline cr 2.1-2.4 (Cr clearance of 25-30, stage 4)is preparing for PD with Dr. [**First Name (STitle) 805**] at [**Last Name (un) **] 10. h/o Duodenal ulcer but on EGD above not seen 11. Anemia of chronic disease. 12. Esophageal dysmotility. 13. h/o VRE UTI 14. Rectal CA-dx [**2148**] no surgery due to comorbidities; s/p palliative XRT 15. Secondary hyperparathyroidism
MEDICATION ON ADMISSION: Norvasc 2.5 mg as directed 1 tab QD Fosrenol 1000 Mg chew one with each meal. Lasix 40mg 1 per day Glucagon Emergency Kit 1mg Phoslo 667mg three times a day 2 tablets Hectorol 0.5mcg twice a day Hydralazine Hcl 50mg twice a day Neurontin 100mg two at bedtime. Procrit 4000 U/ml as directed twice a week. Ferrous Sulfate 325mg 1 time per day Folic Acid 1mg 1 time per day Lantus ? dose Humulin ? dose Lipram 20-4.5-25 four times a day 2 tabs Metoprolol Tartrate 100mg twice a day () Losec 20mg 1 time per day Foltx 1-2.5-25mg 1 time per day ASA 325 qd
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Vitals: Tmin 95.7; Tc95.7, HR 50-61; BP 123-182/49-57; RR 16 on AC 550x16; FIO2 of 0.5; PEEP 5. Gen: chronically ill appearing, somnolent elderly male, intubated, sedated. HEENT: pupils irregular, assymetric and non-reactive; EOMI, b/l periorbital edema, MM dry Neck: supple, no LAD, no JVP elevation, +linear well-healed scar over Right cartoid Cardio: PMI inferiorly displaced and diffuse, RRR, nl S1/S2, no murmurs or rubs appreciated Resp: CTAB, no exp wheezes Abd: + BS, soft/NT/ND, no HSM, no masses Ext: no c/c/e; b/l LE w/ significant atrophy. multiple scars. dopplerable pulses bilat. Neuro: intubated, sedated on boluses, but responding to commands when waking up
FAMILY HISTORY: Mother colon cancer. Father with throat cancer. Brother died of colon cancer at age 62.
SOCIAL HISTORY: Lives with his wife. [**Name (NI) **] smoked for >50yrs at most 2ppd. Now smokes 1ppd. Remote heavy EtOH use in past (3+ drinks per day), quit 2-3 years ago. No recreational drug use. Used to work in greenhouse supply business, then sold real estate now disabled. Sleeps up to 22 hours per day per wife's report. Does not allow visitors to house. Admits to lack of motivation. . Wife, [**Name (NI) 4115**] [**Telephone/Fax (1) 16487**] (H), [**Telephone/Fax (1) 16488**] (C) | 0 |
60,480 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is an 84 year old male with severe aortic stenosis with an aortic valve area of 0.6 square centimeters, coronary artery disease, status post stent placement in [**2171-5-23**], complicated by in-stent restenosis in [**2172-7-22**], who was admitted to [**Hospital1 346**] on [**2173-6-9**], with right lower quadrant pain. He was diagnosed with a right lower quadrant abscess, possibly related to diverticulosis and underwent percutaneous drainage on [**2173-6-10**]. Cultures grew out a mixture of alpha streptococcus and streptococcus milleri, haemophilus, and D. fragilis. The patient was initially treated at that time with Ampicillin, Gentamicin and Flagyl and was subsequently changed to Unasyn. After the patient's abdominal drain was removed, the patient was sent to rehabilitation. The patient completed his course of Unasyn on [**2173-6-27**]. Within the next 72 hours, the patient developed recurrent fevers while at rehabilitation. On [**2173-6-30**], the patient was admitted to [**Hospital1 346**] for investigation of recurrent right lower quadrant pain. CT scan revealed a 5.6 by 2.8 centimeter fluid pocket in his right lower quadrant. This fluid pocket communicated with the skin by a sinus tract from the prior drain.
MEDICAL HISTORY:
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
48,995 | CHIEF COMPLAINT: motorcycle accident
PRESENT ILLNESS: 22yo male with no significant past medical history transferred from outside hospital after a motorcycle accident. By report, he was helmeted and was driving at moderate speed and slid under another car. He extricated himself from the wreckage. At the outside hospital, he was intubated for combativeness. On arrival to the [**Hospital1 **] ED he self-extubated, had an episode of vomitting and was reintubated.
MEDICAL HISTORY: No Medical problems s/p appendectomy
MEDICATION ON ADMISSION: None
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: 96.8 88 130/palp ventilated GCS 14, IV x2 paralyzed with vecuronium NCAT, TMs clear PERRL 3->2mm Midface stable +c-collar R anterior chest abrasion, CTA bilaterally soft, nondistended, mild tenderness, no digns of injury, FAST negative decreased rectal tone, guiac negative No spinal stepoffs, no abrasions Avulsion to R knee pretibial area, R hand laceration.
FAMILY HISTORY: Noncontributory
SOCIAL HISTORY: + tobacco, + EtOH, ? illicit drug use | 0 |
16,160 | CHIEF COMPLAINT: Hyperglycemia, back pain
PRESENT ILLNESS: Ms. [**Known lastname **] is a 55 yo F w/PMHx sx for autoimmune hepatitis on chronic prednisone, IDDM, CAD, seizure d/o, hypertension, asthma, hx RCC, and ET who presents with hyperglycemia. . Patient recently admitted to [**Hospital1 18**] from [**Date range (1) 65044**] with URI and asthma exacerbation and received nebulizers and steroids. Her fingersticks during that admission were in the 200-300s. She had multiple episodes of chest pain while hospitalized, with negative workup for ischemia, with episodes relieved by oxycodone. She improved her peak flows to 300 and was subsequently discharged. At home, patient fell on her back [**2-11**] dizziness thought to be from diarrhea and vomiting, with assoc subjective fevers and chills. SHe was then seen at [**Hospital1 65045**] in [**Location (un) 260**] MA where she was admitted from [**Date range (1) 65046**], and given the diagnosis of an L1 compression fracture. She was taken off her prednisone during this admission per her report, and was sent home without pain medications. Today, she presented to [**Company 191**] complaining of [**10-19**] lower back pain. Patient was also sent home on 65u lantus qhs, decreased from her baseline of 100u qhs. Patient's BS at home have ranged from 300s-500s. She also notes urinary incontinence, which is her baseline from her early 40s, but denies stool incontinence. She also notes numbness, tingling and weakness of her legs. She states that her back pain is relieved only by muscle relaxants and narcotics. Pt also notes polyuria, polydipsia, and extreme thirst. She also notes dizziness on standing. She denies dysuria. She does admit to diffuse abdominal pain, occasional difficulty breathing. She denies chest pain. Pt's baseline BS per her report are in the 200s. . In the ED patient was found to have blood sugars in the 400s. Patient was also found to have an anion gap of 15, with trace ketones in the urine. Patient's EKG showed old ST depressions in V1-V3 with TWI< unchanged from prior. Her UA was negative for infection. Her CXR was unremarkable as well. She was admitted for management of her blood sugars. . ROS: Positive for polyuria, polydipsia, abd pain, fevers, chills, thirst, shortness of breath, abdominal pain, urinary frequency. Negative for headache and dysuria, or fecal incontinence.
MEDICAL HISTORY: 1. Autoimmune hepatitis diagnosed in [**2098**], cirrhosis diagnosed in [**4-/2099**]: h/o encephalopathy, ascites, jaundice 2. DM 3. Asthma 4. Coronary artery disease s/p MI [**2097**] 5. Epilepsy [**2-11**] to being hit by a car at age 5. Was on phenobarb and dilantin for most of life, but self d/c'd these meds approx. 7 years ago and has been seizure free since then. 6. HTN 7. Renal cell cancer 8. Psoriasis 9. s/p cholecystectomy in [**2099**] 10. s/p hysterectomy and b/l oophorectomy 11. Right ankle surgery. 12. Depression 13. Anxiety 14. Recurrent UTIs 15. Thrombocytosis
MEDICATION ON ADMISSION: Keppra 750 mg [**Hospital1 **] Singulair 10 mg qd Imuran 100 mg qAM Lexapro 20 mg qd Omeprazole 40 mg qd Montelukast 10 mg qd Novolog 20/30/30 Lantus 100 qhs Propranolol 40 mg [**Hospital1 **] Aldactone 25 mg [**Hospital1 **] Oxycodone prn Prednisone 20 mg qd
ALLERGIES: Latex Exam Gloves
PHYSICAL EXAM: Vitals: T 98.3 BP 138/70 HR 69 RR 20 96RA GEn: well-appearing, NAD HEENT: OP clear Neck: supple Lung: CTA bilaterally Cor: RRR, nml S1S2 Abd: obese, diffusely tender, no rebound or guarding Ext: no edema, decreased sensation
FAMILY HISTORY: Mother deceased, SLE. . Father deceased, gastric ca.
SOCIAL HISTORY: Lives in [**Location 260**], Mass. alone. Recently moved back to area from [**State 33977**] 9/[**2099**]. 3 children live locally. Denies EtOH or other illicit drug use. Has extensive tobacco hx, approx. 60-70pack year, but quit several years ago. Not currently working as she is on disability [**2-11**] to her health. Her son works as her HHA (she pays him) | 0 |
90,776 | CHIEF COMPLAINT: word finding difficulties
PRESENT ILLNESS: A [**Age over 90 **]yoM with multiple stroke risk factors admitted for after a [**11-28**] minute period of word-finding difficulty, ruled out for stroke and now transferred from neurology service to medicine for management of uncontrolled hypertension. Pt. was on BB and nitrate for bp control prior to admission, and currently remains with SBP>190 on IV ACE-i and BB with IV hydralazine PRN.
MEDICAL HISTORY: h/o strokes in [**2145**], [**2137**] CAD/MI, s/p CABG in [**2144**] hypercholesterolemia s/p R CEA in [**2147**] HTN
MEDICATION ON ADMISSION: Meds (home): pravachol 40QD, toprol XL 100QD, ISMO 60QD, ASA EC 81QD.
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS: 96.8 | 195/87 | 77 | 22 | 97% on RA gen: NAD, breathing sounds and looks distressed (Pt. appears to be gasping and has a lot of secretions) but says he is breathing fine. HEENT: OP clear, dry MMM, no LAD, PERRL and EOM intact. CV: RRR, nl S1S2, no murmurs. chest: CTA b/l, no crackles or wheezes. abd: soft, NT/ND, +bs, no organomegaly. extr: no edema, no cyanosis, [**2-10**]+ distal pulses. neuro: right-handed, awake, alert, garbled speech, when comprehensible Pt. answers appropriately, but usually difficult to understand. nl. muscle tone.
FAMILY HISTORY: NC
SOCIAL HISTORY: lives alone in ECF, ambulates with walker, frequent falls recently, no EtOH. | 1 |
4,675 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 58 year old with diabetes complicated by end stage renal disease on hemodialysis, hypertension, who presents with left hip pain, fever, hyperglycemia. Patient had left hip fracture and was pinned at [**Hospital3 2576**] in [**1-13**]. However, subsequently since [**2114-8-12**], patient has been complaining about pain in her hip and for unclear reasons it increased in severity on the day of admission. She denies any trauma or fall. She also reports fever to 101.9 with chills without nausea at last hemodialysis. She denies rigors, emesis, chest pain, headache, shortness of breath, cough, sputum, abdominal pain, recent antibiotics, back pain, vaginal or urinary symptoms. She also reports that her finger sticks have been elevated for the past three to four days and she complains of polydipsia. She sleeps in a chair secondary to her hip pain, but denies paroxysmal nocturnal dyspnea or orthopnea. She reports increased swelling in her legs. In the emergency department serum glucose was 663, potassium 5.9, anion gap 18 with moderate acetone in her blood. She is anuric. She was given 10 units of insulin and started on an insulin drip and received normal saline times 1 liter, morphine for hip pain. Given her fever, elevated white blood cell count and left shift, she was given vancomycin times 1 gm for presumed line infection. Chest x-ray was performed which revealed left pleural effusion greater than right, interstitial edema. Patient received 2 liters of normal saline only because of concern about volume overload.
MEDICAL HISTORY:
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
26,186 | CHIEF COMPLAINT: Hypoxia
PRESENT ILLNESS: Ms. [**Known lastname 805**] is a 64y.o. woman h/o COPD (on 2L home O2) and CHF (most recent EF=55%) presenting from her PCP's office with RA O2 sat of 52-64%. Per the pt's report, she had been feeling in her usual state of health during her routine visit with her PCP this morning; she reports that on exam, her O2 sat was low (54-62% per PCP [**Name Initial (PRE) 626**]) and he asked her to come to the ED. Of note, pt is normally on 2L O2 at home, but has not used her home O2 x24hrs. The pt reports an ongoing cough productive of yellow phlegm for the past two months, but denies any hemoptysis or recent worsening of this cough. She also reports rhinorrhea x1 wk. Pt reports that she previously had one episode of chest pressure and SOB w/exertion 3 days ago, but that both of these symptoms improved with OTC Theraflu. Currently, pt denies any chest pressure, chest pain, radiating pain, pleuritic pain, SOB, diaphoresis or nausea. Otherwise, she denies any recent fevers/chills. She denies any PND or sleep orthopnea (1 pillow). In the ED, initial VS were T 98.6, HR 100, BP 154/86, RR 22, O2 sat 89% 4L Nasal Cannula. Exam notable for bibasilar crackles greater than wheezes. Labs were notable for WBC 6.9 (66.5 PMN, 27.2 lymph), Hct 44.5, Plt 219. Chem 7 with K 2.8, BUN 24 and Cr 1.1 (baseline 0.5-0.7). Tnt was negative and proBNP 2873 (BL 479 in 09/[**2180**]). Lactate was 2.0. Blood cx are pending. CXR notable for persistent moderate enlargement of the cardiac silhouette with possible minimal pulmonary vascular congestion but without overt pulmonary edema. Pt was given albuterol nebs x2, ipratropium nebs x2, furosemide 40 mg IV, KCl 50 mEq PO, methylprednisode 125mg and started on arithromycin 250mg. She was placed on NRB, satting in mid-90s. Headed for floor, but every time she dozed off, O2 sats down to 70s - 80s. Tried BIPAP and CPAP, but did not tolerate. . On arrival to the MICU, the pt reports feeling "great," in no acute distress. Her O2 sats are in the low 90s, but will desat to low-mid 80s with any activity and sleep. . Review of systems: (+) Per HPI (-) Denies headache, sinus tenderness, or congestion. Reports alternating diarrhea and constipation x2mos; denies abdominal pain. Denies dysuria, hematuria, pyuria. Reports left shoulder pain x3 yrs. Denies rashes or skin changes.
MEDICAL HISTORY: -Grade 1 diastolic CHF: per most recent echo [**1-/2179**], LVEF =55% and mild concentric left ventricular hypertorphy. Impaired LV relaxation (grade I diastolic dysfunction). Most recent BNP 479 (09/[**2180**]). -COPD: Pt is on 2L of home O2, though non-adherent; able to complete AODL and housework w/o difficulty. Most recent spirometry on [**10/2180**] w/moderate mixed restrictive (likely [**2-23**] obesity) and obstructive defect w/FVC 1.39 (58%), FEV1 1.39 (58%), FEV1/FVC 72%. -Hypertension: SBP 110-130s. -HL: most recent on [**8-/2180**] was cholest 115, TG 67, HDL 62, LDL 40 -Atrial fibrillation: on coumadin, INR 4.9 -DM2: HbA1c in [**6-/2180**] was 6.2%, insulin dependent -Gout -OSA: does not use prescribed CPAP -GERD
MEDICATION ON ADMISSION: Colchicine 0.6 mg PO prn gout flare Furosemide 40 mg PO BID Metoprolol Tartrate 25 mg PO BID Pravastatin 80 mg PO QHS Lansoprazole 30 mg PO BID Calcium Carbonate (CALCIUM 500) 500 mg calcium (1,250 mg) PO Ipratropium-Albuterol Nebulizer 0.5 mg-3 mg/3 mL TID and prn Lisinopril 2.5 mg PO DAILY Insulin Lantus 10 units QHS Cholecalciferol, Vitamin D3, 50,000 unit PO QWeek Warfarin 2.5 mg PO 3 days/wk, 3.75 mg PO 4 days/wk Verapamil 240 mg PO Daily
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: Admission- General: Speaking in full sentences, no accessory muscle use, no acute distress. Alert, oriented, no acute distress. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI w/o nystagmus or double vision, PERRL Neck: No JVD. CV: Irregularly irregular, no murmurs, rubs, gallops Lungs: Pt with diffuse end expiratory wheezes in all lung fields and increased E/I ratio. Air movement throughout. No rales or ronchi. Abdomen: Obese abdomen, soft, non-tender, non-distended, bowel sounds x4 quadrants. Organomegaly difficult to appreciate given habitus. No tap tenderness. No suprapubic or CVA tenderness. GU: Foley in place. Ext: 1+ pitting edema to mid-shins BL. Ext warm, well perfused, 2+ pulses DP pulses BL, no clubbing, cyanosis. Neuro: CNII-XII intact, 5/5 strength BL upper extremities and moving lower extremities, grossly normal sensation, gait deferred . Discharge- VS - T 98.7 BP 150/88 P 84 R 20 S 99% on 2.5L GENERAL - well-appearing woman in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple LUNGS - Good air entry, no wheezes/rales/rhonci, resp unlabored, no accessory muscle use HEART - PMI non-displaced, +rate irregularly irregular, no MRG, nl S1-S2 ABDOMEN - NABS, +obesity, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no cyanosis/clubbing, 2+ peripheral pulses (DPs), 1+ LE edema b/l (unchanged). SKIN - no rashes or lesions noted NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-25**] throughout, sensation grossly intact throughout
FAMILY HISTORY: Mom died of MI at age 80. Dad died from "brain cancer" in 50s. Sister died from ESRD at age 52 and brother died of liver cancer in 60s. No known FH of early MI or clotting disorders.
SOCIAL HISTORY: 15 pack year smoking history, still smokes [**6-28**] cigs daily. Pt with 1 EtOH/day. Denies illcits. She previously worked as a switchboard operator, but retired 1 yr ago. She is married, and lives in [**Location 5110**] with her husband. Two daughters. | 0 |
99,955 | CHIEF COMPLAINT: Cardiac arrest/found down in field
PRESENT ILLNESS: 55 yo M with HTN nephropathy s/p renal tx in [**4-15**], on immunosuppressants, h/o DM, CHF, CAD s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] 2 in [**6-13**] brought in to ED after a witnessed cardiac arrest. Per records, the family heard a noise and found pt down. He c/o arm pain before falling. The patient had been down for about 10 minutes. EMS arrived at 20:45. Pt intubated in the field. CPR was initiated. Pt in asystole. Received calcium, bicarb, albuterol, epi/atropine x 3. Transferred to [**Hospital1 18**]. On arrival to [**Hospital1 18**], patient in sinus. BP 210/122 HR 111 RR 18. Then dropped BP to 61/36, HR 44. Femoral line placed. Dopamine was started. Pt went into PEA arrest then asystole. He was given atropine x 3, epi x4, bicarb, calcium chloride. EKG showed nl sinus rate 93; nl axis, peaked [**Last Name (LF) 105445**], [**First Name3 (LF) **] depressions in I, II, V4-V6. CXR with increased interstital markings. Labs notable for K 6.1, BUN 13, Cr 2, lactate 14, Ca [**04**], PO4 10. . On arrival to ICU, BP 70s/50s, HR 130s. Pupils were fixed and dilated. Levophed, Neo, Vasopressin added for BP support. Per family, the patient had been in USOH until the incident. In the ICU, bedside echo showed thickened LV and RV, but no effusion.
MEDICAL HISTORY: 1. ESRD on HD Tues/Thurs/Sat at [**Location (un) 4265**] in [**Location (un) **] 2. s/p 2 [**Location (un) **] in [**6-13**] (LAD and ramus), exercise MIBI [**2-14**] limited by poor exercise tolerance. No definite evidence of reversible perfusion defects. Slightly enlarged cavity size. Global hypokinesis. LVEF of 38% 3. CHF: TTE ([**2196-5-5**]) showed EF=45% to 50%, mild symmetric left ventricular hypertrophy, overall left ventricular systolic function mildly depressed, inferior hypokinesis, moderate (2+) mitral regurgitation is seen, moderate pulmonary artery systolic hypertension. 4. HTN 5. DM2 followed by [**Last Name (un) **] 6. Hyperlipidemia 7. GERD 8. Anemia, baseline hematocrit 30-36% 9. TIA on aspirin
MEDICATION ON ADMISSION: 1. Prograf 2 mg po bid (being transitioned to rapamune) 2. Myfortic 750 [**Hospital1 **] 3. Valcyte 450 qd 4. Bactrim SS 5. Nystatin prn 6. Protonix 40 mg po qd 7. Rapamune 3 mg po qd 8. Carvedilol 50 mg po bid 9. amlodipine 5 mg po qd 10. insulin 70/30 14 units ad 11. Humalog SS .
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS: T 100.1, HR 128; BP 80/50 Vent: 600 x 18 (total 29), PEEP 5, FiO2 1.0 GEN: Intubated HEENT: NC, AT, pupils are fixed and dilated CV: regular, nl S1S2, no M/r/g PULM: fine crackles bilaterally ABD: protuberant, soft, NT, ND, renal transplant scar in RLQ EXTR: lower extremities cool, no edema; fistula in LLE w/o thril
FAMILY HISTORY: Per chart: HTN, no diabetes or heart disease
SOCIAL HISTORY: Per chart: Pt lives with his wife and children. Does not work. Denies tobacco, Etoh or other drugs. Born and raised in [**Country 2045**], lived in [**Country 2560**] 2 years before moving to [**Location (un) 86**]. | 1 |
88,726 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 55-year-old male with no previous cardiac history, referred for outpatient cardiac catheterization to evaluate positive stress test following exertional angina symptoms.
MEDICAL HISTORY: Etoh use, [**1-23**] drinks per day, no past surgical history, no known allergies.
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
59,923 | CHIEF COMPLAINT:
PRESENT ILLNESS: The patient is a 41-year-old woman who on [**2108-7-3**] was admitted status post a syncopal event. She was in her usual state of health when she had a syncopal episode and fell backward. She was admitted through the emergency room to the surgical intensive care unit. She had an angiogram on [**2108-7-4**] which showed a right internal carotid artery bifurcation aneurysm. She was discharged on [**2108-7-5**] and is now readmitted on [**2109-7-11**] status post a clipping of the right internal carotid artery bifurcation aneurysm. There were no intraoperative complications.
MEDICAL HISTORY:
MEDICATION ON ADMISSION:
ALLERGIES:
PHYSICAL EXAM:
FAMILY HISTORY:
SOCIAL HISTORY: | 0 |
81,364 | CHIEF COMPLAINT: Shortness of Breath
PRESENT ILLNESS: This is a 58 year old male with a history COPD who has been intubated in the past recent admitted for hypoxia/COPD exacerbation in [**Month (only) 958**]. At that time he improved on BiPAP and did not require intubation. He was treated with steroids, azithromycin and BiPAP. He also has a history of dCHF and was diuresed on last admit. On this admit he reports shortness of breath for the past few days. He reports using his BiPAP regularly at night. His difficulty breathing started when the tempurature became worse. For the past week, in the heat, his breathing has been particularly bad. He has not had any sick contact or any signs of infection. He denies orthopnea or weight gain or leg edema. He only endorses shortness of breath. . Of note, per the daughter patient likely took his meds twice this week on one night accidentally. He is often forgetful and has difficulty with his medications per his family. . When EMS found patient they reported that his apt was very hot and there was no A/C. . In the ED, initial vs were: 103 (rectal temp). 28 130/87 34 91%. He initially was breathing close to 40 and speaking in 2 word sentances. A chest X-ray was done that showed hyperinflated lungs without clear evidence of pneumonia. Patient was given albuterol and ipratroprium nebs, methylprednisolone 125mg IV, potassium 60mg total, azithromycin and tylenol. He received a total of 2.5L of IVF. He improved slightly after neb treatment and was able to speak in full sentances. He was persistently tachycardic in the ED. His temperature decraesed to 99.4 orally in teh ED. Given the fact that he was still breathing in the low 30s so the decision was made to admit him to the ICU. . On the floor, he is in mild respiratory distress. He has no complaints other than shortness of breath. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias.
MEDICAL HISTORY: -COPD, largely emphysema, FEV1 17%, decreased DLCO, status post right upper lobe resection in [**2106**] (at [**Hospital1 112**] due to "cyst compressing lung"). Requires four liters of oxygen at baseline. -Diastolic CHF, EF 70% in [**2114-2-5**]. -LV dysfunction likely related to pulm HTN -Pulm HTN ([**1-9**] likely due to COPD and chronic hypoxemia) -History of embolic stroke, which had hemorrhagic convergence, status post heparin on [**2110-7-22**], frontal and occipital - now maintained on coumadin -History of PFO. -Factor V Leiden heterozygosity. -Hyperlipidemia. -Inguinal hernia. -Polycythemia likely due hypoxemia. -Eczema. -Colonic polyps. -Dyslipidemia
MEDICATION ON ADMISSION: Docusate Sodium 100 [**Hospital1 **] Simvastatin 40 mg at bedtime. Warfarin Cholecalciferol 800 U Calcium Carbonate 1000 [**Hospital1 **] Fluticasone-Salmeterol 500-50 mcg/Dose Disk with twice a day. Tiotropium Bromide 18 mcg Capsule, w/Inhalation once a day. Pantoprazole 40 mg PO Q24H Albuterol Sulfate 2.5 mg /3 mL theophylline 300 mg twice a daily Lasix 120 mg in the morning and 80 mg in the evening potassium chloride O2 via NC 4L baseline at home
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Admission Exam:
FAMILY HISTORY: Father: CVAs (or MI?) starting at age 53 (deceased in 70s) Mother: breast cancer Brother: liver cancer
SOCIAL HISTORY: Lives with wife, walks with cane. Tobacco: The patient stopped smoking in [**2108**] after his lung resection. He has at least a 40-pack year history. EtOH: Occassional Illicits: Past marijuana, No IVDU | 0 |
90,212 | CHIEF COMPLAINT: dyspnea, acute renal failure
PRESENT ILLNESS: 70yoF with h/o DM2, HTN, L iliac artery stenosis s/p stent who presented with DOE and exertional chest tightness x1 wk. . She saw her PCP today where she c/o new onset exertional chest tightness [**7-19**] associated with neck pain. Also complaining of DOE which was also new and has been progressively worsening as well. She denied diaphoresis, nausea/vomiting, arm / jaw pain. Her vitals were significant for BP 179/88, p105, 100% RA NC. There was concern for new TWI's laterally, and sent to ED. . In the ED: 99.2 98 170/88 18 100% on RA. She denied chest pain, nausea, vomiting, diarrhea, black or bloody stools. She was initially well appearing and exam was reportedly non-focal initially, with clear lungs, RRR, no edema. Labs showed Trop 0.03, ARF with BUN/Cr 64/7.2 (up from Cr 1.4-1.7 baseline), HCO3 20, and K 5.7. EKG concerning for lateral strain pattern STD's with concomitant R precordial J point elevation. Renal consulted; CCU fellow and Atrius Cards notified. . In the ED, she became acutely dyspneic, tachypneic to 30-40's, and satting mid 80% on RA. Exam showed diffuse crackles and increased WOB; she was placed on NRB and given a trial of albuterol inhaler without much effect. Her BP was noted to be 200/100 and there was concern for flash pulmonary edema vs PE vs COPD/asthma. An EJ PIV was placed. CXR showed pulmonary edema. She was given SL NTG then started on Nitro gtt, and given 40 mg IV Lasix x1. BP's improved, then hypoTN to 70/40's and gtt stopped, then restarted when BP's went up to 180/100's; goal SBP 120's. Unable to place arterial line. She was also given 325 ASA. . Vitals before transfer: 97.4 p100 150/87 100% on 4L NC. Currently on Nitro 0.5 mcg/kg/min, and looking much better. . Review of Atrius records shows that she is followed by Atrius Oncologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**]. Per his most recent notes, she was seen in [**6-/2152**] and per his note: "anemia, small IgG lambda monoclonal protein, elevated light chains, elevated Beta 2 Microglobulin, transient mild hypercalcemia suggest either an MGUS, an early MM, or a low-grade lymphoma. Bone marrow biopsy was non-diagnostic." However, there was question whether these were due to the venous obstruction in her iliacs or an evolving lymphoproliferative disorder. Her kidney function was deteriorating as early as [**4-/2152**]; per Atrius records: Cr [**11/2151**]: 0.83 [**12/2151**]: 0.95 [**4-/2152**]: 1.67 [**4-/2152**]: 1.44 [**6-/2152**]: 1.72 . On review of systems, she 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: # Diabetes Mellitus type II on insulin with renal complications (last A1c 7.5 [**6-/2152**]) # HTN # [**Month (only) 116**]-[**Last Name (un) 87639**] Syndrome: an inherited thrombophilic syndrome; compression of the L common iliac vein between overlying right common iliac artery and overlying vertebral body; associated with unprovoked L iliofemoral DVT and chronic venous insufficiency # L common and external iliac veins angioplasty and stenting on [**2152-3-29**], discharged on Coumadin # Asthma "anemia, small IgG lambda monoclonal protein, elevated light chains, elevated B2M, transient mild hypercalcemia suggest either an MGUS, an early MM, or a low-grade lymphoma. Bone marrow biopsy was non-diagnostic." # Lymphadenopathy: multiple enlarged L inguinal LN's noted on pelvic MRV in [**7-/2151**] -> s/p LN biopsy showing reactive LN # SPONDYLOLISTHESIS, ACQUIRED # SCIATICA # RHINITIS, ALLERGIC
MEDICATION ON ADMISSION: - Chlorthalidone 25 daily - Colace [**Hospital1 **] prn - Lantus 20 SQ hs - Metformin 1000 daily - Oxycodone 5mg q4 prn - Percocet 5/325 [**12-12**] q4-6 prn - B12 - Benadryl 25 mg prn allergies - Ibuprofen 200 2-4 tabs prn Atrius records: - Losartan 100 mg Oral Tablet Take 1 tablet daily - Chlorthalidone 25 mg daily - Warfarin 1 mg Oral Tablet take 8 tablets daily or as directed - Lovenox 80 mg q12 hrs - Lantus 15u hs - Ibuprofen 400 mg prn pain - ASA 81 daily
ALLERGIES: Lisinopril
PHYSICAL EXAM: VS: BP= 178/94 HR= 98 RR=16 O2 sat= 99% 3 L GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. PERRL, EOMI. no pallor or cyanosis of the oral mucosa. No NECK: Supple no tracheal deviation CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. crakles at bases ABDOMEN: Soft, NTND. No tenderness. BS+ EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+
FAMILY HISTORY: FAMILY HISTORY: Brother Deceased at 69 Diabetes - Type II Father Deceased train accident Mother Deceased at 72 of MI Son Type 2 diabetes
SOCIAL HISTORY: SOCIAL HISTORY From [**Country 3594**] - Tobacco history: quit 30yrs ago, claims to only smoke [**12-12**] cig/day - ETOH: denies - Illicit drugs: denies | 0 |
4,058 | CHIEF COMPLAINT: Unstable neck fracture
PRESENT ILLNESS: 81M with PMHx of primary speech apraxia, DM2, COPD, asbestosis, and recent fall for which he was admitted and placed in a [**Location (un) 2848**]-J collar (noted to have an old C1-C2 fracture) who presents from rehab with concern for ill-fitting collar and possible mental status changes. Patient was discharged to rehab yesterday to rehab, and was reportedly complaining of nausea, anorexia, dizziness, and headache. There was a question of worsening of his apraxia. He required a 1:1 sitter last night for agitation and was sent to the ED from his rehab for further evaluation. In the ED, initial VS were 98 90 157/70 15 95%. Labs were significant for stable hyponatremia & anemia. Preliminary read of non-contrast head CT showed no acute process. U/A was negative. Patient did not receive any medications or fluids in the ED; they did note that the patient fell asleep twice during interview. Patient was seen by neurosurgery who felt that his mental status was at baseline. They determined that there was no acute neurosurgical issues and that his C-collar was appropriately fit. Patient reportedly denied weakness or gait abnormalities. Patient was admitted to medicine for placement, as his rehab facility refused to take him back. Vital signs on transfer were 98.5 ??????F (36.9 ??????C), Pulse: 99, RR: 16, BP: 139/70, O2Sat: 94%RA. On arrival to the floor, patient appears calm and comfortable. Communication is difficult [**1-29**] apraxia, but pt able to answer yes/no. He correctly circled (on a piece of paper) that he is at the hospital and said "no" when asked if he was in pain.
MEDICAL HISTORY: Copd, Asbestosis, Diabetes, primary speech apraxia
MEDICATION ON ADMISSION: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Albuterol 0.083% Neb Soln 1 NEB IH TID copd 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID Patient may refuse. Hold if patient has loose stools. 5. FoLIC Acid 1 mg PO DAILY 6. Ipratropium Bromide Neb 1 NEB IH TID copd 7. MetFORMIN (Glucophage) 500 mg PO BID 8. Multivitamins 1 TAB PO DAILY 9. Nitroglycerin SL 0.4 mg SL PRN chest pain 10. Omeprazole 20 mg PO DAILY 11. Quinapril 10 mg PO DAILY 12. Simvastatin 20 mg PO DAILY 13. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain 14. Tamsulosin 0.4 mg PO HS 15. Vitamin D 800 UNIT PO DAILY
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: PHYSICAL EXAMINATION ON ADMISSION: O: T: 98 BP: 157/70 HR:90 R 15 O2Sats 95% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: EOMs Neck: Supple. 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: at baseline dysarthria. Primarily communicates by writing
FAMILY HISTORY: NC
SOCIAL HISTORY: Widowed, Remote ETOH and Smoking history, lives in [**Hospital3 **] in [**Location 7182**] : [**Street Address(2) 101207**]. | 0 |
27,959 | CHIEF COMPLAINT: Transfer from OSH after cardiac arrest.
PRESENT ILLNESS: 64 year-old male with history of CAD status post CABG brought to OSH by EMS. The patient is reported to have had chest pain and then syncopized per the family. CPR was initiated by the family. The patient was intubated and shocked x2 by EMS for ventricular fibrillation. At the OSH, the patient was found to be in PEA. The patient was given multiple rounds of epinephrine/atropine --> pacing ---> PEA --- > CPR --- > EPI --- > PEA --- > EPI/lidocaine/dopamine ---> EKG showed IMI ---> PEA ---> CPR ---> EPI ---> junctional/wide complex. Heparin gtt started. Pupils were fixed and dilated. Head CT neg for bleed. TTE with "faint squeeze." The patient was transferred to [**Hospital1 18**] for consideration of cardiac catheterization. . Initial vital signs in the [**Hospital1 18**] ED: 92/44, 136, 90% intubated. The patient was transferred on heparin gtt, however, this was discontinued for coffee-ground emesis.
MEDICAL HISTORY: 1. CAD status post CABG 2. ? Hyperlipidemia 3. ? Depression
MEDICATION ON ADMISSION: Metoprolol 25 daily Lovastatin 40 daily Paroxetine 20 mg po daily Zetia 10 mg po daily Ecotrin 325
ALLERGIES: No Drug Allergy Information on File
PHYSICAL EXAM: Vitals: T 93, 107/74 on Dopamine, dobutamine and Lidocaine, HR 126, RR 16 satting 100% on AC/550/16/5/70% Gen: patient intubated and not responsive to sternal rub Neuro: Pupils fixed and dilated, negative corneal reflex, orbital edema CV: tachy, regular, no g/m/r Pulm: bibasilar crackles, coarse breath sounds bilaterally Abdomen: distended, no bowel sounds Ext: UE edema, no LE edema, dopplerable pulses, cool extremities
FAMILY HISTORY: Non-contributory.
SOCIAL HISTORY: Unknown. | 1 |
49,565 | CHIEF COMPLAINT: Cc: Renal failure, hyperkalemia, and GI bleed
PRESENT ILLNESS: Mr. [**Known lastname 68498**] is a 73M with h/o EtOH cirrhosis and recent admission to [**Hospital 5871**] hospital for ARF and SBP, who presents to the ED with several days of weakness. The patient has a h/o grade I esophageal varices and gastritis, diagnosed [**10-15**] in the context of melanotic stools. He was admitted to [**Hospital 5871**] hospital on [**2168-1-2**] in ARF thought to be prerenal, with K 6.8. During this admission he was also found to have SBP by paracentesis, and was discharged home with instructions to complete a course of ciprofloxacin. 1.5L was removed during the paracentesis. He was discharged on [**1-13**], with increased doses of lasix and aldactone due to 20lb weight gain during the course of his hospitalization, during which he was hydrated for his ARF. He also continued to take lactulose and was having [**4-14**] loose stools per day. After discharge, he continued to feel weak. On [**1-15**], he fell onto his right side at home. He called his hepatologist, Dr. [**Last Name (STitle) 497**], who instructed him to go to the ED. He waited the weekend, when he came to the ED with worsening weakness, fatigue, and dyspnea. He denies F/C/NS, denies CP, denies N/V. He believes he has had some increasing abdominal distension since his paracentesis, but denies any abdominal pain. . In the ED, initial VS were BP 90/42, HR 66, RR 17, SaO2 96% RA. Initial labs were significant for BUN/Cr 76/2.1 (baseline Cr 0.9), and K 7.4. ECG demonstrated preexisting LBBB with widened QRS. He was given 2 amps Calcium gluconate, 1 amp bicarb, 10U insulin with D50, and Kayexylate 15gm x 1. Subsequent K was unchanged at 7.3, and he received an additional 4 amps calcium gluconate. He was given 1L NS for his renal failure, and produced 700mL urine in ED. An initial temp was first recorded at 3:50pm, and was 92F. He was given a bear hugger, and was administered vancomycin 1gm IV, and flagyl 500mg IV. Hct was also found to be 24.4, with baseline 36. INR was 2.4, with plt 55. He was found to have brown, guiaiac positive stool. He was administered 2U PRBC and 2U FFP. A sepsis RIJ TLC was placed, with subsequent significant bleeding at site. CXR confirmed placement, and saw no evidence of an acute pulmonary process. UA was negative for UTI. He was admitted to the MICU for further management.
MEDICAL HISTORY: 1) Alcoholic cirrhosis: Grade 1 varices on [**10-15**] EGD. 2) EF 45%, mod AS 3) Spinal stenosis
MEDICATION ON ADMISSION: Lasix 120mg PO qD Aldactone 200mg PO qD Lactulose 30mL q6h Senna 2 tabs PO qHS Rifaximin 400mg PO tid KCl 40mEq PO qD Ciprofloxacin 500mg PO qD Protonix 40mg PO qD Proscar 5mg PO qHS Zinc 400mg PO qD MVI
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: BP: 112/57, HR 74, RR: 18, SaO2: 98% 4L NC General: Ill-appearing caucasian male, lying in bed, oozing blood from TLC insertion site. HEENT: PERRL, +scleral icterus, OP dry CV: RRR, II/VI SEM LUSB radiating to carotids Chest: Mild crackles at bases, otherwise CTAB Abd: Mod distended, mild tenderness to deep epigastric palpation, +BS, +ecchymosis over R flank and groin. Extr: 2+ LE edema, 1+ DPs bilaterally Neuro: Mild tremor, no asterixis, alert and oriented x 3.
FAMILY HISTORY: not asked
SOCIAL HISTORY: No EtOH x 6 months. Previously, 4-5 drinks/day. 20p-y tob history, no longer smoking. No h/o drug use. Retired engineer, lives at home with wife. | 0 |
78,390 | CHIEF COMPLAINT: DKA
PRESENT ILLNESS: This is a 42 yo F with DM1 and h/o DKA and CVA on anticoagulation who presents with a sudden onset of vomiting this am. Per the patient, she forgot to take her lantus last night, as she fell asleep early and didn't awake till this morning. She reports having a sinus infection and cough last week, but denies any abdominal pain, f/c, possibly a small amount of diarrhea. . In the ED, initial vs were: 97.3 88 132/72/20 98%ra. FS on arrival was 359 and chemistries showed a gap of 19. Labs were also significant for a leukocytosis of 19,000. Lactate 3.2 -> 2.0 with IVF. Patient was given Insulin 10 units of regular and was started on an insulin gtt at 6 units per hour, Ativan 2mg IV and Zofran. She also received 3L NS and when the next FS returned at 135, she was started on a D5 gtt. . On arrival to the ICU, the patient notes that she feels much better. She denies any symptoms currently, aside from thirst and hunger. Her nausea has resolved. She denies f/c/n/v/d, abdominal pain, chest pain, palpitations, shortness of breath. She has no sick contacts. She has a past history of etoh abuse, and she notes that her triggers for her past episodes of DKA was etoh. She claims that her last drink was 3 weeks ago.
MEDICAL HISTORY: Type 1 DM, last a1c was 11.2 in [**3-24**] CVA 5y ago, on anticoagulation - assumed stopped given INR, but PCP was planning to check hypercoagulable work up while she was off, last INR was 1.0 [**2162-1-18**] History of substance abuse, etoh abuse h/o DKA (thought to have been brought on at times by etoh) Anxiety Depression
MEDICATION ON ADMISSION: Lantus 30 units qpm Novolog SS Coumadin 8mg monday, wednesday,thursday Coumadin 6mg [**Name10 (NameIs) 1017**], [**Name10 (NameIs) **], saturday Hydroxyzine 25mg TID PRN Simvastatin 40mg daily Trazodone 50mg qHS PRN Citalopram 60mg daily Buspirone 5mg TID
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: Vitals: T: 99.8 BP:109/82 P: 85 R: 16 O2: 100%ra General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: very subtle left lower extremity weakness in plantar/dorsi flexion.
FAMILY HISTORY: . Family History: Mother died of pancreatic cancer. Father had DM1.
SOCIAL HISTORY: smokes tobacco, 1ppdx20yrs. lives at home with her twin 6 year old boys and husband. ?emotional abuse from husband - in the middle of a divorce. No IVDU. Occ MJ. | 0 |
42,843 | CHIEF COMPLAINT: urosepsis
PRESENT ILLNESS: Pt is a 46 yo man with MMP including Alports' sydrome, ESRD s/p renal transplant X4 currently on HD (via tunnelled line), Hep C, h/o aortic valve endocarditis, recently admitted to [**Hospital1 18**] [**Date range (1) 30706**] w/ polymicrobial bacteremia (MRSA, enterococcus, [**Female First Name (un) **]) who presented from rehab w/ c/o abdominal pain and fevers, found to be hypotensive. . In [**Name (NI) **], pt with SBP 60's-80's, other VSS. Labs notable for elevated WBC 13.8, lactate 2.9, elevated BNP. ED w/u included CXR that demonstrated CHF, U/A positive, CT scan initially concerning for pneumotosis, but rpt negative. He was given IVF (2L NS) and developed some respiratory distress due to presumed CHF (seen on CXR), transiently requiring non rebreather. O2 weaned down and able to tolerate nasal cannula. Pt also given Vanc, CTX, flagyl and levofloxacin in ED. Renal was also consulted and recommended he get steroids for ?adrenal insufficiency, so he received dexamethasone 10mg x 1 in ED. Pt had R fem line placed for central access, and initially required levophed for BP support, but that is now weaned off with stable BP. Of note, pt had extensive hospital course [**Date range (3) 30707**] with sepsis and polymicrobial bacteremia w/ MRSA, enterococcus, [**Female First Name (un) **], with many complications as described: 1) Due to constillation of organisms, concern for GI source. He had U/S on [**1-18**] had noted dilation of biiliary ducts, although RUQ u/s neg for this on rpt on [**2-8**]. GI consulted, given above, who recommended MRCP and colonoscopy, which the pt refused. Pt had numerous abx during hospital course and was eventually d/ced on fluconazole and linezolid to complete course through [**2-24**]. 2) access issues, as the pt had his porta-cath removed given his bacteremia. He has old fistula on R arm and L arm and R leg. Eventually had R IJ placed via IR under fluoroscopy, which was changed to R tunneled cath (in IJ) when pt required dialysis. 3) Pt had developed recurrent renal failure during hospital course requiring dialysis and has been dialysis dependent since. As above, via R IJ tunneled cath. 4) MRI demonstrating C5/6 cord compression from large paracentral disc protrusion. No neurological defecits noted and plans for outpt f/u w/ neurosurg w/ plans for [**Doctor First Name **] in future. 5) RLE DVT. Pt w/ h/o of DVT, but this was new noted during hospital course. Treated w/ hep gtt bridge to coum 6) Hypercarbic respiratory failure requiring intubation, felt to be due to oversedation. 7) Difficult to control HTN 8) Anemia - treated with iron and epo. As above, pt refused colonoscopy. 9) Pseudomonas UTI Most importantly, as stated in problem 1) above, pt had numerous abx during hospital course and was d/ced on fluconazole and linezolid to be continued through [**2-24**]. Pt also w/ h/o pseudomonas in his urine [**1-29**], treated initially w/ aztreonam, then cxs returned insensitive, so switched to amikacin, but developed ?dizziness (?true allergy). Currently appears comfortable.
MEDICAL HISTORY: 1. End-stage renal disease [**2-17**] Alport's. 2. Alport's syndrome. 3. Kidney transplant times four (most recently in [**2145**], recently re-started on dialysis) 4. Hepatitis C. 5. Seizure disorder. 6. Right lower extremity phlebitis. 7. Right eye blindness. 8. Right ear hearing loss. 9. Peripheral vascular disease. 10. Small-bowel obstruction. 11. Osteoporosis. 12. Hypertension. 13. Gastrointestinal bleed in [**2147-4-17**]. 14. Aortic stenosis. 15. Endocarditis 16. DVT [**2148**], new RLE DVT 17. Gout 18. h/o abnormal chest x-ray with multiple lung nodules last year [**64**]. Cavitary lung lesion noted [**1-23**]
MEDICATION ON ADMISSION: 1. Fluconazole 200 mg PO Q24H through [**2153-2-24**]. 2. Linezolid 600 mg PO Q12H through [**2153-2-24**]. 3. Warfarin 2 mg daily 4. Cyclosporine 25 mg PO Q12H 5. Oxycodone 2.5 mg PO Q8H PRN 6. Labetalol 200 mg PO TID 7. Amlodipine 5 mg PO DAILY 8. Prednisone 5 mg PO DAILY 9. Epoetin Alfa 10,000 unit/mL 1mL q HD 10. Levetiracetam 500 mg PO MON WED FRI 11. Levetiracetam 250 mg PO SUN, TUES, THURS. 12. Duloxetine 20 mg PO BID 13. Acetaminophen 500 mg 1-2 Tablets PO Q6H as needed. 14. Simethicone 80 mg Chewable PO QID as needed. 15. Hydrocortisone 0.5 % Ointment Topical TID as needed. 16. Bisacodyl 10 mg PO DAILY as needed. .
ALLERGIES: Codeine / Penicillins / Haldol / Cellcept / Vancomycin / Amitriptyline / Iron / Reglan / Amikacin
PHYSICAL EXAM: Vitals - T 95.7, HR 68, BP 108/50, RR 16, O2 100% on **NC Gen - sleeping but arousable, NAD HEENT - OP dry MM CVS - RRR, grade III/VI SEM Lungs - scattered crackles b/l Abd - soft, + tender to palpation diffusely, no rebound/gaurding, + bowel sounds Ext - No LE edema b/l, R LE > L LE, b/l edema of upper extremities Neuro - alert
FAMILY HISTORY: Father had prostate cancer.
SOCIAL HISTORY: Lives w/ parents in [**Location (un) 1456**]. single, no kids. Occasional ethanol use. One pack per day of tobacco >20packyear smoking hx. Past cocaine abuse (none since fall, [**2151**]). | 0 |
79,032 | CHIEF COMPLAINT: Chest pain
PRESENT ILLNESS: 32 M with pericarditis (dx 2 days pta) presents with worsening CP with radiation to the back, diaphoresis, N/V nad abd pain. BP intially 70s/50s. Bedside U/S by ED showed pericardial effusion with some RV invagination. He received 4L NS with resolution of BP. He had CTA of Torso which showed effusion and evidence of RHF. . The patient reports having similar symptoms last year when he was diagnosed with pericarditis as well. He has had 3 prior episodes of similar symptoms, all with diagnosis of pericarditis, but each time the duration of symptoms has increased. He reports being admitted to St. [**Hospital 11042**] Hospital in [**Location (un) 1468**], MA last year, and was apparently diagnosed with autoimmune mediated pericarditis. At the time of this note, these records were unavailable. He reports having negative TB skin tests in the past, as well as negative HIV test in the last 8 months. . On review of symptoms, he reports having diarrhea the last 2 days with some nausea. He had multiple episodes of vomiting today. 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 significant for chest pain, but absent for dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope.
MEDICAL HISTORY: history of Pericarditis x3
MEDICATION ON ADMISSION: Ibuprofen PRN
ALLERGIES: Patient recorded as having No Known Allergies to Drugs
PHYSICAL EXAM: VS: T 97.5, BP 118/75 , HR 86, RR 25 , O2 95% on 4L Pulsus=8 Gen: WDWN athletic appearing black male, in mild to moderate respiratory distress with difficulty speaking in complete sentences. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Dry mucous membranes Neck: Supple with JVP of 8 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. no friction rub ausculated Chest: No chest wall deformities, scoliosis or kyphosis. Resp were mildly labored and tachypneic. Decreased BS in the bases, but no crackles, wheeze, or rhonchi. Abd: mild to moderate tenderness in RUQ/RLQ with voluntary guarding. difficult to determine liver size given guarding. tenderness to percussion with some dullness in RUQ. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; 2+ DP/PT [**Name (NI) 2325**]: Carotid 2+ without bruit; 2+ DP/PT
FAMILY HISTORY: There is no family history of pericarditis. He has a first cousin with a diagnosis of lupus, otherwise no other rheumatological diseases.
SOCIAL HISTORY: Social history is significant for occasional tobacco and occasional marijuana use. He admits to cocaine use in the past, but not in the past 5 years. He denies IVDU. He occasionally drinks ETOH. | 0 |
69,095 | CHIEF COMPLAINT: respiratory distress and fever
PRESENT ILLNESS: 72F AFib, HTN, breast and thyroid CA, s/p tracheostomy several years ago after breast cancer surgery and hysterectomy presenting from [**Hospital3 **] with respiratory distress and fever. EMS crew arrived on scene to find her in respiratory distress, with a heart rate of 180, febrile although temperature not documented. Patient was in atrial flutter versus atrial fibrillation per EMS report. She was saturating at 75-80% on her trach collar without any supplemental oxygen when EMS arrived, was put on a nonrebreather blow by into the trach collar and quickly raised her saturations to the mid 90s. Of note patient recently was evaluated for cough and fever with CXR done at [**Hospital3 **] that showed possible early PNA, started on avelox on [**3-4**], but either did not receive this at all or not a full course per [**Hospital3 **] staff. UTI recently dx, on cipro starting [**3-2**], completed 3 day course. Per family has lived in [**Hospital3 **] for about 6 months. Looked well on Monday when they saw her. . In the ED, she was quickly put on the ventilator with 5 of PEEP 50% FiO2 and raised her oxygen yet further to 97. Copious blood tinged purulent secretions were noted from trach on arrival. CXR with multiple opacities noted, RUL most prominent, concerning for multifocal PNA. UA concerning for UTI so pt was started on vancomycin, zosyn, and ciprofloxacin. Temp noted to be 101.2 in ED, given 650 mg of tylenol x 2. Exam notable for rhonchi throughout lung fields. Also received IV NS. HR on arrival was HR on arrival was 138 Aflutter or afib per report, w BP 130s-140s systolic. Around 10:20 AM pt converted to sinus rhythm with subsequent decrease in BP to 90's systolic, bolus of IV NS given with improvement. VS on transfer BP 107/48 MAP 62 HR 56 on CPAP 10/5 with 50% FiO2. . On arrival to the ICU, pt is nonverbal but shakes head no when asked if she has any pain, looks comfortable. Pt is still on CPAP 10/5, weaned down to 5/0. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes.
MEDICAL HISTORY: Depression Bilateral breast CA Thyroid CA (had short term trach after this, was removed at age 29) Movement disorder (blepharospasm) psychosis bilateral blindness (recent trauma to R eye) HTN atrial fibrillation hypercholesterolemia hypoparathyroidism s/p tracheostomy (complication of intubation from lumpectomy about 4 years ago)
MEDICATION ON ADMISSION: heparin 5000 units TID fluticasone 110 mg inhaled [**Hospital1 **] ipratropium bromide Q4H PRN dorzolamide-timolol 2-0.5 % Drops [**Hospital1 **] diltiazem HCl 45 mg PO Q6H anastrozole 1 mg daily pantoprazole 40 mg daily levothyroxine 137 mcg daily metoprolol tartrate 100 mg [**Hospital1 **] calcitriol 0.25 mcg daily perphenazine 16 mg [**Hospital1 **] Colace 100 mg [**Hospital1 **] potassium chloride 20 mEq Two (2) packets TID ciprofloxacin 400 mg daily (dc'ed [**2177-3-4**]) multivitamin albuterol nebs [**Hospital1 **] prednisolone acetate eyedrops 1 drop right eye TID tylenol 325 mg Q4H PRN pain/fever aspirin 81 mg daily
ALLERGIES: No Known Allergies / Adverse Drug Reactions
PHYSICAL EXAM: ADMISSION EXAM General: alert, appears comfortable, nonverbal HEENT: MMM, oropharynx clear, pupils 5 mm and irregular bilaterally, nonreactive Neck: supple, JVP not elevated, no LAD Lungs: rhonchi throughout auscultated anteriorly CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic murmur best heard at RUSB, no rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place with clear yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. nonverbal but responds to commands to open eyes, hold fingers, wiggle toes.
FAMILY HISTORY: maternal aunt with [**Name (NI) **] [**Name (NI) **] heart failure in his 60s
SOCIAL HISTORY: lives at [**Hospital3 2558**], sister and brother-in-law live nearby but spend the summers in [**Country 6607**] Retired in [**2165**], social worker quit tobacco in [**2134**] rare EtOH | 0 |
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