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train_0 | completed | 175fae11-4139-43e5-b5dd-e69c2d06685a | Medical Text: Admission Date: [**2117-9-11**] Discharge Date: [**2117-9-17**]
Date of Birth: [**2082-3-21**] Sex: F
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
35F w/ poorly controlled Type 1 diabetes mellitus w/ neuropathy,
nephropathy, HTN, gastroparesis, CKD and retinopathy, recently
hospitalized for orthostatic hypotension [**2-3**] autonomic
neuropathy [**Date range (1) 25088**]; DKA hospitalizations in [**6-12**] and [**7-12**], now
returning w/ 5d history of worsening nausea, vomiting with
coffee-ground emesis, chills, and dyspnea on exertion. Last
week she had a fall and hit her right face. she also had 1 day
of diarrhea, which resolved early last week. Found to be in DKA
with AG 30 and bicarb 11.
.
In the ED inital vitals were 09:00 0 98.2 113 181/99 22 100% RA.
K 4.7, HCO3 11, Anion Gap 30, Cr. 2.7 (baseline 1.6-2.0) She is
on her 3rd L NS. Insulin srip at 5 units/hr. On home at 22
levemir in am and 12 at with difficult to control sugars. BPs
have been high. Given 30 mtroprolol tartrate in ED.
She was started on an insulin drip at 5 units/hr and 3L NS
boluses. Also aspirin 325mg PO and Morphine 4mg IVx1 for pain.
CXr was clear. EKG NAD.
.
Review of systems: otherwise negative.
Past Medical History:
Type 1 diabetes mellitis w/ neuropathy, nephropathy, and
retinopathy - 2 episodes of DKA in [**6-12**] and [**7-12**]
HTN - 5 years
gastroparesis - 1.5 years
CKD - stage III, baseline Cr 2.4-2.5, proteinuria
L1 vertebral fracture - [**2117-7-17**]
Systolic ejection murmur
Social History:
Patient lives at home in [**Location (un) **] with her 8 y/o daughter and
boyfriend. She has no history of EtOH, tobacco, or illicit drug
use. She is currently unemployed and seeking disability.
Family History:
Both parents have HTN and T2DM. Grandfather had an MI in his
40s.
Physical Exam:
GEN: Awake, alert, and oriented
HEENT: PERRLA. MMM. no JVD. neck supple. No cervical LAD
Cards: RRR, S1/S2 normal. II/VI systolic ejection murmur heard
best at the L upper sternal border.
Pulm: CTABL with no crackles or wheezes.
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]
sign
Extremities: wwp, no edema. radials, DPs, PTs 2+.
Skin: no rashes or bruising. no skin tenting.
Neuro: CNs II-XII intact. Upper extremities: Power [**5-6**]
bilaterally. Le: left power: 4.5/5 right: power [**3-6**]. Bilateral
symmetric, reduced sensation distal LE to ankles.
Pertinent Results:
Admission Labs: [**2117-9-11**] 09:22AM
WBC-11.9* RBC-4.58 HGB-13.0 HCT-36.5 MCV-80* PLT COUNT-466*
LIPASE-22 ALT(SGPT)-10 AST(SGOT)-16 ALK PHOS-105 TOT BILI-0.5
GLUCOSE-260* UREA N-48* CREAT-2.7* SODIUM-137 POTASSIUM-4.9
CL-101 CO2-11*
LACTATE-1.9
Discharge Labs: [**2117-9-16**] 07:10AM
WBC-6.8 RBC-3.67* Hgb-10.4* Hct-30.2* MCV-82 Plt Ct-298
Glucose-118* UreaN-20 Creat-2.3* Na-137 K-3.7 Cl-104 HCO3-23
AnGap-14
Calcium-8.7 Phos-3.5 Mg-2.0
Radiology:
CXR: No evidence of pneumonia or other pathological
abnormalities. No
pleural effusions. No pulmonary edema. Normal size of the
cardiac
silhouette.
Microbiology: Urine culture negative, blood cultures no growth
to date, stool for C.difficile negative
Brief Hospital Course:
35 yo F with HTN & poorly controlled type I DM, c/b neuropathy,
gastroparesis, nephropathy ?????? CKD, retinopathy presents with DKA
and hypertension SBP to 200s.
.
# Diabetic ketoacidosis: Patient controls diabetes at home with
Humalog SS and long acting Levemir. Sugars at home recently
have been in 250s. In the ED, glucose was 466. UA was +ve for
ketones ?????? corrected to 200s, but rose again to 300s. She was
treated with an insulin drip which was transitioned to subq when
she tolerated POs. Her electrolytes were repleted and she
received aggressive volume resuscitation. [**Last Name (un) **] saw her and
gave sliding scale recommendations which were implemented. No
source for DKA found, beleived to be [**2-3**] gastroparesis. Nausea
managed with ativan, compazine, and promethazine. She was
discharged on her home Insulin and sliding scale with
instructions to follow-up with [**Last Name (un) **].
# HTN: Hypertensive with SBP in 190s initially, attributed to
DKA, as she has experienced in the past. As she improved her
blood pressures normalized and she was re-started on her home
Lopressor and Midodrine regimen.
# Coffee grounds emesis: Emesis started off as clear, then with
prolonged wretching, she started having coffee-grounds vomiting.
This had also occurred on prior admissions for DKA with
associated vomiting. Her hematocrit remained stable and her
hematemesis self-resolved, and so work-up was deferred to the
outpatient setting.
# Acute on chronic kidney disease, Stage III: Patient's Cr on
admission was 2.7, trending down to 2.1-2.3 following fluids,
consistent with her known CKD secondary to diabetic nephropathy.
Medications on Admission:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levemir 100 unit/mL Solution Sig: Twenty Two (22) units
Subcutaneous every AM.
3. Levemir 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
4. Humalog 100 unit/mL Solution Sig: sliding scale as directed
Subcutaneous four times a day: Please use sliding scale as
directed by MD [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) **].
5. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily): take in the evening.
6. promethazine 25 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8
hours) as needed for nausea.
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*2*
8. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily): Please take
only 1 capsule daily (30 mg) for first 2 weeks of treatment.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours as needed for pain.
10. midodrine 5 mg Tablet Sig: 1.5 Tablets PO every four (4)
hours: Can hold while sleeping.
Disp:*270 Tablet(s)* Refills:*2*
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
Once Daily at 6 PM.
5. midodrine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Levemir 100 unit/mL Solution Sig: As directed by [**Last Name (un) **] units
Subcutaneous As directed.
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic keotacidosis
Hematemesis (blood in your vomit)
Hypertension
Chronic renal insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with DKA, hypertension, and
blood in your vomit. You were initially treated in the ICU with
an insulin drip, and your blood sugars improved. Your blood
pressure medications were adjusted to better control your blood
pressure while you were in DKA, but you were re-started on your
home regimen at discharge. The blood in your vomit was likely
secondary to mechanical trauma from repeated wretching, but you
should follow-up with your primary care doctor to discuss
whether you should undergo further evaluation such as an upper
endoscopy. Given your complaints of chronic cough and heartburn,
you should also discuss beginning a trial of a proton pump
inhibitor such as Nexium or Prilosec to see if this helps your
symptoms.
Your insulin regimen was adjusted by the [**Last Name (un) **] team while you
were here. You should continue to follow-up with them with any
questions or concerns regarding your insulin management.
Followup Instructions:
Please call Dr.[**Last Name (STitle) 805**]' office to schedule a follow-up
appointment within 7-10 days of discharge. Her office number is
[**Telephone/Fax (1) 85219**].
You should also continue to follow-up with your [**Last Name (un) **] doctors
as needed.
ICD9 Codes: 5849 | [
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train_1 | completed | cc865d34-a855-4cab-9384-06845abf3995 | Medical Text: Admission Date: [**2150-4-17**] Discharge Date: [**2150-4-21**]
Date of Birth: [**2090-5-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
coffee ground emesis
Major Surgical or Invasive Procedure:
EGD
Right IJ CVL
History of Present Illness:
Mr. [**Known lastname 52368**] is a 59M w HepC cirrhosis c/b grade I/II esophageal
varices and portal gastropathy (last EGD [**3-/2150**]), who p/w
coffee-ground emesis and melena x2 days.
.
Pt was in his USOH until about 2-3 days PTA, when he began
experiencing intermittent nausea. He had 2-3 episodes of
coffee-ground emesis and 1 episode of tarry black stool in the
morning of admission. He reports some lightheadedness which is
not new, but denies frank hematemesis, BRBPR, abdominal pain,
fever, chills, significant increases in his abdominal girth. He
denies drinking or medication non-compliance. He also reports
taking naproxen for back pain 2-3 times a day in the recent
past.
.
In the ED, his vitals were 97.4, 93/41, 69, 18, 100% on RA. He
was given 4L NS IV, protonix 40mg IV, started on an octreotide
drip. He had guaiac positive brown stool on rectal exam. He was
seen by the liver fellow in the ED who felt this was unlikely a
variceal bleed and recommended work up for infection. An NG tube
was attempted, however, patient was unable to tolerate it in the
ED. Abdominal ultrasound was done which showed a patent portal
vein, scant ascites but not enough to tap. BP dropped to 80/34,
pt transferred to MICU for hemodynamic monitoring.
.
In the MICU, pt was given 3 pRBC, Hct bumped from 21.3 to 28.
Started on norepinephrine gtt for a few hours, but BP
stabilized. On transfer to the floor, remains hemodynamically
stable. Feels good, denies tarry or bloody BMs, emesis.
Past Medical History:
HCV Cirrhosis (tx with interferon x2 with no response)
Portal Gastropathy
Grade II Esophageal varices
HTN
Social History:
He lives alone. He is drinking alcohol, usually one session per
week. He has four to five drinks per session. He was told to
completely abstain from alcohol, effective as of today. He
smokes about 20 cigarettes per day.
Family History:
NC
Physical Exam:
ON ADMISSION:
VS: T95.9 HR 71 BP 83/36 RR 11 96% 2L NC
Gen: somnolent, oriented x 3, unable to assess for asterixis
given somnolence
HEENT: PERRLA, EOMI
Neck: supple, JVP at angle of jaw (fluid bolus running wide
open)
CV: RRR s1 s2 no appreciable murmur
Lungs: CTAB
Abd: distended, non tender, no rebound or guarding, bowel sounds
positive
Ext: 1+ pitting edema bilaterally
Skin: warm, diaphoretic, no rash or lesions noted
Pertinent Results:
LABS ON ADMISSION:
[**2150-4-17**] 01:30PM BLOOD WBC-17.9*# RBC-2.78* Hgb-8.5* Hct-26.0*
MCV-94 MCH-30.6 MCHC-32.7 RDW-20.6* Plt Ct-186
[**2150-4-17**] 01:30PM BLOOD Neuts-61.2 Lymphs-28.8 Monos-6.9 Eos-2.2
Baso-0.9
[**2150-4-17**] 02:13PM BLOOD PT-17.7* PTT-34.5 INR(PT)-1.6*
[**2150-4-17**] 01:30PM BLOOD Glucose-92 UreaN-51* Creat-1.3* Na-131*
K-5.7* Cl-104 HCO3-21* AnGap-12
[**2150-4-17**] 01:30PM BLOOD ALT-126* AST-260* LD(LDH)-426*
AlkPhos-157* TotBili-3.3*
[**2150-4-17**] 06:41PM BLOOD Calcium-7.5* Phos-3.8 Mg-1.9
.
LABS ON DISCHARGE:
[**2150-4-21**] 05:00AM BLOOD WBC-10.7 RBC-2.94* Hgb-9.6* Hct-27.0*
MCV-92 MCH-32.6* MCHC-35.6* RDW-21.2* Plt Ct-110*
[**2150-4-21**] 05:00AM BLOOD PT-17.4* PTT-35.6* INR(PT)-1.6*
[**2150-4-21**] 05:00AM BLOOD Glucose-84 UreaN-15 Creat-1.0 Na-132*
K-4.4 Cl-99 HCO3-25 AnGap-12
[**2150-4-21**] 05:00AM BLOOD ALT-113* AST-210* AlkPhos-111
TotBili-3.6*
[**2150-4-21**] 05:00AM BLOOD Calcium-8.1* Phos-3.8 Mg-1.7
.
OTHER LABS:
[**2150-4-18**] 06:25AM BLOOD CK-MB-9 cTropnT-<0.01
[**2150-4-17**] 06:41PM BLOOD CK-MB-11* MB Indx-4.9 cTropnT-<0.01
[**2150-4-17**] 01:30PM BLOOD Lipase-85*
.
URINE:
[**2150-4-17**] 11:01PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2150-4-17**] 11:01PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
[**2150-4-17**] 11:01PM URINE RBC-63* WBC-7* Bacteri-NONE Yeast-NONE
Epi-<1
.
MICROBIOLOGY:
Blood, urine cultures - negative
H.pylori serum antibody - negative
.
CARDIOLOGY:
.
TTE ([**4-18**]):
Conclusions
The left atrium is dilated. Left ventricular wall thicknesses
and cavity size are normal. Left ventricular systolic function
is hyperdynamic (EF>75%). Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Hyperdynamic LV systolic function. Mild mitral
regurgitation. Moderate pulmonary artery systolic hypertension.
.
EKG ([**4-17**]):
Sinus rhythm
Prolonged QT interval is nonspecific but clinical correlation is
suggested
No previous tracing available for comparison
Intervals Axes
Rate PR QRS QT/QTc P QRS T
70 160 96 462/479 70 55 52
.
GI:
EGD ([**4-20**]):
1. Varices at the lower third of the esophagus and middle third
of the esophagus.
2. Erythema and erosion in the antrum and pylorus compatible
with non-steroidal induced gastritis.
3. Bleeding from a pyloric ulcer in the pylorus compatible with
non-steroidal induced ulcer (injection, thermal therapy).
4. Normal mucosa in the duodenum.
5. Otherwise normal EGD to third part of the duodenum
.
RADIOLOGY:
.
CXR ([**4-17**]):
The prominent bulge to the right heart border could be due to
pericardial
effusion, _____ cyst, and enlarged right atrium. There is no
mediastinal
vascular engorgement to suggest cardiac tamponade. Pulmonary
vasculature is normal. The lungs are clear and there is no
pleural effusion. Overall heart size is normal. Right jugular
line ends at the junction of the
brachiocephalic veins. No pneumothorax or pleural effusion.
.
ABD U/S ([**4-17**]):
IMPRESSION:
1. No son[**Name (NI) 493**] evidence for portal venous thrombosis. Portal
vein flow is hepatopetal and wall-to-wall.
2. No significant ascites. A sliver of perihepatic ascites.
3. Persistent coarsened echotexture of the liver consistent with
known
history of cirrhosis.
4. Splenomegaly
Brief Hospital Course:
Mr [**Known lastname 52368**] is a 59M w HCV cirrhosis w grade II esophageal varices
admitted w coffee-ground emesis and melena concerning for UGIB,
s/p MICU stay for hypotension.
.
# UGIB: Pt did not have any more bleeds while in hospital. EGD
revealed erythema and erosion in the antrum and pylorus
compatible with non-steroidal induced gastritis. Pt did remember
taking increased doses of naproxen for backache. Started on
pantoprazole 40mg PO BID for one week with repeat endoscopy
scheduled in one week ([**4-30**]). Recommended to take tylenol (max
daily dose of 2gm) for pain instead of NSAIDs. Blood pressure
meds were held at first, given MICU admission for hypotension,
but were restarted on discharge.
.
# HCV Cirrhosis: appears to be progressing to liver failure,
with elevated INR at 1.6, decreased albumin at 2.6, tbili
slightly elevated at 3.6, and chronic LE edema. Pt was continued
on prophylactic medications.
.
# FULL CODE
Medications on Admission:
FUROSEMIDE 20mg daily
LISINOPRIL 10 mg daily
SPIRONOLACTONE 100 mg daily
Discharge Medications:
1. Phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane PRN (as needed).
2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**6-15**]
hours as needed: no more than 6 tablets of regular strength
tylenol per day.
8. Terbinafine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) for 1 weeks.
Disp:*qs * Refills:*0*
9. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day for 1 weeks:
then take 1 tablet daily.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
Disp:*qs * Refills:*0*
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Peptic ulcer
GI bleed
Discharge Condition:
asymptomatic
Discharge Instructions:
You were admitted for bleeding from an ulcer in your stomach.
This ulcer is at least partially caused by naproxen. You should
stop taking naproxen and take only tylenol for pain. You should
not take any NSAIDS for pain including ibuprofen, naproxen,
aleve, motrin, aspirin, toradol, or advil. It is okay to take
tylenol but do not take more than 4 extra strength tylenol a day
(2gram daily maximum).
.
The following medication changes were made:
Do not take naproxen
Take pantoprazole 40 mg twice daily for one week. Then take 40
mg daily.
.
You are scheduled to get a repeat endoscopy next week. Prior to
the procedure do not have anything to drink or eat after
midnight.
.
Please return to the ER if you have any chest pain,
lightheadeness, fever, chills, bloody or black stools or any
other concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2150-4-30**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2150-4-30**]
1:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2150-5-7**] 11:00
Completed by:[**2150-4-24**]
ICD9 Codes: 2851, 5715, 4019 | [
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train_2 | completed | ada67549-e029-4c69-aedc-85123fe69134 | Medical Text: Admission Date: [**2108-4-6**] Discharge Date: [**2081-4-7**]
Date of Birth: [**2059-5-7**] Sex: F
Service: O MED
CHIEF COMPLAINT: Dyspnea.
HISTORY OF PRESENT ILLNESS: This is a 48 year old African
American female with a history of multiple myelomas being
admitted for respiratory distress. The patient has been
recently discharged one week ago from outside hospital ([**Hospital3 7900**]) for respiratory distress. Back at [**Hospital3 7362**],
she was given nebulizer, antibiotics and steroids. She also
had elevated INR and was given medication to lower INR
although there was no evidence of bleeding.
Last night, she reports having increased difficulty with
breathing. She has also had a cough. She denies any fever
or chills. The patient admitted to decreased p.o. intake but
has been recently sedimentary. She denies any swelling of
the legs. The patient had noted some wheezing but then took
her Albuterol inhaler without any effect. She has been on a
Prednisone taper but reports that she has been coughing up
thick sputum.
She went to her primary care provider today but could not say
a sentence so was sent to the Emergency Department. In the
Emergency Department, she was tachypneic and wheezing with
heart of 120 and blood pressure of 127/82. She received
Solu-Medrol and continued with nebulizer treatment. She
improved, but seemed to be tiring. Her ABG was done and
showed pH of 7.41; PCO2, 40; PO2, 92. She can speak in full
sentences but still just making wheezing. She is requiring
continued nebulizer treatment but denies any chest pain,
nausea, vomiting, diarrhea or abdominal pain. She feels weak
in general.
PAST MEDICAL HISTORY:
1. Multiple myeloma diagnosed in [**2107-12-9**], with
increase protein in bone marrow biopsy. She is to receive
Decadron 40 mg q d every other week.
2. Pulmonary embolism, [**2108-1-2**].
3. Asthma. No PFTs .....................
4. History of steroid psychosis.
5. Pneumonia requiring intubation in [**2107-12-9**].
MEDICATIONS UPON ADMISSION:
1. Coumadin 2.5 mg p.o. q d.
2. Serevent two puffs q.i.d.
3. Albuterol inhaler one to two puffs q 6 hours prn.
4. Dexamethasone 10 mg p.o. q d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Socially, she lives with her children and
works at home as a home health aid. She has twenty years of
two pack a day smoking history but quit in [**2107-12-9**].
She drinks an occasional alcohol.
FAMILY HISTORY: Family history shows father died of an
myocardial infarction. Sister with ovarian cancer.
PHYSICAL EXAMINATION UPON ADMISSION: Temperature, 96.6;
heart rate, 122; blood pressure, 127/82; respiratory rate,
24; O2 saturation, 99%. Head, eyes, ears, nose and throat,
pupils are equal, round, and reactive to light and
accommodation and extraocular movements intact. No accessory
muscles are being used. Neck is supple without
lymphadenopathy. Pulmonary, diffuse wheezing with bibasilar
crackles with the left greater than right. Cardiac, regular
rate and rhythm with normal S1 or S2. No murmurs or thrills
noted. Abdomen is soft, nontender, nondistended with normal
active bowel sounds. Extremities, no edema, cyanosis or
clubbing noted. Neurologically, the patient is somnolent but
oriented x 3. No focal defects are noted.
LABORATORIES UPON ADMISSION: White count, 9.6; neutrophils,
66%; lymphocytes, 5%; bandemia, 21%; monocytes, 1%. Sodium,
131; potassium, 4.4; chloride, 92; bicarbonate, 24. BUN, 14;
creatinine, 0.8. Glucose, 131. INR, 1.3. PTT, 29.1. ABG,
7.41; PCO2, 40; PO2, 92.
HOSPITAL COURSE:
1. Pulmonary - Dyspnea secondary to chronic obstructive
pulmonary disease/emphysema under this hospital course.
Briefly, the patient received BIPAP, ....................,
intravenous Solu-Medrol, nebulizer treatment and inhaler
treatment while in the Intensive Care Unit. She was able to
be weaned off of the oxygen back to room air, sating to about
93 or 94 percent.
Though her chest x-rays show hyperinflation and no signs of
infection, she was given five days worth of Zithromax. An
echocardiogram was to rule out any cardiac wheezes which then
showed an ejection fraction of greater than 55%, mild right
ventricular dilation and mild pulmonary arterial pressure.
Pulmonary function tests were performed showing obstructive
pattern with FEC of 2.56 which is 93% of the predicted and
FEV1 of 0.9 which is 43% of the predicted in FEV1 to FEC
ratio of 46%.
When the patient was transferred to the Medical Floor, a CT
was performed showed no evidence of a pulmonary embolism but
did show signs of emphysema. Sputum cultures were sent and
showed no growth of any organism. Alpha antitrypsin was sent
out but is still pending.
2. Pulmonary Embolism - The patient was continued on
Coumadin for an INR between 2 and 3. Since she was
subtherapeutic, she was started on Lovenox until she became
therapeutic on the Coumadin.
3. Psychiatry - Anxiety. The patient was quite anxious
during the hospital course. Psychiatry was called to consult
and recommended that she be on Risperidone at 0.25 mg q hs.
The patient did well on this medication.
4. Oncology - Multiple myeloma. A protein electrophoresis
was done showing a monoclonal IGG capa gammaglobulinopathy
(60% of the total protein in [**2108-1-8**], but now is 66%
of total protein on [**2108-4-9**], despite q weekly
Dexamethasone treatment. Bone marrow biopsy was done
revealing 70 to 80 percent plasma cells. Given these
findings, the patient was then transferred to the [**Hospital Ward Name 516**]
for start of chemotherapy with Vincristine,
................... and Decadron in preparation for bone
marrow transplant to be done.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**First Name3 (LF) 30667**]
MEDQUIST36
D: [**2108-4-17**] 15:47
T: [**2108-4-17**] 15:46
JOB#: [**Job Number 30668**]
ICD9 Codes: 486, 2761 | [
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train_3 | completed | ba9abdc6-55c2-4c6b-8f4c-1e8bd2beab09 | Medical Text: Admission Date: [**2145-3-31**] Discharge Date: [**2145-4-7**]
Date of Birth: [**2071-6-4**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Dilantin
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Severe abdominal and back pain
Unable to take oral intake.
No flatus or bowel movement.
Abdominal distention.
Major Surgical or Invasive Procedure:
Exploratory Laparotomy
Lysis of adhesions
Small Bowel Resection
Jejunosotomy
History of Present Illness:
Ms [**Known lastname **] is a 73 year old female with a history of multiple
abdominal surgeries, pancreatitis and previous SBO. She
presented to the Emergency Department on [**2145-3-30**] with complaints
of [**11-10**] abdominal pain, radiating to her back that began in the
morning. She complains of distention, inability to have a bowel
movement, inability to take oral intake, no fever, chills or
diarrhea.
Past Medical History:
Chronic Pancreatitis
Migraines
Surgical history:
Pancreatic diversion, cholecystectomy, appendectomy,
small bowel obstruction.
Social History:
Married, lives with husband who is a retired pediatric
infectious disease doctor.
Family History:
Father: deceased, leukemia
Brother: colon cancer
Physical Exam:
T: 97.9 HR: 79 BP: 153/60 RR: 22 Spo2 100% on RA
Constitutional: in pain
Head/Eyes: mucous membranes dry
ENT/Neck: neck supple
Chest/Respiratory: Clear to auscultation Bilaterally
GI/Abdominal: Tender to light palpation. Multiple well healed
scars + guarding, hypoactive bowel sounds
GU: no costovertebral angle tenderness
Musculoskeletal: WNL
Skin: Dry
Neuro: alert & oriented
Pertinent Results:
[**2145-3-30**] 09:15PM BLOOD Glucose-116* UreaN-16 Creat-0.8 Na-139
K-3.8 Cl-103 HCO3-25 AnGap-15
[**2145-3-31**] 10:26AM BLOOD WBC-12.3*# RBC-4.01* Hgb-12.3 Hct-37.1
MCV-93 MCH-30.6 MCHC-33.0 RDW-14.2 Plt Ct-259
[**2145-3-30**] 09:15PM BLOOD ALT-12 AST-22 AlkPhos-89 Amylase-169*
TotBili-0.3
[**2145-4-2**] 06:15AM BLOOD Amylase-107*
[**2145-3-31**] 10:26AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.6
[**2145-3-31**] 12:44AM BLOOD Lactate-3.1*
[**2145-4-2**] 02:10PM BLOOD Lactate-1.9
[**2145-3-30**] 11:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
.
ABDOMEN (SUPINE & ERECT)
IMPRESSION: Nonspecific bowel gas pattern without evidence of
obstruction.
.
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
IMPRESSION:
1. High grade small-bowel obstruction. Unusual configuration of
a loop of small bowel in the mid abdomen is concerning for
closed loop obstruction. There is a moderate amount of free
fluid within the abdomen.
2. Ill-defined opacity in the right middle lobe representing
infection or BAC and should be further evaluated with PET CT.
3. Thickening of the first portion of the duodenum, of uncertain
clinical significance.
.
CHEST (PORTABLE AP) [**2145-4-2**] 1:51 PM
IMPRESSION: Right lower lobe airspace opacity, which could
represent pneumonia in the appropriate clinical setting. Small
bilateral pleural effusions. Followup to assure resolution is
recommended.
.
CT Chest [**2145-4-2**]
IMPRESSION:
1. New right lower lobe pneumonia. Small bilateral pleural
effusion and left basilar atelectasis.
2. Ill-defined opacity in the right middle lobe representing
either infection or BAC and should be further evaluated once
acute issues resolve.
3. No evidence of pulmonary embolus or aortic dissection.
4. Small mediastinal and axillary lymph nodes, which do not meet
CT criteria for pathologically enlargement.
CXR [**2145-4-6**]
IMPRESSION:
1. Improving airspace consolidation in the right lower lung
field consistent with resolving pneumonia.
2. Small bilateral pleural effusions.
Brief Hospital Course:
Ms [**Known lastname **] was admitted through the emergency room on [**2145-3-31**] and
taken to the operating room. She underwent an uncomplicated
exploratory laparatomy for small bowel resection, jejunosotomy
and lysis of adhesions, see op report for details. She was
stabilized in the PACU, and transferred to SICU on POD#1. She
was extubated, her pain was well controlled with morphine PCA,
she remained NPO with NGT and foley catheter. She was initiated
on Cefazolin/Flagyl x 24 hours.
POD#2 she developed confusion and decreased oxygen saturation,
requiring 3L nasal cannula. Narcotics were stopped, CXR and CT
of chest were obtained and revealed right lower lobe pneumonia,
see pertinent results for details. Vanc/Levo/Flagyl were
initiated as well as an ID and medicine consult. She was
transferred to SICU. POD#[**4-4**] she remained in SICU, her mental
status and respiratory status improved. POD#4 her NGT was
removed and she was transferred to [**Hospital Ward Name 121**] 9, she was weaned to
room air. Her pain was well controlled with tylenol and small
doses of oxycodone. POD#5 she reported flatus followed by
multiple loose stools. Stool for C diff was negative. She was
started on sips, and tolerated it easily. POD#6 she tolerated
clear liquids but no longer wanted to take antibiotics due to
frequent stools. CXR was repeated which showed resolving
pneumonia. She tolerated a regular diet in the evening without
difficulty. Infectious disease team recommended completion of 7
days of Levofloxacin. Clips were removed on POD#7, she was
discharged home in stable condition with antibiotics, pain
medication and all appropriate follow up appointments.
Medications on Admission:
Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).
Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime)
as needed.
Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q6H (every 6
hours).
6. Trileptal
Resume your home dose of trileptal
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 0.5-1 Tablet PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. 7. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*7 Tablet(s)* Refills:*0*
Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q6H (every 6
hours).
6. Trileptal
Resume your home dose of trileptal
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Internal hernia with necrotic jejunum
Pneumonia
Discharge Condition:
good
Discharge Instructions:
Please call your surgeon if you develop chest pain, shortness of
breath, fever greater than 101.5, foul smelling or colorful
drainage from your incisions, redness or swelling, severe
abdominal pain or distention, persistent nausea or vomiting,
inability to eat or drink, or any other symptoms which are
concerning to you.
No tub baths or swimming. You may shower. If there is clear
drainage from your incisions, cover with a dry dressing. Leave
white strips above your incisions in place, allow them to fall
off on their own.
Activity: No heavy lifting of items [**11-15**] pounds until the
follow up
appointment with your doctor.
Medications: Resume your home medications. If you have a problem
with constipation, you should take a stool softener, Colace 100
mg twice daily as needed. You will be given pain medication
which may make you drowsy. No driving while taking pain
medicine.
Followup Instructions:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2145-4-20**] 2:00
You have an appointment to see Dr. [**Last Name (STitle) **] on Friday, [**2145-4-23**] at
3:30. Phone #: [**Telephone/Fax (1) 2723**].
Please see your primary care physician regarding follow up from
your CT scan within 1 month. Your CT results and Discharge
summary will be faxed to her.
Completed by:[**2145-4-7**]
ICD9 Codes: 486, 4019 | [
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train_4 | completed | 0f6a7a99-89e5-4ad7-aa6d-ac86f1cb3b19 | Medical Text: Admission Date: [**2162-5-16**] Discharge Date: [**2162-5-21**]
Date of Birth: [**2101-7-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
[**2162-5-17**]: CABGx4 LIMA-> LAD, RSVG-> Diagonal, Posterior
Descending Artery, Obtuse marginal
[**2162-5-19**]: Right Atrial lead placement
History of Present Illness:
60yo man with known coronary disease (AMI in [**2143**] and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
LCx [**2155**]). Doing well until last week when he developed angina
initially with exertion then progressed to rest angina. Each
episode was releived with SL NTG, no episode lasting more than 5
minutes. He presented to cardiologist for treatment. He was
admitted to MWMC, a cardiac catheterization revealed 3 vessel
disease. He was transferred to [**Hospital1 18**] for coronary bypass
grafting.
Cardiac Catheterization: Date: [**2162-5-11**] Place: MWMC
-LAD- chronic total occlusion proximally(distal filling via
collaterals)
-RCA- chronic total occlusion of non-dominant RCA 90%
-LCx- new complex 90% stenosis of prox LCx involving the
bifurcation of the LCx proper and large OM2.
Old stent in LCx is widely patent
-mod LV systolic dysfx, with anterior, apical, and infero-apical
AK and reduced EF 30%
LVEDP 36mmHg
No valvular dz
Past Medical History:
CAD-(AMI [**2143-7-3**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LCx [**6-/2155**])
Cardiomyopathy- EF 35-45% depending on study
Ventricular tachycardia s/p AICD [**8-/2155**]
Atrial flutter s/p ablation [**8-/2155**]
Hypertension
Dyslipidemia
Insulin dependent diabetes Mellitus
Obesity
Conduction disease-LAFB
Peripheral vascular disease s/p Right fem-[**Doctor Last Name **] bypas [**3-/2161**]
Left leg claudication
Right thigh tumor s/p radiation and excision [**2141**]'s
Social History:
Race: caucasian
Last Dental Exam:
Lives with: wife
Occupation: [**Name2 (NI) 56028**] owns company
Tobacco: 2ppd x20 yrs quit [**2143**]
ETOH: occaisional
Family History:
Father died 50yo cirrhosis, mother died 42yo MI
Physical Exam:
Pulse: 58 Resp: 16 O2 sat: 97%-RA
B/P Right: 124/76 Left:
Height: 5'[**62**]" Weight: 259 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema -none
Varicosities: None [x]. Well healed right vein harvest site.
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left:+2
DP Right:+2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: +2 Left:+2
Carotid Bruit none Right: +2 Left:+2
Pertinent Results:
[**2162-5-17**]:
Prebypass
The left atrium is dilated. No spontaneous echo contrast is seen
in the body of the left atrium or left atrial appendage. No
spontaneous echo contrast is seen in the body of the right
atrium.
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is severely dilated.
There is moderate regional left ventricular systolic dysfunction
with hypokinesis of the apex and septum. Overall left
ventricular systolic function is mildly depressed (LVEF=30-35%).
The estimated cardiac index is depressed (<2.0L/min/m2). Focal
abnormalities are seen in the mid and apical anteroseptal wall,
apical anterior wall, mid and apical inferoseptal wall, apical
inferior wall. NO thrombus was seen in LV apex.
Right ventricular chamber size and free wall motion are normal.
The descending thoracic aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened with focal
calcification of the non-coronary cusp which moves poorly. There
is a minimally increased gradient consistent with minimal aortic
valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**1-3**]+) mitral regurgitation is seen. There is no mitral valve
prolapse or flail segments. There is no pericardial effusion.
Postbypass
The patient is A-paced and on a phenylephrine infusion.
Biventricular systolic function is unchanged. Mitral
regurgitation remains mild-to-moderate. The thoracic aorta is
intact post decannulation.
[**2162-5-20**] 05:00AM BLOOD WBC-10.9 RBC-3.73* Hgb-11.2* Hct-31.7*
MCV-85 MCH-30.1 MCHC-35.4* RDW-13.9 Plt Ct-114*
[**2162-5-20**] 05:00AM BLOOD Glucose-151* UreaN-19 Creat-0.7 Na-135
K-3.9 Cl-100 HCO3-28 AnGap-11
[**2162-5-16**] 05:00PM BLOOD ALT-66* AST-55* LD(LDH)-206 AlkPhos-73
TotBili-0.3
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2162-5-17**] where the patient underwent Coronary
artery bypass graft x 4. See operative note for details.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The Electrophysiology team was consulted now due to non
capturing atrial lead after permanent pacemaker was initially
interrogated and epicardial wires were removed. Ventricular lead
and ICD were functioning appropriately. The right atrial lead
was revised on [**5-19**] without complication. He is to follow up the
device clinic at [**Hospital1 **] in 2 weeks - operative note was given
to patient to bring to follow up appointment. The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight.
Lisinopril was restarted for better blood pressure. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes were discontinued without complication on post
operative day 3. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD 4 the patient was ambulating
freely, the sternal and pacer pocket wound was healing and pain
was controlled with oral analgesics. He is to continue on 1 week
of antibiotics per EP s/p atrial lead placement. The patient
was discharged home with VNA services in good condition with
appropriate follow up instructions. All follow up appointments
were arranged.
Medications on Admission:
Lisinopril 20'
Atenolol 100'
Vytorin [**10/2131**] QHS
Fenofibrate 200'
ASA 325'
NTG-sl/PRN
Insulin-NPH 22u QAM/24u QPM- followed by [**Last Name (un) **]
Insulin- Humalog SS
MVI
Calcium 600'
Plavix - last dose:[**2162-5-12**]
Allergies: NKDA
Discharge Medications:
1. fenofibrate 160 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*1*
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*100 Tablet(s)* Refills:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
15. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1)
Subcutaneous twice a day: Take 22 units in AM and 24 units in
PM.
Disp:*QS 1 month * Refills:*0*
16. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary Artery Disease
CAD-(AMI [**2143-7-3**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LCx [**6-/2155**]),Cardiomyopathy- EF
35-45% Ventricular tachycardia s/p AICD [**8-/2155**], Atrial flutter
s/p ablation [**8-/2155**], Hypertension, Dyslipidemia,Insulin
dependent diabetes Mellitus, Obesity, Conduction disease-LAFB,
Peripheral vascular disease s/p Right fem-[**Doctor Last Name **] bypas [**3-/2161**], Left
leg claudication, Right thigh tumor s/p radiation and excision
[**2141**]'s
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] on [**6-10**] at 1:45pm [**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) 1295**] on [**6-14**] at 3:30pm
EP [**Hospital 19721**] Clinic at [**Hospital1 **] in [**1-3**] weeks: Call for appointment
-
[**Telephone/Fax (1) 6256**]
Wound check appointment in [**Hospital **] Medical office building
[**Telephone/Fax (1) 170**]
Date/Time:[**2162-5-26**] 12:00
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 27187**] in [**4-6**] weeks [**Telephone/Fax (1) 3658**]
Follow up with [**Hospital **] [**Hospital 982**] Clinic to be arranged by patient
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2162-5-24**]
ICD9 Codes: 4111, 2859, 4019, 2720 | [
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train_5 | completed | e23f06b1-14c3-4abc-80d4-efeb9ba243db | Medical Text: Admission Date: [**2177-8-29**] Discharge Date: [**2177-9-12**]
Date of Birth: [**2156-2-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Helmeted motocyclist who hit tree
Major Surgical or Invasive Procedure:
[**2177-8-29**]
1. Irrigation and debridement down to and inclusive of
bone, right open femur fracture.
2. Retrograde intramedullary nailing with Synthes 11 x 360
nail.
3. Open reduction and internal fixation of patella fracture
with K-wires and figure-of-8 tension band construct.
[**2177-9-4**]
Tracheostomy
IVC filter
[**2177-9-12**]
PICC right bascilic vein
History of Present Illness:
21 y.o. male helmeted moped rider who struck a tree with
reported GCS of 6 on the scene. Patient was transported to OSH
and noted to have a right sided open femur fracture. He received
antibiotics and was intubated prior to transfer.
Patient was transported and had radiographic studies performed
that showed right femur fracture, SAH, grade II liver lac,
pulmonary contusions, and small PTX. Patient reportedly received
1 unit of pRBCs in the ED and was placed into a traction splint
on RLE.
Past Medical History:
None
Social History:
tobacco none
ETOH none
Family History:
Non-contributory.
Physical Exam:
96.9 130 150/97 20 100%
intubated and sedated
HEENT - L eye abrasions, pupils nonreactive bilaterally
CTA b/l
rapid HR, regular rhythm
SNDNT
pelvic fracture
+ palpable distal pulses
Pertinent Results:
[**2177-8-29**] 04:35AM BLOOD WBC-17.7* RBC-4.76 Hgb-15.2 Hct-45.5
MCV-96 MCH-32.0 MCHC-33.5 RDW-13.2 Plt Ct-314
[**2177-8-30**] 12:50AM BLOOD WBC-7.6 RBC-2.73* Hgb-9.0* Hct-25.0*
MCV-92 MCH-32.8* MCHC-35.9* RDW-13.5 Plt Ct-188
[**2177-8-31**] 01:49AM BLOOD WBC-9.4 RBC-2.42* Hgb-7.8* Hct-21.7*
MCV-89 MCH-32.1* MCHC-35.9* RDW-14.5 Plt Ct-148*
[**2177-9-1**] 03:13AM BLOOD WBC-9.2 RBC-2.87* Hgb-9.0* Hct-25.6*
MCV-90 MCH-31.6 MCHC-35.3* RDW-15.0 Plt Ct-128*
[**2177-9-2**] 01:40AM BLOOD WBC-7.7 RBC-2.78* Hgb-8.8* Hct-24.6*
MCV-88 MCH-31.5 MCHC-35.7* RDW-15.4 Plt Ct-164
[**2177-9-3**] 12:53AM BLOOD WBC-8.9 RBC-2.94* Hgb-9.3* Hct-26.2*
MCV-89 MCH-31.8 MCHC-35.6* RDW-15.7* Plt Ct-220
[**2177-9-4**] 01:08AM BLOOD WBC-7.7 RBC-2.99* Hgb-9.5* Hct-27.3*
MCV-91 MCH-31.7 MCHC-34.7 RDW-15.5 Plt Ct-313
[**2177-9-5**] 02:32AM BLOOD WBC-8.4 RBC-2.91* Hgb-9.0* Hct-26.9*
MCV-92 MCH-30.9 MCHC-33.5 RDW-15.6* Plt Ct-412
[**2177-9-6**] 01:58AM BLOOD WBC-12.1* RBC-2.86* Hgb-9.0* Hct-26.5*
MCV-93 MCH-31.6 MCHC-34.0 RDW-15.2 Plt Ct-418
[**2177-9-7**] 02:12AM BLOOD WBC-14.4* RBC-3.00* Hgb-9.3* Hct-27.6*
MCV-92 MCH-30.9 MCHC-33.7 RDW-14.7 Plt Ct-556*
[**2177-9-8**] 01:59AM BLOOD WBC-14.7* RBC-3.25* Hgb-10.0* Hct-29.7*
MCV-91 MCH-30.6 MCHC-33.6 RDW-14.5 Plt Ct-748*
[**8-29**]
CT head - Multiple foci of parenchymal hemorrhage as well as
small amount
of likely subarachnoid hemorrhage. The location of some of these
foci at the [**Doctor Last Name 352**]-white matter interface is concerning for
diffuse axonal injury
CT Cspine - No fracture or traumatic malalignment in the
cervical spine
CT torso - Extensive pulmonary contusions, worse on the right
than the left. Hepatic lacerations with a small amount of
abdominal and pelvic free fluid of intermittent density.
Bilateral rib fractures.
Right femur/knee xrays - There is a mid shaft femoral fracture
with mild varus angulation of the distal fragment relative to
the proximal. There is also medial subluxation by ~ 1 cortical
width.
[**9-2**]
MRI cspine - Edema in the interspinous ligaments from C3-C4
through C7-T1, without evidence of distraction. lobal central
canal narrowing due to congenital short pedicles. This is
slightly exacerbated by a disc bulge at C3-4. No cord signal
abnormality. Moderate right C4-5 neural foramen narrowing due to
uncovertebral osteophytes.
[**9-3**]
Bilateral LE LENIs - No deep venous thrombosis involving the
right or left lower extremity.
LUE LENI - No deep venous thrombosis in the left upper
extremity.
[**9-7**]
CT Abdomen/Pelvis - Right pleural effusion with associated
compressive atelectasis. Considerable improvement in the
appearance of the right lobe of the liver laceration. Small
amount of free fluid in the pelvis. Fractures of the left first
and right fourth and fifth ribs. Fracture of
the right transverse process of T1.
Brief Hospital Course:
The patient was admitted to the trauma ICU.
[**8-29**] - Patient was admittd to the ICU. He was taken to the
operation room with ortho for ORIF of his right femur (see
operative report for full details). Neurosurgery was consulted
and an ICP was placed. He was started on dilantin and q1 hour
neurochecks.
[**Date range (1) 58392**] - The patient was transfused 4u PRBC for a decreasing
Hct. He had a right femur hematoma which was expanding but his
limb was soft and there was no fear of compartment symdrome.
His Hct stabilized. Head CT was stable.
[**9-1**] - His ICP was discontinued and neurosurgery signed off.
Head CT was stable.
[**9-2**] - MR of head and c-spine were performed.
[**9-3**] - Bilateral LE and LUE LENIs were performed which
demonstrated no DVT.
[**9-4**] - The patient went the OR with the acute care service for
tracheostomy and IVC filter placement.
[**9-6**] - Patient dc'ed his dophoff tube twice.
[**9-7**] - A CT A/P was done because of persistent fevers and rising
white count. No source for his fevers was identified. Patient
was put to trach collar.
[**9-8**]: Awake, off-versed, following commands. Passed S&S for
regular diet and Passy [**Last Name (un) 87596**] Valve. BAL cultures grew MRSA, kept
only on Vanc now. Patient ready to be transferred to floor,
waiting for a bed. `
Following transfer to the Surgical floor he continued to make
slow progress. His trach tube was plugged with a PMV and he
tolerated it well. After confirming no aspiration by video
swallow he was tolerating a regular diet with thin liquids.
The Physical Therapy and Occupational Therapy services followed
him on a daily basis to increase his mobility and increase
cognitive abilities. His memory is decreased and he
occasionally has some confusion but is improving each day.
He has a PICC line placed on [**2177-9-12**] for IV antibiotics and will
require Vancomycin thru [**2177-9-16**] for MRSA pneumonia. He has
minimal secretions but is undergoing nebulizer treatments.
Potentially his IVC filter can be removed but Dr. [**Last Name (STitle) **] will re
evaluate in a few weeks therefore he will need to return to the
[**Hospital 2536**] Clinic. He will also follow up in the Neuro cognitive clinic
with Dr. [**First Name (STitle) **] following his discharge from rehab.
After a lonfg hospitalization he was transferred to rehab on
[**2177-9-12**] for further therapy with the goal to return home soon.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for temp > 101.5.
2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
4. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed for abrasions.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Vancomycin 1,000 mg Recon Soln Sig: 1500 (1500) mg
Intravenous every eight (8) hours: thru [**2177-9-16**].
10. Morphine Concentrate 20 mg/mL Solution Sig: Fifteen (15) mg
PO Q2H (every 2 hours) as needed for pain.
11. HYDROmorphone (Dilaudid) 1-2 mg IV Q2H:PRN pain
Please use for breakthrough only after PO/NG MSIR.
12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
S/P scooter v tree
1. Left eye abrasion
2. Rib fractures right [**5-5**], left 1
3. Bilat pulmonary contusions
4. Grade 2 liverlaceration
5. Open right femur fracture
6. Right thigh laceration
7. Right patellar fracture
8. Right metatarsal neck fracture [**3-7**]
9. Small SAH
10.Right TP fracture T1
11.[**Doctor First Name **]
12.Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
* You were admitted to the hospital with multiple injuries
following your accident including head trauma, rib fractures,
knee fracture and liver laceration.
* You have made alot of progress but will need further
rehabilitation before you can return home.
* You are now breathing well on your own with your trach tube
plugged and hopefully it will be removed as you improve.
* Continue to work with physical therapy to increase your
mobility.
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 1
month, please call [**Telephone/Fax (1) 1228**] to schedule that appointment.
Call the [**Hospital 2536**] Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment
in [**3-5**] weeks
Call the Vascular Surgery Clinic at [**Telephone/Fax (1) 1237**] for an
appointment in 2 weeks with Dr. [**Last Name (STitle) **].
Call the [**Hospital 4695**] Clinic at [**Telephone/Fax (1) 1669**] for a follow up
appointment in 6 weeks with Dr. [**First Name (STitle) **]. You will need a Head CT
prior to your appointment. The secretary can book that for you.
Call Dr. [**First Name (STitle) **] in the Neuro cognitive Clinic at [**Telephone/Fax (1) 1690**]
for an appointment after your discharge from rehab
Completed by:[**2177-9-12**]
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train_6 | completed | 57fbb39b-e05e-4dba-9317-e8f331b27706 | Medical Text: Admission Date: [**2177-3-12**] Discharge Date: [**2177-3-22**]
Date of Birth: [**2109-6-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Shellfish
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
exertional angina
Major Surgical or Invasive Procedure:
[**2177-3-14**]
Coronary ARTERY BYPASS GRAFTING x3 with: Left Internal Mammary
Artery to Left Anterior Descending Artery, Saphenous Vein Graft
to Obtuse Marginal Artery, Saphenous Vein Graft to Posterior
Descending Artery
History of Present Illness:
67 year old man with known coronary artery disease-s/p stents x
6(2004x5 and [**11-21**]) who developed exertional angina while
walking [**3-9**]. Angina resolved w/
rest after few minutes. Angina recurred [**3-11**], patient was brought
to [**Hospital **] Med Ctr where enzymes were negative. He had cardiac
catheterization which showed: tapering distal LM,70% osteal
LAD,90% mid RCA. LVEF 60% by LVgram.
He was then transferred to [**Hospital1 18**] for surgical management of his
coronary artery disease. At the time of transfer he was pain
free.
Past Medical History:
Coronary artery disease(PCI/stents x6), Hypertension,
HYPERCHOLESTEROLEMIA, CA- Left vocal cord(RT/chemo)[**3-20**]
PSH:Left knee arthroscopy, Left chest Portacath
Social History:
Works as administrator at [**University/College 33918**].
Married, 2 children.
Tob: Former smoker, quit 30 yrs ago.
ETOH: Drinks a few beers or cocktails per night.
No drugs
Family History:
Brother: MI at 60, uncle: MI at 50
Mother: htn
Physical Exam:
Pulse: Resp: O2 sat:
B/P Right:130/72 Left: 128/72
Height: 70" Weight:175#
General:WDWN, NAD
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]glasses
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur n
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right:n Left:n
Pertinent Results:
Admission Labs:
[**2177-3-12**] 04:05PM PT-11.7 PTT-23.8 INR(PT)-1.0
[**2177-3-12**] 04:05PM PLT COUNT-199
[**2177-3-12**] 04:05PM NEUTS-78.7* LYMPHS-9.6* MONOS-5.6 EOS-5.6*
BASOS-0.5
[**2177-3-12**] 04:05PM WBC-6.9 RBC-3.93* HGB-14.0 HCT-38.2* MCV-97#
MCH-35.6* MCHC-36.6* RDW-13.5
[**2177-3-12**] 04:05PM %HbA1c-5.2 eAG-103
[**2177-3-12**] 04:05PM ALBUMIN-4.1 MAGNESIUM-1.7
[**2177-3-12**] 04:05PM ALT(SGPT)-36 AST(SGOT)-24 LD(LDH)-148 ALK
PHOS-100 TOT BILI-2.0*
[**2177-3-12**] 04:05PM GLUCOSE-123* UREA N-14 CREAT-1.0 SODIUM-137
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14
[**2177-3-12**] 04:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2177-3-12**] 04:33PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
Discharge Labs:
Radiology Report CHEST (PORTABLE AP) Study Date of [**2177-3-17**] 7:29
AM
Final Report: Comparison with study of [**3-15**], all of the
monitoring and support devices have been removed except for the
left subclavian catheter and the right IJ sheath. With the chest
tube removed, there is no evidence of pneumothorax. Residual
opacification at the left base is consistent with atelectasis
and effusion.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% >= 55%
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Color-flow imaging of the
interatrial septum raises the suspicion of an atrial septal
defect, but this could not be confirmed on the basis of this
study.
LEFT VENTRICLE: Normal regional LV systolic function. Overall
normal LVEF (>55%).
RIGHT VENTRICLE: Borderline normal RV systolic function.
AORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR.
MITRAL VALVE: No MS. Mild (1+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Small pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Focused Intraoperative TEE during chest exploration for
post-operative bleeding.
Color-flow imaging of the interatrial septum raises the
suspicion of an atrial septal defect, but this could not be
confirmed on the basis of this study.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
Borderline normal RV free wall function.
There are three aortic valve leaflets. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
Mild (1+) mitral regurgitation is seen.
There is a small pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results.
Brief Hospital Course:
Mr [**Known lastname 732**] was transferred fro [**Hospital **] Med Ctr for surgical
management of his coronary artery disease. After the usual
pre-operative workup he was brought to the operating room for
coronary artery bypass grafting on [**2177-3-14**]. Please see the
operative report for details. In summmary he had: Coronary
Artery Bypass Grafting x3 with Lwft Internal Mammary Artery to
Left Anterior Descending Artery, Saphenous Vein Graft to Obtuse
Marginal Artery, and Saphenous Vein Graft to Posterior
Descending Artery. His cardiopulmonary bypass time was 51
minutes with a crossclamp time of 39 minutes. He tolerated the
operation well and post-operatively was transferred to the
cardiac surgery ICU in stable conditio. He remained
hemodynamically stable in the immediate post-op period. He woke
from anesthesia neurologically intact and was extubated on the
operative day.
On POD1 he continued to have significant drainage from his chest
tubes and was brought back to the operating room for mediastinal
exploration-no source of bleeding was found. He tolerated this
procedure well and was again returned to the cardiac surgery ICU
in stable condition. He recovered from anesthesia and was
extubated shortly after the surgery was completed. He remained
hemodynamically stable throughout this period.
All tubes lines and drains were removed per cardiac surgery
protocol. On POD 3 he was transferred from the ICU to the
stepdown floor for continued post-op care and recovery. Physical
therapy worked with the patient to advance his activities of
daily living and to improve strength and endurance.
POD # 4, Pt develope some drainage from his sternal incision. He
was started on IV Vancomycin. Betadine was cleanse TID was
started. from POD # [**4-19**], pts wound improved. He is to be
discharged on PO keflex x 10 days. His wound on DC is without
drainage.
On POD 10 was discharged home with visiting nurses. He is to
follow up with Dr [**Last Name (STitle) **] in 3 weeks, He has a sternal check
[**3-26**] on [**Hospital Ward Name **] 6. He is to follow up with his cardiologist, appt
made, He was also instructed to follow up with his PCP.
Medications on Admission:
Lisinopril 20mg daily,
Lipitor 80mg daily,
Plavix 75 mg [**Last Name (LF) **],
[**First Name3 (LF) **] 325mg daily,
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. [**Last Name (un) 1724**]
Lisinopril 20mg daily,EcASA 325mg daily,Lopressor 25mg
[**Hospital1 **],Plavix 75mg daily,NTG prn,Lipitor 80mg daily
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. potassium chloride 8 mEq Tablet Extended Release Sig: One (1)
Tablet Extended Release PO twice a day for 7 days.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
9. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a
day for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Bypass Grafting x3
PCI/stents(6)
PMH:
Hypertension,
HYPERCHOLESTEROLEMIA,
CA- left vocal cord(RT/chemo)[**3-20**]
PSH:lt knee arthroscopy, LT chest Portacath
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**First Name (STitle) **] [**Name (STitle) **] on [**2177-4-10**] at 9AM at [**Hospital1 **]
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5874**] on [**2177-4-16**] at 3PM
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **],[**First Name3 (LF) 488**] J. [**Telephone/Fax (1) 8036**] in [**4-15**] weeks
You have a wound check scheduled for [**5-26**] at 1000 hrs,
please come to [**Hospital Ward Name **] 6 at this scheduled time. Thw midlevelers
will look at your wound to see if this is stable.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication
Goal INR
First draw
Results to phone fax
Completed by:[**2177-3-22**]
ICD9 Codes: 4019, 2720 | [
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train_7 | completed | 3bf7c14c-4873-4f19-a074-45af82e535bb | Medical Text: Admission Date: [**2188-5-24**] Discharge Date: [**2188-5-30**]
Date of Birth: [**2132-11-19**] Sex: M
Service: MEDICINE
Allergies:
Ampicillin / Thorazine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Respiratory Failure
Major Surgical or Invasive Procedure:
Trach change
Mechanical ventilation
History of Present Illness:
Mr. [**Known lastname 89172**] is a 55 yo man with PMH significant for Downs
Syndrome, MRSA pneumonia and respiratory failure in [**10/2187**]
resulting in tracheostomy which was reversed [**2188-5-13**], who is
transferred from s/p intubation at [**Hospital1 **] in [**Location (un) 1110**] today.
Patient had been predominantly in rehab since developing MRSA
pneumonia in [**10/2187**] (first [**Last Name (un) **] and then [**Hospital 5279**] Rehab
Centers) and presented to [**Hospital1 **] from rehab for respiratory
distress. He had been started on Rocephin [**5-22**] for presumed
pneumonia at Rehab in setting of labored breathing. Patient was
intubated at [**Hospital1 **] for labored breathing, accessory muscle
use. Per report, there may have been some failed attempt in OSH
ED to re-open his tracheostomy prior to intubation.
.
At OSH, patient received, levoquin 750mg @ 03:25, Vancomycin 1g
@ 5:09 for pneumonia. He was ordered for 4L NS and received at
least 2.5L. CXR and CT Chest appeared to show some fluid
overload. Patient was difficult to maintain on sedation; blood
pressure dropped on propofol, so patient was briefly on dopamine
until sedation was switched to versed boluses prn, which he
tolerated well. Trach site had some serosanguinous fluid
leakage, so it was covered with guaze and tegaderm. Respiratory
therapist in ED confirmed no air leakage while on the
ventilator. Patient was transfered to [**Hospital1 18**] for further
management.
.
In ED, initial VS were as follows: 99.9 (Rectal temp) 101
174/100 22 98% on ventilator with 100%FiO2. He was given 1amp
D50 for a blood sugar of 69. He also received 250cc of IVF and
2.5mg bolus of IV versed for sedation while ventilated. EKG
showed sinus tach with rate 103. CXR showed fluid overload with
possible consolidation, so CTA of chest was done to further
characterize ?consolidation and rule out PE. CTA showed no
signs of PE and confirmed RUL and RML pneumonia, as well as
fluid filled esophagus, suggesting aspiration. CT also showed
moderate left and small right effusions, but no pulmonary edema.
Vitals in ED prior to transfer to ICU were as follows: 99.8F HR
91 BP 92/53 RR 16 O2sat100% cpap FIO2 60%, PS 10, PEEP 5.
.
On arrival to the unit, patient is mechanically ventilated and
appears comfortable. He is accompanied by his sister who was
able to corroborate the above story. Of note, the patient is
non-verbal at baseline but does make some signs, only eats
icecream and [**Last Name (un) **] tea by mouth (for pleasure) and is otherwise
fed through tube feeds.
.
Past Medical History:
- Downs Syndrome
- MRSA Pneumonia complicated by tracheostomy [**10/2187**]
- reversed [**2188-5-13**]
- C Diff Colitis - [**2188**]
- Pseudomonas Colitis - [**2188**] - dx by colonoscopy, tx w cipro
through G-tube
- Adrenal Insufficiency
- Seizure History, per sister this [**Name2 (NI) 89173**] with
hospitalization in [**11-3**] - on keppra
- Hx transaminitis - presumed to be secondary to antiepileptics
- Hx of HBV
- Membranoproliferative Glomerulonephritis
Social History:
Lives at Group Home, but has spent significant amount of time at
Rehab since [**10/2187**] and presented from [**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) **]. [**Last Name (NamePattern1) 6961**]
are his guardians, but his sister [**Name (NI) **] is also very involved in
his care and finances.
Family History:
NC
Physical Exam:
ADMISSION EXAM:
GEN: Comfortable appearing, opens eyes to command
HEENT: ETT in place.
NECK: Tegaderm placed over anterior neck; difficult to assess
opening in skin. No drainage or erythema.
CV: RRR, no murmur
LUNGS: Rhonchi anteriorly R>L, CTAB laterally on both sides
ABD: Soft, non-tender but distended. Central G-tube covered with
gauze with tube feeds draining around opening. Ostomy
erythematous, raw. No erythema on surrounding skin.
EXT: LE cachectic, No LE edema.
DISCHARGE EXAM:
GEN: Comfortable appearing, opens eyes to command, not in
distress
HEENT/Neck: EOMI, trach in place with sputum surrounding, mild
erythema around site
CV: RRR, no murmur
LUNGS: Rhonchi anteriorly, CTAB laterally on both sides
ABD: Soft, non-tender but distended. Central G-tube covered with
gauze. Mildly erythematous around opening.
EXT: LE cachectic, No LE edema.
Pertinent Results:
ADMISSION LABS:
.
[**2188-5-24**] 11:50AM PT-18.8* PTT-31.4 INR(PT)-1.7*
[**2188-5-24**] 11:50AM URINE RBC-28* WBC-7* BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-<1
[**2188-5-24**] 11:50AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
[**2188-5-24**] 11:50AM WBC-11.7* RBC-2.84* HGB-10.5* HCT-31.6*
MCV-111* MCH-37.1* MCHC-33.4 RDW-18.9*
[**2188-5-24**] 11:50AM GLUCOSE-69* UREA N-54* CREAT-1.0 SODIUM-136
POTASSIUM-5.0 CHLORIDE-107 TOTAL CO2-24 ANION GAP-10
[**2188-5-24**] 12:00PM LACTATE-2.0
.
DISCHARGE LABS:
.
[**2188-5-30**] 03:56AM BLOOD WBC-8.1 RBC-2.32* Hgb-8.9* Hct-26.7*
MCV-115* MCH-38.5* MCHC-33.5 RDW-17.4* Plt Ct-130*
[**2188-5-30**] 03:56AM BLOOD Glucose-83 UreaN-29* Creat-1.1 Na-135
K-3.7 Cl-108 HCO3-24 AnGap-7*
[**2188-5-30**] 03:56AM BLOOD Calcium-7.3* Phos-2.5* Mg-1.5*
[**2188-5-30**] 03:56AM BLOOD Vanco-25.0*
.
MICRO:
C. diff negative
Urine culture - no growth
Blood culture x2 - no growth to date
IMAGING:
CXR [**2188-5-24**]:
1. Endotracheal tube terminating at the carina.
2. Mild pulmonary interstitial edema.
3. Right upper zone opacity may reflect aspiration pneumonitis
or developing
pneumonia.
CT-A [**2188-5-24**]:
IMPRESSION:
1. RUL and RML pneumonia, possible due to aspiration since the
esophagus is fluid filled and dilated.
2. No PE.
3. Moderate left and small right effusions, but no pulmonary
edema.
4. Mediastinal lymphadenopathy
5. Acute left 7th rib fracture.
G/GJ/GI TUBE CHECK
FINDINGS: Supine radiographs demonstrate jejunostomy tube with
tip at the
junction of the distal duodenum or proximal jejunum. Contrast is
seen passing distally in the jejunum without evidence of leak.
Bowel gas pattern is normal without evidence of leak. Imaged
portion of the lungs are clear. Surgical clips are noted
overlying the base of the heart.
IMPRESSION: Jejunostomy tube in appropriate position with normal
passage of contrast without evidence of leak.
Brief Hospital Course:
55M with hx of Downs Syndrome, MRSA pneumonia c/b respiratory
failure and tracheostomy, s/p tracheostomy reversal 10d prior to
admission, transferred to [**Hospital1 18**] for hypoxic respiratory failure
[**2-27**] RUL/RML aspiration PNA
.
# Aspiration PNA/respiratory distress: PE was ruled out as
potential cause of respiratory distress. Imaging demonstrated
RUL/RML pneumonia secondary to aspiration, as well as airway
narrowing at site of prior tracheostomy. Likely secondary to
aspiration, as patient was also noted to have fluid filled
esophagus on CT scan. Patient was treated with hospital
acquired and community acquired pneumonia with Vancomycin,
Levoquin and Cefepime (8-day course). Cultures of urine and
blood from OSH showed no growth. Aspiration may have been
related to overflow at g-tube site. Tube feeds were initially
held, and G tube study was ordered which showed jejunostomy tube
in appropriate position with normal passage of contrast without
evidence of leak. Patient on steroids at home for adrenal
insufficiency, was not on PCP prophylaxis at home so bactrim
daily was started. Patient was arranged to be transferred to
[**Hospital Ward Name 517**] ICU service for extubation and potential IP
intervention at site of airway narrowing. IP found an 0.8 cm
focal area of stenosis with dynamic collapse at 2nd tracheal
ring. The granulation tissue was debrided and IP replaced
percutaneous trach through existing stoma. Patient will need
evaluation for tracheal resection/reconstruction at IP o/p f/u
in 2 weeks. Post-procedure CXR showed multifocal PNA, unchanged
bilateral effusions, trach in appropriate position. Patient
remained stable with new trach in place and did well prior to
discharge. His last day of levaquin and cefepime will be on
[**2188-5-31**].
.
# Recent history of colitis: Reported recent history of both
C.diff and Pseudomembranous colitis. Patient with with several
episodes of lose stool. C. diff was checked and was negative.
.
# Down syndrome/Anxiety: At baseline, pt nonverbal. Pt was
restarted on home dose of ativan given evidence of anxiety and
aggitation w/groups of people while intubated.
.
# Adrenal Insufficiency: History unclear but patient currently
on prednisone 20 daily - patient has not had outpatient
endocrine evaluation. As per [**Hospital 228**] rehab facility steroids
were started to treat low sodium. Patient currently with normal
blood pressures. Steroid dose tapered to 10mg daily for 1 week
with outpatient follow up of electrolytes. Patient started on
PCP prophylaxis, which he should remain on if he is going to
continue steroids long term. Patient will follow-up with
endocrinology for further work-up of possible renal
insufficiency. OSH records were faxed to endocrinology
department when appointment was made.
.
# Hx of seizure disorder: Reportedly first seizure [**11-3**] at time
of hospitalization with MRSA pneumonia. Continued home dose of
Keppra.
.
#FEN: Concern for leaking at J tube site. Tube feeds were held
as concern for leaking at feeding tube. Surgery was consulted
and sutured the tube in place with clamp. Dressing in place over
tube site.
.
# Prophylaxis: SubQ heparin, Famotidine
.
# Contact: [**Name (NI) 6961**] = guardians, [**Name (NI) 449**] and [**Name (NI) **]
([**0-0-**]), Sister [**Name (NI) **] [**Telephone/Fax (1) 89174**].
.
# Code Status: FULL CODE (Confirmed with family)
Medications on Admission:
Prednisone 20mg daily
Omeprazole 20mg [**Hospital1 **]
Keppra 500mg [**Hospital1 **] (do not crush)
Ativan 0.25-0.5mg via PEG Q8h PRN (for moderate to severe
anxiety)
Duonebs prn wheezing
oxycodone
Zinc
Bacitracin ointment
Bowel Regimen prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) 1110**]
Discharge Diagnosis:
Primary diagnosis:
Subglottic stenosis
Hosptial acquired pneumonia
.
Secondary diagnoses:
? Adrenal insufficiency
Down's syndrome
Seizure disorder
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Mental Status: Confused - sometimes. (baseline)
Discharge Instructions:
It was a pleasure to participate in your care Mr. [**Known lastname 89172**]. You
were admitted to [**Hospital1 18**] for evaluation of respiratory failure.
You were found to have narrowing of your trachea. You were
taken to the OR to have a procedure to replace tracheostomy.
You were also treated for a pneumonia.
.
There was concern for your G tube not working appropriately.
Surgery evaluated you and fixed your J tube.
.
You were started on steroids at your outpatient facility as you
had low sodium. We decreased your dose of steroid and started
you on Bactrim to prevent a type of lung infection called PCP.
[**Name10 (NameIs) **] will have you follow-up with endocrinology here to further
evaluate if you need to take steroids.
.
MEDICATION CHANGES:
START Cefepime 2gm Q24 for one more day
START Levofloxacin 750mg daily for one more day
START Bactrim SS daily for prophylaxis for PCP
DECREASE Prednisone to 10mg daily
Followup Instructions:
Department: Thoracic Multi [**Hospital 4094**] Clinic
When: TUESDAY [**2188-6-10**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: Thoracic Multi [**Hospital 4094**] Clinic
When: TUESDAY [**2188-6-10**] at 3:00 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES - Endocrinology
When: WEDNESDAY [**2188-6-11**] at 3:15 PM
With: MALA [**Last Name (NamePattern4) 16956**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2188-6-10**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2188-6-10**] at 3:00 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2188-6-11**] at 3:15 PM
With: MALA [**Last Name (NamePattern4) 16956**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2188-5-30**]
ICD9 Codes: 5070 | [
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] | [
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] | [
"submitted"
] | [
4
] | [
"be06318c-167f-4be5-9a64-0bb6a430dacf"
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"submitted"
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train_8 | completed | 826b2390-d62e-4d3d-92f7-7361a377d557 | "Medical Text: Admission Date: [**2176-8-29**] Discharge Date: [**2176-9-6**]\n\nDat(...TRUNCATED) | [[{"end":260,"label":"Medical Condition","start":255},{"end":270,"label":"Medical Condition","start"(...TRUNCATED) | [
"be06318c-167f-4be5-9a64-0bb6a430dacf"
] | [
"submitted"
] | [
4
] | [
"be06318c-167f-4be5-9a64-0bb6a430dacf"
] | [
"submitted"
] |
train_9 | completed | 8db83ab5-037d-4306-a97f-bf965b7f1495 | "Medical Text: Admission Date: [**2138-6-9**] Discharge Date: [**2138-6-12**]\n\nDate of Birth(...TRUNCATED) | [[{"end":602,"label":"Medical Condition","start":582},{"end":1038,"label":"Medical Condition","start(...TRUNCATED) | [
"be06318c-167f-4be5-9a64-0bb6a430dacf"
] | [
"submitted"
] | [
4
] | [
"be06318c-167f-4be5-9a64-0bb6a430dacf"
] | [
"submitted"
] |
End of preview. Expand
in Data Studio
Dataset Card for healthcare
This dataset has been created with Argilla. As shown in the sections below, this dataset can be loaded into your Argilla server as explained in Load with Argilla, or used directly with the datasets library in Load with datasets.
Using this dataset with Argilla
To load with Argilla, you'll just need to install Argilla as pip install argilla --upgrade and then use the following code:
import argilla as rg
ds = rg.Dataset.from_hub("Chucks001308/healthcare", settings="auto")
This will load the settings and records from the dataset repository and push them to you Argilla server for exploration and annotation.
Using this dataset with datasets
To load the records of this dataset with datasets, you'll just need to install datasets as pip install datasets --upgrade and then use the following code:
from datasets import load_dataset
ds = load_dataset("Chucks001308/healthcare")
This will only load the records of the dataset, but not the Argilla settings.
Dataset Structure
This dataset repo contains:
- Dataset records in a format compatible with HuggingFace
datasets. These records will be loaded automatically when usingrg.Dataset.from_huband can be loaded independently using thedatasetslibrary viaload_dataset. - The annotation guidelines that have been used for building and curating the dataset, if they've been defined in Argilla.
- A dataset configuration folder conforming to the Argilla dataset format in
.argilla.
The dataset is created in Argilla with: fields, questions, suggestions, metadata, vectors, and guidelines.
Fields
The fields are the features or text of a dataset's records. For example, the 'text' column of a text classification dataset of the 'prompt' column of an instruction following dataset.
| Field Name | Title | Type | Required | Markdown |
|---|---|---|---|---|
| text | text | text | False | False |
Questions
The questions are the questions that will be asked to the annotators. They can be of different types, such as rating, text, label_selection, multi_label_selection, or ranking.
| Question Name | Title | Type | Required | Description | Values/Labels |
|---|---|---|---|---|---|
| span_0 | span_0 | span | True | N/A | N/A |
| rating_1 | rating_1 | rating | True | N/A | [0, 1, 2, 3, 4] |
Data Instances
An example of a dataset instance in Argilla looks as follows:
{
"_server_id": "175fae11-4139-43e5-b5dd-e69c2d06685a",
"fields": {
"text": "Medical Text: Admission Date: [**2117-9-11**] Discharge Date: [**2117-9-17**]\n\nDate of Birth: [**2082-3-21**] Sex: F\n\nService: MEDICINE\n\nAllergies:\nLevaquin\n\nAttending:[**First Name3 (LF) 2195**]\nChief Complaint:\nnausea, vomiting\n\n\nMajor Surgical or Invasive Procedure:\nnone\n\nHistory of Present Illness:\n35F w/ poorly controlled Type 1 diabetes mellitus w/ neuropathy,\nnephropathy, HTN, gastroparesis, CKD and retinopathy, recently\nhospitalized for orthostatic hypotension [**2-3**] autonomic\nneuropathy [**Date range (1) 25088**]; DKA hospitalizations in [**6-12**] and [**7-12**], now\nreturning w/ 5d history of worsening nausea, vomiting with\ncoffee-ground emesis, chills, and dyspnea on exertion. Last\nweek she had a fall and hit her right face. she also had 1 day\nof diarrhea, which resolved early last week. Found to be in DKA\nwith AG 30 and bicarb 11.\n.\nIn the ED inital vitals were 09:00 0 98.2 113 181/99 22 100% RA.\nK 4.7, HCO3 11, Anion Gap 30, Cr. 2.7 (baseline 1.6-2.0) She is\non her 3rd L NS. Insulin srip at 5 units/hr. On home at 22\nlevemir in am and 12 at with difficult to control sugars. BPs\nhave been high. Given 30 mtroprolol tartrate in ED.\n\nShe was started on an insulin drip at 5 units/hr and 3L NS\nboluses. Also aspirin 325mg PO and Morphine 4mg IVx1 for pain.\nCXr was clear. EKG NAD.\n.\nReview of systems: otherwise negative.\n\nPast Medical History:\nType 1 diabetes mellitis w/ neuropathy, nephropathy, and\nretinopathy - 2 episodes of DKA in [**6-12**] and [**7-12**]\nHTN - 5 years\ngastroparesis - 1.5 years\nCKD - stage III, baseline Cr 2.4-2.5, proteinuria\nL1 vertebral fracture - [**2117-7-17**]\nSystolic ejection murmur\n\nSocial History:\nPatient lives at home in [**Location (un) **] with her 8 y/o daughter and\nboyfriend. She has no history of EtOH, tobacco, or illicit drug\nuse. She is currently unemployed and seeking disability.\n\n\nFamily History:\nBoth parents have HTN and T2DM. Grandfather had an MI in his\n40s.\n\nPhysical Exam:\nGEN: Awake, alert, and oriented\nHEENT: PERRLA. MMM. no JVD. neck supple. No cervical LAD\nCards: RRR, S1/S2 normal. II/VI systolic ejection murmur heard\nbest at the L upper sternal border.\nPulm: CTABL with no crackles or wheezes.\nAbd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]\nsign\nExtremities: wwp, no edema. radials, DPs, PTs 2+.\nSkin: no rashes or bruising. no skin tenting.\nNeuro: CNs II-XII intact. Upper extremities: Power [**5-6**]\nbilaterally. Le: left power: 4.5/5 right: power [**3-6**]. Bilateral\nsymmetric, reduced sensation distal LE to ankles.\n\n\nPertinent Results:\nAdmission Labs: [**2117-9-11**] 09:22AM\nWBC-11.9* RBC-4.58 HGB-13.0 HCT-36.5 MCV-80* PLT COUNT-466*\nLIPASE-22 ALT(SGPT)-10 AST(SGOT)-16 ALK PHOS-105 TOT BILI-0.5\nGLUCOSE-260* UREA N-48* CREAT-2.7* SODIUM-137 POTASSIUM-4.9\nCL-101 CO2-11*\nLACTATE-1.9\n\nDischarge Labs: [**2117-9-16**] 07:10AM\nWBC-6.8 RBC-3.67* Hgb-10.4* Hct-30.2* MCV-82 Plt Ct-298\nGlucose-118* UreaN-20 Creat-2.3* Na-137 K-3.7 Cl-104 HCO3-23\nAnGap-14\nCalcium-8.7 Phos-3.5 Mg-2.0\n\nRadiology:\nCXR: No evidence of pneumonia or other pathological\nabnormalities. No\npleural effusions. No pulmonary edema. Normal size of the\ncardiac\nsilhouette.\n\nMicrobiology: Urine culture negative, blood cultures no growth\nto date, stool for C.difficile negative\n\n\nBrief Hospital Course:\n35 yo F with HTN \u0026 poorly controlled type I DM, c/b neuropathy,\ngastroparesis, nephropathy ?????? CKD, retinopathy presents with DKA\nand hypertension SBP to 200s.\n.\n# Diabetic ketoacidosis: Patient controls diabetes at home with\nHumalog SS and long acting Levemir. Sugars at home recently\nhave been in 250s. In the ED, glucose was 466. UA was +ve for\nketones ?????? corrected to 200s, but rose again to 300s. She was\ntreated with an insulin drip which was transitioned to subq when\nshe tolerated POs. Her electrolytes were repleted and she\nreceived aggressive volume resuscitation. [**Last Name (un) **] saw her and\ngave sliding scale recommendations which were implemented. No\nsource for DKA found, beleived to be [**2-3**] gastroparesis. Nausea\nmanaged with ativan, compazine, and promethazine. She was\ndischarged on her home Insulin and sliding scale with\ninstructions to follow-up with [**Last Name (un) **].\n\n# HTN: Hypertensive with SBP in 190s initially, attributed to\nDKA, as she has experienced in the past. As she improved her\nblood pressures normalized and she was re-started on her home\nLopressor and Midodrine regimen.\n\n# Coffee grounds emesis: Emesis started off as clear, then with\nprolonged wretching, she started having coffee-grounds vomiting.\nThis had also occurred on prior admissions for DKA with\nassociated vomiting. Her hematocrit remained stable and her\nhematemesis self-resolved, and so work-up was deferred to the\noutpatient setting.\n\n# Acute on chronic kidney disease, Stage III: Patient\u0027s Cr on\nadmission was 2.7, trending down to 2.1-2.3 following fluids,\nconsistent with her known CKD secondary to diabetic nephropathy.\n\n\nMedications on Admission:\n1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n2. Levemir 100 unit/mL Solution Sig: Twenty Two (22) units\nSubcutaneous every AM.\n3. Levemir 100 unit/mL Solution Sig: Twelve (12) units\nSubcutaneous at bedtime.\n4. Humalog 100 unit/mL Solution Sig: sliding scale as directed\nSubcutaneous four times a day: Please use sliding scale as\ndirected by MD [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) **].\n5. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO DAILY\n(Daily): take in the evening.\n6. promethazine 25 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8\nhours) as needed for nausea.\n7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every\n\n12 hours).\nDisp:*60 Capsule(s)* Refills:*2*\n8. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)\nCapsule, Delayed Release(E.C.) PO DAILY (Daily): Please take\nonly 1 capsule daily (30 mg) for first 2 weeks of treatment.\nDisp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*\n9. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every eight\n(8) hours as needed for pain.\n10. midodrine 5 mg Tablet Sig: 1.5 Tablets PO every four (4)\nhours: Can hold while sleeping.\nDisp:*270 Tablet(s)* Refills:*2*\n\n\nDischarge Medications:\n1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every\n12 hours).\n3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)\nCapsule, Delayed Release(E.C.) PO DAILY (Daily).\n4. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO\nOnce Daily at 6 PM.\n5. midodrine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY\n(Daily).\n6. Levemir 100 unit/mL Solution Sig: As directed by [**Last Name (un) **] units\nSubcutaneous As directed.\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nDiabetic keotacidosis\nHematemesis (blood in your vomit)\nHypertension\nChronic renal insufficiency\n\nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\nDischarge Instructions:\nYou were admitted to the hospital with DKA, hypertension, and\nblood in your vomit. You were initially treated in the ICU with\nan insulin drip, and your blood sugars improved. Your blood\npressure medications were adjusted to better control your blood\npressure while you were in DKA, but you were re-started on your\nhome regimen at discharge. The blood in your vomit was likely\nsecondary to mechanical trauma from repeated wretching, but you\nshould follow-up with your primary care doctor to discuss\nwhether you should undergo further evaluation such as an upper\nendoscopy. Given your complaints of chronic cough and heartburn,\nyou should also discuss beginning a trial of a proton pump\ninhibitor such as Nexium or Prilosec to see if this helps your\nsymptoms.\n\nYour insulin regimen was adjusted by the [**Last Name (un) **] team while you\nwere here. You should continue to follow-up with them with any\nquestions or concerns regarding your insulin management.\n\nFollowup Instructions:\nPlease call Dr.[**Last Name (STitle) 805**]\u0027 office to schedule a follow-up\nappointment within 7-10 days of discharge. Her office number is\n[**Telephone/Fax (1) 85219**].\n\nYou should also continue to follow-up with your [**Last Name (un) **] doctors\nas needed.\n\n\n\nICD9 Codes: 5849"
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"text": "Medical Text: Admission Date: [**2117-9-11**] Discharge Date: [**2117-9-17**]\n\nDate of Birth: [**2082-3-21**] Sex: F\n\nService: MEDICINE\n\nAllergies:\nLevaquin\n\nAttending:[**First Name3 (LF) 2195**]\nChief Complaint:\nnausea, vomiting\n\n\nMajor Surgical or Invasive Procedure:\nnone\n\nHistory of Present Illness:\n35F w/ poorly controlled Type 1 diabetes mellitus w/ neuropathy,\nnephropathy, HTN, gastroparesis, CKD and retinopathy, recently\nhospitalized for orthostatic hypotension [**2-3**] autonomic\nneuropathy [**Date range (1) 25088**]; DKA hospitalizations in [**6-12**] and [**7-12**], now\nreturning w/ 5d history of worsening nausea, vomiting with\ncoffee-ground emesis, chills, and dyspnea on exertion. Last\nweek she had a fall and hit her right face. she also had 1 day\nof diarrhea, which resolved early last week. Found to be in DKA\nwith AG 30 and bicarb 11.\n.\nIn the ED inital vitals were 09:00 0 98.2 113 181/99 22 100% RA.\nK 4.7, HCO3 11, Anion Gap 30, Cr. 2.7 (baseline 1.6-2.0) She is\non her 3rd L NS. Insulin srip at 5 units/hr. On home at 22\nlevemir in am and 12 at with difficult to control sugars. BPs\nhave been high. Given 30 mtroprolol tartrate in ED.\n\nShe was started on an insulin drip at 5 units/hr and 3L NS\nboluses. Also aspirin 325mg PO and Morphine 4mg IVx1 for pain.\nCXr was clear. EKG NAD.\n.\nReview of systems: otherwise negative.\n\nPast Medical History:\nType 1 diabetes mellitis w/ neuropathy, nephropathy, and\nretinopathy - 2 episodes of DKA in [**6-12**] and [**7-12**]\nHTN - 5 years\ngastroparesis - 1.5 years\nCKD - stage III, baseline Cr 2.4-2.5, proteinuria\nL1 vertebral fracture - [**2117-7-17**]\nSystolic ejection murmur\n\nSocial History:\nPatient lives at home in [**Location (un) **] with her 8 y/o daughter and\nboyfriend. She has no history of EtOH, tobacco, or illicit drug\nuse. She is currently unemployed and seeking disability.\n\n\nFamily History:\nBoth parents have HTN and T2DM. Grandfather had an MI in his\n40s.\n\nPhysical Exam:\nGEN: Awake, alert, and oriented\nHEENT: PERRLA. MMM. no JVD. neck supple. No cervical LAD\nCards: RRR, S1/S2 normal. II/VI systolic ejection murmur heard\nbest at the L upper sternal border.\nPulm: CTABL with no crackles or wheezes.\nAbd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]\nsign\nExtremities: wwp, no edema. radials, DPs, PTs 2+.\nSkin: no rashes or bruising. no skin tenting.\nNeuro: CNs II-XII intact. Upper extremities: Power [**5-6**]\nbilaterally. Le: left power: 4.5/5 right: power [**3-6**]. Bilateral\nsymmetric, reduced sensation distal LE to ankles.\n\n\nPertinent Results:\nAdmission Labs: [**2117-9-11**] 09:22AM\nWBC-11.9* RBC-4.58 HGB-13.0 HCT-36.5 MCV-80* PLT COUNT-466*\nLIPASE-22 ALT(SGPT)-10 AST(SGOT)-16 ALK PHOS-105 TOT BILI-0.5\nGLUCOSE-260* UREA N-48* CREAT-2.7* SODIUM-137 POTASSIUM-4.9\nCL-101 CO2-11*\nLACTATE-1.9\n\nDischarge Labs: [**2117-9-16**] 07:10AM\nWBC-6.8 RBC-3.67* Hgb-10.4* Hct-30.2* MCV-82 Plt Ct-298\nGlucose-118* UreaN-20 Creat-2.3* Na-137 K-3.7 Cl-104 HCO3-23\nAnGap-14\nCalcium-8.7 Phos-3.5 Mg-2.0\n\nRadiology:\nCXR: No evidence of pneumonia or other pathological\nabnormalities. No\npleural effusions. No pulmonary edema. Normal size of the\ncardiac\nsilhouette.\n\nMicrobiology: Urine culture negative, blood cultures no growth\nto date, stool for C.difficile negative\n\n\nBrief Hospital Course:\n35 yo F with HTN \u0026 poorly controlled type I DM, c/b neuropathy,\ngastroparesis, nephropathy ?????? CKD, retinopathy presents with DKA\nand hypertension SBP to 200s.\n.\n# Diabetic ketoacidosis: Patient controls diabetes at home with\nHumalog SS and long acting Levemir. Sugars at home recently\nhave been in 250s. In the ED, glucose was 466. UA was +ve for\nketones ?????? corrected to 200s, but rose again to 300s. She was\ntreated with an insulin drip which was transitioned to subq when\nshe tolerated POs. Her electrolytes were repleted and she\nreceived aggressive volume resuscitation. [**Last Name (un) **] saw her and\ngave sliding scale recommendations which were implemented. No\nsource for DKA found, beleived to be [**2-3**] gastroparesis. Nausea\nmanaged with ativan, compazine, and promethazine. She was\ndischarged on her home Insulin and sliding scale with\ninstructions to follow-up with [**Last Name (un) **].\n\n# HTN: Hypertensive with SBP in 190s initially, attributed to\nDKA, as she has experienced in the past. As she improved her\nblood pressures normalized and she was re-started on her home\nLopressor and Midodrine regimen.\n\n# Coffee grounds emesis: Emesis started off as clear, then with\nprolonged wretching, she started having coffee-grounds vomiting.\nThis had also occurred on prior admissions for DKA with\nassociated vomiting. Her hematocrit remained stable and her\nhematemesis self-resolved, and so work-up was deferred to the\noutpatient setting.\n\n# Acute on chronic kidney disease, Stage III: Patient\u0027s Cr on\nadmission was 2.7, trending down to 2.1-2.3 following fluids,\nconsistent with her known CKD secondary to diabetic nephropathy.\n\n\nMedications on Admission:\n1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n2. Levemir 100 unit/mL Solution Sig: Twenty Two (22) units\nSubcutaneous every AM.\n3. Levemir 100 unit/mL Solution Sig: Twelve (12) units\nSubcutaneous at bedtime.\n4. Humalog 100 unit/mL Solution Sig: sliding scale as directed\nSubcutaneous four times a day: Please use sliding scale as\ndirected by MD [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) **].\n5. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO DAILY\n(Daily): take in the evening.\n6. promethazine 25 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8\nhours) as needed for nausea.\n7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every\n\n12 hours).\nDisp:*60 Capsule(s)* Refills:*2*\n8. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)\nCapsule, Delayed Release(E.C.) PO DAILY (Daily): Please take\nonly 1 capsule daily (30 mg) for first 2 weeks of treatment.\nDisp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*\n9. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every eight\n(8) hours as needed for pain.\n10. midodrine 5 mg Tablet Sig: 1.5 Tablets PO every four (4)\nhours: Can hold while sleeping.\nDisp:*270 Tablet(s)* Refills:*2*\n\n\nDischarge Medications:\n1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n\n2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every\n12 hours).\n3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)\nCapsule, Delayed Release(E.C.) PO DAILY (Daily).\n4. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO\nOnce Daily at 6 PM.\n5. midodrine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY\n(Daily).\n6. Levemir 100 unit/mL Solution Sig: As directed by [**Last Name (un) **] units\nSubcutaneous As directed.\n\n\nDischarge Disposition:\nHome\n\nDischarge Diagnosis:\nDiabetic keotacidosis\nHematemesis (blood in your vomit)\nHypertension\nChronic renal insufficiency\n\nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\nDischarge Instructions:\nYou were admitted to the hospital with DKA, hypertension, and\nblood in your vomit. You were initially treated in the ICU with\nan insulin drip, and your blood sugars improved. Your blood\npressure medications were adjusted to better control your blood\npressure while you were in DKA, but you were re-started on your\nhome regimen at discharge. The blood in your vomit was likely\nsecondary to mechanical trauma from repeated wretching, but you\nshould follow-up with your primary care doctor to discuss\nwhether you should undergo further evaluation such as an upper\nendoscopy. Given your complaints of chronic cough and heartburn,\nyou should also discuss beginning a trial of a proton pump\ninhibitor such as Nexium or Prilosec to see if this helps your\nsymptoms.\n\nYour insulin regimen was adjusted by the [**Last Name (un) **] team while you\nwere here. You should continue to follow-up with them with any\nquestions or concerns regarding your insulin management.\n\nFollowup Instructions:\nPlease call Dr.[**Last Name (STitle) 805**]\u0027 office to schedule a follow-up\nappointment within 7-10 days of discharge. Her office number is\n[**Telephone/Fax (1) 85219**].\n\nYou should also continue to follow-up with your [**Last Name (un) **] doctors\nas needed.\n\n\n\nICD9 Codes: 5849"
}
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