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Daniel Fried NLP Lab 10

2162-06-22 20:01:00

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[[21789721, Timestamp('2162-06-22 20:02:43'), '', 'CMED'], [21789721, Timestamp('2162-06-28 18:12:19'), 'CMED', 'MED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. aspart 1 Units Breakfast\naspart 1 Units Lunch\naspart 1 Units Dinner\naspart 1 Units Bedtime\n2. Omeprazole 20 mg PO DAILY \n3. Furosemide 20 mg PO DAILY \n4. LevETIRAcetam 500 mg PO DAILY \n5. Chlorthalidone 25 mg PO DAILY \n6. Fludrocortisone Acetate 0.1 mg PO QID \n7. Metoprolol Tartrate 25 mg PO BID \n8. PARoxetine 40 mg PO DAILY \n\n13. Prochlorperazine 10 mg PO BID:PRN nausea \n14. Psyllium Wafer 2 WAF PO BID \n15. sevelamer CARBONATE 800 mg PO TID W/MEALS \n16. Simethicone 40 mg PO QID:PRN gas pain \n17. Sodium Bicarbonate 1300 mg PO TID \n18. Insulin SC \n Sliding Scale\nInsulin SC Sliding Scale using Novolog Insulin \n19. Chlorthalidone 50 mg PO DAILY \n20. LevETIRAcetam 500 mg PO DAILY \n21. PARoxetine 20 mg PO DAILY \n\nFacility:\n___\n\nSecondary Diagnosis:\n=================\n-Metastatic pancreatic Cancer\n-Malignant effusion \n-Diabetic nephropathy\n-Hyptertension\n-DM2', 'Brief Hospital Course': ':\nPRINICPLE REASON FOR ADMISSION:\n===============================\nMr. ___ is a ___ male with history of metastatic \npancreatic cancer (s/p = hepaticojejunostomy, gastrojejunostomy, \nCCY) who was initially transferred from ___ due to \nconcern for pericardial tamponade (only small effusion seen on \nmost recent echo), and found to be ___ hypoxemic respiratory \nfailure requiring intubation ___ secondary to pneumonia \nand volume overload. Early hospital course complicated by renal \nfailure and ATN. Subsequently received C1D1 FOLFOX ___ house on \n___ with further renal failure and hyperkalemia. Course \notherwise notable for persistent diarrhea, recurrent right \npleural effusion, and hypertension.\n\nACTIVE ISSUES:\n==============\n# Hypoxic Respiratory Failure:\n# Malignant Pleural Effusions: Initially with hypoxic \nrespiratory failure requiring intubation ___ due to PNA \nand anasarca. He is s/p cefepime ___ for pneumonia). \nBrief hypoxia to 90% on ___ required IV lasix. No CMV on BAL. \nCXR ___ with some right pleural effusion increase, IP drained 1L \non ___, but did not place pleurex as CT chest suggested \npersistent pulmonary parenchymal issues as large contributor. On \n___ patient reported worsening SOB and hypoxic to 88% with \nminimal exertion. Repeat CXR showed reaccumulation of right \npleural effusion. Thoracentesis by IP with drainage of 1L. \nPatient has refused Pleurex catheter at that time. Again, \ndeveloped O2 requirement on ___ with recurrent pleural \neffusion. Restarted IV Lasix 120mg bid and will need repeat \nthoracentesis vs. pleurX. \n\n# Acute on chronic renal failure\n# ATN: Initial etiology ATN thougth from from overdiuresis ___ \nsetting of respiratory failure, and improved prior to initiation \nof chemotherapy. More recently, oxaliplatin likely caused \nsignificant kidney damage. Cr has now stabilized around 3.8. \nNephrology has been following, and he has not yet needed \ndialysis. However, K has risen again starting ___, neprhology \naware and Lasix 120mg IV bid, chorthalidone, and po bicarb was \nstarted. Patient refused foley for closer UOP monitoring, but is \nfrequently incontinent of large volume urine. Will need very \nclose monitoring of volume status and potassium. \n\n# Hyperkalemia: See above; was quite severe over a number of \ndays\nearly ___ hospitalization following initial renal insult. \nImproved\nmarkedly at that time after initiation of chlorthalidone.\nChlorthalidone was then held given recurrent renal failure.\nHowever, now that Cr has stabilized a bit, feel OK to continue\nchlorthalidone and IV Lasix. He has been treated with IV Lasix \n120mg bid, chlorthalidone 50mg daily, and sodium bicarbonate. \nReceived IV insulin and dextrose on ___. Kayexelate not given \ndue to severe diarrhea. Also maintained on low K diet.\n\n# Proteinuria: 24 hour urine w/ >3g protein. Per renal likely \ndue to diabetic glomerulopathy as had proteinuria to similar \ndegree at least for past 8 months(300 prot on dipstick ___. Unlikely membranous GN iso active malignancy. C4 wnl, C3 \nslightly low. Hep B/C negative. ___, ANCA negative. Cryo \nnegative. Likely contributing to anasarca.\n\n# Metastatic Pancreatic Cancer: \nBiopsy confirmed metastatic pancreatic ca to the lungs. FOLFOX \ngiven ___ finished ___. Given worsening kidney disease and \nfunctional status C1D15 due ___ on hold, and there are no \nactive plans to resume chemotherapy. Dr. ___ will \ncontinue to re-evaluate patient for possibility of resuming \nchemotherapy if renal function and function status improve. \nPlease maintain contact with Dr. ___ at ___ and \narrange follow up when appropriate.\n\n# N/V/Diarrhea: Patient with significant persistent diarrhea and \nincontinence during entire hospital stay. Initially with \nFlexiseal, removed ___. GI was consulted early ___ course, and \netiology thought to be post-abx diarrhea vs. recent\nliquid diet vs. pancreatic enzyme deficiency vs. post FOLFOX. C. \ndiff was neg x2, O&P and stool cultures were also negative. CT \nabdomen/pelvis w/ PO contrast did not show any cause for \ndiarrhea. He has been managed with loperamide, Lomotil, opium \ntincture along with creon and psyllium wafers. ___ need to \nconsider reconsulting GI, resending stool cultures, and imaging \nstudies of diarrhea persists.\n\n# Anasarca\n# Bilateral Lower Extremity Edema\n# Upper Extremity Edema: Fluid status fluctuates, appears volume \noverloaded. Likely secondary to hypoalbuminemia ___ setting of \npossible nephrotic syndrome and poor nutrition with active \nmalignancy. ___ ___ negative. LUE ultrasound negative for DVT. \n120mg IV Lasix bid as above.\n\n# Transaminitis: Stable/resolving. RUQ US without hepatic mets. \nHBV/HCV serologies negative and HBV VL not detected. Likely from \nportal congestion from anasarca. \n\n# Guaiac-Positive Stools:\n# Anemia: Anemia is stable near baseline Hgb ___. Hemolysis labs \nwere negative. Reported frank bloody BM overnight on ___ with \npreviously guaiac positive stools. No prior colonoscopy on \nrecord. Colonoscopy was deferred.\n\n# HTN: Treated with labetolol 600mg tid and amlodipine. \nChlorthalidone was held much of hospitalization but restarted on \n___ ___ setting of hyperkalemia and stable kidney function. \n\n# Type II Diabetes: Continued Humalog ISS \n\n# Epilepsy: History of grand mal seizures. Continue keppra 500mg \nBID. Was thought to have partial seizure on complex partial \nseizure witnessed by RN on ___. However, EEG did not reveal any \nepileptiform activity x 48 hrs. MRI brain completed w/o contrast \nand w/ significant motion activity but did not reveal any \nobvious acute process. \n\n# Pericardial Effusion: Very small with no evidence of \ntamponade. Likely from severe hypoalbuminemia vs. physiologic as \nopposed to malignant ___ origin. \n\n# Psych: Continued paroxetine 40mg daily\n\n# FEN: replete electrolytes prn, renal diet\n# Prophylaxis: Subcutaneous heparin \n# Access: POC \n# Restraints: Shackles\n# Communication: HCP: ___ (sister) ___ \n# Full Code (confirmed by ICU Team) \n# DISPO: ___\n\nTRANSITIONAL ISSUES:\n====================\n- Please monitor K upon arrival to unit and maintain cardiac \nmonitoring\n- Please evaluate for thoracentesis vs tunneled pleural catheter\n- Consider GI consult for persistent diarrhea refractory to \naggressive antidiarrheals\n- Please continue to re-evaluate fromo oncologic perspective for \npossibility of palliative chemotherapy\n\nBILLING: >30 min coordinating care or discharge\nDISPO: ___\n\n', 'Pertinent Results:': '\nADMISSION LABS:\n===============\n___ 08:14PM BLOOD WBC-9.3# RBC-3.06* Hgb-8.7* Hct-28.2* \nMCV-92 MCH-28.4 MCHC-30.9* RDW-12.2 RDWSD-41.0 Plt ___\n___ 08:14PM BLOOD Neuts-88* Bands-2 Lymphs-6* Monos-4* \nEos-0 Baso-0 ___ Myelos-0 AbsNeut-8.37* \nAbsLymp-0.56* AbsMono-0.37 AbsEos-0.00* AbsBaso-0.00*\n___ 08:14PM BLOOD ___ PTT-46.4* ___\n___ 08:14PM BLOOD Glucose-97 UreaN-29* Creat-1.9* Na-137 \nK-3.9 Cl-106 HCO3-21* AnGap-14\n___ 08:14PM BLOOD ALT-25 AST-43* AlkPhos-250* TotBili-<0.2\n___ 08:14PM BLOOD Albumin-1.1* Calcium-6.8* Phos-4.2 Mg-1.7\n\nIMAGING:\n========\n___ Imaging CHEST (PORTABLE AP) \nLarge layering right pleural effusion and suspected pulmonary \nedema.\n\n___ Imaging RENAL U.S \n1. Limited renal Doppler evaluation, secondary to suboptimal \npatient \ncomplaints during exam. Within this limitation, no evidence of \nmain renal \nartery stenosis or renal vein thrombosis. \n2. Moderate ascites. \n\n___ Imaging MR HEAD W/O CONTRAST \n1. Severely limited study due to motion artifact. No \nabnormalities detected.\n\n___ Imaging CHEST (PORTABLE AP) \n___ comparison with the study of ___, there again are low \nlung volumes that accentuate the enlargement of the cardiac \nsilhouette. Diffuse areas of pulmonary opacification are less \nprominent, consistent with decreasing vascular congestion, \nresolving aspiration, or both. No evidence of increase ___ the \nright pleural effusion. The Port-A-Cath tip is also unchanged. \n\n___BD & PELVIS W/O CON \n1. Multiple metastatic pulmonary nodules are seen the lung \nbases, which appear enlarged compared to the prior study ___ \n___, concerning for worsening metastatic disease. \n2. The known pancreatic mass is not well seen on this \nnoncontrast exam, however, pancreatic ductal dilatation appears \nsimilar to the prior study ___ ___. \n3. There is new mild perihepatic ascites which was not seen ___ \n___ and extends along the right paracolic gutters and \ninto the deep pelvis. \n4. Bilateral pleural effusions are new since ___, \nmoderate on the right and small on the left, with associated \nright lower lobe volume loss. \n\n___ Imaging UNILAT UP EXT VEINS US \nNo evidence of deep vein thrombosis ___ the left upper extremity.\n\n___HEST W/O CONTRAST \n1. Enlargement of multiple pleural based and parenchymal soft \ntissue lesions ___ the thorax with interseptal thickening ___ the \nleft lower lobe, concerning for worsening metastatic disease \nwith lymphangitic spread. \n2. A new 2.4 cm soft tissue lesion seen along the subcutaneous \ntissues of the right chest may represent a site of prior port \ninsertion vs new metastatic lesion. \n3. Increased diffuse anasarca with inflammatory changes seen ___ \nthe right chest wall. \n4. New moderate, nonhemorrhagic, layering right pleural \neffusion. \n5. Interval increase ___ perihepatic ascites compared to the \nprior study ___ ___. \n6. Mild central pneumobilia and pancreatic ductal dilatation \nappear stable. \n\n___ Imaging CHEST (PORTABLE AP) \n___ comparison with study of ___, there has been a \nthoracentesis \nperformed on the right with removal of some pleural fluid. No \nevidence of \npost procedure pneumothorax. \nLittle change ___ the diffuse bilateral pulmonary opacifications. \n\n___ Imaging RENAL U.S. \nNo evidence of hydronephrosis. Thickened bladder wall may be \nsecondary to \nunderdistention of the bladder. \n\n___ Imaging CHEST (PORTABLE AP) \nNo evidence of hydronephrosis. Thickened bladder wall may be \nsecondary to underdistention of the bladder. \n\n___ Imaging RENAL U.S. \nNo evidence of hydronephrosis. Thickened bladder wall may be \nsecondary to \nunderdistention of the bladder. \n\n___ Imaging LIVER OR GALLBLADDER US \n1. Limited exam for evaluation of hepatic lesion and pancreatic \nhead mass due to overlying bowel gas after hepaticojejunostomy. \nHowever, no definite hepatic metastatic disease. \n2. Persistent dilation of main pancreatic duct with abrupt \nocclusion ___ the head. \n3. Moderate right pleural effusion. \n4. Borderline splenomegaly. \n\n___ Imaging BILAT LOWER EXT VEINS \nNo evidence of deep venous thrombosis ___ the right or left lower \nextremity \nveins. Right calf vessels were not definitely visualized. \n\n___ THORACENTESIS NEEDLE\nIMPRESSION: \nSuccessful ultrasound-guided right thoracentesis with removal of \n0.8 L of\nclear, straw-colored fluid, which was sent for cytology.\n\n___ REPLACEMENT\nIMPRESSION: \nSuccessful placement of a single lumen chest power Port-a-cath \nvia the right internal jugular venous approach. The tip of the \ncatheter terminates ___ the right atrium. The catheter is ready \nfor use.\n\nSuccessful removal of the malpositioned right Port-A-cath.\n\n___ U.S.\n\nIMPRESSION: \n\n1. No hydronephrosis.\n2. Echogenic kidneys may reflect medical renal disease.\n3. Trace ascites.\n\n___ ABDOMEN\n\nIMPRESSION: \n\nNo of evidence of bowel obstruction or pneumoperitoneum.\n\n___ LAVAGE\nNEGATIVE FOR MALIGNANT CELLS.\n\n___ TTE\nThe left atrium is normal ___ size. The estimated right atrial \npressure is ___ mmHg. Left ventricular wall thickness, cavity \nsize and regional/global systolic function are normal (LVEF \n>55%). Right ventricular chamber size and free wall motion are \nnormal. There is abnormal septal motion/position. The ascending \naorta is mildly dilated. The aortic valve leaflets (3) are \nmildly thickened but aortic stenosis is not present. No aortic \nregurgitation is seen. The mitral valve appears structurally \nnormal with trivial mitral regurgitation. The pulmonary artery \nsystolic pressure could not be determined. There is a very small \nto small pericardial effusion measuring up to 0.8 centimeters ___ \ngreatest dimension, but generally 0.2-0.4 cm ___ size. The \neffusion appears circumferential. There are no echocardiographic \nsigns of tamponade. \n\n IMPRESSION: Very small to small pericardial effusion without \nechocardiographic evidence of tamponade. Mildly dilated \nascending aorta. Preserved biventricular systolic function. \nIndeterminate pulmonary artery systolic pressure. \n\n___ CXR\nExtensive consolidations ___ particular involving right upper \nlobe as well as bibasal areas is unchanged. Central venous line \ntip terminates at the level of mid right subclavian vein. \nCardiomediastinal silhouette is difficult to assess since it is \nobscured by widespread parenchymal consolidations. Bilateral \npleural effusions are present. No pneumothorax. \n\nMICROBIOLOGY:\n=============\n\n___\nNO CRYPTOSPORIDIUM OR GIARDIA SEEN.\n\n___\n NO OVA AND PARASITES SEEN. \n\n___\n\nFECAL CULTURE (Final ___: \n NO ENTERIC GRAM NEGATIVE RODS FOUND. \n NO SALMONELLA OR SHIGELLA FOUND. \n\n CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n\n OVA + PARASITES (Final ___: \n NO OVA AND PARASITES SEEN. \n This test does not reliably detect Cryptosporidium, \nCyclospora or\n Microsporidium. While most cases of Giardia are detected \nby routine\n O+P, the Giardia antigen test may enhance detection when \norganisms\n are rare. \n\n FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO \nFOUND. \n\n FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA \nFOUND. \n\n___\n\n C. difficile DNA amplification assay (Final ___: \n Negative for toxigenic C. difficile by the Cepheid nucleic \nacid\n amplification assay.. \n\n___ Respiratory Viral Screen & Culture\n\nRespiratory Viral Culture (Final ___: \n No respiratory viruses isolated. \n Culture screened for Adenovirus, Influenza A & B, \nParainfluenza type\n 1,2 & 3, and Respiratory Syncytial Virus.. \n\n___ LAVAGE\n\nGRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000 \nCFU/ml. \n\n LEGIONELLA CULTURE (Final ___: NO LEGIONELLA \nISOLATED. \n\n POTASSIUM HYDROXIDE PREPARATION (Final ___: \n Test cancelled by laboratory. \n PATIENT CREDITED. \n This is a low yield procedure based on our ___ \nstudies. \n if pulmonary Histoplasmosis, Coccidioidomycosis, \nBlastomycosis,\n Aspergillosis or Mucormycosis is strongly suspected, \ncontact the\n Microbiology Laboratory (___). \n\n Immunoflourescent test for Pneumocystis jirovecii (carinii) \n(Final\n ___: NEGATIVE for Pneumocystis jirovecii \n(carinii). \n\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\n NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. \n\n ACID FAST CULTURE (Final ___: NO MYCOBACTERIA \nISOLATED. \n\n___\n\n ACID FAST CULTURE (Final ___: NO MYCOBACTERIA \nISOLATED. \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. \n\n___ BLOOD CX: NO GROWTH x2\n___ SPUTUM GRAM STAIN & CULTURE: \n\nGRAM STAIN (Final ___: \n >25 PMNs and <10 epithelial cells/100X field. \n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS SINGLY. \n\n RESPIRATORY CULTURE (Final ___: \n RARE GROWTH Commensal Respiratory Flora. \n\n___ URINE CX: NO GROWTH\n\nPATHOLOGY:\n==========\n___ Tissue: LUNG, CORE BIOPSY FOR TUMOR \nMetastatic adenocarcinoma\n- Positive: CK7, ___.\n- Negative: CK20, TTF-1, B72.3.\n\nOTHER LABS OF NOTE:\n==================\n___ 06:00AM BLOOD %HbA1c-6.1* eAG-128*\n___ 05:21AM BLOOD Triglyc-110 HDL-20 CHOL/HD-3.9 LDLcalc-36\n___ 06:00AM BLOOD HBsAg-Negative HBsAb-Negative \nHBcAb-Negative\n___ 06:00AM BLOOD ANCA-NEGATIVE B\n___ 06:00AM BLOOD ___\n___ 06:00AM BLOOD C3-78* C4-38\n___ 11:17PM BLOOD HIV Ab-Negative\n\n', 'Physical Exam:|Physical': "\nADMISSION PHYSICAL EXAM: \n========================\nVITALS: 99 81 157/89 31 99% non rebreather at 10 \nGENERAL: Alert, oriented, tachypnic \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: diffusely rhonchirus, wheezy upper airways bilaterally \nCV: tachycardic, normal S1 S2, no murmurs, rubs, gallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: 3+ pitting edema upper and lower extremities bilaterally \nSKIN: no rash \nNEURO: grossly intact \n\nDISCHARGE PHYSICAL EXAM:\n=======================\nVITAL SIGNS: T 98.4 BP 161/89 HR 75 RR 18 O2 95%3L\nGeneral: Fatigued and ill appearing man, withdrawn, keeps sheet \nover head and\ndoesn't maintain eye contact with examiner. Actively vomiting.\nHEENT: MMM. OP clear.\nCV: RRR, prominent S1S2, no S3S4, no MRG.\nPULM: Nonlabored appearing. Decreased BS at right base. Coarse \nthroughout\nABD: BS+, soft, NTND.\nLIMBS: TEDS ___ place, bilateral ___ ___ edema throughout thighs \nto\nsacrum above level of TEDS, Bilateral UE nonpitting edema.\nSKIN: Bilateral skin breakdown at elbows and shins from the \nmetal\nshacks, now ___ padded boots and improving \nNEURO: Awake. Very short answers sporadically to questions,\nalthough appropriate. Symmetric generalized weakness, but moves\nall extremities.\n\n", 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n Mr. ___ is a ___ yo man with a presumed diagnosis metastatic \npancreatic cancer, likely metastatic who is being transferred \nfrom ___ out of concern for tamponande and need for \ncardiac window ___ setting of new hypoxemia. \n\n___ course: Mr. ___ presented to ___ on ___ from \ncorrection facility with SOB and productive cough and low grade \ntemperature. CXR ___ the ED was concerning for an infiltrate vs. \natelectasis vs. edema. He was initiated on levofloxacin and \nthen transitioned to azithromycin and ceftriaxone. Troponin was \n0.07 and BNP 499. Due to troponin bump and history of cancer \ndecision was made to treat empirically with treatment dose of \nenoxaparin. He was also given "low dose" Lasix. D-dimer was \nsent and positive. V/Q scan was performed and indeterminate. On \nevening of ___ he was noted to have increased oxygen \nrequirement and started on ___ mask with 100% oxygen \nsaturation. Later ___ the evening, however, he was noted to be \n"unresponsive and hypoxemic with oxygen mask off." ABG at that \ntime was blood gas showed pH 7.29. PCO2 52 and PO2 ___ the 64 26 \non 100% nonrebreather." He was then transferred to the MICU \nwhere antibiotics were broadened to meropenem and vancomycin. He \nwas reportedly very hypertensive at time of transfer (no vitals \nnoted) and given 5 mg IV metoprolol. An echo was performed that \nshowed, "Cardiologist reports small but pre-tamponade physiology \nseen on TTE." He was transferred to ___ out of concern for \nneed for cardiac window. \n\nAt time of transfer he was on high flow 60% satting 92-95%. ___ \naddition to hypoxemia and cough, he is having diarrhea requiring \nrectal tube. \n\nPancreatic cancer course (per OMR and oncology notes): ___ \n___ he developed new onset abdominal pain and was noted \nto have a pancreatic mass. Biopsies were performed and \nindeterminate. ___ ___ he was admitted to ___ with \nperforated cholecystitis s/p percutaneous cholecystostomy tube. \nMRCP at that time raised\nsuspicion for head of pancreas mass. Later that month she ERCP \nwith Spyglass done showed a malignant-appearing stricture and \nEUS showing an ill-defined mass ___ the pancreatic neck with an \nabrupt transition ___ caliber of the PD, brushings and biopsies \nagain atypical. Repeat ERCP for rising LFTs was performed. A \nfully covered metal stent placed (prior stent dislodged). \nAbscess cavity had collapsed and drain removed. Given all this, \nhad large-volume weight loss with inability to maintain feeds \nwith subsequent malnutrition and hypoalbuminemia requiring NJT \nfeeds. ___ ___ he was planned for Whipple procedure for \ndefinitive diagnosis of pancreatic mass. However, \nintra-operatively he became hypotensive and hypoglycemic. \nSurgery was converted to CCY and double bypass was performed \nwith fiducial placement. Biopsies of the pancreatic head \nreturned positive for ductaladenocarcinoma with invasion of \nperipancreatic adipose tissue. There was a delay ___ follow-up \nbetween ___ and ___ when he followed up with Dr. \n___ ___ oncology. At that visit he was scheduled for \nbiopsy of known lung nodules to make formal diagnosis of \nmetastatic lung cancer. At this time plan is to initiate \npalliative systemic therapy for his pancreatic cancer (once \nbiopsy is done). At that visit it was also noted that he was \ngrossly anasarcic and hypertensive. \n\nOn arrival to the MICU, he states that he is feeling very short \nof breath and weak. He also endorses some diarrhea. \n\nPast Medical History:\n- Metastatic pancreatic cancer, presumed\n- HTN\n- Grand mal seizures\n- Depression\n- HLD\n- DM, insulin dependent\n- History of Biliary obstruction/stricture\n\nSocial History:\n___\nFamily History:\nDenies family history of colon, pancreas, liver,\nbreast or other malignancies. Denies history of other family\ngastrointestinal disease or pancreatitis.\n\n', 'Chief Complaint:|Complaint:': '\nShortness of breath \n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '16013806-DS-23', 23, 'medicine']]

[['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with hypoxemia and metastatic pancreatic cancer. \n// pna ? edema ? pna ? edema ?\n\nIMPRESSION: \n\nExtensive consolidations in particular involving right upper lobe as well as\nbibasal areas is unchanged. Central venous line tip terminates at the level\nof mid right subclavian vein. Cardiomediastinal silhouette is difficult to\nassess since it is obscured by widespread parenchymal consolidations. \nBilateral pleural effusions are present. No pneumothorax.\n', '16013806-RR-38', 38, ''], ['INDICATION: ___ year old man with ETT // Eval ETT placement\n\nTECHNIQUE: AP portable chest radiograph\n\nCOMPARISON: ___ from earlier in the day\n\nFINDINGS: \n\nThe tip of the endotracheal tube projects at the level of the clavicular\nheads. The tip of the right central venous catheter is unchanged.\n\nThere are increased bilateral lung volumes. Grossly unchanged consolidations\ninvolving both lungs but more so involving the right upper lobe. Layering\nbilateral pleural effusions are present. No pneumothorax. The size of the\ncardiac silhouette is enlarged but likely unchanged.\n\nIMPRESSION: \n\nThe tip of the endotracheal tube projects at the level of the clavicular\nheads. Increased bilateral lung volumes with persisting bilateral\nconsolidative opacities.\n', '16013806-RR-39', 39, 'ap portable chest radiograph'], ['INDICATION: ___ year old man with ETT + RIJ CVL with severe pneumonia // Eval\nfor RIJ CVL placement\n\nTECHNIQUE: AP portable chest radiograph\n\nCOMPARISON: ___\n\nFINDINGS: \n\nThe tip of the new right internal jugular central venous catheter projects\nover the distal SVC. A right central venous catheter tip is unchanged\nprojecting over the right clavicle. The tip of the endotracheal tube projects\nover the mid thoracic trachea. A nasogastric tube extends into the stomach.\n\nPersisting diffuse bilateral airspace opacities. Layering bilateral pleural\neffusions are suspected. No pneumothorax. The size of the cardiac silhouette\nis unchanged.\n\nIMPRESSION: \n\nInterval placement of a right internal jugular central venous catheter whose\ntip projects over the distal SVC. The tip of the endotracheal tube projects\nover the mid thoracic trachea.\n', '16013806-RR-40', 40, 'ap portable chest radiograph'], ['EXAMINATION: Chest one view\n\nINDICATION: ___ year old man with intubated. // assess infiltrates\n\nTECHNIQUE: Chest portable AP with the patient supine.\n\nCOMPARISON: ___.\n\nFINDINGS: \n\nAs with the previous exam there are bilateral diffuse pulmonary opacities with\nno interval change. Right IJ tube in distal SVC. ET tube above the carina.\n\nIMPRESSION: \n\nNo interval change.\n', '16013806-RR-41', 41, 'chest portable ap with the patient supine.'], ['EXAMINATION: BILAT UP EXT VEINS US\n\nINDICATION: ___ year old man with ___ upper extremity edema and pancreatic\ncancer.\n\nTECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral\nupper extremity veins.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nThere is normal flow with respiratory variation in the bilateral subclavian\nveins.\n\nThe bilateral internal jugular and axillary veins are patent, show normal\ncolor flow and compressibility.\nThe bilateral brachial, basilic, and cephalic veins are patent, compressible\nand show normal color flow and augmentation.\n\nThere is significant subcutaneous edema involving both upper extremities.\n\nIMPRESSION:\n\n\n1. No evidence of deep vein thrombosis in the bilateral upper extremity veins.\n2. Subcutaneous edema involves both upper extremities.\n', '16013806-RR-43', 43, 'grey scale and doppler evaluation was performed on the bilateral\nupper extremity veins.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with pneumonia // Eval for interval change \nEval for interval change\n\nIMPRESSION: \n\nComparison to ___. No relevant change is noted. Monitoring and\nsupport devices are stable. Moderate cardiomegaly. Bilateral pleural\neffusions and subsequent areas of atelectasis. Moderate parenchymal opacities\nare stable. No new opacities. No overt pulmonary edema.\n', '16013806-RR-44', 44, ''], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with hypoxemic resp failure and metastatic\npancreatic cancer. // interval change interval change\n\nIMPRESSION: \n\nIn comparison with study of ___, the monitoring and support devices are\nessentially unchanged. Continued enlargement of the cardiac silhouette with\nengorged pulmonary vessels and bilateral pleural effusions with compressive\natelectasis, more prominent on the right.\n', '16013806-RR-45', 45, ''], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with vol overload PNA // Eval for interval\nchange Eval for interval change\n\nIMPRESSION: \n\nCompared to chest radiographs ___ through ___.\n\nLeft lower lobe consolidation was severe early on ___ and had\nsubstantially cleared during the day. Therefore this was not pneumonia. Lung\nbases however remain densely consolidated, the left since ___, the\nright since ___. This could be pneumonia, but is always difficult to\ndistinguish from basal atelectasis and concurrent pleural effusion which is\nsmall to moderate on the right.\n\nHeart is mildly enlarged.\n\nET tube, right internal jugular line, and nasogastric drainage tube are in\nstandard placements.\n\nAn intended right subclavian line has been present since prior to this\nadmission and still ends at the level of the right clavicle. It could be in a\nsmall vein or even extravascular. Clinical assessment is essential.\n', '16013806-RR-46', 46, ''], ['INDICATION: ___ year old man with pancreatic cancer now with n/v concerning\nfor obstruction. // Please assess for possible obstruction, ileus.\n\nTECHNIQUE: Portable supine abdominal radiograph was obtained.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nThere are no abnormally dilated loops of large or small bowel.\nThere is no free intraperitoneal air.\nOsseous structures are unremarkable.\nSurgical clips are present in the right upper abdomen. There are no\nunexplained soft tissue calcifications or radiopaque foreign bodies.\n\nIMPRESSION: \n\nNo radiographic evidence of bowel obstruction.\n', '16013806-RR-47', 47, 'portable supine abdominal radiograph was obtained.'], ['INDICATION: ___ year old man with metastatic pancreatic cancer now with n/v\nconcerning for obstruction // Please perform upright abdominal xray to assess\nfor bowel obstruction\n\nTECHNIQUE: Portable supine and upright abdominal radiographs were obtained.\n\nCOMPARISON: Abdominal radiographs from ___ at 0016.\n\nFINDINGS: \n\nThere are no abnormally dilated loops of large or small bowel.\nThere is no free intraperitoneal air.\nOsseous structures are unremarkable.\nA right-sided Port-A-Cath terminates at the cavoatrial junction. Surgical\nclips are present in the right side of the abdomen. There are no unexplained\nsoft tissue calcifications or radiopaque foreign bodies.\n\nIMPRESSION: \n\nNo of evidence of bowel obstruction or pneumoperitoneum.\n', '16013806-RR-48', 48, 'portable supine and upright abdominal radiographs were obtained.'], ['EXAMINATION: RENAL U.S.\n\nINDICATION: ___ year old man with a PMH of (suspected metastatic) pancreatic\ncancer and HTN here with hypoxemic respiratory failure from pneumonia and\nvolume overload. Continues to have worsening kidney function w/ proteinuria \n// eval for hydronephrosis;\n\nTECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were\nobtained.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nThe right kidney measures 11.8 cm. The left kidney measures 13.2 cm. There is\nno hydronephrosis, stones, or masses bilaterally. Bilateral renal cortices\nappear echogenic.\n\nBladder is decompressed about a Foley catheter.\nTrace ascites is noted.\n\nIMPRESSION: \n\n1. No hydronephrosis.\n2. Echogenic kidneys may reflect medical renal disease.\n3. Trace ascites.\n', '16013806-RR-49', 49, 'grey scale and color doppler ultrasound images of the kidneys were\nobtained.'], ["INDICATION: Mr. ___ is a ___ year old man with a PMH of pancreatic cancer and\nHTN here with hypoxemic respiratory failure from pneumonia and volume\noverload. Port in wrong place, plan for chemo in the future. // Please\nreplace outside hospital placed chest port for chemotherapy; ___ aware and\ndiscussed w/ ___ last week.\n\nCOMPARISON: Chest radiograph on ___.\n\nTECHNIQUE: OPERATORS: Dr. ___ and Dr.\n___ radiologist performed the procedure. Dr. ___\nsupervised the trainee during the key components of the procedure and has\nreviewed and agrees with the trainee's findings.\nANESTHESIA: Moderate sedation was provided by administrating divided doses of\n25 mcg of fentanyl and 0.5 mg of midazolam throughout the total intra-service\ntime of 55 minutes during which the patient's hemodynamic parameters were\ncontinuously monitored by an independent trained radiology nurse. 1% lidocaine\nwas injected in the skin and subcutaneous tissues overlying the access site.\nMEDICATIONS: Fentanyl and versed.\nCONTRAST: None.\nFLUOROSCOPY TIME AND DOSE: 2.3 min, 57 mGy\n\nPROCEDURE\n1. Right internal jugular approach chest single lumen Port-a-cath placement.\n2. Right Port-A-Cath removal.\n\nPROCEDURE DETAILS: Following the explanation of the risks, benefits and\nalternatives to the procedure, written informed consent was obtained from the\npatient. The patient was then brought to the angiography suite and placed\nsupine on the exam table. A pre-procedure time-out was performed per ___\nprotocol. The upper chest was prepped and draped in the usual sterile fashion.\nUnder continuous ultrasound guidance, the patent right internal jugular vein\nwas compressible and accessed using a micropuncture needle. Permanent\nultrasound images were obtained before and after intravenous access, which\nconfirmed vein patency. Subsequently a Nitinol wire was passed into the right\natrium using fluoroscopic guidance. The needle was exchanged for a\nmicropuncture sheath. The Nitinol wire was removed and a short ___ wire was\nadvanced to make appropriate measurements for catheter length. The ___ wire\nwas then passed distally into the IVC.\nNext, attention was turned towards creation of a subcutaneous pocket over the\nupper anterior chest wall. After instilling superficial and deeper local\nanesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse\nincision was made and a subcutaneous pocket was created by using blunt\ndissection. The single lumen port was then connected to the catheter. The\ncatheter was tunneled from the subcutaneous pocket towards the venotomy site\nfrom where it was brought out using a tunneling device. The port was then\nconnected to the catheter and checks were made for any leakage by accessing\nthe diaphragm using a non-coring ___ needle. No leaks were found.\nThe port was then placed in the subcutaneous pocket and secured with ___\nprolene sutures on either side. The venotomy tract was dilated using the\nintroducer of the peel-away sheath supplied. Following this, the peel-away\nsheath was placed over the ___ wire through which the port was threaded into\nthe right side of the heart with the tip in the right atrium. The sheath was\nthen peeled away.\nThe subcutaneous pocket was closed in layers with ___ interrupted and ___\nsubcuticular continuous Vicryl sutures. Steri-Strips were used to close the\nvenotomy incision site. Steri-Strips were applied over the sutures. Final spot\nfluoroscopic image demonstrating good alignment of the catheter and no\nkinking. The tip is in the right atrium.\nThe port was accessed using a non coring ___ needle and could be aspirated\nand flushed easily. Sterile dressings were applied. The patient tolerated the\nprocedure well without immediate complication. The port was left accessed as\nrequested.\n\nNext, the final position of right-sided or was identified. After instillation\nof 1% lidocaine and lidocaine with epinephrine into the skin and subcutaneous\ntissues, a 2.5 cm transverse incision was made. Blunt dissection was\nperformed to the port. The port was removed completely. The subcutaneous\npocket was closed in layers with ___ interrupted and ___ subcuticular\ncontinuous Vicryl sutures. Steri-Strips and sterile dressings were applied.\n\nFINDINGS: \n\nPatent right internal jugular vein. Final fluoroscopic image showing port with\ncatheter tip terminating in the right atrium.\n\nExisting malposition port with its tip pulled back into the right subclavian\nvein. The port was removed entirely.\n\nIMPRESSION: \n\nSuccessful placement of a single lumen chest power Port-a-cath via the right\ninternal jugular venous approach. The tip of the catheter terminates in the\nright atrium. The catheter is ready for use.\n\nSuccessful removal of the malpositioned right Port-A-cath.\n", '16013806-RR-50', 50, "operators: dr. ___ and dr.\n___ radiologist performed the procedure. dr. ___\nsupervised the trainee during the key components of the procedure and has\nreviewed and agrees with the trainee's findings.\nanesthesia: moderate sedation was provided by administrating divided doses of\n25 mcg of fentanyl and 0.5 mg of midazolam throughout the total intra-service\ntime of 55 minutes during which the patient's hemodynamic parameters were\ncontinuously monitored by an independent trained radiology nurse. 1% lidocaine\nwas injected in the skin and subcutaneous tissues overlying the access site.\nmedications: fentanyl and versed.\ncontrast: none.\nfluoroscopy time and dose: 2.3 min, 57 mgy"], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: Mr. ___ is a ___ year old man with a PMH of (suspected metastatic)\npancreatic cancer and HTN here with hypoxemic respiratory failure from\npneumonia and volume overload. Now w/ desatting // Fluid? Pna? Fluid? Pna?\n\nIMPRESSION: \n\nCompared to chest radiographs ___ through ___.\n\nLarge right pleural effusion continues to grow. Right upper and lower lobe\nconsolidation have improved, but the middle lobe is probably now collapsed. \nLeft lower lobe atelectasis may also have improved.\n\nRight heart border is obscured so extent of cardiac enlargement is\nindeterminate, but probably unchanged.\n\nPatient has been extubated. Right supraclavicular central venous catheter\nends in the region of the superior cavoatrial junction.\n', '16013806-RR-51', 51, ''], ['INDICATION: ___ year old man with a PMH of (suspected metastatic) pancreatic\ncancer and HTN here with hypoxemic respiratory failure from pneumonia and\nvolume overload. Continues to have pulmonary edema, no s/p diuresis. //\ninterval changes Surg: ___ (Lung biopsy. Please OBTAIN IN AM)\n\nTECHNIQUE: Chest PA and lateral\n\nCOMPARISON: ___\n\nFINDINGS: \n\nRight-sided prepectoral Port-A-Cath in situ with the tip in the distal SVC. \nLarge sized right-sided pleural effusion is again noted and appears relatively\nsimilar in size compared to prior. Associated right lower lobe atelectasis is\nstable. Minor left lower lobe atelectasis.\nNo overt pulmonary edema.\nMultiple pulmonary nodules appear similar compared to prior. Bilateral\ndegenerative changes of the shoulder joints with associated calcifications.\n\nIMPRESSION: \n\nModerate sized right-sided pleural effusion with associated right lower lobe\natelectasis.\nMultiple pulmonary nodules appear similar compared to prior in keeping with\nmetastatic disease.\nNo overt pulmonary edema.\n', '16013806-RR-52', 52, 'chest pa and lateral'], ["EXAMINATION: CT Limited Study\n\nINDICATION: ___ with h/o inoperable pancreatic cancer, for percutaneous\nbiopsy of lung nodules..\n\nTECHNIQUE: Limited preprocedure CT scan of the chest was performed.\n\nDOSE: DLP: ___ MGy-cm\n\nCOMPARISON: CT of the chest from ___\n\nFINDINGS: \n\nThere is a large right pleural effusion with associated atelectasis. The right\nlung shows little aeration and the known lung nodules targeted for biopsy\ncannot be visualized. Multiple nodules are seen in the aerated left lung.\nHowever, due to the patient's renal insufficiency, there is a an increased\nrisk of bleeding which could have negative impact on the patient given that O2\nsaturation on room air is < 90%. The patient may be re-scheduled for biopsy\nonce the pleural effusion is managed and his respiratory status improves.\n\nIMPRESSION: \n\nLimited pre-procedure CT scan of the chest. A lung biopsy was not performed.\n", '16013806-RR-53', 53, 'limited preprocedure ct scan of the chest was performed.'], ["EXAMINATION: Ultrasound-guided thoracentesis\n\nINDICATION: ___ year old man with R pleural effusion // thoracentesis\n\nTECHNIQUE: Ultrasound guided diagnostic and therapeutic thoracentesis.\n\nCOMPARISON: Limited CT of the chest and chest radiograph from ___.\n\nFINDINGS: \n\nLimited grayscale ultrasound imaging of the right hemithorax demonstrated\nmoderate pleural fluid. A suitable target in the deepest pocket in the right\nposterior mid scapular line was selected for thoracentesis.\n\nPROCEDURE: The procedure, risks, benefits and alternatives were discussed\nwith the patient and written informed consent was obtained.\n\nA preprocedure time-out was performed discussing the planned procedure,\nconfirming the patient's identity with 3 identifiers, and reviewing a\nchecklist per ___ protocol.\n\nUnder ultrasound guidance, an entrance site was selected and the skin was\nprepped and draped in the usual sterile fashion. 1% lidocaine buffered with\nsodium bicarbonate was instilled for local anesthesia.\n\nA 5 ___ catheter was advanced into the largest fluid pocket in the right\nposterior mid scapular line and 0.8 L of clear, straw-colored fluid was\nremoved. Fluid samples were submitted to the laboratory for cytology.\n\nThe patient tolerated the procedure well without immediate complication.\nEstimated blood loss was minimal.\n\nDr. ___ personally supervised the trainee during the key components of\nthe procedure and reviewed and agrees with the trainee's findings.\n\nIMPRESSION: \n\nSuccessful ultrasound-guided right thoracentesis with removal of 0.8 L of\nclear, straw-colored fluid, which was sent for cytology.\n", '16013806-RR-54', 54, 'ultrasound guided diagnostic and therapeutic thoracentesis.'], ['INDICATION: ___ year old man with R pleural effusion s/p thoracentesis //\nPost R thoracentesis. Evaluate for pneumothorax. Please perform upright.\n\nCOMPARISON: ___.\n\nIMPRESSION: \n\nThere has been interval resolution of the right-sided pleural effusion since\nthoracentesis. There are no pneumothoraces. There is a right-sided\nPort-A-Cath with the distal lead tip in the proximal right atrium. There is\nagain seen several rounded opacities throughout both lung fields consistent\nwith known pulmonary nodules.\n', '16013806-RR-55', 55, ''], ['EXAMINATION: Chest radiograph\n\nINDICATION: ___ year old man with suspected metastatic pancreatic cancer with\nrecent ___ for right pleural effusion. // Eval for interval changes\n\nTECHNIQUE: Portable semi upright view of the chest\n\nCOMPARISON: Chest radiograph from ___\n\nFINDINGS: \n\nA right Port-A-Cath tip terminates slightly below the caval atrial junction. \nAgain seen are several rounded opacities in the bilateral lung fields,\nconsistent with known pulmonary nodules. There are small bilateral pleural\neffusions, right greater than left. No pneumothorax. The cardiomediastinal\nsilhouette is mildly obscured due to adjacent opacities but likely unchanged.\n\nIMPRESSION: \n\n1. Persistence of small bilateral pleural effusions, right greater than left,\nsince prior study in ___.\n2. Pulmonary metastatic nodules are better seen on the CT chest from ___\n', '16013806-RR-56', 56, 'portable semi upright view of the chest'], ['ADDENDUM The pathology showed: Metastatic pancreatic adenocarcinoma.\nThis result is concordant with imaging findings.\nRecommendations: no further evaluation of this lesion is indicated.\nThe meeting was attended by: , ___.\n', '16013806-AR-57', 57, ''], ["EXAMINATION: CT-guided procedure\n\nINDICATION: ___ year old man with panc cancer, concern for metastatic disease \n// ? metastatic panc cancer\n\nCOMPARISON: CT of the chest from ___\n\nPROCEDURE: CT-guided right lower lobe lung nodule biopsy.\n\nOPERATORS: Dr. ___ fellow and Dr. ___\nradiologist. Dr. ___ supervised the trainee during the key\ncomponents of the procedure and reviewed and agrees with the trainee's\nfindings.\n\nTECHNIQUE: The risks, benefits, and alternatives of the procedure were\nexplained to the patient. After a detailed discussion, informed written\nconsent was obtained. A pre-procedure timeout using three patient identifiers\nwas performed per ___ protocol.\n\nThe patient was placed in a right lateral decubitus position on the CT scan\ntable. Limited preprocedure CTscan of the intended biopsy area was performed.\nBased on the CT findings an appropriate position for the biopsy was chosen. \nThe site was marked. The preprocedural CT demonstrates numerous bilateral\npulmonary nodules as well as bibasilar areas of subsegmental atelectasis and a\nlayering small to moderately sized right pleural effusion. 2 cm right lower\nlobe nodule was chosen for biopsy.\n\nThe site was prepped and draped in the usual sterile fashion. 1% lidocaine\nwere administered to the subcutaneous and deep tissues for local anesthetic\neffect. Under CT guidance, a 17 gauge coaxial needle was introduced into the\npleural space. Positioning of the needle was technically difficult due to the\npresence of the pleural effusion and atelectasis which allowed the lung to be\ndisplaced with the advancement of the needle as well as difficulty in\nreproducing breath holds with the patient. With some difficulty the needle\nwas placed to the edge of the target right lower lobe lung nodule. A 18 gauge\ncore biopsy device with a 20 mm throw was used to obtain a core biopsy\nspecimen. Verification of biopsy needle location after it was deployed was not\npossible as gravity and breathing motion caused the biopsy needle to withdraw.\nPost biopsy CT after the first biopsy demonstrated that the introducer needle\nwas positioned at the chosen nodule for biopsy and it appeared to be an\nappropriate position. A second biopsy was then attempted however\nvisualization of the 2 cm nodule was difficult due to intraparenchymal\nhemorrhage after the first biopsy, but a second 18 gauge core biopsy was\nobtained. Once again verification of the biopsy needle location after it was\ndeployed was not possible. These two specimens were provided to on-site\ncytologist who indicated pulmonary macrophages without evidence of malignancy.\n\nA third 18 gauge biopsy was then attempted noting as above that visualization\nof the nodule was even more difficult as it was obscured by intraparenchymal\nhemorrhage. As the nodule could not be adequately visualized, no additional\nbiopsy attempts were made.\n\nPost procedure limited CT demonstrated that there was no pneumothorax. The\npreviously seen small to moderate right pleural effusion had increased in size\nand was now a moderate right pleural effusion. In addition there was intra\nparenchymal pulmonary hemorrhage at the site of biopsy.\n\nThe procedure was tolerated well and there were no immediate post-procedural\ncomplications.\n\nDOSE: Total DLP (Body) = 839 mGy-cm.\n\nSEDATION: Moderate sedation was provided by administering divided doses of\n0.5 mg Versed and 25 mcg fentanyl throughout the total intra-service time of\n53 minutes during which patient's hemodynamic parameters were continuously\nmonitored by an independent trained radiology nurse.\n\nFINDINGS:\n\n\n1. Preprocedural CT showed multiple bilateral pulmonary nodules, a small to\nmoderately sized right pleural effusion, and bibasilar subsegmental\natelectasis.\n2. Procedure was technically challenging due to the presence of the right\npleural effusion and atelectasis allowing displacement of the lung with\nadvancement of the needle, as well as patient difficulty with reproducing\nbreath holds. 3 x 18 gauge core biopsy of a 2 cm right lower lobe nodule was\nperformed.\n3. Postprocedural CT showed no pneumothorax. The small to moderate right\npleural effusion had increased in size and was now moderate. In addition\nthere was ensure parenchymal pulmonary hemorrhage at the site of biopsy.\n\nIMPRESSION: \n\nTechnically difficult CT-guided lung nodule biopsy targeting a 2 cm right\nlower lobe nodule as noted above, with three 18 gauge core biopsies obtained.\n\nPostprocedural CT showed that there was no pneumothorax but that the\nright-sided pleural effusion head increased in size and was now moderate. \nThere was also intraparenchymal pulmonary hemorrhage at the site of biopsy.\n\nPatient tolerated the procedure well without coughing or oxygen desaturation.\n", '16013806-RR-57', 57, 'the risks, benefits, and alternatives of the procedure were\nexplained to the patient. after a detailed discussion, informed written\nconsent was obtained. a pre-procedure timeout using three patient identifiers\nwas performed per ___ protocol.'], ['EXAMINATION: BILAT LOWER EXT VEINS\n\nINDICATION: ___ year old man with pancreatic ca, metastatic, now w/ b/l lower\next edema // r/o dvt\n\nTECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed\non the bilateral lower extremity veins.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nThere is normal compressibility, flow, and augmentation of the bilateral\ncommon femoral, femoral, and popliteal veins.\nThe posterior tibial and peroneal veins are difficult to visualize\nbilaterally. Compressibility in the left posterior tibial vein is\ndemonstrated as is color within the left posterior tibial and peroneal veins. \nThe right calf vessels are not well seen.\n\nThere is normal respiratory variation in the common femoral veins bilaterally.\n\nNo evidence of medial popliteal fossa (___) cyst.\n\nIMPRESSION: \n\nNo evidence of deep venous thrombosis in the right or left lower extremity\nveins. Right calf vessels were not definitely visualized.\n', '16013806-RR-58', 58, 'grey scale, color, and spectral doppler evaluation was performed\non the bilateral lower extremity veins.'], ['EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)\n\nINDICATION: ___ year old man with pancreatic cancer and about to get chemo\nwith new jump in LFTs // evaluate for biliary obstruction or hepatic mets.\n\nTECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were\nobtained.\n\nCOMPARISON: CTA from ___\n\nFINDINGS: \n\nThere is moderate amount of pleural effusion.\n\nLIVER: The hepatic parenchyma appears within normal limits. The contour of the\nliver is smooth. No focal liver mass, though evaluation is limited due to\nbowel gas from prior hepaticojejunostomy. The main portal vein is patent with\nhepatopetal flow. No ascites.\n\nBILE DUCTS: There is mild intrahepatic biliary dilation with pneumobilia,\nunchanged from prior exam on ___. The CHD was not visualized,\nlikely related to hepaticojejunostomy.\n\nGALLBLADDER: The patient is status post cholecystectomy and status post\nhepaticojejunostomy.\n\nPANCREAS: The pancreas is not well visualized, largely obscured by overlying\nbowel gas. The main pancreatic duct is dilated, measuring up to 8 mm. The\nknown pancreatic head mass is not well seen due to overlying bowel gas.\n\nSPLEEN: Normal echogenicity, measuring 12.9 cm.\n\nKIDNEYS: The kidneys were not well seen due to overlying bowel gas.\n\nRETROPERITONEUM: The visualized portions of aorta and IVC are within normal\nlimits.\n\n\nIMPRESSION:\n\n\n1. Limited exam for evaluation of hepatic lesion and pancreatic head mass due\nto overlying bowel gas after hepaticojejunostomy. However, no definite\nhepatic metastatic disease.\n2. Persistent dilation of main pancreatic duct with abrupt occlusion in the\nhead.\n3. Moderate right pleural effusion.\n4. Borderline splenomegaly.\n', '16013806-RR-59', 59, 'grey scale and color doppler ultrasound images of the abdomen were\nobtained.'], ['EXAMINATION: Chest radio\n\nINDICATION: ___ year old man with pancreatic cancer and pleural effusion now\nwith dyspnea // eval for progression of pleural effusion\n\nTECHNIQUE: Chest PA and lateral\n\nCOMPARISON: Chest radiograph from ___.\nCT chest from ___\n\nFINDINGS: \n\nAgain seen are several rounded opacities seen projecting over the bilateral\nlung fields, compatible with known pulmonary nodules. There is again\nelevation of the right hemidiaphragm with mild interval increase in the size\nof the right pleural effusion, now appearing moderate in size. A small left\npleural effusion is unchanged. There is no pneumothorax. The\ncardiomediastinal silhouette is mildly obscured due to adjacent opacities, but\nlikely unchanged.\n\nIMPRESSION: \n\n1. Mild interval increase in the size of the now moderate right pleural\neffusion with stable appearance of a small left pleural effusion.\n2. Again seen are several rounded opacities projecting over the bilateral\nlung fields, compatible with known pulmonary nodules, better seen on the CT\nchest exam from ___.\n', '16013806-RR-60', 60, 'chest pa and lateral'], ["EXAMINATION: RENAL U.S.\n\nINDICATION: ___ year old man with metastatic pancreatic cancer and renal\nfailure, worsening // please evaluate for obstruction/hydronephrosis, if you\ncan also comment on whether bladder distended that would be useful to eval for\npost-obstr process also thank you!Pt is a prisoner and can't leave the floor\nplease come to floor sorry thanks\n\nTECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were\nobtained.\n\nCOMPARISON: ___\n\nFINDINGS: \n\nThe right kidney measures 10.9 cm. The left kidney measures 12.6 cm. There is\nno hydronephrosis, stones, or masses bilaterally. There is normal\ncorticomedullary differentiation bilaterally. There is no evidence of\nhydronephrosis or stones. Bladder wall appears thickened, but the bladder is\npoorly distended.\n\nIMPRESSION: \n\nNo evidence of hydronephrosis. Thickened bladder wall may be secondary to\nunderdistention of the bladder.\n", '16013806-RR-61', 61, 'grey scale and color doppler ultrasound images of the kidneys were\nobtained.'], ['EXAMINATION: CT chest without contrast\n\nINDICATION: ___ year old man with pancreatic cancer // please do on ___.\nplease establish baseline for staging as initiating chemotherapy. noncontrast\nchest CT\n\nTECHNIQUE: Contiguous axial images were obtained through the chest without\nintravenous contrast. Coronal and sagittal reformats were obtained.\n\nCOMPARISON: CT chest with contrast from ___\n\nFINDINGS: \n\nHEART AND VASCULATURE: The thoracic aorta is normal in caliber. Mild\natherosclerotic calcifications are seen in the aortic arch. The heart and\ngreat vessels are within normal limits based on an unenhanced scan. \nAtherosclerotic calcifications are again seen in the coronary arteries. A\nright Port-A-Cath tip is seen at the cavoatrial junction. There is a small\npericardial effusion, likely physiologic.\n\nAXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is\npresent. A new soft tissue lesion is seen along the subcutaneous tissues of\nthe right chest, measuring approximately 1.6 x 2.4 cm, which may represent a\nsite of prior port insertion vs new metastatic nodule (series 3: Image 14). \nThere is diffuse anasarca throughout the visualized thorax. In addition to\nthe diffuse anasarca, there is increased soft tissue thickening and\ninflammatory changes in the right chest wall, which is new since the prior\nstudy. No mediastinal mass or hematoma.\n\nPLEURAL SPACES: There is a new moderate, dependent, nonhemorrhagic, layering\nright pleural effusion. There is associated near complete volume loss of the\nright lower lobe.\n\n\nLUNGS/AIRWAYS: Of note, the study is slightly limited due to motion,\nparticularly in the lung bases. Again seen are innumerable pleural and\nparenchymal soft tissue nodules, many of which appear enlarged compared to the\nprior study in ___ under concerning for worsening metastatic\ndisease. There is increased interseptal thickening in combination with\nincreased nodularity in the left lower lobe, which may represent lymphangitic\nspread. The airways are patent to the level of the segmental bronchi\nbilaterally.\n\nBASE OF NECK: Visualized portions of the base of the neck show no abnormality.\n\nABDOMEN: Included portion of the unenhanced upper abdomen demonstrates\nperihepatic ascites. There is mild central pneumobilia, compatible with\nbiliary stenting. Fiducials are noted at the uncinate process. There is\nagain pancreatic ductal dilatation, measuring up to 9 mm.\n\nBONES: No suspicious osseous abnormality is seen.? There is no acute fracture.\n\n\nIMPRESSION: \n\n1. Enlargement of multiple pleural based and parenchymal soft tissue lesions\nin the thorax with interseptal thickening in the left lower lobe, concerning\nfor worsening metastatic disease with lymphangitic spread.\n2. A new 2.4 cm soft tissue lesion seen along the subcutaneous tissues of the\nright chest may represent a site of prior port insertion vs new metastatic\nlesion.\n3. Increased diffuse anasarca with inflammatory changes seen in the right\nchest wall.\n4. New moderate, nonhemorrhagic, layering right pleural effusion.\n5. Interval increase in perihepatic ascites compared to the prior study in\n___.\n6. Mild central pneumobilia and pancreatic ductal dilatation appear stable.\n\nRECOMMENDATION(S): Recommend correlation with clinical exam and history for\nthe 2.4 cm soft tissue lesion seen along the right chest wall.\n', '16013806-RR-62', 62, 'contiguous axial images were obtained through the chest without\nintravenous contrast. coronal and sagittal reformats were obtained.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with right pleural effusion // s/p thoracentesis\ns/p thoracentesis\n\nIMPRESSION: \n\nIn comparison with study of ___, there has been a thoracentesis\nperformed on the right with removal of some pleural fluid. No evidence of\npost procedure pneumothorax.\nLittle change in the diffuse bilateral pulmonary opacifications.\n', '16013806-RR-63', 63, ''], ['EXAMINATION: UNILAT UP EXT VEINS US\n\nINDICATION: ___ year old man with pancreatic cancer and left upper extremity\nedema.// Please evaluate for left upper extremity DVT.\n\nTECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper\nextremity veins.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nThere is normal flow with respiratory variation in the left subclavian vein.\nThe left internal jugular and axillary veins are patent, show normal color\nflow and compressibility. The left brachial, basilic, and cephalic veins are\npatent, compressible and show normal color flow and augmentation. There is\nsubcutaneous edema in the Left upper extremity.\n\nIMPRESSION: \n\nNo evidence of deep vein thrombosis in the left upper extremity.\n', '16013806-RR-64', 64, 'grey scale and doppler evaluation was performed on the left upper\nextremity veins.'], ['EXAMINATION: CT Abdomen and Pelvis without contrast\n\nINDICATION: ___ year old man with metastatic pancreatic cancer with resolved\nrespiratory distress complicated by acute on chronic kidney with persistent\nculture negative as well as nausea/vomiting.// Please evaluate for colitis,\netiology of diarrhea and nausea. OK for PO contrast. No IV contrast.\n\nTECHNIQUE: THIS EXAMINATION WAS PERFORMED WITHOUT INTRAVENOUS CONTRAST oral\ncontrast was administered.\nCoronal and sagittal reformations were performed and reviewed on PACS.\n\nDOSE: Acquisition sequence:\n 1) Spiral Acquisition 9.1 s, 58.9 cm; CTDIvol = 25.6 mGy (Body) DLP =\n1,493.6 mGy-cm.\n Total DLP (Body) = 1,494 mGy-cm.\n\nCOMPARISON: CT Chest without contrast from ___.\n\nFINDINGS: \n\nLOWER CHEST:\nThere is a moderate nonhemorrhagic, dependent, layering right pleural\neffusion. A small left pleural effusion is also noted. There is associated\ndependent atelectasis. Multiple metastatic nodules are again seen in the lung\nbases, which appear enlarged compared to the prior study in ___ but\nsimilar to the prior CT Chest exam in ___, compatible with worsening\nmetastatic disease. There is associated volume loss of the right lower lobe. \nSuperimposed pneumonia would be difficult to exclude in the right lower lobe\nin the appropriate clinical setting. Atherosclerotic calcifications are noted\nin the coronary arteries.\n\nABDOMEN:\n\nHEPATOBILIARY:\nThe liver demonstrates homogeneous attenuation throughout. Intrahepatic\nbiliary air is unchanged compared to the prior study, and is expected in the\npost-sphincterotomy setting. There is no evidence of focal lesions within the\nlimitations of an unenhanced scan. The gallbladder is surgically absent. \nThere is mild perihepatic ascites which is new since the prior study in\n___ and is seen tracking along the right paracolic gutters and into\nthe pelvis.\n\nPANCREAS:\nThe known pancreatic mass is not well seen on this noncontrast exam. There is\nredemonstration pancreatic ductal dilatation, measuring 7-8 mm, which is\nsimilar to the prior study in ___. A fiducial is noted at the\npancreatic head. There is no peripancreatic stranding.\n\nSPLEEN: The spleen shows normal size and attenuation throughout.\n\nADRENALS: The right and left adrenal glands are normal in size and shape.\n\nURINARY: The kidneys are of normal and symmetric size there is no evidence of\nfocal renal lesions within the limitations of a non-contrast enhanced exam. \nThere is no nephrolithiasis or hydronephrosis. There is no perinephric fluid\ncollection.\n\nGASTROINTESTINAL: The stomach is distended with food products and contrast. \nSmall bowel loops demonstrate normal caliber, wall thickness, and enhancement\nthroughout. The colon and rectum are within normal limits. There is no\ndefinite bowel wall thickening to suggest colitis. The appendix is not\nvisualized.\n\nPELVIS: The urinary bladder and distal ureters are unremarkable. A small\namount of simple appearing free fluid is noted in the deep pelvis.\n\nREPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.\n\nLYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There\nis no pelvic or inguinal lymphadenopathy.\n\nVASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic\ndisease is noted.\n\nBONES: There is no evidence of worrisome osseous lesions or acute fracture.\n\nSOFT TISSUES: There is diffuse anasarca, unchanged.\n\nIMPRESSION:\n\n\n1. Multiple metastatic pulmonary nodules are seen the lung bases, which appear\nenlarged compared to the prior study in ___ but similar to ___, compatible with worsening metastatic disease.\n2. The known pancreatic mass is not well seen on this noncontrast exam,\nhowever, pancreatic ductal dilatation appears similar to the prior study in\n___.\n3. there is new mild perihepatic ascites which was not seen in ___\nand extends along the right paracolic gutters and into the deep pelvis.\n4. Bilateral pleural effusions are new since ___, moderate on the\nright and small on the left, with associated right lower lobe volume loss. \nSuperimposed pneumonia is difficult to exclude in the appropriate clinical\nsetting.\n', '16013806-RR-65', 65, 'this examination was performed without intravenous contrast oral\ncontrast was administered.\ncoronal and sagittal reformations were performed and reviewed on pacs.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with pancreatic cancer and pleural effusion.//\nPlease evaluate for effusion. Please evaluate for effusion.\n\nIMPRESSION: \n\nIn Comparison with study of ___, there has been a substantial increase\nin the right pleural effusion. The degree of pleural effusion is similar to\nthe pre thoracentesis study of ___.\nOtherwise, little change.\n', '16013806-RR-66', 66, ''], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with pleural effusion// s/p thoracentesis \ns/p thoracentesis\n\nIMPRESSION: \n\nIn comparison with the earlier study of this date, there has been a right\nthoracentesis with removal of a substantial amount of pleural fluid. No\nevidence of pneumothorax. Little overall change in the appearance of the\nheart and lungs.\n', '16013806-RR-67', 67, ''], ['EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD\n\nINDICATION: ___ year old man with pancreatic ca now w/ altered mental status,\nh/o seizures// eval for acute cva\n\nTECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was\nperformed with gradient echo, FLAIR, diffusion, and T2 technique were then\nobtained.\n\nCOMPARISON Head CT ___.\n\nFINDINGS: \n\nThe study is severely limited by motion artifact. Although a variety of fast\nimaging methods were attempted, the image quality is for the most part\nnondiagnostic. T2 weighted images demonstrate partial opacification of the\nmastoid air cells bilaterally. No masses are identified. Limited diffusion\nimaging reveals no definite abnormalities. There is no evidence of mass\neffect.\n\nIMPRESSION:\n\n\n1. Severely limited study due to motion artifact. No abnormalities detected..\n', '16013806-RR-68', 68, 'sagittal t1 weighted imaging was performed. axial imaging was\nperformed with gradient echo, flair, diffusion, and t2 technique were then\nobtained.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with inc hypoxia// eval for aspiration or\nworsening pleural effusions eval for aspiration or worsening pleural\neffusions\n\nIMPRESSION: \n\nIn comparison with the study of ___, there again are low lung volumes\nthat accentuate the enlargement of the cardiac silhouette. Diffuse areas of\npulmonary opacification are less prominent, consistent with decreasing\nvascular congestion, resolving aspiration, or both.\nNo evidence of increase in the right pleural effusion. The Port-A-Cath tip is\nalso unchanged.\n', '16013806-RR-69', 69, ''], ['EXAMINATION: RENAL U.S.\n\nINDICATION: ___ year old man with metastatic pancreatic ca w/ worsening renal\nfunction//- eval for hydronephrosis- eval renal veins for thrombosis\n\nTECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the\nkidneys were obtained.\n\nCOMPARISON: CT abdomen and pelvis without contrast dated ___.\n\nFINDINGS: \n\nThe right kidney measures 11.8 cm. The left kidney measures 10.7 cm. There is\nno hydronephrosis, stones, or masses bilaterally. Normal cortical\nechogenicity and corticomedullary differentiation are seen bilaterally.\n\nLimited renal Doppler examination, due to lack of patient compliance. Given\nthis limitation:\n\nRenal Doppler: Intrarenal arteries show normal waveforms with sharp systolic\npeaks and continuous antegrade diastolic flow. The resistive indices of the\nright main renal artery is 0.86. The resistive index on the left is 0.8. \nBilaterally, the main renal arteries are patent with normal waveforms. The\npeak systolic velocity on the right is 65.8 centimeters/second. The peak\nsystolic velocity on the left is 67.5 centimeters/second. Main renal veins are\npatent bilaterally with normal waveforms.\n\nA Foley catheter is present within a decompressed urinary bladder.\n\nThere is a moderate amount of ascites.\n\nIMPRESSION: \n\n1. Limited renal Doppler evaluation, secondary to suboptimal patient\ncomplaints during exam. Within this limitation, no evidence of main renal\nartery stenosis or renal vein thrombosis.\n2. Moderate ascites.\n', '16013806-RR-70', 70, 'grey scale, color and spectral doppler ultrasound images of the\nkidneys were obtained.'], ['INDICATION: ___ year old man with pancreatic cancer and history of right\npleural effusion with worsening hypoxia.// Evaluate for recurrent pleural\neffusion.\n\nTECHNIQUE: AP portable chest radiograph\n\nCOMPARISON: ___\n\nFINDINGS: \n\nA right chest wall Port-A-Cath is present the tip, projecting over the right\natrium.\n\nSuboptimal evaluation secondary to patient positioning. A large right\nlayering pleural effusion is present. Superimposed pulmonary edema is also\nnoted. No pneumothorax. Evaluation of the cardiac silhouette is limited.\n\nIMPRESSION: \n\nLarge layering right pleural effusion and suspected pulmonary edema.\n', '16013806-RR-71', 71, 'ap portable chest radiograph']]

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['medicine']

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20:14:00'), Timestamp('2162-06-22 21:13:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:13:00'), 'Glucose'], [50934, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:13:00'), 'H'], [50947, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:13:00'), 'I'], [50960, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:13:00'), 'Magnesium'], [50970, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:13:00'), 'Phosphate'], [50971, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:13:00'), 'Potassium'], [50983, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:13:00'), 'Sodium'], [51006, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:13:00'), 'Urea Nitrogen'], [51678, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:13:00'), 'L'], [51237, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:48:00'), 'INR(PT)'], [51274, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:48:00'), 'PT'], [51275, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:48:00'), 'PTT'], [51133, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Absolute Lymphocyte Count'], [51137, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Anisocytosis'], [51143, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Atypical Lymphocytes'], [51144, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Bands'], [51146, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Basophils'], [51200, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Eosinophils'], [51221, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'Hematocrit'], [51222, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'Hemoglobin'], [51233, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Hypochromia'], [51244, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Lymphocytes'], [51246, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Macrocytes'], [51248, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'MCH'], [51249, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'MCHC'], [51250, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'MCV'], [51251, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Metamyelocytes'], [51252, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Microcytes'], [51254, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Monocytes'], [51255, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Myelocytes'], [51256, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Neutrophils'], [51265, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'Platelet Count'], [51266, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Platelet Smear'], [51267, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Poikilocytosis'], [51268, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Polychromasia'], [51277, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'RDW'], [51279, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'Red Blood Cells'], [51301, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'White Blood Cells'], [52069, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Absolute Basophil Count'], [52073, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Absolute Eosinophil Count'], [52074, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Absolute Monocyte Count'], [52075, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Absolute Neutrophil Count'], [52172, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'RDW-SD'], [50861, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Alanine Aminotransferase (ALT)'], [50863, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Alkaline Phosphatase'], [50868, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Anion Gap'], [50878, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Asparate Aminotransferase (AST)'], [50882, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Bicarbonate'], [50885, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Bilirubin, Total'], [50893, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Calcium, Total'], [50902, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Chloride'], [50912, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Creatinine'], [50931, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Glucose'], [50934, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'H'], [50947, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'I'], [50954, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Lactate Dehydrogenase (LD)'], [50960, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Magnesium'], [50970, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Phosphate'], [50971, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Potassium'], [50983, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Sodium'], [51006, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Urea Nitrogen'], [51009, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 07:02:00'), 'Vancomycin'], [51678, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'L'], [51221, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'Hematocrit'], [51222, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'Hemoglobin'], [51248, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'MCH'], [51249, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'MCHC'], [51250, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'MCV'], [51265, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'Platelet Count'], [51277, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'RDW'], [51279, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'Red Blood Cells'], [51301, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'White Blood Cells'], [52172, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'RDW-SD'], [51237, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:30:00'), 'INR(PT)'], [51274, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:30:00'), 'PT'], [51275, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:30:00'), 'PTT'], [50802, Timestamp('2162-06-23 06:07:00'), Timestamp('2162-06-23 06:10:00'), 'Base Excess'], [50804, Timestamp('2162-06-23 06:07:00'), Timestamp('2162-06-23 06:10:00'), 'Calculated Total CO2'], [50818, Timestamp('2162-06-23 06:07:00'), Timestamp('2162-06-23 06:10:00'), 'pCO2'], [50820, Timestamp('2162-06-23 06:07:00'), Timestamp('2162-06-23 06:10:00'), 'pH'], [50821, Timestamp('2162-06-23 06:07:00'), Timestamp('2162-06-23 06:10:00'), 'pO2'], [52033, Timestamp('2162-06-23 06:07:00'), Timestamp('2162-06-23 06:08:00'), 'Specimen Type'], [51463, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Bacteria'], [51464, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Bilirubin'], [51466, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Blood'], [51476, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Epithelial Cells'], [51478, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Glucose'], [51482, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Hyaline Casts'], [51484, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Ketone'], [51486, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Leukocytes'], [51487, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Nitrite'], [51491, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'pH'], [51492, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Protein'], [51493, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'RBC'], [51498, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Specific Gravity'], [51506, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Urine Appearance'], [51508, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Urine Color'], [51512, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Urine Mucous'], [51514, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Urobilinogen'], [51516, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'WBC'], [51519, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Yeast'], [51082, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:17:00'), 'Creatinine, Urine'], [51087, Timestamp('2162-06-23 10:17:00'), NaT, 'Length of Urine Collection'], [51099, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:27:00'), 'Protein/Creatinine Ratio'], [51102, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:27:00'), 'Total Protein, Urine'], [50868, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Anion Gap'], [50882, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Bicarbonate'], [50893, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Calcium, Total'], [50902, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Chloride'], [50912, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Creatinine'], [50931, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Glucose'], [50934, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'H'], [50947, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'I'], [50960, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Magnesium'], [50970, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Phosphate'], [50971, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Potassium'], [50983, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Sodium'], [51006, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Urea Nitrogen'], [51678, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'L']]

Question: A 50 M is admitted. He/she says he/she has Shortness of breath . History of illness: Mr. ___ is a ___ yo man with a presumed diagnosis metastatic pancreatic cancer, likely metastatic who is being transferred from ___ out of concern for tamponande and need for cardiac window ___ setting of new hypoxemia. ___ course: Mr. ___ presented to ___ on ___ from correction facility with SOB and productive cough and low grade temperature. CXR ___ the ED was concerning for an infiltrate vs. atelectasis vs. edema. He was initiated on levofloxacin and then transitioned to azithromycin and ceftriaxone. Troponin was 0.07 and BNP 499. Due to troponin bump and history of cancer decision was made to treat empirically with treatment dose of enoxaparin. He was also given "low dose" Lasix. D-dimer was sent and positive. V/Q scan was performed and indeterminate. On evening of ___ he was noted to have increased oxygen requirement and started on ___ mask with 100% oxygen saturation. Later ___ the evening, however, he was noted to be "unresponsive and hypoxemic with oxygen mask off." ABG at that time was blood gas showed pH 7.29. PCO2 52 and PO2 ___ the 64 26 on 100% nonrebreather." He was then transferred to the MICU where antibiotics were broadened to meropenem and vancomycin. He was reportedly very hypertensive at time of transfer (no vitals noted) and given 5 mg IV metoprolol. An echo was performed that showed, "Cardiologist reports small but pre-tamponade physiology seen on TTE." He was transferred to ___ out of concern for need for cardiac window. At time of transfer he was on high flow 60% satting 92-95%. ___ addition to hypoxemia and cough, he is having diarrhea requiring rectal tube. Pancreatic cancer course (per OMR and oncology notes): ___ ___ he developed new onset abdominal pain and was noted to have a pancreatic mass. Biopsies were performed and indeterminate. ___ ___ he was admitted to ___ with perforated cholecystitis s/p percutaneous cholecystostomy tube. MRCP at that time raised suspicion for head of pancreas mass. Later that month she ERCP with Spyglass done showed a malignant-appearing stricture and EUS showing an ill-defined mass ___ the pancreatic neck with an abrupt transition ___ caliber of the PD, brushings and biopsies again atypical. Repeat ERCP for rising LFTs was performed. A fully covered metal stent placed (prior stent dislodged). Abscess cavity had collapsed and drain removed. Given all this, had large-volume weight loss with inability to maintain feeds with subsequent malnutrition and hypoalbuminemia requiring NJT feeds. ___ ___ he was planned for Whipple procedure for definitive diagnosis of pancreatic mass. However, intra-operatively he became hypotensive and hypoglycemic. Surgery was converted to CCY and double bypass was performed with fiducial placement. Biopsies of the pancreatic head returned positive for ductaladenocarcinoma with invasion of peripancreatic adipose tissue. There was a delay ___ follow-up between ___ and ___ when he followed up with Dr. ___ ___ oncology. At that visit he was scheduled for biopsy of known lung nodules to make formal diagnosis of metastatic lung cancer. At this time plan is to initiate palliative systemic therapy for his pancreatic cancer (once biopsy is done). At that visit it was also noted that he was grossly anasarcic and hypertensive. On arrival to the MICU, he states that he is feeling very short of breath and weak. He also endorses some diarrhea. Past Medical History: - Metastatic pancreatic cancer, presumed - HTN - Grand mal seizures - Depression - HLD - DM, insulin dependent - History of Biliary obstruction/stricture Social History: ___ Family History: Denies family history of colon, pancreas, liver, breast or other malignancies. Denies history of other family gastrointestinal disease or pancreatitis. Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: 0.9% Sodium Chloride Calcium Gluconate Iso-Osmotic Dextrose Vancomycin Insulin Furosemide Ipratropium Bromide MDI Syringe (0.9% Sodium Chloride) Alteplase (Catheter Clearance) 0.9% Sodium Chloride (Mini Bag Plus) CefePIME PARoxetine Fludrocortisone Acetate Insulin Lidocaine 1% (For PICC/Midline Insertions) Glucose Gel Furosemide Albuterol Inhaler Azithromycin Iso-Osmotic Dextrose Vancomycin Omeprazole Glucagon Bisacodyl Dextrose 5% Levofloxacin 0.9% Sodium Chloride (Mini Bag Plus) CefePIME LevETIRAcetam HydrALAZINE Heparin Flush (10 units/ml) Insulin Fludrocortisone Acetate Bisacodyl Albumin 25% 0.9% Sodium Chloride Calcium Gluconate Dextrose 50% 0.9% Sodium Chloride Calcium Gluconate HydrALAZINE Albuterol 0.083% Neb Soln 0.9% Sodium Chloride Calcium Gluconate 5% Dextrose Ciprofloxacin IV 0.9% Sodium Chloride (Mini Bag Plus) CefePIME Sodium Chloride 0.9% Flush Ipratropium-Albuterol Neb Senna Heparin Labetalol Target Lab Orders: Alanine Aminotransferase (ALT) Albumin Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose H I Magnesium Phosphate Potassium Sodium Urea Nitrogen L INR(PT) PT PTT Absolute Lymphocyte Count Anisocytosis Atypical Lymphocytes Bands Basophils Eosinophils Hematocrit Hemoglobin Hypochromia Lymphocytes Macrocytes MCH MCHC MCV Metamyelocytes Microcytes Monocytes Myelocytes Neutrophils Platelet Count Platelet Smear Poikilocytosis Polychromasia RDW Red Blood Cells White Blood Cells Absolute Basophil Count Absolute Eosinophil Count Absolute Monocyte Count Absolute Neutrophil Count RDW-SD Alanine Aminotransferase (ALT) Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatinine Glucose H I Lactate Dehydrogenase (LD) Magnesium Phosphate Potassium Sodium Urea Nitrogen Vancomycin L Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD INR(PT) PT PTT Base Excess Calculated Total CO2 pCO2 pH pO2 Specimen Type Bacteria Bilirubin Blood Epithelial Cells Glucose Hyaline Casts Ketone Leukocytes Nitrite pH Protein RBC Specific Gravity Urine Appearance Urine Color Urine Mucous Urobilinogen WBC Yeast Creatinine, Urine Length of Urine Collection Protein/Creatinine Ratio Total Protein, Urine Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose H I Magnesium Phosphate Potassium Sodium Urea Nitrogen L Target Procedures: Respiratory Ventilation, 24-96 Consecutive Hours Insertion of Endotracheal Airway into Trachea, Via Natural or Artificial Opening Insertion of Infusion Device into Superior Vena Cava, Percutaneous Approach DOCTOR'S NOTE Hospital Notes: : PRINICPLE REASON FOR ADMISSION: =============================== Mr. ___ is a ___ male with history of metastatic pancreatic cancer (s/p = hepaticojejunostomy, gastrojejunostomy, CCY) who was initially transferred from ___ due to concern for pericardial tamponade (only small effusion seen on most recent echo), and found to be ___ hypoxemic respiratory failure requiring intubation ___ secondary to pneumonia and volume overload. Early hospital course complicated by renal failure and ATN. Subsequently received C1D1 FOLFOX ___ house on ___ with further renal failure and hyperkalemia. Course otherwise notable for persistent diarrhea, recurrent right pleural effusion, and hypertension. ACTIVE ISSUES: ============== # Hypoxic Respiratory Failure: # Malignant Pleural Effusions: Initially with hypoxic respiratory failure requiring intubation ___ due to PNA and anasarca. He is s/p cefepime ___ for pneumonia). Brief hypoxia to 90% on ___ required IV lasix. No CMV on BAL. CXR ___ with some right pleural effusion increase, IP drained 1L on ___, but did not place pleurex as CT chest suggested persistent pulmonary parenchymal issues as large contributor. On ___ patient reported worsening SOB and hypoxic to 88% with minimal exertion. Repeat CXR showed reaccumulation of right pleural effusion. Thoracentesis by IP with drainage of 1L. Patient has refused Pleurex catheter at that time. Again, developed O2 requirement on ___ with recurrent pleural effusion. Restarted IV Lasix 120mg bid and will need repeat thoracentesis vs. pleurX. # Acute on chronic renal failure # ATN: Initial etiology ATN thougth from from overdiuresis ___ setting of respiratory failure, and improved prior to initiation of chemotherapy. More recently, oxaliplatin likely caused significant kidney damage. Cr has now stabilized around 3.8. Nephrology has been following, and he has not yet needed dialysis. However, K has risen again starting ___, neprhology aware and Lasix 120mg IV bid, chorthalidone, and po bicarb was started. Patient refused foley for closer UOP monitoring, but is frequently incontinent of large volume urine. Will need very close monitoring of volume status and potassium. # Hyperkalemia: See above; was quite severe over a number of days early ___ hospitalization following initial renal insult. Improved markedly at that time after initiation of chlorthalidone. Chlorthalidone was then held given recurrent renal failure. However, now that Cr has stabilized a bit, feel OK to continue chlorthalidone and IV Lasix. He has been treated with IV Lasix 120mg bid, chlorthalidone 50mg daily, and sodium bicarbonate. Received IV insulin and dextrose on ___. Kayexelate not given due to severe diarrhea. Also maintained on low K diet. # Proteinuria: 24 hour urine w/ >3g protein. Per renal likely due to diabetic glomerulopathy as had proteinuria to similar degree at least for past 8 months(300 prot on dipstick ___. Unlikely membranous GN iso active malignancy. C4 wnl, C3 slightly low. Hep B/C negative. ___, ANCA negative. Cryo negative. Likely contributing to anasarca. # Metastatic Pancreatic Cancer: Biopsy confirmed metastatic pancreatic ca to the lungs. FOLFOX given ___ finished ___. Given worsening kidney disease and functional status C1D15 due ___ on hold, and there are no active plans to resume chemotherapy. Dr. ___ will continue to re-evaluate patient for possibility of resuming chemotherapy if renal function and function status improve. Please maintain contact with Dr. ___ at ___ and arrange follow up when appropriate. # N/V/Diarrhea: Patient with significant persistent diarrhea and incontinence during entire hospital stay. Initially with Flexiseal, removed ___. GI was consulted early ___ course, and etiology thought to be post-abx diarrhea vs. recent liquid diet vs. pancreatic enzyme deficiency vs. post FOLFOX. C. diff was neg x2, O&P and stool cultures were also negative. CT abdomen/pelvis w/ PO contrast did not show any cause for diarrhea. He has been managed with loperamide, Lomotil, opium tincture along with creon and psyllium wafers. ___ need to consider reconsulting GI, resending stool cultures, and imaging studies of diarrhea persists. # Anasarca # Bilateral Lower Extremity Edema # Upper Extremity Edema: Fluid status fluctuates, appears volume overloaded. Likely secondary to hypoalbuminemia ___ setting of possible nephrotic syndrome and poor nutrition with active malignancy. ___ ___ negative. LUE ultrasound negative for DVT. 120mg IV Lasix bid as above. # Transaminitis: Stable/resolving. RUQ US without hepatic mets. HBV/HCV serologies negative and HBV VL not detected. Likely from portal congestion from anasarca. # Guaiac-Positive Stools: # Anemia: Anemia is stable near baseline Hgb ___. Hemolysis labs were negative. Reported frank bloody BM overnight on ___ with previously guaiac positive stools. No prior colonoscopy on record. Colonoscopy was deferred. # HTN: Treated with labetolol 600mg tid and amlodipine. Chlorthalidone was held much of hospitalization but restarted on ___ ___ setting of hyperkalemia and stable kidney function. # Type II Diabetes: Continued Humalog ISS # Epilepsy: History of grand mal seizures. Continue keppra 500mg BID. Was thought to have partial seizure on complex partial seizure witnessed by RN on ___. However, EEG did not reveal any epileptiform activity x 48 hrs. MRI brain completed w/o contrast and w/ significant motion activity but did not reveal any obvious acute process. # Pericardial Effusion: Very small with no evidence of tamponade. Likely from severe hypoalbuminemia vs. physiologic as opposed to malignant ___ origin. # Psych: Continued paroxetine 40mg daily # FEN: replete electrolytes prn, renal diet # Prophylaxis: Subcutaneous heparin # Access: POC # Restraints: Shackles # Communication: HCP: ___ (sister) ___ # Full Code (confirmed by ICU Team) # DISPO: ___ TRANSITIONAL ISSUES: ==================== - Please monitor K upon arrival to unit and maintain cardiac monitoring - Please evaluate for thoracentesis vs tunneled pleural catheter - Consider GI consult for persistent diarrhea refractory to aggressive antidiarrheals - Please continue to re-evaluate fromo oncologic perspective for possibility of palliative chemotherapy BILLING: >30 min coordinating care or discharge DISPO: ___ Other Results: ADMISSION LABS: =============== ___ 08:14PM BLOOD WBC-9.3# RBC-3.06* Hgb-8.7* Hct-28.2* MCV-92 MCH-28.4 MCHC-30.9* RDW-12.2 RDWSD-41.0 Plt ___ ___ 08:14PM BLOOD Neuts-88* Bands-2 Lymphs-6* Monos-4* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-8.37* AbsLymp-0.56* AbsMono-0.37 AbsEos-0.00* AbsBaso-0.00* ___ 08:14PM BLOOD ___ PTT-46.4* ___ ___ 08:14PM BLOOD Glucose-97 UreaN-29* Creat-1.9* Na-137 K-3.9 Cl-106 HCO3-21* AnGap-14 ___ 08:14PM BLOOD ALT-25 AST-43* AlkPhos-250* TotBili-<0.2 ___ 08:14PM BLOOD Albumin-1.1* Calcium-6.8* Phos-4.2 Mg-1.7 IMAGING: ======== ___ Imaging CHEST (PORTABLE AP) Large layering right pleural effusion and suspected pulmonary edema. ___ Imaging RENAL U.S 1. Limited renal Doppler evaluation, secondary to suboptimal patient complaints during exam. Within this limitation, no evidence of main renal artery stenosis or renal vein thrombosis. 2. Moderate ascites. ___ Imaging MR HEAD W/O CONTRAST 1. Severely limited study due to motion artifact. No abnormalities detected. ___ Imaging CHEST (PORTABLE AP) ___ comparison with the study of ___, there again are low lung volumes that accentuate the enlargement of the cardiac silhouette. Diffuse areas of pulmonary opacification are less prominent, consistent with decreasing vascular congestion, resolving aspiration, or both. No evidence of increase ___ the right pleural effusion. The Port-A-Cath tip is also unchanged. ___BD & PELVIS W/O CON 1. Multiple metastatic pulmonary nodules are seen the lung bases, which appear enlarged compared to the prior study ___ ___, concerning for worsening metastatic disease. 2. The known pancreatic mass is not well seen on this noncontrast exam, however, pancreatic ductal dilatation appears similar to the prior study ___ ___. 3. There is new mild perihepatic ascites which was not seen ___ ___ and extends along the right paracolic gutters and into the deep pelvis. 4. Bilateral pleural effusions are new since ___, moderate on the right and small on the left, with associated right lower lobe volume loss. ___ Imaging UNILAT UP EXT VEINS US No evidence of deep vein thrombosis ___ the left upper extremity. ___HEST W/O CONTRAST 1. Enlargement of multiple pleural based and parenchymal soft tissue lesions ___ the thorax with interseptal thickening ___ the left lower lobe, concerning for worsening metastatic disease with lymphangitic spread. 2. A new 2.4 cm soft tissue lesion seen along the subcutaneous tissues of the right chest may represent a site of prior port insertion vs new metastatic lesion. 3. Increased diffuse anasarca with inflammatory changes seen ___ the right chest wall. 4. New moderate, nonhemorrhagic, layering right pleural effusion. 5. Interval increase ___ perihepatic ascites compared to the prior study ___ ___. 6. Mild central pneumobilia and pancreatic ductal dilatation appear stable. ___ Imaging CHEST (PORTABLE AP) ___ comparison with study of ___, there has been a thoracentesis performed on the right with removal of some pleural fluid. No evidence of post procedure pneumothorax. Little change ___ the diffuse bilateral pulmonary opacifications. ___ Imaging RENAL U.S. No evidence of hydronephrosis. Thickened bladder wall may be secondary to underdistention of the bladder. ___ Imaging CHEST (PORTABLE AP) No evidence of hydronephrosis. Thickened bladder wall may be secondary to underdistention of the bladder. ___ Imaging RENAL U.S. No evidence of hydronephrosis. Thickened bladder wall may be secondary to underdistention of the bladder. ___ Imaging LIVER OR GALLBLADDER US 1. Limited exam for evaluation of hepatic lesion and pancreatic head mass due to overlying bowel gas after hepaticojejunostomy. However, no definite hepatic metastatic disease. 2. Persistent dilation of main pancreatic duct with abrupt occlusion ___ the head. 3. Moderate right pleural effusion. 4. Borderline splenomegaly. ___ Imaging BILAT LOWER EXT VEINS No evidence of deep venous thrombosis ___ the right or left lower extremity veins. Right calf vessels were not definitely visualized. ___ THORACENTESIS NEEDLE IMPRESSION: Successful ultrasound-guided right thoracentesis with removal of 0.8 L of clear, straw-colored fluid, which was sent for cytology. ___ REPLACEMENT IMPRESSION: Successful placement of a single lumen chest power Port-a-cath via the right internal jugular venous approach. The tip of the catheter terminates ___ the right atrium. The catheter is ready for use. Successful removal of the malpositioned right Port-A-cath. ___ U.S. IMPRESSION: 1. No hydronephrosis. 2. Echogenic kidneys may reflect medical renal disease. 3. Trace ascites. ___ ABDOMEN IMPRESSION: No of evidence of bowel obstruction or pneumoperitoneum. ___ LAVAGE NEGATIVE FOR MALIGNANT CELLS. ___ TTE The left atrium is normal ___ size. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a very small to small pericardial effusion measuring up to 0.8 centimeters ___ greatest dimension, but generally 0.2-0.4 cm ___ size. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Very small to small pericardial effusion without echocardiographic evidence of tamponade. Mildly dilated ascending aorta. Preserved biventricular systolic function. Indeterminate pulmonary artery systolic pressure. ___ CXR Extensive consolidations ___ particular involving right upper lobe as well as bibasal areas is unchanged. Central venous line tip terminates at the level of mid right subclavian vein. Cardiomediastinal silhouette is difficult to assess since it is obscured by widespread parenchymal consolidations. Bilateral pleural effusions are present. No pneumothorax. MICROBIOLOGY: ============= ___ NO CRYPTOSPORIDIUM OR GIARDIA SEEN. ___ NO OVA AND PARASITES SEEN. ___ FECAL CULTURE (Final ___: NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. ___ Respiratory Viral Screen & Culture Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. ___ LAVAGE GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Final ___: NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final ___: Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our ___ studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (___). Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ___: NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Final ___: NO MYCOBACTERIA ISOLATED. ___ ACID FAST CULTURE (Final ___: NO MYCOBACTERIA ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ___ BLOOD CX: NO GROWTH x2 ___ SPUTUM GRAM STAIN & CULTURE: GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS SINGLY. RESPIRATORY CULTURE (Final ___: RARE GROWTH Commensal Respiratory Flora. ___ URINE CX: NO GROWTH PATHOLOGY: ========== ___ Tissue: LUNG, CORE BIOPSY FOR TUMOR Metastatic adenocarcinoma - Positive: CK7, ___. - Negative: CK20, TTF-1, B72.3. OTHER LABS OF NOTE: ================== ___ 06:00AM BLOOD %HbA1c-6.1* eAG-128* ___ 05:21AM BLOOD Triglyc-110 HDL-20 CHOL/HD-3.9 LDLcalc-36 ___ 06:00AM BLOOD HBsAg-Negative HBsAb-Negative HBcAb-Negative ___ 06:00AM BLOOD ANCA-NEGATIVE B ___ 06:00AM BLOOD ___ ___ 06:00AM BLOOD C3-78* C4-38 ___ 11:17PM BLOOD HIV Ab-Negative

2143-11-17 21:09:00

ENGLISH

MARRIED

WHITE

F

[[23153038, Timestamp('2143-11-17 21:10:24'), '', 'CMED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 10 mg PO DAILY \n2. Lorazepam 1 mg PO QAM:PRN anxiety \n3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze, sob \n\nSECONDARY DIAGOSES:\n- Hypertension\n- Anxiety\n- H/O Undifferentiated right neck tumor in ___, s/p resection \nand chemotherapy and radiation at ___. \n- H/O Malignant spindle cell tumor of right posterior shoulder, \ns/p \n excisional biopsy ___, \n- H/O Left breast cancer', 'Brief Hospital Course': 'NIL', 'Pertinent Results:': '\nADMISSION LABS:\n___ 06:05PM BLOOD WBC-6.0 RBC-3.63* Hgb-11.9 Hct-35.3 \nMCV-97 MCH-32.8* MCHC-33.7 RDW-12.4 RDWSD-43.8 Plt ___\n___ 06:05PM BLOOD Neuts-59.1 ___ Monos-9.4 Eos-3.0 \nBaso-1.3* Im ___ AbsNeut-3.57 AbsLymp-1.58 AbsMono-0.57 \nAbsEos-0.18 AbsBaso-0.08\n___ 06:05PM BLOOD ___ PTT-28.2 ___\n___ 06:05PM BLOOD Glucose-81 UreaN-9 Creat-0.4 Na-138 K-3.9 \nCl-102 HCO3-24 AnGap-16\n___ 06:05PM BLOOD proBNP-2292*\n___ 06:05PM BLOOD cTropnT-<0.01\n___ 06:05PM BLOOD Calcium-9.6 Phos-3.1 Mg-1.7\n___ 06:05PM BLOOD TSH-3.4\n\nCXR ___\nFINDINGS: \nPreviously seen left parenchymal opacity has resolved. Lungs \nare now clear without effusion, edema or consolidation. Right \napical pleural based opacity with superior retraction of the \nright hilum is most compatible with scarring as identified on \nprevious exams. The cardiomediastinal silhouette is stable. \nPortions of the right clavicle are not visualized. No acute \nosseous abnormalities. \nIMPRESSION: \nNo acute cardiopulmonary process. \n\nCTA ___\nIMPRESSION: \n1. No evidence of pulmonary embolism. \n2. Resolution of previously seen airspace opacities since ___. \n3. Unchanged borderline right hilar lymphadenopathy. \n4. Small right pleural effusion. \n5. Patulous thoracic esophagus, unchanged. \n6. Enlarged heterogeneous left thyroid with a discrete 10 mm \nposterior thyroid nodule, a nonemergent thyroid ultrasound can \nbe obtained for further evaluation if not already performed. \n\n#DYSPNEA ON EXERTION: Patient presented with dyspnea on exertion \nwithout chest pain. EKGs with ST depressions in inferior limb \nleads and lateral precordial leads have been seen previously, \nare unchanged, and likely due to LVH rather than ischemia. Her \ntroponins were negative x2 and BNP elevated. CT findings showed \nemphysema and mild right pleural effusion without evidence of \npulmonary embolus. Echo in ___ was unremarkable, with normal \nLVEF, normal RV function, and only mildly elevated TR gradient, \nalthough interval worsening is possible. COPD felt to be most \nlikely, given her heavy smoking history, wheezing, emphysematous \nchanges on CT. Monitored on telemetry overnight without acute \nevent. Treated with ipratropium nebulizers and furosemide 10mg \nIV. Discharged on Spiriva Respimat 2 puffs daily and aspirin \n81mg daily. Consider repeat ECHO as outpatient if concern for \ncardiac health arises. \n\n# Thyroid nodule: Enlarged heterogeneous left thyroid with a \ndiscrete 10 mm posterior thyroid nodule found on CTA from \n___. TSH normal. Given history of malignancy recommend \nthyroid ultrasound for further evaluation if not already \nperformed.\n\n#Hypertension: BP well controlled, continued lisinopril. \n\n#Anxiety: Continued AM lorazepam PRN \n\nTRANSITIONAL ISSUES:\n- Like previous providers, recommend ___ as outpatient, please \nfollow up scheduling.\n- Discharged on ASA 81 daily and Spiriva 2 puffs daily. \n- Consider repeat ECHO if any changes in cardiac status. \n- Patient given instructions to call for follow up with PCP and \npulmonology \n- NEW!!!! ****Enlarged heterogeneous left thyroid with a \ndiscrete 10 mm posterior thyroid nodule, a nonemergent thyroid \nultrasound recommended for further evaluation if not already \nperformed. ****\n\n# CODE STATUS: FULL CODE\n\n', 'Physical Exam:|Physical': '\nADMISSION PHYSICAL EXAM:\nVitals: 97.6-98.8, 105/65-118/67, 90-92, 20, 96-99% RA\n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL \n Neck: Supple, JVP 8-9cm above RA with patient at 45 degrees \n CV: Regular rate and rhythm, normal S1 + S2, pre-systolic click \nwith ___ last systolic murmur. \n Lungs: Decreased breath sounds. Prolonged expiratory phase. Low \npitch wheezing and faint rhonchi. Unlabored breathing at rest on \nRA. \n Abdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \n GU: No foley \n Ext: Warm, well perfused, 2+ pulses. 1+ pitting edema to lower \nshins. \n Neuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, gait deferred. \n\nDISCHARGE PHYSICAL EXAM:\nVitals: 97.6-98.8, 105/65-118/67, 90-92, 20, 96-99% RA\nGeneral: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL \n Neck: Supple, JVP 8 cm above RA with patient at 45 degrees \n CV: Regular rate and rhythm, normal S1 + S2, pre-systolic click \nwith ___ last systolic murmur. \n Lungs: CTAB. Unlabored breathing at rest on RA. \n Abdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding.\n GU: No foley \n Ext: Warm, well perfused, 2+ pulses. trace pitting edema at the \nankles.\n Neuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, gait deferred. \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n ___ year old woman with history of undifferentiated carcinoma of \nthe right neck, malignant ___ cell tumors, and left breast \ncancer, HTN, and likely emphysema (no ___, not on medications), \npresenting with dyspnea on exertion. \n She was admitted from ___ to ___ for shortness of \nbreath, cough, left sided chest pain, hypoxemia. SHe was \nadmitted to the MICU with hypoxemic respiratory failure and \nsepsis due to pneumonia; she was quickly transitioned of ___ \nmask to nasal canula and transferred to the floor. Blood \ncultures grew strep pneumo; she was treated with ceftriaxone and \nazithro; vancomycin added given severe initial hypoxemia; \ntransitioned to levofloxacin to complete treatment. She followed \nup with ___ in pulmonology in ___, who receommended \n___, which the patient has not done yet. \n She returned several days ago from a 2 week vacation in ___. \nOne week ago, she developed dyspnea on exertion and severe \nfatigue. She becomes short of breath with walking short \ndistances on a flat surface, and must walk more slowly and stop \nfor several minutes to catch her breath. Has had several \nepisodes of feeling short of breath at rest, but her symptoms \nare mainly with exertion. Her symptoms have not progressed over \nthe past week. She has had adequate improvement in her symptoms \nif she uses her albuterol inhaler (has been using BID in order \nto conserve limited supply). She states she is able to breath \nmore comfortably if propped up in bed, concerning for orthopnea. \nShe has mild cough. No pleuritic pain or discomfort; able to \ntake deep breaths. She denies fevers, chills, sputum production, \nchest pain, lightheadedness, diaphoresis, nausea, vomiting, \ndiarrhea, urinary symptoms, myalgia/arthralgia, or lower \nextremity edema. No sick contacts. \n In ___, she had a CXR and a CTA for PE, which reportedly \nshowed a "7cm mass" in lungs (not seen on ___ radiology \nreview). \n In the ED, initial vitals were: T 97.3 HR 102 BP 141/74 RR 18 \nSPO2 100% RA \n - Labs were significant for : \n -- WBC 6.0, Hgb 11.9, Plt 296 \n --INR 1.0 \n --proBNP 2292 \n --Chem 7 normal (creat 0.4) \n --troponin T <0.01 \n EKG: sinus tachy, ST depressions lat/inf, STE V2 ~1mm. NEW \n Repeat EKG: NSR 95, NA, NI, 1mm STE v2, STD laterally, improved \nfrom prior, but new from ___. \n - Imaging: \n -- CTA chest: no PE, small right pleural effusion. Enlarged \nheterogeneous left thyroid with a discrete 10mm posterior \nthyroid nodule. \n -- CXR: no acute process . \n\n -The patient was given lorazepam 0.5mg PO and aspirin 325mg PO. \n\n Vitals prior to transfer were: t 97.8 HR 97 BP 115/71 RR 25 \nSPO2 98% RA \n Upon arrival to the floor, she denies complaints. \n REVIEW OF SYSTEMS: \n (+) Per HPI \n (-) Denies fever, chills, night sweats, recent weight loss or \ngain. Denies headache, sinus tenderness, rhinorrhea or \ncongestion. Denies chest pain or tightness, palpitations. Denies \nnausea, vomiting, diarrhea, constipation or abdominal pain. No \nrecent change in bowel or bladder habits. No dysuria. Denies \narthralgias or myalgias. \n\nPast Medical History:\n1. Undifferentiated right neck tumor in ___, s/p \nresection and chemotherapy and radiation at ___ \n___. \n2. Malignant spindle cell tumor of right posterior shoulder, s/p \nexcisional biopsy ___, 7 x 4 x 1 cm overlying the right \nsupraspinatus muscle. The original pathology from the tumor in \n___ has been unavailable so it has been difficult to know \nwhether this is a new tumor, or a recurrence. A follow-up MRI \nand CT-guided biopsy of the right supraspinatus prominence in \n___ did not reveal evidence of tumor. In ___ had 2 \nmore spindle cell tumors \nremoved from her right shoulder. \n3. Left breast cancer, ___, likely ___ previous radiation. s/p \nlumpectomy without radiation or chemotherapy. Then tubular \ncarcinoma ___ s/p mastectomy ___. \n4. R clavicular fracture s/p repair ___\n5. Hypertension\n6. Anxiety \n\nSocial History:\n___\nFamily History:\nMother had MI in her ___ and congestive heart disease. Unknown \nwhat father died of. No other family members with heart disease \nor malignancies. \n\n', 'Chief Complaint:|Complaint:': '\nDyspnea on Exertion\n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '12823948-DS-18', 18, 'medicine']]

[['INDICATION: ___ with sob // eval for sob\n\nTECHNIQUE: Frontal lateral views the chest.\n\nCOMPARISON: Chest x-ray from ___.\n\nFINDINGS: \n\nPreviously seen left parenchymal opacity has resolved. Lungs are now clear\nwithout effusion, edema or consolidation. Right apical pleural based opacity\nwith superior retraction of the right hilum is most compatible with scarring\nas identified on previous exams. The cardiomediastinal silhouette is stable. \nPortions of the right clavicle are not visualized. No acute osseous\nabnormalities.\n\nIMPRESSION: \n\nNo acute cardiopulmonary process.\n', '12823948-RR-75', 75, 'frontal lateral views the chest.'], ['EXAMINATION: CTA CHEST.\n\nINDICATION: ___ woman with shortness of breath, evaluate for\npulmonary embolism. The patient has a history of sarcoma, spindle cell\nneoplasm, and left breast cancer.\n\nTECHNIQUE: Images were acquired at an outside hospital and submitted for\nreview. No sagittal images and only coronal MIPS images were available for\nreview.\n\nDOSE: Dose report not provided.\n\nCOMPARISON: Comparison is made to CTA chest ___ and PET-CT from ___.\n\nFINDINGS: \n\nCTA:\n\nThe pulmonary arteries are well opacified to the subsegmental level. There is\nno filling defect to suggest pulmonary embolism. The main pulmonary trunk is\nnormal in size measuring 2.7 cm. The thoracic aorta is not well opacified\nhowever, there is no evidence of aneurysmal dilation. There is mild\natherosclerotic calcification at the level of the aortic arch.\n\nCT CHEST: The left thyroid lobe is heterogeneous with a 10 mm posterior\nhypodense thyroid nodule, better seen on the current study (series 5, image\n4).\n\nThere is no axillary or supraclavicular adenopathy. There is no significant\nmediastinal adenopathy. There are prominent hilar lymph nodes measuring up to\n10 mm on the right (series 5, image 46), not significantly changed from ___.\n\nHeart size is normal. Coronary artery and aortic valvular calcifications are\nmoderate.\n\nThe thoracic esophagus is mildly patulous. Views of the upper abdomen are\nunremarkable.\n\nThe airway is patent to the subsegmental level bilaterally. There is moderate\ncentrilobular emphysema, most pronounced at the lung bases. Previously seen\nconsolidative opacities in the right upper lobe, right lower lobe, right\nmiddle lobe and lingula have resolved. Pleural thickening with adjacent\nparenchymal scarring at the right lung apex is unchanged since ___ and likely\npost radiation. There is also pleural thickening of the left lung apex, to a\nlesser degree, also unchanged. There is a small amount of pleural fluid on\nthe right (series 6, image 141). There is no left-sided pleural effusion. \nThere are multiple scattered calcified granulomas.\n\nOSSEOUS STRUCTURES: A left breast prosthesis is present. An old right\nclavicular fracture is present. Irregular sclerosis of the superior right\nribs is also likely post treatment related. Mixed lucency and sclerosis in\nthe upper thoracic vertebral bodies is also noted as on prior. There is no\nacute fracture identified. There are no new suspicious bony lesions.\n\nIMPRESSION:\n\n\n1. No evidence of pulmonary embolism.\n2. Resolution of previously seen airspace opacities since ___.\n3. Unchanged borderline right hilar lymphadenopathy.\n4. Small right pleural effusion.\n5. Patulous thoracic esophagus, unchanged.\n6. Enlarged heterogeneous left thyroid with a discrete 10 mm posterior thyroid\nnodule, a nonemergent thyroid ultrasound can be obtained for further\nevaluation if not already performed.\n', '12823948-RR-76', 76, 'images were acquired at an outside hospital and submitted for\nreview. no sagittal images and only coronal mips images were available for\nreview.']]

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[]

['medicine']

[[51221, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'Hematocrit'], [51222, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'Hemoglobin'], [51248, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'MCH'], [51249, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'MCHC'], [51250, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'MCV'], [51265, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'Platelet Count'], [51277, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'RDW'], [51279, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'Red Blood Cells'], [51301, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'White Blood Cells'], [52172, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'RDW-SD'], [50868, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 09:11:00'), 'Anion Gap'], [50882, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 09:11:00'), 'Bicarbonate'], [50902, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 09:11:00'), 'Chloride'], [50912, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 09:11:00'), 'Creatinine'], [50931, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 09:11:00'), 'Glucose'], [50971, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 09:11:00'), 'Potassium'], [50983, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 09:11:00'), 'Sodium'], [51003, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 09:11:00'), 'Troponin T'], [51006, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 09:11:00'), 'Urea Nitrogen']]

Question: A 50 F is admitted. He/she says he/she has Dyspnea on Exertion . History of illness: ___ year old woman with history of undifferentiated carcinoma of the right neck, malignant ___ cell tumors, and left breast cancer, HTN, and likely emphysema (no ___, not on medications), presenting with dyspnea on exertion. She was admitted from ___ to ___ for shortness of breath, cough, left sided chest pain, hypoxemia. SHe was admitted to the MICU with hypoxemic respiratory failure and sepsis due to pneumonia; she was quickly transitioned of ___ mask to nasal canula and transferred to the floor. Blood cultures grew strep pneumo; she was treated with ceftriaxone and azithro; vancomycin added given severe initial hypoxemia; transitioned to levofloxacin to complete treatment. She followed up with ___ in pulmonology in ___, who receommended ___, which the patient has not done yet. She returned several days ago from a 2 week vacation in ___. One week ago, she developed dyspnea on exertion and severe fatigue. She becomes short of breath with walking short distances on a flat surface, and must walk more slowly and stop for several minutes to catch her breath. Has had several episodes of feeling short of breath at rest, but her symptoms are mainly with exertion. Her symptoms have not progressed over the past week. She has had adequate improvement in her symptoms if she uses her albuterol inhaler (has been using BID in order to conserve limited supply). She states she is able to breath more comfortably if propped up in bed, concerning for orthopnea. She has mild cough. No pleuritic pain or discomfort; able to take deep breaths. She denies fevers, chills, sputum production, chest pain, lightheadedness, diaphoresis, nausea, vomiting, diarrhea, urinary symptoms, myalgia/arthralgia, or lower extremity edema. No sick contacts. In ___, she had a CXR and a CTA for PE, which reportedly showed a "7cm mass" in lungs (not seen on ___ radiology review). In the ED, initial vitals were: T 97.3 HR 102 BP 141/74 RR 18 SPO2 100% RA - Labs were significant for : -- WBC 6.0, Hgb 11.9, Plt 296 --INR 1.0 --proBNP 2292 --Chem 7 normal (creat 0.4) --troponin T <0.01 EKG: sinus tachy, ST depressions lat/inf, STE V2 ~1mm. NEW Repeat EKG: NSR 95, NA, NI, 1mm STE v2, STD laterally, improved from prior, but new from ___. - Imaging: -- CTA chest: no PE, small right pleural effusion. Enlarged heterogeneous left thyroid with a discrete 10mm posterior thyroid nodule. -- CXR: no acute process . -The patient was given lorazepam 0.5mg PO and aspirin 325mg PO. Vitals prior to transfer were: t 97.8 HR 97 BP 115/71 RR 25 SPO2 98% RA Upon arrival to the floor, she denies complaints. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: 1. Undifferentiated right neck tumor in ___, s/p resection and chemotherapy and radiation at ___ ___. 2. Malignant spindle cell tumor of right posterior shoulder, s/p excisional biopsy ___, 7 x 4 x 1 cm overlying the right supraspinatus muscle. The original pathology from the tumor in ___ has been unavailable so it has been difficult to know whether this is a new tumor, or a recurrence. A follow-up MRI and CT-guided biopsy of the right supraspinatus prominence in ___ did not reveal evidence of tumor. In ___ had 2 more spindle cell tumors removed from her right shoulder. 3. Left breast cancer, ___, likely ___ previous radiation. s/p lumpectomy without radiation or chemotherapy. Then tubular carcinoma ___ s/p mastectomy ___. 4. R clavicular fracture s/p repair ___ 5. Hypertension 6. Anxiety Social History: ___ Family History: Mother had MI in her ___ and congestive heart disease. Unknown what father died of. No other family members with heart disease or malignancies. Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Lorazepam Heparin Furosemide Lorazepam Lisinopril Ipratropium Bromide Neb Sodium Chloride 0.9% Flush Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Anion Gap Bicarbonate Chloride Creatinine Glucose Potassium Sodium Troponin T Urea Nitrogen Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: NIL Other Results: ADMISSION LABS: ___ 06:05PM BLOOD WBC-6.0 RBC-3.63* Hgb-11.9 Hct-35.3 MCV-97 MCH-32.8* MCHC-33.7 RDW-12.4 RDWSD-43.8 Plt ___ ___ 06:05PM BLOOD Neuts-59.1 ___ Monos-9.4 Eos-3.0 Baso-1.3* Im ___ AbsNeut-3.57 AbsLymp-1.58 AbsMono-0.57 AbsEos-0.18 AbsBaso-0.08 ___ 06:05PM BLOOD ___ PTT-28.2 ___ ___ 06:05PM BLOOD Glucose-81 UreaN-9 Creat-0.4 Na-138 K-3.9 Cl-102 HCO3-24 AnGap-16 ___ 06:05PM BLOOD proBNP-2292* ___ 06:05PM BLOOD cTropnT-<0.01 ___ 06:05PM BLOOD Calcium-9.6 Phos-3.1 Mg-1.7 ___ 06:05PM BLOOD TSH-3.4 CXR ___ FINDINGS: Previously seen left parenchymal opacity has resolved. Lungs are now clear without effusion, edema or consolidation. Right apical pleural based opacity with superior retraction of the right hilum is most compatible with scarring as identified on previous exams. The cardiomediastinal silhouette is stable. Portions of the right clavicle are not visualized. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. CTA ___ IMPRESSION: 1. No evidence of pulmonary embolism. 2. Resolution of previously seen airspace opacities since ___. 3. Unchanged borderline right hilar lymphadenopathy. 4. Small right pleural effusion. 5. Patulous thoracic esophagus, unchanged. 6. Enlarged heterogeneous left thyroid with a discrete 10 mm posterior thyroid nodule, a nonemergent thyroid ultrasound can be obtained for further evaluation if not already performed. #DYSPNEA ON EXERTION: Patient presented with dyspnea on exertion without chest pain. EKGs with ST depressions in inferior limb leads and lateral precordial leads have been seen previously, are unchanged, and likely due to LVH rather than ischemia. Her troponins were negative x2 and BNP elevated. CT findings showed emphysema and mild right pleural effusion without evidence of pulmonary embolus. Echo in ___ was unremarkable, with normal LVEF, normal RV function, and only mildly elevated TR gradient, although interval worsening is possible. COPD felt to be most likely, given her heavy smoking history, wheezing, emphysematous changes on CT. Monitored on telemetry overnight without acute event. Treated with ipratropium nebulizers and furosemide 10mg IV. Discharged on Spiriva Respimat 2 puffs daily and aspirin 81mg daily. Consider repeat ECHO as outpatient if concern for cardiac health arises. # Thyroid nodule: Enlarged heterogeneous left thyroid with a discrete 10 mm posterior thyroid nodule found on CTA from ___. TSH normal. Given history of malignancy recommend thyroid ultrasound for further evaluation if not already performed. #Hypertension: BP well controlled, continued lisinopril. #Anxiety: Continued AM lorazepam PRN TRANSITIONAL ISSUES: - Like previous providers, recommend ___ as outpatient, please follow up scheduling. - Discharged on ASA 81 daily and Spiriva 2 puffs daily. - Consider repeat ECHO if any changes in cardiac status. - Patient given instructions to call for follow up with PCP and pulmonology - NEW!!!! ****Enlarged heterogeneous left thyroid with a discrete 10 mm posterior thyroid nodule, a nonemergent thyroid ultrasound recommended for further evaluation if not already performed. **** # CODE STATUS: FULL CODE

2116-01-18 10:00:00

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[[21835428, Timestamp('2116-01-18 02:25:50'), '', 'VSURG']]

[[{'Medications on Admission': ':\npercocet ___ tabs q8h, ultram, ibuprofen 800mg TID\n\nFacility:\n___ \n- ___', 'Brief Hospital Course': ":\nThe patient was admitted to the surgery service for evaluation \nand treatment.\n\nNeuro: The patient received a lumbar epidural with good effect \nand adequate pain control. This was used for the first 2 days \npost operatively and then removed.When tolerating oral intake, \nthe patient was transitioned to oral pain medications. He also \nrecieved toradol for better pain control. \n\nCV: The patient was stable from a cardiovascular standpoint; \nvital signs were routinely monitored.\n\nPulmonary: The patient was stable from a pulmonary standpoint; \nvital signs were routinely monitored. Good pulmonary toilet, \nearly ambulation and incentive spirometry were encouraged \nthroughout this hospitalization. \n\nGI/GU/FEN: \nPost operatively, the patient was made NPO with IVF. \nThe patient's diet was advanced when appropriate, which was \ntolerated well. \nThe patient's intake and output were closely monitored, and IVF \nwere adjusted when necessary. The patient's electrolytes were \nroutinely followed during this hospitalization, and repleted \nwhen necessary. \n\nID: The patient's white blood count and fever curves were \nclosely watched for signs of infection. \n\nEndocrine: The patient's blood sugar was monitored throughout \nthis stay; insulin dosing was adjusted accordingly. \n\nHematology: The patient's complete blood count was examined \nroutinely; no transfusions were required during this stay.\n\nProphylaxis: The patient received subcutaneous heparin during \nthis stay, and was encouraged to get up and ambulate as early as \npossible. \n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. \n\n", 'Pertinent Results:': '\n___ 01:54PM BLOOD WBC-7.2 RBC-4.19* Hgb-12.7* Hct-35.9* \nMCV-86 MCH-30.3 MCHC-35.3* RDW-13.4 Plt ___\n___ 01:54PM BLOOD Glucose-99 UreaN-10 Creat-0.7 Na-136 \nK-4.6 Cl-99 HCO3-32 AnGap-10\n___ 01:54PM BLOOD Calcium-8.5 Phos-3.5 Mg-1.9\n___ 06:35AM BLOOD WBC-8.7 RBC-3.85* Hgb-11.8* Hct-33.8* \nMCV-88 MCH-30.5 MCHC-34.8 RDW-13.7 Plt ___\n\n', 'Physical Exam:|Physical': '\n98.3 HR: 54 BP: 112/70 RR: 16 Spo2: 97%\nNAD, alert and oriented x 3\nRRR, n mrg,, + S1 S2\nlungs CTA bilaterally\nsoft, NT, ND\nLeft BKA site clean dry anf intact. Right ___ warm without edema. \nPalpable femoral and right pedal pulses\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ is a ___, nondiabetic man on Tramadol and \nMotrin, who, ___ years ago, was involved in a motorcycle accident, \nresulting in multiple\nfractures of his left ankle. Since then, his foot causes \nextreme pain and swelling, preventing him from walking. It \nmakes it uncomfortable for him to stand for any length of time. \n\nPast Medical History:\ndenies\n\nSocial History:\n___\nFamily History:\nn/a\n\n', 'Chief Complaint:|Complaint:': '\nLeft foot chronic pain\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '11287511-DS-11', 11, 'surgery']]

[]

[[21835428, Timestamp('2116-01-19 01:00:00'), Timestamp('2116-01-19 14:00:00'), 'ADDITIVE', 'Bupivacaine 0.1%', '', '0', '250 mL CADD Med Cassette'], [21835428, Timestamp('2116-01-19 01:00:00'), Timestamp('2116-01-19 14:00:00'), 'BASE', 'Yellow CADD Cassette', '', '0', '250 mL CADD Med Cassette'], [21835428, Timestamp('2116-01-19 01:00:00'), Timestamp('2116-01-19 14:00:00'), 'MAIN', 'HYDROmorphone', '004100', '59011044225', '250 mL CADD Med Cassette'], [21835428, Timestamp('2116-01-19 00:00:00'), Timestamp('2116-01-21 18:00:00'), 'MAIN', 'Acetaminophen', '004490', '00904198861', '500mg Tablet'], [21835428, Timestamp('2116-01-19 08:00:00'), Timestamp('2116-01-21 18:00:00'), 'MAIN', 'Gabapentin', '021414', '00172438210', '300mg Capsule'], [21835428, Timestamp('2116-01-19 08:00:00'), Timestamp('2116-01-19 16:00:00'), 'MAIN', 'Heparin', '006549', '63323026201', '5000 Units / mL- 1mL Vial'], [21835428, Timestamp('2116-01-19 00:00:00'), Timestamp('2116-01-19 23:00:00'), 'BASE', 'Bag', '', '0', '50 mL Bag'], [21835428, Timestamp('2116-01-19 00:00:00'), Timestamp('2116-01-19 23:00:00'), 'MAIN', 'Magnesium Sulfate', '016546', '00409672924', '2 g / 50 mL Premix Bag'], [21835428, Timestamp('2116-01-19 01:00:00'), Timestamp('2116-01-21 18:00:00'), 'BASE', '0.45% Sodium Chloride', '001209', '00338004304', '1000mL Bag']]

[]

['surgery']

[[51221, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 14:35:00'), 'Hematocrit'], [51222, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 14:35:00'), 'Hemoglobin'], [51248, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 14:35:00'), 'MCH'], [51249, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 14:35:00'), 'MCHC'], [51250, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 14:35:00'), 'MCV'], [51265, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 14:35:00'), 'Platelet Count'], [51277, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 14:35:00'), 'RDW'], [51279, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 14:35:00'), 'Red Blood Cells'], [51301, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 14:35:00'), 'White Blood Cells'], [50868, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Anion Gap'], [50882, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Bicarbonate'], [50893, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Calcium, Total'], [50902, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Chloride'], [50910, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Creatine Kinase (CK)'], [50912, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Creatinine'], [50931, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Glucose'], [50960, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Magnesium'], [50970, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Phosphate'], [50971, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Potassium'], [50983, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Sodium'], [51003, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Troponin T'], [51006, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Urea Nitrogen'], [51221, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:13:00'), 'Hematocrit'], [51222, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:13:00'), 'Hemoglobin'], [51248, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:13:00'), 'MCH'], [51249, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:13:00'), 'MCHC'], [51250, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:13:00'), 'MCV'], [51265, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:13:00'), 'Platelet Count'], [51277, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:13:00'), 'RDW'], [51279, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:13:00'), 'Red Blood Cells'], [51301, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:13:00'), 'White Blood Cells'], [50861, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Alanine Aminotransferase (ALT)'], [50863, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Alkaline Phosphatase'], [50868, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Anion Gap'], [50878, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Asparate Aminotransferase (AST)'], [50882, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Bicarbonate'], [50885, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Bilirubin, Total'], [50893, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Calcium, Total'], [50902, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Chloride'], [50912, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Creatinine'], [50931, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Glucose'], [50960, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Magnesium'], [50970, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Phosphate'], [50971, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Potassium'], [50983, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Sodium'], [51003, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Troponin T'], [51006, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Urea Nitrogen']]

Question: A 38 M is admitted. He/she says he/she has Left foot chronic pain . History of illness: ___ is a ___, nondiabetic man on Tramadol and Motrin, who, ___ years ago, was involved in a motorcycle accident, resulting in multiple fractures of his left ankle. Since then, his foot causes extreme pain and swelling, preventing him from walking. It makes it uncomfortable for him to stand for any length of time. Past Medical History: denies Social History: ___ Family History: n/a Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Bupivacaine 0.1% Yellow CADD Cassette HYDROmorphone Acetaminophen Gabapentin Heparin Bag Magnesium Sulfate 0.45% Sodium Chloride Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Anion Gap Bicarbonate Calcium, Total Chloride Creatine Kinase (CK) Creatinine Glucose Magnesium Phosphate Potassium Sodium Troponin T Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Alanine Aminotransferase (ALT) Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Troponin T Urea Nitrogen Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : The patient was admitted to the surgery service for evaluation and treatment. Neuro: The patient received a lumbar epidural with good effect and adequate pain control. This was used for the first 2 days post operatively and then removed.When tolerating oral intake, the patient was transitioned to oral pain medications. He also recieved toradol for better pain control. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout this hospitalization. GI/GU/FEN: Post operatively, the patient was made NPO with IVF. The patient's diet was advanced when appropriate, which was tolerated well. The patient's intake and output were closely monitored, and IVF were adjusted when necessary. The patient's electrolytes were routinely followed during this hospitalization, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Endocrine: The patient's blood sugar was monitored throughout this stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required during this stay. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Other Results: ___ 01:54PM BLOOD WBC-7.2 RBC-4.19* Hgb-12.7* Hct-35.9* MCV-86 MCH-30.3 MCHC-35.3* RDW-13.4 Plt ___ ___ 01:54PM BLOOD Glucose-99 UreaN-10 Creat-0.7 Na-136 K-4.6 Cl-99 HCO3-32 AnGap-10 ___ 01:54PM BLOOD Calcium-8.5 Phos-3.5 Mg-1.9 ___ 06:35AM BLOOD WBC-8.7 RBC-3.85* Hgb-11.8* Hct-33.8* MCV-88 MCH-30.5 MCHC-34.8 RDW-13.7 Plt ___

2181-11-17 01:08:00

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"[[29830193, Timestamp('2181-11-17 01:09:55'), '', 'CMED'], [29830193, Timestamp('2181-11-19 11:41:4(...TRUNCATED)

"[[{'Medications on Admission': ':\\nAggrenox 1cap BID, Trazadone 50mg qhs, lorazepam 1mg Q6H, \\npa(...TRUNCATED)

"[['PORTABLE CHEST, ___\\n\\nCOMPARISON: Chest x-ray ___.\\n\\nFINDINGS: Radiodense tip of an intr(...TRUNCATED)

"[[29830193, Timestamp('2181-11-17 04:00:00'), Timestamp('2181-11-19 15:00:00'), 'BASE', '0.9% Sodiu(...TRUNCATED)

[]

['cardiothoracic']

"[[50861, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 04:00:00'), 'Alanine Aminotransfer(...TRUNCATED)

"\n\nQuestion: A 54 M is admitted. He/she says he/she has \nchest pain\n\n. \nHistory of illness:\n\(...TRUNCATED)

"\nTARGETS\n\nTarget Prescriptions: \n0.9% Sodium Chloride\nPotassium Chloride\nLorazepam\nFamotidin(...TRUNCATED)

2185-12-21 00:00:00

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SINGLE

WHITE

M

[[26762034, Timestamp('2185-12-21 02:17:04'), '', 'CSURG']]

"[[{'Medications on Admission': ':\\n1. Lisinopril 10 mg PO DAILY \\n2. Atorvastatin 80 mg PO QPM(...TRUNCATED)

[]

"[[26762034, Timestamp('2185-12-21 16:00:00'), Timestamp('2185-12-21 23:00:00'), 'MAIN', 'PNEUMOcocc(...TRUNCATED)

[]

['cardiothoracic']

[]

"\n\nQuestion: A 78 M is admitted. He/she says he/she has \nnone\n\n. \nHistory of illness:\n\n___ y(...TRUNCATED)

"\nTARGETS\n\nTarget Prescriptions: \nPNEUMOcoccal 23-valent polysaccharide vaccine\nMultivitamins\n(...TRUNCATED)

2130-08-13 18:14:00

ENGLISH

SINGLE

BLACK/AFRICAN AMERICAN

F

[[26810295, Timestamp('2130-08-13 18:15:53'), '', 'OBS']]

"[[{'Medications on Admission': ':\\nPNV', 'Brief Hospital Course': 'NIL', 'Pertinent Results:': '\\(...TRUNCATED)

[]

"[[26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-13 18:00:00'), 'MAIN', 'Docusate S(...TRUNCATED)

[]

['obstetrics/gynecology']

[[51221, Timestamp('2130-08-14 00:00:00'), Timestamp('2130-08-14 00:45:00'), 'Hematocrit']]

"\n\nQuestion: A 25 F is admitted. He/she says he/she has \ntransfer of care for NICU proximity\n\n.(...TRUNCATED)

"\nTARGETS\n\nTarget Prescriptions: \nDocusate Sodium\nMilk of Magnesia\nAcetaminophen\nSimethicone\(...TRUNCATED)

2124-12-30 10:15:00

?

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WHITE - BRAZILIAN

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[[25448487, Timestamp('2124-12-30 01:00:19'), '', 'ORTHO']]

"[[{'Medications on Admission': \":\\nnorvasc,colace,fosamax,ayclovir,senna,zocor,T3,Ca\\n\\n1. Docu(...TRUNCATED)

"[['HISTORY: Total hip replacement.\\n\\nSingle AP supine radiograph of the pelvis apparently obtai(...TRUNCATED)

"[[25448487, Timestamp('2124-12-30 22:00:00'), Timestamp('2125-01-03 18:00:00'), 'MAIN', 'Morphine S(...TRUNCATED)

[]

['orthopaedics']

"[[50868, Timestamp('2124-12-30 16:15:00'), Timestamp('2124-12-30 17:18:00'), 'Anion Gap'], [50882, (...TRUNCATED)

"\n\nQuestion: A 57 F is admitted. He/she says he/she has \nleft hip pain\n\n. \nHistory of illness:(...TRUNCATED)

"\nTARGETS\n\nTarget Prescriptions: \nMorphine Sulfate\nSenna\nDiphenhydrAMINE\nBisacodyl\nDiphenhyd(...TRUNCATED)

2142-04-08 19:58:00

ENGLISH

MARRIED

WHITE

M

[[27574184, Timestamp('2142-04-08 19:59:25'), '', 'CMED']]

"[[{'Medications on Admission': ':\\n- Pravastatin 80 mg Oral Tablet Take 1 tablet every evening for(...TRUNCATED)

"[['CHEST RADIOGRAPHS \\n\\nHISTORY: Intermittent chest pain.\\n\\nCOMPARISONS: None.\\n\\nTECHNIQ(...TRUNCATED)

"[[27574184, Timestamp('2142-04-09 10:00:00'), Timestamp('2142-04-09 12:00:00'), 'MAIN', 'NIFEdipine(...TRUNCATED)

[]

['medicine']

"[[51078, Timestamp('2142-04-08 22:56:00'), Timestamp('2142-04-08 23:11:00'), 'Chloride, Urine'], [5(...TRUNCATED)

"\n\nQuestion: A 91 M is admitted. He/she says he/she has \nChest pressure \n\n. \nHistory of illnes(...TRUNCATED)

"\nTARGETS\n\nTarget Prescriptions: \nNIFEdipine CR\nDextrose 50%\nInfluenza Virus Vaccine\nOmeprazo(...TRUNCATED)

2160-04-23 01:18:00

ENGLISH

SINGLE

WHITE

F

[[20682033, Timestamp('2160-04-23 01:18:58'), '', 'MED']]

"[[{'Medications on Admission': ':\\nThe Preadmission Medication list is accurate and complete.\\n1.(...TRUNCATED)

[]

"[[20682033, Timestamp('2160-04-23 06:00:00'), Timestamp('2160-04-26 20:00:00'), 'MAIN', 'Mirtazapin(...TRUNCATED)

[]

['medicine']

"[[51464, Timestamp('2160-04-22 21:39:00'), Timestamp('2160-04-22 22:44:00'), 'Bilirubin'], [51466, (...TRUNCATED)

"\n\nQuestion: A 71 F is admitted. He/she says he/she has \nRight low back/flank pain\n\n. \nHistory(...TRUNCATED)

"\nTARGETS\n\nTarget Prescriptions: \nMirtazapine\nNitrofurantoin Monohyd (MacroBID)\nClonazePAM\nAt(...TRUNCATED)

2206-01-06 03:22:00

ENGLISH

SINGLE

BLACK/AFRICAN AMERICAN

F

[[27264929, Timestamp('2206-01-06 03:22:58'), '', 'MED']]

"[[{'Medications on Admission': ':\\nThe Preadmission Medication list is accurate and complete.\\n1.(...TRUNCATED)

"[['EXAMINATION: CT abdomen/pelvis without contrast.\\n\\nINDICATION: ___ with HIV w/ abd pain, di(...TRUNCATED)

"[[27264929, Timestamp('2206-01-06 06:00:00'), Timestamp('2206-01-07 10:00:00'), 'MAIN', 'Insulin', (...TRUNCATED)

[]

['medicine']

"[[50868, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 09:11:00'), 'Anion Gap'], [50882, (...TRUNCATED)

"\n\nQuestion: A 43 F is admitted. He/she says he/she has \nabdominal pain, fevers/chills\n\n. \nHis(...TRUNCATED)

"\nTARGETS\n\nTarget Prescriptions: \nInsulin\nHYDROmorphone (Dilaudid)\nOmeprazole\nGlucagon\nFluti(...TRUNCATED)