Datasets:
metaboulie
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c2n2_2018_processed

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LUMBAR SPINE [ * * 2115 - 3 - 11 * * ]
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100035.txt
101
CLINICAL INFORMATION : Evidence of fracture , seizure , fall , low back pain .
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100035.txt
102
FINDINGS :
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100035.txt
103
Three views of the lumbar spine demonstrate mild narrowing of the left femoroacetabular joint .
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100035.txt
104
There is mild scoliosis of the thoracolumbar spine .
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100035.txt
105
The ventricular lead of a pacemaker is identified .
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100035.txt
106
No fracture of L2 through L5 is identified .
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100035.txt
107
However , there is a compression fracture of L1 , with compression of the superior endplate , and a sclerotic fracture line .
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100035.txt
108
Given the mechanism of fall , if there is acute pain referable to L1 , then this would be considered an acute finding .
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100035.txt
109
There is no apparent retropulsion of the posterior margin of L1 into the spinal canal .
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100035.txt
110
No other fractures are identified at this time .
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100035.txt
111
Facet joints are aligned .
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100035.txt
112
There is early calcification of the aorta .
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100035.txt
113
IMPRESSION : Compression fracture of L1 with anterior wedge deformity , likely an acute finding .
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100035.txt
114
No other fractures identified .
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100035.txt
115
EKG : Normal sinus rhythm .
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100035.txt
116
Complete right bundle - branch block with left anterior fascicular block .
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100035.txt
117
Diffuse ST - T wave changes laterally .
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100035.txt
118
CT Head : COMPARISON : [ * * 2115 - 2 - 22 * * ] .
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100035.txt
119
TECHNIQUE : Non - contrast axial images were obtained through the brain .
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100035.txt
120
FINDINGS : There is no intracranial hemorrhage , edema , or loss of [ * * Doctor Last Name 352 * * ]/white matter differentiation .
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100035.txt
121
Ventricles and sulci are normal in size and configuration .
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100035.txt
122
The basilar cisterns are not compressed .
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100035.txt
123
Paranasal sinuses demonstrate fluid in the sphenoid air cells and right posterior ethmoid air cell , likely related to prolonged hospitalization .
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100035.txt
124
Mastoid air cells are well aerated .
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100035.txt
125
IMPRESSION : No evidence of acute intracranial abnormalities .
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100035.txt
126
Brief Hospital Course : Mr .
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100035.txt
127
[ * * Known lastname 3234 * * ] is a 36 year old gentleman with a PMH signifciant with dilated cardiomyopathy s/p AICD , PE not on anticoagulation , asthma , and HTN admitted to an OSH with dyspnea now the transferred to [ * * Hospital1 18 * * ] MICU after PEA arrest x2 .
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100035.txt
128
# PEA arrest and subsequent anoxic brain injury. : Suspect that original OSH PEA arrest due to hypoxemia or acidosis , with [ * * Hospital1 18 * * ] ED PEA arrest due to acidosis with admission pH 7.16 on arrival .
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100035.txt
129
TTE with evidence of RV failure to suggest PE .
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100035.txt
130
LVEF 30 % with known dilated cardiomyopathy .
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100035.txt
131
He was cooled per protocol .
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100035.txt
132
Initially , his EEG was concerning without evident brain activity .
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100035.txt
133
On hospital day 3 , there was only comatose activity and his prognosis was guarded .
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100035.txt
134
However , the patient was able to be weaned off the vent and over the course of the next three days his mental status improved .
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100035.txt
135
He was alert , oriented to place and day of the week and moving all 4 extremities .
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100035.txt
136
He became more interactive on transfer to the floor , was initially speaking in spanish and English and not always making sense but then started responding more appropiately and following commands .
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100035.txt
137
On hospital day 11 he had a witnessed grand mal seizure and was given ativan and started on Keppra with neurology consult .
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100035.txt
138
His mental status was worse for 24 hours after the seizure but then he slowly returned to his recent baseline .
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100035.txt
139
He was somewhat aggitated so his Keppra was switched to Topiramate .
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100035.txt
140
He had a subsequent seizure on [ * * 3 - 18 * * ] with LUE tonic clonic activity and impaired consciousness but this resolved spontaneously after 1 - 2 minutes .
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100035.txt
141
He was contineud on topamax per neuro recommendations .
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100035.txt
142
OT and PT were consulted and worked with the patient as he will likely require a long rehabilitation course .
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100035.txt
143
At the time of discharge the patient was alert , oriented ( though not always to date ) , following commands but impulsive with poor motor planning leading to several falls .
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100035.txt
144
Neurology notes indicate the patient has the potential toimprove from a neurologic standpoint .
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100035.txt
145
He also may have recurrent seizures which should be treated with ativan IV or IM and do not neccessarily indicate patient needs to return to hospital unless they continue for greater than 5 minutes or he has multiple recurrent seizures or complications such as aspiration .
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100035.txt
146
- patient will be on Topiramate 25mg PO BID until [ * * 3 - 22 * * ] PM then increase to 50mg po BID for seven days then increase to 75mg [ * * Hospital1 * * ] ongoing .
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100035.txt
147
- patient will follow up with Dr .
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100035.txt
148
[ * * Last Name ( STitle ) * * ] [ * * Name ( STitle ) * * ] in his s/p arrest neurology clinic - patient will require intensive PT and OT in an anoxic brain injury unit .
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100035.txt
149
.
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100035.txt
150
# Respiratory failure : Believed to be due to status asthmaticus , although inciting event unclear .
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100035.txt
151
[ * * Name2 ( NI ) 227 * * ] multiple cardiac arrests , also a concern for development of ARDS .
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100035.txt
152
The patient was initially treated broadly with vancomycin , cefepime , flagyl , cipro , and oseltamavir .
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100035.txt
153
He was treated with IV soludemedrol and albuterol MDI .
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100035.txt
154
He was ventialted according to ARDS - Net protocol .
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100035.txt
155
On admission , he had two chest tubes placed for pneumothoraces .
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100035.txt
156
They were removed on hospital day 1 .
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100035.txt
157
In his first several days , his respiratory status was comprimised by lobar collapse , first of the RUL and then of the RML .
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100035.txt
158
His extubation was initially limited both by agitation requiring sedation and by requirements for high PEEP to maintain oxygenation .
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100035.txt
159
His oxygenation was improved with diuresis and agitation was better controlled with seroquel .
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100035.txt
160
He was extubated on [ * * 3 - 1 * * ] and respiratory status was stable .
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100035.txt
161
His Asthma was treated with standing and PRN albuterol and ipratriopium and a slow prednisone taper which he l completed on [ * * 2115 - 3 - 18 * * ] and he was restarted on Advair - patient may require additional nebs on top of his standing advair though his respiratory status has been very stable , without wheezing for the last week .
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100035.txt
162
- would like benefit from outpatient PFTs and is scheduled to see a pulmonologist in follow up .
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.
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# Ventilator associated pneumonia : Patient developed a fever on [ * * 2 - 27 * * ] with new infiltrates on chest xray while intubated .
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He was initially covered with vanc / cefepime and cipro .
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Cipro was eventually discontinued .
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He did not grow any organisms other than yeast in his sputum .
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He completed an 8 day course of Vanco / Cefepime .
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.
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# Myoclonus : when mental status improved , was noted to have myoclonic jerks .
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per neurology , likely [ * * First Name8 ( NamePattern2 ) * * ] [ * * Last Name ( NamePattern1 ) 1683 * * ] Syndrome which is anoxic injury to the purkinje cells .
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These jerks continued for about one week and then became rare .
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.
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# dilated [ * * Last Name ( LF ) 89982 * * ] , [ * * First Name3 ( LF ) * * ] 30 % .
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s/p ICD .
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Patient was diuresed with IV lasix in the ED and then transitioned to PO lasix , home dose , on the floor .
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His respiratory status remained stable .
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Also continued on home dose of carvedilol and Lisinopril but ACE downtitrated from 40 to 20 when had elevated Cr 1.9 on [ * * 3 - 18 * * ] and slightly low BPs high 90s/60s .
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BP improved to 100s/60s .
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.
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# Hypertension : Patient's home regimen was continued on the floor , but his SBP dipped into the high 80s and low 90s so lisinopril was decreased to 20mg po daily and his SBP remained 100 - 130 .
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.
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# L1 compression fracture : After the patient fell , he was complaining of low back pain so a L - spine Xray was performed and showed L1 compressin fracture with No cord impingement on imaging .
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The patient had no localizing deficits on serial neuro exam .
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He was treated with pain medication including low dose ultram , standing tylenol and a lidocaine patch .
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Calcitonin was tried for pain with compression fracture but this did not seem to help with symptoms so was discontinued .
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.
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# Leukocytosis : WBC >20 persistently in the MICU even after being treated for infection .
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Since no new infection was found this was presumed [ * * 12 - 26 * * ] steroids and the leukocytosis improved with prednisone taper .
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WBC 12 on day of discharge .
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# Hyperglycemia : Patient is not known to be a diabetic and was felt [ * * 12 - 26 * * ] steroids , his sugars were controlled on sliding scale insulin in the hospital but he no longer had insulin requirements as his prednisone was tapered .
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.
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# .
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[ * * Last Name ( un ) * * ] : Cr 1.9 on [ * * 3 - 18 * * ] from 1.2 which improved to 1.4 on [ * * 3 - 19 * * ] with decreasing ACE and 500cc bolus .
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He should have repeat creatinine and labs on [ * * 3 - 22 * * ] to ensure stability .
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# Guardianship : Guardianship paperwork was started in the hospital .
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Medications on Admission : Carvedilol 25 [ * * Hospital1 * * ] Lasix 80 mg po bid Xanax 0.25 mg 1 - 2 tabs prn albuterol MDI Ibuprofen prn Benadryl prn Advair diskus Lsinopril 40 daily
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Discharge Medications : 1 .
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bisacodyl 5 mg Tablet , Delayed Release ( E.C. ) Sig : Two ( 2 ) Tablet , Delayed Release ( E.C. ) PO DAILY ( Daily ) as needed for Constipation .
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100035.txt