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0389,78559,5849,4275,41071,4280,6826,4254,2639 | 3 | 145,834 | Admission Date: [**2101-10-20**] Discharge Date: [**2101-10-31**]
Date of Birth: [**2025-4-11**] Sex: M
Service: Medicine
CHIEF COMPLAINT: Admitted from rehabilitation for
hypotension (systolic blood pressure to the 70s) and
decreased urine output.
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
male who had been hospitalized at the [**Hospital1 190**] from [**10-11**] through [**10-19**] of [**2101**]
after undergoing a left femoral-AT bypass graft and was
subsequently discharged to a rehabilitation facility.
On [**2101-10-20**], he presented again to the [**Hospital1 346**] after being found to have a systolic
blood pressure in the 70s and no urine output for 17 hours.
A Foley catheter placed at the rehabilitation facility
yielded 100 cc of murky/brown urine. There may also have
been purulent discharge at the penile meatus at this time.
On presentation to the Emergency Department, the patient was
without subjective complaints. In the Emergency Department,
he was found to have systolic blood pressure of 85. He was
given 6 liters of intravenous fluids and transiently started
on dopamine for a systolic blood pressure in the 80.s
PAST MEDICAL HISTORY:
1. Coronary artery disease with diffuse 3-vessel disease;
right-dominant, status post proximal left circumflex stent in
[**2101-7-9**] with occlusion of the distal left circumflex;
status post right coronary artery stent on [**2101-8-26**] (no
percutaneous coronary intervention to 99% diagonal left
circumflex, 80% small proximal left anterior descending
artery, or 80% small distal left anterior descending artery).
2. Congestive heart failure (with an ejection fraction
of 15% to 20%).
3. Type 2 diabetes with neuropathy.
4. Hypertension.
5. Diverticulosis (found on colonoscopy in [**2101-7-9**]).
6. Alzheimer's dementia.
7. History of gastrointestinal bleed (while the patient was
taking eptifibatide).
8. Cardiac risk factors (with a baseline creatinine
of 1.4 to 1.6).
9. Hypercholesterolemia.
10. History of methicillin-resistant Staphylococcus aureus
and Pseudomonas growth in wound cultures.
11. Severe peripheral vascular disease; status post left
femoral-AT bypass graft on [**2101-10-11**].
12. Chronic nonhealing foot ulcers.
13. Recent right pedal cellulitis.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Vancomycin 1 g intravenously q.24h. for a level of less
than 15 (started on [**2101-10-4**]).
2. Levofloxacin 250 mg p.o. q.d. (started on [**2101-10-4**]).
3. Metronidazole 500 mg p.o. q.8h. (started on [**2101-10-4**]).
4. Heparin 5000 units subcutaneous b.i.d.
5. Simvastatin 40 mg p.o. q.d.
6. Lisinopril 5 mg p.o. q.d.
7. Furosemide 40 mg p.o. q.d.
8. Vitamin E 400 IU p.o. q.d.
9. Atenolol 25 mg p.o. q.d.
10. Pantoprazole 40 mg p.o. q.d.
11. Ascorbic acid 500 mg p.o. b.i.d.
12. NPH 17 units b.i.d.
13. Regular insulin sliding-scale.
14. Bisacodyl 10 mg p.o./p.r. as needed.
15. Docusate 100 mg p.o. b.i.d.
16. Percocet 5/325 mg one tablet p.o. q.4-6h. as needed for
pain.
17. Aspirin 81 mg p.o. q.d.
18. Metoprolol 75 mg p.o. b.i.d.
SOCIAL HISTORY: The patient is retired and had been living
at home with his wife prior to his admission to the hospital
on [**2101-10-11**]; he had been living at [**Hospital3 1761**] for the day prior to admission. He is a
social drinker and has a 40-pack-year smoking history;
although, he quit smoking 20 years ago.
PHYSICAL EXAMINATION ON PRESENTATION: Initial physical
examination revealed temperature was 96.1 degrees Fahrenheit,
heart rate was 83, blood pressure was 124/42 (following
administration of 3 liters of normal saline), respiratory
was 24, and his oxygen saturation was 100% on 2 liters nasal
cannula. His heart had a regular rate and rhythm. There
were normal first and second heart sounds. There was a 2/6
systolic ejection murmur, and there were no rubs or gallops.
His lungs were clear to auscultation bilaterally. His
abdomen was soft, nontender, and nondistended, and there were
hypoactive bowel sounds. He had a palpable bypass graft
pulse, [**Hospital3 17394**] dorsalis pedis and posterior tibialis
pulses bilaterally; and his surgical incision was clean, dry,
and intact. Please note that the above examination was done
by the Vascular Surgery team, which was the team that was
initially planning to admit the patient to the hospital.
PERTINENT LABORATORY DATA ON PRESENTATION: On initial
laboratory evaluation the patient had a white blood cell
count of 12.7, hematocrit was 30.2, and platelets
were 282,000. His PT was 13.5, PTT was 30.7, and INR
was 1.3. His serum chemistries revealed sodium was 136,
potassium was 5.4, chloride was 99, bicarbonate was 25, blood
urea nitrogen was 53, creatinine was 3.2, and blood glucose
was 91. His calcium was 8.2, magnesium was 2.4, and
phosphate was 4.8. Blood cultures drawn on admission were
pending, but ultimately negative. A urine culture taken on
admission was initially pending, but ultimately grew out
yeast. A sputum culture taken on admission was also
initially pending, but ultimately also grew out yeast.
RADIOLOGY/IMAGING: His admission chest x-ray demonstrated
stable prominence of the right main pulmonary artery; no
focal areas of consolidation; overall stable appearance of
the chest compared with a [**2101-10-15**] study. No
radiographic evidence of congestive heart failure or
pneumonia.
His admission electrocardiogram demonstrated a sinus rhythm,
nonspecific inferior/lateral T wave changes, low QRS voltages
in the limb leads, and T wave changes in V5 and V6 when
compared with an electrocardiogram dated [**2101-10-12**].
An initial abdominal CT was a limited noncontrast examination
that demonstrated diffuse vascular calcifications. No
evidence of an abdominal aortic aneurysm or free fluid,
incompletely imaged coronary artery calcification, a simple
left renal cyst, sigmoid diverticulosis, and an enlarged and
partially calcified prostate gland.
HOSPITAL COURSE BY SYSTEM:
1. CARDIOVASCULAR: The patient was initially admitted to
the Vascular Intensive Care Unit with hypotension, decreased
urine output, and acute renal failure; most likely secondary
to a presumed gram-negative urosepsis (although there were
never any positive culture data to confirm this diagnosis).
While boarding in the Medical Intensive Care Unit on the
night of admission, the patient had a sudden
cardiorespiratory arrest. He was resuscitated with
epinephrine, lidocaine, and direct current cardioversion
times four. He was also intubate for airway protection.
Following these measures, the patient returned to a sinus
rhythm with a systolic blood pressure of approximately 100;
the total time elapsed from the beginning of the arrest to
the return of a pulse was approximately 16 minutes. He
subsequently required double pressors to maintain his blood
pressure.
An echocardiogram performed at the bedside demonstrated a
trivial pericardial effusion and a left ventricular ejection
fraction of 20% to 25% in the setting of tachycardia and a
hyperdynamic right ventricle; suggesting elevated right-sided
filling pressures. Although the definitive etiology of this
arrest remained unknown, the most likely trigger was a
non-Q-wave myocardial infarction, as his troponin values were
elevated to greater than 50 following his arrest.
A repeat echocardiogram done on [**2101-10-21**]
demonstrated mild left atrial dilation, an ejection fraction
of 15% to 20%, resting regional wall motion abnormalities
including inferior, mid, and apical left ventricular
akinesis, depressed right ventricular systolic function, and
moderate mitral regurgitation. Compared with the prior study
of [**2101-10-20**]; the left ventricular function was
unchanged. There was moderate mitral regurgitation, and the
right ventricular function appeared worse.
On [**2101-10-21**], the patient was loaded with amiodarone
and was subsequently started on oral amiodarone. The
following day, he was started on heparin intravenously given
his elevated serum troponin to greater than 50; this
medication was continued for 72 hours. Given his elevated
troponins and non-Q-wave myocardial infarction, the patient
was a candidate for cardiac catheterization.
After discussions between the Medical Intensive Care Unit
team and the patient's family, however, the decision was made
to not pursue further invasive procedures given that the
patient had been made do not resuscitate/do not intubate
following the resuscitation mentioned above, and his family
no longer wished for aggressive resuscitating measures.
By [**2101-10-23**], he was off pressors and he was
restarted on a beta blocker and ACE inhibitor at low doses.
On the evening of [**2101-10-25**], the patient complained
of substernal chest pain that was relieved by NPG SL and
morphine. He also had ST segment depressions in V2 and V3
that reverted to baseline after the resolution of his pain.
Therefore, the patient was again started on heparin;
although, this was discontinued on [**2101-10-26**] when
the patient ruled out for a myocardial infarction by cardiac
enzymes. He again had substernal chest pain on [**2101-10-27**]; although, he had no electrocardiogram changes, and he
again ruled out for a myocardial infarction by cardiac
enzymes.
By hospital day four, the patient began to develop evidence
of congestive heart failure given his aggressive fluid
resuscitation, and gentle diuresis with furosemide was begun.
By the time of his transfer to the General Medicine Service
on [**2101-10-26**], the patient was still significantly
volume overloaded following his aggressive fluid
resuscitation in the Medical Intensive Care Unit. Therefore,
he was continued on the program of gentle diuresis given that
he was having signs and symptoms of right-sided congestive
heart failure. He achieved adequate diuresis by the time of
his discharge to rehabilitation, as his oxygen saturation was
greater than 95% on 2 liters nasal cannula.
2. INFECTIOUS DISEASE/SEPSIS: The patient was started on
gentamicin and piperacillin/tazobactam in addition to the
levofloxacin, metronidazole, and vancomycin he was already
taking for right lower extremity cellulitis prior to
admission for empiric coverage of a presumed gram-negative
urosepsis, and he was aggressively hydrated with intravenous
fluids.
On [**2101-10-21**], his levofloxacin and metronidazole was
discontinued, and he was started on fluconazole given the
growth of yeast on urine culture. He was taken off of
gentamicin on hospital day three, and his fluconazole was
discontinued on hospital day five (as per the Infectious
Disease Service). He was taken off of vancomycin on
[**2101-10-28**], and his piperacillin/tazobactam was
discontinued on [**2101-10-29**].
Despite the presumption of a gram-negative urosepsis
precipitating this admission, the patient did not have any
positive blood or urine cultures aside from the growth of
yeast in two urine cultures noted above. He remained
afebrile both before and after discontinuation of his
antibiotics, and he was found to be Clostridium difficile
negative on [**2101-10-28**].
3. PULMONARY: As noted above, the patient was intubated and
he was extubated on [**2101-10-24**]. He subsequently
developed wheezing and mild hypoxia; most likely secondary to
cardiac asthma and fluid overload in the setting of his
aggressive fluid resuscitation. He was gently diuresed
toward the end of his hospitalization, and by the time of his
he was maintaining an oxygen saturation of greater than 95%
on 2 liters nasal cannula, intermittent ipratropium
nebulizers, and chest physical therapy for clearance of his
respiratory secretions.
4. RENAL: The patient presented with acute renal failure
and prerenal azotemia that rapidly resolved following fluid
resuscitation. By the time of discharge, his serum
creatinine was stable and at his preadmission baseline.
5. NUTRITION: The patient was found to be profoundly
malnourished with a serum albumin of 1.8 on admission. Once
he was extubated and taking orals, he performed poorly on a
modified barium swallowing study and was started on a thin
liquid, ground-solid diet with whole medication tablets,
small bites and sips, upright posture with meals, and
aspiration precautions. He was also given ProMod shakes with
and between meals for nutritional supplementation of his
heart-healthy/diabetic diet.
6. VASCULAR: The patient's operative incisions and foot
ulcers continued to heal throughout this admission. He was
started on an multivitamin, vitamin C, and zinc for improved
wound healing.
7. HEMATOLOGY: The patient was transfused one unit of
packed red blood cells on [**2101-10-27**] to maintain a
hematocrit of greater than 30 given his history of severe
coronary artery disease. His hematocrit subsequently
remained stable.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Cardiorespiratory arrest.
2. Non-Q-wave myocardial infarction.
3. Acute renal failure.
4. Coronary artery disease with diffuse 3-vessel disease;
right-dominant, status post proximal left circumflex stent in
[**2101-7-9**] with occlusion of distal left circumflex; status
post right coronary artery stent on [**2101-10-27**] (no
percutaneous coronary intervention to 99%, distal left
circumflex, 80% small proximal left anterior descending
artery, 80% small distal left anterior descending artery).
5. Congestive heart failure (with an ejection fraction
of 15% to 20%).
6. Type 2 diabetes with neuropathy.
7. Hypertension.
8. Diverticulosis (found on colonoscopy in [**2101-7-9**]).
9. Alzheimer's dementia.
10. History of gastrointestinal bleed (while the patient was
taking eptifibatide).
11. Cardiac risk factors (with a baseline creatinine
of 1.4 to 1.6).
12. History of methicillin-resistant Staphylococcus aureus
and Pseudomonas growth in wound cultures.
13. Severe peripheral vascular disease; status post left
femoral-AT bypass graft on [**2101-10-11**].
14. Chronic nonhealing foot ulcers.
MEDICATIONS ON DISCHARGE:
1. Amiodarone 400 mg p.o. b.i.d. (through [**2101-11-2**]), then 400 mg p.o. q.d. (times one week), then 200 mg
p.o. q.d.
2. Metoprolol 50 mg p.o. b.i.d.
3. Captopril 6.25 mg p.o. t.i.d.
4. Aspirin 325 mg p.o. q.d.
5. Pantoprazole 40 mg p.o. q.d.
6. Heparin 5000 units subcutaneously b.i.d.
7. Multivitamin one tablet p.o. q.d.
8. Zinc sulfate 220 mg p.o. q.d.
9. Vitamin C 500 mg p.o. q.d.
10. Ipratropium nebulizers q.4-6h. as needed (for wheezing).
11. Acetaminophen 325 mg to 650 mg p.o. q.4-6h. as needed
(for pain).
12. Miconazole 2% powder to groin b.i.d.
13. Santyl lotion to heels b.i.d.
14. Regular insulin sliding-scale.
CODE STATUS: Do not resuscitate/do not intubate.
NOTE: If applicable, an addendum to this Discharge Summary
will be dictated to include follow-up appointments as well as
any changes to the medication list noted above.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1604**], M.D. [**MD Number(1) 1605**]
Dictated By:[**Name8 (MD) 2507**]
MEDQUIST36
D: [**2101-10-31**] 01:07
T: [**2101-11-5**] 03:44
JOB#: [**Job Number **]
|
04111,2763,7994,1363,042,5715,V090,E9317,7907 | 4 | 185,777 | Admission Date: [**2191-3-16**] Discharge Date: [**2191-3-23**]
Date of Birth: [**2143-5-12**] Sex: F
Service:
CHIEF COMPLAINT: Shortness of breath and fevers.
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old
female with a history of human immunodeficiency virus (last
CD4 count 42 and a viral load of 65,000), cirrhosis,
diabetes, and hypothyroidism presented with eight days of
fevers to 104, chills, shortness of breath, cough, dyspnea on
exertion, and fatigue.
The patient states she has become progressively dyspneic to
the point where she is short of breath with speaking. She
has also had night sweats for the past two days and whitish
sputum. She complains of myalgias. No recent ill contacts.
[**Name (NI) **] known tuberculosis exposure.
In the Emergency Department, the patient was initially 96% on
room air, with a respiratory rate of 20, and a heart rate of
117. A chest x-ray showed diffuse interstitial opacities.
She received 3 liters of normal saline, clindamycin, and
primaquine for likely Pneumocystis carinii pneumonia. She
spiked a temperature to 102.1 and became progressively
dyspneic with her respiratory rate increasing to 40, and her
oxygen saturations dropping to 89% on room air. She was
placed on 6 liters by nasal cannula, and an arterial blood
gas showed 7.47/28/74. The patient was given prednisone and
aztreonam for possible cholangitis.
PAST MEDICAL HISTORY:
1. Human immunodeficiency virus diagnosed in [**2175**]; acquired
from her ex-husband (in [**2190-10-13**], CD4 count was 42 and
viral load was 65,000).
2. Cirrhosis; status post liver biopsy in [**2190-10-13**]
consistent with cytosis and sinusoidal fibrosis consistent
with toxic metabolic disease possibly from highly active
antiretroviral therapy.
3. Insulin-dependent diabetes mellitus since [**2190-10-13**].
4. Hypothyroidism.
5. Esophagogastroduodenoscopy in [**2190-11-13**] was normal
with no varices.
MEDICATIONS ON ADMISSION:
1. Viread 300 mg once per day.
2. Epivir 150 mg twice per day.
3. Acyclovir 400 mg twice per day.
4. Diflucan 200 mg twice per day.
5. Videx 400 mg once per day.
6. Zantac 150 mg once per day.
7. Klonopin as needed.
8. Lantus 6 units subcutaneously in the morning; no
sliding-scale.
ALLERGIES: PENICILLIN and SULFA DRUGS (cause a rash).
DAPSONE (causes nausea).
FAMILY HISTORY: Family history was noncontributory.
SOCIAL HISTORY: The patient lives at home with her son. She
quit tobacco five years ago. No alcohol. No illicit drugs.
No intravenous drug use. No transfusions.
PHYSICAL EXAMINATION ON PRESENTATION: On admission, the
patient had a temperature of 102.1, her heart rate was 118,
her respiratory rate was 40, her blood pressure was 117/57,
and her oxygen saturation was 89% on room air and 94% on 6
liters. In general, she was ill and toxic appearing. She
was unable to speak in complete sentences. She was
cachectic. Head, eyes, ears, nose, and throat examination
revealed anicteric. The mucous membranes were dry. The
extraocular movements were intact. No thrush. The neck was
supple. There was no jugular venous distention. Thorax
revealed bilateral basilar rales. No wheezes.
Cardiovascular examination revealed tachycardia. There were
no murmurs. The abdomen revealed mild diffuse tenderness to
percussion, hepatomegaly 6 cm below the costal margin, no
spleen palpated, positive bowel sounds. There was no rebound
or guarding. Extremities revealed no lower extremity edema.
Pulses were 2+. Neurologic examination revealed cranial
nerves II through XII were intact. Strength was [**5-18**] in all
extremities.
PERTINENT LABORATORY VALUES ON PRESENTATION: The patient had
a white blood cell count of 9.7 (with 89% neutrophils and 7%
lymphocytes), and her hematocrit was 34.2. Chemistries were
within normal limits with a blood urea nitrogen of 9 and a
creatinine of 0.5. Her aspartate aminotransferase was 69,
her alanine-aminotransferase was 28, her alkaline phosphatase
was 994, and her total bilirubin was 2.2, and her direct
bilirubin was 1.5. Her lactate was 2.1. Urinalysis was
negative for leukocyte esterase or nitrites. It was positive
for 30 protein.
PERTINENT RADIOLOGY/IMAGING: An electrocardiogram revealed
sinus tachycardia; unchanged from [**2187**].
A chest x-ray revealed bilateral interstitial opacities in
the left mid lung; consistent with Pneumocystis carinii
pneumonia or viral pneumonia.
A right upper quadrant ultrasound revealed no cholelithiasis.
No gallbladder wall edema. Common bile duct was 4 mm.
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. PULMONARY ISSUES: From the Emergency Room, the patient
was transferred to the [**Hospital Ward Name 332**] Intensive Care Unit secondary
to respiratory distress. Symptoms consistent with a
respectively alkalosis. A chest x-ray was consistent with
possible Pneumocystis pneumonia versus a viral pneumonia.
Given her allergies to both sulfa and dapsone, she was
started on empiric Pneumocystis carinii pneumonia coverage
with primaquine and clindamycin. She was also started on
prednisone given her low oxygen saturations, and given her
low PAO2.
In the [**Hospital Ward Name 332**] Intensive Care Unit, she requested noninvasive
positive pressure ventilation. A bronchoscopy was performed
with 1+ gram-positive cocci in pairs and positive
Pneumocystis carinii pneumonia. Acid-fast bacillus smears
were negative.
The patient's respiratory status continued to improve on her
medication regimen. She was weaned off of the noninvasive
positive pressure ventilation and eventually was able to
saturate 98% on room air. She was to be continued on
primaquine and clindamycin for a total of a 21-day course of
antibiotics as well as a 21-day steroid taper.
2. BACTEREMIA ISSUES: The patient's blood cultures from
admission from [**3-15**] and [**3-16**] grew out
methicillin-sensitive Staphylococcus aureus ([**4-19**] blood
cultures). At that time, the patient was started on
vancomycin therapy with quick clearance of her blood
cultures.
A transthoracic echocardiogram was performed to rule out
endocarditis, and it did not show any valvular abnormalities;
although, the tricuspid valve was obscured by her
peripherally inserted central catheter line. The subsequent
surveillance blood cultures from [**3-17**] on were negative,
and the patient was to be continued on vancomycin
intravenously for a 3-week course. After that time, blood
cultures should be repeated for surveillance. The patient
remained afebrile during the remainder of her hospital stay.
3. CIRRHOSIS ISSUES: The patient has Child A class
cirrhosis from a liver biopsy done in [**2190-10-13**]. Her
cirrhosis was thought to be secondary to her highly active
antiretroviral therapy. She was to follow up with Dr. [**Last Name (STitle) 497**]
in [**2191-4-14**] for a visit.
A right upper quadrant ultrasound was performed as the
patient's alanine-aminotransferase was slightly elevated and
was within normal limits.
4. HUMAN IMMUNODEFICIENCY VIRUS ISSUES: The patient was
restarted on her highly active antiretroviral therapy regimen
on hospital day four. The patient tolerated these
medications without any problems. She was also continued on
acyclovir and fluconazole for prophylaxis. The patient was
to follow up with Dr. [**Last Name (STitle) 20066**] in clinic over the next two
weeks.
5. DIABETES MELLITUS ISSUES: The patient was placed on
original regimen of Lantus without a sliding-scale secondary
to her steroid taper. Her blood sugars remained elevated
while in house; ranging from the 200s to the 400s. Her
Lantus was increased to 12 units subcutaneously in the
morning, and her sliding-scale was increased as well with
improved blood sugars. She was to be discharged on 12 units
of Lantus in the morning with a strict sliding-scale for the
next three days until her prednisone is tapered; at which
time her Lantus will be decreased to 7 units in the morning,
and her sliding-scale will be decreased as well.
6. HYPOTHYROIDISM ISSUES: The patient was continued on her
Levoxyl.
7. ACCESS ISSUES: A peripherally inserted central catheter
line was placed on [**2191-3-19**] for intravenous antibiotics.
It was found to be in the right atrium on chest x-ray and was
pulled back 6 cm with a repeat chest x-ray location in the
superior vena cava. She will need the peripherally inserted
central catheter line for 14 more days as she finishes her
course of intravenous vancomycin.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with Dr. [**Last Name (STitle) 497**] for cirrhosis and with Dr.
[**Last Name (STitle) 20066**] for her human immunodeficiency virus. She was to
follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4390**] next
Friday for primary care.
MEDICATIONS ON DISCHARGE:
1. Prednisone 40 mg once per day times three days; then 20
mg once per day times 11 days.
2. Acyclovir 200 mg by mouth twice per day.
3. Fluconazole 200 mg by mouth twice per day.
4. Primaquine 26.3 two tablets by mouth every day (times 14
days).
5. Levoxyl 25 mcg by mouth once per day.
6. Tenofovir disoproxil fumarate 300 mg by mouth once per
day.
7. Lamivudine 300 mg twice per day.
8. Didanosine 400 mg by mouth once per day.
9. Lantus 12 units subcutaneously in the morning times
three days; and then 7 units subcutaneously in the morning.
10. Regular insulin sliding-scale as directed (per
sliding-scale).
11. Clindamycin 300 mg by mouth four times per day (times 14
days).
12. Vancomycin 750 mg intravenously twice per day (times 14
days).
13. Codeine/guaifenesin syrup 5 cc to 10 cc by mouth q.6h.
as needed.
14. Klonopin 0.75 mg by mouth in the morning and 0.5 mg by
mouth at hour of sleep.
15. Multivitamin one tablet by mouth once per day.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern1) 3476**]
MEDQUIST36
D: [**2191-3-23**] 14:55
T: [**2191-3-25**] 08:50
JOB#: [**Job Number 20067**]
|
2766,4440,40391,2767,2859,2753,V1582,9972 | 6 | 107,064 | Admission Date: [**2175-5-30**] Discharge Date: [**2175-6-15**]
Date of Birth: Sex: F
Service:
ADMISSION DIAGNOSIS: End stage renal disease, admitted for
transplant surgery.
HISTORY OF PRESENT ILLNESS: The patient is a 65 year-old
woman with end stage renal disease, secondary to malignant
hypertension. She was started on dialysis in [**2174-2-7**]. She currently was on peritoneal dialysis and appears
to be doing well. She has a history of gastric angiectasia
which she requires endoscopy. She was admitted on [**2175-5-30**] for
a scheduled living donor kidney transplant by her son, who is
the donor. She does have a donor specific antibody (B-51)
and will have a final T & B cell class match prior to
transplantation.
PAST MEDICAL HISTORY: End stage renal disease, secondary to
malignant hypertension on dialysis. History of anemia
following gastric angiectasia. She has no known history for
coronary artery disease for diabetes.
ALLERGIES: No known drug allergies.
MEDICATIONS: Unknown.
SOCIAL HISTORY: Married, lives with her husband. She has a
history of a half pack of cigarettes per day for 20 years.
Occasional alcohol.
PHYSICAL EXAMINATION: The patient was afebrile. Vital signs
were stable. Blood pressure was 124/58; heart rate 76; weight
160 pounds. Abdomen soft and nontender. She has a peritoneal
dialysis catheter in the right lower quadrant. She has good
femoral pulses bilaterally. Mild pedal edema.
HOSPITAL COURSE: On [**2175-5-30**], the patient went to the
operating room for living donor kidney transplant, performed
by Dr. [**Last Name (STitle) **] and assisting by Dr. [**Last Name (STitle) **]. Please see details
of this surgery in operating room note. Also during her
operating room time, the patient also had a right iliac
artery thrombosis. It was noted that at the end of the
completion of the procedure, that she had an ischemic
appearing right foot and absence of a right femoral pulse. In
the operation, there was some difficulty with arterial
anastomosis, renal artery to the left iliac artery and Dr.
[**Last Name (STitle) **] came to assist Dr. [**Last Name (STitle) **]. Again, please see
details of that operation in the operative report.
Postoperatively, the patient went to the Intensive Care Unit.
The patient had an A line, a central line, Foley. She was
placed on a heparin drip to keep PTT between 45 and 50. The
patient's dressing was clean, dry and intact. The patient had
2 [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drains in place. Good femoral pulse and good
dorsalis pedis pulse. These pulses were palpable. The
patient was making good urine output postoperatively. Renal
was consulted and made recommendations. Postoperatively, the
patient had a renal ultrasound demonstrating an unremarkable
renal transplant ultrasound with normal size and appearance
of the transplanted kidney and normal arterial wave forms and
resistive disease, ranging from 0.63 to 0.75 throughout.
On postoperative day number one, the patient had another
ultrasound secondary to her hematocrit decreasing and they
wanted to rule out hematoma. The ultrasound demonstrated that
there was no hematoma seen adjacent to the transplanted
kidney. The transplanted kidney is minimally changed from
yesterday which was on [**2175-5-30**] with a small amount of pelvic
ectasis. Relatively unchanged resistive indices. The
patient did get multiple transfusions for her low hematocrit.
Her heparin was discontinued on [**2175-6-1**]. The patient received
1/2 cc per cc of replacement and on [**6-1**], Tacrolimus was
started. On [**2175-6-2**], the patient had some complaint of right
foot numbness. Lower extremity ultrasound was obtained to
rule out deep venous thrombosis and this showed no evidence
of right lower extremity deep venous thrombosis. On [**2175-6-2**],
WBC was 2.9, hematocrit of 35.2. Also on [**6-2**], PT was 13.5,
PTT was 36.7, INR of 1.2. Sodium that day was 129 and 4.4,
100 BUN, creatinine of 69 and 6.2 with a glucose of 96.
Vascular surgery continued to see the patient. It was
decided that hematocrit was stable, that heparin could be
continued. The patient was restarted on heparin. The patient
still complained of right foot numbness but it was about the
same and not worse. She was continued on all of her
immunosuppressive medications, including Tacrolimus, Valcyte,
Cellcept, Bactrim, Solu-Medrol. The patient was transitioned
from heparin to Coumadin. The patient was transferred to the
floor, continued to make excellent urine output. The patient
had another ultrasound on [**2175-6-6**] because there was blood in
her [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drain and with the decreasing hematocrit.
Ultrasound demonstrated normal arterial and venous color,
blood flow and wave form with normal residual indices. 7.6
by 3.5 cm fluid collection, likely simply fluid, anterior to
the contrast. Focal area of heterogeneity within the lateral
aspect of the mid pole, probably which demonstrates normal
blood flow and may represent artifact; however, attention to
this area on a follow up scan is recommended to document
interval change or resolution.
On [**2175-6-9**], the patient's right lower extremity was swollen.
The patient complained of right hip and thigh pain, pitting
edema of right lower extremity greater than left lower
extremity so an ultrasound was performed which included the
right iliac artery. This demonstrated acute deep venous
thrombosis within the right common femoral and superficial
femoral veins which had developed since [**2175-6-2**]. There
is a right groin hematoma which was unchanged. The patient
continued to be anticoagulated for DVT. One drain was
eventually removed, continued on [**2175-6-12**] with drain output of
170, afebrile, vital signs stable. She went home with
services on the following medications: Valcyte 450 mg q.
day, Bactrim SS 1 tab q. day, Protonix 40 mg q. day, Nystatin
5 ml suspension, 5 ml four times a day, Colace 100 mg twice a
day, Movlapine 10 mg q. day, Percocet 22 tabs q. day,
Lopressor 100 mg twice a day, MMF 500 mg q.o.d. Coumadin 2 mg
q. day. This should be monitored to keep the INR between 2
and 3. Reglan 10 mg four times a day before meals and at
bedtime. Tacrolimus 10 mg p.o. twice a day. Potassium sodium
phosphate, one packet q. day and Compazine 10 mg q. 6 hours
prn. The patient has a follow up appointment with Dr.
[**Last Name (STitle) **], please call [**Telephone/Fax (1) 673**] for an appointment. The
patient needs to change dressings on her wound twice a day
located on her groin, place a dry gauze between the wound and
her skin. No heavy lifting of greater than 10 pounds for the
first 6 weeks after surgery.
DIAGNOSES: End stage renal disease, status post renal
transplant.
Arterial thrombosis.
Deep venous thrombosis.
Resolving hypertension.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 55494**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2175-9-15**] 16:39:51
T: [**2175-9-15**] 17:14:46
Job#: [**Job Number 55495**]
|
431,5070,4280,5849,2765,4019 | 9 | 150,750 | Admission Date: [**2149-11-9**] Discharge Date: [**2149-11-13**]
Date of Birth: [**2108-1-26**] Sex: M
Service: NEUROLOGY
CHIEF COMPLAINT: Weakness, inability to talk.
HISTORY OF THE PRESENT ILLNESS: This is a 41-year-old
African-American male with a history of hypertension who was
in his usual state of health until about 10:25 a.m. on the
morning of admission. He had gone to use the restroom and a
few minutes later his family found him slumped onto the
floor, apparently unable to talk and with weakness in his
right arm and leg. EMS was called and he was brought into
the Emergency Department at [**Hospital1 18**].
The patient has not had strokes or previous similar symptoms.
He has a history of hypertension but no history of cardiac
symptoms. The patient was unable to talk for examination and
no family members were present at the bedside and were not at
home (apparently they were on the way to the Emergency Room).
The history was obtained by EMS.
PAST MEDICAL HISTORY: Hypertension.
ADMISSION MEDICATIONS: The patient was on no medications
upon admission.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: Unknown.
SOCIAL HISTORY: The patient lives [**Location (un) 6409**].
PHYSICAL EXAMINATION ON ADMISSION: During the five minute
examination, the patient became progressively less responsive
and then vomited requiring intubation and paralytics during
the examination. Vital signs: Blood pressure 229/137, heart
rate 85, respiratory rate 20, temperature 98.8. General:
This was a well-developed African-American male. HEENT: The
neck was supple without lymphadenopathy or thyromegaly.
Cardiovascular: Regular rate and rhythm. No murmurs, rubs,
or gallops noted. Lungs: Clear to auscultation bilaterally.
Abdomen: Soft, nontender, nondistended with no hepatomegaly.
Extremities: No clubbing, cyanosis or edema noted.
Neurologic: On the mental status examination, the patient
was alert but nonverbal. Language was aphasic but can
comprehend one-step commands. There was no evidence of
neglect. The patient can follow one-step commands. On the
cranial nerve examination, his optic disk margins were sharp.
His extraocular eye movements were intact. His pupils were
equal and reactive to light. His face was symmetrical at
rest. Motor: He had normal bulk and tone with no tremors.
His power was 0/5 in the right arm and leg. His left arm and
leg was apparently [**5-5**]. Sensory: He was reactive to noxious
stimuli in all four extremities. His reflexes were minimal
throughout. His toes were mute bilaterally. Coordination
and gait examination was not tested.
LABORATORY/RADIOLOGIC DATA: White count 7.5, hematocrit 45,
platelets 258,000. PT 12.7, PTT 21.7, INR 1.1.
The EKG was normal sinus rhythm at 99 with normal axis and
intervals. LVH was noted. There were T wave inversions in
I, II, III, aVL, V1 through V3.
Serum and urine toxicology was negative. ESR was 18. The
urinalysis was negative. CT scan of the head showed 55 by 55
by 21 mm left putaminal bleed with a 5 mm midline shift to
the right.
Chest x-ray showed cardiomegaly with CHF.
HOSPITAL COURSE: 1. NEUROLOGIC: Left putaminal bleed
secondary to presumed hypertension. The patient's blood
pressure was initially controlled with a Nipride drip to keep
the cephalic pressure between 130-160. The Nipride drip was
then weaned as labetalol IV was added along with a
nicardipine drip. The patient was also given Dilantin load
followed by a maintenance dose of 400 mg q.d. His level has
been therapeutic around 20. Considerations for a CTA and
angiogram for possible AVM or aneurysm were considered but
the patient's renal function and health status did not allow
such studies to be done at the current time.
Repeated noncontrast CT of the head revealed no increase in
the bleeding but showed subsequently increases in cerebral
edema with some pressure onto the brain stem. The patient's
neurological examination did deteriorate to the point that he
only had reactive pupils that were equal and intact corneal
reflexes. In addition, he had a gag reflex. However, he
began to not move any extremities and not respond to any
noxious stimuli in the four extremities.
By 4:00 p.m. on [**2149-11-13**], his neurological condition
deteriorated to the point that his pupils were dilated and
nonreactive. He lost gag and corneal reflex. Calorics were
done at this time which revealed no response. Neurosurgery
was reconsulted for a question of craniotomy but they felt
that the patient would not be a candidate for the surgery in
that it would not help him. Mannitol was then started along
with hyperventilation to keep the PC02 below 30 in an attempt
to decrease the cerebral edema.
Despite clinical examination that the patient is clinically
brain dead, the family wishes to continue aggressive
treatment. The family requested that the patient be
transferred to the [**Hospital6 1129**]. However,
Dr. [**Last Name (STitle) 54029**] at the [**Hospital3 **] Stroke Service said
that the patient would not be accepted at the [**Hospital3 **] given that there would be no other intervention that
would be done differently at [**Hospital3 **].
2. CARDIOVASCULAR: As mentioned above, the patient was
initially started on a Nipride drip to control the blood
pressure between 130-160. However, he was slowly weaned off
the Nipride to be switched over to Cardene drip. The Cardene
drip was then weaned to allow for the addition of p.o.
Labetalol. Three serial CKs and troponins were checked and
found to be negative, thus, ruling the patient out for a
myocardial infarction.
3. PULMONARY: The patient was initially intubated when
first seen down in the Emergency Room for airway protection
since he vomited. He then showed a left lower lobe pneumonia
on the chest x-ray. He was started on levofloxacin and
Flagyl since the day of admission for aspiration pneumonia.
Vancomycin was added on day number four of hospitalization
due to sputum cultures showing Staphylococcus aureus
coagulase-positive organisms and gram-negative rods.
Susceptibilities are still pending. The patient did have one
or two episodes of desaturation secondary to breathing trials
and increased secretion in his nostrils. In an attempt to
decongest him, saline nasal spray was started.
4. RENAL: Acute renal failure secondary to dehydration.
The patient's creatinine upon admission was 1.4 and continued
to rise to 2 as he started third spacing his fluids. Urine
electrolytes were checked which showed a phena of less than 1
which is evidence of the patient being dehydrated and
prerenal. He was subsequently given IV fluids and his
creatinine improved to 1.6. A renal ultrasound was done
which showed no evidence of hydronephrosis.
5. INFECTIOUS DISEASE: Leukocytosis: Given the aspiration
pneumonia and elevated white count of 18.6, levofloxacin and
Flagyl were started on the day of admission. Blood cultures
were obtained. The first two sets showed one out of four
blood cultures that grew staphylococcus coagulase-negative.
Since this was deemed a contaminent, no further antibiotics
were given. However, on day number four of hospitalization,
his sputum culture returned showing Staphylococcus
coagulase-positive organisms so vancomycin was added. More
blood cultures were drawn but nothing has grown to date.
6. GASTROINTESTINAL: The patient was given and orogastric
tube for tube feeds. He had some high residuals so the tube
feeds were stopped. Reglan was then administered to promote
GI motility so that the tube feeds could be restarted.
7. FLUIDS, ELECTROLYTES, AND NUTRITION: Hyponatremia: The
patient's sodium slowly fell from 136 upon admission to 130
on the fourth day of hospitalization. It was felt that this
was due to salt wasting from his cerebral problems so he was
then fluid restricted. Although he has acute renal failure
secondary to dehydration and third spacing, it was felt that
he needed to be fluid restricted given that the overall
hyponatremia was more likely due to salt wasting.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 5930**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 6125**]
Dictated By:[**Last Name (NamePattern1) 4270**]
MEDQUIST36
D: [**2149-11-13**] 07:03
T: [**2149-11-13**] 19:46
JOB#: [**Job Number 54030**]
|
V3000,7742,76525,76515,V290 | 10 | 184,167 | Admission Date: [**2103-6-28**] Discharge Date: [**2103-7-6**]
Date of Birth: [**2103-6-28**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 48639**] is a 1,385
gram, former 30 and [**5-23**] week premature baby, born to an 18
year old, Gravida I, Para 0, now I, mother with prenatal
serologies as follows:
A positive, antibody negative, RPR nonreactive, hepatitis B
surface antigen negative; GBS unknown.
Pregnancy was complicated by PPROM on [**2103-6-23**] when the
mother was transferred from [**Name (NI) 1474**] Hospital to [**Hospital1 346**]. Mother received Betamethasone
times two as well as Ampicillin and Erythromycin. She
progressed to a spontaneous vaginal delivery on the morning
of [**2103-6-28**]. The baby emerged vigorous with spontaneous
cry; apgars of eight and nine. She was warm, dried and bulb
suctioned in the delivery room and brought to the Neonatal
Intensive Care Unit for further management for prematurity.
PHYSICAL EXAMINATION: Weight 1,385 grams (25th to 50th
percentile); length 38 cms (10 to 25 percentile); head
circumference 27.5 cms (10 to 25 percentile). She was an
active, alert infant, pink, appropriate for gestational age
of 31 weeks. Anterior fontanel was open and flat with some
molding and caput. No dysmorphism. Lungs clear to
auscultation. Heart regular rate and rhythm without murmurs.
Abdomen was soft without hepatosplenomegaly or masses. Hips
were stable. Premature female genitalia. Extremities were
well perfused.
HOSPITAL COURSE: 1.) Respiratory: Baby Girl [**Known lastname 48639**]
remained stable on room air throughout her Neonatal Intensive
Care Unit stay at [**Hospital1 69**]. She
had one apnea and bradycardia episode on day of life five,
requiring mild stimulation.
2.) Cardiovascular: Baby Girl [**Known lastname 48639**] had seemed
hemodynamically stable throughout her Neonatal Intensive Care
Unit stay. She had no murmurs on examination.
3.) Fluids, electrolytes and nutrition: Baby Girl [**Known lastname 48639**]
had gradually been advanced to total fluids of 150 cc per kg
per day; currently tolerating breast milk 22, maintaining
good blood glucose.
Her admission weight was 1,385 grams; her weight on day of
life seven prior to discharge was 1,445 grams.
Gastrointestinal: Baby Girl [**Known lastname 48639**]' bilirubin level peaked
on day of life three at 8.3, at which time phototherapy was
initiated. Subsequently, her bilirubin level was 4.2 on day
of life six, at which time the phototherapy was discontinued.
Her rebound bili on day of life seven was 5.1.
Infectious disease: Baby Girl [**Known lastname 48639**] was initiated on
Ampicillin and Gentamycin for rule out sepsis. Her blood
culture remained negative at 48 hours at which time the
antibiotics were discontinued.
Hematology: The patient's initial hematocrit was 42.8 and
required no transfusions during this admission.
Neurology: Baby Girl [**Known lastname 48639**] had a screening head
ultrasound on day of life seven which was negative.
CONDITION AT TRANSFER: Baby Girl [**Known lastname 48639**] has been stable on
room air and hemodynamically stable, tolerating full feeds of
breast milk 22.
DISCHARGE DISPOSITION: Baby Girl [**Known lastname 48639**] is being
discharged to [**Hospital1 1474**] special care nursery.
CARE AND RECOMMENDATIONS:
Feeds at discharge: Total fluids of 150 cc per kg per day
with breast milk 24.
MEDICATIONS: None.
STATE NEWBORN SCREEN: Sent.
FOLLOW-UP APPOINTMENT: Recommended in two to three days
after discharge from the Neonatal Intensive Care Unit.
DISCHARGE DIAGNOSES:
Prematurity at 31 weeks.
Rule out sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Name8 (MD) 48640**]
MEDQUIST36
D: [**2103-7-5**] 01:59
T: [**2103-7-5**] 13:41
JOB#: [**Job Number 48641**]
|
1913 | 11 | 194,540 | Admission Date: [**2178-4-16**] Discharge Date: [**2178-5-11**]
Date of Birth: [**2128-2-22**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
CC:[**CC Contact Info 71794**]
Major Surgical or Invasive Procedure:
STEREOTACTIC BRAIN BIOPSY, Neuronavigation guided tumor
resection.
History of Present Illness:
HPI: 50 year old female presents after having fallen in the
bathtub 4 days ago and hitting the back of her head. Since then
she has had a "massive headache" which did not resolve with
Tylenol. She states that she has a high threshold for pain and
did not realize how bad it was during the day while at work but
then when she got home at night she noticed it. The patient
noticed "silvery spects" in her vision and she had trouble with
some simple tasks like finding the tags on the back of her
clothing in the morning. She reported that she had to check
several times to make sure she did not put her clothes on
backwards. She has had some dizziness, but no nausea or
vomiting.
Her speech has not been affected.
Past Medical History:
Newly diagnosed GBM as above
otherwise, none
Family History:
Physical Exam:
ON ADMISSION:
PHYSICAL EXAM:
T:98.4 BP:105/55 HR:95 RR:15 O2Sats: 98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs-intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-9**] throughout. No pronator drift.
When asked to rotate fists around each other, her right fist
orbits the left, which may show slight LUE weakness.
Sensation: Intact to light touch bilaterally.
Reflexes: intact
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
Pertinent Results:
CT HEAD W/O CONTRAST [**2178-4-21**] 12:28 PM
CT HEAD W/O CONTRAST
Reason: please evaluate for any new changes
[**Hospital 93**] MEDICAL CONDITION:
50 year old woman with brain mass. Now has headache.
REASON FOR THIS EXAMINATION:
please evaluate for any new changes
CONTRAINDICATIONS for IV CONTRAST: None.
NON-CONTRAST HEAD CT SCAN
HISTORY: Brain mass. Now has headache. Evaluate for any changes.
TECHNIQUE: Non-contrast head CT scan.
COMPARISON STUDY: [**2178-4-17**] CT scan of the head, reported
by Drs. [**Last Name (STitle) 21881**] and [**Name5 (PTitle) **] as revealing "unchanged mass
effect and edema around large right parietal mass, without
evidence of new intracranial hemorrhage following biopsy."
FINDINGS: Since the prior study, there is now mild linear
hyperdensity within the basal cisterns of this could be
hemorrhage, occasionally the tributaries of the circle of [**Location (un) 431**]
can be somewhat denser appearing, in the setting of increased
intracranial pressure, which would mimic the presence of
subarachnoid blood.
No other new intracranial or extracranial abnormalities are
discerned.
CONCLUSION: Possible small amount of subarachnoid blood or
relatively stagnant vascular flow, in the face of increased
intracranial pressure, as noted above. We have telephoned (Dr.
[**Last Name (STitle) **] with this report immediately after the conclusion of the
study.
ADDENDUM: There is a tiny residual gas collection superior to
the biopsy site, definitely decreased in extent compared to the
prior study of [**4-17**].
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Cardiology Report ECG Study Date of [**2178-4-16**] 3:21:48 PM
Normal sinus rhythm. Within normal limits. No previous tracing
available for
comparison.
Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
90 142 82 [**Telephone/Fax (2) 71795**] 45 48
([**-7/2007**])
MR HEAD W & W/O CONTRAST [**2178-4-16**] 5:01 AM
MR HEAD W & W/O CONTRAST
Reason: evaluate extent of ring enhancing brain mass w/ edema
seen o
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
50 year old woman with brain mass
REASON FOR THIS EXAMINATION:
evaluate extent of ring enhancing brain mass w/ edema seen on CT
EMERGENCY MRI SCAN OF THE BRAIN.
HISTORY: Ring-enhancing brain mass with edema seen on CT scan.
TECHNIQUE: Multiplanar T1 and T2-weighted brain images with
gadolinium enhancement.
COMPARISON STUDIES: None available at this time.
WET READ REPORT: Dr. [**Last Name (STitle) 71796**] interpreted this study as
revealing "bilateral parenchymal masses, suggesting metastatic
disease. The largest mass in the right parietal lobe has a
complex appearance, at least 5 cm in greatest dimension with at
least 8 cm greatest dimension of surrounding edema and 7 mm
leftward midline shift." Dr. [**Last Name (STitle) 71796**] is a member of the
"Nighthawk" Radiology group.
FINDINGS: The study indeed reveals a large right parietal,
irregularly thick ring enhancing mass, possibly with some tiny
"daughter" cystic components extending towards the cortical
surface. As mentioned in the wet [**Location (un) 1131**], there is a substantial
area of surrounding edema, with effacement of the right atrium
and approximately 7 mm leftward subfalcine herniation. A smaller
area of edema is seen within the white matter of the left
occipital lobe, but I cannot delineate any specific area of
enhancement associated with it. A third, very well circumscribed
18 x 26 mm area of elevated T2 signal is seen contiguous to the
left temporal lobe, and it is difficult to determine whether the
lesion is intra- or extra-axial in locale. Again, there is no
associated enhancement and no abnormal susceptibility is noted,
either. On the coronal post-contrast images, there is a
questionable area of enhancement, approximately 3 mm,
immediately subjacent to the left temporal lesion- I am not
certain that the two findings are necessarily related. The
principal vascular flow patterns are identified. There is no
overt extracranial abnormality noted.
CONCLUSION: Large right parietal lobe mass, which may represent
either a primary or metastatic brain neoplasm. The additional
abnormalities within the left temporal lobe and left occipital
lobe, while they may represent extremely unusual manifestations
of metastatic disease, which would then render the right
parietal lobe lesion more likely metastatic, could have
alternative diagnoses, including hemorrhage or a calcified left
temporal meningioma as an explanation for the left temporal
lesion, and either an inflammatory or ischemic process to
account for the left occipital lesion. I discussed this case
this morning with Dr. [**Last Name (STitle) **], it was decided that a non-contrast
head CT scan would be a helpful followup diagnostic procedure to
further characterize the left cerebral hemispheric lesions prior
to brain biopsy of the right parietal lesion.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Approved: [**Doctor First Name **] [**2178-4-16**] 4:07 PM
CHEST (PORTABLE AP) [**2178-4-16**] 3:50 PM
CHEST (PORTABLE AP)
Reason: please evaluate preop
[**Hospital 93**] MEDICAL CONDITION:
50 year old woman with bilateral masses
REASON FOR THIS EXAMINATION:
please evaluate preop
INDICATION: Bilateral brain masses for pre-op evaluation.
PORTABLE CHEST: There are no priors for comparison. Heart size
is normal. Mediastinal and hilar contours are normal. Pulmonary
vasculature is normal. Lungs are clear, and there are no
effusions or pneumothorax.
IMPRESSION:
1. No acute cardiopulmonary disease.
2. No evidence of a primary pulmonary neoplasm, but PA/Lateral
CXR or CT would be more sensitive than a portable study and may
be helpful for more complete assessment, if not already recently
obtained.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: FRI [**2178-4-17**] 9:02 AM
****
*******
Brief Hospital Course:
A/P: 50 year-old woman without significant PMH who presented
[**2178-4-16**] from OSH with new dx of brain mass after fall, with
biopsy that showed GBM, for which she had craniectomy/debulking
[**2178-4-23**] and was started on XRT without event.
.
1) Glioblastoma Multiforme: She was transferred to [**Hospital1 18**] after
fall and was noted to have a brain mass. She had a biopsy which
showed glioblastoma, WHO grade IV. She was noted on [**4-21**] to have
headache, with 4/18 she had mental status changes and imaging
c/w herniation. She was taken emergently to the OR [**4-23**] for
craniotomy and subtotal tumor debulking. She was then
transferred to Omed for XRT and chemotherapy. She was maintained
on keppra and decadron for seizure/cerebral edema prevention.
She was maintained on seizure precautions with frequent neuro
checks. She used a helmet with ambulation given s/p craniectomy.
She was started on XRT with temador. She remained stable without
signs of elevated intracranial pressure during this so was
thought stable to go home and continue XRT as an outpatient. She
was seen by PT and though stable to go home. She was continued
on pantoprazole and sliding scale insulin while on
dexamethasone.
.
Medications on Admission:
none
Discharge Medications:
1. Diabetic.com Starter Kit Kit Sig: One (1) kit
Miscellaneous once a day.
Disp:*1 kit* Refills:*0*
2. Insulin Lispro (Human) 100 unit/mL Solution Sig: 0-15 units
Subcutaneous ASDIR (AS DIRECTED): per sliding scale, check blood
glucose 4 times daily.
Disp:*QS units* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Dexamethasone 4 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*15 Tablet(s)* Refills:*2*
10. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO DAILY (Daily): 2 pills 30 minutes prior to
Temodar (chemotherapy) or [**1-6**] pills as needed every 8 hours for
nausea.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*2*
11. Omega-3 Fatty Acids 550 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
12. Melatonin Oral
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
GLIOBLASTOMA
Discharge Condition:
STABLE
Discharge Instructions:
Please take all medications as prescribed. Please keep all
follow-up appointments. You will be contact[**Name (NI) **] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]
regarding your Temodar prescription.
.
Please call your primary care physician or Dr. [**First Name (STitle) **] [**Name (STitle) 4253**]
if you experience headaches, visual changes, nasea, vomitting,
hiccups, change in strength, sensation, or coordination. These
could be signs of elevated intercranial pressure and could
require urgent treatment.
*
Please limit exercise to walking; no lifting, straining,
excessive bending.
Please continue to use your helmet with ambulation.
You may wash your hair only after sutures and/or staples have
been removed. You may shower before this time with assistance
and use of a shower cap.
Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Please continue with your daily radiation therapy treatments: to
continue this as an outpatient you will need to call: ([**Telephone/Fax (1) 54862**] first thing in the morning of [**2178-5-12**]. If you have
any difficulty schduling these treatments or questions please
call ([**Telephone/Fax (1) 71797**] and ask for [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
.
Please follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) 4253**] on [**Last Name (LF) 766**], [**2178-5-18**]. You should be contact[**Name (NI) **] with the time of this appointment
but if you do not hear from her office please call [**Telephone/Fax (1) 1844**].
.
Please call [**Telephone/Fax (1) 28193**] to schedule follow-up with your primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 28190**] [**Name (STitle) 16528**] in the next 2 weeks.
|
9971,57410,4275,99811,4019,5680,55321,E8782,1570 | 12 | 112,213 | Admission Date: [**2104-8-7**] Discharge Date: [**2104-8-20**]
Date of Birth: [**2032-3-24**] Sex: M
Service: Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 363**] is a
72-year-old male with a past medical history significant for
pancreatic cancer, ulcerative colitis, hypertension, status
post endoscopic retrograde cholangiopancreatography, and
status post total abdominal colectomy 20 years ago with an
end-ileostomy.
The patient underwent an endoscopic retrograde
cholangiopancreatography recently, but a stent was unable to
be placed. A computed tomography was performed which
demonstrated a head of the pancreas mass with dilated
intrahepatic duct along with vascular involvement of the
gastroduodenal artery and superior mesenteric vein. He
presented for exploratory laparotomy with possible pancreatic
mass resection.
PAST MEDICAL HISTORY:
1. Ulcerative colitis.
2. Hypertension.
3. Benign prostatic hypertrophy.
PAST SURGICAL HISTORY:
1. Total abdominal colectomy with end-ileostomy.
2. Status post transurethral resection of prostate.
MEDICATIONS ON ADMISSION:
1. Moexipril 15 mg by mouth once per day.
2. Aspirin 81 mg by mouth once per day.
3. Atenolol 25 mg by mouth once per day.
4. Allopurinol 300 mg by mouth once per day.
5. Multivitamin.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: The patient is a thin,
cachectic Caucasian male who was alert and oriented times
three. In no apparent distress. The sclerae were anicteric.
The patient was jaundiced. The oropharynx was clear with
moist mucous membranes. The neck was supple and without
lymphadenopathy. The heart was regular in rate and rhythm.
The lungs were clear to auscultation bilaterally. The
abdomen was soft, nontender, and nondistended. There was a
well-healed midline scar and ileostomy present. The
extremities were warm without cyanosis, clubbing, or edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: His hematocrit
was 43.2. His INR was 1.2. Creatinine was 1.6. Aspartate
aminotransferase was 51, his alanine-aminotransferase was 89,
his alkaline phosphatase was 395, and his total bilirubin was
12.5.
BRIEF SUMMARY OF HOSPITAL COURSE: On the day of admission,
the patient was taken to the operating room where an
exploratory laparotomy was performed. The patient had
evidence of unresectable pancreatic cancer with biliary
obstruction seen intraoperatively. Adhesiolysis was
therefore performed along with a Roux-en-Y
hepaticojejunostomy, and open cholecystectomy, an open
pancreatic biopsy, and a gastrojejunostomy. The estimated
blood loss for the procedure was 250 cc.
The patient was discharged to the regular hospital floor
after being extubated in the Postanesthesia Care Unit in good
condition.
In the evening on postoperative day one, the patient was
taken back to the operating room emergently for likely
mesenteric bleeding. This was controlled with suture
ligation, and the patient was admitted to the Surgical
Intensive Care Unit postoperatively for close monitoring.
The patient remained intubated in the Intensive Care Unit on
pressor support and received total parenteral nutrition until
postoperative day seven. At this time, the patient's mental
status was extremely labile requiring Haldol for agitation.
The patient's hematocrit was stable at 35.8 at this time.
Tube feeds were initiated on postoperative day eight. On
postoperative day nine, the patient was transferred to the
regular hospital floor. At this time, tube feeds were held
for elevated residuals and nausea. He was still receiving
total parenteral nutrition at this time. The patient's
mental status was still not completely improved. A computed
tomography scan was performed on postoperative day ten which
did not demonstrate any intra-abdominal pathology.
The patient was started on sips on postoperative day eleven
and was started on his home medications. At this time, he
was seen by the Physical Therapy Service and was being
screened for rehabilitation placement.
However, on the evening on postoperative day twelve the
patient spiked a temperature to 101.5 degrees Fahrenheit. A
fever workup was done including a chest x-ray and blood
cultures.
Early the next morning, the patient was found unresponsive
without a pulse at approximately 2:45 a.m. At this time, a
code blue was called and advanced cardiac life support
protocol was initiated. However, the patient was asystolic
without any respiratory effort at this time. He did receive
multiple rounds of epinephrine along with attempts at
ventilation. However, the patient never regained electrical
activity and was pronounced deceased at 2:57 a.m. The
patient's wife was notified at this time. However, a
postmortem examination was declined.
CONDITION AT DISCHARGE: The patient expired on [**2105-8-21**].
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 26023**]
MEDQUIST36
D: [**2105-3-16**] 16:05
T: [**2105-3-16**] 18:33
JOB#: [**Job Number 105917**]
|
41401,4111,25000,4019,2720 | 13 | 143,045 | Admission Date: [**2167-1-8**] Discharge Date: [**2167-1-15**]
Date of Birth: [**2127-2-27**] Sex: F
Service: Cardiac surgery
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: This is a 39-year-old woman with
diabetes, hypertension, hyperlipidemia and obesity, with a
one to two months of chest burning with exertion. For the
past six months, she has been participating in a new vigorous
exercise program to lose weight. Her symptoms do gradually
resolve with rest, but they have started to occur now with
walking. She does acknowledge that there is associated
nausea, diaphoresis and shortness of breath. Now recently she
started to get symptoms for the past two days while at rest.
She was referred for an outpatient exercise tolerance test,
where she had chest pain and significant EKG changes. She was
referred to [**Hospital1 18**] for cardiac catheterization today, which
revealed significant left main artery disease. Just prior to
her transfer to [**Hospital1 18**], she did complain of chest pain and
back pain at about 7/10 intensity and a nitroglycerin drip
was started and she received 5 mg of IV Lopressor and 2 mg of
IV Ativan, which did resolve her pain. While she was in the
cath lab, she had an intraaortic balloon pump placed, and now
she is not actively complaining of any pain.
REVIEW OF SYSTEMS: She denies any orthopnea, lower extremity
edema, but she does acknowledge that she does have
dysmenorrhea.
PRIOR MEDICAL HISTORY: She has diabetes mellitus, type 2,
diagnosed in [**2157**]. She has been able to control it with diet
since [**2166-6-22**]; hypertension and obesity; however, she has
lost 40 pounds in the last six months.
SHE HAS AN ALLERGY TO SHELLFISH.
MEDICATIONS ON TRANSFERS TO [**Hospital1 18**]: Atenolol 50 mg a day,
lisinopril 10 mg a day, Lipitor 20 mg a day, aspirin 325 mg
once a day, progesterone, nitroglycerin drip, Lopressor,
Ativan.
SOCIAL HISTORY: She does not smoke. She does not use ethanol
and she does not use cocaine. Her father had a brain tumor.
Her brother did have coronary artery disease and a myocardial
infarction in his late 30s. Her mother has hypertension. She
does have a strong family history for hyperlipidemia.
PHYSICAL EXAMINATION: The patient is comfortable appearing,
in no apparent distress. Vital signs: Temperature 99.1, pulse
72, blood pressure 144/87. Pulse oximetry is 98% on room air.
Head and neck: PERRLA. EOMI. Anicteric. Mucous membranes
moist. Neck supple, no lymphadenopathy, no JVD. Cardiac:
Regular rate and rhythm. Lungs clear to auscultation
bilaterally. Abdomen is soft, nontender, nondistended, but
she is morbidly obese, positive bowel sounds. Her extremities
are warm, no edema. She has got 5/5 strength in all
extremities.
Her laboratories prior to admission from [**Hospital3 1280**] were
white count 7.4, hematocrit of 39.8, platelets 190,000.
Hemoglobin A1c was 7.1. Sodium was 140, potassium 4.1,
chloride 103, bicarbonate 28, BUN 14, creatinine 0.6. Total
cholesterol was 307, triglycerides were 79, and HDL was 50.
[**Last Name (STitle) 54218**], which was at [**Hospital3 1280**] (it was not at
[**Hospital1 18**]), showed diffuse left main and proximal left anterior
descending artery stenosis, 60% to 70%, which was ulcerative;
50% mid LAD stenosis; 50% left circumflex stenosis after OM1;
moderate right coronary artery stenosis; a normal ejection
fraction of 78%; no mitral regurgitation. Note that the right
coronary artery stenosis that I am reported is different than
what was actually reported on the initial catheterization
results from [**Hospital3 1280**]. This was discussed between Dr. [**Last Name (Prefixes) 411**] and Dr. [**Last Name (STitle) 911**], and was not actually considered to be
80% as previously reported.
So this was a woman who was considered to have unstable
angina but not actively ischemic. She was put on an
intraaortic balloon pump, followed in the cardiac care unit,
and was "preoped" and consented for a CABG on the next day
because of her three-vessel disease. She was made n.p.o.
after midnight and then in the morning she was taken to the
operating room.
On[**Last Name (STitle) 19203**] of [**2167-1-9**], Ms. [**Known lastname 42915**] went to the
operating room with Dr. [**Last Name (Prefixes) **] for bypass surgery.
Please refer to the previously dictated operative note by Dr.
[**Last Name (Prefixes) **] for the specifics of this surgery. In brief,
three grafts were made. One was a left internal mammary to
the left anterior descending artery and then two saphenous
vein grafts were connected to the OM1 and OM2. She was on
cardiopulmonary bypass for 76 minutes and the aorta was cross
clamped for 53 of those minutes.
She tolerated the surgery well and was transferred to the
intensive care unit on propofol and Neo-Synephrine drips.
Postoperatively, Ms. [**Known lastname 42915**] did extremely well. Her
intraaortic balloon pump and all of her intravenous drips
were discontinued on postoperative day one. On postoperative
day two she was extubated and on postoperative day three she
was transferred to the floor. Ms. [**Known lastname 54219**] major floor issues
were as follows.
Ms. [**Known lastname 42915**] was followed by physical therapy, which cleared
her to go home with home physical therapy to assist with
mobility, strength and endurance. She was also actively
diuresed with Lasix and had her potassium repleted
accordingly. Finally, she was noted to have hyperglycemia
while she resumed her regular diet. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8392**] consultation
was obtained and they recommended metformin 500 mg twice a
day to maintain euglycemia. She would follow her sugar as an
outpatient and report this back in an outpatient followup
appointment.
On [**1-14**] the patient's central line was discontinued.
She was scheduled to leave, but she developed chest pain;
however, this chest pain was considered not to be cardiac, to
be more gastrointestinal in nature, and she had ......... and
an EKG, both of which confirmed a noncardiac source for this
chest pain.
She is, therefore, on [**1-15**], postoperative day six,
being discharged home in good condition with home physical
therapy scheduled.
FINAL DIAGNOSES:
1. Type 2 diabetes mellitus.
2. Hypertension.
3. Obesity.
4. Hyperlipidemia.
5. Unstable angina.
6. Three-vessel coronary artery disease, status post
coronary artery bypass grafting, status post intraaortic
balloon pump.
7. Hypokalemia.
DISCHARGE MEDICATIONS:
1. Metoprolol 100 mg t.i.d.
2. Aspirin 325 mg p.o. q.d.
3. Captopril 50 mg p.o. t.i.d.
4. Lipitor 20 mg p.o. q.d.
5. Lasix 20 mg p.o. b.i.d. for one week.
6. Potassium chloride 10 mEq p.o. b.i.d. for one week.
7. Metformin 500 mg p.o. b.i.d.; follow your blood sugar
levels and follow up with [**Doctor First Name 8392**].
8. Percocet one to two tablets every four hours as needed
for pain.
9. Colace 100 mg p.o. b.i.d. as needed for constipation.
[**Last Name (STitle) 54220**]owup appointments are with Dr. [**Last Name (STitle) **], her primary
care physician, [**Name10 (NameIs) **] one to two weeks, Dr. [**Last Name (STitle) 911**], her
cardiologist, in two to three weeks, Dr. [**First Name (STitle) **] from [**Doctor First Name 8392**]
as directed, and Dr. [**Last Name (Prefixes) **] in one month. She is also
recommended to follow up in [**Hospital1 18**] Wound Care Clinic in one to
two weeks to remove her staples.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 1179**]
MEDQUIST36
D: [**2167-1-14**] 16:37
T: [**2167-1-14**] 18:16
JOB#: [**Job Number 54221**]
|
2724,71946,7220,311,4589,78551,5119,4239 | 17 | 161,087 | Admission Date: [**2135-5-9**] Discharge Date: [**2135-5-13**]
Date of Birth: [**2087-7-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Bactrim / Ampicillin / Remeron
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
chest pressure/cardiac tamponade/ cardiogenic shock
Major Surgical or Invasive Procedure:
emergent sternotomy for pericardial window [**2135-5-9**]
History of Present Illness:
Underwent min. inv. PFO closure in [**12-11**]. Had emergent admission
on [**5-9**] for hypotension, pericardial effusion , pleural effusion
and chest pain for several days. Did not resolve with pain med
and had increasing SOB. Admitted to ER for emergent eval. and
bedside TTE. Started on dopamine drip for hypotension.
Past Medical History:
s/p min. inv. closure of Patent foramen ovale [**12-11**]; History of
Stroke/TIA; Depression; Anxiety; Borderline Hyperlipidemia;
Herniation of Cervical Discs; Patella-Femoral Syndrome; s/p
Bunionectomies
Social History:
Denies tobacco. Admits to occasional ETOH. She is an employee of
the [**Hospital1 18**] in the Neuro-Pysch Department. She is married with two
children. She denies IVDA and recreational drugs.
Family History:
Father underwent CABG at age 72. Cousin died of an MI at age 46.
Physical Exam:
pt. in distress
SBP 70- 80's
lungs CTA
tachycardic, RR, no murmur or rubs
palpable pedal pulses
Pertinent Results:
[**2135-5-11**] 08:40AM BLOOD WBC-11.3* RBC-3.62* Hgb-9.9* Hct-28.8*
MCV-80* MCH-27.3 MCHC-34.3 RDW-14.4 Plt Ct-413
[**2135-5-9**] 11:45AM BLOOD Neuts-86.5* Lymphs-7.0* Monos-5.2 Eos-1.2
Baso-0.2
[**2135-5-11**] 08:40AM BLOOD Plt Ct-413
[**2135-5-11**] 08:40AM BLOOD Glucose-118* UreaN-8 Creat-0.6 Na-136
K-3.7 Cl-102 HCO3-24 AnGap-14
[**2135-5-9**] 11:45AM BLOOD CK(CPK)-26
[**2135-5-9**] 11:45AM BLOOD CK-MB-NotDone cTropnT-<0.01
Brief Hospital Course:
Admitted through ER as above and referred to CT [**Doctor First Name **] for
emergent pericardial window/pericardectomy via sternotomy, as
the patient was hypotensive.This was performed by Dr. [**Last Name (STitle) 1290**]
on [**5-9**]. Transferred to CSRU in stable condition on phenylephrine
and propofol drips. Extubated and awoke neurologically intact.
Beta blockade started on POD #1 and transferred out to the floor
to start increasing her activity level. Mediastinal tubes
removed on POD #1. Crepitus was noted on anterior chest wall
after pleural tubes removed on POD #2. Beta blockade also
titrated up. Crepitus improved and CXR confirmed. She made good
progress and was discharged to home with VNA services on POD #4.
Medications on Admission:
ASA 325 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 3 days.
Disp:*3 Packet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
s/p emergent pericardial window via sternotomy [**2135-5-9**]
cardiogenic shock/tamponade
s/p Min inv. PFO closure [**12-11**]
s/p CVA
anxiety/depression
cervical disc herniation
patella-femoral syndrome
borderline hyperlipidemia
Discharge Condition:
stable
Discharge Instructions:
may shower over incision and gently pat dry
no lotions, creams or powders on incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100, redness or drainage
Followup Instructions:
follow up with Dr. [**Last Name (STitle) **] (PCP) in [**2-7**] weeks
follow up with Dr. [**Last Name (STitle) **] (Card)in [**3-11**] weeks
follow up with Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2135-5-13**] |
7455,45829,V1259,2724 | 17 | 194,023 | Admission Date: [**2134-12-27**] Discharge Date: [**2134-12-31**]
Date of Birth: [**2087-7-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Bactrim / Ampicillin / Remeron
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
History of stroke
Major Surgical or Invasive Procedure:
[**2134-12-27**] Minimally invasive closure of patent foramen ovale
History of Present Illness:
Mrs. [**Known lastname 11679**] is a 47 year old female who suffered a cerebellar
stroke in [**2134-3-9**]. Workup at that time revealed a patent
foramen ovale. She is currently followed by Dr.
[**Last Name (STitle) 1693**](neurologist) from the [**Hospital1 18**]. Full hypercoagulability
workup was unremarkable. Since [**Month (only) 956**], she has had no other
neurological events. In preperation for surgical intervention,
she underwent cardiac catheterization in [**Month (only) **] which showed
normal coronary arteries and normal left ventricular function.
Past Medical History:
Patent foramen ovale; History of Stroke/TIA; Depression;
Anxiety; Borderline Hyperlipidemia; Herniation of Cervical
Discs; Patella-Femoral Syndrome; s/p Bunionectomies
Social History:
Denies tobacco. Admits to occasional ETOH. She is an employee of
the [**Hospital1 18**] in the Neuro-Pysch Department. She is married with two
children. She denies IVDA and recreational drugs.
Family History:
Father underwent CABG at age 72. Cousin died of an MI at age 46.
Physical Exam:
Vitals: BP 114/68, HR 90, RR 14
General: well developed female in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD, no carotid bruits
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2134-12-31**] 06:15AM BLOOD WBC-6.6# RBC-2.98* Hgb-9.1* Hct-26.1*
MCV-88 MCH-30.6 MCHC-35.0 RDW-13.1 Plt Ct-192
[**2134-12-27**] 06:19PM BLOOD WBC-10.5 RBC-3.42*# Hgb-10.5*# Hct-30.0*
MCV-88 MCH-30.8 MCHC-35.2* RDW-12.6 Plt Ct-138*
[**2134-12-31**] 06:15AM BLOOD Glucose-121* UreaN-12 Creat-0.7 Na-140
K-5.1 Cl-106 HCO3-28 AnGap-11
[**2134-12-27**] 07:21PM BLOOD UreaN-11 Creat-0.8 Cl-112* HCO3-23
[**2134-12-31**] 06:15AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.0
Brief Hospital Course:
Mrs. [**Known lastname 11679**] was admitted and underwent surgical closure of her
patent foramen ovale. The operation was performed minimally
invasive and there were no complications. Following the
procedure, she was brought to the CSRU. She initially remained
hypotensive, requiring volume and Neosynephrine. Within 24
hours, she awoke neurologically intact and was extubated without
difficulty. By postoperative day two, she successfully weaned
from inotropic support. She maintained stable hemodynamics and
transferred to the floor. On telemetry, she remained mostly in a
normal sinus rhythm with brief periods of accelerated junctional
rhythm. She otherwise continued to make clinical improvements
and was cleared for discharge on postoperative day four. She
remained just on Aspirin therapy. Aggrenox was not resumed as
her PFO was surgically repaired. At discharge, her systolic
blood pressures were in the 100's with heart rate of 80-90. Her
room air saturations were 93% and she was ambulating without
difficulty. She had good pain control with Dilaudid and all
wounds were clean, dry and intact.
Medications on Admission:
Bupropion 150 [**Hospital1 **], Aggrenox qd, Centrum, Calcium, Erythromycin
eye gtts
Discharge Medications:
1. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours
as needed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Patent foramen ovale - s/p surgical closure; History of
Stroke/TIA; Depression; Anxiety; Borderline Hyperlipidemia;
Herniation of Cervical Discs; Patella-Femoral Syndrome; s/p
Bunionectomies
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**5-11**] weeks - call for appt,
[**Telephone/Fax (1) 170**]. Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**3-11**] weeks - call for
appt. Local cardiologist, Dr. [**Last Name (STitle) 11255**] in [**3-11**] weeks - call for
appt
Completed by:[**2134-12-31**] |
78057,47829,V5869,78321,E9323,V5867,29633,78039,25080,4019,4264,2720,V170 | 18 | 188,822 | Admission Date: [**2167-10-2**] Discharge Date: [**2167-10-4**]
Date of Birth: [**2116-11-29**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
Depression
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50 yo M w/ Type 2 DM, depression who was admitted to Deaconness
4 for major depressive episode and possible [**First Name3 (LF) **]. While on [**Hospital1 **]
4, the patient was given ativan 1 mg x 1. His klonopin was held.
He was given [**1-11**] normal dose of NPH as NPO for [**Month/Day (2) **]. The
following am, the paitent was found to be shaking. He was given
2 mg ativan and became nonresponsive over the next 20 minutes
and a code was called. The patient's fingerstick was 30 so he
was given 1 amp of D50. He was also given 4 mg IV ativan. He
stopped shaking and mental status cleared in 30 minutes. He was
started on a dilantin load. He was seen by neuro who felt that
in the setting of hypoglycemia (severe)and withdrawal of his
Klonopin, he was at risk to have a seizure.
Past Medical History:
- IDDM, Type II
- OSA
- Borderline HTN
- Hypercholestremia
- h/o RBBB
PAST PSYCHIATRIC HISTORY:
Panic d/o x 20yrs on Klonopin x 12 yrs, occassional Xanax
Outpt psychiatry intermittently, until 4 weeks ago when he began
to see Dr. [**Last Name (STitle) 10166**] with significant depression since [**Month (only) 205**].
[**Month (only) 404**] of this year pt and wife sought counseling for sleep
issue with children x 2 sessions.
No assaultive or suicidal behavior
Social History:
SUBSTANCE ABUSE HISTORY:
Denies alcohol, tobacco or other street drugs. One episode of
MJ use
in [**2140**].
SOCIAL HISTORY:
Attorney for [**Company 28241**], [**Location (un) 511**] division. Married
to [**Doctor First Name **] for 11 yrs this [**5-11**] children 4yo [**Known firstname 122**] and 2
yo [**Doctor First Name **]. Denies physical or sexual abuse in past or
currently. Denies military or legal hx.
Family History:
Denies
Physical Exam:
VS: Tm 99.8 HR 87-133 (98) BP 117-166/75-97 RR 17-27
O2 Sat - 95-100% RA 2740/2455
GEN: NAD, sitting in bed
HEENT: PERRL, EOMI, sclera anicteric, mmm, no OP lesions
CV: Normal S1/S2, RRR, no m/g/r.
PUL: CTA b/l.
ABD: Soft, NT, ND +BS.
EXT: No edema.
Neuro: A and Ox3, CN 2-12 intact, M [**5-14**] UE/LE b/l, sensation
grossly intact
Pertinent Results:
[**2167-10-3**] 07:30PM BLOOD WBC-12.8* RBC-4.69 Hgb-13.8* Hct-39.7*
MCV-85 MCH-29.5 MCHC-34.9 RDW-13.9 Plt Ct-217
[**2167-10-3**] 07:30PM BLOOD Plt Ct-217
[**2167-10-4**] 07:45AM BLOOD Glucose-186* UreaN-12 Creat-1.0 Na-139
K-3.9 Cl-101 HCO3-25 AnGap-17
[**2167-10-3**] 07:30PM BLOOD CK-MB-1 cTropnT-<0.01
[**2167-10-3**] 06:14AM BLOOD CK-MB-1 cTropnT-<0.01
[**2167-10-2**] 03:38PM BLOOD Phenyto-15.5
[**2167-10-2**] 11:36AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2167-10-2**] 11:44AM BLOOD Type-ART pO2-198* pCO2-29* pH-7.54*
calHCO3-26 Base XS-3
.
EEG
This is a normal EEG in the awake and drowsy states. Note
is incidentally made of a resting tachycardia.
Brief Hospital Course:
A/P: 50M with history of hypertension, type II diabetes,
originally admitted to psychiatry for [**Month/Day/Year **], made NPO p MN for [**Month/Day/Year **]
in AM with 1/2 dose of insulin, who was found unresponsive and
in apparent seizure state, who was found to have a blood glucose
of 30.
.
1)Convulsions:
A code was called and the patient was given Ativan 2mg po x1, as
well as an amp of D50, loaded with Dilantin and transferred to
the MICU. The seizure was attributed to his hypoglycemic state,
although psych thought there was an element of Klonopin
withdrawal and thus continued to give Ativan 0.5mg po q4. Pt
had frequent BS checks in the MICU and patient recovered from
his initial event without any post-seizure sequelae. Pt
continued to be monitored and had no further events. Neurology
was consulted for his ? seizure event and after a negative exam
and negative EEG, concluded that it was all due to hypoglycemia,
and that further Dilantin would not be necessary.
Dilantin was d/ced and patient continued to do well. He was
eventually transferred to the floor. All home medications were
continued and patient continued to express interest in his [**Month/Day/Year **]
treatment on Monday, although refused to be transferred back to
[**Hospital1 **] 4.
All home medications although his insulin dose (nph 20 qPM) was
halved (--> NPH 10 qPM) on the floor, and his sugars were
running in the 150s-250s range.
Pt was sent home to return for [**Hospital1 **] on Monday as an outpatient.
Explicit instructions were given to take all medications as
normal the night before, including his Klonopin, and only take
[**1-13**] dose of NPH insulin the night before, NPO p MN, no morning
NPH dose, and to cover his elevated morning sugars with Humalog
at a conservative sliding scale. Goal sugars 150s-250s.
2) Type 2 DM - follow sugars closely
- Continue normal dose insulin while taking POs, and when NPO p
MN for [**Month/Day (4) **] in AM, pt was instructed to take [**1-13**] NPH dose the
evening before, no NPH in the AM, and to cover with Humalog prn
according to conservative insulin SS to prevent hypoglycemic
episodes.
.
3) Depression:
Pt with a h/o refractory depression that was originally admitted
to the psych service for [**Month/Day (4) **]. Psych consult remained aware as
pt was admitted to the MICU and then called out to the floors.
Recommended continuing his Klonopin 3mg po bid for his anxiety,
and added Ativan 0.5mg po q4 for coverage of his anxiety and
alleviation of ? withdrawal during periods when he is off the
Klonopin. Continued his home doses of Celexa, Nortriptyline,
Seroquel and trazodone for sleep.
Pt was to be discharged to return on Monday for [**Month/Day (4) **] treatments
as an outpatient.
.
4) F/E/N:
-Diabetic diet, replete lytes prn
.
5) Code: full
.
6) Dispo:
Medically cleared per MICU team as well as PCP. [**Name10 (NameIs) **] to be
discharged to follow up with outpatient [**Name10 (NameIs) **] on Monday.
Medications on Admission:
Nortriptylline 50mg qd (started a week PTA)
Seroquel 50mg tid
Klonopin 3mg [**Hospital1 **]
Lexapro 20mg po qd
Trazadone 200mg qhs
Crestor 10mg po qd
Insulin SS + NPH 20 qhs
Lisinopril 10mg po qd
Discharge Medications:
1. Nortriptyline 50 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
2. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
3. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
Disp:*60 Tablet(s)* Refills:*2*
4. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous qAM (in the morning) .
Disp:*qs units* Refills:*2*
9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Five (5)
units Subcutaneous qhs (at bedtime) for 1 doses.
Disp:*qs units* Refills:*0*
10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous at bedtime: Please start after [**Hospital1 **]
treatments tomorrow night [**10-5**]. Do not use this dose when not
eating.
Disp:*qs units* Refills:*2*
11. Klonopin 1 mg Tablet Sig: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*2*
12. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Major Depression
Hypoglycemic seizure
.
DMII
HTN
Discharge Condition:
Afebrile, FS running in high normal range, stable to be
discharged home.
Discharge Instructions:
1. Please return Monday morning to receive your [**Month/Year (2) **] treatment
with psychiatry as below. Please call [**Telephone/Fax (1) **] for your
scheduled time.
.
2. For preparations for [**Telephone/Fax (1) **] tomorrow morning:
(a) Please take NPH 5 units tonight, no regular insulin
(b) Do not take NPH morning dose tomorrow.
(c) Nothing to eat past midnight.
(d) Take your Klonopin 3mg dose tonight.
(e) No morning medications prior to [**Telephone/Fax (1) **] including Klonopin.
(f) Have fingersticks checked in morning, and prior to [**Telephone/Fax (1) **], and
give Regular Insulin based on sliding scale.
.
3. Please take your other medications as below.
.
4. If develop lightheadedness, dizziness, sweating, chest pain,
shortness of breath, confusion, or other symptoms, please call
Dr. [**First Name (STitle) **] (or Dr. [**Last Name (STitle) 10166**] or report to the nearest ER.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Hospital **] CLINIC Where: [**Hospital **] CLINIC
Date/Time:[**2167-10-5**] 8:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28258**], MD Where: RA [**Hospital Unit Name **]
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) HMFP Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2167-11-11**] 9:50
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28258**], MD Where: RA [**Hospital Unit Name **]
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) HMFP Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2167-11-17**] 1:30
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**]
Completed by:[**2167-10-5**] |
78057,E9323,47829,V5869,V5867,29633,78039,25080,78321,4019,4264,2720,V170 | 18 | 188,822 | Admission Date: [**2167-9-30**] Discharge Date: [**2167-10-2**]
Date of Birth: [**2116-11-29**] Sex: M
Service: PSYCHIATRY
Allergies:
Bactrim
Attending:[**First Name3 (LF) 7342**]
Chief Complaint:
"I'm just so depressed, I can't do anything"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt reports 3-4 weeks ago he noticed an increase of stress at
work and at home at the same time that he was losing weight to
gain better control over his diabetes (40lb in [**5-15**] weeks). Pt
reports having increasingly frequent panic attacks which he
controlled with Klonopin and occassional Xanax. He also noticed
decrease in sleep, energy, concentration, interest and
motivation, and an increase in anhedonia over the past [**2-12**]
weeks.
His psychiatrist began Zoloft which after 3-4 days made him
jittery and this was switched to Celexa which he seems to be
tolerating better, although his neurovegetative sx seem to
worsen. He denies SI but reports fleeting, ego dystonic
thoughts of hurting his wife, and has not acted on any of these
thoughts. Pt reports ruminations concerning whether he is
schizophrenic, will have to stay in the hospital forever, or
will be on meds forever. Pt and wife also report guilt over
allowing two children to develop bad sleeping habits such that
now children and wife sleep in bed and pt sleeps in chair
downstairs.
Past Medical History:
- IDDM, Type II
- OSA
- Borderline HTN
- Hypercholestremia
- h/o RBBB
PAST PSYCHIATRIC HISTORY:
Panic d/o x 20yrs on Klonopin x 12 yrs, occassional Xanax
Outpt psychiatry intermittently, until 4 weeks ago when he began
to see Dr. [**Last Name (STitle) 10166**] with significant depression since [**Month (only) 205**].
[**Month (only) 404**] of this year pt and wife sought counseling for sleep
issue with children x 2 sessions.
No assaultive or suicidal behavior
Social History:
SUBSTANCE ABUSE HISTORY:
Denies alcohol, tobacco or other street drugs. One episode of
MJ use
in [**2140**].
SOCIAL HISTORY:
Attorney for [**Company 28241**], [**Location (un) 511**] division. Married
to [**Doctor First Name **] for 11 yrs this [**5-11**] children 4yo [**Known firstname 122**] and 2
yo [**Doctor First Name **]. Denies physical or sexual abuse in past or
currently. Denies military or legal hx.
Family History:
Denies
Physical Exam:
MENTAL STATUS EXAM ON ADMISSION
APPEARANCE & FACIAL EXPRESSION: well-groomed, anxious
POSTURE: sitting up in chair
BEHAVIOR (NOTE ANY ABNORMAL MOVEMENTS): none noted
ATTITUDE (E.G., COOPERATIVE, PROVOCATIVE): cooperative in
conversation but somewhat guarded
SPEECH (E.G., PRESSURED, SLOWED, DYSARTHRIC, APHASIC, ETC.):
normal flow, articulation and prosody
MOOD: anxious
AFFECT (NOTE RANGE, REACTIVITY, APPROPRIATENESS, ETC.): blunted
affect with moderate range/reactivity, congruent
THOUGHT FORM (E.G., LOOSENED ASSOCIATIONS, TANGENTIALITY,
CIRCUMSTANTIALITY, FLIGHT OF IDEAS, ETC.): No LOA/FOI, [**Doctor Last Name **],
circ
THOUGHT CONTENT (E.G., PREOCCUPATIONS, OBSESSIONS, DELUSIONS,
ETC.): Fears he is schizophrenic because of the thoughts to
hurt his wife, distorted thinking regarding work, somewhat
paranoid about confidentiality issues and conditions of CV
ABNORMAL PERCEPTIONS (E.G., HALLUCINATIONS): denied
NEUROVEGETATIVE SYMPTOMS (E.G., DISTURBANCES OF SLEEP, APPETITE,
ENERGY, LIBIDO): poor sleep, energy, interest
SUICIDALITY/HOMICIDALITY (INCLUDE IDEATION, INTENT, PLAN):
fleeting thoughts as above to hurt wife, denies plan, SI
INSIGHT AND JUDGMENT: limited
COGNITIVE ASSESSMENT:
SENSORIUM (E.G., ALERT, DROWSY, SOMNOLENT): alert
ORIENTATION: x 3
ATTENTION (DIGIT SPAN, SERIAL SEVENS, ETC.): not tested
MEMORY (SHORT- AND LONG-TERM): registration and long term intact
CALCULATIONS: not tested
FUND OF KNOWLEDGE (ESTIMATE INTELLIGENCE): above average
PROVERB INTERPRETATION: not tested
SIMILARITIES/ANALOGIES: not tested
PHYSICAL EXAM ON ADMISSION:
VSS, exam within normal limits
Pertinent Results:
[**2167-9-30**] 11:23AM %HbA1c-6.3*# [Hgb]-DONE [A1c]-DONE
[**2167-9-30**] 11:15AM GLUCOSE-255* UREA N-11 CREAT-0.9 SODIUM-137
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-28 ANION GAP-13
[**2167-9-30**] 11:15AM VIT B12-271 FOLATE-13.0
[**2167-9-30**] 11:15AM TSH-1.6
[**2167-9-30**] 11:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2167-9-30**] 11:15AM WBC-9.9 RBC-5.07 HGB-14.8 HCT-42.0 MCV-83
MCH-29.1 MCHC-35.2* RDW-13.9
[**2167-9-30**] 11:15AM PLT COUNT-217
[**2167-9-30**] 11:01AM URINE HOURS-RANDOM
[**2167-9-30**] 11:01AM URINE GR HOLD-HOLD
[**2167-9-30**] 11:01AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2167-9-30**] 11:01AM URINE RBC-0-2 WBC-[**3-14**] BACTERIA-MOD YEAST-NONE
EPI-0-2
Brief Hospital Course:
SOMATIC INTERVENTIONS:
The patient was continued on his outpatient medication regimen
of Lexapro, Nortriptyline, Seroquel, Klonopin and Trazodone. He
was also offerred Ambien at HS as needed. The patient was
admitted for ECT and was cleared by Medicine and Anesthesia.
Of note, per ECT consult, the patient's HS and a.m. doses of
Klonopin were held for procudure. Overnight, prior to transfer,
the DOC was called in response to the patient being agitated and
tremulous reporting "I'm going to die". Fingerstick glucose was
found to be over 300 - in response, the patient was given 10
units NPH and received Ativan 2mg IM with fair effect. On the
morning of transfer, the patient was again found to be tremulous
and disoriented, repeating that he felt he was going to die. He
was again given Ativan 2mg IM with minimal effect. Fingerstick
was checked and found to be 30. In the process of obtaining
D50, the patient began to demonstrate myoclonic jerking of arms
and legs. Code was called when the patient became unresponsive.
THERAPEUTIC INTERVENTIONS:
The patient is followed as an outpatient by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10166**] who
referred him to the inpatient unit for stabilization of his
significant depression as well as for evaluation for ECT. Mr.
[**Known lastname 28257**] admitted to significantly low mood since [**Month (only) 205**], and
endorsed neurovegetative symptoms consistent with an agitated
depression.
BEHAVIORAL:
The patient remained in good behavioral control for the duration
of his admission, requiring only 15 minute checks.
LEGAL:
The patient signed in under conditional voluntary upon arrival.
DISPOSITION:
The patient was transfered to an ICU bed after code was called
for unresponsiveness and possible seizure activity.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 18**]
Discharge Diagnosis:
AXIS I: MDD
AXIS II: Deferred
AXIS III: IDDM, Type II; OSA; Borderline HTN; h/o RBBB; Seizure
A/W hypoglycemia
Discharge Condition:
MENTAL STATUS EXAM ON DISCHARGE:
The patient is lying supine in bed, jerking arms and legs, with
writhing movements in his trunk. The patient is unresponsive,
will not attend to voice etc. Unable to make eye contact.
Unable to assess mood, affect or thought process and content.
Insight and judgment n/a.
Discharge Instructions:
Transfer to ICU bed
Followup Instructions:
- Transfer to ICU bed
- Psychiatry C/L service will follow while on Medicine
Completed by:[**2167-10-2**] |
80502,5990,5964,E8809,8220,73300,2948,4019,44321 | 19 | 109,235 | Admission Date: [**2108-8-5**] Discharge Date: [**2108-8-11**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo male s/p unwitnessed fall at home; found at bottom of
stairs by family member; down for unknown period of time.
Patient unable to recall events surrounding the fall.
Past Medical History:
Atonic Bladder
Hypertension
Dementia
+VDRL
Social History:
Retired truck driverLives alone in 2 story building; has VNA to
change suprapubic tube. HHA to assist with ADL's. Has one son
who visits on weekends.
Family History:
Noncontributory
Physical Exam:
VS upon arrival to trauma bay:
T 96.4 BP 127/72 HR 89 RR 20 room air Sats 98%
Gen: NAD, alert
HEENT: PERRL, EOMI
Chest: CTA bilat, no crepitus
Cor: RRR
Abd: soft, NT, ND. Suprapubic catheter in place
Back: diffusely tender spine, no stepoffs, no deformities
Rectum: Normal tone, guaiac negative
Extr: no edema, DP 2+ bilat, FROM x4
Pertinent Results:
[**2108-8-5**] 04:00PM cTropnT-0.05*
[**2108-8-5**] 04:00PM CALCIUM-9.2 PHOSPHATE-2.9 MAGNESIUM-2.0
[**2108-8-5**] 04:00PM TSH-1.5
[**2108-8-5**] 04:00PM PT-13.6* PTT-29.2 INR(PT)-1.2
[**2108-8-5**] 08:18AM GLUCOSE-155* LACTATE-2.7* NA+-137 K+-4.8
CL--101 TCO2-24
[**2108-8-5**] 08:18AM HGB-14.6 calcHCT-44
[**2108-8-5**] 08:10AM ALT(SGPT)-33 AST(SGOT)-54* CK(CPK)-371* ALK
PHOS-85 AMYLASE-71 TOT BILI-0.8
[**2108-8-5**] 08:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2108-8-5**] 08:10AM WBC-14.8* RBC-4.98 HGB-14.9 HCT-42.9 MCV-86
MCH-30.0 MCHC-34.8 RDW-13.8
[**2108-8-5**] 08:10AM PLT COUNT-230
CTA NECK W&W/OC & RECONS [**2108-8-7**] 11:03 AM
CTA NECK W&W/OC & RECONS; CT 150CC NONIONIC CONTRAST
Reason: r/o vascular injury (CTA neck only)
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **]yo M s/p fall with dens fx, change in MS
REASON FOR THIS EXAMINATION:
r/o vascular injury (CTA neck only)
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post fall with dens fracture, change in
mental status. Rule out vascular injury. CTA neck only.
TECHNIQUE: CTA neck with multiplanar reconstructions,
three-dimensional reconstructions.
FINDINGS: There is a plaque with ulceration at the origin of the
left internal carotid artery. The residual lumen at site of the
stenosis is approximately 3 mm. There is also an ulcerative
plaque seen in the right internal carotid artery at a similar
level without significant stenosis. The remainder of the
visualized vessels is within normal limits without stenosis,
extravasation or aneurysm formation. Calcified plaques are noted
in the aortic arch. The visualized soft tissue structures appear
unremarkable without pathologic enhancement. The visualized lung
portions are unremarkable without pneumo- or hemothorax. Mucosal
thickening is noted in the sphenoid and bilateral maxillary
sinuses without air fluid levels.
IMPRESSION: Plaque with ulceration at the proximal left internal
carotid artery with a residual lumen of 3 mm. This represents a
50% stenosis. Ulcerated plaque without significant stenosis in
the right proximal internal carotid artery. No active
extravasation.
PRELIMINARY REPORT: No active extravasation. Proximal right ICA
may contain a web as there is very focal narrowing. Proximal
left ICA has an area that may represent an ulcerative plaque or
early dissection. [**First Name8 (NamePattern2) **] [**Doctor Last Name 18954**] MDMBA
CT HEAD W/O CONTRAST [**2108-8-7**] 11:02 AM
CT HEAD W/O CONTRAST
Reason: r/o bleed
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with agitation, s/p fall with dens fx
REASON FOR THIS EXAMINATION:
r/o bleed
CONTRAINDICATIONS for IV CONTRAST: None.
CT SCAN OF THE BRAIN, [**2108-8-7**]
INDICATION: [**Age over 90 **]-year-old man with agitation after a fall and dens
fracture, rule out intracranial hemorrhage.
TECHNIQUE: Axial non-contrast CT scans of the brain were
obtained. Comparison is made to an MRI of the brain from
[**8-5**] and a CT scan of the brain from [**2108-8-5**].
FINDINGS:
There is no change in the appearance of the brain, compared to
previous studies. No acute hemorrhage is evident. There are no
abnormal extra-axial collections. There is no intracranial mass
effect or shift of structures. The ventricles are not dilated.
An old right cerebellar infarction and areas of white matter
hypodensity, likely chronic microvascular infarction, are noted
and unchanged.
There is mucosal thickening in the ethmoid and frontal sinuses
and a small amount of fluid in the right sphenoid sinus. The
mastoids are aerated.
IMPRESSION: Stable appearance of the brain, compared to recent
previous studies. No evidence of acute intracranial hemorrhage.
KNEE (AP, LAT & OBLIQUE) LEFT [**2108-8-8**] 1:38 PM
KNEE (AP, LAT & OBLIQUE) LEFT
Reason: r/o fx
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man s/p fall
REASON FOR THIS EXAMINATION:
r/o fx
INDICATION: [**Age over 90 **]-year-old man status post fall. Evaluate for
fracture.
THREE VIEWS OF THE LEFT KNEE:
There is a fracture of the inferior patella transfixed by a
cerclage wire. The fracture margins appear indistinct and old.
There is a joint effusion, with an equivocal fat-fluid level.
The oblique view demonstrates a vertical linear lucency with
could represent an more acute non- displaced fracture. If the
hardware in the patella was not placed in the past several weeks
or months, then that lucency does indeed represent a new non-
displaced patellar fracture. No other acute fracture is
identified about the knee.
IMPRESSION:
Old patellar fracture transfixed by cerclage wire. Probable new
nondisplaced patellar fracture.
ADDENDUM [**2108-8-10**] - Please note that the original house officer
dictation did not reflect the presence of the joint effusion or
suspected acute fracture. This change in [**Location (un) 1131**] was discussed
with [**First Name8 (NamePattern2) 17148**] [**Last Name (NamePattern1) 2819**] on [**2108-8-10**] at 2:45 pm, who confirms that the old
patellar fracture was remote.
Brief Hospital Course:
Patient admitted to the trauma service. Orthopedic Spine was
immediately consulted because of his cervical spine injuries.
Recommended non-surgical intervention with cervical collar for
2-3 months. Neurosurgery consulted for patient's cervical
fracture as well, recommendations for further radiologic imaging
to evaluate for any vertebral artery dissection and monitoring
neurological status. Vascular surgery consulted for likely
dissection of left ICA, recommendations for ASA for
anticoagulation; no Heparin given history falls; and re imaging
if patient develops signs and symptoms. Geriatrics consulted
given patient's mechanism of injury; delirium identified and
recommendations made re: treating his delirium; Olanzapine
started; bone densitometry while in rehab to screen for
osteoporosis and initiating Calcium with Vit D. Speech and
Swallow consulted for his dysphagia; bedside swallow study
performed. Recommendations for nectar thick liquids and ground
diet. Physical therapy consulted due to patient's decreased
functional mobility and falls; recommendations for rehab stay
after discharge from hospital. Patient sustained a mechanical
fall during his hospitalization; a head CT scan and films of his
left knee were obtained; no intracranial hemorrhage identified.
Knee films revealed questionable non displaced patellar
fracture, Orthopedics was consulted and recommended a knee
immobilizer and and follow up in 3 weeks.
Medications on Admission:
Aricept
Toprol
Trazadone
Discharge Medications:
1. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p Fall
C2 dens fracture
Discharge Condition:
Stable
Discharge Instructions:
You must continue to wear your cervical collar for next [**9-12**]
weeks.
Follow up with Orthopedic Spine & Vascular Surgery after your
discharge.
Followup Instructions:
Follow up with Orthopedic Spine in [**3-7**] weeks after discharge,
call [**Telephone/Fax (1) 3573**] for an appointment.
Follow up with Vascular Surgery, Dr. [**Last Name (STitle) **] in 4 weeks,
call [**Telephone/Fax (1) 2625**] for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
41401,4111,25000,2724,4019 | 20 | 157,681 | Admission Date: [**2183-4-28**] Discharge Date: [**2183-5-3**]
Date of Birth: [**2107-6-13**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 65 year old female
with a 20 year history of hypertension and a ten year history
of Type 2 diabetes who demonstrated a positive exercise
stress test in [**2183-3-1**] suggestive for possible coronary
artery disease. The patient received a stress test as part
of a risk stratification workup and at no point demonstrated
any evidence of chest pain. A subsequent exercise MIBI study
performed [**2183-3-28**] revealed an exercise capacity of
only 2 minutes 15 seconds on the [**Doctor First Name **] protocol. There was
no chest pain noted on the test and the peak exercise
electrocardiogram showed 1.5 to 2 mm horizontal to upsloping
ST depression in the inferior leads and in V1 and V2.
Imaging studies revealed a large apical to a small anterior
defect that was reversible. The patient's ejection fraction
was noted to be 56% with normal wall motion. The patient
subsequently underwent a cardiac catheterization on [**2183-4-22**] which demonstrated three vessel coronary artery disease
and mild diastolic ventricular dysfunction. The patient was
thereafter referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] for surgical
evaluation and was subsequently scheduled for a coronary
artery bypass graft on [**2183-4-28**].
HOSPITAL COURSE: On [**2183-4-28**], the patient underwent a
coronary artery bypass graft times three with grafts from the
left internal mammary artery to the left anterior descending,
saphenous vein graft to the right coronary artery and
saphenous vein graft to the obtuse marginal. The patient
tolerated the procedure well. The patient's pericardium was
left open. Lines were placed including an arterial line and
a Swan-Ganz catheter ; both atrial and ventricular wires were
placed; tubes placed included in a mediastinal and bilateral
pleural tubes. The patient was subsequently transferred to
the Cardiac Surgery Recovery Unit, intubated, for further
evaluation and management. Shortly after arriving in the
Cardiac Surgery Recovery Unit, the patient was easily weaned
and extubated without complication. On postoperative day #1,
the patient was noted to be stable for transfer to the floor
and was subsequently admitted to the Cardiothoracic Service
under the direction of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]. The patient's
postoperative course was uneventful and she progressed well
clinically. On postoperative day #1, the patient's chest
tube and Foley catheter were successfully removed without
complications. Follow up chest x-ray demonstrated no
evidence of pneumothorax, and the patient was noted to be
independently productive of adequate amounts of urine for the
duration of her stay. Physical therapy performed an initial
evaluation with the patient and followed her progress for the
duration of her stay. On postoperative day #3, the patient's
pacer wires were removed without complications and her
sternal incision was noted to be clean, dry and intact with
Steri-Strips in place. The patient was successfully advanced
to a regular diet, which she tolerated well and was noted to
have adequate pain control via oral pain medications. The
patient steadily advanced in her ability to ambulate freely
and was subsequently cleared for discharge to home by
physical therapy. The patient was subsequently cleared for
discharge to home on postoperative day #4, [**2183-5-3**], with
instructions for follow up.
CONDITION ON DISCHARGE: The patient is to be discharged to
home with instructions for follow up.
DISCHARGE STATUS: Stable.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. q.12 hours times ten days
2. Potassium chloride 20 mEq p.o. q. 12 hours times ten days
3. Colace 100 mg p.o. b.i.d.
4. Enteric coated Aspirin 325 mg p.o. q.d.
5. Percocet 1 to 2 tablets p.o. q. 4-6 hours prn for pain
6. Glipizide 5 mg p.o. q.d.
7. Lipitor 20 mg p.o. q.d.
8. Valsartan 160 mg p.o. q.d.
9. Lopressor 50 mg p.o. b.i.d.
DISCHARGE INSTRUCTIONS: The patient is to maintain her
incisions clean and dry at all times. The patient may shower
but she is to pat dry the incisions afterwards; no bathing or
swimming. The patient may resume a regular diet. The
patient has been advised to limited physical activity; no
heavy exertion. No driving while taking prescription pain
medications. The patient has been advised to follow up with
her primary care provider within one to two weeks following
discharge. The patient is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]
within four weeks following discharge; the patient is to call
to schedule an appointment.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 1053**]
MEDQUIST36
D: [**2183-5-3**] 23:29
T: [**2183-5-4**] 07:30
JOB#: [**Job Number 49530**]
|
41401,4111,25000,2724,4019 | 20 | 157,681 | Admission Date: [**2183-5-10**] Discharge Date: [**2183-5-12**]
Date of Birth: [**2107-6-13**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
woman status post coronary artery bypass grafting times three
on [**4-28**] and discharged home on [**5-3**], who the day prior
to admission noted increasing redness of her right lower
extremity at the saphenectomy site. She denied fevers,
chills or leg pain. She had no shortness of breath and
otherwise felt well.
PAST MEDICAL HISTORY: Coronary artery disease status post
coronary artery bypass grafting. Non-insulin-dependent
diabetes mellitus. Hypertension. Arthritis. Total
abdominal hysterectomy. Appendectomy.
ALLERGIES: ZESTRIL.
MEDICATIONS: Lasix 20 b.i.d., Potassium Chloride 20 b.i.d.,
Colace 100 b.i.d., Aspirin 325 q.d., Glipizide 5 q.d.,
Lipitor 20 q.d., Valsartan 60 q.d., Lopressor 50 b.i.d.,
Percocet p.r.n.
PHYSICAL EXAMINATION: Vital signs: Temperature 98.4??????, heart
rate 64 in sinus rhythm, blood pressure 156/43, respirations
20, oxygen saturation 98% on room air. General: Well
appearing in no acute distress. HEENT: Pupils equal, round
and reactive to light. Extraocular movements intact.
Anicteric. Noninjected. Neck: Supple. No lymphadenopathy.
Cardiovascular: Regular, rate and rhythm. Lungs: Clear but
with diminished breath sounds at the bases. Abdomen: Soft
and nontender. Positive bowel sounds. Extremities:
Dopplerable pulses of both dorsalis pedis and posterior
tibial bilaterally. Right lower extremity with multiple
areas of erythema and warmth. Tender to touch along the
saphenectomy site with scant serous drainage.
LABORATORY DATA: White count 14.1, hematocrit 30.5, platelet
count 494; sodium 136, potassium 4.9, chloride 101, CO2 22,
BUN 21, creatinine 1.1, glucose 195.
The patient at that time underwent a lower extremity
ultrasound to rule out deep venous thrombosis. The exam
showed no evidence of deep venous thrombosis.
HOSPITAL COURSE: The patient was admitted to
................... She was begun on Vancomycin and
Levofloxacin for her lower extremity cellulitis. Over the
next two days, the patient's cellulitis improved. On
hospital day #3, it was decided that she was stable and ready
for discharge to home.
At the time of discharge the patient's physical exam revealed
her vitals signs to be stable, afebrile and alert and
oriented times three. She moves all extremities. Breath
sounds were clear to auscultation bilaterally. Heart sounds
were regular, rate and rhythm. Sternal incision is healing
well with no erythema or purulence. Abdomen soft, nontender
and nondistended. Extremities with no edema. Right lower
extremity saphenous vein graft site incision clean and dry
with mild surrounding erythema decreased from the previous
day with no drainage at this time.
DISCHARGE MEDICATIONS: Lasix 20 mg b.i.d., Colace 100 mg
b.i.d., Aspirin 325 q.d., Percocet [**1-2**] tab q.[**4-6**] p.r.n.,
Glipizide 5 mg b.i.d., Lipitor 20 mg q.d., Valsartan 160 mg
q.d., Lopressor 50 mg b.i.d., Ciprofloxacin 500 mg p.o. q.12
hours x 10 days.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post coronary artery
bypass grafting times three.
2. Non-insulin-dependent diabetes mellitus.
3. Hypertension.
4. Arthritis.
5. Total abdominal hysterectomy.
6. Appendectomy.
7. Cellulitis of the right lower extremity at saphenous vein
graft site.
DISPOSITION: She is to be discharged to home.
FOLLOW-UP: She is to have follow-up with her primary care
physician in two weeks. She is to follow-up with Dr. [**Last Name (STitle) 1537**] in
his office four weeks from the date of her initial discharge
from coronary artery bypass grafting; appointment to be made
by the patient.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2183-5-12**] 09:27
T: [**2183-5-12**] 09:32
JOB#: [**Job Number 49529**]
|
2749,43889,V1046,2720,1122,28521,25000,41401,4271,42731,5070,4592,4280,40391,5849,5781,78551,41071 | 21 | 109,451 | Admission Date: [**2134-9-11**] Discharge Date: [**2134-9-24**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
chest pain, dyspnea
Major Surgical or Invasive Procedure:
cardiac catheterization with placement of three stents and IABP.
Swan catheter placement.
History of Present Illness:
HISTORY OF PRESENT ILLNESS: 87 yo M with chronic kidney disease
s/p AV Graft placement [**8-2**], stroke, hypertension, diabetes, and
peripheral vascular disease presents with chest pain and
shortness of breath. He reports that his chest pain began
approximately one week ago. During the week it has gotten worse.
It is substernal, radiating to left shoulder, especially with
inspiration. It is associated with shortness of breath. He came
to the hospital today because the pain was much worse, [**9-6**]. In
addition, he noted today black stools. He has been taking iron.
He reports lightheadedness. Denies nausea, vomiting,
diaphoresis, arm paresthesias. He has also noticed a cough
recently but has not been able to produce sputum (though he
feels congested).
.
The pt was seen in Geriatric Urgent Care clinic on [**9-11**] for
dyspnea. He noted worsening in the supine position. An CXR at
the time to evaluate possible CHF showed "No evidence of
congestive heart failure or pneumonia. Elevation of the right
hemidiaphragm".
.
In the ED, the patient was given 80mg IV lasix x 2 with UOP of
100-200cc. He received nitropaste, lopressor IV and [**Last Name (LF) **], [**First Name3 (LF) **], and
morphine, and was started on a nitro gtt. Heparin was started as
well, and 1 unit PRBCs was transfused. He was given one dose of
protonix, levofloxacin and . BPs were in the 110s-120s/50s-60s,
HR 70s-80s. Renal, GI, and cardiology consults were called. The
patient continued to report [**9-6**] pain, eventually decreased to
[**6-6**] with titration of the nitro gtt. On arrival in the CCU, he
still reported [**6-6**] pain. He was on nitro at 120 mcg/min and
heparin at 850 units/hr.
.
Past Medical History:
PAST MEDICAL HISTORY:
1. ESRD secondary to hypertensive nephrosclerosis s/p right
upper extremity AV graft 9'[**56**]'[**33**] in preparation for dialysis.
Graft placement was complicated by cellulitis, for which he was
treated with keflex
2. DM, on glyburide and glipizide at home
3. HTN, on clonidine, lisinopril, nifedipine
4. PVD s/p aortic bypass
5. CVA, with residual weakness of his left side
6. R CEA
7. Secondary hyperparathyroidism
8. Chronic anemia on procrit injections
9. Prostate CA on Lupron
10. Gout
Social History:
SOCIAL HISTORY: Lives at a senior facility in [**Location (un) 745**]. Has help
with cleaning, other chores. Denies alcohol and tobacco.
Family History:
Coronary artery disease
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 97.2, HR 75, BP 112/55, RR 28, Sao2 97%/4L O2 NC
HEENT: NCAT, PERRL, EOMI, dry mucous membranes, OP clear
Neck: JVP elevated approx 4cm above sternal notch
CV: RRR, nl S1, S2, no murmurs, rubs, gallops
Pulm: diffusely decreased BS on R. Bibasilar crackles.
Abd: soft, nontender, nondistended, BS+
Ext: warm and dry, 1+ pitting edema, 1+ bilateral pulses in PT
Neuro: alert and oriented, CN III-XII intact, moves all
extremities (strength not tested)
Pertinent Results:
EKG: NSR at 80bpm, axis in nl quadrant, QRS borderline, q waves
in V1-V3, ST depressions in I, II, aVL, V4-6, STE in V1-3,
biphasic TW in V4-6.
.
CXR [**2134-9-11**]: Interval development of perihilar patchy opacities
consistent with left ventricular heart failure.
CXR 8pm: read pending
.
[**2134-9-12**] Cath
COMMENTS:
1. Right heart catheterization revealed elevated right and left
sided
pressures. (PCWP = 25 mmhg).
2. Left heart catheterization revealed no evidence of systolic
hypertension. Calculated cardiac output and index were 5.0/2.8.
3. Selective coronary angiography of this right dominant system
revealed
three vessel coronary artery disease. The left main coronary
artery had
a 40% mid-vessel stenosis. The left anterior descending artery
had
diffuse proximal disease with serial 70-80% stenosis. The left
anterior
descending had mild diffuse disease in the mid and distal
segments. The
large first diagonal had an 80% proximal lesion. The left
circumflex
coronary artery had mild diffuse disease in the proximal, mid,
and
distal segments. There was a subtotal occlusion of the OM1.
The right
coronary artery was the dominant vessel. There was total
occlusion of
the right coronary artery in the proximal segment. The distal
RCA
filled via collaterals from the LCA septal branches.
4. No left ventriculography was undertaken given elevated Cr.
5. Successful predilation using 2.0 X 12 sprinter balloon and
stenting
using a minivision 2.5 X 23 stent of the proximal OM1 with
lesion
reduction from 99 to 0%
6. Successful predilaton using a 2.0 X 20 Maverick balloon and
stenting
using 3.0 X 30 Driver stent of the proximal LAD with lesion
reduction
from 80% to 0%.
7. Successful predilation using 2.0 X 12 sprinter balloon and
stenting
using a 2.25 X 15 minivision stent of the proximal D1 with
lesion
reduction from 80% to 0%. The final angiogram showed TIMI III
flow in
the vessels intervened with no residual stenoses in any of the
stents.
Thre was no distal embolisation or dissection noted in any
vessel.
8. Successful insertion of IABP via right femoral artery.
( see PTCA comments for the above procdures from 5 through to 8)
9. At the request of the renal consultants, a 12 French Dialysis
central
venous catheter was placed using the Seldinger technique in the
left
common femoral vein.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Elevated right and left sided pressures.
3. Preserved cardiac output/cardiac index.
4. Successful stenting of the OM, LAD and D1.
5. Successful insertion of IABP via right femoral artery.
6. Successful implantation of a central venous dialysis catheter
in the
left femoral vein.
URINE CULTURE (Final [**2134-9-23**]):
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION.
>100,000 ORGANISMS/ML..
IDENTIFICATION BEING PERFORMED ON CULT# 196-9912C
[**2134-9-19**] AS
REQUESTED BY DR. [**Last Name (STitle) 9974**] ON [**2134-9-21**]..
Brief Hospital Course:
1. Rhythm: pt had 2 episodes of monomorphic VT accompanied by
fall in BP, LOC, terminated x 1 via precordial thumb.
Electrolytes were repeleted, pt was bolused with Amiodarone x 2,
and started on an Amio gtt. Amiodarone was then changed to po,
with a dosing schedule of 400 mg [**Hospital1 **] for one week, followed by
400 mg daily for one week, then 200 mg per day. Monomorphic VT
thought to be likely due to a fixed area of scarring from
previous MI. Placement of an ICD was discussed. However, given
the pt's poor prognosis for non sudden cardiac death reasons,
and given his increased infectious risk, it was decided to treat
his arrhythmia medically. Of note, the QT interval was
prolonged (506), likely secondary to amiodarone. Patient
remained in sinus rhythm on Amiodarone.
2. CAD: Pt with NSTEMI. Cath on [**9-12**] showed 3 vessel disease,
subsequently underwent successful stenting of OM, D1, LAD and
IABP placement. IABP was discontinued after the patient was able
to maintain his own pressure.
Echo completed on [**9-13**], which showed apical akinesis, with
severely depressed systolic function. Patient was initially
started on heparin and bridged to Coumadin, however, he had
another episode of guaiac positive stool, and given his history
of melena and coffee ground emesis, the risk for GI bleed was
thought to be high and anticoagulation was discontinued.
The patient was continued on an aspirin, Statin, beta blocker,
and was started on an ACE, all of which he will continue as an
outpatient. His swan and sheath were discontinued without
complications.
3.PUMP: CHF: EF 20% by ECHO
He was initially placed on Imdur/Hydral for afterload reduction
and an ACE was initially avoided in an attempt to salvage his
kidneys. However, he was eventually started on low-dose
lisinopril to be titrated up if necessary. Patient also
underwent hemodialysis on Mon/Wed/Fri schedule.
4. Renal: Chronic renal disease, secondary to hypertensive
nephrosclerosis, is status post graft placement with mature A-V
graft. Quentin catheter initially used, then discontinued once
graft accessible. On [**9-22**], graft noted to be difficult to
access per renal, patient underwent AV fistulogram, and
successful angioplasty was performed.
5. ID: Patient completed a seven day course of levofloxacin for
suspected pneumonia, white blood count noted to be persistently
elevated. Patient was pan cultured, and a urine culture was
positive for yeast. Foley catheter was discontinued and a
repeat culture was sent, also positive for [**Female First Name (un) **]. Patient
started on a 2 week course of Fluconazole. Blood cultures
pending at time of discharge, no growth to date.
6. Heme: anemia, likely anemia of chronic disease from chronic
renal disease. Patient also had an episode of melena and coffee
ground emesis, guaiac positive stool. Hematocrit was followed,
and patient was transfused as necessary to keep hematocrit above
30. Patient will need GI workup as an outpatient. Oral iron
supplementation was discontinued as patient receiving Fe in
addition to EPO and Procrit at hemodialysis
7. DM: Patient was started on glargine for persistent
hyperglycemia and covered with a regular insulin sliding scale
with Accu-Check to monitor.
8. Psych: Patient was continued on his home dose of Zoloft 100
mg once daily.
Patient tolerated a low Na/cardiac healthy diet and was placed
on a PPI for GI prophylaxis.
Patient was discharged to rehab facility with plan to follow up
with cardiology and PCP within the next month.
Medications on Admission:
. Nifedipine XL 60 mg daily
2. Calcitriol 0.25 mcg dialy
3. Lisinopril 2.5 mg once daily
4. Aspirin 325 mg once daily
5. Lasix 40 mg once daily
6. Glyburide 10 once daily recently changed to Glipizide
7. Clonidine 0.2mg [**Hospital1 **]
8. Zoloft 100mg daily
9. Simvastatin 40mg daily
10. Tums one tablet TID
11. Procrit injections 16,000 units q. week.
12. Lupron injections at Heme/[**Hospital **] clinic
13. Niferex 150 mg daily (supplemental iron).
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
5. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Please continue to take twice a day for the next two
days. Please begin taking 400mg once a day on [**9-24**], and
continue for one week. Then please take 200mg once a day.
11. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
12. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 14 days.
13. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Acute Coronary Syndrome
Congestive heart failure
chronic renal disease
urinary tract infection
Discharge Condition:
Good- patient hemodynamically stable and afebrile, heart rate
and rhythm has been well controlled.
Discharge Instructions:
We have started you on a new medication to help control your
heart rhythm, and a new medication to help control your blood
pressure. In addition, we have started you on a medication to
help treat a urinary tract infection. Please take these and all
of your medications as instructed. Please maintain all of your
follow-up appointments. Please return to the hospital if you
develop chest pain, shortness of breath, fevers, or chills.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1589**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2134-10-14**] 2:30
Provider: [**First Name11 (Name Pattern1) 177**] [**Known lastname 720**], M.D. Date/Time:[**2134-10-20**] 10:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2134-11-24**] 10:00
You have an appointment scheduled with Dr. [**Last Name (STitle) **] at the [**Hospital 61**] [**Hospital 620**] campus on [**10-7**] at 10am. Please arrive
at 9:45am to register.
|
2449,4439,185,41401,2749,43889,2859,25000,V0980,99592,5720,00845,99859,6823,5119,70709,42731,40391,78552,0388,E8788 | 21 | 111,970 | Admission Date: [**2135-1-30**] Discharge Date: [**2135-2-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Transfer from Nursing home for fever and elevated white count
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87 yo M with PMH of DM, CAD, ESRD on HD who was transferred from
[**Hospital 26563**] Rehab to ED for eval of Fever.
.
Per referal note, patient 2 days ago developed increase
leukocytosis and delirim. Apparently, he was started on iv
vancomycin, Flagyl and Ceftazidime for PNA. On day of admission
patient developed a fever to 101.2, pulse 76 BP 102/68R 18 and
sat 92%. Blood Cx and Urine Cx were drawn.
.
Of note he was recently operated on by vascular [**Doctor First Name **] for a R sup
femoral and [**Doctor Last Name **] angioplasty and stenting along with Left femoral
patch angioplasty with bovine patch. He was discharged home on
Levoflox for probable RLL PNA
.
In the ED, VS 100.8 HR 85 BP 81/28 RR 20 Sats 95%. A femoral
line was placed and he was given 1000 cc NS. Given pooor
response, and after CVP measure 12, patient was started on
levophed and transfer to [**Hospital Unit Name 153**].
Past Medical History:
PAST MEDICAL HISTORY:
1. ESRD secondary to hypertensive nephrosclerosis s/p right
upper extremity AV graft 9'[**56**]'[**33**] in preparation for dialysis.
Graft placement was complicated by cellulitis, for which he was
treated with keflex
2. DM, on glyburide and glipizide at home
3. HTN, on clonidine, lisinopril, nifedipine
4. PVD s/p aortic bypass
5. CVA, with residual weakness of his left side
6. R CEA
7. Secondary hyperparathyroidism
8. Chronic anemia on procrit injections
9. Prostate CA on Lupron
10. Gout
Social History:
Denies past or present Tob, EtOH, or Illicit drug use. Was
living at a senior facility in [**Location (un) 745**] with his wife prior to
last admission. Now at [**Hospital 100**] Rehab.
Family History:
NC
Physical Exam:
T 99.7 BP 114/60 Hr 78 RR Sats 98% 4 L NC
General: Patient in mild apparent distress, alert, responding to
questions
HEENT: dry oral mucose, no LAD, JVD
Lungs: crackles bilaterally
CV: Regular heart sounds, soft holosystolic murmur RLSB
Back: sacral ulcers
Abdomen: BS +, soft, non tender non distended
Extremities: cold, distal pulses decreased, heel ulcers
bilaterally, necrotic. 3-4th underneath nail toe right foot
black. RU extremiti AVF , no trhill, no erythema.
Left upper extremity- picc line
Right femoral line in place
Neuro: patient alert, oriented to person, movilizing grossly all
extremities.
Pertinent Results:
[**2135-1-30**] 07:18PM LACTATE-1.6
[**2135-1-30**] 07:05PM GLUCOSE-200* UREA N-49* CREAT-4.2*#
SODIUM-137 POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-23 ANION GAP-19
[**2135-1-30**] 07:05PM CORTISOL-19.5
[**2135-1-30**] 07:05PM WBC-30.5*# RBC-3.05* HGB-9.1* HCT-29.6*
MCV-97 MCH-29.8 MCHC-30.7* RDW-16.9*
[**2135-1-30**] 07:05PM NEUTS-89* BANDS-1 LYMPHS-5* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2135-1-30**] 07:05PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+
[**2135-1-30**] 07:05PM PLT SMR-NORMAL PLT COUNT-275
[**2135-1-30**] 07:05PM PT-18.1* PTT-31.7 INR(PT)-1.7*
Brief Hospital Course:
Assessment and plan:
87 yo M with MMP including DM, HTN, CAD, PVD on HD with L arm
fistula presents with septic shock.
.
1. Sepsis:
The pt was found to be hypotensive and febrile in the ED and
admitted through sepsis protocol. He was infused with muliple
boluses of normal saline, put on levophed for blood pressure
support. He was covered with broad spectrum antibiotic
empirically as culture data was sent. Blood cultures were found
to be positive for gram postive cocci which was ultimately shown
to be VRE. Vancomycin was changed to linezolid. The pt remained
hypotensive on pressors for the next several days and a work-up
was initiated to determine the source of infection. MRI of the
foot was pursued to r/o osteomyelitis, and a CT of the abdomen
was down to r/o an abdominal source of infection.
The CT Abdomen and pelvis showed possible abscess in liver
and spleen. There was also pancolitis. GI and Surgery were
[**Year/Month/Day 4221**] for assistance in the management of these problems.
For the pancolitis, the pt was kept NPO and he was treated for
possible c. diff infection while c. diff cultures were sent and
found to be positive. A RUQ U/S [**2135-2-2**] was pursued which showed
evidence of hypoechoic lesion could be flegmon or mass. It was
unable to be confirmed on imaging whether these lesions on CT
which were new compared with a previous scan in [**10-1**] were
abscesses vs possible mets from an unknown primary. IR was
[**Date Range 4221**] for possible drainage or biopsy, however option
declined given localization of lesions and the pts significant
bleeding risk. The GI team suggested an MRI to further evaluate
the liver lesions although this was unable to be pursued because
the pt was too unstable requiring pressors for bp support. A TTE
Echo was done to r/o endocarditis or abscess and was negative.
Head CT was negative for abscess as well.
.
2. CMO:
On the morning of [**2135-2-6**], the ICU team discussed with Mr
[**Known lastname **] wife and daughter the different alternatives for Mr
[**Known lastname **] care. It was explained that the feeling of the medical
staff and nurse staff was that Mr [**Known lastname **] has been extremily
uncomfortable with all the procedures that he undergoes during
the day. Despite giving pain medicines he has shown signs of a
lot of discomfort. We explained to the family that we would need
a NGT place in order to feed him and give him some of his
medicines now that he is having trouble swallowing given his
mental status. Also we have explained that we still not have a
clear dx on his liver lesions, and in order to obtained a dx he
might need a surgical intervention for biopsy. It would be a
long road ahead before he is able to go back to where he was
previously.
Ms [**Known lastname **] feels that her husband would not want to have all this
procedures done along the road and that we should change the
focus of care towards making him as comfortable as possible.
The antibiotics and pressors were d/c'ed. The plan was to
have no more dialysis. There were no more lab draws. A morphine
drip was started for pain. The pt remained arousable though
sleepy. His blood pressure was in the 80s-90s systolic off
pressors and his extremities continued to show evidence of
perfusion. On the evening of [**12-10**], he skin became more pale and
his sensorium less alert. At 2:08 am he was found to have ceased
respirations and was without a heart rate on the monitor. By
2:15 am he was pronounced deceased.
.
2. CAD: h/o MI.
Continued sinvastatin, aspirin until made CMO. BB and BP
medications were held in the setting of hypotension
.
3. Peripheral vascular disease: continued plavix, Aspirin until
CMO
The vascular team followed the pt.
.
4. DM: insulin sliding scale was continued before the pt was
made CMO.
.
#. ESRD: The pt continued to recieve periodic dialysis sessions
while in house until he was made CMO.
.
#. FEN:
He was kept NPO given the colitis and sepsis.
.
# Hypothyroidism: continued levothyroxine until CMO.
.
# PPX: Pantoprazole, pneumoboots until CMO.
.
#Code: DNR-DNI was changed to CMO on [**2-6**]
.
# Communication: Next of [**First Name8 (NamePattern2) **] [**Known lastname **], [**First Name3 (LF) **] wife, [**Numeric Identifier 26800**]
Medications on Admission:
1. Clopidogrel 75 mg qday
2. Docusate Sodium 100 mg [**Hospital1 **]
3. Epoetin Alfa Injection
4. Sertraline 100 mg daily
5. Fexofenadine 60 mg [**Hospital1 **]
6. Amiodarone 200 mg qd
7. Aspirin 325 mg qday
8. Insulin Glargine 10u/hs.
9. Lisinopril 5 mg day
10. Multivitamin daily.
11. Oxycodone 5 mg q4h-6h
12. Pantoprazole 40 mg /day
13. Senna 8.6 mg [**Hospital1 **]
14. Levothyroxine 50 mcg /daily
15. Metoprolol Succinate 25 mg sustain release
16. Simvastatin 40 mg /daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
gram positive VRE sepsis
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
4019,29620,3488,E9503,E9502,9693,9678 | 22 | 165,315 | Admission Date: [**2196-4-9**] Discharge Date: [**2196-4-10**]
Date of Birth: [**2131-5-7**] Sex: F
Service: ICU
CHIEF COMPLAINT: Unresponsiveness
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
female with a history of hypertension, depression, prior
suicide attempt by overdose, recently with exacerbated mood
disorder status post the death of her husband in [**2195-6-2**], now presented after being found unresponsive. The
patient's daughters found her in the morning of the day of
presentation, unresponsive with empty bottles of Ambien and
Zyprexa at the bedside. Pill count revealed that the patient
had likely taken 26 Ambien and 12 Zyprexa. The patient has
been unable to be alone secondary to depression with suicidal
ideation, and has been living with her daughters. They note
that the patient went to bed at 11 P.M. the night prior to
admission and was found at 11 A.M. unresponsive with
respiratory depression. The patient had seen her primary
psychiatrist the day before.
In the Emergency Department, the patient was charcoaled,
gastric lavaged, and intubated for airway protection. She
was hemodynamically stable. She was transferred to the
Intensive Care Unit.
In the Intensive Care Unit, the patient was able to open her
eyes, and was moving all four extremities and responsive to
command.
PAST MEDICAL HISTORY:
1. Hypertension
2. Depression with suicide attempt ten years ago by
overdose. The patient was hospitalized for two weeks at that
point. The patient's outpatient psychiatrist is Dr. [**Last Name (STitle) **].
ALLERGIES: No known drug allergies.
MEDICATIONS: Zyprexa 2.5 mg by mouth daily at bedtime,
Zestril 20 mg by mouth once daily, Ambien 10 mg by mouth
daily at bedtime, Estradiol 1 mg by mouth once daily,
nortriptyline 25 mg by mouth daily at bedtime, Klonopin 0.5
to 1 mg daily at bedtime, Biotin and calcium supplementation.
SOCIAL HISTORY: The patient lives with her daughter. [**Name (NI) **]
husband died in [**2196-1-2**]. The patient denied any
tobacco, alcohol or drug use.
FAMILY HISTORY: Unknown.
PHYSICAL EXAMINATION: The patient's temperature was 97.7,
with a blood pressure of 130/65, pulse of 84, respiratory
rate of 14, and oxygen saturation of 100%. The patient was
ventilated on IMV pressure support with a rate of 14,
pressure support of 10, PEEP of 7.5, volume of 500, and 40%
FIO2. On general examination, the patient was a very
ill-appearing female, in no apparent distress. She was
intubated. Head, eyes, ears, nose and throat examination
revealed 1 to 2 mm nonreactive pupils. Neck examination
revealed no jugular venous distention and no bruits. Cardiac
examination revealed a regular rate and rhythm, normal S1 and
S2, and no murmurs, gallops or rubs. Pulmonary examination
revealed that the lungs were clear to auscultation
bilaterally. Abdominal examination revealed a belly that was
soft, nontender, nondistended, with normal bowel sounds.
Extremity examination revealed no edema, with 2+ dorsalis
pedis pulses bilaterally. Neurological examination revealed
a patient that was moving all four extremities, opening eyes
intermittently, withdrawing to pain. The patient had 2+ deep
tendon reflexes, and downgoing plantar reflexes.
LABORATORY DATA: The patient had a white blood cell count
of 5.1, hematocrit of 35.9, platelets of 259. The patient
had a sodium of 140, potassium of 4.4, chloride of 103,
bicarbonate of 28, BUN of 17, creatinine of 0.6, and glucose
of 102. The patient's INR was 1.1. The patient had an ALT
of 19, an AST of 26. Arterial blood gas was performed
post-intubation and was found to be pH of 7.47, PACO2 of 29,
and PAO2 of 287.
Electrocardiogram: Normal sinus rhythm at 80, with normal
axis, [**Doctor Last Name 1754**] and intervals, and ST elevations in V2 and
Lead I.
Other studies: Urine toxicology was negative, serum
toxicology was negative. Urinalysis revealed negative
nitrates, leukocytes, blood, no red blood cells, no white
blood cells, occasional bacteria, and less than one
epithelial cell.
Head CT: No signs of intracranial hemorrhage or mass effect.
HOSPITAL COURSE: The patient is a 64-year-old female with a
history of hypertension and depression with suicidal ideation
and previous history of overdose attempt, status post likely
overdose on Ambien and Zyprexa, status post intubation and
hemodynamically stable.
1. Toxicology: Patient with likely Ambien overdose and
Zyprexa overdose. Her symptoms of light coma, somnolence and
respiratory compromise were consistent with Ambien overdose.
The patient also had evidence of myosis, which was consistent
with Zyprexa overdose. The patient had been gastric lavaged,
charcoaled and supported in the Emergency Department. In the
Intensive Care Unit, the patient was supported with
intravenous fluids and gradually weaned on the ventilator to
the point where she was successfully extubated shortly after
arriving to the Intensive Care Unit.
2. Psychiatric: Patient with major depression, recently
exacerbated by the loss of her husband, now with a second
overdose attempt in her lifetime. Likely Zyprexa and Ambien
were the agents responsible. Multiple attempts were made in
the effort to contact the patient's outpatient psychiatrist,
Dr. [**Last Name (STitle) **]. She was unable to be reached. Psychiatry was
consulted, who felt that the patient needed inpatient
evaluation and treatment. They also recommended
psychotropics be avoided, and that the patient have a
one-to-one sitter. Social Work and Case Management were
consulted.
3. Cardiovascular: Patient was hemodynamically stable with
history of hypertension. Her antihypertensives were held.
Her electrocardiogram was unremarkable, although there were
no studies for comparison.
4. Pulmonary: Patient intubated secondary to decreased
mental status without a primary lung process.
Post-extubation arterial blood gas did not suggest any
obstructive lung process leading to hypercarbia or hypoxemia
from other pulmonary process. The examination was
unremarkable. A facile extubation was anticipated, and the
patient was extubated within several hours of arriving in the
Intensive Care Unit.
5. Psychosocial: Communication was maintained with the
patient's daughters, who also felt that the patient should
receive inpatient evaluation and treatment.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to an inpatient
psychiatric bed.
DISCHARGE MEDICATIONS: Zestril 20 mg by mouth once daily,
Estradiol 1 mg by mouth once daily.
DISCHARGE DIAGNOSIS:
1. Major depression
2. Ambien and Zyprexa overdose
3. Hypertension
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2196-4-10**] 02:10
T: [**2196-4-10**] 02:20
JOB#: [**Job Number 38050**]
|
V1582,V4579,V4581,2724,2720,4019,4241,78039,3485,2252 | 23 | 124,321 | Admission Date: [**2157-10-18**] Discharge Date: [**2157-10-25**]
Date of Birth: [**2082-7-17**] Sex: M
Service: NEUROSURGERY
Allergies:
Morphine
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
[**2157-10-21**]: Left craniotomy for mass resection
History of Present Illness:
Mr. [**Known lastname 18661**] is a 75yo RHM with CAD s/p CABG, AS, HTN,
Hyperlipidemia, now here for resection of parasagittal
meningioma. Pt first noted symptoms three years ago with
dizziness, was evaluated in [**State 108**] where a head CT revealed L
frontal extraxial mass (~2cm per pt). Seen by a neurosurgeon in
[**State 108**] and told watchful waiting was best. However 6 weeks ago
the patient had an episode where his right lower extremity "gave
way." Occasionally "feels like wood." He underwent MRI scan
which revealed enlargement of the mass, with descriptions from
records documenting 2.5x3.4x2cm L frontal lobe extraaxial mass,
and also
a much smaller 12mmx8mmx4mm mass in the R temporal lobe (per
[**Hospital3 417**] report). He was started on decadron 1mg [**Hospital1 **].
Pt was scheduled for resection with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2157-10-22**].
However last night he was moving furniture, and upon moving a
bureau back into his home he developed a sensation of numbness
at his foot that travelled to his upper thigh over the course of
only a few seconds. He then noted rhythmic low amplitude shaking
of the limb that was not suppressable. His right arm then
extended outwards beyond his volitional control. His wife took
him to [**Hospital3 417**] where he was given ativan IV, loaded with
Fosphenytoin 1,000mg IV. The movements subsided in about 15
minutes. No loss of consciousness. No speech/language deficits.
No visual loss. He reports no further episodes since. Currently
feeling well. Denies any headaches. He does still feel a loss of
sensation in a stocking distribution of his right foot to his
ankle. When he walks he feels like he does not have command over
his right leg. No bowel or bladder dysfunction.
Past Medical History:
PMHx:
CAD- CABG x 4 ([**2153**]) here at [**Hospital1 18**]
HTN
AS- no syncopal symptoms.
Hypercholesterolemia
Past Surgical Hx:
Appendectomy
Bilateral Inguinal hernia repair
Anal fissure repair
Cholecystectomy
tonsillectomy and adenoidectomy
Social History:
Social Hx: married, retired electrical equipment designer with
three years of engineering training, Korean War Veteran,
Currently smokes pipe tobacco x last 55yrs, smoked cigarettes
during the war but none since, rare social ETOH use. No
illicits.
Family History:
Family Hx:
Mother- d. 93, CAD
Father- d. 73, Parkinson's Disease, CAD
Brother- d. 73, had hemo
Physical Exam:
On Admission:
PHYSICAL EXAM:
O: T: 97.3 BP: 118/70 HR: 71 R: 20 O2Sats: 96% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. crescendo-decrescendo murmur best at RUSB radiates
throughout precordium and abdomen.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-29**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 5 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally with
sustained nystagmus at lateral end-gaze.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-31**] throughout. No pronator drift
Sensation: Reduced to LT only on right foot in stocking
distribution to the ankle. Otherwise intact to light touch,
propioception, pinprick and vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2------> -
Left 2------> -
Toes mute bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Gait: good initiation, wide based, discoordinated stride with
right lower extremity, leans to the right. Absent Romberg.
Pertinent Results:
Labs on Admission:
[**2157-10-19**] 04:55AM BLOOD WBC-10.9 RBC-4.29* Hgb-13.4* Hct-38.9*
MCV-91 MCH-31.3 MCHC-34.6 RDW-14.4 Plt Ct-216
[**2157-10-19**] 04:55AM BLOOD Neuts-88.7* Lymphs-7.0* Monos-3.6 Eos-0.3
Baso-0.3
[**2157-10-19**] 04:55AM BLOOD PT-11.9 PTT-26.6 INR(PT)-1.0
[**2157-10-19**] 04:55AM BLOOD Glucose-141* UreaN-16 Creat-0.7 Na-140
K-4.2 Cl-104 HCO3-27 AnGap-13
[**2157-10-19**] 04:55AM BLOOD ALT-26 AST-21 AlkPhos-68 TotBili-0.8
[**2157-10-19**] 04:55AM BLOOD Albumin-4.1 Calcium-8.9 Phos-3.0 Mg-2.1
-------------------
IMAGING:
-------------------
MRI Head [**10-20**]:
FINDINGS: Limited post-contrast MRI of the brain demonstrates an
enhancing
left parafalcine lesion measuring approximately 2.1 x 3.3 x 3.5
cm. This
lesion is in close proximity to the adjacent sagittal sinus
although it does not appear to be involving the sinus. No other
abnormal enhancing lesions are identified. There is minimal
surrounding edema and no significant mass effect.
IMPRESSION: Dural-based enhancing lesion arising from the left
parafalcine
region with minimal mass effect and small amount of surrounding
edema. This
likely represents a meningioma.
MRI Head [**10-22**](post-op):
FINDINGS: Since the previous study, the patient has undergone
resection of
left parietal parafalcine extra-axial mass. Blood products are
seen in the
region with edema. Air is seen intracranially. Bilateral small
subdural
collections are seen. These findings are indicative of
post-operative change.No acute infarct seen. No midline shift or
hydrocephalus identified. No residual nodular enhancement is
identified.
IMPRESSION:
1. Status post resection of left parietal parafalcine mass with
expected
post-surgical changes of blood products and air in the region
and intracranial air and bilateral small subdural collections.
No acute infarct, mass effect, or hydrocephalus. No residual
nodular enhancement seen.
EEG [**10-20**]:
BACKGROUND: A 9 Hz posterior predominant rhythm was seen in the
brief
waking state.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Produced no activation of the
record.
SLEEP: The patient progressed from wakefulness to drowsiness but
did
not attain stage II sleep.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate
of 60 bpm.
IMPRESSION: This is a normal predominantly drowsy routine EEG in
the
waking and drowsy states. There were no focal lateralize or
epileptiform features.
Brief Hospital Course:
Patient was admitted to the Neurosurgical service on [**10-18**]
following an episode of seizure. The patient underwent
resection of the left para-sagittal mass on [**10-21**]. He tolerated
this procedure well and remained neurologically unchanged
post-resection. He was taken to the ICU post-operatively for
close monitoring on POD0. On POD#1, he was transferred to the
neurosurgical floor. He was subsequently seen and evaluated by
PT and OT and was cleared for discharge home.
Medications on Admission:
Aspirin 81mg daily (currently held)
Tylenol PRN
Decadron 1mg [**Hospital1 **]
Amlodipine 5mg daily
Lisinopril 40mg daily
Simvastatin 40mg daily
Synthroid 50mcg daily
Decadron 2mg q6hrs
Dilantin 100mg PO TID
Nexium 40mg daily
Metoprolol 25mg [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
9. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 3 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
left parasagital brain mass
Discharge Condition:
Neurologically stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE:
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry, you may shower from the neck
down. You will not need to have sutures removed, as Dr. [**First Name (STitle) **] has
used dissolvable sutures.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? You were on Aspirin, prior to your surgery. You may restart
this one week after your surgery.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
?????? You are being sent home on steroid medication taper, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
FOLLOW UP APPOINTMENT INSTRUCTIONS
??????Please return to the office in [**8-5**] days (from your date of
surgery) a wound check(your sutures are dissolvable). This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**11-28**] at 10:30am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will / will not need an MRI of the brain with/ or without
gadolinium contrast. If you are required to have a MRI, you may
also require a blood test to measure your BUN and Cr within 30
days of your MRI. This can be measured by your PCP, [**Name10 (NameIs) **]
please make sure to have these results with you, when you come
in for your appointment.
Completed by:[**2157-10-25**] |
41401,4241,V4582,2724,4019,60000,3899,4111 | 23 | 152,223 | Admission Date: [**2153-9-3**] Discharge Date: [**2153-9-8**]
Date of Birth: [**2082-7-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain, SOB, positive ETT
Major Surgical or Invasive Procedure:
[**2153-9-3**] Four vessel coronary artery bypass grafting(LIMA to LAD,
SVG to Diagonal, SVG to OM, SVG to PDA)
History of Present Illness:
This is a 71 year old male with known CAD. He underwent PTCA to
LAD and diagonal in [**2145**]. Prior to hernia repair operation, an
ETT in [**2153-7-27**] was notable for EKG changes. An ECHO in [**Month (only) 205**]
[**2153**] was notable for mild MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] AS. The [**Location (un) 109**] was
estimated at 1.1 cm2 with peak/mean gradients of 34 and 22 mmHg.
The was mild concentric LVH with an LVEF of 60%. He was
subsequently referred for cardiac catheterization. This was
performed at the [**Hospital1 18**] on [**2153-8-16**]. Angiography showed a right
dominant system with 80% ostial LAD lesion; first diagonal had a
60% stenosis; the circumflex had a 60% lesion while the RCA had
a 40% stenosis. There was only mild AS with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 1.8 cm2
and mean gradient of 18mmHg. Left ventriculogram showed
preserved LV function. Based on the above results, he was
referred for CABG.
Past Medical History:
CAD - s/p PTCA, HTN, Hypercholesterolemia, BPH, Hernia,
Decreased hearing, s/p L knee arthroscopy, s/p appy
Social History:
50 year history of pipe smoking. Admits to [**5-2**] ETOH drinks per
week.
Family History:
No premature CAD
Physical Exam:
Temp 98.0, BP 126/74, HR 61, Resp 18(sat 98% on RA)
General: elderly male in NAD
Neck: supple, no JVD
HEENT: benign
Lungs: clear bilaterally
Heart: regular rate and rhythm, 4/6 SEM radiating to carotids
Abdomen: benign
Ext: warm, no edema, no varicosities
Neuro: nonfocal
Pulses: 2+ distally, no femoral bruits
Pertinent Results:
[**2153-9-8**] 10:00AM BLOOD Hct-26.1*
[**2153-9-5**] 05:55AM BLOOD WBC-8.6 RBC-2.89* Hgb-9.3* Hct-25.7*
MCV-89 MCH-32.0 MCHC-36.0* RDW-13.8 Plt Ct-113*
[**2153-9-6**] 05:45AM BLOOD UreaN-20 Creat-0.8 K-3.8
[**2153-9-5**] 05:55AM BLOOD Glucose-115* UreaN-20 Creat-0.7 Na-140
K-4.1 Cl-107 HCO3-27 AnGap-10
[**2153-9-6**] 05:45AM BLOOD Mg-1.9
Brief Hospital Course:
Patient was admitted and underwent four vessel CABG on [**2153-9-3**] by
Dr. [**Last Name (STitle) **]. Surgery was uneventful - see op note for further
details. Following the operation, he was brought to the CSRU in
stable condition. There he was weaned from inotropic support and
was extubated without difficulty. He was noted to have some
ventricular ectopy which improved after intravenous Lidocaine
and PO beta blockade. K and Mg levels were monitored closely and
repleted per protocol. He otherwise maintained stable
hemodynamics. Units of PRBCs were intermittently transfused to
maintain hematocrit close to 30%. On POD 1, he transferred to
the SDU. He remained in a normal sinus - no further ventricular
ectopy was noted. Beta blockade was slowly advanced as
tolerated. Over several days, he made clinical improvements. By
discharge, he was near his preoperative weight with oxygen
saturations over 96% on room air. He also worked daily with
physical therapy and made steady progress. His hospital course
was otherwise uneventful and he was cleared for discharge to
home on POD 5. He is scheduled to follow up with Dr. [**Last Name (STitle) **] and
his local cardiologist in approximately 4 weeks.
Medications on Admission:
Isordil 20 [**Hospital1 **], Lescol 40 qd, Accupril 40 qd, Hytrin 5 qd, HCTZ
12.5 [**Last Name (LF) **], [**First Name3 (LF) **] 325 qd, Cartia 80 qd, KCL 20 [**Hospital1 **], TNG prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
4. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 10 days.
Disp:*50 Tablet(s)* Refills:*0*
9. Lescol 40 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
s/p CABGx4 (Lima->LAD, SVG->Diag, SVG->OM, SVG->PDA)
PMH: CAD s/p PCI, HTN, ^chol, BPH, Hernia repair
Discharge Condition:
Good
Discharge Instructions:
keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
Followup Instructions:
[**Hospital 409**] clinic in 1 week
Dr [**Last Name (STitle) **] in [**3-30**] weeks
Dr [**Last Name (STitle) **] in 4 weeks
Completed by:[**2153-9-20**] |
41041,41401,53081,25000 | 24 | 161,859 | Admission Date: [**2139-6-6**] Discharge Date: [**2139-6-9**]
Date of Birth: [**2100-5-31**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
Inferior MI
Major Surgical or Invasive Procedure:
Cardiac catheterization with 4 overlapping stents to RCA
History of Present Illness:
39 yo male with history of GERD woke up w/ SOB and LUE
discomfort 1 day PTA. He presented to [**Hospital1 1474**] where he was
ruled out for MI by enzymes. He underwent stress test the
following day at [**Hospital1 1474**]. He developed SOB and shoulder pain
during the test. The stress test was discontinued and he
reportedly had STE inferiorly and w/ inf WMA on echo. He was
transferred to [**Hospital1 18**] for cath. At cath, he had 90% prox RCA &
80-90% mid-distal RCA lesions s/p 4 TAXUS stents w/ PCWP 17,
hemodynamically stable throughout.
.
Post-procedure he was doing well, no SOB, no CP on arm
discomfort and admitted to the CCU for monitoring.
Past Medical History:
GERD
Social History:
Works as police officer, lives alone, never married, no
children; + tobacco 1p/week x 5 yrs, quit yesterday, occ EtOH
last drink 4 days ago, no IVDU;
Family History:
father w/ MI's in 60's, + DMII;
Physical Exam:
97.1 123/78 12 100% 2L NC
Gen: cauc M lying in bed flat in NAD, alert, Ox3.
HEENT: anicteric
Neck: thick neck, no masses
Heart: RRR, S1, S2, no m/r/g
Lungs: CTBLA, no rales, no wheezing
Abd: NABS/S/NT/ND/no masses, no HSM
Ext: no edema
Pertinent Results:
Labs:
@ [**Hospital1 1474**] [**2139-6-5**]
Na 137 K 4.1 Cl 102 CO2 27 BUN 13 creat 1.0
glu 148 Ca 9.1 alb 4.2 T.bili 0.6 [**Doctor First Name **]/lip wnl alp phos 87
ALT/AST 167/71
.
# 1 CK 314 MB 1.2 TNI <0.10
# 2 CK 273 MB 3.6 TnI 1.0 [ref 0.0-0.4]
# 3 235 3.5 0.9
# 4 210 2.3 0.8
.
wbc 9 hct 43.5 plt 222 INR 1.0 PTT 22
chol 236 LDL 154 HDL 33 Trig 244
.
EKG: [**6-5**] 9am TW flattening inferior and 1mm STE in III;
post cath: TWI in III, aVF; q in III, hyperacute T's.
.
Cath: [**2139-6-6**]
LMCA 30%, distal LAD diffuse 40%, mid 50% prox large D1
LCx nl, RCA 99% prox w/ thrombus, TIMI 2 distal flow, diffuse
60-70% throughout mid-distal RCA
S/P 4 overlapping TAXUS stents to RCA
mean PCWP 17, RA mean 12
.
Echo [**2139-6-6**]
1. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). No abnormal regional left ventricular wall
motion is seen. The inferior wall is not well seen.
2. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
.
Rad @ [**Hospital1 1474**] by report: [**2139-6-5**]
CXR no acute disease
RUQ U/S cholelithiasis w/ gallstone possibly impacted in GB
neck;
Abd aorta U/S no aneurism, max diameter 2.7cm;
Hida scan - no cystic or CBD obstruction, wnl;
.
[**2139-6-9**] 07:10AM BLOOD WBC-9.1 RBC-4.56* Hgb-14.4 Hct-41.2
MCV-90 MCH-31.6 MCHC-34.9 RDW-12.7 Plt Ct-213
[**2139-6-9**] 07:10AM BLOOD Plt Ct-213
[**2139-6-7**] 04:00AM BLOOD PT-12.4 PTT-22.5 INR(PT)-1.0
[**2139-6-7**] 04:00AM BLOOD WBC-9.8 RBC-4.44* Hgb-14.1 Hct-40.4
MCV-91 MCH-31.8 MCHC-35.0 RDW-12.8 Plt Ct-203
[**2139-6-6**] 06:54PM BLOOD Plt Ct-215
[**2139-6-9**] 07:10AM BLOOD Glucose-114* UreaN-11 Creat-1.0 Na-141
K-4.0 Cl-104 HCO3-26 AnGap-15
[**2139-6-6**] 06:54PM BLOOD Glucose-100 UreaN-13 Creat-0.9 Na-139
K-4.1 Cl-105 HCO3-24 AnGap-14
[**2139-6-7**] 04:00AM BLOOD ALT-166* AST-65* CK(CPK)-120 AlkPhos-93
TotBili-0.5
[**2139-6-7**] 04:00AM BLOOD CK-MB-3 cTropnT-0.04*
[**2139-6-9**] 07:10AM BLOOD Calcium-9.7 Phos-3.2 Mg-2.2
[**2139-6-6**] 06:54PM BLOOD %HbA1c-6.5* [Hgb]-DONE [A1c]-DONE
Brief Hospital Course:
39 yo male with history of GERD admitted with IMI.
.
IMI - His EKG and cardiac enzymes were consistent with IMI. He
has risk factors that included family history and
hypercholesterolemia and tobacco use. He had a stent placed in
the RCA and was given aggrastat post cath for 18 hours. He was
continued on ASA, started on maximum dose statin, beta blocker
and ACE inhibitor, plavix. He should remain on plavix for at
least 6 months. Echo showed preserved EF. He was also counseled
on smoking cessation and diet/nutrition.
.
Hypercholesterolemia - He was started on maximum dose statin,
80mg atorvastatin. If his triglycerides remain elevated,
gemfibrozil could be added as an outpatient.
Elevated glucose: He may have glucose intolerance. He was
counseled on a low sugar diet and should have this followed up
by his PCP. [**Name10 (NameIs) 61986**] he can be managed with diet control only.
Transaminitis - He likely has NASH given hypercholesterolemia
and obesity; His
hepatitis serologies were pending at time of discharge. His
LFT's should be followed up in 6 weeks with initiation of statin
therapy.
Medications on Admission:
Outpt Meds: aciphex
Meds on transfer: ASA, plavix, lopressor, aggrastat
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
4. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*6*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
Discharge Disposition:
Home
Discharge Diagnosis:
Inferior MI
Hypertension
Hypercholesterolemia
Discharge Condition:
Good
Discharge Instructions:
Follow up with your cardiologist in [**Hospital1 1474**], Dr. [**Last Name (STitle) **], within
1 month.
Take your new medications as precribed. You must take plavix
every day for at least 6 months or until told to stop by your
cardiologist.
You are encouraged to go to cardiac rehab.
You should eat a low sugar diet as you are at risk for
developing diabetes.
Followup Instructions:
Follow up with your cardiologist in [**Hospital1 1474**], Dr. [**Last Name (STitle) **], within
1 month.
Follow up with your PCP with regards to possible early signs of
diabetes.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
|
4019,41401,25011,41071 | 25 | 129,635 | Admission Date: [**2160-11-2**] Discharge Date: [**2160-11-5**]
Date of Birth: [**2101-11-21**] Sex: M
Service: MEDICINE
Allergies:
Motrin
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
transferred from OSH for DKA, r/o MI
Major Surgical or Invasive Procedure:
s/p cardiac catheterization with stenting of left circumflex
artery
History of Present Illness:
58 yo male with hx type 1 DM on insulin pump, ?vertigo, no known
[**Hospital **] transferred to CCU for management of presumed DKA in the
setting of new EKG changes and borderline enzymes. No previous
CAD history althouth cath in '[**41**] reported to be negative with
subsequent negative stress test. Pt has history of vertigo with
recent flare after fall from slipping on ice. Otherwise, pt was
in USOH until 1 day prior to admission when his insulin pump
fell out at 2am. Pt took some short acting insulin, but no
lantus. Pt developed worsening nausea followed by several
episodes of emesis. Denies chest pain, SOB, diaphoresis. In OSH
[**Name (NI) **], pt was afebrile, hemodynamically stable, but found to have
blood sugar to 555, bicarb 18, anion gap 25, and ABG 7.27/38/73.
EKG was performed which showed diffuse ST depressions in V3-V6,
1, 2, AVF which were new from EKG from [**3-16**]. CPK and Tn were
negative but given DM, he was started on IV heparin and
integrillin and transfered to [**Hospital1 18**] for cath. Per OSH report,
head CT and CXR were negative. Repeat EKG showed decreased ST
depressions with 2nd Tn of 0.11 and CPK 153/MB 12. Recent
increased anion gap closed to 18. Pt remained chest pain free on
transfer to [**Hospital1 18**].
.
ROS: negative for recent fever, chills, cough, URI symptoms,
abdominal pain, diarrhea, constipation, dysuria, urinary
symptoms. Pt denies CP, SOB, PND, orthopnes, LE edema
Past Medical History:
Type I DM since [**2125**], on insulin pump
?vertigo
Spinal fusion, [**2155**]
R knee surgery
Social History:
quit tobacco 20 years ago, smoked 6-7 years
Denies ETOH; history of alcohol abuse
Denies drugs
Lives with wife
works as plumbing/electrician
Family History:
CAD in father and grandfather
Physical Exam:
VS: p96.2, p60, 90/44, 18, 100% 2L, FS 393
Pertinent Results:
[**2160-11-2**] 01:05AM WBC-12.2* RBC-4.17* HGB-13.1* HCT-37.9*
MCV-91 MCH-31.3 MCHC-34.4 RDW-13.0
[**2160-11-2**] 01:05AM PLT COUNT-269
[**2160-11-2**] 01:05AM NEUTS-84.6* BANDS-0 LYMPHS-9.5* MONOS-5.2
EOS-0.5 BASOS-0.2
[**2160-11-2**] 01:05AM PT-12.8 PTT-34.6 INR(PT)-1.0
[**2160-11-2**] 01:05AM GLUCOSE-378* UREA N-50* CREAT-1.6* SODIUM-134
POTASSIUM-3.3 CHLORIDE-95* TOTAL CO2-23 ANION GAP-19
[**2160-11-2**] 01:05AM CK(CPK)-153
[**2160-11-2**] 01:05AM CK-MB-12* MB INDX-7.8* cTropnT-0.11*
.
EKG (OSH): SR@80, nl axis/interval, borderline 1 degree AVD,
26-mm ST depressions in V3-V6, 2-3mm ST depressions in 2,3,f;
?ST elevation in V1, low limb voltage
.
old EKG ([**3-16**]): sinus brady @80 with atrial ectopy, low limb
voltage, nl axis/interval, no ST changes
Brief Hospital Course:
1. CAD: Initial EKG showed marked depressions in v3-6. On
admission to the CCU, art line was placed, after which pt was
noted to be bradycardic to the 40s and hypotensive to 70s
according to the art line. Pt was bolused with IVF without
significant increase in BP. Dopamine was started. Pt was
asymptomatic. Pt was taken emergently to the cath lab as we were
concerned about acute ischemia. Pt was found to have diffuse
disease and 60-70% stenosis of LCx. In retrospect, pt's
hypotensive episode was most likely spurious, as the arterial
line BP and cuff pressures did not correlate. Cuff pressures did
not drop below 90s systolic during the entire time. Pt may have
some arterial stenosis which led to spurious BP. By cardiac
enzymes, pt was found to have NSTEMI with peak CK of 573 and
peak Tn of 1.09. Pt was started on Aspirin, Statin, plavix. BB
and ACE were initially held in setting of "hypotension", but
then was started. Later, decision was made to perform another
cath and to stent the LCx lesion which was done successfully.
2. DM: Pt was admitted in DKA with AG 17. He was started on
insulin drip and IVF and frequent electrolyte checks/repletions.
Gap was successfully closed. Pt was transitioned to insulin
pump.
Medications on Admission:
Insulin pump
neurontin
Isopril
Actos
Lasix 80 qd
ASA 325mg 2 tabs qhs
alleve prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Calcium Carbonate 1,250 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Insulin Pump Eng/French R1000 Misc Sig: One (1) Miscell.
once a day.
9. Neurontin 300 mg Capsule Sig: Three (3) Capsule PO three
times a day.
Disp:*270 Capsule(s)* Refills:*2*
10. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Glyset 25 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p non-ST elevation MI
DKA
Discharge Condition:
Stable
Discharge Instructions:
If you develop chest pain or difficulty breathing, call your
doctor or return to the emergency room
Followup Instructions:
Follow up with your primary care doctor: [**Last Name (LF) **],[**First Name3 (LF) **] L.
[**Telephone/Fax (1) 17663**]
|
99604,4271,4280,42731,41401,412,5939,2720,60000 | 26 | 197,661 | Admission Date: [**2126-5-6**] Discharge Date: [**2126-5-13**]
Date of Birth: [**2054-5-4**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Patient is a 72-year-old male
with coronary artery disease status post myocardial
infarction, CHF with an ejection fraction of 15% and ICD for
DF/VT. Here for possible ICD malfunction after he was
shocked three times at home the night before admission to an
outside hospital. The first shock occurred on the morning
prior to admission with no preceding symptoms. The second
shock occurred while walking downstairs, and he reported
reaching out his arm. Third shock occurred shortly after
this when he was reaching out with his left hand, and the
final and fourth shock occurred when he was reaching out in
bed with his left arm and received multiple shocks in a row.
At the outside hospital, the patient had a magnet placed over
his ICD, and was given magnesium sulfate. He was
hemodynamically stable, and had no complaints otherwise.
On review of symptoms, the patient reported occasional
orthostatic hypotension, but denied chest pain, shortness of
breath, nausea, or vomiting. The patient denies fever or
chills. Denied bloody stools or black stools. The patient
denied orthopnea, PND, or dyspnea.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post myocardial infarction
and ischemic cardiomyopathy.
2. ICD for VF with second SVC coil because of high DFTs with
three-lead fracture in 03/99.
3. Atrial fibrillation.
4. Chronic renal insufficiency.
5. CHF with an EF of 15%.
6. Hypercholesterolemia.
7. Obesity.
8. History of unsuccessful VT ablation.
9. Osteoarthritis.
10. BPH.
11. Reactive airway disease.
12. Diabetes mellitus type 2.
MEDICATIONS:
1. Toprol 50 b.i.d.
2. Vasotec 10 b.i.d.
3. Lasix 40 b.i.d.
4. Imdur 60 q.d.
5. Lanoxin 125 mcg.
6. Levoxyl 125 mcg.
7. Lipitor 40.
8. Plavix 75.
9. Spironolactone 25.
10. Dofetilide 250 q.d.
11. Coumadin 10 two days a week, 7.5 five days a week.
SOCIAL HISTORY: Patient reports coronary artery disease in
his father. [**Name (NI) **] also has a 50 pack year smoking history, but
quit 34 years ago. He denies alcohol use.
ALLERGIES: Shellfish and IV dye, which causes hives, and
amiodarone which caused edema.
PHYSICAL EXAM ON ADMISSION: Temperature 97.7, heart rate of
80, blood pressure 86/52, respiratory rate 16. Saturating
97% on room air. Patient was alert and oriented times three
in no acute distress. Neck was supple. Pupils are equal,
round, and reactive to light. Clear oropharynx. There was
no JVD and no carotid bruits. Cardiovascular reveals
regular, rate, and rhythm with occasional irregular beats.
Faint systolic ejection murmur at the left lower sternal
border. Respiratory: Lungs are clear to auscultation
bilaterally. The abdomen was soft, nontender, nondistended.
Extremities revealed trace bilateral lower extremity edema.
SUMMARY OF HOSPITAL COURSE:
1. Cardiac rhythm: Patient is admitted with multiple shocks
from his ICD. The shocks had occurred when the patient was
using his left arm predominantly. This is likely due to the
fact that there was a device malfunction. The device was
interrogated, and found to be oversensing noise from certain
arm movements. The device was turned off and programmed DDD.
The INR was 2.5, so the patient was given vitamin K with plan
for future need revision.
Overnight the patient had a four-second pause on telemetry,
although the patient was asymptomatic. The patient returned
to the Electrophysiology Laboratory and had a pacing catheter
placed. The patient was transferred to the CCU on [**2126-5-7**] for further monitoring in the setting of transvenous
pacing. The patient remained comfortable and when his INR
trended down, he returned to the EP Laboratory for device
revision and lead revision. Patient tolerated the procedure
well.
After this, the patient returned to the [**Hospital3 **]
floors and received multiple shocks on the morning, which
were appropriate for ventricular tachycardia. The patient's
pacemaker was interrogated and found to be functioning well.
It was reprogrammed to over pace out of ventricular
tachycardia prior to shocking. The patient had additional
episodes of ventricular tachycardia, which were successfully
paced out of by his pacemaker. Patient was started on
lidocaine drip given his significant ventricular tachycardia
and the episodes of VT diminished significantly. The patient
was transitioned to mexiletine on the next day, and tolerated
this well. The patient had no further episodes of
significant ventricular tachycardia.
2. Coronary artery disease: The patient currently had no
symptoms. He was continued on his Plavix, statin,
beta-blocker, and Imdur. Patient was not admitted on an
aspirin, although he was given an aspirin during his
hospitalization given the fact that was Coumadin was held.
Plan for no aspirin on discharge with resuming his Coumadin
as per his prior home regimen.
3. Congestive heart failure: Patient has an ischemic
cardiomyopathy with an ejection fraction of less than 20%.
An echocardiogram on this hospitalization again revealed an
ejection fraction of 15-20%. While the patient was NPO
during episodes of this hospitalization, his Lasix and
aldactone was held; however, he was continued on his Lasix,
aldactone, digoxin, and ACE inhibitor. Patient had no
evidence of congestive heart failure during this
hospitalization and he resumed his prior medications before
discharge.
4. Endocrine: Patient with hypothyroidism: The patient was
continued on his Levoxyl. He was also maintained on a
regular insulin-sliding scale. Blood sugars remained in
normal levels, and he did not require significant amounts of
insulin.
5. Renal: Patient with chronic renal insufficiency.
Remained stable throughout this hospitalization.
6. Heme: Patient's INR was reversed with vitamin K, and the
patient was instructed to resume Coumadin dosing on the
evening following discharge. The patient will follow up with
his cardiologist or primary care physician for further
monitoring of his INR and adjustment of his Coumadin dose.
7. ID: The patient had a temperature greater than 101.5
following his pacemaker placement, and therefore was
continued on his cephalosporin, which was originally given
for prophylaxis. The patient was transitioned to p.o.
antibiotics, plan for seven-day course.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. ICD firing.
2. ICD revision.
3. Ventricular tachycardia.
DISCHARGE MEDICATIONS:
1. Furosemide 40 b.i.d.
2. Spironolactone 25 q.d.
3. Plavix 75 q.d.
4. Atorvastatin 40 q.d.
5. Levothyroxine 125 mcg.
6. Digoxin 125 mcg q.d.
7. Mexiletine 150 p.o. b.i.d.
8. Isosorbide mononitrate 30 q.d.
9. Enalapril 2.5 q.d.
10. Dofetilide 125 b.i.d.
11. Ibuprofen prn.
12. Metoprolol succinate 25 q.d.
13. Keflex 500 t.i.d. for three days.
14. Coumadin 7.5 mg p.o. q.d.
FOLLOW-UP PLANS: The patient will follow up with his primary
care physician in the week following discharge. In addition
to this, the patient will follow up with the
electrophysiologist, Dr. [**Last Name (STitle) **], on [**6-7**] in addition
to his appointment in Device Clinic on [**5-29**].
[**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**]
Dictated By:[**Name8 (MD) 12502**]
MEDQUIST36
D: [**2126-5-15**] 20:55
T: [**2126-5-17**] 08:54
JOB#: [**Job Number 20814**]
|
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This is the MIMIC III dataset used to finetune Meta Llama3 model. The data is from MIMIC III's NoteEvents table and the DIAGNOSES_ICD table. It specifies the discharge summary and the icd codes given a patient and an admission to the hospital. The dataset includes patients with ID in range 0-10000, 15000-20000, 25000-70000.
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