notes_small.csv

PARSED
"Admission Date:  2130-4-14     Discharge Date:  2130-4-17
Date of Birth:   2082-12-11     Sex:  M
Service:  #58
HISTORY OF PRESENT ILLNESS:  Mr. Jefferson is a 47 year-old man
with extreme obesity with a body weight of 440 pounds who is
5'7"" tall and has a BMI of 69.  He has had numerous weight
loss programs in the past without significant long term
effect and also has significant venostasis ulcers in his
lower extremities.  He has no known drug allergies.
His only past medical history other then obesity is
osteoarthritis for which he takes Motrin and smoker's cough
secondary to smoking one pack per day for many years.  He has
used other narcotics, cocaine and marijuana, but has been
clean for about fourteen years.
He was admitted to the General Surgery Service status post
gastric bypass surgery on 2130-4-14.  The surgery was
uncomplicated, however, Mr. Jefferson was admitted to the Surgical
Intensive Care Unit after his gastric bypass secondary to
unable to extubate secondary to a respiratory acidosis.  The
patient had decreased urine output, but it picked up with
intravenous fluid hydration.  He was successfully extubated
on 4-15 in the evening and was transferred to the floor
on 2130-4-16 without difficulty.  He continued to have
slightly labored breathing and was requiring a face tent mask
to keep his saturations in the high 90s.  However, was
advanced according to schedule and tolerated a stage two diet
and was transferred to the appropriate pain management.  He
was out of bed without difficulty and on postoperative day
three he was advanced to a stage three diet and then slowly
was discontinued.  He continued to use a face tent overnight,
but this was discontinued during the day and he was advanced
to all of the usual changes for postoperative day three
gastric bypass patient.  He will be discharged home today
postoperative day three in stable condition status post
gastric bypass.
DISCHARGE MEDICATIONS:  Vitamin B-12 1 mg po q.d., times two
months, Zantac 150 mg po b.i.d. times two months, Actigall
300 mg po b.i.d. times six months and Roxicet elixir one to
two teaspoons q 4 hours prn and Albuterol Atrovent meter dose
inhaler one to two puffs q 4 to 6 hours prn.
He will follow up with Dr. Morrow in approximately two weeks as
well as with the Lowery Medical Center Clinic.
                          Kevin Gonzalez, M.D.  R35052373
Dictated By:Dotson
MEDQUIST36
D:  2130-4-17  08:29
T:  2130-4-18  08:31
JOB#:  Job Number 20340"
"Admission Date:  2188-1-12       Discharge Date:  2188-1-25

Date of Birth:   2148-1-24       Sex:  M

Service:

HISTORY OF PRESENT ILLNESS:  The patient is a 39 year old
male who was an unrestrained driver involved in a rollover
motor vehicle accident.  He was partially ejected from the
vehicle.  He had a prolonged extrication time, approximately
30 minutes and was found unresponsive by paramedics at the
scene and intubated.  The patient was transferred to an
outside medical facility where he had some left side crepitus
noted.  He had a left chest tube placed for relief of this
pneumothorax.  The patient, at that time, was noted to be
hypotensive and had a diagnostic peritoneal lavage performed
which was negative.  The patient's chest x-ray at that time
showed a pneumothorax on the opposite side, on the right
side, for which another chest tube was placed.  The patient
was packaged and prepared for transfer through Flores Memorial Hospital, however, upon wheeling the patient
away from that facility, he was found to be hypotensive
initially and then had an asystolic arrest.  Two additional
bilateral chest tubes were placed with relief of bilateral
tension hemopneumothoraces with return of perfusing cardiac
rhythm.

The patient was stabilized for transfer to Flores Memorial Hospital.  Upon arrival in our Trauma Bay,
the patient was intubated, sedated, and paralyzed.  The
patient had three chest tubes in place and was
hemodynamically stable.

HOSPITAL COURSE:   Trauma work-up at our facility revealed
bilateral pneumothoraces with minimal hemothoraces,
adequately drained by his chest tubes.  However, persistent
air leaks were noted and it was identified that the patient'a
proximal ports of his chest tubes were out of the chest.
During the CT scan, he became hypotensive and these tubes had
to be emergently advanced with good result.

The patient's trauma series revealed multiple rib fractures
and hemopneumothoraces as stated above.  The patient had a
head CT scan which was negative and a CT scan of the cervical
spine which showed a tiny C5 avulsion fracture which was
non-displaced.  CT scan of his chest revealed bilateral
pulmonary contusions, bilateral consolidation and a left
clavicular fracture.  CT scan of his abdomen and pelvis
showed a minimal amount of free fluid consistent with his
diagnostic left clavicular fracture.  CT scan of his abdomen
and pelvis showed a minimum amount of free fluid consistent
with his diagnostic peritoneal lavage.  The patient also
noted to have multiple bilateral rib fractures.

The patient's plain film also on a later read revealed
question of a left iliac Dr. Sanchez fracture which was
non-displaced.  The patient also was noted by a consultation
by Orthopedic Surgeons to have a glenoid fracture in addition
to a humerus fracture.

The patient was transferred to the Surgical Intensive Care
Unit where two fresh sterile chest tubes were placed and his
three other chest tubes were removed.  He required
intermittent pressor support and aggressive fluid
resuscitation.  Neurosurgery was consulted and determined
that this C5 fracture was nondisplaced, not requiring any
specific therapy, however, that the patient should be in a
hard collar for six weeks.

The patient developed pulmonary infiltrate and some fevers
for which he was started on Ceftriaxone for some Gram
negative rods growing in his sputum.  On hospital day four,
the patient was taken to the Operating Room by the Orthopedic
surgeons for open reduction and internal fixation of his
humeral fractures; the patient tolerated this procedure well
without any complications.

Postoperatively, he was transferred back to the Surgical
Intensive Care Unit where he underwent a prolonged
ventilatory wean.  The patient was extubated but noted to be
somewhat confused and initially combative.  The patient was
thought to be withdrawing from alcohol and was started on
Ativan drips to control this.  He progressed very well.
Mental status improved.  He was transferred to the floor.  On
the floor, he continued to do well with slowly improving
mental status.  Psychiatry was consulted for care of this and
recommended a slow Ativan wean and slow Haldol wean.

The patient's antibiotic course was completed.  Follow-up
chest x-ray revealed resolution of his consolidations and the
patient's sputum became normal.  He began working with
Physical Therapy and advanced to a regular diet which he
tolerated well and will be discharged to rehabilitation.



                          DR.Tisdale,Adele 02-349

Dictated By:Weston
MEDQUIST36

D:  2188-1-24  08:52
T:  2188-1-24  10:40
JOB#:  Job Number 38197
"
"Admission Date:  2126-3-21              Discharge Date:   2126-4-9

Date of Birth:  2074-3-9             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:Jaime
Chief Complaint:
struck on head by large beam

Major Surgical or Invasive Procedure:
anterior cervical fusion 3-21
posterior cervical fusion 3-24
Open trach, PEG 3-29

History of Present Illness:
52 year-old male who had a large metal Dr. Tran fall 8 inches onto
his head. No LOC but on arrival of EMS had no sensation or motor
function beloow nipples. In field SBP was in 90s started on
levophed. On arrival there was no sensation/motor function below
nipple line. The patient was intubated for agitation and started
on salumedrol drip.


Past Medical History:
healthy

Social History:
married

Family History:
non-contributory

Physical Exam:
Awake and alert on arrival.
10 cm head laceration stapled in the trauma bay.  Pupils are
equal and reactive.
Lungs are clear bilaterally.
Heart is regular.
Abdomen is soft, nontender, and nondistended.
Extremities are warm, perfused, but sensation to pin-prick is
absent over all extremities.  there is no motor function over
any extremity.


Pertinent Results:
2126-3-21 09:30AM URINE  RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
2126-3-21 09:30AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG
2126-3-21 09:30AM URINE  COLOR-Yellow APPEAR-Clear SP Cooper-1.026
2126-3-21 09:30AM   FIBRINOGE-251
2126-3-21 09:30AM   PT-12.7 PTT-21.4* INR(PT)-1.1
2126-3-21 09:30AM   PLT COUNT-187
2126-3-21 09:30AM   WBC-6.7 RBC-4.33* HGB-14.1 HCT-39.1* MCV-90
MCH-32.7* MCHC-36.1* RDW-13.3
2126-3-21 09:30AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
2126-3-21 09:30AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
2126-3-21 09:38AM   GLUCOSE-167* LACTATE-1.4 NA+-140 K+-4.3
CL--106 TCO2-23
2126-3-21 12:51PM   TYPE-ART PO2-225* PCO2-43 PH-7.29* TOTAL
CO2-22 BASE XS--5
2126-3-21 01:11PM   HCT-42.1
2126-3-21 01:11PM   CALCIUM-8.6 PHOSPHATE-2.8 MAGNESIUM-1.9
2126-3-21 01:11PM   GLUCOSE-214* UREA N-21* CREAT-0.9 SODIUM-137
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15

Brief Hospital Course:
Mr. Adam was evaluated in the Trauma Bay and a spine
consult was obtained immediately.

His injuries included:
C4-6,2-1 fractures, nonenhancing vertebral artery R C3-6, R 1st
rib, R clavicle, scalp lac, cervical epidural hematoma no
motor/senstn UEs or Esther
Zuniga/CTA Hd: no acute bleed
CT/CTA Csp: as above
CT Torso: as above

The steroid protocol was initiated and continued for a total of
24 hours.  He was brought to the operating room for an anterior
cervical fusion (3-21).  The patient was stabilized and returned
to the OR for a posterior fusion (3-24).

An IVC filter was placed by the Vascular surgery service.

After the spine surgery team cleared the patient, an open
tracheostomy and percutaneous endoscopic gastrostomy tube were
performed (3-29).

His postoperative course has been complicated by a postoperative
pneumonia.  He was treated with a 7 day course of levofloxacin
for a pan sensitive enterobacter pneumonia (3-27).  At present
he has MRSA (4-1, 4-2) growing from sputum and has been treated
now with 8 days of vancomycin.  He also has been started on
pipercillin-tazobactam (4-8) for gram negative rods in his
sputum (4-2).

Medications on Admission:
none

Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
9. Therapeutic Multivitamin     Liquid Sig: Five (5) ML PO Q 24H
(Every 24 Hours).
10. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1)  PO DAILY
(Daily).
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

12. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscell.  Q2H (every 2 hours) as needed.
13. Lansoprazole 15 mg Susp,Delayed Release for Recon Sig: One
(1)  PO DAILY (Daily).
14. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H
(Every 3 to 4 Hours) as needed.
15. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for mucous production.
16. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed.
17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
18. Metoclopramide 5 mg/mL Solution Sig: One (1)  Injection Q6H
(every 6 hours).
19. Lorazepam 2 mg/mL Syringe Sig: 12-31  Injection Q2H PRN () as
needed for anxiety.
20. Vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln
Intravenous  Q 8H (Every 8 Hours).
21. Ampicillin-Sulbactam 1-30 g Recon Soln Sig: Three (3) Recon
Soln Injection Q8H (every 8 hours).
22. Acetazolamide Sodium 500 mg Recon Soln Sig: One (1) Recon
Soln Injection Q6H (every 6 hours).


Discharge Disposition:
Extended Care

Facility:
True Corporation

Discharge Diagnosis:
C4-6, T2-3 fractures with quadraplegia


Discharge Condition:
stable


Discharge Instructions:
tracheostomy care
gastrostomy care



"
"Admission Date: 2126-10-24        Discharge Date: 2126-10-30

Date of Birth:  2063-1-14        Sex:  M

Service:  CSU


HISTORY OF PRESENT ILLNESS:  This is a 63 year old gentleman
who has a prior history of myocardial infarction in 2122-2-17 who underwent stent to his left anterior descending and
right coronary artery at the time with subsequent multiple
episodes of instant restenosis, requiring brachytherapy.  The
patient underwent a routine stress test, which showed
reversible anterior ischemia and was referred to Shaw Medical Center for cardiac catheterization.

PAST MEDICAL HISTORY:  Hypercholesterolemia.  Status post
myocardial infarction.  Status post multiple PCI.
Hypertension. Status post removal of colonic polyps.  Status
post appendectomy.  Status post removal of lipoma.  Status
post removal of precancerous lesion from his back.

ALLERGIES:  No known drug allergies.

PREOPERATIVE MEDICATIONS:
1. Accupril 40 mg p.o. q. Day.
2. Hydrochlorothiazide 25 mg p.o. q. Day.
3. Toprol XL 50 mg p.o. twice a day.
4. Verapamil SA 240 mg p.o. q. Day.
5. Aspirin 325 mg p.o. q. Day.
6. Plavix 75 mg p.o. q. Day.
7. Lipitor 40 mg p.o. q. Day.
8. Folic acid 1 mg p.o. twice a day.
9. Tums.
10.      Multi-vitamin supplements.


HOSPITAL COURSE:  The patient was admitted to Shaw Medical Center on 2126-10-24 and underwent
cardiac catheterization which showed left ventricular end
diastolic pressure of 17, which rose to 22 after the LV gram;
ejection fraction of 50 percent; 90 percent left main lesion
and patent stents in the left anterior descending, left
circumflex and right coronary artery.  The patient was
referred to cardiac surgery for operative management.  The
patient was taken to the operating room on 2126-10-25
with Dr. Soule for coronary artery bypass graft times two;
left internal mammary artery to left anterior descending and
saphenous vein graft to ramus.  Total cardiopulmonary bypass
time was 61 minutes; cross clamp time 44 minutes.  The
patient was transferred to the Intensive Care Unit in stable
condition.  The patient was weaned and extubated from
mechanical ventilation on his first postoperative evening.
On postoperative day number one, the patient was transferred
from the Intensive Care Unit to the regular part of the
hospital.  The patient began ambulating with physical
therapy. The patient was started on low dose Lopressor.  On
postoperative day number two, the patient's chest tubes and
pacing wires were removed without incident.

On postoperative day number three, the patient complained of
seeing flashing lights when he was trying to read.  He had no
history of this sensation prior.  An ophthalmology consult
was obtained. It was determined that the patient's blood
vessels in his eyes were normal.  He had a posterior vitreous
detachment in the left eye which required no intervention and
was probably an old finding.  They recommended that the
patient follow-up as needed.  The patient was restarted on
ace inhibitor for hypertension control.  By postoperative day
number four, the patient was able to ambulate 500 feet and
climb one flight of stairs with physical therapy.  ON
postoperative day number five, the patient was cleared for
discharge to home.

CONDITION ON DISCHARGE:  Temperature maximum of 100.3; pulse
87 and sinus rhythm; blood pressure 140/90; respiratory rate
16; oxygen saturation 95 percent on room air.  The patient's
weight was 95.5 kg.  Neurologically, the patient was awake,
alert and oriented times three.  Cardiovascular:  Regular
rate and rhythm without murmur or rub.  Respiratory breath
sounds are decreased at bilateral bases without rhonchi,
wheezes or rales.  Abdomen:  Soft, nondistended, nontender.
Sternal incision was clean, dry and intact.  Sternum is
stable.  Right lower extremity vein harvest site with
significant ecchymosis in the right thigh, mildly tender to
palpation.  No apparent hematoma.  The incision was clean,
dry and intact.

LABORATORY DATA:  White blood cell count of 10.9; hematocrit
of 28.3; platelet count of 316.  Sodium of 140; potassium of
3.8; chloride 107; bicarbonate of 24; BUN 14; creatinine 0.7;
glucose 139.

DISPOSITION:  The patient was discharged home in stable
condition.

DISCHARGE DIAGNOSES:  Coronary artery disease.

Status post coronary artery bypass graft.

Hypertension.

DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. q. Day times 7 days.
2. Potassium chloride 20 mEq p.o. q. Day times 7 days.
3. Colace 100 mg p.o. twice a day.
4. Zantac 150 mg p.o. twice a day.
5. Aspirin 325 mg p.o. q. Day.
6. Plavix 75 mg p.o. q. Day.
7. Lipitor 40 mg p.o. q. Day.
8. Dilaudid 2 mg tablets, one p.o. every four to six hours
   prn.
9. Accupril 40 mg p.o. q. Day.
10.      Toprol XL 150 mg p.o. q. Day.

The patient is to be discharged home in stable condition. He
is to follow-up with his primary care physician, Baker. Soule,
in one to two weeks.  He is to follow-up with his
cardiologist, Dr. Soule, in two to three weeks. He is to follow-
up with Dr. Soule in three to four weeks.







                        Jacqueline Marcos, M.D. G57933924

Dictated By:Halsey
MEDQUIST36
D:  2126-10-30 18:05:44
T:  2126-10-30 21:26:14
Job#:  Job Number 31718
"
"Admission Date: 2176-9-25        Discharge Date: 2176-10-4

Date of Birth:                    Sex:  M

Service:  General Surgery


DIAGNOSES:
1. Mesenteric venous thrombosis with bowel ischemia and
   infarction.
2. Congestive heart failure.
3. Respiratory failure.
4. Sepsis.
5. Tetralogy of Fallot.
6. Down syndrome.
7. Paget disease.
8. Chronic conjunctivitis.
9. Seizure disorder.
10.      Peripheral vascular disease.


CHIEF COMPLAINT:  Respiratory failure with mesenteric
thrombosis.

HISTORY OF PRESENT ILLNESS:  The patient is a 37-year-old
gentleman with Down syndrome and tetralogy of Fallot who
presented to Poe Memorial Hospital Hospital from his group care facility
on 2176-9-22, with complaints of diarrhea, nausea, vomiting
and acute abdominal pain x 48 hours.  He was initially
admitted to the medical floor but acutely desaturated and
went into respiratory failure.  He required intubation and
was transferred to the ICU.  He had bilateral pulmonary
infiltrates.  He was started empirically on intravenous
antibiotics and began spiking temperatures and his abdominal
pain worsened.  He started passing bright red blood per
rectum and a CT scan was performed, which demonstrated
mesenteric venous thrombosis.  He had a hematocrit drop from
43 to 29 and he was transfused for supportive therapy.  His
respiratory status deteriorated and he was transferred to the
West Memorial Hospital for further tertiary
care on 2176-9-25.

PAST MEDICAL HISTORY:
1. Down syndrome.
2. Congenital heart disease.
3. Tetralogy of Fallot.
4. Paget disease.
5. Chronic conjunctivitis.
6. Seizure disorder.
7. Mental retardation.
8. Depression.
9. Peripheral vascular disease.


PAST SURGICAL HISTORY:  None could be elicited, as the
patient was not responsive.

MEDICATIONS ON ADMISSION:
1. Dilantin.
2. Ativan.
3. Colace.
4. Aspirin.
5. Valium.
6. Multivitamin.
7. Bacitracin.
8. Lasix.
9. Digoxin.
10.Claritin.
11.Tinactin.
12.Penicillin.
13.Zoloft.
14.Protonix.
15.Vancomycin.


ALLERGIES:  GENTAMICIN EYE DROPS causing rash.

SOCIAL HISTORY:  He lives in a group home and he is
profoundly retarded and nonambulatory, nonverbal and
frequently combative.  He does not drink or smoke.

PHYSICAL EXAMINATION:  His temperature is 101.8, heart rate
88, blood pressure 104/54, he is saturating 96 percent on
assist  control with 100 percent FiO2.  Generally, he was
sedated, intubated and nonresponsive.  His head was
normocephalic.  His mucous membranes were dry and he had
nasogastric tube and an endotracheal tube.  Reflexes could
not be elicited.  His chest had coarse breath sounds
bilaterally with diminishment at the bases.  He was without
wheezes or crackles.  His heart was regular rate and rhythm
with a 4/6 systolic murmur.  His abdomen was distended and
soft.  He had no bowel sounds.  He had anasarca with pitting
edema in both extremities.  His white blood cell count was
11.2.  His hematocrit 32, his platelet count 159, 87
neutrophils, no bands, 9 lymphocytes.  Sodium was 150,
potassium was 3.8, chloride was 114, bicarbonate 27, BUN 23,
creatinine 0.9 and glucose 96.  His calcium was 8.1,
magnesium was 1.8, phosphorus was 2.2.  AST 44, ALT 20,
alkaline phosphatase 77, amylase 73, lipase 13, albumin 2.1,
and total bilirubin 0.4.  Blood cultures were taken and a
urine culture was taken.  His PT was 16.8 and INR 1.8.  His
ABG was pH 7.33, pO2 of 136 and pCO2 of 60.  Lactate of 1.

Chest x-ray showed bilateral fluffy infiltrates about
pneumoperitoneum.

CT scan was reviewed from the outside hospital and
demonstrated mesenteric venous thrombosis with bowel wall
thickening and ascites.

CONCISE SUMMARY OF HOSPITAL COURSE:  The patient was admitted
on 2176-9-25, started on intravenous heparin and broad-
spectrum antibiotics.  His condition initially improved and
then did plateau.  A central line was placed for access for
parenteral nutrition and he was started on parenteral
nutrition.  The patient continued to have heme-positive stool
and his hemodynamics secondary to his tetralogy of Fallot and
his ischemia did not improve.  Cardiology consult, Vascular
consult and Infectious Disease consult were all obtained.
The patient's condition stabilized but did not significantly
improve over the course of approximately 1 week.  After
detailed discussions with the patient's family, it was
decided that no surgery would be performed in the event that
the bowel declared itself as being infarcted rather than
merely ischemic.  The patient was transferred to the Medical
Service for supportive therapy.  The patient continued with
lack of improvement and the Balmora Organ Bank was
contactJames and the patient was chosen for donation.  On
2176-10-4, the patient was taken to the operating room.  He
was extubated and declared dead and his organs were
harvested.


DATE OF DEATH:  2176-10-4.



                        Judy Filler, T42279639

Dictated By:Gomez
MEDQUIST36
D:  2176-12-17 14:47:01
T:  2176-12-17 23:06:56
Job#:  Job Number 50984




"
"Admission Date:  2195-10-19              Discharge Date:   2195-10-19

Date of Birth:  2156-3-29             Sex:   M

Service: MEDICINE

Allergies:
Fish Protein / Shellfish Derived

Attending:Alexis
Chief Complaint:
multi-organ failure

Major Surgical or Invasive Procedure:
none

History of Present Illness:
The patient is a 45 y.o. man with pmh significant for
hypertension and obstructive sleep apnea, who presented to an
outside hospital with abdominal pain, shortness of breath,
nausea and vomiting, chest pain, and hematuria. His wife reports
his symptoms began friday when he noticed hematuria. he
presented to the OSH ED, where CT abdomen was unrevealing and he
was told he passed a kidney stone. He went home, where he
developed abdominal pain. His pain was crampy in nature, and
localized over the left lower quadrant. He then developed lower
back pain and shortness of breath, with profound dyspnea on
exertion. Sunday night his abdominal pain was increasing in
severity. He then presented to the Plymel Medical Center ED
Monday Morning. At presentation he had an INR of 4.0, other labs
consistent with DIC, hypotension with systolic blood pressure in
the 60's and oxygen saturation in the 70's. He was reporting
epigastric tenderness. Liver enzymes were also elevated, with T
bili 8.8, Direct Bili 5.5, AST 13,000, ALT 7820, LDH 11,000.
BUN/Cr 20/3.5. He was intubated, given ceftriaxone, levaquin,
and flagyl, and 1L NS, and transferred to Hadley Hospital. On arrival here
he was still hypotensive. A right IJ line was placed. A femoral
arterial line was placed as well. levophed was added and his
blood pressure was 66/34. he was given 5 Liters of NS.
vancomycin and zosyn were added. Initial labs in ED showed pH
6.90/76/86/16, lactate of 14.0.
.
On presentation to the ICU he underwent TEE which revealed
hypertrophic obstructive cardiomyopathy, but no aortic
dissection. The patient became asystolic during this procedure
and was coded, receiving CPR, epinephrine, CaCl2, HCO3. .
.
He was placed on levophed, vasopressin, neosynephrine. He
received 3 more liters of 150meq sodium HCO3, and is receiving
continuous 150meq NaHCO3.


Past Medical History:
Hypertension
Sleep apnea


Social History:
 drinks one pint of rum or vodka daily, last drink was 4 days
ago.
No cigarettes or tobacco.
No illicit drug use.


Family History:
Mother and father with Diabetes.

Physical Exam:
Vitals: T: BP:115/39 P:115 R:25 O2: 91% on FiO2 100%, TV 600,
PEEP 15, PIP 40.
General: intubated, sedated. obese
HEENT: Sclera anicteric
Neck: obese, difficult to assess.
Lungs: diffuse rhonchi bilaterally
CV: tachycardic, regular, no m/g/r
Abdomen: obese. NT
Ext: poor capillary refill. no edema.


Pertinent Results:
2195-10-19 02:30PM   FIBRINOGE-96.6*
2195-10-19 02:30PM   PLT COUNT-131*
2195-10-19 02:30PM   PT-60.9* PTT-86.4* INR(PT)-6.9*
2195-10-19 02:30PM   WBC-17.4* RBC-4.54* HGB-13.9* HCT-44.5 MCV-98
MCH-30.5 MCHC-31.1 RDW-14.0
2195-10-19 02:30PM   NEUTS-93.6* LYMPHS-4.6* MONOS-1.2* EOS-0.2
BASOS-0.3
2195-10-19 02:30PM   ASA-NEG ETHANOL-NEG ACETMNPHN-34.5*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
2195-10-19 02:30PM   CORTISOL-46.4*
2195-10-19 02:30PM   D-DIMER->68341
2195-10-19 02:30PM   HAPTOGLOB-20*
2195-10-19 02:30PM   ALBUMIN-3.7 CALCIUM-8.0* PHOSPHATE-11.3*
MAGNESIUM-2.4
2195-10-19 02:30PM   LIPASE-66*
2195-10-19 02:30PM   ALT(SGPT)-6680* AST(SGOT)-19417* CK(CPK)-452*
ALK PHOS-144* TOT BILI-8.0* DIR BILI-5.5* INDIR BIL-2.5
2195-10-19 03:25PM   O2 SAT-89
2195-10-19 03:25PM   LACTATE-13.2*

Micro:
2195-10-19 BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY Perez Clinic
2195-10-19 BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY Perez Clinic

Imaging:
CT abd/pelvis:
1. Left lower lobe consolidation consistent with pneumonia. In
this location, aspiration is a potential etiology.
2. Fatty liver.
3. Air and decompressed urinary bladder consistent with
instrumentation,
correlate clinically.

CXR:
support lines remain in place; OGT not completely visualized.
allowing for
portable supine technique and low lung volumes, heart size may
not be
enlarged. left lower lobe consolidation and ill-defined right
perihilar
opacity are as seen on earlier same day CXR and CT abd/pelv.
areas of
consolidation in RUL and LUL somewhat more confluent. no supine
evidence of large ptx or large effusion seen. rt lateral sulcus
excluded.

TEE:
LVEF 75%, no evidence of aortic dissection


Brief Hospital Course:
45 year old man with pmh significant for obstructive sleep
apnea, hypertension, presenting with profound lactic acidosis
and hypotension despite three vasopressors.
.
#Hypotension: Differential included septic shock, vs. mesenteric
ischemia. Aortic dissection was not found on TEE. CT abdomen was
significant only for mild retroperitoneal fat stranding.
Babesiosis is a possibility given residence on Olympus. Other infectious sources include cholangitis or
cholecystitis given elevated liver enzymes.  Patient was
administered broad spectrum antibiotics-vanc, zosyn, flagyl,
doxycycline. He was maintained on vasopressin, phenylephrine,
dopamine, and levophed for pressor support. He was given NaHCO3,
LR for fluids. Patient expired before RUQ ultrasound could be
done.

.
# Lactic Acidosis: Differential included sepsis and mesenteric
ischemia given history of abdominal cramping pain.  He was
maintained on broad spectrum antibiotic. He was not a surgical
candidate in light of his other comorbidities.

.
# Transaminitis: Likely shock liver in setting of reported
hypotension at OSH. Must also consider other liver etiologies,
including acetaminophen, alcoholic hepatitis (given EtOH
history). Serum and urine tox were sent.  He did have an
elevated acetaminophen level, which could have contributed to
fulminant hepatic failure especially in light of heavy ETOH use.

.
# DIC:  Patient was supported with FFP, cryoprecipitate, and
vitamin K.

# Myocardial infarction: Patient had ST elevations in V1 through
V4, likely secondary to demand ischemia in light of severe
hypotension.

Patient expired at 20:35 on 2195-10-19. His wife requested autopsy
to determine cause of death.

Medications on Admission:
amlodipine
celexa
lisinopril


Discharge Medications:
Patient expired

Discharge Disposition:
Expired

Discharge Diagnosis:
pt expired

Discharge Condition:
pt expired

Discharge Instructions:
pt expired

Followup Instructions:
pt expired


"
"Admission Date:  2187-8-17       Discharge Date:  2187-8-23


Service:  Orthopedic Surgery

HISTORY OF PRESENT ILLNESS:  Mrs. Grant is a 87-year-old
woman who was transferred to Blair Clinic from Morris Clinic with a diagnosis of left
intertrochanteric hip fracture.  The patient fell earlier on
the  day of admission and subsequent to this was unable to
walk secondary to pain.  The patient denied weakness, numbness
or paresthesias in left lower extremity.

PAST MEDICAL HISTORY:
1.  Hypertension
2.  Cataract

ADMISSION MEDICATIONS:
1.  Toprol
2.  Calcium
3.  Aspirin 81 mg po q day

ALLERGIES:  No known drug allergies.

PHYSICAL EXAM:
GENERAL:  Pleasant 87-year-old woman in no acute distress.
VITAL SIGNS:  Temperature 98??????, blood pressure 135/80, heart
rate 80, respiratory 18, O2 saturation 98% on room air.
HEAD, EARS, EYES, NOSE AND THROAT:  Pupils equal, round and
reactive to light.  Oropharynx clear.
LUNGS:  Clear to auscultation bilaterally.
HEART:  Regular rate and rhythm, no murmurs, rubs or gallops.
ABDOMEN:  Soft, nontender, nondistended with positive bowel
sounds.
EXTREMITIES:  Left lower extremity was shortened and
externally rotated.  There was focal tenderness in the great
trochanter area of the left hip.  Strength was 5-13 in left
toes, ankle and knee.  Sensation was intact.  Pulses were
normal, including popliteal, DP and PT pulses.

The rest of the physical exam was unremarkable.

X-RAYS revealed a left intertrochanteric fracture.  Chest
x-ray was normal.  Electrocardiogram was within normal
limits.

LABS:  White blood cell count was 6.7, hematocrit was 34,
platelets 187.  Sodium, potassium chloride, bicarbonate, BUN,
creatinine and glucose were all within normal limits.

HOSPITAL COURSE:  The patient was taken to the Operating Room
on 2187-8-19 and underwent open reduction and internal
fixation of left intertrochanteric fracture.  For more
details about the operation, please refer to the operative
note from that date.  The patient did not have any
postoperative complications.  The operation was under general
anesthesia.

Preoperatively, the patient was started on Coumadin for deep
venous thrombosis prophylaxis.  The patient also received 48
hours of Kefzol perioperatively.  The patient's diet was
advanced as tolerated.  The patient was noted to have some
mild difficulty with swallowing and a swallow study consult
was obtained.  It was determined the patient did not have any
significant physiological or mechanical problems and those
difficulties were likely due to anxiety the patient was
experiencing postoperatively.  The patient eventually
successfully tolerated a regular diet.

The patient was switched to oral pain medications
successfully.  The patient made good progress with physical
therapy and was able to bear weight and walk successfully.
The patient will be discharged to the rehabilitation center.
During the hospital stay, the patient's hematocrit has
remained stable.

DISCHARGE MEDICATIONS are identical to the medications on
admission, plus Coumadin 2.5 mg po q day for target INR of
1.5.




                            David Farber, M.D.  R43148808

Dictated By:Dylan
MEDQUIST36

D:  2187-8-22  13:26
T:  2187-8-22  13:33
JOB#:  Job Number 35270
"
"Admission Date:  2163-1-10              Discharge Date:   2163-1-19

Date of Birth:  2090-4-20             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:Latonya
Chief Complaint:
N/V

Major Surgical or Invasive Procedure:
None


History of Present Illness:
72 M who is 1 week s/p R. colectomy for colon cancer, presents
with increasing nausea and emesis for the past 2 days. He was
discharged 3 days ago, and has had increasing abdominal
distention since. He denies any fever or chills, and reports
continuing to pass flatus.

Past Medical History:
HTN, BPH, GERD, arthritis, monoclonal gammopathy

Social History:
Lives with wife


Family History:
Mother passed away from breast cancer

Physical Exam:
At time of admission:

97.4   108   95/45   25   94%RA
A&O X 3, conversant
PERRL, EOMI, feculent breath
Heart irregularly irregular
Lungs CTAB
Abd distended, hypertympanic, tender to deep palpation in
epigastrium
Incision C/D/I
Rectal guiac negative
Ext without c/c/e

NGT with 2L feculent output

Pertinent Results:
2163-1-10: PT-12.4 PTT-20.4* INR(PT)-1.0
PLT COUNT-416# WBC-8.1 RBC-3.94* HGB-11.4* HCT-32.7* MCV-83
MCH-28.8 MCHC-34.8 RDW-13.3
ALBUMIN-3.5 CALCIUM-9.1 PHOSPHATE-6.1*# MAGNESIUM-4.2*
CK-MB-7 cTropnT-<0.01
ALT(SGPT)-53* AST(SGOT)-80* CK(CPK)-377* ALK PHOS-203*
AMYLASE-108* TOT BILI-0.6
LIPASE-148*

Brief Hospital Course:
On 2163-1-10 Mr. Michael was admitted to the surgery service under
the care of Dr. Melancon. He had been discharged 3 days prior
after having a right colectomy for colon cancer. He was
readmitted with a partial SBO, ARF, and new onset of a. fib. He
was initially admitted to the ICU for volume resuscitation and
heart rate control. An NG tube was place and initally put out
over 2 liters of feculent material. After converting in and out
of atrial fibrillation, Mr. Michael was started on amiodarone
and heparin. By HD 3 he remained in sinus rhythm. He was
transferred out of the ICU on HD 6 when is renal status had
improved and his HR and BP were stable. His diet was slowly
advanced after his NGT was removed. During this time he was
treated for a UTI with cipro. He was also started on Zosyn when
an abdominal CT revealed a small fluid collection in the RUQ. He
was transitioned to po Levo and Flagyl. By HD 10, Mr. Michael
was tolerating a regular diet, ambulating with minimal
assistance, and therapeutic on his coumadin. He was discharged
home with instructions to follow-up with his PCP for INR checks,
cardiology, and Dr. Melancon.

Medications on Admission:
atenolol 50', doxazosin 4', amlodipine 5', lisinopril 10',
nexium 40, colace, percocet, klonapin

Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
2. 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*
3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Please take 2 pills twice a day for 3 days, then 2 pills
once a day for 7 days, and then 1 pill once a day from then on.
Disp:*120 Tablet(s)* Refills:*2*
4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
6. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
Disp:*qs 1* Refills:*2*
7. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO at bedtime:
Adjust dose based on INR.
Disp:*90 Tablet(s)* Refills:*2*
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 5-12
hours.
Disp:*50 Tablet(s)* Refills:*0*
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Partial small bowel obstruction s/p R. colectomy
New onset A. fib.
Acute renal failure


Discharge Condition:
Good


Discharge Instructions:
Please call your doctor or go to the ER if you experience any of
the following: high fevers >101.5, severe pain, increasing
shortness of breath, chest pain, palpitations, or worsening
nausea/emesis. Please follow-up with your primary care doctor
regarding your coumadin dose. Also please follow-up with
cardiology.

Followup Instructions:
Provider: Geraldine,Crystal Henrietta.  688-710-1461  Follow-up
appointment should be in 2 weeks
Provider: Geraldine,Olga Henrietta. (CARDIOLOGY)  504-466-7865  Call to
schedule appointment
Provider: Geraldine,Crystal Henrietta. (PCP)  870-348-1117  Call to schedule
appointment



"
"Admission Date:  2159-10-9       Discharge Date:  2159-10-16

Date of Birth:   2091-9-13       Sex:  M

Service:
HISTORY OF PRESENT ILLNESS:  The patient is a 68-year-old
gentleman with a left meningioma diagnosed two weeks prior to
admission.  The patient had left head pain with expressive
aphasia and then seizure.  He was taken to
Davis Memorial Hospital Hospital where CT of the brain showed this

PAST MEDICAL HISTORY:  Diabetes.

PAST SURGICAL HISTORY:  Bilateral hip replacement, the left
in 2151, the right 2152.  Cataract surgery in 2156.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.
PHYSICAL EXAMINATION:  General:  He was an overweight
gentleman.  He was cooperative but a poor historian.  HEENT:
Pupils equal, round and reactive to light.  Extraocular
movements full.  Right palate was soft but did not fully rise
with phonation.  His uvula was deviated to the left.  Tongue
midline.  Smile symmetric.  Shoulder shrug intact.  Chest:
Rhonchi in the posterior breath sounds and expiratory
wheezes, otherwise clear anteriorly.  Cardiovascular:  S1 and
S2.  Distant heart sounds.  Abdomen:  Soft, nontender,
nondistended.  Negative bruits.  Extremities:  No edema.  He
had 2+ pulses.  Gait was unsteady secondary to his hip
replacements.  Neurological:  Intact.

LABORATORY DATA:  Head CT showed a left frontotemporal dural
based lesion consistent with meningioma.

HOSPITAL COURSE:  The patient underwent a left frontotemporal
craniotomy for excision of meningioma without intraoperative
complications.  Postoperatively the patient was agitated and
confused.  It was discovered that the patient has a
significant alcohol history.  The patient was then
transferred to the Intensive Care Unit for close monitoring
on postoperative day #1 and was given Ativan for DTs.

He remained in the Intensive Care Unit until 2159-10-13, and was then transferred to the regular floor where he
was seen by Physical Therapy and Occupational Therapy.  On
10-16, the patient was found to be safe for discharge
to home with follow-up home physical therapy and occupational
therapy.  His mental status cleared. His sitter was
discontinued.  He was discharged to home in stable condition.
His staples were removed prior to discharge.  His incision
was clean, dry, and intact.

DISCHARGE MEDICATIONS:  He will be weaned from Decadron
starting at 4 mg p.o. q.12 hours and weaned off over 6-7
days.  He is also to remain on Dilantin 200 mg p.o. b.i.d.,
Zantac 150 mg p.o. b.i.d.

FOLLOW-UP:  He will follow-up with Dr. Paul in one month.

CONDITION ON DISCHARGE:  He was stable at the time of
discharge.






                            Stacey Helwig, M.D.  P86678299

Dictated By:Banks
MEDQUIST36

D:  2159-10-16  13:06
T:  2159-10-16  13:08
JOB#:  Job Number 45663
"
"Admission Date:  2177-5-14              Discharge Date:   2177-5-17

Date of Birth:  2146-7-21             Sex:   F

Service: SURGERY

Allergies:
Dilaudid

Attending:Bruce
Chief Complaint:
ventral hernia

Major Surgical or Invasive Procedure:
umbilical and ventral hernia repair

History of Present Illness:
30yo female currently on HD, had PD catheter removed in September
2176, with ongoing complaint of pain from an umbilical hernia.

Past Medical History:
- ESRD since 2174-8-29, currently on HD via tunneled line
- Peritonitis 8-7
- Type I DM complicated by neuropathy and nephropathy
- Bilateral cataract surgeries
- Ventral Hernia


Social History:
- Lives with her mother, + tobacco history, social ETOH,
marijuana use noted in history



Family History:
DM type II, otherwise NC


Physical Exam:
upon admission:
Gen - NAD, AOx3
CV - RRR, S1/S2 appreciated
Chest - CTAB
Abdomen - soft, nontender, nondistended, well healed PD cath
removal site left abdomen, normal bowel sounds
Ext - no C/C/E

Pertinent Results:
upon admission:
WBC-7.9 RBC-3.72* Hgb-10.9* Hct-34.8* MCV-94 MCH-29.2 MCHC-31.2
RDW-18.1* Plt Ct-239
Glucose-78 UreaN-21* Creat-6.4*# Na-144 K-3.6 Cl-104 HCO3-30
AnGap-14
Calcium-8.4 Phos-3.3 Mg-2.1

2177-5-17 07:30AM BLOOD WBC-7.1 RBC-3.83* Hgb-11.4* Hct-36.3
MCV-95 MCH-29.9 MCHC-31.5 RDW-17.8* Plt Ct-253
2177-5-17 04:40AM BLOOD Glucose-122* UreaN-20 Creat-8.5*# Na-140
K-3.9 Cl-100 HCO3-24 AnGap-20

Brief Hospital Course:
The patient was admitted to the West-1 surgery for scheduled
ventral/umbilical herniorrhaphy on 2177-5-14, which went well
without complication (please refer to Operative Note for
details). In the PACU, the patient experienced significant pain
control issues as well as nausea and emesis.  After
stabilization and improvement in symptoms, the patient was
transferred to the inpatient floor in stable condition.

Neuro: The patient received dilaudid with adequate pain control,
however patient experienced nausea likely related to narcotic
analgesia.  She was transitioned to oxycodone during her
admission after improvement in surgical site pain.

CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.

Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.

GI/GU/FEN: Post-operatively, diet was advanced when appropriate
and tolerated. Patient's intake and output were closely
monitored, and IV fluid was adjusted when necessary.
Electrolytes were routinely followed, and repleted when
necessary. Patient underwent scheduled hemodialysis while an
inpatient.

ID: The patient's white blood count and fever curves were
closely watched for signs of infection.

Endocrine: Post-operatively, the patient's blood sugar levels
were monitored and a sliding scale implemented.

Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.

Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.

At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.

Medications on Admission:
Carvedilol 12.5 mg Gaudio Medical Center, Sensipar 30 mg Tdaily, Furosemide 60 mg
daily, Novolog
100 unit/mL Solution per sliding scale QID, Glargine 100 unit/mL
Solution
15 units qhs- fluctuates with appetite and blood sugars,
Lisinopril 20 mg daily, Oxycodone 5 mg Tablet 11-30 every four (4)
hours as needed for pain   Sevelamer HCl 800 mg TID with meals,
Travoprost (Benzalkonium) [Travatan]
0.004 % Drops 1 gtt ou hs, Aspirin 81 mg daily, B complex
Vitamins daily,  Folic Acid 1 mg daily,


Discharge Medications:
1. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. B Complex Vitamins     Capsule Sig: One (1) Cap PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
11. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
13. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous once a day.
14. Novolog 100 unit/mL Solution Sig: follow sliding scale
Subcutaneous four times a day.
15. Epogen 10,000 unit/mL Solution Sig: One (1) ml Injection
once a week.


Discharge Disposition:
Home With Service

Facility:
South Park Dialysis South Park

Discharge Diagnosis:
ESRD
Ventral hernia repair


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Please call Dr.Doris office 903-535-3620 if you have any of
the warning signs listed below.
Continue with your usual dialysis schedule
No heavy lifting/straining
No driving while you are taking pain medication

Followup Instructions:
Provider: James Myers, MD Phone:903-535-3620
Date/Time:2177-5-30 3:40
Provider: Ray Alysia, MD Phone:903-535-3620
Date/Time:2177-6-13 10:40
Provider: Vickie Michaud, MD Phone:512-597-7329 Date/Time:2177-7-4
10:40



Completed by:2177-5-21"