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:  2143-11-10              Discharge Date:   2143-12-11

Date of Birth:  2089-2-6             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:Griffin
Chief Complaint:
Fevers, Altered Mental status

Major Surgical or Invasive Procedure:
intubated

History of Present Illness:
Patient unable to give history himself. Most history is from
Thomas Memorial Hospital. 54M with a history of CABG, remote MI, hip/shoulder
surgery, liver failure, hypertension, hyperlipidemia,
depression, alcohol and tobacco abuse who is transferred from
Williams Medical Center Hospital after decompensating there. The patient is a
54-year-old man who was brought into Thomas Memorial Hospital from Quahog detox
with significant juandice, lethargy, and an episode of syncope
while exiting the bathroom. At Thomas Memorial Hospital, his initial
presentation was alert and oriented x 3 and speech clear.
Pertinent labs at Thomas Memorial Hospital: WBC 19.6 Hct 29 Plt 210 INR 2.7
Lipase 20 K 3.2 Cl 88 Ammonia 66 Ca 7.9 CO2 37 K 3.2 Total bili
14.7 Direct bili 10.0 Total protein 6.3 Alb 2.6 AST 213 ALT 23.
The patient then became febrile to nearly 102 and lethragic,
only oriented to self. He became agitated as well,
intermittently. At Thomas Memorial Hospital before transfer the patient had
received 8mg Ativan, 1gm ceftriaxone, 600mg ibuprofen, 40mg K,
2g IV MG. The patient's urine output began to drop despite 3L
NS.
.
In the ED, temp 98 Hr 120 Bp 123/84 RR 18 94% RA.  Patient was
given 1mg ativan for sedation, placed in wrist restraints.
[x] EKG: sinus tachycardia with nonspecific ST-T changes
[x] CXR:
[x] RUQ ultrasound was performed.
[x] Liver consult was called.
[x] LFTs:
[x] UA, Ucx:
[x] Bcx: pending
[x] Guaiac: Negative
[x] ICU transfer requested
[x] Serum, urine tox, tylenol
[x] SIRS treatment: vancomycin, cefepime, flagyl
.
.
On the floor, was intermittently agitated. BP was 92/52 HR ws 98
RR was 14 he was 100%on RA.
.
Review of sytems:
could not be obtained as patient is not cooperative

Past Medical History:
Per OSH history:
history of CABG
remote MI,
hip/shoulder surgery,
liver failure,
hypertension,
hyperlipidemia,
depression,
alcohol and tobacco abuse

Social History:
Tunnel worker. Speaking with sister, he drinks close to a quart
a day of vodka with gatorade. Rooks last drink. Smokes a pack a
day. Drugs:Wentzel, but may have in the past. He lives with his
gilfriend


Family History:
unknown.

Physical Exam:
VS: T: 97.9, P: 128, BP: 112/53, RR: 26, 91% RA
General: Oriented to name only.  Intermittently responsive.
HEENT: Icteric Sclerae, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachycardic, normal S1 + S2,
Chest: multiple spider angiomas throughout.
Abdomen: tense, +bowel sounds, non-tender, no rebound tenderness
or guarding, no organomegaly, without shifting dullness,
tympanitic on percussion.
GU: foley in place.
Ext: mild palmar erythema, warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Neuro: A&Ox1, Cranial Nerves intact grossly, good strenght in
his extremities, profound asterixis.

Discharge
expired

Pertinent Results:
2143-11-10 09:05PM BLOOD WBC-17.9*# RBC-2.74*# Hgb-10.0*#
Hct-29.1*# MCV-106*# MCH-36.4* MCHC-34.3 RDW-14.0 Plt Ct-171
2143-11-10 09:05PM BLOOD Neuts-90* Bands-0 Lymphs-4* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
2143-11-10 09:05PM BLOOD PT-23.9* PTT-39.2* INR(PT)-2.3*
2143-11-10 09:05PM BLOOD Glucose-89 UreaN-10 Creat-0.7 Na-137
K-3.3 Cl-92* HCO3-36* AnGap-12
2143-11-10 09:05PM BLOOD ALT-24 AST-194* CK(CPK)-65 AlkPhos-261*
TotBili-14.1* DirBili-9.7* IndBili-4.4
2143-11-10 09:05PM BLOOD Albumin-2.4* Calcium-7.5* Phos-1.6*
Mg-1.8 Iron-111
2143-11-10 09:05PM BLOOD TSH-0.72
2143-11-11 04:41AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
2143-11-11 04:41AM BLOOD AMA-NEGATIVE Smooth-POSITIVE *
2143-11-11 04:41AM BLOOD Dr. Edwards-POSITIVE * Titer-1:40
2143-11-10 09:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
2143-11-11 04:41AM BLOOD HCV Ab-NEGATIVE

discharge
expired

Brief Hospital Course:
54M with a history of remote MI, hip/shoulder surgery, liver
failure, hypertension, hyperlipidemia, depression, alcohol and
tobacco abuse who is transferred from Williams Medical Center Hospital with
fevers, leukocytosis and altered mental status, transferred to
the ICU for hypoxemic respiratory failure. He expired during
this admission.
.
#Hypoxemic Resp. failure- could have been due to mucous
plugging, pontine demylination. Regardless he was intubated and
successfully extubated on the 2144-10-1. He tolerated 40% face
mask and 4-5 L NC. He was re-intubated after transfer to the ICU
for respiratory distress again later in his course, believed to
be related to aspiration. He did not recover, family meeting was
held and he was made CMO, and expired.


Medications on Admission:
n/a

Discharge Medications:
expired

Discharge Disposition:
Expired

Discharge Diagnosis:
expired

Discharge Condition:
expired

Discharge Instructions:
expired

Followup Instructions:
expired

                             Initials (NamePattern4)  Pereira Sandra MD L41590496

"
"Admission Date:  2149-11-26              Discharge Date:   2149-11-27


Service: MEDICINE

Allergies:
Penicillins

Attending:Rita
Chief Complaint:
Sepsis

Major Surgical or Invasive Procedure:
ERCP/stent placement

History of Present Illness:
This is a Age over 90  year old female with hx recent PE/DVT, atrial
fibrillation, CAD who is transfered from  Allen Clinic Hospital
for ERCP. She has had multiple admissions to Allen Clinic this
past month, most recently on 2149-11-20. In early June, she
presented with back pain and shortness of breath. She was found
to have bilateral PE's and new afib and started on coumadin. Her
HCT dropped slightly, requiring blood transfusion, with guaic
positive stools. She was discharged and returned with abdominal
cramping and black stools. She was found to have a HCT drop from
32 to 21. She was given vit K, given a blood transfusion and
started on protonix. She received an IVF filter and EGD.  EGD
showed a small gastric and duodenal ulcer (healing), esophageal
stricture, no active bleeding.  She also had an abdominal CT
demonstrating a distended gallbladder with gallstones and
biliary obstruction with several CBD stones. She was started on
Levo/Flagyl and transfered here for ERCP. Per nursing, her BP
had been low in 90's at OSH and 80's enroute.

In the ERCP suite, she received vancomycin, Ampicillin and
Gentamicin as well as Fentanyl. A biliary stent was placed
successfully in the upper third of the common bile duct. No
sphincterotomy was done given elevated INR. In addition, a
single cratered non-bleeding 20mm ulcer was found in the antrum.


Past Medical History:
Recent PE/DVT
Afib
HTn
Hypotension
Hypothyroidism
CAD
? mild CHF

Social History:
lives with daughter and granddaughter, functional at home ,
non-smoker, no alcohol use

Family History:
NC

Physical Exam:
GEN: ill appearing, pale, awake but minimally responsive,
well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: mildly tender abd diffusely w/o rebound or guarding, ND,
hypoactive bowelsounds, diff to assess HSM, a soft large
masses/protuberance in RLQ
EXT: midly swollen left lower ext, no palpable cords
NEURO: awake, answering some basic questions but not conversant,
unable to assess orientation
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses

Pertinent Results:
Admission Labs:
2149-11-26 03:15PM   WBC-11.4* RBC-3.61* HGB-11.3* HCT-32.8*
MCV-91 MCH-31.3 MCHC-34.5 RDW-17.9*
2149-11-26 03:15PM   NEUTS-76* BANDS-13* LYMPHS-6* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
2149-11-26 03:15PM   HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL
POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL
BURR-OCCASIONAL
2149-11-26 03:15PM   PLT SMR-NORMAL PLT COUNT-166
2149-11-26 03:15PM   PT-25.8* PTT-39.2* INR(PT)-2.5*
2149-11-26 06:12PM   ALT(SGPT)-56* AST(SGOT)-68* LD(LDH)-357* ALK
PHOS-100 TOT BILI-1.3
2149-11-26 06:12PM   GLUCOSE-128* UREA N-85* CREAT-2.8* SODIUM-139
POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-16* ANION GAP-17

Other important labs:
2149-11-27 03:35AM BLOOD WBC-14.8* RBC-3.15* Hgb-10.0* Hct-28.9*
MCV-92 MCH-31.9 MCHC-34.8 RDW-17.8* Plt Ct-162
2149-11-27 03:35AM BLOOD Glucose-81 UreaN-85* Creat-3.0* Na-138
K-4.4 Cl-107 HCO3-15* AnGap-20
2149-11-27 03:35AM BLOOD ALT-50* AST-63* AlkPhos-87
2149-11-27 03:35AM BLOOD Calcium-7.5* Phos-4.8* Mg-1.8
2149-11-27 10:14AM BLOOD Type-ART Temp-36.7 O2 Flow-4 pO2-101
pCO2-13* pH-7.20* calTCO2-5* Base XS--20 Intubat-NOT INTUBA
2149-11-27 10:14AM BLOOD Lactate-10.5*

KUB: Supine film shows gas-filled loops of large and small bowel
with gas in the region of the rectum. The appearances are
inconsistent with obstruction and do not suggest ileus

CXR: no failure

RUQ ultrasound: report pending at time of death

Brief Hospital Course:
Septic from the time of transfer from the OSH for ERCP. Required
blood pressure support with levophed, which was changed to
neosynephrine due to elevated HR.  Difficult to volume
resuscitate given developement of crackles/increasing O2
requirement with fluid.  Treated with vanc/cipro/flagyl and
changed to meropenem/vanc. Had stent done by ERCP, but
sphincterotomy/stone removal not done due to elevated INR.  Most
likely source of sepsis is biliary/ascending cholangitis.
Evaluated by General surgery team, who thought she was not a
surgical candidate and would not recommend IR cholecystostomy
tube. Lactate rose to 10.5, last ABG 7.2/13/101.  The patient
complained of significant pain, difficult to control with bolus
morphine.  Bedside ultrasound was being done to evaluate for
cholecystitis when the family decided to make the patient CMO
and the study was stopped. Preliminary report not available at
the time of death.  The patient was made CMO by her family and
expired comfortably on a morphine gtt at 16:20 on 2149-11-27.
Medical examiner declined the case, family declined autopsy.

Medications on Admission:
ASA 325mg
Lopressor 25mg Patrick Clinic
Amiodarone 200mg Patrick Clinic
Coumadin 2.5mg daily
Isosorbide 60mg daily
Levothyroixine 50mcg daily

Discharge Medications:
expired

Discharge Disposition:
Expired

Discharge Diagnosis:
Septic shock due to ascending cholangitis
Choledocholithiasis
Atrial fibrillation with rapid ventricular response
Pulmonary emboli
Deep venous thrombosis
Upper GI bleed
Peptic ulcer disease

Discharge Condition:
expired

Discharge Instructions:
expired

Followup Instructions:
expired


"
"Admission Date:  2182-2-23              Discharge Date:   2182-2-28


Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:Drew
Chief Complaint:
Abdominal pain

Major Surgical or Invasive Procedure:
ERCP 2182-2-24

History of Present Illness:
This patient is a 84 year old woman who initially presented to
Jamison Medical Center hospital with 3 day history of abdominal pain. She was
found to have gallstone pancreatitis and received Levo/flagyl.
She was subsequently transferred to the Ruiz Memorial Hospital. She has had known
gallstones for the last 30-40 year without symptoms.
.
At Ruiz Memorial Hospital, the patient reported epigastric pain radiating to
back, nausea, vomiting, chills but no fever. She denied chest
pain and shortness of breath. She denied jaundice. She had one
bowel movement on the day prior to presentation.

Past Medical History:
PMH:  CAD/MI, HTN, h/o gallstones (no prior symptoms), ""blood
poisoning"" resulting in trach, breast cancer
PSH:  CABGx4 '67, appy, hysterectomy, trach, lumpectomy/XRT, B/L
cataracts

Social History:
Quit tobacco 30 years ago
Rarely drinks EtOH

Physical Exam:
102.2 76 97/34 22 93% 3l
NAD, alert and oriented x 3
neck supple
CTAB
RRR
abdomen mildly distended, tender to percussion/palpation in
epigastrium, +Dr. Reynolds with guarding
rectal tone normal, negative guiac at French
Foley with clear urine
RLE edema (chronic)

Pertinent Results:
ERCP 2182-2-24: Dilated CBD and PD, Multiple CBD stones and
biliary pus, Biliary sphincterotomy, Stone extraction, CBD stent

2182-2-23 10:50PM   WBC-9.0 RBC-3.35* HGB-10.6* HCT-30.0* MCV-90
MCH-31.7 MCHC-35.3* RDW-13.7
2182-2-23 10:50PM   PLT COUNT-159
2182-2-23 10:50PM   NEUTS-90.8* BANDS-0 LYMPHS-6.1* MONOS-2.8
EOS-0.2 BASOS-0.1
2182-2-23 10:50PM   GLUCOSE-140* UREA N-25* CREAT-1.1 SODIUM-137
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-21* ANION GAP-13
2182-2-23 10:50PM   ALBUMIN-3.1* CALCIUM-8.1* PHOSPHATE-2.0*
MAGNESIUM-1.6

2182-2-23 10:50PM   ALT(SGPT)-568* AST(SGOT)-537* CK(CPK)-66 ALK
PHOS-581* AMYLASE-553* TOT BILI-2.9*

Brief Hospital Course:
This patient was admitted to the SICU with cholangitis,
pancreatitis and cholecystitis. In the ED, the patient
experienced respiratory distress and was intubated. ERCP was
perfomed at the bedside at which time the findings included:
Dilated CBD and PD, Multiple CBD stones and biliary pus, Biliary
sphincterotomy, Stone extraction, CBD stent. In the unit, the
patient was started on Zosyn, and was supported briefly with
Levophed. On hospital day #2, the patient was successfully
extubated. On hospital day #3, she was transferred to the floor.
Her antibiotics were changed from IV Zosyn to PO
Levaquin/Flagyl. Her diet was advanced gradually which she
tolerated well. On hospital day #5 she was cleared by physical
therapy for discharge to home with services. She was discharged
in stable condition on hospital day #6. She will continue PO
Levaquin/Flagyl for 4 days at home and will follow up with Dr.
Bird in 12-31 weeks for cholecystectomy.


Medications on Admission:
Sherwood:  toprol XL 25QD; ASA 325QD; enalapril 10QD; lipitor 5QD;
fluoxetine prn; xanax 0.5prn; MVI; slo niacin 500QD

Discharge Medications:
1. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Cholangitis
Pancreatitis
Cholecystitis

Discharge Condition:
Stable, tolerating po

Discharge Instructions:
worsening abdominal pain, signs of jaundice or any other
worrisome symptoms.

Please follow-up as directed.

Please resume all medications as taken prior to this
hospitalization. In addition, you should take the antibiotics
and iron tablets as prescribed.

Maintain a low fat diet. For additional nutritional support we
recomment nutritional supplements such as Boost, Ensure, or
Resource at breakfast, lunch, and dinner.

Continue antibiotics.


Followup Instructions:
Provider: Roszel. Kenneth Initial (NamePattern1)  Roszel Phone:942-852-2246
Date/Time:2182-4-11 9:30
Provider: William SUITE GI ROOMS Date/Time:2182-4-11 9:30

Follow-up with Dr. Bird in 12-31 weeks.  Call her office at
484-466-8077 to schedule your appointment.



"
"Admission Date:  2115-5-30     Discharge Date:  2115-6-4

Date of Birth:   2061-3-22     Sex:  F

Service:

ADMISSION DIAGNOSIS:  Breast cancer.

DISCHARGE DIAGNOSES:
1. Breast cancer.
2. Status post Cranford on the right, mastectomy.

HISTORY OF PRESENT ILLNESS:  The patient is a 54-year-old
woman who had a recent diagnosis of right breast cancer.
Core biopsy returned as invasive carcinoma.  The patient had
a lumpectomy and sentinel node biopsy which were negative but
with positive margins.  Patient went back for re-excision and
again had positive margins.  The patient is now consulted for
a right mastectomy with Cranford, free flap reconstruction.  The
patient understands all surgical alternatives, and has agreed
to this decision.

PAST MEDICAL HISTORY:
1. Mitral valve prolapse.
2. Status post C section.
3. Status post right breast biopsy.
4. Status post right lumpectomy with sentinel node.

ALLERGIES:  Penicillin and sulfa.

MEDICATIONS:
1. Vitamins.
2. Calcium.
3. Antioxidant.

PHYSICAL EXAMINATION ON ADMISSION:  Vital signs stable,
afebrile.  General:  Is in no acute distress.  Chest was
clear to auscultation bilaterally.  Cardiovascular is
regular, rate, and rhythm without murmurs, rubs, or gallops.
Abdomen is soft, nontender, nondistended with no masses or
organomegaly.  Extremities are warm, noncyanotic,
nonedematous x4.  Neurologic is grossly intact.

HOSPITAL COURSE:  The patient was admitted for semielective
mastectomy with Cranford on the right reconstruction.  The
patient was taken to the operating room on 2115-5-30, and had
the procedure performed as outlined above.  The patient
tolerated the procedure well without complication in the
postoperative course, she was immediately placed in the
Intensive Care Unit for close monitoring.  The patient had
flap checks per protocol q 30 minutes for the first 12 to 24
hours followed by q1 hour followed by q2 hour checks.  The
flap seemed to be doing well, and a Doppler probe was left
close to the venous outflow postoperatively.  Flap was seen
to be doing very well, and the patient was transferred to the
floor on postoperative day #3.  Subsequent to this, the
patient had an unremarkable hospital stay, and the Doppler
probe was removed on postoperative day #4, the patient
subsequently discharged to home.

DISCHARGE CONDITION:  Good.

DISPOSITION:  Home.

DIET:  Adlib.

MEDICATIONS:  Resume all home medications.
1. Magnesium hydroxide.
2. Milk of magnesia prn.
3. Percocet 5/325 1-24 q4-6h prn.
4. Colace 100 mg Malone Clinic.
5. Clindamycin 300 mg q6 x7 days.
6. Enteric coated aspirin 81 mg q day.

DISCHARGE INSTRUCTIONS:  The patient is to followup with Dr.
Diana in his clinic within one week.  No heavy lifting.
Patient should return if any problems with either incision
sites or any signs of cellulitis or infection.




                          Joanne Elizondo, M.D.  R87779244

Dictated By:George

MEDQUIST36

D:  2115-6-3  09:28
T:  2115-6-3  11:56
JOB#:  Job Number 49686
"
"Admission Date:  2115-2-9              Discharge Date:   2115-2-10

Date of Birth:  2075-6-15             Sex:   F

Service: MEDICINE

Allergies:
Shellfish

Attending:Wendy
Chief Complaint:
DKA

Major Surgical or Invasive Procedure:
None

History of Present Illness:
39 y/o female with T1DM who presents with weakness and was found
to be hyperglycemic. Pt reports that she had been feeling weak
over the past 1-2 days and did not take her insulin for two
days. Denies F/C. Denies CP or SOB. Denies urinary or bowel
symptoms. Does admit to N/V. Denies hematemesis, melena, or
hematochezia. Admits to mild URI symptoms over the past 2 days.


In the ED, vitals upon presentation were T 98.6 HR 123 BP 132/69
RR 19 99%RA. Laboratory testing revealed DKA and she was given a
bolus of 10 units of regular insulin and started on an insulin
gtt. She was also aggressively fluid resuscitated with IVF, a
total of 4L NS. Her FSBG improved to ~240 and she was started on
D51/2NS. Her symptoms improved dramaticallly. She was also given
potassium and zofran. CXR was WNL. She was admitted to the ICU
for further care.


Past Medical History:
Type I Diabetes Mellitus with mild retinopathy, las A1C 10%


Social History:
Former tobacco, quit 9 years ago. Rare EtOH. No IVDU, lives with
two children. ETOH socially. Works at Rubalcava Clinic as practive
manager.


Family History:
Grandmother had diabetes and leukemia.  Mother has benign breast
disease.  Son recently diagnosed with DM type I.

Physical Exam:
On Presentation:

VSS
GEN: NAD.
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear.
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline.
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2.
PULM: Lungs CTAB, no W/R/R.
ABD: Soft, NT, ND, +BS, no HSM, no masses.
EXT: No C/C/E, no palpable cords.
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses


Pertinent Results:
CXR: No acute process

Brief Hospital Course:
39 y/o female with T1DM who presents with weakness and was found
to be hyperglycemic and in DKA, resolved with insulin gtt,
fluids and electrolytes.  Discharged home in stable condition on
home insulin regimen.

# DKA - Unclear precipitant, patients with vague URI and
abdominal complaints though no diarrhea. Anion gap in 30's on
admission with kentones in urine. FAggressively fluid
recussitated with electrolyte repletion with subsequent closeure
of anion gap to 10. Initially treated with insulin gtt and
transitioned to home dose of Levemir 35 untis qday and home
sliding scale. Cultures negative

# Ppx:  Received heparin products.

# Code: full code


Medications on Admission:
Zocor 40 mg daily
Novalog Insulin
Levemir Insulin
Flonase PRN
Aspirin 81 mg daily (although probably only takes 1-2x a week
because she forgets to take it)


Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Insulin Detemir 100 unit/mL Solution Sig: Thirty Five (35)
units Subcutaneous once a day.
4. Insulin Aspart 100 unit/mL Solution Sig: One (1) unit
Subcutaneous four times a day: Please take per your sliding
scale.
5. Flonase 50 mcg/Actuation Spray, Suspension Sig: 1-2 puffs
Nasal twice a day as needed for shortness of breath or wheezing.



Discharge Disposition:
Home

Discharge Diagnosis:
Diabetic Ketoacidosis


Discharge Condition:
Stable, Afebrile


Discharge Instructions:
You were admitted to the hospital for your very high blood sugar
and diabetic ketoacidosis, it is likely you got this as you were
not able to take your insulin. Whilst in the hospital you were
started on diabetes medication and your blood sugars were
monitored carefully. Prior to discharge your labs showed your
diabetic ketoacidosis had resolved.

We made no changes to your insulin regimen, please take it as
prescribed. Please continue taking a diabetic diet.

Please call Miller Diabetes Centre at 216-684-4607 within the
next 2 weeks to set up an appointment to see a diabetes
specialist.

Please continue to check your blood sugar 4 times a day and take
your insulin as prescribed to you.

Followup Instructions:
Please call Miller Diabetes Centre at 546-756-3070 for an
appointment to see a diabetes specialist within the next two
weeks.

Provider: Sarah Phone:128-516-1705 Date/Time:2115-4-13 10:00



"
"Admission Date:  2183-4-21     Discharge Date:  2183-4-30

Date of Birth:   2122-4-9     Sex:  M

Service:  UROLOGY Dr. Mccormick

HISTORY OF PRESENT ILLNESS:  This is a 61 year old male with
left renal cell carcinoma admitted status post renal
embolization by Interventional Radiology, in anticipation for
a debulking left radical nephrectomy.  Approximately two
months prior to his presentation, the patient had a chest
x-ray obtained by primary care physician secondary to Jacqueline
progressive cough.  The chest x-ray revealed a pulmonary
nodule.  A chest CT scan was then obtained which revealed
multiple bilateral pulmonary nodules.  The needle-biopsy was
consistent with metastatic disease from renal cell carcinoma.
An abdominal CT scan revealed a 6 cm necrotic left renal
mass.

The patient denied hematuria or bony pain, fever or chills,
appetite changes or weight loss.  An MRI obtained on 4-10, revealed an 8.1 by 7.1 by 6 cm left renal mass.

PAST MEDICAL HISTORY:
1.  Left knee arthroscopy in 2165.

MEDICATIONS:
Ativan p.r.n.

ALLERGIES:   No known drug allergies.

PHYSICAL EXAMINATION:  Vital signs were temperature of 96.3
F.; heart rate 69; blood pressure 117/64; respiratory rate
16; O2 saturation 93% on room air.  Cor:  Regular rate and
rhythm.  Lungs are clear to auscultation.  Abdomen soft,
nontender, nondistended.  The patient had renal embolization
performed on the 25th.  On 4-22, the patient was brought
to the Operating Room where a left radical nephrectomy was
performed.  The mass/kidney was adherent to the pancreas but
was dissected free.  An intraoperative consultation was
obtained with Dr. Flint.

Postoperatively, the patient was on perioperative Ancef, NG
tube, Thundera-Metropolis drain, epidural, Foley catheter, PCA,
chest tube.  The patient was transferred to the Medical
Intensive Care Unit postoperatively for aggressive fluid
resuscitation.  On postoperative day one, the patient was
transferred to the Floor.  By postoperative day two, the
chest tube was removed.  A chest x-ray obtained after
removing the chest tube revealed no pneumothorax.

The patient continued to ambulate and await return of bowel
function.  On postoperative day five, the patient's epidural
and NG tube were removed.  A Physical Therapy consultation
was obtained at that time also.  On postoperative day six,
the patient's Foley catheter was removed.  On postoperative
day seven, a clear liquid diet was started as the patient
reported some flatus.  This was tolerated well with no nausea
or vomiting and therefore the diet was advanced to regular.
This was also tolerated well.  All of the patient's
medications were converted to oral form including oral pain
control.

On postoperative day eight, the Initials (NamePattern4) 228 Jackson-Metropolis drain
was noted to be minimal, approximately 20 cc per 24 hours.  Initials (NamePattern4) 
Jackson-Metropolis amylase was sent and the value was 110.
Therefore, the Thundera-Metropolis was removed.

LABORATORY DATA:  Upon discharge, sodium 139, potassium 3.9,
chloride 108, bicarbonate 28, BUN 7, creatinine 1.1, glucose
102.

CONDITION AT DISCHARGE:   Stable.

DISCHARGE MEDICATIONS:
1.  Percocet one to two tablets p.o. q. four to six hours
p.r.n. pain.
2.  Colace 100 mg p.o. twice a day.
3.  Ativan 1 mg p.o. q. six hours p.r.n.

DISCHARGE STATUS:  Home with home Physical Therapy.

DISCHARGE INSTRUCTIONS:
1.  The patient will follow-up with Dr. Hosey, in one to two
weeks.

DISCHARGE DIAGNOSES:
1.  Status post left radical nephrectomy.
2.  Metastatic renal cell carcinoma.



                          Margaret Castro, M.D.  L47035828

Dictated By:Vera

MEDQUIST36

D:  2183-4-30  13:35
T:  2183-4-30  14:01
JOB#:  Job Number 38115
"
"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:  2168-10-24       Discharge Date:  2168-11-3


Service:  CARDIOTHORACIC SURGERY

HISTORY OF PRESENT ILLNESS:  This is an 80-year-old physician
with three vessel disease, left ventricular dysfunction,
mitral regurgitation, admitted for unstable angina.  Similar
episode several months ago.  Thrombus in left anterior
descending, without evidence of plaque rupture.  Exercising
regularly without angina.  Last night, walked in cold wind,
gave the patient angina.  During the night, recurrent
episodes at rest, relieved by nitroglycerin.

PHYSICAL EXAMINATION:  Heart rate 60, blood pressure 140/80.
Neck:  Jugular venous pressure normal.  Lungs:  Clear to
auscultation.  Cardiovascular:  II/VI systolic murmur.
Extremities:  No edema.

LABORATORY DATA:  Troponin less than 0.3, CK 180, MB
negative.  Electrocardiogram showed stable, no acute changes.

HOSPITAL COURSE:  The patient was admitted on 2168-10-24 to the
Medrano Medical Center service, where the patient was continued on his aspirin,
beta blocker, ACE inhibitor, Lipitor and Plavix.  He was
brought to the cardiac catheterization laboratory on 2168-10-25,
where they found the LMCA with moderate calcification and
distal taper to the left anterior descending/RI/LCX of 70%,
the left anterior descending with an ostial 60% calcified
lesion, the origin of the D1 with a 50% lesion, left
circumflex with a non-dominant vessel ostial 80% with
mid-segment tubular 70% stenosis, and right coronary artery
with dominant vessel proximally.

Due to the extent of the patient's disease, it was decided
that he should proceed with coronary artery bypass graft.  On
2168-10-28, the patient was brought to the operating room, at
which time a four vessel coronary artery bypass graft was
performed.  The left internal mammary artery was brought to
the left anterior descending, saphenous vein graft to the
diagonal, saphenous vein graft to the obtuse marginal,
saphenous vein graft to the posterior descending artery.  The
patient tolerated the procedure well, and was brought to the
Cardiothoracic Intensive Care Unit.

Postoperatively, the patient continued to do well, and was
extubated without incident.  The patient maintained his
pulmonary artery pressure at 31/12, CVP of 9, coronary index
was maintained at 2.8, and on a milrinone drip at 0.2.

On postoperative day three, the patient was found to be
maintaining his blood pressure and heart rate without the use
of drips, and he was subsequently transferred to the Surgical
floor.  On postoperative day three in the late afternoon, the
patient converted to atrial fibrillation, at which time he
was started on amiodarone of 400 three times a day as well as
given 15 mg of intravenous Lopressor and 2 grams of
magnesium.  The patient remained in atrial fibrillation for
the next 48 hours, at which time it was decided to DC
cardiovert the patient.

On postoperative day six, the patient was brought to the EP
unit and was cardioverted using 200 joules.  The patient
converted to normal sinus rhythm and tolerated the procedure
well.  Amiodarone was subsequently continued.

On postoperative day seven, the patient converted back to
atrial fibrillation and it was believed at that time that the
patient should remain rate controlled, so the amiodarone was
decreased to 200 mg once daily and the patient was started on
his previous dose of atenolol 25 mg once daily.  The patient
was heparinized throughout his entire course of atrial
fibrillation and remained heparinized until his INR reached
greater than 2.0.

DISCHARGE STATUS:  Good

DISCHARGE DIAGNOSIS:  Status post coronary artery bypass
graft x 4 complicated by atrial fibrillation

DISCHARGE MEDICATIONS:
1.  Atenolol 25 mg by mouth once daily
2.  Amiodarone 200 mg by mouth once daily
3.  Warfarin 5 mg by mouth once daily
4.  Calcium carbonate 500 mg by mouth twice a day
5.  Aspirin 325 mg by mouth once daily
6.  Colace 100 mg by mouth twice a day
7.  Lasix 20 mg by mouth every 12 hours for one week
8.  K-Dur 20 mg by mouth every 12 hours for one week




                            Vanessa Schill, M.D.  I60652135

Dictated By:Nguyen
MEDQUIST36

D:  2168-11-2  21:06
T:  2168-11-3  00:00
JOB#:  Job Number 95629
"
"Name:  Julia, Latosha                    Unit No:  22958

Admission Date:  2106-2-15     Discharge Date: 2106-3-23

Date of Birth:   2024-2-4     Sex:  M

Service:

ADDENDUM:  This is an addendum starting 2106-2-15.

1.  CARDIOVASCULAR:  The patient admitted initially for
worsening congestive heart failure and was sent to the
Coronary Care Unit for diuresis with a Swan-Ganz catheter for
Thundera therapy.  The patient was aggressively diuresed to the
point of developing hypernatremia and dehydration with
worsening renal function.  Eventually, the patient was
discharged to the floor.

From a cardiovascular standpoint, the patient remained stable
for the rest of his stay; however, when the patient developed
a respiratory arrest in the hospital on 2106-2-23 the
patient subsequently became hypotensive requiring multiple
pressors.  Likely the patient had sepsis physiology.  A
Swan-Ganz catheter was reintroduced in the Coronary Care Unit
which showed the patient having elevated cardiac output and
decreased systemic vascular resistance consistent with septic
physiology.

The patient was started on broad spectrum antibiotics and was
put on multiple pressors including Levophed and pitressin.
However, after further discussion with the patient's
daughters, the patient was able to be made comfort measures
only and pressors were discontinued, and the patient remained
off pressors until expiration.

2.  PULMONARY:  Again, the patient was doing well until
hypoxic respiratory arrest on 2106-2-23 thought secondary
to an aspiration episode.  The patient also with large
bilateral pleural effusions.  The patient underwent bilateral
thoracentesis which revealed a transudative fluid secondary
to congestive heart failure or malnutrition with low oncotic
pressure.  The patient was initially intubated after his
respiratory arrest; however, again, after discussion with the
family, the patient had a terminal extubation and was then
able to maintain decent saturations with a nonrebreather and
finally face mask.  The patient was started on a morphine
drip for comfort.  Unfortunately, the patient eventually
developed a respiratory arrest and expired.

3.  INFECTIOUS DISEASE:  The patient initially treated for a
line sepsis with vancomycin.  However, again, after the
patient's hypoxic arrest on 2-23, the patient became
hypotensive; likely secondary to aspiration and multiorgan
system failure.  The patient was covered with broad spectrum
antibiotics.  No organisms were cultured.  Again, after
discussion with the patient's daughters, antibiotics were
withdrawn and the patient was made comfortable.

The patient expired on 2106-3-4.  Time of death at
7:07 p.m.  The patient had been on a morphine drip titrated
to comfort prior to expiration.  A family meeting was held
with both daughters who agreed to this treatment course.  One
daughter was present at the bedside at the time of
expiration.  Autopsy was offered but refused.




                          Sandy Joe, M.D.  U54613350

Dictated By:Jammie

MEDQUIST36

D:  2106-3-23  17:37
T:  2106-3-23  18:55
JOB#:  Job Number 17745
"