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"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 | |
" | |