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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" | |
" | |
Initial CCC Note Date: 11/08/16 Signed by (ORTHOPEDIC SURGEON), MD, PHD on 11/11/16 at 3:32 pm Affiliation: HOSPITAL --------------- --------------- --------------- --------------- Active Medication list as of 11/08/16: Medications - Prescription FLUROSEMIDE – 20 mg daily TYLENOL – OTC as needed --------------- --------------- --------------- --------------- This is a first office visit to my clinic by Mr. Smith, a very pleasant 57-year-old male patient, who sustained in 1993, as the result of a ski accident, a pelvic fracture with vertical shear that has healed in about an inch vertical shortening. Nevertheless, Mr. Smith has had a remarkably active life. He exercises and has been managing very well over the last few years until recently when he has developed some groin type pain, very reminiscent of arthritic symptoms. Films obtained today confirmed that finding with some bone-on-bone contact and significant posttraumatic hip osteoarthritis. He actually has a remarkably good gait. He has overall good strength. He has pain along the groin. He has a little bit of anterior medial pain that may be muscular in nature and even though he has a leg length discrepancy, he walks a very normal gait on exam. His extremity appears to be sensory intact and well perfused. He reports the typical symptoms of pain on initiation of motion, winter pain and pain at end of the day. Mr. Smith's past medical history and intake sheet was reviewed. He has a past medical history that is not relevant to his musculoskeletal presentation and manages his pain with occasional Tylenol. We had a long and frank conversation with Mr. Smith. I have explained to him that given the nature of his hip he is at this point, based on the radiographic standpoint, certainly a candidate for hip arthroplasty. Though, he is 57 years old and I have explained to him that his if done at this age could potentially require revision before he is ready to become more hip sedentary at a later age. I explained to him that ultimately it is his choice, and it is not unreasonable to do a hip replacement at this point, but if he is comfortable and this condition is not severely affecting his lifestyle, he would benefit from waiting. We recommend that Mr. Smith have full length film taken to measure the leg length discrepancy and meet with an Orthotist to discuss a lift. Follow up with physical therapy for strength training is also recommended. Overall, we had a nice conversation, and we will keep in touch with Mr. Smith in the future. We spent half the time of this new 30-minute visit discussing and counseling regarding his findings, assessing his gait and counseling regarding the need for hip replacement. | |
" | |
"Admission Date: 2198-2-8 Discharge Date: 2198-2-20 | |
Date of Birth: 2122-5-23 Sex: F | |
Service: NEUROLOGY | |
Allergies: | |
No Known Allergies / Adverse Drug Reactions | |
Attending:Doris | |
Chief Complaint: | |
unresponsive | |
Major Surgical or Invasive Procedure: | |
none | |
History of Present Illness: | |
The pt is a 75 y/o woman who presents from Hall Clinic | |
as OSH transfer for ICH. Limited history obtained at this | |
moment. Jean family available. From Records she had pushed her | |
lifeline button for unknown reason. EMS arrived to find patient | |
with minimal responsiveness. Was taken to OSH where a CT head | |
was obtained and found to have a large Left side ICH at the | |
basal ganglia. She was transferred here for further care | |
intubated. Here she was found to be hypertensive to 245/124. A | |
repeat CT head was obtained which showed interval increase in | |
blood product with midline shift. Neurosurgery was first | |
consulted which they declined an intervention at this moment. | |
neurology was asked for | |
consultation and she was seen initially on propofol and | |
intubated. | |
Past Medical History: | |
COPD | |
PVD | |
Stents in external iliacs | |
Hypertension | |
Hx of Atrial Fibrillation | |
Current smoker | |
Social History: | |
Never married. Cares for adult son with mental health issues. | |
Smoker | |
Family History: | |
unknown | |
Physical Exam: | |
Vitals: T:98 BP:245/124 R: 16vent P:60 SaO2:100% | |
General: Intubated, Propofol held x 10 min. | |
CV: RRR. Positive murmur. no ventricle heave appreciated. | |
Pulm: Slight rhonchi, no crackles at frontal fields. | |
EXT: No edema | |
Abd: Soft. | |
Neurologic: Off Propofol for 10 min. eyes closed. Open eyes in | |
conjugate gaze (forward). pupils 2mm non reactive. no movement | |
to dolls. slight blink to corneal stimulation. Positive cough. | |
decerebrate posturing to upper extremity pain stimuli. triple | |
flexion at lower extremities. upgoing toes. tone increased in | |
all four extremities. | |
Pertinent Results: | |
Admission Labs | |
URINE | |
COLOR-Straw APPEAR-Clear SP Gagne-1.009 | |
BLOOD-MOD NITRITE-NEG PROTEIN-25 GLUCOSE-100 KETONE-NEG | |
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG | |
RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-<1 | |
cTropnT-<0.01 | |
2198-2-8 10:18PM PT-12.5 PTT-21.4* INR(PT)-1.1 | |
GLUCOSE-171* UREA N-19 CREAT-0.7 SODIUM-137 POTASSIUM-3.7 | |
CHLORIDE-102 TOTAL CO2-25 ANION GAP-14 | |
CALCIUM-9.0 PHOSPHATE-3.8 MAGNESIUM-2.2 | |
WBC-13.5* RBC-4.60 HGB-13.2 HCT-39.2 MCV-85 MCH-28.8 MCHC-33.8 | |
RDW-14.1 | |
PLT COUNT-243 | |
LACTATE-2.3* | |
TYPE-ART TEMP-36.7 PO2-541* PCO2-31* PH-7.48* TOTAL CO2-24 BASE | |
XS-1 | |
CT Head Admission | |
IMPRESSION: | |
1. Increase in 7.1 x 4.5 cm left basal ganglia hemorrhage, with | |
extension | |
into the left frontal and temporal lobes. | |
2. Increased intraventricular hemorrhage, with left lateral | |
ventricular | |
entrapment and developing hydrocephalus. | |
3. Increased midline shift to 5 mm. | |
4. Progressive rightward subfalcine herniation to 11 mm. | |
5. Early left uncal herniation. | |
Brief Hospital Course: | |
The pt is a 75 year-old woman with an unknown history is a | |
transfer from an OSH for further care regarding a large BG bleed | |
likely related to underlying Hypertension. | |
Neurosurgery was consulted on presentation but it was felt that | |
the pt had a devastating hemorrhage and an external ventricular | |
drainage and hemicranietomy were | |
not an option. She was managed medically with | |
antihypertensives,hypertonic saline and seizure prophylaxis with | |
dilantin. EEG showed Periodic Lateralized Epileptiform | |
Discharges and Keppra was initiated. She was stable for several | |
days but on 2-15 at midnight her left pupil was found blown. | |
Hypertonic saline and BP management was continued, Depakote | |
started out of concern for continued seizures. Sputum cultures | |
returned with moraxella and Levofloxacin was started on 2-17. | |
On 2-18, the right pupil was noted to be blown in am. 100g of | |
Mannitol given. She was made 'CPR not indicated' per ICU and | |
primary team criteria based on DNR policy. Serum sodium and osm | |
continue to trend up and urine output increased; likely due to | |
DI. | |
At noon on 2-20, the patient was noted to become asystolic. She | |
had abrief return of electrical activity without a pulse. | |
Before intervention could be made, the heart again went | |
asystolic and the patient was declared deceased at 12:10pm. | |
The patient's nephew and intended guardian, Blanche Octavia, | |
declined autospy. | |
Medications on Admission: | |
None | |
Discharge Medications: | |
Expired | |
Discharge Disposition: | |
Expired | |
Discharge Diagnosis: | |
Intracranial hemorrhage | |
Discharge Condition: | |
Expired | |
Discharge Instructions: | |
Expired | |
Followup Instructions: | |
Expired | |
Linda Elma MD N89064582 | |
Completed by:2198-2-20" | |
"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 | |
" | |
"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: 2198-7-16 Discharge Date: 2198-7-16 | |
Date of Birth: 2132-10-18 Sex: M | |
Service: MEDICINE | |
Allergies: | |
Patient recorded as having No Known Allergies to Drugs | |
Attending:Wren | |
Chief Complaint: | |
black stool | |
Major Surgical or Invasive Procedure: | |
Endoscopy | |
History of Present Illness: | |
65 yr old male with hx of crohn's disease who presents to ED | |
with one day of dizziness and black diarrhea. Pt states that on | |
the afternoon of admission, he acutely developed vertigo and | |
nausea and then had an episode of black diarrhea which was | |
associated with diaphoresis and near syncope. He notes that a BM | |
that morning was darker than normal. Pt denies previous hx of GI | |
bleed, no recent NSAID use. No fevers, chills, abd pain. | |
* | |
In the ED, NG lavage was positive for dark black liquid that did | |
not clear with 250cc of normal saline. Pt's HR was initially 112 | |
to decreased to 80s after fluid; he received a total of 3L in | |
the ED. GI service was consulted in ED and attempted EGD but due | |
to a large clot in the fundus that could not be mobilized; they | |
could not visualize the source of bleeding. He was admitted to | |
the MICU overnight for scope in the am. | |
Past Medical History: | |
1. Crohn's disease since age of 24; hx of ileo-cutaneous fistula | |
(flares 1-2x/yr) | |
2. hx of herniated disk | |
3. hx of hip arthritis | |
4. HTN | |
Social History: | |
occasional alcohol | |
previous tobacco hx, quit 16 yrs ago | |
Family History: | |
mother died of ovarian cancer | |
father died of pancreatic cancer | |
no hx of IBD | |
Physical Exam: | |
Exam: temp 98.8, BP 95/42, HR 101, R 12, O2 100%RA | |
Gen: NAD, AO x 3 | |
HEENT: PERRL, dry MM | |
CV: RRR, nl murmurs | |
Chest: clear | |
Abd: +BS, soft, NTND; guaic pos black stool | |
Ext: 1+ pedal edema | |
Pertinent Results: | |
initial HCT = 34.6, dropped to 28.7 then after 2 unit pRBCs and | |
3 L IVF returned to Hct 31.4. | |
Brief Hospital Course: | |
65 yr old male with hx of crohn's disease who presents with one | |
day of melena and dizziness | |
. | |
1. UGIB: Pt s/p EGD in ED showing nl esophagus, antrum and | |
duodenum but a large clot in the fundus that could not be | |
mobilized. Per GI recs, given erythromycin x 8hrs to break up | |
clot and rescoped in am showing erosions in the pre-pyloric | |
region and | |
Grade III esophagitis in the gastroesophageal junction. They | |
recommended no aspirin for 4 weeks. Protonix 40 mg before | |
breakfast and dinner for one month and then Protonix 40 mg | |
before breakfast long term. Patient was discharged on day #2 | |
with stable hemodynamics and rising hematocrit. | |
. | |
2. Crohn's disease: stable; continued mercaptopurine outpt dose. | |
. | |
3. HTN: held felodipine in setting of GI bleed. | |
Medications on Admission: | |
1. Mercaptopurine 50mg qd x 6yrs | |
2. ASA 81mg qd | |
3. Felodipine 10mg qd | |
Discharge Medications: | |
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: | |
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). | |
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* | |
2. take all medications as prior to hospitalization. | |
Discharge Disposition: | |
Home | |
Discharge Diagnosis: | |
Upper GI Bleed | |
Erosions | |
Discharge Condition: | |
stable | |
Discharge Instructions: | |
Do not take aspirin for at least 4 weeks. Please talk with your | |
gastroenterologist before restarting your aspirin. | |
Take protonix 40 mg po before breakfast and dinner daily. | |
Followup Instructions: | |
Follow up with your gastroenterologist within the next week in | |
King's Landing. Please have your hematocrit checked. | |
Initials (NamePattern4) Ramon Mary MD S16118943 | |
" | |
"Name: Ava,Jerome Unit No: 48768 | |
Admission Date: 2181-7-6 Discharge Date: 2181-7-10 | |
Date of Birth: 2132-1-24 Sex: M | |
Service: MEDICINE | |
Allergies: | |
Patient recorded as having No Known Allergies to Drugs | |
Attending:Marjorie | |
Addendum: | |
Please see attached pertinent results | |
Pertinent Results: | |
ADMISSION LABS: | |
2181-7-6 11:00AM BLOOD WBC-2.5* RBC-3.04* Hgb-10.9* Hct-32.2* | |
MCV-106* MCH-35.9* MCHC-34.0 RDW-16.1* Plt Ct-38* | |
2181-7-6 11:00AM BLOOD Neuts-53 Bands-1 Lymphs-16* Monos-27* | |
Eos-2 Baso-0 Atyps-1* Metas-0 Myelos-0 | |
2181-7-6 11:00AM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL | |
Poiklo-1+ Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL | |
Target-1+ | |
2181-7-6 11:00AM BLOOD Plt Smr-VERY LOW Plt Ct-38* LPlt-1+ | |
2181-7-6 11:00AM BLOOD PT-14.5* PTT-27.5 INR(PT)-1.3* | |
2181-7-6 11:00AM BLOOD Glucose-130* UreaN-6 Creat-0.6 Na-141 | |
K-4.5 Cl-105 HCO3-25 AnGap-16 | |
2181-7-6 11:00AM BLOOD CK(CPK)-3133* | |
2181-7-6 05:30PM BLOOD ALT-125* AST-504* LD(LDH)-572* | |
CK(CPK)-2943* AlkPhos-223* TotBili-2.9* | |
2181-7-6 11:00AM BLOOD CK-MB-37* MB Indx-1.2 cTropnT-0.04* | |
2181-7-6 11:00AM BLOOD Ethanol-362* | |
CARDIAC Ballard: | |
2181-7-6 11:00AM BLOOD CK(CPK)-3133* | |
2181-7-6 05:30PM BLOOD CK(CPK)-2943* | |
2181-7-7 02:24AM BLOOD CK(CPK)-2628* | |
2181-7-9 04:05AM BLOOD CK(CPK)-1122* | |
2181-7-10 06:05AM BLOOD CK(CPK)-668* | |
2181-7-6 11:00AM BLOOD CK-MB-37* MB Indx-1.2 cTropnT-0.04* | |
2181-7-6 05:30PM BLOOD CK-MB-39* MB Indx-1.3 cTropnT-0.04* | |
2181-7-7 02:24AM BLOOD CK-MB-30* MB Indx-1.1 cTropnT-0.04* | |
HCT TREND: | |
2181-7-6 11:00AM BLOOD Hct-32.2* | |
2181-7-6 09:30PM BLOOD Hct-28.5* | |
2181-7-7 02:24AM BLOOD Hct-27.4* | |
2181-7-7 09:28AM BLOOD Hct-32.1* | |
2181-7-7 03:18PM BLOOD Hct-31.6* | |
2181-7-7 09:15PM BLOOD Hct-32.4* | |
2181-7-8 04:00AM BLOOD Hct-33.0* | |
2181-7-8 11:53AM BLOOD Hct-32.8* | |
2181-7-8 05:15PM BLOOD Hct-34.8* | |
2181-7-9 04:05AM BLOOD Hct-33.4* | |
2181-7-9 12:10PM BLOOD Hct-34.6* | |
2181-7-10 06:05AM BLOOD Hct-33.3* | |
PLT CT: | |
2181-7-6 11:00AM BLOOD Plt Smr-VERY LOW Plt Ct-38* LPlt-1+ | |
2181-7-7 02:24AM BLOOD Plt Smr-VERY LOW Plt Ct-26* | |
2181-7-8 04:00AM BLOOD Plt Ct-56*# | |
2181-7-9 04:05AM BLOOD Plt Ct-50* | |
2181-7-10 06:05AM BLOOD Plt Ct-51* | |
IMAGING: | |
2181-7-6 R shoulder x-ray: There is no fracture or dislocation. | |
Joint | |
spaces are normal. There is no degenerative change. Soft tissues | |
appear | |
normal. | |
2181-7-6 CXR: Cardiomegaly and new mild pulmonary venous | |
congestion. No | |
consolidation, mass, or pneumothorax. | |
2181-7-7 KUB: Supine and decubitus film demonstrated normal bowel | |
gas pattern without air-fluid levels. There is no evidence for | |
obstruction and no free air is identified. | |
2181-7-7 Upper endoscopy: Noel Landis tear | |
2181-7-7 Liver U/S with dopplers: 1. Diffusely echogenic liver | |
compatible with patient's known history of cirrhosis. | |
Recannulization of the umbilical vein and splenomegaly that is | |
also compatible with known cirrhosis. 2. Extremely limited | |
Doppler examination secondary to poor penetration. The main | |
portal vein is patent with appropriate direction of flow. | |
Limited assessment of the right portal vein, the hepatic veins, | |
and the right and left hepatic arteries. The main hepatic artery | |
is patent with appropriate arterial waveforms. | |
2181-7-10 CT head: No evidence of acute intracranial hemorrhage | |
DISCHARGE LABS (2181-7-10): | |
2181-7-10 06:05AM BLOOD WBC-4.1 RBC-3.23* Hgb-11.7* Hct-33.3* | |
MCV-103* MCH-36.2* MCHC-35.1* RDW-17.8* Plt Ct-51* | |
2181-7-10 06:05AM BLOOD Glucose-96 UreaN-5* Creat-0.7 Na-135 | |
K-3.2* Cl-101 HCO3-27 AnGap-10 | |
2181-7-10 06:05AM BLOOD CK(CPK)-668* TotBili-5.1* | |
2181-7-10 06:05AM BLOOD Calcium-8.4 Phos-2.5* Mg-1.7 | |
Discharge Disposition: | |
Home | |
Barbara Carver MD A91367927 | |
Completed by:2181-7-15" | |
"Name: William, Joshua Unit No: 82021 | |
Admission Date: 2125-7-3 Discharge Date: 2125-7-8 | |
Date of Birth: 2044-5-5 Sex: M | |
Service: | |
ADDENDUM: | |
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM | |
(CONTINUED): | |
4. CORONARY ARTERY DISEASE ISSUES: The patient was switched | |
from his home atenolol to metoprolol while in house. His | |
Isordil was held, and he was continued on his home dose of | |
Pravachol. | |
His cardiac enzymes were cycled on admission and remained | |
negative. A repeat cycling of enzymes was done following an | |
episode of pulmonary edema. His troponin T peaked at 0.1, | |
but creatine kinase and CK/MB levels remained negative. | |
The patient was ultimately discharged on metoprolol 50 mg by | |
mouth twice per day in addition to lisinopril 10 mg by mouth | |
once per day. | |
5. STATUS POST FEMORAL-POPLITEAL BYPASS ISSUES: For this | |
history, the patient received perioperative ampicillin prior | |
to undergoing esophagogastroduodenoscopy. | |
6. ATRIAL FIBRILLATION ISSUES: The patient's | |
anticoagulation was reversed with fresh frozen plasma and | |
vitamin K. Plan for continuation off of anticoagulation for | |
the several weeks considering the severity of his | |
gastrointestinal bleed. | |
CONDITION AT DISCHARGE: Ambulating independently. His | |
hematocrit remained stable overnight with a discharge | |
hematocrit of 36.8. | |
DISCHARGE STATUS: The patient was discharged to home. | |
DISCHARGE DIAGNOSES: | |
1. Gastrointestinal bleed. | |
2. Atrial fibrillation. | |
3. Anemia secondary to blood loss. | |
4. Congestive heart failure. | |
5. Coagulopathy secondary to anticoagulation with Coumadin. | |
MEDICATIONS ON DISCHARGE: | |
1. Pravastatin 40 mg by mouth at hour of sleep. | |
2. Timolol 0.25% drops one drop each eye twice per day. | |
3. Metoprolol 50 mg by mouth twice per day. | |
4. Protonix 40 mg by mouth once per day. | |
5. Lisinopril 10 mg by mouth once per day. | |
DISCHARGE INSTRUCTIONS/FOLLOWUP: | |
1. The patient was instructed to contact his primary care | |
physician to schedule followup within one to two weeks. | |
2. The patient was informed that it was imperative to follow | |
up with his primary care physician to Charles his | |
anticoagulation. | |
Joseph Nelson, M.D. | |
I38071681 | |
Dictated By:Elmer | |
MEDQUIST36 | |
D: 2125-10-3 17:05 | |
T: 2125-10-4 07:13 | |
JOB#: Job Number 18338 | |
" | |
"Admission Date: 2195-4-21 Discharge Date: 2195-4-26 | |
Date of Birth: 2146-10-25 Sex: M | |
Service: | |
HISTORY OF PRESENT ILLNESS: The patient is a 48 year old | |
gentleman who began having exertional chest pressure in | |
May. He underwent cardiac catheterization on 4-21///02, | |
and was found to have severe left main disease with 95% | |
stenosis. The dominant right coronary artery had mild | |
proximal disease and a discrete 70% stenosis before the | |
bifurcation of the right posterior descending artery. His | |
ejection fraction was 60%. Intra-aortic balloon pump was | |
placed. The patient was referred to the Cardiac Surgery | |
Service on 2195-4-21, for an emergency coronary artery bypass | |
graft. | |
PAST MEDICAL HISTORY: | |
1. Gastroesophageal reflux disease. | |
2. Headaches. | |
3. Back pain. | |
4. Obesity. | |
5. Sleep apnea, uses CPAP at night. | |
6. Hypercholesterolemia. | |
7. Status post appendectomy. | |
8. Status post tonsillectomy and adenoidectomy. | |
9. Status post right elbow surgery times four. | |
10. Status post right knee arthroscopy. | |
11. Status post sinus surgery. | |
ALLERGIES: No known drug allergies. | |
HOSPITAL COURSE: The patient was taken to the operating room | |
on 2195-4-21, and underwent coronary artery bypass graft times | |
four with left internal mammary artery to the left anterior | |
descending, saphenous vein graft to the posterior descending | |
artery, saphenous vein graft to OM2 to the OM1. The patient | |
tolerated the surgery without complication and was | |
transferred to the CSRU. The patient was extubated overnight | |
and his balloon pump was weaned and discontinued on | |
postoperative day number one. | |
He continued to do well and was transferred to the floor on | |
postoperative day number two. In the CSRU, he was maintained | |
on insulin drip which was discontinued upon arrival to the | |
floor, and the patient was then covered with subcutaneous | |
regular insulin. The patient was not requiring insulin prior | |
to this hospitalization and Martin consultation was obtained. | |
The patient was started on Metformin 500 mg p.o. b.i.d. and | |
Glucotrol XL 5 mg p.o. q.d. Margaret Martin consultation. | |
The patient continued to improve and had no complications. | |
He is being discharged to home on postoperative day number | |
four. On discharge, he is afebrile. Vital signs are stable. | |
His oxygen saturation is 94% in room air. His heart rate is | |
in the low 80s. His blood sugar has ranged from 180 to 50. | |
On examination, his heart is regular. His sternum is stable. | |
The wounds are clean, dry and intact. His lungs are clear to | |
auscultation bilaterally. His abdomen is soft, nontender, | |
nondistended. His extremities are warm. | |
Laboratory data on discharge revealed white count 4.8, | |
hematocrit 27.5, and his platelets are 143,000. His blood | |
urea nitrogen is 12 and creatinine is 0.7. His potassium is | |
4.3. | |
MEDICATIONS ON DISCHARGE: | |
1. Lasix 20 mg p.o. b.i.d. times fourteen days. | |
2. Potassium Chloride 20 meq p.o. b.i.d. times fourteen | |
days. | |
3. Colace 100 mg p.o. b.i.d. | |
4. Enteric Coated Aspirin 325 mg p.o. q.d. | |
5. Prilosec 40 mg p.o. q.d. | |
6. Lipitor 20 mg p.o. q.d. | |
7. Paxil 60 mg p.o. q.h.s. | |
8. Nortriptyline 50 mg p.o. q.h.s. | |
9. Lopressor 75 mg p.o. b.i.d. | |
10. Metformin 500 mg p.o. b.i.d. | |
11. Percocet one to two tablets p.o. q4-6hours p.r.n. pain. | |
12. Glucotrol XL 5 mg p.o. q.d. | |
13. Niferex 150 mg p.o. q.d. | |
14. Multivitamin. | |
The patient is being discharged to home in good condition. | |
He is to follow-up with Dr. Margaret Leggett, Dr. Margaret | |
Leggett and Dr. Margaret Leggett in two weeks. He will | |
follow-up with Dr. Morgan in six weeks. | |
Peggy Mackey, M.D. I14414089 | |
Dictated By:Johnson | |
MEDQUIST36 | |
D: 2195-4-26 11:17 | |
T: 2195-4-26 11:35 | |
JOB#: Job Number 102917 | |
" | |
"Admission Date: 2143-3-2 Discharge Date: 2143-3-5 | |
Date of Birth: 2069-1-30 Sex: F | |
Service: SURGERY | |
Allergies: | |
No Known Allergies / Adverse Drug Reactions | |
Attending:Isabel | |
Chief Complaint: | |
Abdominal pain | |
Major Surgical or Invasive Procedure: | |
none | |
History of Present Illness: | |
74 yoF with vascular dementia and history of cadaveric | |
kidney transplant at Cannon Memorial Hospital ten years ago, comes form Rolfes Medical Center center where she had been complaining of persistent non | |
productive cough and dysuria for one week. This morning she | |
complained of worsening LLQ abdominal pain. She was brought to | |
ED where a CT scan of her abdomen revealed a large 6.6 (TRV) x | |
4.5 (AP) x 21.6 (CC) cm rectus sheath hematoma. | |
She is pleasantly demented, and complains only of some mild Left | |
sided abdominal pain. Her daughter, who is with her, reports | |
that she has been experiencing a peristent non productive cough | |
and dysuria. | |
ROS: she denies any chest pain, SOB, headache, vision changes, | |
musculoskeletal pain, nausea, vomiting or diarrhea. | |
Past Medical History: | |
history of DVT bilateral legs 2131 - told by PCP she CANNOT go | |
off | |
anticoagulation. Anxiety, frequent UTI, hypercholesterolemia, | |
CRF s/p CRT in 2132(?), HTN, vascular dementia. | |
PSgH: CRTx in 2132 at Cannon Memorial Hospital. | |
Social History: | |
Lives at Lakeview Alzheimer Unit (Olympus) | |
Physical Exam: | |
AAO x 1, pleasantly demented | |
RRR no MRG appreciated on auscultation | |
CTA B/L no RRW | |
Soft, minimally tender in Left side, palpable mass c/w rectus | |
sheath hemoatoma on left side, scars c/w prior surgery as above. | |
+ edema B/L | |
Brief Hospital Course: | |
74 yo F h/o Vascular Dementia, Renal transplant, DVTs on | |
coumadin admitted with recuts sheath hematoma on | |
supratherapeutic Coumadin. She was admitted and started on | |
Vitamin K and give FFP given in ED. Coumadin was held. FFP 4 | |
units and a total of 3 units of PRBC and 2 units of platelets | |
were administered. Serial HCT checks and coags were done until | |
stable. Serial abdominal exams were done noting increased | |
bruising along left flank and abdomen. Discomfort abated. | |
Bruising stopped. Vital signs remained stable. She did not | |
requird embolizaton. | |
Initially, she was kept NPO, but once stable, diet was resumed | |
and tolerated. PT was consulted and noted that patient was at | |
baseline. Recommendations were to return to chronic placement at | |
alzheimer unit at Lakeview in Olympus. | |
The decision was made to stop the coumadin given hematoma and | |
h/o falls. Information communicated to Dr.Don (PCP)nurse | |
(147-240-3018). She was discharged in stable condition back to | |
Lakeview off Coumadin. | |
Medications on Admission: | |
Garroutte: ativan 0.5 q6 PRN, tylenol, benzonatate 100 TID prn cough, | |
robitussin prn cough, namenda 10 q am and 5 q pm, pravastatin 40 | |
qhs, prednisone 10 q am, citalopram 10 q am, lisinopril 20 q am, | |
mycophenolate 1500 Vick Medical Center, donepezil 10 q am, CaCO3 600 Vick Medical Center, MVI, | |
Coumadin 2.5 M,F and 3.5 T,W,Th,Sa,Dr. Staples. | |
ALL: nkda | |
Discharge Medications: | |
1. Discontinued Meds | |
Coumadin | |
2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). | |
3. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). | |
4. memantine 5 mg Tablet Sig: Two (2) Tablet PO q am (). | |
5. memantine 5 mg Tablet Sig: One (1) Tablet PO q pm (). | |
6. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY | |
(Daily). | |
7. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). | |
8. mycophenolate mofetil 500 mg Tablet Sig: Three (3) Tablet PO | |
BID (2 times a day). | |
9. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). | |
Discharge Disposition: | |
Extended Care | |
Facility: | |
Lakeview | |
Discharge Diagnosis: | |
Left rectus sheath hematoma | |
supra therapeutic inr | |
h/o dvts | |
h/o renal transplant | |
Discharge Condition: | |
Mental Status: Confused - sometimes. | |
Level of Consciousness: Alert and interactive. | |
Activity Status: Ambulatory - requires assistance or aid (walker | |
or cane). | |
See PT notes | |
Discharge Instructions: | |
You will transfer back to Lakeview in Olympus with | |
Smalltown VNA | |
Followup Instructions: | |
follow up with Dr. Vahle in 1 week | |
Completed by:2143-3-5" | |