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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: 2181-6-24 Discharge Date: 2184-7-26 | |
Date of Birth: 2125-9-30 Sex: M | |
Service: Parker | |
HISTORY OF PRESENT ILLNESS: This is a 55-year-old gentleman | |
status post pancreas and kidney in 2164 that was resected in | |
2172 and cadaveric renal transplant in 12/99, who had a | |
Hartmann pouch, transverse colostomy for diverticulitis in | |
1-31, who now presents for preoperative evaluation and bowel | |
prep for colostomy takedown tomorrow by Dr. Juan. No | |
fevers or chills. No shortness of breath, no abdominal pain. | |
No other problems with ostomy. | |
PAST MEDICAL HISTORY: Diabetes type 1, coronary artery | |
disease, status post MI, status post PTCA, multiple coronary | |
artery stents, congestive heart failure with an ejection | |
fraction of 50 to 55 percent, cardiomyopathy, hepatitis B | |
virus, hepatitis C virus, hypothyroidism, | |
hypercholesterolemia, benign prostatic hypertrophy, | |
peripheral vascular disease, cerebrovascular accident in 2174 | |
with residual left-sided weakness. | |
PAST SURGICAL HISTORY: Status post simultaneous pancreas and | |
kidney and cadaveric renal transplant as above, status post | |
left femoropopliteal bypass; status post left toe amputations | |
1 and 2, status post multiple digit amputations, left 2, 3, | |
and 4 and right 5; status post transurethral resection of | |
prostate, status post left olecranon open reduction and | |
fixation, status post open cholecystectomy, and status post | |
Hartmann pouch. | |
ALLERGIES: CODEINE AND GENTAMICIN. | |
OUTPATIENT MEDICATIONS: | |
1. Isosorbide 30 mg p.o. q.d. | |
2. Prednisone 5 mg p.o. q.d. | |
3. Protonix 40 mg p.o. q.d. | |
4. Lasix 80 mg p.o. q.d. | |
5. Rapamune 1 mg p.o. q.d. | |
6. Toprol XL 25 mg p.o. q.d. | |
7. Phos-Lo. | |
8. Bactrim SS 1 tablet q.d. | |
9. Hydralazine 10 mg q.8 h. | |
10. Lantus 15 units and sliding scale insulin. | |
SOCIAL HISTORY: Lives with wife in Kathryn. No cigarettes, | |
no ETOH. | |
PHYSICAL EXAMINATION: On admission, his temperature was 97.8 | |
degrees, pulse of 60, BP of 150/70, respiratory rate of 18, | |
saturation 100 percent on room air. He was alert and | |
oriented x 3, in no apparent distress. Cardiovascular: | |
Regular rate and rhythm without murmurs. No JVD. Pulmonary: | |
Clear to auscultation bilaterally. Abdomen: Soft, positive | |
bowel sounds, the left lower quadrant ostomy was pink. | |
LABORATORY DATA: His hematocrit on admission was 38.9, white | |
count of 3.6, potassium 4.1; creatinine 2.0, baseline 1.5 to | |
1.8. | |
RADIOGRAPHIC STUDIES: Chest x-ray showed no infiltrates or | |
effusions. | |
HOSPITAL COURSE: Status post Hartmann take-down, the patient | |
was transferred to ICU because the patient required fluid | |
resuscitation and pressors, Levophed and vasopressin. The | |
patient did enjoy this slow but steady recovery over his | |
hospital stay, complicated by gram-negative rods in his urine | |
differentiated as Pseudomonas. The patient was started on | |
Zosyn. When tested these were specific, it was sensitive to | |
meropenem, and he was switched to meropenem. The patient | |
also grew out yeast from urine on 2181-7-21 and is currently | |
on fluconazole 200 mg q.d. because of its ability to | |
concentrate in the urine. | |
The Lee Medical Center hospital course also was complicated by a slow | |
healing surgical wound that measured approximately 12 x 4 x 2 | |
cm and it had multiple debridements and wet-to-dry dressings. | |
VAC dressings have been applied and will continue after | |
discharge. The patient also has received dialysis while an | |
inpatient. At times insulin management has been difficult. | |
He has received Lasix. When his creatinine peaked at 4.1, he | |
was transferred to the Westworld for nesiritide drip for a | |
short period of time, which did not seem to benefit him much, | |
so he was restarted on dialysis and brought back to the tenth | |
floor. | |
CONSULTATIONS: Consults include Parker who has helped manage | |
his diabetes, Renal with Dr. Guerra who helped manage his | |
renal failure, occupational therapy and physical therapy, Dr. | |
Jose from cardiology who helped with his nesiritide drip | |
and his history of arrhythmias with the management of | |
amiodarone, and his endocrinologist for the management of his | |
hypothyroidism. | |
Donna Cordoba, I44721328 | |
Dictated By:Haglund | |
MEDQUIST36 | |
D: 2181-7-27 08:58:53 | |
T: 2181-7-27 23:28:24 | |
Job#: Job Number | |
" | |
"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" | |