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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"