Update notes_small.csv

notes_small.csv

@@ -47,114 +47,8 @@ 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 
+"
+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