diff --git "a/notes_small.csv" "b/notes_small.csv" --- "a/notes_small.csv" +++ "b/notes_small.csv" @@ -1,2217 +1,1403 @@ PARSED -"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: 2107-11-13 Discharge Date: 2107-11-15 - -Date of Birth: 2078-9-5 Sex: M - -Service: EMERGENCY - -Allergies: -No Known Allergies / Adverse Drug Reactions - -Attending:Annetta -Chief Complaint: -DKA - -Major Surgical or Invasive Procedure: -None - -History of Present Illness: -Mr. Abel is a 29 year old man with h/o Type I DM, 10 prior -admissions for DKA since 1-4, who presents with SOB/chest -discomfort, found to be in DKA. - -The patient was at work today when he started feeling dyspnea on -exertion and substernal chest discomfort. CP worsened with deep -breaths. No difference with change in position. FS at that time -was 491, so the patient gave himself Humalog 7units. Repeat FS -369. He drove himself to the ED for further evaluation. - -Of note, the patient was just admitted to Sprague Clinic 4 days prior in DKA, symptoms of N/V, discharged the -following day without any changes to his prior regimen. He had -been on insulin pump in the past, but was discontinued in 1-4. -Just restarted on insulin pump 10 days prior to this admission - -basal rate 0.75units/hr with bolus dosing at mealtime. Follows -with Dr. Rothwell as an outpatient, last seen on 2107-11-4 and -started on insulin pump at that time. - -In the ED, initial vs were: 98.4 100 112/72 15 100% RA. Chest -discomfort resolved on arrival to the ED. Initial FS was >500, -with anion gap of 22, urine ketones 150. Patient was given IVF - -2LNS, 1L IVF with K, and started on 1L D5NS; started on insulin -gtt. Repeat lytes showed improved gap from 22 -> 18. - -On the floor, the patient is currently comfortable. Only -complaint is that he is hungry. No fevers, chills, cough, sore -throat, N/V, abdominal pain, dysuria. SOB and CP are still -resolved. +"Admission Date: 2174-12-26 Discharge Date: 2175-1-9 + +Date of Birth: 2174-12-26 Sex: M + +Service: NEONATOLOGY + +HISTORY OF PRESENT ILLNESS: Baby Candice Kyle Virginia is a +2600 gram boy born at 34-4/7 weeks gestational age to a +34-year-old G2, P0-1 mother. Prenatal screens were notable +for maternal blood type B positive, antibody negative, +hepatitis B surface antigen negative, RPR nonreactive, +Rubella immune, GBS unknown. No reported pregnancy +complications. Delivery was done for concerns of ""leaking +fluid."" No other risk factors. Delivery by cesarean section +due to breech positioning. Apgars of 7 at one minute and 9 +at five minutes. + +The infant was initially sent to the Newborn Nursery for +questions of whether gestational age was actually greater +than 35 weeks. However, in the Newborn Nursery, poor +regulation of temperature and grunting was noted and the +patient was transferred to the Neonatal Intensive Care Unit +for further management. + +PHYSICAL EXAMINATION ON ADMISSION: Weight 2600 grams (75th +percentile). General: Pink, grunting with no retractions or +flaring. HEENT: Anterior fontanelle soft and flat, palate +intact. Clavicles intact. No ear anomalies. Neck supple. +Lungs clear to auscultation with good aeration. Regular rate +and rhythm with no murmur noted, 2+ femoral pulses. Soft +abdomen with bowel sounds present and no hepatosplenomegaly. +There was bruising of the left flank and inguinal area. +Normal male genitalia with bilaterally descended testes. +Penis patent with no sacral anomalies. Hips hyperflexed with +knees hyperextended- typical breech positioning. Hips stable +with negative Ortolani and Barlow signs. Extremities pink +and well-perfused. Tone and activity normal. + +HOSPITAL COURSE BY SYSTEM: +1. Respiratory: The grunting resolved within the first day +of life and Dr. Geisler has been stable with saturations greater +than 96% with room air without any respiratory distress for +the remainder of the hospitalization. No active respiratory +issues. There has been no apnea of prematurity noted. + +2. Cardiovascular: Dr. Geisler has remained cardiovascularly +stable with an intermittent very soft murmur of no apparant +clinical significance. On the discharge exam the murmur was +not audible. + +3. Fluids, Electrolytes and Nutrition: On admission, we +initially attempted ad lib p.o. feeds of Premature Enfamil-20 +(mother decided not to breast feed). However, he was unable +to maintain adequate p.o. intake and was started on p.o. and +p.g. feeds. By nine days of age his p.o. intake was +improving markedly and he was switched to ad lib p.o. +Enfamil-20 with 140 cc/kg/day minimum. At the time of +discharge he was taking in ad lib p.o. Enfamil-20 at 166 cc +per kilo per day. At discharge, his weight was 2595 grams +(still down five grams from birth weight). + +4. Gastrointestinal: Dr. Geisler was noted to be jaundiced and +phototherapy was started when he was five days old for a +bilirubin of 12.8 total over 0.4 direct. Phototherapy was +discontinued on 1-2. He was seven days old with +subsequent bilirubins off phototherapy declining from 5.6 +down to 5.3 on 1-5. + +5. Hematology: Maternal blood type was B positive. Baby's +blood type is not known. Hematocrit on admission was 48. No +transfusions had been required. + +6. Infectious Disease: Initial sepsis evaluation included a +CBC which showed a white blood cell count of 9.7 with 46% +polys, 1% bands, hematocrit 48, platelets 230. Blood culture +was negative. Antibiotics were not initiated given the +absence of significant sepsis risk factors. He has not had +any active infectious disease issues. + +7. Sensory: Hearing screening was performed with automated +auditory brainstem responses with pass in both ears. + +CONDITION AT DISCHARGE: Stable. + +DISCHARGE DISPOSITION: Home. + +PRIMARY PEDIATRICIAN: Dr. Karl Stephens, Gonzalez Memorial Hospital. Phone +number 291-383-8038. + +CARE/RECOMMENDATIONS: +1. Feeds at discharge are Enfamil-20 p.o. ad lib. +2. No medications. +3. Car seat position screening passed. +4. State newborn screen last sent on 12-29 with +results pending. +5. Hepatitis B immunization #1 administered on 1-2. +6. Synagis RSV prophylaxis should be considered from December +through November for any of the following three criteria: A. +Born at less than 32 weeks gestational age; B. Born between +32 and 35 weeks gestational age with two of the following risk +factors: planned daycare, smoker in the house, neuromuscular +disease, airway abnormality or school age siblings; C. with +chronic lung disease. + +FOLLOW-UP APPOINTMENTS: Schedule includes: +1. An appointment with the primary care physician on +1-10 at 1:30. +2. Additional follow up should include an ultrasound of the +hips at approximately six weeks of age due to the breech +presentation and according to the latest AAP guidelines. -Past Medical History: -- Type I DM, diagnosed 2096, frequent hospitalizations with DKA -- Diabetic cataract left eye s/p phacoemulsification with -posterior chamber lens implant 2098. -- Senile cataract right eye s/p phacoemulsification with -posterior chamber lens implant 2099. -- R shoulder subluxation - -Social History: -- Tobacco: 10 cigarettes/day x 3 years -- Alcohol: occasional -- Illicits: none -The patient works as a line cook at House of Blues. - - -Family History: -Diabetes mellitus Type II in his father, paternal grandfather, -paternal aunts and uncles and maternal aunt; maternal GF/GM both -died of heart failure +DISCHARGE DIAGNOSES: +1. Prematurity at 34-3/7 weeks gestational age. +2. Mild early respiratory distress consistent with transient +tachypnea of the newborn. +3. Intermittent soft murmur. +4. Immature feeding. +5. Physiologic hyperbilirubinemia. +6. Sepsis ruled out (off antibiotics). +5. Breech positioning in utero. -Physical Exam: -Vitals: T: 96.8 BP: 120/66 P: 82 R: 13 O2: 100%RA -General: Alert, oriented, no acute distress -HEENT: Sclera anicteric, MMM, oropharynx clear -Neck: supple, JVP not elevated, no LAD -Lungs: Clear to auscultation bilaterally, no wheezes, rales, -rhonchi -CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, -gallops -Abdomen: soft, non-tender, non-distended, bowel sounds present, -no rebound tenderness or guarding, no organomegaly -GU: no foley -Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or -edema -Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly -intact in all extremities -Pertinent Results: -Admission labs: -2107-11-13 04:30PM WBC-6.0 RBC-4.58* HGB-14.4 HCT-40.9 MCV-89 -MCH-31.4 MCHC-35.1* RDW-11.7 -2107-11-13 04:30PM NEUTS-69.7 LYMPHS-26.3 MONOS-2.7 EOS-0.9 -BASOS-0.4 -2107-11-13 04:30PM PLT COUNT-271# -2107-11-13 04:30PM PT-10.6 PTT-22.1 INR(PT)-0.9 -2107-11-13 04:37PM PH-7.26* -2107-11-13 04:37PM GLUCOSE-GREATER TH LACTATE-1.8 NA+-130* -K+-4.9 CL--96 TCO2-12* -2107-11-13 04:37PM freeCa-1.19 -2107-11-13 04:30PM GLUCOSE-575* UREA N-23* CREAT-1.3* -2107-11-13 05:26PM URINE COLOR-Straw APPEAR-Clear SP Tucker-1.021 -2107-11-13 05:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG -GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 -LEUK-NEG - -EKG: NSR @ 80bpm, nl axis and intervals, diffuse STE, more -pronounced than prior in 9-4. - -Discharge labs: -2107-11-15 05:54AM BLOOD WBC-7.2 RBC-4.72 Hgb-14.9 Hct-41.8 MCV-89 -MCH-31.5 MCHC-35.6* RDW-11.9 Plt Ct-276 -2107-11-15 05:54AM BLOOD Plt Ct-276 -2107-11-15 05:54AM BLOOD Glucose-67* UreaN-17 Creat-0.9 Na-143 -K-3.7 Cl-104 HCO3-26 AnGap-17 -2107-11-15 05:54AM BLOOD Calcium-9.6 Phos-4.5 Mg-1.8 + Charles Keith, M.D. D13268118 -Brief Hospital Course: -Mr. Abel is a 29 year old man with h/o DM1, frequent -hospitalizations for DKA, recently restarted on insulin pump, -who was admitted in DKA. -. -#. DKA: Patient admitted for the 11th time this year with DKA. -Recently started on insulin pump, now with his second admission -in 10 days; insulin dosing did not appear to be adequate. No -signs or symptoms of infection as a trigger at this time, though -patient later had a persistent cough that was treated with -azithromycin. -On admission, patient was put on a regular insulin drip, and -started on D5 1/2NS when glucose came down <200. The next -morning, he was restarted on his insulin pump at a higher basal -dose. -The second day of admission, there was some confusion on two -levels. The patient misunderstood the calorie counts in the menu -and gave himself very low amounts of insulin based on his -calorie counting scale. His glucose meter was also poorly -calibrated and was giving finger stick readings about 150 lower -than actual. He was hyperglycemic to the 400s, but did not have -recurrent acidosis. His glucose levels subsequently improved. -The next day we spoke with his outpatient endocrinologist Dr. -Rothwell (114-594-2840), who said that he had only met the -patient once. He has few insulin pump patients, so the decision -was to have the patient return to Hughes for further follow-up. -He will see Dr. Ray the day after discharge to re-establish -care with him. -. -#. Cough: Patient had a productive cough. CXR negative. The -decision was made to treat him with azithromycin for a suspected -upper-respiratory tract infection. -. -#. ARF: Patient with Cr 1.3 on admission, baseline Cr 1.0. -Improved with fluid resuscitation. - -Medications on Admission: -Insulin - on pump since 2107-11-4, basal rate 0.75units/hr, bolus -dosing for meals +Dictated By:Bobby +MEDQUIST36 -Discharge Medications: -1. azithromycin 250 mg Tablet Sig: One (1) Tablet PO DAILY -(Daily) for 2 days. -Disp:*2 Tablet(s)* Refills:*0* -2. Burke Industries Insulin Pump Sig: One (1) once a day. -3. One Touch Ultra Test Strip Sig: One (1) strip -Miscellaneous four times a day. -4. Humalog 100 unit/mL Solution Sig: As directed units -Subcutaneous four times a day: Use with insulin pump per -directions. -Discharge insulin pump settings: - -Basal Rates: - Midnight - midnight: 1.3 Units/Hr -Meal Bolus Rates: - Breakfast = 1:8 - Lunch = 1:8 - Dinner = 1:8 - Snacks = 1:8 -High Bolus: - Correction Factor = 1:50 - Correct To mg/dL +D: 2175-1-9 12:42 +T: 2175-1-9 12:46 +JOB#: Job Number 52585 +" +"Admission Date: 2133-1-28 Discharge Date: 2133-1-31 + +Date of Birth: 2063-3-16 Sex: F + +Service: CCU + +CHIEF COMPLAINT: Chest pain. + +HISTORY OF PRESENT ILLNESS: Ms. Eva is a 69-year-old +woman who was recently discharged from Butler Clinic one week ago with chest pain and +electrocardiogram changes in the inferior leads. + +She was then transferred to the cardiac catheterization +laboratory and had a catheterization which revealed she had a +right-dominant system with a 70% proximal lesion and a 95% +mid lesion. The two lesions were dilated with difficulty. +The ostial lesion was easily stented. However, the mid +lesion stenting was initially complicated by dissection and +slow flow but was then stented with an additional two stents. +Because the ostial stent had migrated distally, another stent +was placed proximally to reopen the ostial lesion. She +received a total of five since the RCA approximately one week +ago with dissection mid to distally. + +She presents tonight with acute recurrence of her chest pain +with 5-mm to 10-mm ST elevations in the inferior leads, and +was again taken to the catheterization laboratory emergently +this evening. + +In the cardiac catheterization laboratory, it was noted that +between two of the mid right coronary artery stents, where +some dissection remained, there was a large fresh thrombus. +Due to technical reasons, this was unable to be stented or +receive Angio-Jet but was amenable to balloon angioplasty. +TIMI-III flow resulted after angioplasty. There was a stable +70% long tubular lesion of the left anterior descending +artery noted upon the last catheterization. During the +procedure, the patient experienced transient hypotension to +the 70s and bradycardia which was quickly relieved with +atropine, intravenous fluids, and dopamine. The dopamine was +turned off at the end of the case, and the patient recovered +with systolic blood pressures in the mid 120s. + +She arrived in the Coronary Care Unit without any complaints. -Discharge Disposition: -Home +PAST MEDICAL HISTORY: +1. Prominent coronary artery disease, status post +catheterization 17 years ago which was reported as negative; +and as above in the History of Present Illness. +2. Hypertension. +3. Hypercholesterolemia. + +MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. q.d., +Plavix 75 mg p.o. q.d. times 90 days, Lovenox 30 mg +subcutaneous b.i.d., atenolol 25 mg p.o. q.d., Lipitor 80 mg +p.o. q.d., Prinzide 20/12.5 1 tablet p.o. q.d. + +ALLERGIES: CODEINE and BENADRYL. + +SOCIAL HISTORY: Denies any tobacco. Admits to drinking +alcohol socially. + +PHYSICAL EXAMINATION ON PRESENTATION: On physical +examination her pulse was 80, blood pressure of 124/52, +respiratory rate of 16, satting 100% on 2 liters. In +general, she was comfortable, in no apparent distress, lying +flat. Head, eyes, ears, nose, and throat revealed pupils +were equally round and reactive to light. Sclerae were +anicteric. The oropharynx was clear. Neck revealed jugular +venous pulsation was approximately 4 cm at 10 degrees. +Respiratory was clear to auscultation bilaterally. +Cardiovascular revealed a regular rate and rhythm. No +murmurs, rubs or gallops. Abdominal examination was benign. +Extremities revealed no cyanosis, clubbing or edema. She had +good distal pulses. + +RADIOLOGY/IMAGING: Her electrocardiogram revealed that she +was in normal sinus rhythm at a rate of 84. She had 5-mm to +10-mm ST elevations in leads II, III, and aVF; with +reciprocal ST depressions in V1, V2, and V3. + +Post catheterization electrocardiogram revealed that she was +in normal sinus rhythm with left axis deviation, Q waves +inferiorly, with resolving ST-T wave changes. + +HOSPITAL COURSE: Her hematocrit was found to be 26.9 post +catheterization and she was transfused 2 units of packed red +blood cells which increased her hematocrit to 35.7. She was +then transferred to the floor for further observation. + +A transthoracic echocardiogram revealed that her left atrium +was moderately dilated. There was mild symmetric left +ventricular hypertrophy with a normal left ventricular cavity +size. There was mild regional left ventricular systolic +dysfunction with hypokinesis/akinesis of the inferior septum +and inferoposterior wall. She ejection fraction was noted to +be 40% to 45%. Her right ventricular size and systolic +function were normal. She had 1+ mild aortic regurgitation +and moderate 2+ mitral regurgitation. + +Examination of her groin revealed no hematoma. Her femoral +and distal pulses were 2+. Because a left femoral bruit was +heard on auscultation, a femoral ultrasound was obtained +which revealed no evidence of left inguinal pseudoaneurysm or +arteriovenous fistula. Her creatine kinases steadily trended +downward, and her creatinine remained stable status post +catheterization. + +CONDITION AT DISCHARGE: Condition on discharge at the time +of discharge was stable. + +DISCHARGE STATUS: Discharged to home. + +MEDICATIONS ON DISCHARGE: +1. Prinzide 20/12.5 1 tablet p.o. q.d. +2. Atenolol 25 mg p.o. q.d. +3. Lovenox 60 mg subcutaneous b.i.d. times two weeks. +4. Lipitor 80 mg p.o. q.d. +5. Plavix 75 mg p.o. q.d. times six months. +6. Aspirin 325 mg p.o. q.d. +7. Sublingual nitroglycerin 0.4 mg sublingually q.5min. +times three p.r.n. for chest pain. + +DISCHARGE INSTRUCTIONS: Return to the hospital if you +develop worsening chest pain or shortness of breath, or if +you develop worsening back pain, leg pain, or flank pain. + +DISCHARGE FOLLOWUP: Follow up with your cardiologist +Dr. Woolery at Sanders Medical Center Hospital in one week. -Discharge Diagnosis: -Diabetic ketoacidosis -Type I diabetes +DISCHARGE DIAGNOSES: +1. Coronary artery disease. +2. Hypertension. +3. Hypercholesterolemia. -Discharge Condition: -Mental Status: Clear and coherent. -Level of Consciousness: Alert and interactive. -Activity Status: Ambulatory - Independent. -Discharge Instructions: -You were admitted with dangerously high blood sugar levels and -ketoacidosis. Your blood sugar levels improved with a continuous -insulin infusion and a lot of IV fluids. Your insulin pump was -restarted at a higher level, and you are now safe to go home. -You will need to follow your blood sugar very closely over the -next couple of days to make sure that your insulin pump is -properly titrated. -Your only medications are to continue using your insulin pump -and to take azithromycin for 2 more days. + Walter Gutierrez, M.D. T37912963 -Followup Instructions: -Please see Dr. Ray, at Hughes Diabetes Center, tomorrow, -11-15, at 3pm. You can call (250-886-7061 if you need -to make changes to that appointment. +Dictated By:Hancock -Please follow-up with your primary care doctor, Dr Lareau, -within the next 2 weeks. You can call his office at -314-618-2706. +MEDQUIST36 +D: 2133-2-3 14:59 +T: 2133-2-3 18:51 +JOB#: Job Number 104258 -Completed by:2107-11-16" -"Admission Date: 2180-5-18 Discharge Date: 2180-5-25 +cc:Sorrell Memorial Hospital" +"Admission Date: 2181-4-25 Discharge Date: 2181-5-4 -Date of Birth: 2118-11-28 Sex: F -Service: NEUROSURGERY +Service: MEDICINE Allergies: -No Known Allergies / Adverse Drug Reactions +Amiodarone / Quinidine/Quinine -Attending:Joel +Attending:Gregory Chief Complaint: -confusion - - +CC:CC Contact Info 94136 Major Surgical or Invasive Procedure: -L Craniotomy for evacuation of L SDH +hemodialysis History of Present Illness: -This is a 61 year old woman without significant PMH who -presented to her PCP's office after becoming confused at work. -She remembers having a fall two weeks prior to presntation. An -MRI Brain was performed which revealed a large subacute left -SDH. She was sent to Reed Memorial Hospital ED and subsequently -transferred to Lorenzo Hospital. Neurosurgical consultation requested for -evaluation and treatment. -She states that she fell two weeks ago remembers hitting her -head -but does not recall which side. She does not think she is -confused but her co-workers believe that she is. She states that -her friends thought her walking was impaired. Otherwise she -reports no headache. She does say that she had trouble with her -right hand when writing. She denies seizure like -activity, LOC, fever, chills, Nausea, vomiting, chest pain or -pressure, sob, or weakness in other extremities. - +HPI: This is a 88My.o male with h/o of afib on comadin, CHF, +OSA, and advance prostate CA s/p TURP, h/o urosepsis sp b/l +stents, seen in clinic c/foul smelling urine today. +. +Patient describes that over the last 2 days he has been feeeling +more tired, lack of energy and his urine is coming out ""milky +and foul smelling"". He was given two doses of TMP/SMX or ?Cipro +last night and one this morning. +. +He denies any fever, chills, nausea, vomit, diaphroesis, +shortness of breath, chest pain, back pain, diarrhea, aabdominal +pain, but reported 10 lb wt loss in the past 3 months due to +loss of appetite from lost of taste budd. +When asked about his bruise on his left forehead, he said that +he bumped his head on Sunday with the refrigerator. He did not +lose any conciousness. Denies any headachees, blurred vision or +unsteady gait associated after the episode. +. +In ED, hemodynamically stable, has +UA, received Levoflox, and +cefepime. Past Medical History: -rheumatoid arthritis, rectal bleeding, HTN, seasonal -allergies +PMH - +- OSA +- History of sinus infections. +- Prostate CA s/p XRT/resection +- DM2 +- A. fib on Coumadin +- Right cataract. +- Left retinal tear. +- Macular degeneration status post laser treatment. +- Gout. +- Clarence Mcdonald tear. +- Squamous cell carcinoma of ear followed by derm +- IBS w/chronic diarrhea for years/lactulose intolerance +- myelodysplasia +. +PSH - +- Spontaneous pneumothorax 15 years ago. +- s/p cholecystectomy +- s/p left inguinal hernia repair, +- s/p hemorrhoidectomy +- Prostate CA s/p TURP and XRT s/p urethral stricture +- back surgery Social History: -She works for the city of Lakeview, married, husband is currently -ill. Denies tobacco,etoh, drugs +SH - Retired psychiatrist. Lives at home with his wife. Quit +tobacco many years ago. No EtOH, no illicits. Family History: -non-contributory - +FH - NC Physical Exam: -On Admission: -O: T: BP: 130/60 HR: 92 R 18 O2Sats 99% 3L -Gen: WD/WN, comfortable, NAD. -HEENT: Pupils: 4 to 2mm equal. EOMs Intact no nystagmus -Neck: Supple. -Lungs: CTA bilaterally. -Cardiac: RRR. S1/S2. -Abd: Soft, NT, BS+ -Extrem: Warm and well-perfused. - -Neuro: -Mental status: Awake and alert, cooperative with exam with mild -inattentiveness. Orientation: Oriented to person, place, and -date. Language: Speech fluent with good comprehension and -repetition. -Naming intact. No dysarthria or paraphasic errors. - -Cranial Nerves: -I: Not tested -II: Pupils equally round and reactive to light, 4mm to 2 -mm bilaterally. Visual fields perceived as full although -inattentive to task at times. -III, IV, VI: Extraocular movements intact bilaterally without -nystagmus. -V, VII: Facial strength and sensation intact and symmetric. -VIII: Hearing intact to voice. -IX, X: Palatal elevation symmetrical. -Dr. Brown: Sternocleidomastoid and trapezius normal bilaterally. -XII: Tongue midline without fasciculations. -Motor: tone increased b/l lower extremities. No abnormal -movements, -tremors. no drift noted. Motor impersistence. Strength was full -with the following exceptions, has b/l tricep 4-25, IP's 5-/5 and -Hamstrigs 5-/5. The hands have significant pain and rheumatic -changes and finger extension and wrist extension were not tested -adequately. -Sensation: Intact to light touch bilaterally. -Reflexes: were grade 3 throughout. -Toes upgoing bilaterally - -Gait: able to get up and out of bed with minimal assistance, -unsteady gait with swaying backward upon standing. - -On Discharge: PERRLA, AAx O to person, hospital, Lakeview, time. -No word finding difficulties. Right pronator drift. LE's full -strength. RUE strength is 4- to 4-25 and LUE is 4 to 4+/5. +Physical Exam: +Vitals: T 96.9 P: 67 BP 146/66 RR 17 Sats 96%RA +General: Awake, alert, NAD. +HEENT: dry oral mucose. echimosis on his left forehead. +Neck: supple, no JVD, left side adenopathy x 2, small, non +tender, mobile. +Pulmonary: Lungs CTA bilaterally without R/R/W +Cardiac: RRR, nl. S1S2, no M/R/G noted +Abdomen: BS+, soft, obese non tender, mildly distended. Liver +1cm below costal margin. +Extremities: asymetric bilateral LLE edema 2+. +Neurologic: +-mental status: Alert, oriented x 3. CNII-XII intact. Movilizing +all extremities. Pertinent Results: -CT HEAD W/O CONTRAST 2180-5-18 -Evolving large left vertex subdural hematoma with rightward -subfalcine herniation and moderate effacement of the left -lateral ventricle. Allowing for differences in technique, the -findings are little changed since the 14:11 MRI examination. - -CT head 2180-5-19 -1. Status post left craniotomy with evacuation of large subdural -hematoma. Post-surgical changes with bilateral pneumocephalus, -left more than right with interval decrease of rightward shift -of normally midline structures. -2. No new focus of hemorrhage. Ventricles are stable in size. - - -CT head 2180-5-22 -1. Increased size of a left vertex subdural hematoma with -increased -neighboring sulcal effacement and slight increase in rightward -subfalcine -herniation. -2. Increased hyperdense material subjacent to the craniotomy -site indicative of interval bleeding since 2180-5-19. -3. New minimal effacement of the quadrigeminal and suprasellar -cisterns. -4. Increased soft tissue swelling and subgaleal hematoma at the -craniotomy -site. -5. Evolving focal left frontal infarct at the subfalcine -herniation site. - - +Laboratory Data: see below +EKG: afib, with VR 70x, left axis, no st changes, difuse +flattenin t waves on v4-v5-v6. QTC 460 +. +Radiologic Data: +Renal US: pending +. +2181-4-25 05:40PM BLOOD WBC-12.1* RBC-4.64 Hgb-12.5* Hct-40.4 +MCV-87 MCH-26.9* MCHC-30.8* RDW-17.3* Plt Ct-258 +2181-5-4 04:21AM BLOOD WBC-19.7* RBC-3.46* Hgb-9.9* Hct-29.9* +MCV-87 MCH-28.6 MCHC-33.0 RDW-18.5* Plt Ct-93* +2181-4-25 05:40PM BLOOD PT-74.7* PTT-42.8* INR(PT)-9.7* +2181-4-25 05:40PM BLOOD Plt Smr-NORMAL Plt Ct-258 +2181-5-4 04:21AM BLOOD PT-23.7* PTT-29.7 INR(PT)-2.4* +2181-5-4 04:21AM BLOOD Plt Smr-LOW Plt Ct-93* +2181-4-25 05:40PM BLOOD Glucose-304* UreaN-59* Creat-2.4* Na-136 +K-4.2 Cl-101 HCO3-20* AnGap-19 +2181-5-3 05:41AM BLOOD Glucose-89 UreaN-63* Creat-3.7* Na-125* +K-6.6* Cl-94* HCO3-10* AnGap-28* +2181-5-4 04:21AM BLOOD Glucose-116* UreaN-60* Creat-3.6* Na-130* +K-5.2* Cl-91* HCO3-13* AnGap-31* +2181-4-27 06:45AM BLOOD ALT-32 AST-57* LD(LDH)-529* AlkPhos-312* +TotBili-1.0 +2181-5-4 04:21AM BLOOD ALT-476* AST-PND LD(LDH)-PND AlkPhos-573* +TotBili-1.9* +2181-5-4 04:21AM BLOOD Albumin-2.2* Calcium-7.2* Phos-8.5* +Mg-2.0 +2181-4-27 06:45AM BLOOD PSA-<0.1 +2181-5-3 12:51PM BLOOD Type-ART pO2-81* pCO2-25* pH-7.04* +calHCO3-7* Base XS--23 +2181-5-3 07:11PM BLOOD Type-Smith Temp-35.0 O2 Flow-3 pO2-37* +pCO2-28* pH-7.20* calHCO3-11* Base XS--16 Intubat-NOT INTUBA Brief Hospital Course: -This is a 61 y/o woman who had a fall 2 weeks prior to admision, -striking her head. She presents to the ED with confusion. Head -CT revealed L SDH with significant midline shift. She was taken -to OR emergently for a L side craniotomy for evacuation of SDH. -Post operatively patient was transferred to ICU for recovery. On -5-19, post op head CT showed minimal improvement of midline -shift and pneumocephalus. On examination, patient was a&ox3, R -triceps 4-25, otherwise she was intact. She was transferred to -step down unit and PT/OT consulted. -On 5-21 the patient was neurologically stable and dilantin level -was therapeutic. -On 5-22 a repeat head CT was performed which revealed an increase -in MLS. Fluid and air was aspirated from the crani site at the -bedside and she was placed on 100%O2 for pneumocephalus. Her -exam improved and word finding difficulties resolved. She was -sorking with PT and OT and was being screened for rehab. Her BUN -elevated to 21 on 5-23 and IVF were restarted at 50cc/hr. Her Bun -stabilized to 20 and she was discharged to rehab on 5-25. - - -Medications on Admission: -Amlodipine Besy-Benxapril 11-9, plaquenil 1 tab Self Memorial Hospital (250mg), -naprosyn 500mg Self Memorial Hospital, prednisone 5mg daily - - -Discharge Medications: -1. insulin regular human 100 unit/mL Solution Sig: Two (2) units -Injection ASDIR (AS DIRECTED). -2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). - -3. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). - -4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 -hours) as needed for pain or fever: max 4g/24 hrs. -5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One -(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). -6. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule -PO TID (3 times a day). -7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a -day): hold for loose stools. -8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) -as needed for pain. -9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) -Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for -constipation. -10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID -(2 times a day): hold for loose stools. -11. heparin (porcine) 5,000 unit/mL Solution Sig: 14428 (14428) -units Injection TID (3 times a day). -12. benazepril 10 mg Tablet Sig: Two (2) Tablet PO Daily (): -Hold if SBP <105 or K> 4.5 +87 y/o male with advanced prostate CA s/p TURP, h/o bilateral +hydronephrosis due to tumor at trigone s/p post stents (Right), +OSA, afib on coumadin who presents with UTI and ARF on CRI, and +elevated INR. Given worsening renal failure secondary to +underlying metatstaic malingnancy and poor prognosis, Cory wife +and family decided to concentrate on comfort and avoid +aggressive measures. After several sessions of hemodialysis, +Family chose to further withdrawl care. Pt pronounced dead at +15:36 on 2181-5-4. Family present in the room. Autopsy deferred . +#. Acute on chronic renal failure - Patient has a baseline Cr of +1.6 with an elevation in BUN/Cr to 59/2.4. Pt with progressive +renal failure 1-18 to underlying malignancy and associated +obstruction. Pt initiated on Hemodialysis which he tolerated +well. Discussed with urology who recomended revision of uretral +stents which was not pursued as family wished to stress comfort. - -Discharge Disposition: -Extended Care - -Facility: -Duncan Medical Center Martinez Memorial Hospital Rehabilitation and Nursing Center - Eerie - -Discharge Diagnosis: -L SDH with midline shift - - -Discharge Condition: -Level of Consciousness: Alert and interactive. -Activity Status: Ambulatory - Independent. -Mental Status: Confused - always. - - -Discharge Instructions: -?????? Have a friend/family member check your incision daily for -signs of infection. -?????? Take your pain medicine as prescribed. -?????? Exercise should be limited to walking; no lifting, straining, -or excessive bending. -?????? You may wash your hair only after sutures and/or staples have -been removed. They should be removed on 5-27. -?????? You may shower before this time using a shower cap to cover -your head. -?????? Increase your intake of fluids and fiber, as narcotic pain -medicine can cause constipation. We generally recommend taking -an over the counter stool softener, such as Docusate (Colace) -while taking narcotic pain medication. -?????? You may resume taking prednisone -?????? If you were on a medication such as Coumadin (Warfarin), or -Plavix (clopidogrel), or Aspirin, prior to your injury, you may -safely resume taking after post-op review -?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure -medicine, take it as prescribed and follow up with laboratory -blood drawing in one week. This can be drawn at your PCP??????s -office, but please have the results faxed to 311-654-8171. -?????? Clearance to drive and return to work will be addressed at -your post-operative office visit. -?????? Make sure to continue to use your incentive spirometer while -at home, unless you have been instructed not to. - -CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE -FOLLOWING - -?????? New onset of tremors or seizures. -?????? Any confusion or change in mental status. -?????? Any numbness, tingling, weakness in your extremities. -?????? Pain or headache that is continually increasing, or not -relieved by pain medication. -?????? Any signs of infection at the wound site: redness, swelling, -tenderness, or drainage. -?????? Fever greater than or equal to 101?????? F. - - -Followup Instructions: -Follow-Up Appointment Instructions - -??????You may return to the office in 7-30 days(from your date of -surgery) for removal of your staples/sutures and/or a wound -check. This can alos be done at rehab by 5-27. -??????Please call (505-473-5282 to schedule an appointment with Dr. -Wise, to be seen in 4 weeks. -??????You will need a CT scan of the brain without contrast. - - - Ashley Jerald MD I17811034 - -Completed by:2180-5-25" -"Admission Date: 2177-10-2 Discharge Date: 2177-10-30 - -Date of Birth: 2120-8-4 Sex: M - -Service: CARDIOTHORACIC - -Allergies: -Patient recorded as having No Known Allergies to Drugs - -Attending:Johnny -Chief Complaint: -Epigastric discomfort and lethargy - -Major Surgical or Invasive Procedure: -2177-10-6 Five Vessel Coronary Artery Bypass Grafting(LIMA to -LAD, with vein grafts to first diagonal, second diagonal, obtuse -marginal, and PDA), Mitral Valve Repair(30mm Annuloplasty Ring), -with Insertion of an IABP. - - -History of Present Illness: -Mr. Gladys is a 57 year old male who presented to OSH in mid -September with shortness of breath, gastric discomfort and -fatigue. He ruled in for a ST elevation MI. Subsequent cardiac -catheterization revealed severe three vessel coronary artery -disease and an LVEF of 36%. Echocardiogram at that time was -notable for an LVEF of 40% with inferior wall akinesis and -moderate mitral regurgitation. Patient was declined for surgery -at Starr Clinic(secondary to poor distal targets) and -eventually transferred to the Wood Memorial Hospital for further evaluation and -treatment. - -Past Medical History: -Ischemic Cardiomyopathy, Coronary Artery Disease with inferior -wall ST Elevation MI on 2177-9-30, Mitral Regurgitation, -Hypertension, Type II Diabetes Mellitus(poorly controlled), -Hyperlipidemia - -Social History: -Denies tobacco and ETOH. He lives alone. He is a truck driver. - -Family History: -Denies family history of premature coronary artery disease. - -Physical Exam: -Admission -HR 74 SR BP 126/62 RR 20 Sat 96% on 4L -Neuro Arousable, follows commands with encouragement. MAE, -strength 5/5 t/o. PERRL. -CV RRR no M.R.G -Lungs wheezes, crackles -Abdomen soft/NT -Extrem 1+ edema, warm 2+ pulses t/o -no carotid bruits -Discharge -T 99.6 HR 76SR BP104/60 RR22 O2sat 96%RA -Neuro: Awake, moves rt side to command, left dense hemiparesis -CV: RRR, sternum stable -Pulm: course rhonchi -Abdm: soft, NT/+BS -Ext: left LE 3+ edema, Rt LE no edema - -Pertinent Results: -COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct -2177-10-30 02:29AM 8.6 2.90* 8.3* 24.9* 86 28.8 33.5 16.0* -281 -Source: Line-CVL - BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) -2177-10-30 02:29AM 281 -Source: Line-CVL -2177-10-30 02:29AM 20.5*1 65.6* 1.9* - RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap -2177-10-30 02:29AM 150* 25* 1.2 137 3.8 99 30 12 - -RADIOLOGY Final Report -CHEST (PORTABLE AP) 2177-10-29 1:30 PM -CHEST (PORTABLE AP) -Reason: dobhoff placement -Choudhury Medical Center MEDICAL CONDITION: -57 year old man with s/p CABG -REASON FOR THIS EXAMINATION: -dobhoff placement -CHEST, SINGLE AP FILM -History of CABG. -Status post CABG. Distal end of feeding tube overlies body of -stomach. There is cardiomegaly and a left pleural effusion with -associated atelectasis in the visualized left lower lung. No -pneumothorax. The left subclavian CV line has tip located over -the proximal SVC. -IMPRESSION: No definite pneumothorax. Left pleural effusion and -associated atelectasis in left lower lobe, overall appearances -being essentially unchanged since prior study of 2177-10-28. - -DR. Herbert Castaneda - -2177-10-2 10:30PM BLOOD WBC-10.5 RBC-5.03 Hgb-14.2 Hct-43.4 -MCV-86 MCH-28.2 MCHC-32.7 RDW-14.1 Plt Ct-273 -2177-10-2 10:30PM BLOOD PT-15.1* PTT-91.3* INR(PT)-1.4* -2177-10-2 10:30PM BLOOD Glucose-364* UreaN-35* Creat-1.4* Na-133 -K-4.7 Cl-94* HCO3-27 AnGap-17 -2177-10-2 10:30PM BLOOD ALT-207* AST-93* LD(LDH)-531* -AlkPhos-325* Amylase-35 TotBili-0.6 -2177-10-2 10:30PM BLOOD Albumin-3.3* Mg-2.5 -2177-10-2 10:49PM BLOOD Type-ART pO2-76* pCO2-36 pH-7.49* -calTCO2-28 Base XS-4 -2177-10-2 10:49PM BLOOD Glucose-282* Lactate-1.6 Na-132* K-4.1 -Cl-94* -2177-10-5 08:58PM BLOOD %HbA1c-12.4* -2177-10-3 Non Contrast Head CT Scan: -There is no evidence of intracranial hemorrhage, mass effect, or -shift of normally midline structures. Dr. Butler-white matter -differentiation is preserved. The ventricles are normal in size -and symmetric. There is no evidence of acute major vascular -territorial infarction. There are moderate cavernous carotid -calcifications. There is complete opacification of the right -maxillary sinus. The remaining paranasal sinuses and mastoid air -cells are clear. -2177-10-6 Intraoperative TEE: -PRE-BYPASS: -Pt requiring dobutamine infusion at 7.5 -1. No atrial septal defect is seen by 2D or color Doppler. -2. There is mild to moderate global left ventricular hypokinesis -(LVEF = 35-40 %), with basal to mid inferior and -inferior-lateral akinesis. [Intrinsic left ventricular systolic -function is likely more depressed given the severity of valvular -regurgitation.]. -3. Right ventricular chamber size is normal. There is mild to -moderate global right ventricular free wall hypokinesis. -4. There are simple atheroma in the ascending aorta. The -descending thoracic aorta is mildly dilated. There are simple -atheroma in the descending thoracic aorta. -5. There are three aortic valve leaflets. The aortic valve -leaflets are mildly thickened. Trace aortic regurgitation is -seen. -6. The mitral valve leaflets are mildly thickened. Moderate to -severe (3+) mitral regurgitation is seen, with noted centrally -directed regurgitant jet. The mitral regurgitation vena -contracta is >=0.7cm. -7.The tricuspid valve leaflets are mildly thickened; there is -mild to moderate (12-17+) tricuspid regurgitation. -POST-BYPASS: -Pt removed from cardiopulmonary bypass on vasopression, -milrinone, epinephrine and norephinephrine infusions and -placement of intra-aortic balloon pump. -1. Pt s/p mitral valve annuloplasty. There is no mitral -regurgitation. -2. Biventricular function is improved. Right ventricular is -normal sized and function has improved from moderate to mild -dysfunction. Left ventricular function remains globally -depressed; basal to mid inferior walls remain akinetic; there is -improvement of anterior wall function. -3. Aortic contours are intact post-decannulation. There is an -intra-aortic balloon noted in the proper position. -2177-10-15 Transthoracic ECHO: -The left atrium is moderately dilated. There is mild symmetric -left ventricular hypertrophy with normal cavity size. There is -moderate regional left ventricular systolic dysfunction with -akinesis of the inferior and inferolateral walls. The remaining -segments contract normally (LVEF = 35-40 %). The aortic valve -leaflets (3) are mildly thickened but aortic stenosis is not -present. No aortic regurgitation is seen. The mitral valve -leaflets are mildly thickened. A mitral valve annuloplasty ring -is present. The mitral annular ring appears well seated and is -not obstructing flow. No mitral regurgitation is seen. There is -borderline pulmonary artery systolic hypertension. There is a -very small pericardial effusion most prominent around the right -atrium. -2177-10-16 Cardiac Catheterization: -1. Selective coronary angiography of this right dominant system -demonstrated native 3 vessel coronary artery disease. The LMCA -had -diffuse mild disease. The LAD was occluded in the mid vessel. -The LCX -was occluded proximally. The RCA was occluded proximally. The -SVG-PDA -was patent with slow flow into a small PDA. The SVG-D1 was -patent as was -SVG-D2, both with slow flow into small distal vessels. The -SVG-OM was -patent with slow flow as well. The LIMA-LAD was patent. The LAD -beyond -the LIMA was diffusely small with slow flow. -2. Limited resting hemodynamics were performed. The systemic -arterial pressures were borderline low measuring 86/63mmHg. -2177-10-20 Non contrast Head CT Scan: -There is no sign for the presence of an intracranial hemorrhage. -There is a question of a 1cm area of low density seen within the -region of the right uncus, which did not appear to be present on -the prior CT scan. If real, this finding could represent an area -of developing infarction. No other definite interval changes are -appreciated. There is no hydrocephalus or shift of normally -midline structures. -2177-10-21 MRA Brain: -Multiple areas of restricted diffusion bilaterally including -also the right cerebellar hemisphere as described above, areas -of subacute ischemic changes extending from the posterior limb -of the right internal capsule to the right, hippocampal area. -These December are suggestive of subacute infarcts likely from -an embolic source involving multiple vascular territories. - - +. +# UTI: u/a compatible with urinary tract infection. Given prior +history of VRE and gram negative bacteremia (pseudomona) in +recent past, Pt was covered broadly. +. +#. Anion Gap Acidosis: Mixed lactic acidosis with acute renal +failure. BG elevated on presentation, but urine ketones +negative. Pt started on NaHCO3 and HD with little improvement +in acidosis. Worsening lactic acidosis 1-18 tumor necrosis -Brief Hospital Course: -Mr. Gladys was admitted to the cardiac surgical service. He -remained pain free on intravenous Heparin and Nitroglycerin. He -was initially evaluated by the Neurology service for an altered -mental status, experiencing periods of unresponiveness, -confusion and agitation/delirium. A head CT scan was -unremarkable and his altered mental status was attributed -metabolic encephalopathy. There was no evidence of stroke. Over -the next several days from a cardiac standpoint, he gradually -developed cardiogenic shock and required inotropic support. -Given his critical condition, he was urgently brought to the -operating room on 10-6 where Dr. Hess performed -coronary artery bypass grafting and mitral valve repair. Given -his low ejection fraction, an IABP was placed prior to weaning -from cardiopulmonary bypass. For additional surgical details, -please see seperate dictated operative note. Following the -operation, he was brought to the CVICU in critical condition. -His postoperative course will now be broken down into systems: - -CARDIAC: Initially required multiple inotropes for poor -hemodynamics. Started on Amiodarone on postoperative day two for -atrial and ventricular arrhythmias. The IABP was slowly weaned -and eventually removed on postoperative day four without -complication. He remained pressor dependent at that time. -Cardioversion was performed on postoperative day six for -episodes of atrial fibrillation associated with a decrease in -SVO2. By postoperative seven, all inotropic support was weaned. -Despite Amiodarone, he continued to experience atrial and -ventricular arrhythmias. He went on to develop an episode of -sustained ventricular fibrillation/torsades on postoperative day -eight for which successfull defibrillation was performed. -Amiodarone was discontinued and switched to Lidocaine. A calcium -channel blocker was concomitantly initiated. The EP/cardiology -services were consulted and recommended EPS with potential VT -ablation. To rule out ischemia as the cause for ventricular -tachycardia, cardiac catheterization was performed on 10-16 which showed patent grafts. Given ventricular arrhythmias, -he was eventually started on Mexiletine. - -PULMONARY: Given critical condition, required prolonged -mechanical ventilation. Eventually extubated on postoperative -day nine. He was electively re-intubated for cardiac -catheterization on 10-16, and re-extubated later that -night. Unfortunatly, he went on to develop acute respiratory -failure later that night and required reintubation. Bronchoscopy -was performed on 10-17 which found patent airways without -evidence of mucous plugs and only minimal scant secretions. A -left sided chest tube was placed for pleural effusion. The -effusion improved and the chest tube as removed. - -NEURO: Given his critical condition, had a prolonged period of -sedation. Following his initial extubation, he awoke -neurologically intact. Following his second re-extubation on -postoperative day 14, he was noted to have new onset left -hemiparesis and left sided neglect. Neurology was consulted -while head CT scans and MR Donald Scrivens consistent with -embolic stroke(see result section). Heparin and coumadin were -started. - -RENAL: Developed oliguric acute renal failure. Creatinine peaked -to 2.9 on postoperative day eight. The renal service was -consulted and attributed his renal insufficiency to pre-renal -etiology. Renal function gradually improved and he responded -nicely to diuretics. - -ENDOCRINE: Initially maintained on Insulin drip. Transitioned to -lantus insulin. - -HEME: Mild postoperative anemia and was intermittently -transfused to maintain hematocrit near 30%. - -ID: Remained afebrile with no evidence of infection. - -GI: Bedside swallow on 10-22 recommended continuing NPO/tube -feeding as he was not consistently awake enough to safely -attempt anything by mouth. Tolerating tube feedings. - -Skin: A hematoma formed at an ex-chest tube site on his left -flank and began bleeding with anticoagulation. It was sutured on -10-26 and subsequently improved. +Medications on Admission: +. +Medications: +Lasix 60 mg a day, Glipizide ER 10 mg, Lipitor 10 mg, Casodex 50 +mg, Allopurinol 100 mg, potassium 10 mEq, Verapamil 40 mg, +Prilosec OTC 20 mg, vitamin B-12, Coumadin, 1-2.5 mg as dosed by -Medications on Admission: -Intravenous Nitroglycerin -Docusate Sodium 100 Showalter Medical Center -Metoprolol 75 Showalter Medical Center -Pantoprazole 40 qd -Aspirin 325 qd -Lisinopril 2.5 qd -Simvastatin 40 qd -Glargine 20 units qhs -RISS +his INR, folic acid 1 mg a day, cholestyramine 1 pack daily, +ferrous sulfate, nitrofurantoin which he just finished as I +mentioned, and Ambien XL 6.25 mg. Discharge Medications: -1. Simvastatin 40 mg Tablet Showalter Medical Center: One (1) Tablet PO DAILY -(Daily). -2. Aspirin 81 mg Tablet, Chewable Showalter Medical Center: One (1) Tablet, Chewable -PO DAILY (Daily). -3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Showalter Medical Center: Two -(2) Puff Inhalation Q4H (every 4 hours). -4. Fluticasone 110 mcg/Actuation Aerosol Showalter Medical Center: Two (2) Puff -Inhalation Showalter Medical Center (2 times a day). -5. Docusate Sodium 50 mg/5 mL Liquid Showalter Medical Center: One (1) PO BID (2 -times a day). -6. Carvedilol 12.5 mg Tablet Showalter Medical Center: Two (2) Tablet PO BID (2 times -a day). Tablet(s) -7. Mexiletine 150 mg Capsule Showalter Medical Center: One (1) Capsule PO Q8H (every -8 hours). -8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR Kenison: One (1) -Tablet,Rapid Dissolve, DR Kenison DAILY (Daily). -9. Bisacodyl 10 mg Suppository Kenison: One (1) Suppository Rectal -DAILY (Daily). -10. Sodium Chloride 0.65 % Aerosol, Spray Kenison: 12-17 Sprays Nasal -QID (4 times a day) as needed. -11. Ipratropium Bromide 0.02 % Solution November: One (1) Inhalation -Q6H (every 6 hours) as needed. -12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution November: One (1) - Inhalation Q4H (every 4 hours) as needed. -13. Artificial Tear with Lanolin 0.1-0.1 % Ointment November: One (1) -Appl Ophthalmic PRN (as needed). -14. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution November: One (1) - Inhalation Q6H (every 6 hours) as needed. -15. Warfarin 1 mg Tablet November: as directed Tablet PO DAILY -(Daily): target INR 2-2.5 -Pt to receive 7.5mg on 10-30. -16. Lisinopril 5 mg Tablet April: One (1) Tablet PO DAILY (Daily). - -17. Furosemide 80 mg Tablet April: One (1) Tablet PO BID (2 times -a day). - +na Discharge Disposition: -Extended Care - -Facility: -Blackwater Senior Care - Thomas Memorial Hospital +Home with Service Discharge Diagnosis: -- Ischemic Cardiomyopathy, ST Elevation Myocardial Infarction, -Coronary Artery Disease, Mitral Regurgitation, Cardiogenic Shock -- s/p Urgent CABG and Mitral Valve Repair on IABP -- Postoperative Stroke -- Postoperative Acute Respiratory Failure -- Postoperative Acute Renal Failure -- Postoperative Atrial Fibrillation/Flutter -- Postoperative Ventricular Tachycardia -- Postoperative Bradycardia -- Postoperative Anemia -- Postoperative Pleural Effusion -- Hypertension -- Hyperlipidemia -- Type II Diabetes Mellitus +renal failure +hyperkalemia Discharge Condition: -Stable. +deceased Discharge Instructions: -1)Please shower daily. No baths. Pat dry incisions, do not rub. -2)Avoid creams and lotions to surgical incisions. -3)Call cardiac surgeon if there is concern for wound infection. -4)No lifting more than 10 lbs for at least 10 weeks from -surgical date. - -Dineenp Instructions: -Dr. Smith 4-5 weeks, please call for appt -Cardiology clinic-Dr Kenison (EP) in 2-16 weeks, please call -for appt - - - -Completed by:2177-10-30" -"Name: Kelli,Elizabeth Unit No: 66109 - -Admission Date: 2183-7-12 Discharge Date: 2183-7-27 - -Date of Birth: 2127-9-2 Sex: F - -Service: MED - -Allergies: -Percocet / Codeine / Robaxin / Lomotil / Vancomycin And -Derivatives - -Attending:Courtney -Chief Complaint: -Fatique, fever - -Major Surgical or Invasive Procedure: -surgical removal of port. - - -Brief Hospital Course: -See prior addenda - -Discharge Medications: -additional d/c medication, insulin: - -Lantus(Glargine) - 13 Units q evening, Loftus Memorial Hospital. - -Discharge Disposition: -Extended Care - -Facility: -Blackwater House Nursing Home - Thundera - -Discharge Diagnosis: -Line sepsis from infected Lt. port; MRSA bacteremia +none +Followup Instructions: +NA -Discharge Condition: -Good - John Sorrell MD J60211121 -Completed by:2183-7-27" -"Admission Date: 2135-6-22 Discharge Date: 2135-7-2 +" +"Admission Date: 2182-7-23 Discharge Date: 2182-7-29 -Date of Birth: 2076-4-4 Sex: M Service: -HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old -male with a history of metastatic melanoma to bowel and known -pulmonary and CNS metastases status post craniotomy with -resection of the brain metastases. The patient presented -with a three day history of intermittent worsening and crampy -abdominal pain in the lower quadrants, worse on the right -than on the left. The pain was described as severe. The -patient had a bowel movement until the day prior to -admission. KUB on arrival in the Emergency Department showed -dilated loops of small bowel with air fluid levels. A CT -scan obtained shortly thereafter showed two large mesenteric -masses with erosion into small bowel and free perforation of -the more proximal segment of small bowel, as well as -mechanical mid small bowel obstruction. +This is an 84-year-old female who was initially evaluated for +progressive claudication and rest pain. She was hospitalized +2182-7-11 to 2182-7-12 during this admission she was evaluated by +Cardiology because of her known extensive coronary artery +disease. She underwent a P-Thal at that time which showed no +angina symptoms or ischemic electrocardiogram changes though +the nuclear report was negative for a reversal ischemic +effect however, due to the patient's high risk Cardiology +recommended a cardiac catheterization for further evaluation. +The patient refused cardiac catheterization and chose to be +discharged to home to take care of ""personal matters""before +undergoing any vascular surgery. + +The patient returns now for elective surgery. + +PAST MEDICAL HISTORY: No known drug allergies. + +ADMISSION MEDICATIONS: +1. Colace 100 mg at h.s. +2. Milk of Magnesia 30 cc's p.o. p.r.n. +3. Dulcolax suppository p.r.n. +4. Vicodin tablets, one q 4 hours p.r.n. +5. Nitroglycerin sublingual 0.4 mg p.r.n. +6. Glucotrol 10 mg b.i.d. +7. Lopressor 12.5 mg p.o. b.i.d. +8. Flagyl 500 mg three times a day. +9. Aspirin 325 mg p.o. daily. +10. Levaquin 500 mg q day. +11. Vitamin D complex 100 mg q day. +12. Vitamin C 500 mg q day. +13. Vitamin E 400 units q day. +14. Lasix 20 mg q day. +15. Oxycontin 20 mg q 12 hours. PAST MEDICAL HISTORY: -1. Metastatic melanoma with metastases to the lung, brain, -bowel, left flank - -MEDICATIONS: -1. Nexium 40 mg po qd -2. Flomax -3. Flonase -4. Compazine -5. Ambien 10 mg -6. Quinine 260 mg -7. Prednisone 10 mg po -8. 50 mcg fentanyl patch - -The patient had recently been on his first week to Taxol -dexamethasone therapy and had also been through four cycles -of IL-2/temozolomide for his metastatic melanoma. - -ALLERGIES: The patient has no known drug allergies. - -SOCIAL HISTORY: The patient had smoked one pack per day for -about 20 years, but quit 20 years ago. - -PHYSICAL EXAM: -VITAL SIGNS: Temperature 98.8??????, blood pressure 120/70, pulse -117, respiratory rate 20, O2 saturation 96% on room air. -GENERAL: The patient was awake and comfortable and appeared -well nourished. -HEAD, EARS, EYES, NOSE AND THROAT: No jugular venous -distention, no palpable nodes. Oropharynx was clear. -NECK: Supple. -HEART: S1, S2, tachycardic with no murmurs, rubs or gallops. -LUNGS: Clear to auscultation bilaterally. -ABDOMEN: Distended, nontender, no hepatosplenomegaly. There -were decreased bowel sounds. Abdomen was tense and was a 7 -cm subcutaneous mass on the left flank. -EXTREMITIES: There was no lower extremity edema, cyanosis or -clubbing. - -LABS: White cell count 9.8, hematocrit 13.8, platelets 947. -PT 12.8, PTT 21.5, INR 1.1. Chem-7 - sodium 136, potassium -4.8, chloride 98, bicarbonate 23, BUN 23, creatinine 0.6, -glucose 146, calcium 8.7, magnesium 1.8, phosphorus 4.2. - -HOSPITAL COURSE: The patient arrived in the hospital on the -evening of 6-22 and evaluation was initiated. The patient -was taken to the Operating Room late in the night of 6-22 -where, per the Operating Room note, tumors were discovered in -the ileum and jejunum with free perforation of both lesions. -The patient was then transferred to the Intensive Care Unit. -The patient was started on ampicillin, levofloxacin and -Flagyl. - -On postoperative day #2, which was 2135-6-25, the patient was -started on TPN. His antibiotics were continued. On -postoperative day #3, the patient was noted to have a -slightly increased temperature to 100.2??????. He was pan -cultured given the fact he had recently been on steroids. -His central line was also changed. During the course of the -day, the patient was agitated at one point and pulled his -A-line. Haldol was prescribed. - -On postoperative day #4, the patient appeared to be less -confused. He was transferred to the floor with a sitter. By -postoperative day #5, while the patient was on the floor, he -was appearing much more lucid, communicating appropriately -and the sitter was discontinued. The patient was continued -on total parenteral nutrition. Because of continued increase -in white cell count from 14.3 on postoperative day #4 to 16.0 -on postoperative day #5, the patient was sent for an -abdominal CT. Although no abscess was identified that could -explain the patient's increase in white cell count, the -patient was noted to have developed mural thrombus in his -abdominal aorta and in the left iliac artery. The patient -was also noted to develop some new bilateral pleural -effusions with some barium in the left lung base. On being -notified of these findings, the surgical team immediately -consulted the patient's neuro-oncologist and oncologist team -for advice on the propriety of placing the patient on -anticoagulation. - -The patient was seen by his neuro-oncologist on postoperative -day #6, which was the 4-29. The patient's -neuro-oncologist requested head CT be obtained to rule out -any new brain metastases with bleeding because this would -determine the patient's suitably for anticoagulation. The -head CTs were negative and per neuro-oncology, there was no -contraindication to anticoagulating the patient. The patient -was seen by his oncologist team also on postoperative day #6. -Oncology was of the opinion of the patient, was unsuitable -for anticoagulation with Coumadin or heparin but that aspirin -could be initiated. The patient was therefore started on -aspirin. - -The patient's steroids were also tapered beginning on -postoperative day #7. His fluconazole was discontinued. At -the suggestion of the patient's oncology team, the surgery -team also transfused the patient with 1 unit packed red blood -cells on postoperative day #8 for borderline low hematocrit -of 26.1. On postoperative day #7, the patient's diet was -changed from NPO to sips. The patient tolerated this well -and so on postoperative day #8, the patient was advanced to a -clear liquid diet and his TPN was discontinued. By the -evening of postoperative day #8, the patient was able to -tolerate a regular diet and on the day of discharge, which -was 2135-7-2, the patient had a regular breakfast without any -problems. Lindsey is to be discharged home with visiting nurse -assistant for wound care. Mr. Jeannette continues to have an -open vertical incision in the midline of his abdomen that -would require wet to dry dressings twice a day. +1. Coronary artery disease, status post myocardial +infarction in 2182-3-25, status post cardiac catheterization +with Triple vessel disease. +2. Diabetes mellitus Type II. +3. Hypertension. +4. Osteoarthritis. +5. Radiculopathy. +6. Psoriasis. + +PAST SURGICAL HISTORY: Status post hysterectomy and bilateral +oophorectomy in 2160. Status post cholecystectomy. Status +post Cesarean section times four. Status post bilateral +cataract surgery. + +PHYSICAL EXAMINATION: General appearance, alert and +cooperative female in no acute distress. Vital signs: 98.5, +98, 62, blood pressure 110/60. Respiratory rate 18, O2 sat +95% on room air. + +Head, eyes, ears, nose and throat examination: Pupils are +small, minimally reactive, equal bilateral. Cardiac exam is +regular rate and rhythm with no murmurs. Respiratory: Clear +the auscultation bilateral. Abdominal exam is unremarkable. +Extremities show right great toe gangrene, some erythema on +the right foot. Pulse exam shows Dopplerable posterior +tibial pulse. Left leg there is no dorsalis pedis pulse on +the right or the left and there is no posterior tibial pulse +on the right. The femoral pulses are dopplerable +bilaterally. + +HOSPITAL COURSE: The patient was brought to the preoperative +holding area. She underwent on 2182-7-23 a right iliofemoral +bypass graft with 8 mm Dacron and a right first toe +amputation. Her intraoperative course was complicated by +massive bleed requiring 11 units of packed red blood cells of +FFP and 750 cc's of crystalloid. The patient was admitted to +the SICU postoperatively for continued care. Her postop CBC +was white count 10.1, hematocrit 45.5, platelet count 48 K. +BUN 20, creatinine 1.1, K 4.1. Blood gases: 7.30, 39, 180, +18, -7. The Troponin was less than .3. + +Chest x-ray was without pneumothorax, Swann-Ganz was in good +position. Exam showed arm Dopplerable biphasic pulses, +popliteal, no Dorsalis pedis or posterior tibial. The +patient remained in the Intensive Care Unit postoperative day +one. Overnight events is low urinary output requiring volume +supplementation. White count 15.8, hematocrit 40.5 with a +platelet count of 55. BUN and creatinine remained stable. +Coags were normal. The right foot was warm with Dopplerable +biphasic posterior tibial but no dorsalis pedis, she had a +palpable femoral and the wounds were clean, dry and intact. + +The patient remained in the SICU, intubated until her +acidosis was corrected. She remained on Levofloxacin and +Flagyl perioperatively while lines were in place. +Postoperative day two there were no overnight events. She +remained hemodynamically stable. Her white count was 16.6, +hematocrit 38.3. BUN and creatinine remained stable. K of +3.9 which was supplemented. She was weaned and extubated. +She required Lasix for diuresis. + +Postop day three, the patient was transferred to the MICU for +continued monitor and care. Postoperative day four there +were no overnight events. She continued to do well, her +hematocrit was 36.9, BUN 26, creatinine 1.0, K 3.6. She was +tolerating orals well, her fluids were Hep-locked. Her +Levofloxacin and Flagyl were discontinued and Kefzol was +begun. The patient was transferred to the regular nursing +floor. Physical therapy was consulted for assessment for +discharge planning. + +Postoperative day two she continued to do well, she remained +afebrile, hemodynamically stable, incisions were clean, dry +and intact. Her amputation site was clean, dry and intact. +She had a dopplerable pulses bilaterally. Case management +began screening. The patient was transferred to +rehabilitation for continuing monitoring and care. Condition +was stable. At the time of discharge her hematocrit was +36.2. DISCHARGE MEDICATIONS: -1. Flomax -2. Flonase -3. Compazine -4. Ambien -5. Quinine -6. Prednisone 10 mg po qd -7. Protonix 40 mg po bid -8. Percocet 5 1 to 2 tablets by mouth every 4 to 6 hours -9. Levofloxacin 500 mg po qd x5 more days +1. Lasix 40 mg q day. +2. Acetaminophen 325 mg to 650 mg q day. +3. Heparin 5000 units subcutaneously q 12 hours. +4. Aspirin 325 mg q day. +5. Insulin sliding scale, please see flow sheet. +6. Albuterol and Ipratropium inhalers one to two puffs + q 4 hours p.r.n. +7. Metoprolol 12.5 mg b.i.d. hold for systolic blood + pressure of less than 100, heart rate less than 60. +8. Percocet tablets 5/325 mg one to two q 4 to 6 hours + p.r.n. for pain. -FOLLOW UP: The patient is to follow up with oncology on 7-18. The patient is to call Dr.Ervin office for -follow up appointment this coming week. +DISCHARGE DIAGNOSIS: +1. Right iliac occlusion with first right toe gangrene. + Status post right ileofem bypass with 8 mm Dacron and + a right first toe amputation. +2. Blood loss anemia, corrected. +3. Thrombocytopenia secondary to multiple transfusions, + stabilized. +4. Coronary artery disease stable. +5. Type 2 diabetes mellitus stable. +6. Hypertension controlled. +7. Osteoarthritis stable. - Barbara Sundberg, M.D. W92784896 - - -Dictated By:George -MEDQUIST36 - -D: 2135-7-2 10:51 -T: 2135-7-2 11:14 -JOB#: Job Number 18599 -" -"Admission Date: 2161-12-15 Discharge Date: 2161-12-22 - -Date of Birth: 2118-1-10 Sex: F - -Service: - -DIAGNOSIS: -Tracheal bronchial malacia. -HISTORY OF PRESENT ILLNESS: The patient is a delightful 43 -year-old woman who was found to have tracheal bronchial -malacia and has suffered from years of dyspnea on exertion, -persistent tracheal bronchitis and recurrent infections. She -is therefore admitted to undergo a right thoracotomy and -tracheoplasty. -HOSPITAL COURSE: The patient is admitted to the hospital and -underwent minimally invasive muscle sparring oscillatory -triangle thoracotomy with tracheal bronchoplasty on the day -of admission. She did well and was discharged without -problems. - - - - - - - Diane Lewis, M.D. C45888251 - -Dictated By:Vail + Charles Wells, M.D. N52931579 +Dictated By:Ellis MEDQUIST36 -D: 2162-4-5 05:00 -T: 2162-4-7 09:38 -JOB#: Job Number 33135 +D: 2182-7-29 13:44 +T: 2182-7-29 16:12 +JOB#: Job Number " -"Admission Date: 2163-11-21 Discharge Date: 2163-12-1 +"Unit No: 70286 +Admission Date: 2155-5-2 +Discharge Date: 2155-5-11 +Date of Birth: 2097-3-27 +Sex: M +Service: ENT -Date of Birth: 2086-12-16 Sex: M -Service: MEDICINE +PRIMARY DIAGNOSIS: Invasive thyroid cancer. -Allergies: -Patient recorded as having No Known Allergies to Drugs +PRIMARY PROCEDURE: Total thyroidectomy, central neck +dissection, resection of cricothyroid membrane. -Attending:Flossie -Chief Complaint: -CHF, ARF, Mediastinal lymphadenopathy +HISTORY OF PRESENT ILLNESS: Mr. Lloyd Tory is a 58-year- +old gentleman with a large anterior neck mass, known to be a +thyroid cancer. This mass is invasive into his cricothyroid +membrane. He presents for surgical correction. -Major Surgical or Invasive Procedure: -Bronchoscopy x 2 -Mediastinoscopy with lymph node biopsy - -History of Present Illness: -76M initially went to Davis Hospital hospital with L flank and sent -home with narcs. Represented with DOE, weight gain and L flank -pain. He reports that he has had intermittent DOE for year but -notice a sharp increase in his weight over a period of 10 days. -He gained 8-10lbs with associated LE swelling, but without -medication noncompliance, dietary changes, chest pain, -orthopnea, PND. This happened at the beginning of July and -his Lasix was increased from 40 to 60 daily. He also had a -holter revealing afib (rate 40-100), nuclear stress -(2163-11-1)without ischemia and normal ECHO on 2163-11-3 (mild AS, -mild MR). Upon arrival to the ED he was found to be hypotensive -with hyperkalemia and ARF (Cr ~4 from basline of 1.2) He was -sent to the floor, diuresed and then sent to the ICU after he -was hypotensive requiring dopamine and vasopressin. He had a -Swan-Ganz catheter placed on 11-19 and had renally dosed -dopamine. He was thought to be fluid overloaded and had a -transudative thoracentesis (amount removed unknown). He was -aggressively diuresed with Lasix and renally dosed Dopamine. His -renal function improved prior to transfer. -Swan numbers: -RA: 25 -RV: 55/20/10 -PA: 55/25 -PCW: 26 -His L flank pain was evaluated with a CT Abdomen and he was -found to have L nephrolithiasis and an exophytic cyst on the -lower pole of the L kidney. His pain has been controlled with -narcotics. -He had also been recieving Zyvox for presumed pneumonia and -solumedrol 60 mg q6h for presumed COPD. -He was transferred for evaluation of his mediatinal LAD. This -has been watched for seveal years and he has two non-FDG avid -PET CTs, most recently in 2163-6-26. He denies any B symptoms. -He does have decreased appetite, but has been active with -outside hobbies including golf and curling. The thoracics -service was contactTammy for this evaluation and it was suggested -that the patient be admitted to the MICU given his underlying -medical problems. - - -Past Medical History: PAST MEDICAL HISTORY: -==================== -AF, on coumadin at home -CRI Cr:1.6 -Chronic Anemia -CHF EF -Bladder CIS s/p BCG washout in 10/2163 -Colonic dysplastic lesions on bx -OSA- unable to tolerate CPAP -low grade NHL with diffuse stable LAD -AS -R popliteal artery endarterectomy -uretral stent -Gout -PVD -L CEA 2159 -UGIB 2161 -LLL lobectomy in 2135 -Nephrolithiasis - - -Social History: -EtOH: 2 martinis daily -Tobacco: quit 1ppd 25 yrs ago -outside hobbies included golf and curling +1. Urinary stricture. +2. Type 2 diabetes. -Family History: -no history of malignancy - -Physical Exam: -Tmax: 35.9 ??????C (96.6 ??????F) - -Tcurrent: 35.9 ??????C (96.6 ??????F) - -HR: 74 (67 - 75) bpm +MEDICATIONS: None -BP: 113/46(60) {112/46(60) - 113/57(71)} mmHg +ALLERGIES: No known drug allergies. -RR: 20 (20 - 24) insp/min +COURSE IN HOSPITAL: Mr. Tory was taken to the operating +room on 2155-5-2. He underwent a total thyroidectomy with +central lymph node dissection, as well as cricotracheal +resection. The start of the case was delayed as the nurses +and residents were unable to place a Foley catheter. +Intraoperative urology consultation was obtained. The patient +underwent a rigid cystoscopy in order to place a Foley +catheter. Dense strictures throughout his urethra were found. -SpO2: 96% +Postoperatively, Mr. Tory was observed in the PAC unit for +two nights. He was kept intubated until postoperative day #3. +No NG tube was placed for fear of damaging the area of the +cricotracheal resection and reconstruction. -Heart rhythm: AF (Atrial Fibrillation) -Physical Examination - -General Appearance: Well nourished, No acute distress - -Eyes / Conjunctiva: PERRL - -Head, Ears, Nose, Throat: Normocephalic, MMM +On postoperative day #1 Mr. Tory was noted to have some +runs of supraventricular tachycardia. An EKG was done and was +normal. His electrolytes were managed and this spontaneously +resolved. -Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) -Cervical adenopathy +On postoperative day #2 Mr. Horace calcium was noted to +trend down. He was started on calcium intravenously, as he +was still intubated. + +On postoperative day #3 Mr. Tory was weaned off the +ventilator, however, after extubation he became stridorous +with increasing work of breathing. He required reintubation. +For this reason he underwent a tracheostomy on the same day. + +Hematology oncology consultation was requested given the +invasive nature of the patient's thyroid carcinoma. + +On postoperative day #4 Mr. Tory was successfully weaned +off the vent and onto a tracheostomy collar. As his calcium +started to drop further, he was started on calcium twice a +day, as well as Rocaltrol 0.5 mcg daily. + +On postoperative day #5 the patient's cuff was taken down and +he was started on calcium, as well as Rocaltrol for dropping +calcium. + +He was seen by the speech and swallow team. The patient was +noted to have gross aspiration on his first few days of +swallow on 2155-5-7. However, the speech and swallow team +had a Passy-Muir valve placed for the patient, which he did +well with while awake and not eating. + +The patient was given a Passy-Muir valve by the speech and +swallow team, which he did well with when he was awake. + +On postoperative day #6 the patient was started on p.o. He +could also be started on p.o. medication including +liothyroxine 50 mcg p.o. daily and his calcium was increased +to 2 gm twice a day. His Rocaltrol was also increased to 0.5 +mcg p.o. daily. + +On postoperative day #6 urology was reconsulted to see if +there was any further recommendations to be made about his +Foley catheter. They recommended discontinuing his Foley and +catheterizing himself once per day. The patient received +adequate teaching in hospital and was prepared to do this +task by the time he went home. + +On 5-8, the endocrine service was consulted because of Mr. +Horace hypocalcemia. They recommended increasing his +calcium carbonate to 500 mg p.o. four times daily and +continue his Calcitrol at 0.5 mcg daily. They also +recommended changing the parathyroid hormone level. + +On postoperative day #7, Mr. Tory did have his Foley +removed and was taught to straight catheterize. His blood +sugars came under better control as he was started on +metformin. + +A radiation oncology consultation was obtained to see if +radiation would be of benefit for Mr. Tory, given the +aggressiveness of his cancer. + +On 2155-5-9, Mr. Tory was seen by speech and swallow +again. His speech and swallow examination revealed minimal +penetration with liquids and trace aspiration. They +recommended him receiving an oral diet, which he did +successfully. He was able to have his nasogastric tube +removed and was discharged home in stable condition on 2155-5-10. + +CONDITION ON DISCHARGE: Afebrile. Vital signs stable. +Patient was tolerating a full soft solid diet. His neck was +flat. His incision was clean, dry and intact. The +tracheostomy site was clean. Cranial nerves V-VII and Dr. Zbinden-XII +were intact. + +INSTRUCTIONS ON DISCHARGE: Mr. Tory is to followup with +Dr. Wheeler. He was instructed to call and make an +appointment. He is to call Dr.Erin office or +proceed to the closest emergency room if he experiences +fever, wound redness or drainage or any other significant +problems. Mr. Tory is to straight catheterize himself once +per day in order to keep his urethra patent. He is to +followup with a urologist, which will be coordinated by his +primary care physician. Mandi is also to followup with Dr. +Drake, of radiation oncology. The patient also has his +own private endocrinologist, whom he is to followup with. + +MEDICATIONS ON DISCHARGE: +1. Levoxyl 100 mcg p.o. daily +2. Calcitrol 0.25 mcg p.o. twice a day +3. Percocet 1-2 tablets p.o. q.4-6h p.r.n. for pain. +4. Famotidine 20 mg p.o. twice a day. +5. + Metformin 500 mg p.o. q.a.m. +6. Calcium carbonate 1250 mg p.o. twice a day. + + + + + Christopher Martinez, V48469443 + +Dictated By:Lamb +MEDQUIST36 +D: 2155-6-3 10:14:44 +T: 2155-6-3 15:05:13 +Job#: Job Number 33224 -Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), -III/VI holosystolic murmur @ apex, III/VI holosystolic murmur at -base -Peripheral Vascular: (Right radial pulse: Present), (Left radial -pulse: Present), (Right DP pulse: Present), (Left DP pulse: -Present) -Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: -Crackles : bilateral bases) -Abdominal: Soft, No(t) Non-tender, No(t) Bowel sounds present, -Distended, No(t) Tender: , No(t) Obese, hypoactive bowel sounds -Extremities: Right: Trace, Left: Absent, No(t) Cyanosis, No(t) -Clubbing +" +"Admission Date: 2183-12-31 Discharge Date: 2184-1-11 -Skin: Not assessed -Neurologic: Responds to: Not assessed, Movement: Not assessed, -Tone: Not assessed +Service: +ADMISSION DIAGNOSIS: +Right colon cancer. + +HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old +woman with a history of diabetes mellitus, hypertension and +elevated cholesterol who, on an evaluation as an outpatient, +was found to be anemic and a colonoscopy revealed a right +colon cancer in 2183-12-18. The patient was then +scheduled for elective right colectomy. + +PAST MEDICAL HISTORY: As above. + +MEDICATIONS ON ADMISSION: +Procardia 60 mg p.o. q.d. +Captopril 50 mg p.o. t.i.d. +Lipitor 10 mg p.o. q.d. +Insulin 409 units of NPH q.a.m. + +PAST SURGICAL HISTORY: The patient had an open +cholecystectomy in 2162. + +ALLERGIES: The patient had an allergy to penicillin. + +PHYSICAL EXAMINATION: Vital signs revealed a temperature of +98.8??????F, a heart rate of 100, a blood pressure of 136/59, +respirations of 18 and an oxygen saturation of 100% on room +air. In general, the patient was a pleasant, obese, elderly +woman. On head, eyes, ears, nose and throat examination, the +mucous membranes were moist. The neck had no +lymphadenopathy. The heart had a regular rate and rhythm. +The lungs were clear. The abdomen was soft. There was mild +right sided tenderness and the abdomen was nondistended. + +LABORATORY: The patient had a white blood cell count of +13,100 with a hematocrit of 35.5 and a platelet count of +543,000. Potassium was 4.0. BUN was 12 and creatinine was +0.7. Glucose was 130. + +RADIOLOGY: A chest x-ray showed no evidence of infiltrate or +metastatic disease. + +ELECTROCARDIOGRAM: An electrocardiogram had sinus rhythm at +100. + +HOSPITAL COURSE: The patient was admitted for bowel prep and +tolerated the bowel prep. On 2184-1-2, she underwent right +colectomy without complications. Postoperatively on that +night, the patient was stable. However, she required +intravenous fluid bolus for low urine output. + +On postoperative day #1, the patient continued to require +intravenous fluid boluses for urine output and developed a +persistent tachycardia. After receiving intravenous fluid +resuscitating without good response to intravenous fluid +bolus, the patient became short of breath and was transferred +to the Intensive Care Unit for further management. + +The patient was treated for congestive heart failure and was +ruled in for a myocardial infarction with electrocardiogram +changes and elevated levels of troponin. A cardiology +consultation was requested and an echocardiogram was +performed, which revealed a significantly decreased ejection +fraction of approximately 15% with severe hypokinesis and +akinesis of the inferior and lateral walls. The patient was +started on beta blocker and ACE inhibitor for afterload +reduction to optimize her hemodynamics. The patient was also +started on aspirin. + +Once her hemodynamics were optimized and diuresis of fluid +was initiated, the patient improved and, on postoperative day +#4, she was transferred back to the hospital floor. The +patient then soon passed flatus and was slowly advanced to a +regular diet. She was continued on Lasix diuresis as well as +beta blockade, afterload reduction and aspirin. + +The patient continued to do well with good response to +diuresis and improved pulmonary function and was saturating +well on room air and breathing comfortably. On postoperative +day #9, the patient was tolerating a regular diet and was +ambulatory with physical therapy. However, the patient +required significant assistance, which indicated a +rehabilitation transfer. + +On postoperative day #7, an ultrasound of the right upper +extremity was performed, which showed a cephalic vein deep +vein thrombosis, and the patient was started on Coumadin at +that time for treatment of the deep vein thrombosis as well +as for prophylaxis for the severe wall motion abnormality of +the heart. + +DISCHARGE DIAGNOSIS: +1. Right colon cancer. +2. Status post right colectomy on 2184-1-2. +3. Postoperative myocardial infarction. +4. Diabetes mellitus. +5. Hypertension. +6. Elevated cholesterol. +7. Right cephalic vein deep vein thrombosis. -Pertinent Results: -2163-11-22 Echo: The left atrium is elongated. The right atrium is -markedly dilated. The right atrial pressure is indeterminate. -There is moderate symmetric left ventricular hypertrophy. The -left ventricular cavity size is normal. Left ventricular -systolic function is hyperdynamic (EF>75%). Right ventricular -chamber size and free wall motion are normal. The aortic root is -mildly dilated at the sinus level. The ascending aorta is mildly -dilated. The aortic valve leaflets (3) are mildly thickened. -There is mild to moderate aortic valve stenosis (area 1.2 cm2). -No aortic regurgitation is seen. The mitral valve leaflets are -mildly thickened. Physiologic mitral regurgitation is seen -(within normal limits). [Due to acoustic shadowing, the severity -of mitral regurgitation may be significantly UNDERestimated.] -The tricuspid valve leaflets are mildly thickened. Moderate [2+] -tricuspid regurgitation is seen. There is moderate pulmonary -artery systolic hypertension. There is a small pericardial -effusion. There are no echocardiographic signs of tamponade. - -2163-11-23 Pathology report -1. Lymph nodes, 4L, biopsy (A-C): -Metastatic neuroendocrine neoplasm, most consistent with -carcinoid tumor, in two of ten lymph nodes/lymph node fragments. -2. Lymph nodes, 7, biopsy (D): -Metastatic neuroendocrine neoplasm, most consistent with -carcinoid tumor, in three of four lymph nodes/lymph node -fragments. See note. -3. Lymph nodes, level 7, biopsy (E): -Metastatic neuroendocrine neoplasm, most consistent with -carcinoid tumor, in one of two lymph nodes/lymph node fragments. -Note: -Immunohistochemical stains show the tumor cells are diffusely -positive for synaptophysin and chromogranin and are negative for -CK 7 and TTF-1. Rare tumor cells are positive for CK20. -Despite the negative TTF-1, the tumor is compatible with a lung -primary. Clinical correlation recommended. - -FLOW CYTOMETRY 11-23: -FLOW CYTOMETRY IMMUNOPHENOTYPING: - -The following tests (antibodies) were performed: HLA-DR, FMC-7, -Kappa, Lambda and CD antigens: 2,3,5,7,19,20,23, and 45. - - - -RESULTS: - -Three color gating is performed (light scatter vs. CD45) to -optimize lymphocyte yield. B cells comprise 34% of -lymphoid-gated events, are polyclonal, and do not express -aberrant antigens. T cells comprise 50% of lymphoid gated -events, and express mature lineage antigens. - -INTERPRETATION: -Non-specific T cell dominant lymphoid profile; diagnostic -immunophenotypic features of involvement by lymphoma are not -seen in specimen. Correlation with clinical findings and -morphology (see S08-85352) is recommended. Flow cytometry -immunophenotyping may not detect all lymphomas due to -topography, sampling or artifacts of sample preparation. - -11-23 Bronchial Washings: - Bronchial washing, left upper lobe: - - NEGATIVE FOR MALIGNANT CELLS. - - Reactive bronchial epithelial cells and alveolar - macrophages. - -ADDENDUM: Hematology slide 0559R of bronchoalveolar lavage (BAL) -was - reviewed and shows alveolar macrophages. No evidence of - malignancy. - -11-23 CXR: -FINDINGS: No pneumothorax. There is complete opacification of -the left lung, which is indicating collapse in the left upper -lung, likely due to mucus plug. There is overlapping -opacification, which was seen on the previous film, in the left -lower lung which might be postoperative, inflammatory, or -malignant and further evaluation is needed. - -There is a small right pleural effusion, unchanged. There is no -consolidation in the right lung. The right jugular line was -removed. - -2163-11-23 CXR Post-Bronch: - -FINDINGS: As compared to the previous examination, the left lung -is slightly better aerated. There is no evidence of left-sided -pneumothorax. In the right lung, in the middle lobe, some subtle -areas of atelectasis are seen. No evidence of larger pleural -effusions. - -2163-11-24 CXR: -PORTABLE CHEST RADIOGRAPH: Compared to recent studies of -2163-11-23, there is improved aeration of the left upper lung, -without evidence of new -pneumothorax. There persists opacification of the left perihilar -and left -lower lung, likely representing combination of pleural effusion -and -atelectasis, although underlying consolidation cannot be -excluded. There is also improved aeration of the right lung -although small right pleural effusion persists. - -2163-11-25 CXR: -REASON FOR EXAM: Status post mediastinoscopy and bronchoscopy. - -Since yesterday, diffuse opacification of the left lung is -overall unchanged, mostly in the perihilar and left lower lung -region, likely a combination of left pleural effusion and -atelectasis, possibly consolidation. Small right pleural -effusion is unchanged. The right lung is otherwise normal. There -is no other change. - -2163-11-25 CT Scan Chest: - -IMPRESSIONS: -1. Subcutaneous gas consistent with recent mediastinoscopy. A -small left -lower paratracheal collection containing fluid and gas could -represent post- procedural changes. Correlation with recent -procedure and clinical symptoms recommended. Multiple -mediastinal lymph nodes are noted. Larger soft tissue density in -the subcarinal region could represent lymphadenopathy or in the -right clinical context could also represent a hematoma. -Comparison with prior study if available could help -differentiate between the two. - -2. Status post left lower lobectomy with fibrotic changes and -atelectasis -noted in the left lung. Fluid collection with thick enhancing -rind in the -left posterior sulcus is chronic and organized. - -3. Nodule in the anterior left lung could represent rounded -atelectasis, -though in atypical location. Recurrent tumor cannot be excluded. - - -4. Moderate right dependent pleural effusion with associated -dependent -atelectasis of the left lower lobe. - -5. Left adrenal mass. Dedicated imaging of the adrenal glands -recommended -for further evaluation. There is also suggestion of -lymphadenopathy in the -retroperitoneum that is incompletely imaged. Small ascites noted -along the -dome of the liver. - -EKG 2163-11-27: -Normal sinus rhythm. Poor R wave progression, possibly related -to lead -placement. No other abnormality. No previous tracing available -for -comparison. - Intervals Axes -Rate PR QRS QT/QTc P QRS T -72 0 88 912-120-18471 - -OCTREOTIDE SCAN (SOMATOSTATIN) Study Date of 2163-11-29 -Reason: NHL AND LUNG CA BX SHOWED MALIGNANT NEUROENDOCRINE -NEOPLASM -Prelim findings c/w metastatic carcinoid, full report pending. - -2163-11-21 07:32PM GLUCOSE-130* UREA N-119* CREAT-2.2* -SODIUM-141 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-29 ANION GAP-16 -2163-11-21 07:32PM estGFR-Using this -2163-11-21 07:32PM CALCIUM-9.0 PHOSPHATE-5.3* MAGNESIUM-2.4 -2163-11-21 07:32PM URINE HOURS-RANDOM UREA N-828 CREAT-45 -SODIUM-LESS THAN -2163-11-21 07:32PM URINE OSMOLAL-427 -2163-11-21 07:32PM WBC-11.5* RBC-4.11* HGB-11.7* HCT-36.4* -MCV-88 MCH-28.4 MCHC-32.1 RDW-15.1 -2163-11-21 07:32PM NEUTS-96* BANDS-0 LYMPHS-2.0* MONOS-2 EOS-0 -BASOS-0 -2163-11-21 07:32PM PLT COUNT-389 -2163-11-21 07:32PM PT-33.9* PTT-43.6* INR(PT)-3.6* -2163-11-21 07:32PM URINE COLOR-Yellow APPEAR-Clear SP Gruwell-1.013 -2163-11-21 07:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG -GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR - -Other labs: -Hematology - COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct -2163-12-1 05:45AM 5.1 3.50* 10.0* 32.4* 93 28.7 31.0 14.6 -288 -2163-11-30 08:05AM 5.3 3.41* 9.9* 31.5* 92 29.0 31.3 14.7 -277 -2163-11-29 06:45AM 5.5 3.52* 10.3* 32.3* 92 29.3 31.9 15.1 -280 -2163-11-28 07:00AM 6.2 3.41* 9.9* 30.7* 90 28.9 32.1 15.4 -242 -2163-11-27 07:25AM 9.3 3.49* 10.1* 32.4* 93 29.1 31.3 14.5 -247 - - RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap -2163-12-1 05:45AM 96 18 1.0 147* 4.0 105 37* 9 -2163-11-30 08:05AM 81 20 0.9 145 4.0 108 34* 7* -2163-11-29 06:45AM 77 22* 0.9 1441 4.0 106 36* 6* -2163-11-28 07:00AM 79 27* 1.0 144 4.1 105 32 11 -2163-11-27 07:25AM 95 30* 1.0 143 4.0 106 33* 8 -2163-11-26 07:00AM 103 37* 0.9 143 4.2 107 33* 7* -2163-11-25 03:37PM 104 43* 1.0 147* 4.4 110* 33* 8 -2163-11-25 02:07AM 168* 60* 1.0 146* 4.3 110* 31 9 -2163-11-24 04:25AM 92 87* 1.2 150* 4.2 113* 31 10 -2163-11-23 07:05AM 97 115* 1.7* 147* 4.5 108 31 13 -2163-11-22 02:52PM 126* 2.0* -2163-11-22 05:34AM 122* 125* 2.1* 143 4.5 104 28 16 -DIG ADDED 9:08AM -2163-11-21 07:32PM 130* 119* 2.2* 141 3.8 100 29 16 - -2163-11-27 07:25AM BNP 7554*1 - - - CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron - -2163-12-1 05:45AM 8.9 3.2 2.2 -2163-11-30 08:05AM 9.0 3.4 2.3 -2163-11-29 06:45AM 9.0 2.8 2.3 -2163-11-28 07:00AM 8.6 2.7 2.2 - -HEMATOLOGIC calTIBC Ferritn TRF -2163-11-22 05:34AM 153* 270 118* -DIG ADDED 9:08AM -PROTEIN AND IMMUNOELECTROPHORESIS PEP IgG IgA IgM IFE -2163-11-22 05:34AM NO SPECIFI1 1700-410-4771 NO MONOCLO2 - - DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone -Bilirub Urobiln pH Leuks -2163-11-22 01:50PM NEG NEG NEG NEG NEG NEG NEG 5.0 NEG -Source: Catheter -MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE -RenalEp -2163-11-22 01:50PM 3* 2 FEW NONE <1 <1 -Source: Catheter -URINE CASTS CastHy -2163-11-22 01:50PM 9* -Source: Catheter - -OTHER BODY FLUID ANALYSIS WBC RBC Polys Lymphs Monos Macro Other - -2163-11-24 08:13AM 01 01 71* 8* 6* 15* 02 -BRONCHIAL LAVAGE - - -2163-11-25 3:37 pm SPUTUM Source: Expectorated. - - **FINAL REPORT 2163-11-27** - - GRAM STAIN (Final 2163-11-27): - <10 PMNs and >10 epithelial cells/100X field. - Gram stain indicates extensive contamination with upper -respiratory - secretions. Bacterial culture results are invalid. - PLEASE SUBMIT ANOTHER SPECIMEN. - -2163-11-24 8:13 am BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. - - **FINAL REPORT 2163-11-26** - - GRAM STAIN (Final 2163-11-24): - NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. - NO MICROORGANISMS SEEN. - - RESPIRATORY CULTURE (Final 2163-11-26): NO GROWTH, <1000 -CFU/ml. - -2163-11-23 7:10 pm TISSUE Site: LYMPH NODE - - GRAM STAIN (Final 2163-11-23): - 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR -LEUKOCYTES. - NO MICROORGANISMS SEEN. - - TISSUE (Final 2163-11-26): NO GROWTH. +DISCHARGE MEDICATIONS: +1. Lopressor 25 mg p.o. b.i.d. +2. Captopril 50 mg p.o. t.i.d. +3. Coumadin, adjust for INR of 2 to 3. +4. Lasix 40 mg p.o. b.i.d. +5. Daniel Finlay 20 mEq p.o. b.i.d. +6. Percocet one to two tablets p.o. every three to four +hours p.r.n. for pain. +7. Aspirin. +8. Clonidine patch. +9. Subcutaneous heparin. +10. Insulin sliding scale. - ANAEROBIC CULTURE (Final 2163-11-29): NO GROWTH. - ACID FAST SMEAR (Final 2163-11-24): - NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. - ACID FAST CULTURE (Preliminary): - FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. + Richard Lavender, M.D. H33349570 - POTASSIUM HYDROXIDE PREPARATION (Final 2163-11-24): - NO FUNGAL ELEMENTS SEEN. +Dictated By:Jordan +MEDQUIST36 - LEGIONELLA CULTURE (Final 2163-11-30): NO LEGIONELLA -ISOLATED. +D: 2184-1-10 22:06 +T: 2184-1-10 22:56 +JOB#: Job Number 104767 +" +"Name: William, Joshua Unit No: 82021 - Immunoflourescent test for Pneumocystis jirovecii (carinii) -(Final - 2163-11-24): NEGATIVE for Pneumocystis jirovecii -(carinii).. +Admission Date: 2125-7-3 Discharge Date: 2125-7-8 +Date of Birth: 2044-5-5 Sex: M -Brief Hospital Course: -76M initially admitted to Davis Hospital hospital for CHF -exacerbation, and then transferred ICU-to-ICU for workup of -chronic mediastinal LAD. Thoracic Surgery had been contactTammy -and was interested in seeing the patient and deemed that he -would be most appropriate for MICU given his ongoing ARF. While -in the ICU his renal function improved with gentle intravascular -hydration. Echo was performed which revealed severe diastolic -dysfunction with ejection fraction of >70%. His digoxin was -therefore discontinued. He was discharged to the floor after -~24 hours of observation. - -While on the medical service, the patient was brought to the OR -on 2163-11-23 for Flexible bronchoscopy with bronchoalveolar -lavage of the left upper lobe, cervical mediastinoscopy and -bronchoscopy. On post-op CXR there was noticeable whiteout of -the left lung field and the patient was kept in the PACU for -observation. He was treated with Chest PT, IS and suctioning -for the thought of possible mucus plugging. As per -documentation, the patient was doing well until the morning when -he had increasing oxygen requirements and more labored -breathing. At 8am on 2163-11-24 the patient underwent -unremarkable bronchoscopy by IP. Patient continued to have a -significant oxygen requirement, satting 93% on 40% facemask, -thus was transferred to the ICU for monitoring. - -In ICU on 11-25, patient underwent upper airway suctioning, -along with albuterol, ipratropium, and mucinex treatment. He -utilized incentive spirometry as well. Serial chest x-rays -showed eventual clearing of his left lung. His oxygen saturation -improved to 100% on 4L. He underwent a chest CT which showed a -large right pleural effusion and left airspace disease possibly -consistent with pneumonia. he continued to produce increasing -amounts of airway mucous. Though he did not spike a fever or -develop a leukocytosis, he was started on empiric coverage for -hospital acquired pneumonia with vancomycin and zosyn. This was -continued for a total of 4 days, and then discontinued. His -respiratory status continued to improve, and he was weaned down -to 2L NC O2, and often maintained O2 sats > 94% on room air at -rest. - -He was transferred from the ICU to the medicine floor on 11-25, -where the below issues were addressed: - -Hypoxia: Thought to be due to mucus plugging in setting of -procedure. Given the acuity of both the change and the reversal -it is likely that he experienced lung collapse and then -reaeration of expectorating mucus. Received 4 days of vanc/zosyn -for presumed HAP coverage in setting of hypoxia and increased -sputum production, this was d/c'd 11-28 with no additional fevers -and decreasing sputum. He was continued on ipratropium nebs, -mucomyst nebs, guaifenesin, incentive spirometry. During his -stay, his oxygen requirement was weaned, now requiring 2L NC -only intermittently. Will continue albuterol and ipratropium -nebs on a prn basis. -. -Hypernatremia: Na as high as 150, did decrease with IVF but -still mildly elevated on transfer to floor. Improved to 147 -with D5W. IV hydration stopped at this time and POs encouraged -given risk of CHF. Free water deficit estimated at 2.3L on -transfer to floor. Na remained stable in range of 143-147 when -taking more PO fluid. Recommend continued intermittent -monitoring. - -LAD: s/p mediastinoscopy. -His mediastinal lymph node biopsy results were consistent with -carcinoid. The hematology/oncology service was consulted, and -they recommended getting an octreotide scan, the preliminary -read showed metastatic carcinoid. These results were discussed -with the patient and his outpatient oncologist. The patient -requested to be followed by his oncologist in Lewis Memorial Hospital. -. -diastolic Congestive Heart Failure: ECHO with EF of 75%, has -severe dCHF. Cards consulted while in ICU. Digoxin was -discontinued in setting of diastolic CHF. Cardiology -recommended using either BB or verapamil to control HR, goal to -have <80. HR was well controlled without meds on transfer from -ICU. Added Metoprolol 12.5 mg Meredith Medical Center on 11-26, though this was -d/c'd 11-27 for episodes of bradycardia to 30s. Added 12.5 -Metoprolol SR 11-28, which he has tolerated well. Also added -Candesartan at low-dose (4mg, home dose 16 mg) given h/o -diastolic CHF and goal of reducing afterload. This can be -titrated up as his blood pressure allows. He did have some -increased edema during his stay on the medical floor, and was -given TEDs stockings and encouraged to ambulate. He also -received 40 mg IV lasix x 1 2163-11-28, and an additional dose of -40 mg po on 11-30 and 40mg IV on 12-1. The long-term goal -remains to minimize diuretics, but use extreme caution with -fluids as pt is exquisitely volume sensitive due to severity of -dCHF. Discharged with instructions to continue home lasix (40 -mg) for 3 days with monitoring of daily weights and chemistries, -this may need to be reassessed and monitored. -. -RHYTHM: He has chronic afib. His heparin was held after -surgery. He was restarted on coumadin 1.25 mg daily on 11-26. -His INR rose to the therapeutic range, and was 2.5 on discharge. - Recommend intermittent monitoring to tritrate necessary dosing -regimen. -. -ARF: Improved with hydration. Renal signed off prior to transfer -to floor. Diuresis minimized on the floor, received 40 mg IV -lasix and 40mg PO lasix on two occasions with good diuresis, pt -maintained blood pressures. The goal continues to be to -minimize diuresis to prevent excessive preload reduction. -. -CAD: He was continued on his statin, held ASA due to h/o GI -bleed +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. -Medications on Admission: -PPI -Lipitor 10 -Atacand 16 (confirmed with spouse) -Digoxin 0.125 mg qd -Aldactone 25 qd -Lasix 40 qd -Allopurinol 100 mg qd -Verapamil 180 qd -Coumadin 2.5 (MWF); 1.25 (TTSS) -Flomax 0.5 +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. -Discharge Medications: -1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr -Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). -2. Warfarin 1 mg Tablet Sig: 1.25 Tablets PO DAILY (Daily). -3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One -(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). -4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY -(Daily). -5. Candesartan 4 mg Tablet Sig: One (1) Tablet PO daily (). -6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) -Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. -7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a -day) as needed. -8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 -times a day). -9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for -Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as -needed. -10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb -Inhalation Q6H (every 6 hours) as needed. -11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 3 -days. +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 Disposition: -Extended Care +DISCHARGE STATUS: The patient was discharged to home. -Facility: -Lianes Medical Center - Thundera +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. -Discharge Diagnosis: -Primary: -Mediastinal Lymphadenopathy -Metastatic Carcinoid -Acute renal failure -Secondary: -chronic diastolic congestive heart failure -anemia -atrial fibrillation -chronic renal insufficiency -Discharge Condition: -fair, tolerating PO, afebrile, VS wnl, O2 95-100% on -supplemental O2 2L Tomblin Hospital transfer to chair with assist + Joseph Nelson, M.D. +I38071681 +Dictated By:Elmer -Discharge Instructions: -You were admitted to the hospital with mediastinal -lymphadenopathy. You had a mediastinoscopy and bronchcoscopy. -The pathology reports showed this was consistent with carcinoid. - You were seen by the oncologists, who recommended an Octreotide -scan; you indicated you would like to follow up with your -outpatient oncologist. - -You were also noted to have an exacerbation of your heart -failure. You were seen by the cardiologists, who recommended -you stop your digoxin. You were given diuretics to remove -fluid. You also had acute renal failure, which resolved during -your stay. -. -A CT scan showed a mass on your left adrenal gland, this should -be worked up as an outpatient, you should talk with your primary -care doctor about further evaluation. -. -The following changes were made to your medications: -Your digoxin, verapamil and aldactone were stopped -Your atacand dose was decreased to 4 mg -You were started on metoprolol -You were started on docusate, senna, and bisacodyl as needed for -constipation and albuterol and ipratropium nebs as needed for -SOB/wheezing -Your allopurinol and flomax were held, these can be restarted -during your rehab stay -Your coumadin was decreased to 1.25 mg daily, this can be -adjusted based on your INR -. -Please call your doctor or return to the ED for: -- fevers/chills -- shortness or breath or chest pain -- increasing sputum production -- weight gain > 3 lbs -- any other new or concerning symptoms +MEDQUIST36 -Followup Instructions: -Follow up with your primary care provider, Cooper. Audry Hall -(576-277-8956, within 1 week of leaving rehab. On a CT scan, -you were noted to have a mass on your left adrenal gland, and -they recommended dedicated CT or MRI for better -characterization. Dr. Mora should help you this setting this -up. +D: 2125-10-3 17:05 +T: 2125-10-4 07:13 +JOB#: Job Number 18338 +" +"Unit No: 19413 +Admission Date: 2197-8-9 +Discharge Date: 2197-8-9 +Date of Birth: 2197-8-9 +Sex: F +Service: NB + + +HISTORY: Baby Girl Judy is the 2.025 kg infant born via C- +section for failure to progress at 34-3/7 weeks gestation +with an estimated date of confinement of 2197-9-17. +She was born to a 30-year-old gravida 1, para 0 mother with +prenatal screens blood type B negative, antibody negative, +RPR nonreactive, rubella immune, hepatitis B negative and GBS +unknown. Pregnancy was complicated by a late diagnosis on +fetal ultrasound of polyhydramnios and duodenal atresia. The +mom was seen and brought to the hospital. She was noted to +have fetal anomaly. She was transferred to Anderson Memorial Hospital for further management. The mom +reported that she had been leaking amniotic fluid for the +past 2 weeks, but prior to deliver, she was noted to have a +bulging bag which was ruptured at 10 p.m. the night before +delivery. The infant was born again by cesarean section for +failure to progress with Apgar scores of 7 and 8. In the +delivery room, there was late clampage of the cord with a +minimal amount of blood loss. The infant was transferred to +the NICU for further management. + +FAMILY HISTORY: Mom has history of HSV with her last +outbreak 9 years ago. The family has a 9-year-old niece who +has trisomy 21. + +SOCIAL HISTORY: The parents are married. The mother denied +any tobacco, alcohol or drugs. + +PHYSICAL EXAMINATION ON ADMISSION: The infant was in bed in +no apparent distress. Some facies typical of Down syndrome or +trisomy 21. Her temperature was 98.5, heart rate 175, +respiratory rate 46, blood pressure 63/49 with a mean of 54, +oxygen saturation 100% on room air. Her D-stick was 66. Her +weight was 2215 gm which is the 50th percentile. The head +circumference was 31.5 cm which is 25th-50th percentile, and +her length was 47 cm which is the 90th percentile. HEENT: +There was molding of the head with a moderate caput noted on +the left temporoparietal region. Her anterior fontanelle was +open and flat. Her palate was intact. She had flat facies +with slanted palpebra fissures. Her red reflux was present +bilaterally. No Brushfield spots were noted. Her tongue was +protruding, and her ears were small. Her neck was supple. Her +skin was pink, clear. Her lungs were clear to auscultation +bilaterally. CV had regular rate and rhythm with no murmur. +Femoral pulses were 2+ bilaterally. GU: She had immature +female external genitalia. Her anus was patent. Her spine was +midline. Her clavicles were intact. Her extremities were warm +and well perfused with brisk capillary refill. She had mild +clinodactyly noted on bilateral fifth digits, left greater +than right. She had normal palmar creases. She had sandal +toes present. Neurologically, she had globally decreased +tone, but she had a normal suck. + +HOSPITAL COURSE: Respiratory: She was on room air and +remained comfortable throughout the hospitalization. + +Cardiovascular: She was stable without issues. She should +likely have an echocardiogram for evaluation. + +Fluids, electrolytes and nutrition: Her D-stick was stable. +She was made n.p.o. She was maintained on IV fluid of D10 at +60 mL/kg per day. + +GI: She was noted to have duodenal atresia confirmed by x- +ray. Surgery was consulted. + +Hematology: She had a hematocrit of 41 and plt count 231 prior to +discharge. + +Infectious disease: There is a potential history of prolonged +rupture of membranes. She had a CBC that showed wbc count 12.2 +(69P 0B 27L). Blood cultures were sent prior to discharge. She +did not start on antibiotics. + +Neurology: She seemed neurologically intact at the time. + +Genetics: She had a karyotype and a FISH for trisomy 21 sent +prior to discharge. + +Sensory: Hearing screen was not performed. We recommend one +prior to her discharge to home. + + +CONDITION ON DISCHARGE: Stable. + +DISCHARGE DISPOSITION: To Vasquez Hospital NICU. + +PRIMARY CARE PEDIATRICIAN: The parents cannot recall at this +time, but they said that physician is in Lynda. + +CARE AND RECOMMENDATIONS: +1. Feeds at time of discharge: N.p.o. on IV fluids. +2. Medications: None. +3. Car seat positioning should probably be done prior to + discharge. +4. State newborn screen: One was drawn prior to discharge but + because the infant was less than 24 hours old and not yet + feeding, a repeat will need to be done. +5. Immunizations received: None. +6. Immunization recommendations: RSV prophylaxis should be + considered from March through December for infants who + meet any of the following 4 criteria - (a) born at less + than 32 weeks; (b) born between 32 and 35 weeks with 2 of + the following - daycare during RSV season, a smoker in + the household, neuromuscular disease, airway + abnormalities, school age siblings; (c) chronic lung + disease; (d) hemodynamically significant chronic lung + disease. +7. Influenza immunization is recommended annually in the + fall for all infants once they reach 6 months of age. + Before this age and for the first 6 months of the child's + life, immunization against influenza is recommended for + household contacts and out of home caregivers. +8. This infant has not received Rotavirus vaccine. The + American Academy of Pediatrics recommends initial + vaccination of preterm infants at or following discharge + from the hospital if they are clinically stable and at + least 6 weeks but fewer than 12 weeks of age. -Follow up with your cardiologist Dr. Morales Carol 118-669-6208, -fax 186-417-7342 within the next 2-3 weeks for reevaluation and -adjustment of heart failure meds as needed. +DISCHARGE DIAGNOSES: +1. Prematurity at 34-3/7 weeks. +2. Possible trisomy 21. +3. Possible sepsis. +4. Duodenal atresia. -Oncology Dr. Gean 989-690-8790. You have an appointment on -12-13 at 1:20 PM, call if you need to reschedule or be -seen sooner. + Robert Pamela, MD N25676134 +Dictated By:Tobin +MEDQUIST36 +D: 2197-8-9 14:49:15 +T: 2197-8-9 15:19:36 +Job#: Job Number 74014 " -"Admission Date: 2139-2-27 Discharge Date: 2139-3-10 +"Admission Date: 2118-4-26 Discharge Date: 2118-5-6 +Date of Birth: 2068-7-18 Sex: F -Service: +Service: #58 -ADMITTING DIAGNOSIS: Barrett's esophagus with high grade -dysplasia. +HISTORY OF PRESENT ILLNESS: The patient is a 49 year-old +woman diagnosed with metastatic renal cell cancer with spinal +and pelvic mets on 2118-3-27. The patient had a bony +destruction of the left pedicle of L3 as well as posterior +elements on the left side of L3 with impingement on the L3 +nerve root without evidence of cord compression. The patient +is preoped for lumbar embolization, renal embolization +followed by left radical nephrectomy and removal of the L3 +vertebra and L2-L4 spinal fusion. -DISCHARGE DIAGNOSES: -1. Barrett's esophagus with high grade dysplasia. -2. Status post trans-hiatal esophagectomy. -3. Aspiration. -4. Myocardial infarction. -5. Cardiogenic shock. -6. Anoxic encephalopathy. -7. Death. - -HISTORY OF PRESENT ILLNESS: The patient is an 84 year old -male who had a long standing history of gastroesophageal -reflux disease and Barrett's esophagus and had high grade -dysplasia diagnosed on recent endoscopy. The patient elected -to have an esophagectomy performed. +PAST MEDICAL HISTORY: None. -PAST MEDICAL HISTORY: -1. Hypertension. -2. Question renal insufficiency. -3. Gastroesophageal reflux disease. +PAST SURGICAL HISTORY: None. MEDICATIONS: -1. Norvasc. -2. Prilosec. -3. Carafate. - -PHYSICAL EXAMINATION: On admission, the patient is an -elderly man in no acute distress. Vital signs are stable. -Afebrile. Chest is clear to auscultation bilaterally. -Cardiovascular is regular rate and rhythm without murmur, rub -or gallop. Abdomen is soft, nontender, nondistended without -masses or organomegaly. Extremities are warm, not cyanotic -and not edematous times four. Neurological is grossly -intact. - -HOSPITAL COURSE: The patient was taken to the Operating -Room on 2139-2-27, where he underwent transhiatal -esophagectomy without significant complication. In the -postoperative course, he was initially admitted under the -Intensive Care Unit care and kept in the Post Anesthesia Care -Unit overnight. The patient was seen to have a low urine -output and both metabolic and respiratory acidosis and was -given approximately 8.5 liters of Crystalloid in the -perioperative period, including OR. - -The patient was briefly agitated in the Post Anesthesia Care -Unit and discontinued his nasogastric tube. On postoperative -day number one, the patient was doing well with a fairly -normalized blood gas of 7.35/43/94/25/minus 1 and was -transferred to the floor. - -On postoperative day two, the patient was seen to have a -baseline oxygen requirement of 70% face mask in the morning -but was saturating well and otherwise seemed to be doing -relatively well. - -The patient had a white count of 22.1 which prompted a chest -x-ray showing bilateral pleural effusion and patchy bibasilar -atelectasis but no focal infiltrates. Over the course of the -day, the patient had deteriorating in his respiratory status -and became increasingly tachypneic with wheezing and coarse -breath sounds. - -An EKG was performed which showed atrial fibrillation but no -ischemic changes. A baseline arterial blood gas was obtained -at that point which was 7.37/47/86/28/zero, again on 70% face -mask. - -Intravenous fluids were then stopped and the patient was -begun on 20 mg of intravenous Lasix and albuterol nebulizers. -The patient was transferred to another floor for Telemetry -purposes and cycled for myocardial infarction. His -respiratory status during transfer seemed somewhat improved. -Upon arrival to the other floor, the patient stopped -respiring briefly and went bradycardic. Upon stimulation, he -was tachycardic to the 110s with a blood pressure 130/70. - -Immediately subsequent to that the patient went pulseless and -into respiratory and cardiac arrest and was down for -approximately two to three minutes. CPR was begun and the -patient intubated and 15 to 20 cc. of brownish fluid was -suctioned from the endotracheal tube post intubation. - -The patient regained pulse and cardiac activity and was -transferred to the Intensive Care Unit. - -Cardiac consultation at that time recommended aspirin, -cycling enzymes and agreed with probable aspiration event. -They suggested a heparin drip but not is surgically -contraindicated. A heparin drip was not started. The -patient ruled in for myocardial infarction with a troponin of -26.5. - -In the patient's Intensive Care Unit stay, he was supported -with a dopamine drip and diuresed for fluid overload. -Pressors were weaned off on postoperative day number eight. -Respiratory function was supported throughout his Intensive -Care Unit course appropriately with mechanical ventilation. - -The patient was noted to be unresponsive after the aspiration -event, with some slow return of responsiveness over the next -several days, but no purposeful movement. To evaluate -possible neurologic injury, a CT scan was obtained after the -patient was felt to be stable enough to be transferred. - -On postoperative day six, the CT scan showed no acute -intracranial event but was consistent with chronic -microvascular infarction. EEG was also obtained which -revealed diffuse widespread encephalopathy. There was a -question of possible seizure activity involving the left -upper extremity and phenytoin was begun empirically. - -A repeat EEG was obtained on postoperative day number 10 and -again showed moderately severe diffuse encephalopathy with no -seizure focus. - -A Neurology consultation was obtained and assessed the -patient to have minimal chance for a meaningful recovery. - -In accordance with the patient's living will, the family's -wishes and discussion with the surgical attending, the -patient was made comfort measures only and expired on -postoperative day number 11. - - - Joshua Guttmann, M.D. P39287153 - -Dictated By:Branch - +1. Oxycontin SR. +2. Percocet. +3. Colace. +4. Ambien. + +PHYSICAL EXAMINATION: In general, the patient was awake, +alert and oriented times three, pleasant, cachectic looking +female. Temperature 100. Blood pressure 120/62. Heart rate +117. Respiratory rate 18. Sat 98%. Pupils are equal, round +and reactive to light. Mucous membranes are moist. Neck was +supple. Pulmonary clear bilaterally. Cardiac tachy S1 and +S2 within normal limits. Abdomen soft, nontender, +nondistended. Positive bowel sounds. Extremities no edema. +Back there was no swelling in the lumbar area. +Neurologically the patient was awake, alert and oriented +times three. Cranial nerves II through XII were intact, +mildly symmetric. She had no drift. Her strength was 5 out +of 5 in all muscle groups. Her sensation was intact to light +touch. She was hyperreflexic throughout with clonus of the +left lower extremity. + +PREOPERATIVE LABORATORIES: Sodium was 137, K 4.9, chloride +99, CO2 29, BUN 15, creatinine .8, glucose 154. + +HOSPITAL COURSE: The patient was preoped for a embolization +of her lumbar spine area, which was done on 2118-4-28 without +complications. The patient was monitored in the Intensive +Care Unit postoperatively. The patient then underwent an +embolization of her right kidney on 2118-4-28 without +complications. She was again monitored in the Intensive Care +Unit and then preoped for the Operating Room for left +nephrectomy and L3 vertebrectomy with L2 to L4 fusion. She +had this on 2118-4-29. She tolerated the procedure well. +There were no intraoperative complications. She was again +monitored in the Intensive Care Unit. Postoperatively she +was fitted for a TLSO brace. She remained on flat bed rest. +She was moving both lower extremities with good strength. +Her dressings were clean, dry and intact. She had a chest +tube in place, which was draining serosanguinous fluid. She +also had a JP drain in place. JP drain was removed on +2118-5-2. The patient's brace was brought in on 2118-5-2 and +the patient was out of bed on 2118-5-2. Chest tube was +removed on 2118-5-3 and she was out of bed in her brace. +Her strength remained 5 out of 5 in all muscle groups. She +was awake, alert and oriented times three and afebrile. She +was transferred to the floor on 2118-5-3 and continued to do +well and continued to be followed by physical therapy and +occupational therapy and was found to be safely discharged to +home. She was discharged to home on 2118-5-6 in stable +condition with follow up with Dr. Riddle on Tuesday the 17th +at 10:40 a.m. for staple removal. She will follow up with +Dr. Mcdavid on 5-23 and with the oncology people on 5-18. + +CONDITION ON DISCHARGE: Stable. She was afebrile. Her +dressing was clean, dry and intact. + +MEDICATIONS ON DISCHARGE: +1. Percocet one to two tabs po q 4 hours prn. +2. Nystatin 5 cc q.i.d. prn. +3. Lasix 20 mg po q.d. times one day and then discontinued. +4. Hydrocodone sustained release 30 mg po q.a.m. +5. Hydrocodone 40 mg one tab at bedtime. +6. Calcium carbonate 500 mg t.i.d. +7. Phosphorus one packet b.i.d. for three days. +8. Zolpidem tartrate 5 mg at h.s. prn. +9. Lorazepam .5 mg q 4 to 6 hours prn. + + + + + + + Laura Clark, M.D. M16484198 + +Dictated By:Imai MEDQUIST36 -D: 2139-3-24 10:08 -T: 2139-3-28 16:18 -JOB#: Job Number 48824 +D: 2118-5-6 11:48 +T: 2118-5-6 12:13 +JOB#: Job Number 48401 " -"Admission Date: Discharge Date: +"Unit No: 96586 +Admission Date: 2157-1-29 +Discharge Date: 2157-1-31 +Date of Birth: 2157-1-29 +Sex: F +Service: NB + + +HISTORY: This infant was born at 34-6/7 weeks gestation with +an EDC of 2157-3-7 born to a 29-year-old G3, P0 (now 1) +mother with a prenatal screen as follows: Blood type A+, +antibody negative, RPR nonreactive, rubella immune, GBS +negative. Mother had a history of positive PPD on 2152-6-21 which she was treated for 9 months at that time and a +follow-up chest x-ray was negative. This pregnancy was +complicated by possible rupture of membrane on 2157-1-29. There was also some concern for maternal UTI on 2157-1-25 due to increased urinary frequency. The morning of +delivery, the mother was induced due to PPROM. Labor was +uncomplicated. The infant was vigorous at birth and received +only blow-by oxygen in the Delivery Room. She had Apgars of 7 +and 8 at 1 and 5 minutes and was transferred to the NICU for +further management of prematurity. + +FAMILY HISTORY: Mom was treated for chlamydia in 2156-5-4 +but otherwise noncontributory. + +SOCIAL HISTORY: Mom smokes 7 cigarettes daily. Father of the +baby is mother's boyfriend, Donald. + +MEASURES AT BIRTH: Weight of 2550 gm which is 75th +percentile, head circumference of 30 cm which is 10th-25th +percentile, length of 47 cm which is 50th-75th percentile. + +DISCHARGE PHYSICAL EXAMINATION: Active, alert female infant. +HEENT: Anterior fontanel soft and flat with mild __________ +molding, small caput. Intact palate. Normal facies. Bilateral +red reflexes. Respiratory: Breath sounds clear and equal with +slight retractions, comfortable respirations. Cardiac: Normal +rate and rhythm. Normal S1/S2, no murmur. Normal pulses. +Brisk capillary refill. Abdomen: Soft and round with active +bowel sounds. Patent anus. GU: Normal preterm female. +Musculoskeletal: Normal spine. Straight spine. No sacral +dimple. Intact hips. Moves all extremities well. Neuro: +Normal reflexes, tone. Good suck. + +SUMMARY OF HOSPITAL COURSE BY SYSTEMS: +1. Respiratory: Breath sounds are clear and equal. This + infant has remained on room air since admission to the + NICU. Has had no issues with apnea, bradycardia, or + desaturations. +2. Cardiovascular: Infant has had no cardiovascular issues. + Normal heart rates and blood pressures have been + observed. +3. Fluid/electrolytes/nutrition: The infant was started on + ad lib p.o. feedings with ___________ 20 cal/ounce. She + is voiding and stooling normally. The weight at + discharge is 2475 gm which is down 25 gm from birth + weight. No electrolytes have been measured on this baby. +4. GI: Bilirubin was done at 40 hours of age and the + bilirubin was 9.4/0.3. It is recommended to do a repeat + bilirubin check on 2157-2-1 with the + pediatrician. +5. Hematology: Mother's blood type is A+, DAT negative. + Infant's blood typing was not done. There was a CBC + drawn at birth to rule out sepsis. The hematocrit on + that CBC was 62 with 285,000 platelets. There have been + no further hematocrits or platelets measured. Infant has + required no blood product transfusions. +6. Infectious disease: CBC and blood culture were screened + on admission due to the PPROM and preterm labor. The CBC + was benign. The infant received 48 hours of ampicillin + and gentamycin which were subsequently discontinued when + the blood culture remained negative at that time. +7. Neurology: The infant has maintained normal neurologic + exam for gestational age. +8. Sensory: + a. Audiology: A hearing screen was performed with + automated auditory brain stem responses and the infant + passed in both ears. +9. Psychosocial: There are no active issues at this time. + Parents are unmarried. Father of the baby is involved. + If there are any psychosocial concerns, the social + worker can be reached at 349-753-6799. + +CONDITION ON DISCHARGE: Good. + +DISCHARGE DISPOSITION: Home with parents. + +PRIMARY PEDIATRICIAN: Sharon Brunson, 439-643-4464. + +CARE RECOMMENDATIONS: Ad lib p.o. feedings of ___________ 20 +cal/ounce. Medications: None. + +IRON AND VITAMIN D SUPPLEMENTATION: +1. Iron supplementation is recommended for preterm and low + birth weight infants until 12 months corrected age. +2. All infants fed predominantly breast milk should receive + vitamin D supplementation at 200 international units + which may be provided as a multivitamin preparation + daily until 12 months corrected age. + +__________ This infant has passed the car seat position +screening test. +State newborn screen was sent on 2156-10-31: Result is +pending. +Immunizations received: ____________. +Immunizations recommended: ____________. +A follow-up appointment is recommended with the pediatrician +on 2157-2-1. -Date of Birth: Sex: M +DISCHARGE DIAGNOSES: +1. Prematurity born at 34-6/7 weeks gestation. +2. Sepsis ruled out. +3. Mild hyperbilirubinemia ongoing. -Service: UROLOGY -HISTORY OF PRESENT ILLNESS: Mr. Stephen is a 53-year-old -gentleman who presented on 2121-6-28 for cystectomy and -neobladder diversion. He had grade 3 of 3 TCC. -PAST MEDICAL HISTORY: -2. Myocardial infarction in '09 -3. Hypertension -4. Left internal capsule cerebrovascular accident in '18 -5. Hypothyroidism -6. Gastroesophageal reflux disease -7. Hypercholesterolemia -8. Depression -PAST SURGICAL HISTORY: -1. TURBT's in '13 and '15 - -ALLERGIES: He has no known drug allergies. - -HOME MEDICATIONS: -1. Aspirin 250 mg q.d. which was held -2. Metoprolol 25 mg b.i.d. -3. Levoxyl 300 mcg once a day -4. Paxil 40 mg once a day -5. Lipitor 20 once a day - -ADMISSION LABS: CBC of 9.3, 43.6, 252. Chem-7 of 135, 4.4, -97, 23, 16, 0.8, 252. PT 12.8, PTT 24.4, INR 1.1. Liver -enzymes: ALT 23, AST 18, alkaline phosphatase 101, albumin -3.8, total protein 7.4. - -IMAGING: Preoperative electrocardiogram showed left atrial -abnormalities with Q-waves in 2, 4, AVF, V5, V6. Thallium -stress test done preoperatively showed normal heart rate, -normal blood pressure, normal respirations, no acute -electrocardiogram changes, some portal V-function from an old -infarction prior myocardial infarction, however it was clear -for the operation. His chest films revealed no acute -cardiopulmonary process. - -The inital surgery resulted in creation of a neobladder from -ileum. Postoperatively, the patient remained intubated with a -septic picture that deteriorated, requiring pressor agents. - The patient returned to the Operating Room on -2121-7-8 for an exploratory laparotomy and excision of an -infarcted neobladder and resection of a nonviable segment of -small bowel x2, creation of a jejunal conduit. His postop -course was equally stormy with spiking fevers, renal failure, -and BP instability -A third surgical exploration was necessary on 7-26. At this time, -the patient -More ischemic bowel was removed where perforations had occurred -resulting in peritonitis. The jejunal loop was excised and the -right ureter ligated. A left cutaneous ureterostomy was created. -Postop he had bilateral nephrostomies inserted and continued to -have an extended stormy ICU course. A tracheostomy was -necessary because of hi need for prolonged ventilator support. -He also developed extensive DVT requiring anticoagulation. -Bowel function gradually returned allowing for tube feedings. -Multiple courses of antibiotic therapy were given during his -hospital stay. - -NEUROLOGICALLY: By system, neurologically the patient is -status post a left internal capsule infarct with residual -right sided weakness. His history of depression leaves on -Paxil and he was started on such. Radiologically, the -patient had a CT done of the head done during his admission. -Showed a stable appearance, considering no definitive -evidence of any type of abscess. Neurologically, the patient -is being discharged home and is stable. He is alert, however -he is unable to move secondary to his wasting and being in -bed for so long without assistance. The patient is able to -get out of bed to chair. Neurologically, the patient has no -acute issues upon discharge. - -CARDIOVASCULAR: The patient is status post myocardial -infarction in 2109 and he did not have a myocardial -infarction during the course of his stay in-house at the -hospital and he was ruled out by enzymes with no acute -electrocardiogram changes. The patient has no acute -cardiovascular issues. The patient is not on clonidine, nor -is he on Lopressor currently and his pressure is tolerating, -basically being on nothing. The patient had been on pressors -immediately because of sepsis which was weaned off slowly -during the course of his stay. He has not been on pressors -for the previous month. - -RESPIRATORY: The patient had poor respiratory failure and -required full respiratory support. He is postoperative his -three operations and has been slowly weaned down to a -pressure support of 40 with a CPAP pressure support with 405 -FIO2 with a PEEP of 5 and a pressure support of 5 with tidal -volumes ranging from 550 to 650. The patient -was also bronched on 8-22 and mucous plugs were removed from -the patient. A CT done on this patient in the last two weeks -in the middle of January showed that he had no acute -pulmonary process with possible left lower lobe pneumonia. -At that point, he had also been on antibiotics with this -course. Upon discharge, the patient has no acute pulmonary -process and his lungs are sounding remarkably clearer. - -GASTROINTESTINAL: The patient is not able to eat on his own -and has a left Dobbhoff tube and is suffering from short--gut -syndrome requiring B12 injections. The patient is currently -tolerating his tube feeds of Impact at goal rate of 90 cc an -hour and is having some stool output. Clostridium difficile -sent on the patient recently as of 9-15 came back negative. -The patient is receiving all his feeds through tube feeds and -is not a candidate for a PEG given his previous abdominal -surgery. The patient's other gastrointestinal issues are -obviously evolving around the reception as previously stated -of massive portions of his small bowel, as well as the large -bowel and appendix. Upon discharge, there are no acute -discharge issues for this patient. - -GENITOURINARY: The pathology report from the original -surgery showed a high grade invasive TCC involving the -bladder neck, prostate, urethral margin and regional -nodes. His right ureter is tied off secondary to -the leak and he has a right nephrostomy tube which was -changed on 9-16 as well as his left nephrostomy tube. His -ureterostomy tube on the left side was changed on 9-18. All -this was done in response to his febrile episode he had which -will be outlined later which was felt to be urosepsis. On -discharge, it was found that his nephrostomies were positive -for yeast, most likely colonized. The patient was not on any -type of antimicrobial for that. The patient has been showing -yeast growing from the left side nephrostomy and -ureterostomies almost to his Intensive Care Unit stay, but no -evidence of acutely febrile as a result most likely due to -colonization. The patient has a left nephrostomy tube in -addition to the ureterostomy of the left side and does not -have a Foley inserted into his neobladder obviously because -of drainage from that point of view. Upon discharge from a -urological standpoint, the patient is stable. His tubes are -draining clear urine and there is no blood present. Some -blood may be noted in the urine with positional changes on -the patient and that is completely normal as long as it is -consistent with old blood and no massive bleeds. - -EXTREMITIES: The patient was found to have a lower extremity -deep venous thrombosis on 8-3, as well as 8-8 which found -upper extremity bilateral deep venous thromboses. The -patient basically had deep venous thromboses x4 and was -started on a heparin drip continuously to resolve his deep -venous thromboses and heparin drip was continued until -Coumadin was started in the last two weeks of January prior -to his discharge. An ultrasound of the upper extremities -done on Mr. Stephen on 9-12, showed that he resolved his -upper extremity clots completely with the exception of some -small residual clot at the left and right IJ. The patient is -being discharged on Coumadin with the hope of achieving an -INR of approximately 2 to 2.5. The most recent INR was 1.3, -came back on 9-18 and the patient continued to receive -Coumadin until he reaches his goal without any heparin. In -addition, the patient's hematocrit has remained stable, -however. - -HEME: The patient has been on Coumadin. His hematocrit has -remained stable as of late and his last blood transfusion was -on 7-12. Since then, his hematocrit has remained stable at -around 29 to 28 with no acute signs of bleeding. As far as -his renal function, the patient has been increasing sodium -and has been given free water to resolve that. His -hematocrit is stable and his white cell count on 9-18 was -8.0. - -INFECTIOUS DISEASE: The patient was febrile postoperative -and several cultures were sent out. Regarding his blood -cultures, from 7-8 to the middle of January, he did not -grow anything out. He was on triple antibiotics which were -actually discontinued on 2121-8-29. He failed to grow -anything however fluconazole was continued until 9-2 to rule -out any other type of infection and to make sure that there -was no acute yeast systemic process going on even though he -had colonized his tubes. The patient became febrile again on -9-8 unfortunately with a T-max of 104.4??????. The patient was -started immediately on vancomycin, Zosyn and fluconazole -until cultures came back. Blood cultures and catheter -cultures came back revealing that the patient had been -infected and was handling what was later decided was probably -urosepsis for Klebsiella. Based on this, the patient resumed -a 10 day treatment cycle of Levaquin based on infectious -disease's recommendation and the other antibiotics were -stopped. This is actually day 8 of 10 of his levofloxacin -course and as of 2121-9-19 the patient will be receiving two -more days of Levaquin. - -The patient upon discharge is afebrile and his surveillance -blood cultures have come back negative even though his -nephrostomy tubes which were changed showed some fungal -colonization growth. His blood has remained negative for any -type of infection. During his stay, other cultures sent off -included blood flowing through his catheter lines which were -negative except for that one change which was required on -9-8 after he became febrile. His left subclavian has -changed. Today, on 9-19, he has a right sided subclavian of -the left sided one which was considered a possible source of -infection. His lines are not likely the source of the -infection. It is hoped that he will get a PICC line before -he is discharged to rehabilitation today and his central line -will be taken out. - -MICROBIOLOGY: A spinal tap was also done and no consequence -of that resulted. No significant findings. - -Today, the patient is being discharged and he is on the -following medications: -1. Glutamine 5 mg p.o. tube feeds to prevent excessive -stool, secondary to short-gut. -2. NPH 8 units subcutaneous b.i.d. -3. Thyroxine 200 mcg p.o. q.d. -4. Vitamin C p.o. per the nasogastric tube every day. -5. Insulin sliding scale 2, 4, 6, 8 which is not being used -much. -6. Paxil 20 mg nasogastric tube q.d. -7. Levofloxacin 500 mg intravenous to be continued for -another two days hopefully. -8. Tincture of iodine 10 drops to every 500 cc of tube -feeds. - -He received 2.5 mg of Coumadin last night. He has not -received any recent Dilaudid or albuterol nebulizer -treatment. He is receiving KCL 40 mg intravenous prn for low -potassium of less than 4, magnesium of 2 gm intravenous prn -for less than 2.0 magnesium levels, last dose on 9-18, as was the last dose of potassium. The patient has not -been requiring any Ativan or Dilaudid or sedation as of -recently. He was on Epogen for a hematocrit which has now -been stabilized, so it is no longer as issue. It was felt -that the patient was in early on acute renal failure which -turned out to be a leak and the patient is not on renal -failure, no requiring any Epogen. On this date, 9-19, Mr. -Stephen is basically receiving in addition to just the -glutamine 5 mg tube feeds, Synthroid which are outlined and -he is also getting Protonix 40 mg intravenous q.d. for -gastrointestinal prophylaxis, as well as Coumadin to keep an -INR of 2 to 2.4 for prophylaxis. - -It is our hope that Mr. Schrack, despite his advanced -cancer and multiple surgeries, will be rehabilitated and able -to resume assemblance of his functional life. We hope that -he continues receiving chest PT, that he is respiratorily -stable with no acute issues at this time. We also hope that -he will eventually no longer require ventilatory support and -a collar could be used on him as well as eventually assume -breathing on room air. - -Final Diagnoses: -1. Transitional Cell Ca of Bladder and Prostate, metstatic to -regional nodes -2. Multiple postoperative complications, including intestinal -perforation with peritonitis, neobladder infarction, sepsis, -vascular instability with hypotension, DVT, and renal -insufficiency. -3. Respiratory insufficiency -4. s/p tracheostomy - - - - Michele Initial (NamePattern1) Beaufort, MD A79903668 - -Dictated By:Leon -MEDQUIST36 -D: 2121-9-19 09:01 -T: 2121-9-19 09:11 -JOB#: Job Number 39316 + Dr. West Dr. West E M.D P79910145 -rp 2121-9-19 +Dictated By:Mary +MEDQUIST36 +D: 2157-1-31 13:01:51 +T: 2157-1-31 14:05:08 +Job#: Job Number 76433 " +"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"